CIRCUMCISION: MALE - EFFECTS UPON HUMAN SEXUALITY

Circumcision, once accepted as the norm in the United States, has become controversial. Technically, circumcision is the surgical removal of the skin that normally covers and protects the head, or glans, of the penis. At birth, the penis is covered with a continuous layer of skin extending from the pubis to the tip of the penis where the foreskin (prepuce) folds inward upon itself, creating a double protective layer of skin over the glans penis. The inner lining of the prepuce is mucous membrane and serves to keep the surface of the glans penis (also mucous membrane) soft, moist, and sensitive. The prepuce is often erroneously referred to as ``redundant'' tissue, which allows the medical community and society-at-large to consider the foreskin an optional part of the male sex organ and, therefore, to condone its routine removal in a variety of procedures collectively known as ``circumcision.''

Circumcision, however, was also a part of religious ritual, including Judaism and Islam as well as others. However, 85 percent of the world's male population is not circumcised. Circumcision in 1992 was still the most commonly performed surgical procedure in America, where 59 percent of newborn males underwent this operation. Circumcision reached its peak of 85 to 90 percent during the 1960s and 1970s. The surgery, usually performed on baby boys within the first few days of life, is often considered "routine." The most popular methods, the Gomco clamp and the Plastibell procedures, differ somewhat in technique and instrumentation but the effects on the penis and the baby are basically the same. Most of the American circumcisions are not done for religious reasons, but rather, for hygienic ones.

Medical Procedure
Usually, the procedure for circumcision in America involves the baby being strapped spread-eagle to a plastic board, with his arms and legs immobilized by Velcro straps. A nurse scrubs his genitals with an antiseptic solution and places a surgical drape - with a hole in it to expose his penis - across his body. The doctor grasps the tip of the foreskin with one hemostat and inserts another hemostat between the foreskin and the glans. (In 96 percent of newborns, these two structures are attached to one another by a continuous layer of epithelium, which protects the sensitive glans from urine and feces in infancy and childhood.) The foreskin is then torn from the glans. The hemostat is used to crush an area of the foreskin lengthwise, which prevents bleeding when the doctor cuts through the tissue to enlarge the foreskin opening. This allows insertion of the circumcision instrument. The foreskin is crushed against this device circumferentially and amputated.

Anesthesia was not used to alleviate infant suffering until recently because it was believed that babies do not feel pain. Additionally, it was recognized that anesthesia was risky for the newborn, thus contributing to the medical reluctance to use it for painful procedures on infants, such as circumcision. Currently, some doctors use a dorsal penile nerve block to numb the penis during infant circumcision. While not always effective, this anesthesia may afford some pain relief during the surgery, although it offers no pain relief during the recovery period (which can last up to 14 days) when the baby urinates and defecates into the raw wound.

Function of the Foreskin
To understand the function of the prepuce, it is necessary to understand the function of the penis. While it is commonly recognized that the penis has two functions - urination and procreation - in reality, it is essential only for procreation, since it is not required for urination.

For procreation to occur, the normally flaccid penis must become erect. As it changes from flaccidity to rigidity, the penis increases in length about 50 percent. As it elongates, the double fold of skin (foreskin) provides the skin necessary for full expansion of the penile shaft. But microscopic examination reveals that the foreskin is more than just penile skin necessary for a natural erection; it is specialized tissue, richly supplied with blood vessels, highly innervated, and uniquely endowed with stretch receptors. These attributes of the foreskin contribute significantly to the sexual response of the intact male. The complex tissue of the foreskin responds to stimulation during sexual activity. Stretching of the foreskin over the glans penis activates preputial nerve endings, enhances sexual excitability, and contributes to the male ejaculatory reflex. Besides the neurological role of the preputial tissue, the mucosal surface of the inner lining of the foreskin has a specific function during masturbation or sexual relations.

During masturbation, the mucosal surface of the foreskin rolls back and forth across the mucosal surface of the glans penis, providing nontraumatic sexual stimulation. During heterosexual activity, the mucosal surfaces of the glans penis and foreskin move back and forth across the mucosal surfaces of the labia and vagina, providing nontraumatic sexual stimulation of both male and female. This mucous-membrane-to-mucous-membrane contact provides the natural lubrication necessary for sexual relations and prevents both the dryness responsible for painful intercourse and the chafing and abrasions which allow entry of sexually transmitted diseases, both viral and bacterial.

When normal, sexually functioning tissue is removed, sexual functioning is also altered. Changes of the penis that occur with circumcision have been documented. These may vary according to the procedure used and the age at which the circumcision was performed, nevertheless penile changes will inevitably occur following circumcision.

Circumcision performed in the newborn period traumatically interrupts the natural separation of the foreskin from the glans that normally occurs somewhere between birth and age 18. The raw, exposed glans penis heals in a process that measurably thickens the surface of the glans and results in desensitization of the head of the penis.

When circumcision is performed after the normal separation of the foreskin from the glans, the damage done by forcible separation of these two parts of the penis is avoided, but the glans must still thicken in order to protect itself from constant chafing and abrasion by clothing.

The thickened, drier tissue covering the glans of the circumcised penis may necessitate the use of synthetic lubricants to facilitate nontraumatic sexual intercourse. Often, it is erroneously considered the woman's lack of lubrication that makes intercourse painful rather than the lack of natural male lubrication, which is more likely the cause. During masturbation, the circumcised male must use his hands for direct stimulation of the glans, and this may require synthetic lubrication as well.

In addition to the predictable physical changes that occur with circumcision, there are inherent risks and potential complications from the surgery. These include, but are not limited to, hemorrhage, infection, surgical damage and, while rare, death. Surgical damage and healing complications can result in extensive scarring, skin bridging, curvature of the penis, and deformities of the glans penis and urethral meatus (urinary opening). Extreme mutilations have resulted from inappropriate electrocautery use in circumcision, causing loss of the entire penis. Sex-change operations have been used as a ``remedy'' for this iatrogenic condition.

While circumcision has potential risks and alters normal, sexual functioning of the penis, proponents of the practice consider it to confer many "prophylactic" benefits on the recipient. This rationale was initiated in the English-speaking countries during the 19th century when the etiology of diseases was unknown. At that time, circumcision evolved from a religious ritual or puberty rite into routine surgery for "health" reasons.

Within the miasma of myth and ignorance, a theory emerged that masturbation caused many and varied ills, so some physicians thought it logical to perform genital surgery on both sexes to stop masturbation. In 1891, P.C. Remondino advocated circumcision to prevent or to cure alcoholism, epilepsy, asthma, hernia, gout, rheumatism, curvature of the spine, and headaches. As scientific research uncovered legitimate pathological etiology for diseases previously thought to be prevented or cured by circumcision, new rationales were postulated to validate the practice. Prophylactic circumcision of females fell out of vogue in English-speaking countries, but the incidence of male circumcision steadily rose. In the early 20th century, circumcision was advocated as a hygienic measure. Though criticism of the practice mounted, it was not until 1975 that the American Academy of Pediatrics came out in opposition, arguing that good personal hygiene would offer all the advantages of routine circumcision without the attendant surgical risk. The advent of antibiotics negated the rationale that circumcision was needed to prevent venereal disease.

As a religious ritual, circumcision is practiced by Jews and Moslems in accordance with the biblical account of Abraham's covenant with God. Even so, the ``purpose'' of the Jewish ritual of circumcision has been argued by Jews throughout history. Noted Rabbi Moses Maimonides, in the Guide of the Perplexed, explains a rationale for circumcision that merits attention when circumcision is considered relative to human sexuality.

As regards circumcision... [s]ome people believe that circumcision is to remove a defect in man's formation; but every one can easily reply: How can products of nature be deficient so as to require external completion, especially as the use of the foreskin to that organ is evident. This commandment has not been enjoined as a complement to a deficient physical creation, but as a means for perfecting man's moral shortcomings. The bodily injury caused to that organ is exactly that which is desired; it does not interrupt any vital function, nor does it destroy the power of generation. Circumcision simply counteracts excessive lust; for there is no doubt that circumcision weakens the power of sexual excitement, and sometimes lessens the natural enjoyment; the organ necessarily becomes weak when it loses blood and is deprived of its covering from the beginning.

The Moslems, who also circumcise in accordance with the biblical covenant between Abraham and God, traditionally circumcised their males at age 13. More recently, however, Moslem boys are circumcised at varying ages from birth to puberty.

In the United States, the religious rights of parents are being questioned in regard to the constitutional rights of infants and children. Freedom of religion became a legal issue when it was introduced in a circumcision lawsuit claiming a male had been denied his right to freedom of religion when his body was marked by circumcision in accordance with his parents' religion.

The inalienable body ownership rights of infants and children continue to be addressed within the U.S. legal system in lawsuits asserting that the only person who can legally consent to a circumcision is a person making this personal decision for himself. The reports of dissatisfaction with parental circumcision decisions by circumcised men help to illustrate this point. Performed on their penises without their consent, thousands are now undergoing foreskin restoration, either medical or surgical, to reconstruct what they consider was violently taken from their bodies early in their lives. The Declaration of the First International Symposium on Circumcision acknowledges the unrecognized victims of circumcision and, in support of genital ownership rights of infants and children, states: ``We recognize the inherent right of every human being to an intact body. Without religious or racial prejudice, we affirm this basic human right.'' Due to the lifelong consequences of the permanent surgical alteration of children's genitals, it becomes imperative that children have the right to own their own reproductive organs and to preserve their natural sexual function.

These, then, are the human genitals. Considering their great delicacy, complexity and sensitivity, one might imagine that an intelligent species like man would leave them alone. Sadly, this has never been the case. For thousands of years, in many different cultures, the genitals have fallen victim to an amazing variety of mutilations and restrictions. For organs that are capable of giving us an immense amount of pleasure, they have been given an inordinate amount of pain. (Morris, 1985)

REFERENCES