THE CIRCUMCISION REFERENCE LIBRARY
by Francisco Garcia
Infant circumcision is made more acceptable by believing the notion that there is a flap of skin at the end of the penis called the foreskin which hangs over the glans and circumcision simply removes that flap. This is factually incorrect. By thinking that the foreskin is separate or "extra" tissue it is easier to believe that its removal does little to impact or change the rest of the skin of the penis.
There is really no separate anatomical structure called the foreskin. Rather there is one single continuous skin sheath of the penis which is called the skin system. This single, uninterrupted skin sheath may, at any given time, fold to varying degrees over the glans or retract to reveal it. The amount of the skin system that is folded over can be referred to as the forefold of the skin system. Its extent changes often to accommodate degrees of erection, and it is never a separate structure from the skin of the shaft.
What the operation called circumcision actually does then
is to interrupt and significantly reduce the skin system of
the penis to a fraction of its normal anatomical and
The intact penis is covered by one single continuous skin sheath or skin system. The skin sheath is partly folded at different times. This folded part of the skin system is called the foreskin or prepuce.
The fold of skin is often mistaken as a single layer, or a flap of skin. This is wrong. Instead, it is a free, two-layer fold that forms when the skin coming down the penis from the shaft folds underneath itself somewhere near the tip of the penis then travels back to an attachment point behind the glans (see figures 6 and 4). The two sides of the fold do not adhere to each other even though they lie flat against each other appearing to form a single flap of skin.
Also, in the adult the skin system does not adhere to the
glans so it can unfold back off of the glans, leaving it
fully exposed. When we speak of this skin sheath we are not
talking about the surface of the glans itself in the same way
that we talk about the surface of the shaft, because the
glans has no real skin. When we talk about the skin covering
of the glans, this can only mean the foreskin. The foreskin
is its skin covering.
A significant anatomical error has been made historically and continues today in describing the penis by delineating the "foreskin" as a separate anatomical structure from the shaft skin. People talk about the "foreskin" separately from the shaft skin. This is a mistake. It is not correct.
The foreskin is not a separate anatomical structure from the rest of the skin of the penis. This is actually an artificial separation. When the word foreskin is used, rather than referring to a separate part of the penis, it means the part of the continuous skin system which happens to be folded over the glans at any given time. So there is no real anatomical border to the "foreskin." Since the proportion of the skin system that is folded over the glans increases and decreases by folding and unfolding to various degrees all the time, we realize that "foreskin" is a poor way of describing the anatomy of the penis. Instead, more accurate terminology might be to describe that part of the skin system which covers the glans as the "forefold of the skin system."
Unlike the false border between "foreskin" and shaft skin,
there is a real anatomical border which exists in the skin
system. It is between the mucosal, or non-keratinized, part
of the skin system (which consists of the inner lining of the
foreskin along with the surface of the glans) and the
keratinized part (which is the outer penile skin, including
the outer foreskin). That border is at the most distal part,
or tip, of the skin system - it is the tip of the forefold
(see figures 6 and 7).
The entire skin system moves freely. In the intact (uncircumcised) male, the penis has a low friction gliding plane immediately beneath the surface of the skin which is like no other body structure. This means that the skin of the penis does not adhere to the underlying tissue the way that skin adheres to other parts of the body. This unique quality allows the entire skin of the penis to move as a unit back and forth longitudinally or around the shaft circumferentially making it the most mobile skin in the intact male.
The skin system covers the head of the penis to varying degrees depending on moment-to-moment factors such as the state of erection and temperature. The free fold of the skin system which we call "foreskin" unfolds and re-folds constantly to varying degrees, adjusting to the current state of the penis. It is a very dynamic system. The foreskin, among other functions, provides the penis with a reservoir of skin which is needed during erection. The skin of the erect, intact penis is still mobile and loose, allowing the mucosal inner foreskin to roll back and forth over the glans (see figure 7).
Thus, the dividing line between what we call the skin of the shaft and foreskin is regularly crossed by the "shaft skin" or "foreskin." The delineated "foreskin" may become entirely "shaft skin" when the penis becomes more erect because it is now around the shaft. And if the penis shrinks momentarily beyond its usual flaccid state, perhaps due to a cold swim at the beach, some of the "shaft skin" is now "foreskin" because it covers the glans. The skin system is a dynamic, mobile and flexible skin sheath that moves and adjusts to the momentary needs of the penis (see figure 7). Such a system is not normally observed in the circumcised male.
Another anatomical error is committed in describing the foreskin as a flap of skin protruding from the shaft skin (figure 6a). This notion presumes that the foreskin is a single layer of skin, like the skin of the shaft, which grows from the shaft to cover the glans. In describing the foreskin this way it is easier to see it as redundant or "extra skin" and it is more difficult to see how removing it might impact the rest of the penis. This description of the foreskin is inaccurate. The foreskin is not "extra" skin which protrudes from the shaft. There is no extra skin on the body - this is a silly notion. Instead, it is a free, double-layered fold - an integral part of the skin system. The foreskin extends from a point on the shaft behind the glans to cover the glans then folds back underneath itself to the same attachment point on the shaft, usually near the glans (see figure 6). The eyelid works much the same way. The eye lid is not a single flap of skin, but rather two freely moving layers of a fold of skin, so that both the foreskin and the eyelid have two layers. That's why it is more appropriate to refer to the "foreskin" as the forefold of the skin system.
In reality then, infant circumcision does not remove the
"tip of the penis" or "redundant skin" nor does it remove a
separate structure called "the foreskin." Rather, infant
circumcision deletes a significant percentage of the skin
system of the penis, rendering the skin system relatively
dysfunctional and rendering the penis less dynamic.
A common misperception is that infant circumcision is preferable to adult circumcision because it spares a man pain and trauma. Many physicians however say the opposite and critics admit that most of their objections to infant circumcision cannot be applied to the adult procedure. Here's why:
Even though the facts do not support the claim that adult circumcision is "worse" than infant circumcision, some pro-circumcision advocates contend that adult circumcision is painful, traumatic and dangerous, and that for this reason most adult men who are intact choose to remain uncircumcised. But when intact men are asked about the idea of being circumcised, most say that they have no desire to give up this part of their body - there is no reason to even consider it. Their foreskin gives them no more trouble than their eyelids, lips or testicles. Instead it affords them pleasure and comfort. Anti-circumcision advocates say that it is ridiculous to presume that the idea would even cross an uncircumcised man's mind. To them, it is the same as asking why intact women don't think about having the clitoral foreskin removed.
December 11, 1995