Arguably, the functions of the foreskin should be the most important aspect of the circumcision debate. That is, forms of preventative medicine have thrived for periods of time on the assumption that the part they're removing is useless, until evidence that they do have a function arose. Routine tonsillectomies are one recent example of this occurring in American medicine, once done at the first sign of throat problems but now reserved for those that can't be treated any other way. Its simple logic that before a body part is removed you should know exactly what it is you are removing.
With this in mind, it's not very surprising that literature promoting circumcision always devotes very little time to the subject of the foreskin's function, if they devote any time at all. Usually they'll state that the foreskin is a "useless flap of skin" or some similar euphemism or just that any male can easily get along without it and go on to explain all the good things about circumcision from there, giving only half of the story. Gerald Weiss for example in his opinion paper Neonatal Circumcision Is Necessary says:
"The prepuce covers the head of the penis (glans) and in some animals contains a functional muscle which assists the male in intercourse. There was an evolutionary time when the prepuce had a purpose. Now, even the function as a protective covering in primitive man is unnecessary. The prepuce has thus become a functionless vestigal tissue in the human male."1
However, just in the rest of this article Weiss gives no citation for this claim and it amounts in the end to nothing more than his opinion. Even supposedly unbiased articles listing the pros and cons of circumcision at best usually state that anti-circumcision advocates believe that the foreskin has value, but won't say why. In this essay I hope to give the reasons why the foreskin has value and should not be removed unless there is a definite medical indication that cannot be treat any other way. Circumcision can always be performed at any time in a man's life with the same results and the medical benefits of the procedure are not sufficient enough for it to be considered beneficial, but once the foreskin is cut it is gone forever.
Despite what Gerald Weiss says, the foreskin still does have a purpose of covering the glans by preventing it from undergoing a process known as keratinization. Even pro-circumcision advocates are forced to admit this, and they use it for the basis of their claim that circumcision protects from STD's. (There however is no direct evidence that a keratinized glans makes one less susceptible to a virus.) Dr. Thomas Ritter explains how this work Say Not To Circumcision:
"The skins…possesses a coating layer of keratin. The greater the exposure of the skin to abrasion, pressure, and use, the thicker the layer of keratin. Skin is in constant contact with the environment. It is also subject to great temperature variations. It becomes thick when it is subject to rough treatment…Mucous membrane normally possesses no keratin layer…It is softer, usually constantly moist, and it's thermal environment usually approaches or is at body temperature.
No long-term studies on the effects of keratinization have yet to be done (if you know of any please inform me) but it's not that hard to figure what kind of effect it has. Mucous membranes (such as in the mouth, anus and vulva) are significantly more sensitive than regular skin. By allowing the glans to become keratinized makes the mucous membrane on the penis tougher and the nerve endings in the glans become a lot less accessible.
By turning the usually internal glans into an external organ circumcision also puts the glans in exposure to elements that it normally would not encounter. The worse consequences of this are in the diaper years when the penis is exposed to urine and feces. The lack of protection of the circumcised penis from the elements is manifested in the rate of meatus infections in circumcised boys. The AAP identified this in a 1984 pamphlet:
"The unkeratinized mucous membrane of the normal glans penis can select its environmental contacts. The normal glans can be an internal or an external organ. The dry, keratinized circumcised glans has no such choice; it is irreparably locked into a condition of constant exposure to a variety of unusual, non-intended, and in a sense, unnatural environmental agents.
"The glans is no longer an internal organ and there is no way of protecting it from environmental objects that it was never meant to contact (for example, urine, feces, dry and wet diapers, and clothing). The epithelium (surface) of the glans eventually becomes dry, dull, leathery, brownish, and keratinized, taking on the character of skin rather than mucous membrane."2
"The Function of the Foreskin: The glans at birth is delicate and easily irritated by urine and feces. The foreskin shields the glans; with circumcision this protection is lost. In such cases, the glans and especially the urinary opening (meatus) may become irritated or infected, causing ulcers, meatitis (inflammation of the meatus), and meatal stenosis (a narrowing of the urinary opening). Such problems virtually never occur in uncircumcised penises. The foreskin protects the glans throughout life."3
More recently Williams and Kapila identify that meatus infections are almost never seen in uncircumcised boys and men while they occur at a rate of 8-20% in circumcised ones:
"Meatal stenosis is generally a direct consequence of that is seldom encountered in uncircumcised men; meatal calibre is know to be greater in uncircumcised individuals. The incidence of meatal ulceration following circumcision is from 8 to 20 per cent. The aetiology is thought to be irritation of the external urethral meatus by ammoniacal substances present in wet sodden nappies. Such irritation is unlikely in the presence of a normal prepuce, which serves to protect the glans from these irritant substances. In a prospective study of 140 consecutive neonatal circumcisions, Mackenzie found a 20 per cent incidence of meatal ulceration within the first 2-3 weeks after circumcision. It is thought that meatal ulceration after circumcision is the initiating event in a vicious cycle of stenosis and ulceration, followed by more stenosis. Meatal stenosis following circumcision has been advanced as a cause of recurrent pyelonephitis and obstructive uropathy, for which meatotomy is curative."4
This should be very significant in the circumcision debate, but you almost never hear it from anyone promoting circumcision. (In fact, I have yet to hear anyone who is pro-circumcision even acknowledge this fact.) When talking about the benefits of circumcision they will always list those that accrue over a lifetime while the risks are always listed only as immediately recognised surgical complications. Compare this 8-20% rate of meatal stenosis against UTIs (usually acknowledged as the best benefit of circumcision) which occurs at a rate of 1% in uncircumcised boys for the first year of life.
Returning to the subject of sensitivity, the definitive study on this was done by Taylor, Lockwood and Taylor and published in the British Journal of Urology.5 What they found was that the foreskin contains a high concentration of specialized nerve endings and specialized mucosa that are stimulated by touch not found anywhere else on the penis.
Circumcision advocates have asked how we know whether these nerves have a sexual function or not. Taylor's findings show that they are very similar to those on the glans that we already know to be sexual. We also know that the inner foreskin is a mucous membrane and nerves in mucous membranes are usually very sensitive. The penis has three main functions; reproduction, urination and sensory and it's doubtful that these nerve endings serve the first two functions. When asked about the function of the nerve endings in the foreskin Dr, Taylor answered:
"The prepuce is a structure in its own right and it has to be given a value before you make any decision. You'd have to say to them: Look, this is specialized skin and mucous membrane, it's built very much like the lips, or the vulva in the female. It's a junction between skin and the inner lining. It contains highly specialized nerve endings, which are only found in a few places in the body, and we only find this sort of tissue in areas where it has to perform specialized function, and this specialized function has to do with sex. This is sexual tissue, and there's no way you can avoid the issue. Most people look at the child and the prepuce, and say that, well, the prepuce isn't much use for a child. Well the prepuce isn't designed for a child, it's designed for an adult and you can't look at it in childish terms."6
The foreskin also provides what is commonly referred to as the gliding mechanism. How it works is that the foreskin glides over the glans for stimulation. Given the rich nerve endings in both and the moisture provided by the foreskin it's not difficult to see how this works. When the foreskin is absent some men rely on artificial lubrication.
I addition to the protective, sensory and sexual functions of the foreskin there is new evidence suggesting that foreskin secretions have an immunological function which may help protect against infection.7 More research is needed before this is conclusive.
In conclusion, in light of all this evidence it can no longer be said that the foreskin is useless or functionless. The penis can still function easily without a foreskin and circumcised men get along just without them but that still doesn't make them useless. Today there is a growing number of men who are upset at being circumcised and believe that losing their foreskins has affected them adversely who number in the thousands. If a man is not circumcised but wishes to be he always has the choice to undergo a voluntary circumcision himself. But when a man is circumcised at birth he's lost the foreskin and everything that goes with it forever and it cannot be easily returned. Now that it's been shown circumcise offers no strong benefits when performed in the neonatal period the ethical decision is to allow boys the choice of whether they'd wish to keep their foreskins or not.
1.) Weiss, Gerald N., M.D. Neonatal Circumcision Is Necessary
2.) Ritter, Thomas J., M.D., Say No To Circumcision!, Aptos, CA, Hourglass Book Publishing, 1992, p. 32
3.) Care of the Uncircumcised Penis. American Academy of Pediatrics. Elk Grove Village, 1984
4.) Williams N, Kapila L. Complications of circumcision. British Journal Surgery 1993; 80:1231-36.
5.) Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. British Journal Urology 1996;77:291-295.
6.) Interview with Dr. Taylor by Lawrence Barichello
7.) Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sexually Transmitted Infections 1998;74:364-367.
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