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[[Circumcision]] is performed in many ways which vary by culture, the person performing it, and the age of the subject. It may be performed by a specialized ritual circumciser in a non-medical setting, or a medical practitioner at a hospital or clinic. In some cultures, only the protruding end of the [[foreskin]] is cut off, and in others, the entire foreskin which covers the [[glans]] is removed. Some circumcisers take more [[skin]] than others, resulting in a "loose" or "tight" circumcision.
Generally, the [[foreskin ]] is pulled forward and enough of it is removed to permanently expose the [[glans ]] of the [[penis]]. Sometimes a protective device is used to avoid hurting the glans, and sometimes the circumciser simply performs the procedure freehand. In adults, stitches are used to stop the [[bleeding ]] and help close the wound. In infants, circumcisers often use a clamp that crushes the foreskin and seals the wound, eliminating the need for stitches.
== Circumcision in detail: Styles, techniques and instruments ==
The inner [[foreskin]], which originally faced inwards lying on the [[Glans penis|glans]], now faces outward; this causes the differently coloured section between [[Glans penis|glans]] and [[shaft skin]] which is characteristic for this style.
Of all styles, the tight ones remove the most [[skin]]. They already limit the mobility of the penile [[penile skin]] to a great extent when the [[penis]] is flaccid, and during an [[erection ]] the [[skin]] is fully stretched and immobile. An insufficient amount of reserve [[skin]] can hamper a complete [[erection ]] and lead to painful tension. Also, a skewed [[penis]] can occur due to an uneven distribution of the remaining [[skin]], often caused by an inaccurately placed cut or a uneven growth during wound healing. Due to the extensive shortening of the inner [[foreskin]], this style also means the loss of large amounts of sensitive tissue.
==== Low & Tight ====
This style is the most radical, as it removes the entire sensitive tissue of the [[foreskin]]. As in the high & tight style, large amounts of [[skin]] are removed. In a flaccid state, the [[skin]] is barely movable, and in an erect state it is totally immobile.
An insufficient amount of reserve [[skin]] can hamper an [[erection ]] and lead to painful tension and a skewed [[penis]] in this style as well.
==== High & Loose ====
The outer foreskin is completely removed, as well as parts of the [[shaft skin]]. The inner foreskin is folded back and sewed to the [[shaft skin]]. The scar is located towards the body, hence the term "high". Unlike the high & tight style, the inner [[foreskin]] is less reduced, and lies in folds behind the [[Glans penis|glans]].
There is enough remaining reserve [[skin]] to ensure a complete and unhindered [[erection]]. Of all variants, this one removes the smallest amount of sensitive tissue.
==== Low & Loose ====
[[image:Low_and_loose.jpg|200px|center]]
The inner [[foreskin]] is removed, the outer [[foreskin]] is sewed on below the [[Glans penis|glans]]. The scar is therefore located close to the [[Glans penis|glans]], hence the term "low". The outer [[foreskin]] lies in folds behind the [[Glans penis|glans]]. Enough [[skin]] is left in place to ensure a complete and unhindered [[erection]].
Since, in contrast to the high & loose style, the inner instead of the outer [[foreskin]] is removed, this style results in the loss of almost all of the sensitive tissue.
Over time, a vast variety of methods has been developed to remove the [[foreskin]]. A multitude of clamps and tools is available to ease the work of the circumciser, to improve the chance for visually symmetrical results and to prevent injuries to the [[Glans penis|glans]] from inexpert cuts. I will introduce some of the most widely spread variants.
====Restraint====
When an infant boy is to be [[circumcised]], it is the usual practice to immobilize the infant for the [[Pain| painful]] surgery by securely tying his limbs to a molded plastic board , called a [[Circumstraint]], specially made for that purpose. The infant thus is preventing from fighting or fleeing, which is the [[trauma]]-producing situation of ''inescapable [[shock]]'', described as a "physical condition in which the organism cannot do anything to affect the inevitable."<ref name="vanderkolk2014">{{REFbook
|last=van der Kolk
|first=BesselA. |init=BBA |author-link=Bessel van der Kolk
|year=2014
|title=The Body Keeps the Score
|url=
|pagespage=76
|isbn=978-0-14-312774-1
|accessdate=2021-08-09
[[File:Circumpendium-6-2-1-b.jpg||center|thumb]]
In modern operating theatres the [[foreskin]] is first grasped with forceps, pulled out and clamped above the [[Glans penis|glans]] for a while to reduce [[bleeding]]. Next, the [[skin]] is cut along the forceps with a scalpel. Following that, the remaining [[skin]] is manually trimmed according to the desired style and finally sutured.
[[File:Circumpendium-6-2-1-c.jpg||center|thumb]]
Completely freehand techniques are also common. The penile [[penile skin]] is first cut in two places along the circumference, in the area of the [[shaft skin]] and [[foreskin]]. After that the [[skin]] area between the cuts is removed and the remaining [[skin]] sutured.
Also among the freehand techniques are the shield variants.
[[File:Circumpendium-6-2-1-Mogen-clamp.jpg||center|thumb|Mogen-clamp]]
The [[Mogen]]-Clamp works in a similar way (middle), with the difference that it is locked shut after the [[foreskin]] is inserted, thus clamping it. After a few minutes the [[foreskin]] is cut in the same fashion as with the simple shield. The clamping is meant to reduce or prevent [[bleeding ]] from the wound.
[[File:Circumpendium-6-2-1-Sheldon-clamp.jpg||center|thumb|Sheldon-Clamp]]
The Sheldon-Clamp (right) works in a similar way. The inner clamp grasps the tip of the [[foreskin]], pulling it into the outer clamp which is closed. The outer clamp then grips the [[skin]]. After a few minutes of pressure, the [[foreskin]] is cut between the two clamps.
The use of a shield, rather than forceps, is meant to provide a better protection of the [[Glans penis|glans]] from cutting injuries. However, if used improperly both the [[Mogen ]] and the Sheldon clamp are subject to the risk of the tip of the [[Glans penis|glans]] being accidentally clamped and being cut into or severed.
==== Complex clamps ====
[[File:Circumpendium-6-2-2-Gomco-clamp.jpg|center|thumb|Gomco clamp]]
One of the most widely used clamps in the USA is the [[Gomco ]] clamp. First, a cut is placed into the [[foreskin]], then the metal bell is placed over the [[Glans penis|glans]]. After that, the bell, together with the [[foreskin]], is pulled through the opening in the base plate and hung into the lever. By fastening the screw the lever pulls the bell upwards, jamming the [[foreskin]] between bell and base plate. After several minutes of clamping, the [[skin]] is cut off with a scalpel along the upper side of the base plate and the clamp removed.
[[File:Circumpendium-6-2-2-plastibell.jpg|center|thumb|Plastibell method]]
[[File:Circumpendium-6-2-2-Smartclamp.jpg|center|thumb|Smartclamp]]
The Smartclamp and a couple of similar designs are one way clamps, representing a mixture of the [[Gomco]] and [[Plastibell]] methods. The [[Glans penis|glans]] is inserted into the plastic tube, the [[foreskin]] pulled over it. The base plate of the outer clamping mechanism is pushed over the [[foreskin]] and cocked shut, jamming the [[foreskin]] between the bulging lower rim of the tube and the lower base plate. The [[foreskin]] is now cut off along the upper side of the base plate. The entire clamping mechanism remains on the [[penis]], until it - — like the [[Plastibell]] - — falls off by itself after the clamped [[skin]] dies off in the following days.
All of these methods have in common that the [[foreskin]] has to be separated from the [[Glans penis|glans]] first. In case of the circumcision of a child, it is in most cases (see chart above) necessary to forcibly tear apart the [[synechia| balanopreputial membrane]], which fuses the [[foreskin]] to the [[Glans penis|glans]], either by violently retracting the [[foreskin]] or separating it by pushing a blunt instrument underneath the [[foreskin]], both of which can result in injuries and inflammations of the [[Glans penis|glans]].
{{SEEALSO}}
* [[Pain]]
* [[Trauma]]
{{REF}}
[[Category:Body modification]]
[[Category:Education]]
[[Category:Genital cutting]]
[[Category:Genital surgery]]
[[Category:Trauma]]
[[de:Beschneidungsmethoden]]