Circumcision: what do we cut when we are cutting?

The term circumcision refers to partial or complete excision of the foreskin.
There are three types of circumcision: ritual circumcision, performed for religious practice,
as a rite of passage, usually during neonatal or transpubertal age; prophylactic circumcision,
as preventive measure against future potential diseases; therapeutic circumcision,
performed because of an evident pathology of the foreskin with clear medical indications.
The investigation on the meaning of the ritual circumcision goes beyond the boundaries of
the present paper; we are referring to anthropological literature to better understand its origin
and reasons. Prophylactic circumcision spread among English-speaking peoples in the
nineteenth century as a means against masturbation. In the twentieth century prevention
against cancer, urinary infections, sexually transmitted diseases and, eventually, AIDS took
over. The controversy about prophylactic circumcision is increasing nowadays in the United
States whereas in the other English-speaking countries the procedure has almost disappeared
and this represents what Edward Wallerstein calls “the uniquely American medical
enigma”. There are many interpretations for prophylactic circumcision and its lasting
success in the United States. Each explanation probably hits the target only partially because
this procedure takes its roots in the cultural history of the above mentioned country
and in the relation with its puritan origins. Therapeutic circumcision is performed because
of a clear and evident pathology of the prepuce. The embryological development of the prepuce
is completed at the sixteenth week of pregnancy. At birth, this tissue covers the glans
without an apparent plane of cleavage and should be defined as ‘non-retractile prepuce’
instead of ‘phymosis’. The prepuce in its free development becomes completely retractile
at puberty. These evolutionary concepts about prepuce have been described by Douglas
Gairdner in 1948 and Jacob Oster in 1968. The prepuce is an integrant part of the male
genital system. It has three functions: protective, immunological and sexual. The extremely
complex innervation of the prepuce explains its sensibility and makes it an extraordinary
erogenous zone. In view of these features, the excision of the prepuce necessarily interferes
with the patient’s sexual function, and possibly involves serious psychological concerns.
Circumcision represents a minor surgical procedure but, like any other surgical techniques,
can result in complications: A) operative: hemorrhage, removal of too much skin
from the penile shaft infection; B) post-operative: sepsis, urethrocutaneous fistula, gangrene
of the penis; C) long-term complications: meatal stenosis, skin bridge between the
glans and the penile shaft. Sometimes complications are severe and can cause death of the
patient, especially during ritual circumcision.
Given these aspects, a well informed consent is mandatory both in terms of potential complications
linked to surgical procedures, and in terms of sexual and psychological consequences.