Why foreskin isn’t doing you any favours

Appendicitis? Get rid of your appendix. Recurring tonsillitis? Do away with those troublesome tonsils. Stubborn genital infections? …well…no…

Go for circumcision. Studies have found that men (and their female partners) are better off without their foreskin: circumcised men have a significantly lower risk of urinary tract infections, herpes,  syphilis,  cancer of the penis/HPV, gonorrhoea, genital warts, and prostate cancer . Also their female partners enjoy a significantly reduced risk of Chlamydia trachomatis infection and cervical cancer (although this is unlikely to be a successful chat-up line).

So, while non-medical circumcision of boys at birth is very controversial in the Western world and is sometimes considered a form of genital mutilation, voluntary adult male circumcision enjoys a very different image, especially since its promotion into the anti-HIV arsenal. Studies conducted between 2002 and 2013 have demonstrated that circumcised men are up to 60% less likely to contract HIV from vaginal intercourse with an infected woman.

The exact mechanism by which this happens is still unclear but a number of hypothesis have been suggested. Uncircumcised men may have a higher occurrence of genital ulcers – possible entry points for the HIV virus. Also, it appears that in the inner surface of the foreskin and in the section of the penis shaft normally covered by the foreskin,  the CD4+ T cells, macrophages and Langerhans cells (the cells that the HIV virus uses as entry points into the body) are closer to the surface, due to the presence of less keratin in the skin. On the contrary, in circumcised men, the skin on the penis shaft has become more keratinized and this provides a barrier to the virus. Also, a higher proliferation of bacteria under the foreskin in uncircumcised men is likely to attract more of the HIV-target cells to the area, making them available to infection.

If the loss of the foreskin brings about so many benefits, why are men born with it in the first place?

There is currently no consensus about the role of the foreskin, with hypothesis ranging from keeping the glans moist and protecting the penis while developing in utero to enhancing sexual pleasure. On the other hand, studies have demonstrated that no ill effect comes from parting with one’s foreskin. One study  even indicates that circumcision slightly lengthens ejaculation time, although the researchers stops short of recommending circumcision as a cure for premature ejaculation. Finally, it has been suggested that the only reason why humans have a cover over their penile glans is that their closest evolutionary relatives, the chimpanzees, have it too.

Humans have been cutting out their foreskin for many thousands years. From the Latin circumcidere (“to cut around”), circumcision is one of the oldest planned surgical procedure, possibly dating back to prehistoric times and mostly connected with cultural identity and a rite of passage into adulthood. Male circumcision was practiced in the Arab regions already in the 4th millennium BC and Egyptian carvings from about 2,300 BC depict circumcision rites.

In 2006, around 30% of the world’s males over 15 years of age were circumcised, with almost 70% of them being Muslims. In Islam, circumcision is strongly encouraged and can take place from the seventh day after birth until just before puberty. Circumcision is compulsory for Jews, who routinely circumcise their baby boys eight days after birth. Circumcision at birth is also practiced by some Christian groups and is common in some countries like the US and South Korea for hygiene reasons. Victorian Britons considered circumcision a preventive measure against masturbation, syphilis and nocturnal incontinence, among other things. Prevalence of circumcision among males over 15 has dropped in recent years (from 20-30% in the 1940s to 6% now, in the UK). No data is available for Ireland but a study conducted in Northern Ireland has shown a 66% decrease in children circumcisions from 1991 to 2002. 

As a medical intervention, circumcision is the treatment of choice for balanitis xerotica obliterans (a thickening of the skin with atrophic patches on the glans and foreskin, which is also a risk factor for cancer of the penis), balanposthitis (an acute or chronic inflammation of the mucosal surface of the foreskin) and phimosis (when the foreskin opening is so tight that the foreskin cannot be retracted over the glans and it interferes with urination and erection).

The circumcision of teens and adults is a more serious procedure than that of babies and children and it usually requires general anaesthetic and a recovery time of four to six weeks. In its fight against HIV in Africa, the World Health Organisation has been looking for alternative ways to perform circumcision on adults, which could be performed by trained nurses in clinics rather than by surgeons in operating theatres. As a result of this interest, a number of devices has been developed, ranging from elastic bands, to clamps and cutters,  which either work on starving the foreskin of blood until it dies and falls off or on reducing its the blood supply before snipping it off. Among others, there are the Shang Ring (which last June was approved for worldwide use on adults and teens by the WHO) and the CCSAC, both from China;  from Turkey comes the Alisklamp; from Israel the Prepex  which was tested by the WHO alongside the Shang Ring in field studies in Africa.

No anesthesia. No bleeding. No stiches and no Frankenstein-look. The discomfort of having one’s own foreskin clamped inside a pair of biscuit-cutter-like rings or trapped by an elastic band seems well offset by the benefits – not least, the cosmetic one. No wonder lots of volunteers flocked to the African trails.

Not all of them, though, were able to take part:  some were turned down because of a narrow foreskin opening, a short foreskin, a short frenulum, or adhesions. Others – enviably – were turned down because their penis circumference was beyond the device’s range. 

Will the most uncomfortable part of the new, non-surgical, circumcision, be the qualifying stage?

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