THE CIRCUMCISION REFERENCE LIBRARY
Five men underwent circumcision in adulthood for reasons of infection, inflammation, or phimosis. Several years later, they reported on the erotosexual sequalae. All reported a prolongation of the period prior to ejaculation, though none had been genuine premature ejaculators. Other variable sequalae were diminished penile sensitivity, less penile gratification, more penile pain, and cosmetic deformity. Orgasm frequency was the same or less, and there was not postsurgical impotence. Loss of stretch receptors and reflexes might explain the major erotosexual changes. In most instances, a dorsal cut and/or antibiotic treatment achieves the same effect as circumcision, and is less risky in terms of possible pathological sequelae.
Male circumcision, though a surgical procedure possessed of its own morbidity and mortality statistics, is as widely taken for granted as a haircut. Even in the current era of criticism of health costs, failure to get a second surgical opinion, routine hysterectomy and other unnecessary operations, scarcely a criticism is leveled at routine circumcision which, in almost 100% of cases, serves no health purpose. (Wallerstein, 1980). Until a little more than a century ago, American males kept their foreskins. The change in favor of circumcision had its origin in the 18th medical theory of degeneracy (de'ge'ne'rescence) which replaced demonic possession theory. Masturbation was decreed to be the prime cause of degeneracy both it oneself and ones pedigree - the sin of the father visited upon the children for generations to come. As the masturbation heresy escalated into a disease, it became fashionable to prescribe circumcision (and also clitoridectomy in girls) as the cure, and then as a prevention.
Since a heresy needs no proof, no data were assembled on the effects of circumcision on either masturbation or other variables of erotosexual function. Instead as the 20th century progressed, non-sexual rationalizations of the practice of circumcision, such as the prevention of cervical cancer in wives, were propounded - and still quoted despite evidence to the contrary (Wallerstein, 1980, Wiener, Note 1). In consequence, there continues to be a gap in knowledge concerning what circumcision does to the erotosexual function of the penis. It is a gap that becomes increasingly difficult to close, for there are relatively few adult men with a foreskin who underwent circumcision and who are prepared to give a before-and-after report on how it affected them erotosexually.
The purpose of this paper is to present data on five men who were circumcised in adulthood for reasons of infection, inflammation, or phimosis. Five is a small number on which to base a research publication, but it is better than none at all, since the topic is of sexological importance, and funding for enlargement of the sample unlikely.
The sample is one of convenience; hence, the preliminary nature of this report. The five men ranged in age from 19 to 41 years when circumcised, and from 32 to 47 years when interviewed. A schedule of inquiry was designed specifically for this interview. It was administered orally, tape recorded, and transcribed. The transcript was indexed, and the data abstracted and coded as required for the findings, below.
In all five cases, the man was able, after circumcision, to hold back longer before having an orgasm. As a corollary, if formerly he might have had a problem with "coming too soon," it was less. These changes were regarded by none of the men as a disadvantage, by one a positive improvement, and by the other four as no major consequence. Since none of the four had a clinical history of premature ejaculation, it is evident that these findings neither support nor refute circumcision as a treatment for premature ejaculation. However, the majority of American premature ejaculators were circumcised in infancy.
Penis sensitivity was rated as diminished by four of the men and the fifth regarded his penis as more sensitive to abrasive as well as erotic stimuli. Penile pain increase (2 cases) in one case was attributed by the patient as his physician to the removal of too much foreskin, and in the other to scar tissue near the corona.
The self-rating of gratification was consistent across all modes of erotic stimulation. Individual variation could not be attributed to any variable beyond subjective experience. Orgasm frequency remained unchanged except for the one man who had the most severe side effects, including pain, consequent upon the removal of too much foreskin. There were no cases of impotence prior to circumcision and no development of impotence subsequently.
In four of the cases, it would be more accurate to say that the foreskin had been shortened rather than totally removed. In the fifth case, not only was the foreskin taken, but the upper part of the penile shaft was denuded also, not leaving enough loose skin to cover the penis in erection. In consequence, the hair bearing skin from the mons pubis, above, and from the scotal junction below, was dragged along the shaft of the penis about two-thirds of the way toward the glans.
Partial foreskin removal may heal with a ragged edge. There were three such cases, in one of which the man was cosmetically offended by the appearance of his penis. The cosmetic problem was a serious one also for the man whose penis may be too much denuded.
Removal of the entire foreskin, or even part of it, may require a change in masturbatory technique, insofar as there is less or no redundant skin to be stretched forward or backward. Thus, there needs to be more reliance on some other surface, for example, the lubricated skin of the fingers or palm, to provide ether rotary or longitudinal friction directly to the shaft of the penis. What has been lost in circumcision is the stretch effect and hypothetically, receptors that provide proprioceptive stretch sensation from the foreskin. Inside the vagina, the penis must move in and out in the fashion of a finger, rather than being sometimes able, like the head of a turtle to pull in and out of the carapuce of its own foreskin, while the pubococcygeal muscles at the vaginal entrance grip the lower part of the shaft. Stretch sensations may be additionally altered if the frenulum is severed in the circumcision.
Cosmetics becomes a problem when the body image is involved, and that may affect the entire sense of wellbeing, work capability included, as well as erotosexual bonding and family life.
The erotosexual gains of circumcision, if any, are restricted to taking longer to achieve orgasm which is, hypothetically, secondary to diminished sensory input from stretch receptors in the less mobile skin of the shaft of the penis, as well as loss of foreskin stretch receptors. For those who find this change an improvement, it is possible that it could be achieved by masturbatory and/or coital training in coital delay, instead. The same effect could be achieved also, if requested, by more conservative penile surgery, namely the dorsal slit. According to the urologist, Rainer Engel (personal communication), the dorsal slit procedure would achieve the same effect as circumcision in almost all cases requiring surgical intervention. Some cases of infection could be treated by antibiotics alone.
Either method avoids the hazards of circumcision which are indicated in even so few as five cases, none of which was selected because of adverse post-surgical effects. In one case, the adverse effects were very serious and will require additional surgery to attempt correction.
Circumcision is an operation that needs to be resorted to rarely. It should be done with specific attention to cosmetic and erotosexual outcome, neither of which were so much as mentioned to the five men of this study, so that they had not chance to give their truly informed consent to the risk of negative cosmetic and erotosexual results and the possibility of mutilation. Erotosexually and cosmetically, the operation is, for the most part, contraindicated, and it should always be evaluated in terms of possible pathological sequelae.
John Money, PhD, is a professor of Medical Psychology and an Associate Professor of Pediatrics in the Department of Psychiatry and Behavioral Sciences and the Department of Pediatrics at the Johns Hopkins Medical Institutions, Baltimore, Maryland. Jackie Davison, PhD, is a post-doctoral Fellow in the Department of Behavioral Sciences at the Johns Hopkins University and Hospital. This report was supported by USPHS Grants HD00325 and HD07111.
Requests for reprints should be sent to John Money, PhD, Meyer 3-164, The Johns Hopkins Hospital, Baltimore, MD 21205.
WALLERSTEIN, E. Circumcision, an American health fallacy. New York, Springer, 1980.
Accepted for publication October 22, 1982
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