Foreskin

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Foreskin - Anatomy and function

The foreskin or prepuce is the double-layered fold of smooth muscle tissue, blood vessels, neurons, skin, and mucous membrane part of the penis that creates the preputial sac, while covering and protecting the glans penis and the urinary meatus.

The nature of the prepuce or foreskin, which is amputated and destroyed by circumcision, must be considered and fully understood in any discussion of male circumcision.[1]

Purpura et al. (2018) described the foreskin as follows:

Few parts of the human anatomy can compare to the incredibly multifaceted nature of the human foreskin. At times dismissed as “just skin,” the adult foreskin is, in fact, a highly vascularized and densely innervated bilayer tissue, with a surface area of up to 90 cm, and potentially larger. On average, the foreskin accounts for 51% of the total length of the penile shaft skin and serves a multitude of functions. The tissue is highly dynamic and biomechanically functions like a roller bearing; during intercourse, the foreskin “unfolds” and glides as abrasive friction is reduced and lubricating fluids are retained. The sensitive foreskin is considered to be the primary erogenous zone of the male penis and is divided into four subsections: inner mucosa, ridged band, frenulum, and outer foreskin; each section contributes to a vast spectrum of sensory pleasure through the gliding action of the foreskin, which mechanically stretches and stimulates the densely packed corpuscular receptors. Specialized immunological properties should be noted by the presence of Langerhans cells and other lytic materials, which defend against common microbes, and there is robust evidence supporting HIV protection. The glans and inner mucosa are physically protected against external irritation and contaminants while maintaining a healthy, moist surface. The foreskin is also immensely vascularized and acts as a conduit for essential blood vessels within the penis, such as supplying the glans via the frenular artery.[2]

Origin

Evolution of the foreskin over hundreds of thousands of years by natural selection provided better fitness for survival.[3] Evolution provided protective functions that protect the penis from trauma, infection,[4] and also to provide functions that promote reproduction.[1]

Structure

The medical community usually omits information on the nature and functions of the foreskin from information provided to the public and to parents.

Foreskin in infancy and childhood

Baby boys are born with the foreskin fused with the glans penis by the balanopreputial lamina, a synechial membrane, which prevents retraction. The preputial sac is closed by the synechia and cannot be infected.[4] The synechia breaks down over a widely variable period of years to release the foreskin and allow retraction.

In addition, the tip of the foreskin (acroposthion) is usually too narrow to allow retraction of the foreskin, but usually widens as puberty approaches to permit retraction.

Forcible attempts to retract the foreskin result in injury to the boy, so should be avoided. The first person to retract the foreskin should be the boy himself since he will not retract if it is painful.[5]

Thorvaldsen & Meyhoff (2005) conducted a survey of 4,000 boys in Denmark. They reported that the mean age of first foreskin retraction is 10.4 years in Denmark.[6]

Foreskin in adolescence

The foreskin is in a transitional state during puberty and adolesence in which it is changing from the non-retractile foreskin of childhood to thh fully retractable foreskin of adulthood. Many adolescents complain of a non-retractable foreskin. Many need to do manual stretching. They usually achieve full retraction by age 16.

Foreskin in adulthood

The foreskin (also known as the prepuce) is the layered fold of smooth muscle tissue, blood vessels, neurons, skin, and mucous membrane part of the penis that covers and protects the glans penis and the urinary meatus.[1] There are four layers in the foreskin. The top layer is either epidermis in the outer foreskin or mucosa, in the inner foreskin. The second layer is the lamina propria. The third layer is the dartos. The fourth layer is the dermis. It is normal for the foreskin to be darker in color than the rest of one's body after puberty. This condition is called hyperpigmentation.

The adult foreskin measures about 3 inches by 5 inches or 15 square inches.[7] The foreskin creates the preputial sac. The two foreskin layers provide a skin reserve. When the penis becomes erect, the foreskin may wholly or partially unfold to provide the necessary skin to allow for expansion of the penis during erection.

The foreskin is the movable part of the penis. The foreskin is not attached to the underlying structure and is free to glide back and forth.[8] The gliding action reduces the friction of intercourse and helps to prevent abrasions, while conserving vaginal lubrication and moisture.[9] The foreskin is attached to the glans penis on the ventral side by the frenulum, which usually limits retraction to a widely variable degree. The ridged band emanates from the frenulum.[1]

The epithelium of the outer layer of the foreskin is true skin while the epithelium of the inner layer is mucosal membrane. There is a mucocutaneous boundary at the tip of the foreskin. The mucocutaneous junction is a specific erogenous zone,[10] Taylor et al. reported:

The vascular ridges of the `ridged band' and its Meissner's corpuscles firmly separate preputial epithelium from true skin and place preputial mucosa amongst other mucocutaneous mucosae. Winkelmann emphasized the structural and functional importance of junctional regions of the body and focused on mucocutaneous end-organs, or `genital corpuscles', of the glans penis and prepuce. Some of these end-organs resemble Krause end-bulbs; others resemble Meissner's corpuscles. … Meissner's corpuscles of the prepuce may be compared with similar nerve-endings in the finger-tips and lips, which respond in a fraction of a second to contact with light objects that bring about deformation of their capsules. … The prepuce provides a large and important platform for several nerves and nerve endings. The innervation of the outer skin of the prepuce is impressive; its sensitivity to light touch and pain are similar to that of the skin of the penis as a whole.[7]

The highly innervated ridged band area is found at the mucocutaneous junction. The ridged band area is characterized by rete ridges with Meissner's corpuscles in the ridges.[7]

As with other neurologic structures such as the brain, the tip of the prepuce is richly supplied with blood by important vascular structures.[7] The prepuce serves as a conduit for several important veins.[4] The glans penis receives blood through the frenular artery.[11] The adult foreskin frequently has prominent visible veins.

The layer of dartos muscle is contained within the foreskin.[1] It makes the foreskin rather stretchy. The dartos muscle keeps the foreskin snugly against the glans. The fibers of the dartos muscle form a whorl at the tip that functions as a sphincter. The sphincter opens to allow urine to flow out, but closes to protect the penis from foreign matter, contaminants, and pathogens.[8][12]

The outer foreskin usually becomes somewhat darker after puberty due to increased melanin.[13]

Foreskin length

Natural foreskins are found in all lengths from very short to very long. Most fall near the center of the range. Longer foreskins appear to perform their protective and immunological function more satisfactorily. A short or inadequate foreskin may be lengthened by tissue expansion to improve function and aesthetics.

The tapered tip of a longer foreskin that extends beyond the glans penis is known as the acroposthion. A very few of the longest foreskins will not remain retracted when released, but will spontaneously glide forward to recover the glans penis. Longer foreskins improve protection and gliding action and do not usually create an issue. There is no recognized definition of an excessively long or so-called "redundant" foreskin.[14]

See Adult foreskin.

Physiological functions

Antique research by Alfred Kinsey (1948)[15] and Masters & Johnson (1966)[16] misled medical science into believing that the foreskin had no function. This meant the foreskin could be excised without doing harm. In actuality, the foreskin has many functions,[17] so its amputation does great harm.[18]

The human race evolved over perhaps 700 millenia. The foreskin evolved its physiological functions that improve fitness for survival during that time.[19]

Protective functions

The foreskin provides physical protection to the glans penis and inner mucosa,[20] supplying moisture and natural oils by transudation, while protecting the mucosal tissue from pathogens, pollutants, friction, injury, keratinization, de-sensitization, and drying out. The foreskin protects the glans penis and meatus of infant boys from abrasion and irritation from ammoniacal diapers.[21] [22]

In the absence of the foreskin about ten to twenty percent of circumcised boys suffer urethral stricture (meatal stenosis) requiring further treatment.[23] Frisch & Simonsen (2016) reported the incidence of meatal stenosis to be 3.7 times higher in circumcised boys.[23]

The foreskin continues to protect the glans penis throughout life, keeping it smooth, glossy, moist, sensitive, and free from keratinization and loss of sensation.

Immunological functions

Fleiss et al. (1998) have listed numerous immunological functions of the foreskin that help to protect the human body against infection. The foreskin maintains the moistness of the preputial mucosa and the glans penis by transudation. The sub-preputial moisture contains cathepsin B, chymotrypsin, neutrophil elastase, cytokines, and lysozyme, which has the capacity to destroy the cell walls of bacteria. The preputial muscles keep the tip of the foreskin closed to keep out pathogens.[4]

The foreskin is highly vascularized. The high rate of blood flow helps to prevent infection.[4]

Although claims have been made that the presence of the foreskin increases the risk of infection with human immune deficiency virus (HIV), that is not correct. The claims are based on the reported findings of three randomized clinical trials (RCTs) that were carried out more than a decade ago in Africa. Boyle & Hill (2011) have shown these RCTs to be have significant methodological flaws and statistical errors that render their claims invalid.[24]

Fleiss et al. noted the presence of Langerhans cells in the prepuce.[4] De Witte et al. (2007) have discovered that Langerhans cells produce Langerin, which is a "natural barrier to HIV infection".[25]

For more information, see Immunological and protective function of the foreskin.

Sexual functions

The foreskin is a sexual organ.[18] It provides both mechanical and erogenous functions in sexual intercourse,[17] as well as pheromones for the excitement and arousal of the partner.[4] Winkelmann (1959) classified the foreskin as specific erogenous tissue.[10] When the penis becomes erect, the foreskin unfolds to provide the skin necessary to allow the penis to expand to full size and length.

The gliding action provides stimulation and facilitates intromission.[9][26] [27] At times of sexual arousal, the foreskin may be lubricated by pre-ejaculate. During the thrusting of sexual congress, the gliding action reduces abrasions and irritation in the female partner and avoids problems with vaginal dryness.[9][26] The foreskin may protect the corona glandis from hyper-stimulation and prevent premature ejaculation.

Sensory functions

Nature designed the foreskin to be an erogenous sensory organ.[18] Hill (2003) commented the foreskin has a layer of muscle called the dartos muscle sheath that provides the foreskin with elasticity, flexibility, and stretchiness, which allows full stimulation of the nerves in the ridged band that sense movement and stretching to provide foreskin sensitivity.[28] There is a mucocutaneous region at the tip of the foreskin where outer skin changes to inner mucosa. Winkelmann (1959) identified the foreskin as a specific erogenous zone (meaning an area of acute erogenous sensation). Winklemann reported rete ridges in the foreskin with nerves set close to the surface with closely set networks.[10]

Lakshamanan & Prakash (1980) report the "prepuce covers the glans completely and snugly like a hosiered material and continues to do so through the entire span of life of the male", which they explain as being caused by the smooth muscle fibers within the prepuce. The prepuce is free to glide back and forth. When it does, it must stretch to go over the glans penis.[8]

Taylor et al. (1996) carried out a histological study of the foreskin. (Histology is the microscopic examination of cells and tissues.) Taylor et al. found an area of rete ridges just inside the tip of the foreskin that he called the ridged band. The ridges were found to have nerve endings at the top of the ridges. They report that the ridged band area moves to the shaft of the penis when the penis becomes erect where the nerves are subject to stimulation. They stated:

The prepuce provides a large and important platform for several nerves and nerve endings. The innervation of the outer skin of the prepuce is impressive; its sensitivity to light touch and pain are similar to that of the skin of the penis as a whole.[7]

Sorrells et al. (2007) conducted a fine-touch study of the penis of both circumcised and intact men. Sorrells et al. concluded:

In conclusion, circumcision removes the most sensitive parts of the penis and decreases the fine-touch pressure sensitivity of glans penis. The most sensitive regions in the uncircumcised penis are those parts ablated by circumcision. When compared to the most sensitive area of the circumcised penis, several locations on the uncircumcised penis (the rim of the preputial orifice, dorsal and ventral, the frenulum near the ridged band, and the frenulum at the muco-cutaneous junction) that are missing from the circumcised penis were significantly more sensitive.[29]

Bronselaer et al. (2013) surveyed a large group of intact and circumcised men in Belgium. They reported:

Of the men in Group A [intact males], 90.6% rated the sexual pleasure provided when the foreskin was stimulated by themselves or their partners from ‘mild’ to ‘very strong’ and 61.9% the respective orgasm from ‘mild’ to ‘very strong’.

For the glans penis, men in Group B [circumcised males] reported significantly less sexual pleasure than men in Group A at the dorsal side (P ≤ 0.001), and the lateral (P ≤ 0.001) and ventral sides (P = 0.02). Orgasm was less intense in Group B at the dorsal side (P = 0.006) and at the lateral sides (P = 0.02). Group B required more effort in achieving orgasm at the lateral sides (P = 0.04). Furthermore, a larger percentage of men in this group reported numbness at the dorsal, lateral, and ventral sides (all P ≤ 0.001), as well as unusual sensations (burning, prickling, itching, or tingling) at the lateral sides (P = 0.02) and at the ventral side (P = 0.003) of the glans.[30]

García-Mesa et al. (2021) reported the foreskin has an abundance of Meissner's corpuscles which provide pleasant sexual sensation when mechanically stimulated by motion of the foreskin.[31]

Sexual behavior

The foreskin is a source of comfort to foreskinned men that is not available to circumcised men.

Laumann et al. (1997) reported that men who lack a foreskin "engage in a somewhat more elaborated set of sexual practices than do men who are not circumcised. For each of the practices examined, lifetime experience of various forms of oral and anal sex and masturbation frequency in the past year, circumcised men engaged in these behaviors at greater rates. The difference between circumcised men was greatest for masturbation — ironically, a practice that circumcision was once thought to limit. A total of 47% of circumcised men reported masturbating at least once a month vs 34% for their uncircumcised peers."[32] Dave et al. (2003) reported that men without foreskins "were more likely to report having had homosexual partner(s) (7.5% v 5.3%, p =0.012) and partners from abroad (19.7% v 13.1%, p...0.001)."[33]

Cold & Taylor (1999) commented, "The increased frequency of masturbation, anal intercourse and fellatio reported by circumcised men in the USA may possibly be due to the sensory imbalance caused by circumcision. Clearly, amputation of the prepuce causes changes in sexual behaviour in human males and females."[1]

Frisch et al. (2011) surveyed the sexual function and behavior of a large group of intact and circumcised men in Denmark. They reported that "circumcised men were more likely (38%) than uncircumcised men (28%) to report ≥10 sex partners."[34]

The role of the foreskin in heterosexual relations

The knowledge of the important of the intact penis in heterosexual relations long has been known to the Jews who give us our earliest evidence of the value of the foreskin to the female partner.

Moses Maimonides, a Jewish rabbi and physician, stated in the 12th century:

“ It is hard for a woman with whom an uncircumcised man has had sexual intercourse to separate from him.
– Moses Maimonides[35]

According to the Rabbi Isaac ben Yedaiah, who lived in Southern France in the late 13th century:

She too will court the man who is uncircumcised in the flesh and lie against his breast with great passion, for he thrusts inside her a long time because of his foreskin, which is a barrier against ejaculation in intercourse. Thus she feels pleasure and reaches an orgasm first. When an uncircumcised man sleeps with her, and then resolves to return to his home, she brazenly grabs him, holding on to his genitals and says to him, "Come back, make love to me." This is because of the pleasure that she finds in intercourse with him, from the sinews of his testicles—sinew of iron—and from his ejaculation—that of a horse which he shoots like an arrow into her womb. They are united without separating, and he makes love twice and three times in one night, yet the appetite is not filled.[36]

As previously reported, the foreskin reduces the force required for penetration of the female partner's vagina by as much as ninety percent.[27] The gliding action of the foreskin reduces friction and abrasion, while conserving vaginal lubrication.[9]

In a first of its kind, O'Hara & O'Hara (1999) carried out a retrospective survey of 138 women with experience of both intact and circumcised partners. The women overwhelmingly concurred that the mechanics of coitus was different for the two groups of men. Of the women, 73% reported that circumcised men tend to thrust harder and deeper, using elongated strokes, while unaltered men by comparison tended to thrust more gently, to have shorter thrusts, and tended to be in contact with the mons pubis and clitoris more, according to 71% of the respondents. Women with intact partners had a higher rate of orgasms than women with circumcised partners. O'Hara & O'Hara concluded:

Clearly, the anatomically complete penis offers a more rewarding experience for the female partner during coitus. While this study has some obvious methodological flaws, all the differences cannot be attributed to them. It is important that these findings be confirmed by a prospective study of a randomly selected population of women with experience with both types of men. It would be useful to examine the role of the foreskin in other sexual activities. Because these findings are of interest, the negative effect of circumcision on the sexual enjoyment of the female partner needs to be part of any discussions providing 'informed consent' before circumcision.[37]

Solinis & Yiannaki (2007) concluded; "[t]here was a decrease in couple’s sexual life after circumcision indicating that adult circumcision adversely affects sexual function in many men or/and their partners, possibly because of complications of surgery and loss of nerve endings."[38]

Frisch et al. (2011) surveyed a very large group of men and women in Denmark. They concluded:

"Circumcision was associated with frequent orgasm difficulties in Danish men and with a range of frequent sexual difficulties in women, notably orgasm difficulties, dyspareunia and a sense of incomplete sexual needs fulfilment."[34]

Videos

Why you need to pull back your foreskin.

Male Foreskin is Important - Here's Why


Pathologist Ken McGrath, Senior Lecturer in Pathology at the Faculty of Health, Auckland University of Technology and Member of the New Zealand Institute of Medical Laboratory Scientists, discusses the neurological structures in the foreskin:

Dr. Willam Collins explains the nature of the prepuce.


See also

External links

a region of great sensitivity and possessed of an abundant nerve supply,”11 and later (1959) identified the prepuce as a specific erogenous zone.13 Falliers (1970) noted the “sensory pleasure associated with tactile stimulation of the foreskin.”15 A landmark study by Sorrells et al. (2007) of the fine-touch sensitivity of the penis finds that the areas most sensitive to fine touch are on the foreskin.16 Circumcision, therefore, amputates the most sensitive areas of the penis.

References

  1. ↑ a b c d e f REFjournal Cold CJ, Taylor JR. The prepuce. BJU Int. January 1999; 83, Suppl. 1: 34-44. PMID. DOI. Retrieved 8 July 2021.
  2. ↑ REFjournal Purpura V, Bondioli E, Cunningham EC, et al. The development of a decellularized extracellular matrix–based biomaterial scaffold derived from human foreskin for the purpose of foreskin reconstruction in circumcised males. J Tissue Eng. 22 December 2018; PMID. PMC. DOI. Retrieved 9 February 2020.
  3. ↑ REFbook Darwin, Charles (1859): Chapter Four: Natural Selection, in: The Origin of Species. Retrieved 18 December 2024.
  4. ↑ a b c d e f g REFjournal Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Infect. October 1998; 74(5): 364-67. PMID. PMC. DOI. Retrieved 14 January 2022.
  5. ↑ REFjournal Wright JE. Further to the "Further Fate of the Foreskin". Med J Aust. 7 February 1994; 160: 134-135. PMID. Retrieved 16 May 2020.
  6. ↑ REFjournal Thorvaldsen MA, Meyhoff H. Patologisk eller fysiologisk fimose? [Pathological or physiological phimosis?] (Danish). Ugeskr Læger. 2005; 167(17): 1858-1862. Retrieved 14 November 2019.
  7. ↑ a b c d e REFjournal Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol. 1996; 77: 291-5. PMID. DOI. Retrieved 23 September 2019.
  8. ↑ a b c REFjournal Lakshmanan S, Prakash S. Human prepuce: some aspects of structure and function. Indian J Surg. 1980; 44: 134-7.
  9. ↑ a b c d REFjournal Warren J, Bigelow J. The case against circumcision. Brit J Sex Med. September 1994; Retrieved 28 October 2019.
  10. ↑ a b c REFjournal Winkelmann RK. The erogenous zones: their nerve supply and significance. Mayo Clin Proc. 21 January 1959; 34(3): 39-47. PMID. Retrieved 4 June 2021.
  11. ↑ REFjournal Persad R, Sharma S, McTavish J, et al. Clinical presentation and pathophysiology of meatal stenosis following circumcision. Brit J Urol. 1995; 75(1): 91-3. PMID. DOI. Retrieved 15 October 2019.
  12. ↑ REFjournal Jefferson. The peripenic muscle; some observations on the anatomy of phimosis. Surgery, Gynecology, and Obstetrics (Chicago). 1916; 23(2): 177-81. Retrieved 14 October 2019.
  13. ↑ REFweb (2012). hyperpigmentation, Medical Dictionary for the Dental Professions. Retrieved 25 September 2024.
  14. ↑ REFweb (2022). The ‘Tip’ At The End, Acroposthion. Retrieved 21 June 2022.
  15. ↑ REFbook Kinsey, Alfred C. (1948): Sexual behavior in the human male. Retrieved 16 June 2022.
  16. ↑ REFbook Masters, William (1966): Human sexual response. ISBN 978-0-553-20429-2. Retrieved 16 June 2022.
  17. ↑ a b REFweb Garrett, Connor (19 February 2024). 6 Things You Need to Know About The Intact Penis, Intact America. Retrieved 21 October 2024.
  18. ↑ a b c REFjournal Hill G. The case against circumcision PDF. Journal of Men's Health and Gender. 2007; 4(3): 318-323. Retrieved 1 October 2023.
  19. ↑ REFweb Wikipedia article: Evolution
  20. ↑ REFjournal Morgan WKC. The rape of the phallus. JAMA. 19 July 1965; 193(3): 123-4. PMID. DOI. Retrieved 21 May 2024.
    Quote: This ritual, however, has become so widespread in the United States that it is no longer much of a status symbol, and a situation has arisen where any recently delivered mother who is eccentric enough to wish her child to retain his prepuce, would be well advised to maintain permanent guard over it until such time as they both leave the hospital.
  21. ↑ REFjournal Gairdner DMT. The fate of the foreskin: a study of circumcision. British Medical Journal. 1949; 2(4642): 1433-7. PMID. PMC. DOI. Retrieved 28 October 2019.
  22. ↑ REFjournal Dobanavacki D, Lucić Prostran B, Sarac D, et al. Prepuce in boys and adolescents: what when, and how?. Med Pregl. 2012; 65(7-8): 295-300. PMID. DOI. Retrieved 14 October 2019.
  23. ↑ a b REFjournal Frisch M, Simonsen J. Cultural background, non-therapeutic circumcision and the risk of meatal stenosis and other urethral stricture disease: Two nationwide register-based cohort studies in Denmark 1977-2013. The Surgeon. 1 April 2016; 16(2): 107-18. PMID. DOI. Retrieved 23 October 2019.
  24. ↑ REFjournal Boyle GJ, Hill G. Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns PDF. Thompson Reuter. December 2011; 19(2): 316-34. PMID. Retrieved 30 December 2020.
  25. ↑ REFjournal de Witte L, Nabatov A, Pion M, Fluitsma D, de Jong MAWP, de Gruijl T, Piguet V, van Kooyk Y, Geijtenbeek TBH. Langerin is a natural barrier to HIV-1 transmission by Langerhans cells PDF. Nature Medicine. 4 March 2007; 13(3): 367-71. PMID. PMC. DOI. Retrieved 6 October 2022.
  26. ↑ a b REFjournal Morgan WKC. The rape of the phallus. JAMA. 1965; 193: 123-4. PMID. DOI. Retrieved 15 October 2019.
  27. ↑ a b REFjournal Taves D. The intromission function of the foreskin. Med Hypotheses. 2002; 59(2): 180. PMID. DOI. Retrieved 15 October 2019.
  28. ↑ REFjournal Hill G. Foreskin motion generates Meissner corpuscle stimulation. BMJ. 16 December 2003; 309: 679. Retrieved 6 December 2024.
  29. ↑ REFjournal Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, Van Howe RS. Fine‐touch pressure thresholds in the adult penis. BJUI. 19 March 2007; 99(4): 864-9. PMID. DOI. Retrieved 10 January 2021.
  30. ↑ REFjournal Bronselaer G, Schoeber JM, Meyer-Bahlburg HM, T'Sjoen G, Vlietinck R, Hoebeke PB. Male circumcision decreases penile sensitivity as measured in a large cohort. BJU Int. May 2013; 111(5): 820-7. DOI. Retrieved 23 October 2019.
  31. ↑ REFjournal García-Mesa, Yolanda, García-Piqueras, Jorge, Cobo, Ramón, Martín-Cruces, José, Suazo, Iván, García-Suárez, Olivia, Feito, Jorge. Sensory innervation of the human male prepuce: Meissner's corpuscles predominate. Journal of Anatomy. October 2021; 239(4): 892-902. PMID. PMC. DOI. Retrieved 15 November 2021.
  32. ↑ REFjournal Laumann EO, Masi CM, Zuckerman CW. Circumcision in the United States. JAMA. 2 April 1997; 277(13): 1052-7. PMID. Retrieved 23 October 2019.
  33. ↑ REFjournal Dave SS, Johnson AM, Fenton KA, Mercer CH, Erens B, Wellings K. Male circumcision in Britain: findings from a national probability sample survey. Sex Trans Infect. December 2003; 79: 499-500. PMID. PMC. DOI. Retrieved 29 October 2019.
  34. ↑ a b REFjournal Frisch M, Lindholm M, Grønbæk M. Male circumcision and sexual function in men and women: a survey-based, cross-sectional study in Denmark. Int J Epidemiol. 14 June 2011; 40(5): 1367-81. PMID. DOI. Retrieved 26 September 2021.
  35. ↑ REFbook Maimonides M (1963): The Guide of the Perplexed. P. 609. Retrieved 11 October 2019.
  36. ↑ REFbook Saperstein M (1980): Decoding the Rabbis: A Thirteenth-Century Commentary on the Aggadah. Retrieved 22 October 2019.
  37. ↑ REFjournal O'Hara K, O'Hara J, et al. The effect of male circumcision on the sexual enjoyment of the female partner. BJU Int. 1999; 83 Suppl 1: 79-84. PMID. DOI. Retrieved 22 October 2019.
  38. ↑ REFjournal Solinis, Yiannaki. Does circumcision improve couple's sex life?. Journal of Men's Health and Gender. September 2007; 4(3): 361. Retrieved 23 October 2019.
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