How One Company Aims to Help Circumcised Men Grow Their Foreskin Back
Like a salamander tail.
Image: Lia Kantrowitz
If someone has grown up male in the United States, odds are that he doesn't have a foreskin. Most Americans likely haven't given this much thought, and if they have, it's probably along the lines of "good, it's better this way."
But a growing number of men known as "intactivists" are expressing outrage about being circumcised—which they call an "unnecessary amputation"—before they were old enough to understand the implications of the procedure and consider providing consent.
As adults, short of undergoing a complex surgery that transplants scrotal tissue onto the penile shaft, or practicing a body mod technique called 'tugging' that can sometimes stretch the remaining foreskin tissue back over the head of the penis, these men have been left to wonder: "What would sex be like with a foreskin?"
Now, a company called Foregen purports to soon be able to help these men answer that question by using regenerative medicine to regrow their foreskins—much like a salamander can regrow a severed appendage.
"The premise behind Foregen is that if we are regenerating entire body parts from more complex body parts, why not apply this to the only body part that hundreds of millions of boys are missing," says Foregen spokesperson Eric Clopper.
Of the 660 million circumcised men worldwide, 115 million of them are American, making the United States the country with the most circumcised men, even outnumbering African and Middle Eastern countries, according to stats from the World Health Organization. In fact, the United States is the only developed country where male infant circumcision is the norm, rather than something done out of religious ceremony.
Today, national circumcision rates hover between 50–60 percent, but in the 1980s as many as 83 percent of infants were circumcised in the Midwest; in some places it was so common that physicians wouldn't even bother consulting new mothers on whether or not they want their infant sons circumcised, they'd just go ahead and do it.
Though circumcision has been steadily decreasing in the US, dropping about 10 percent over the past 35 years and hitting a regional low of 30 percent on the present day West Coast, rates are much higher than in European countries. There, only about 10 percent of boys are circumcised, and rates are as low as 1.6 percent in Denmark.
But what exactly are circumcised guys missing? Depending on who you ask, the answer ranges from "penile cancer" to "the best sex you and your partner have never had." It's hard to weigh the factors around this issue, as the science is wrought with bias and even deliberate interference, and sexual enjoyment is largely subjective. But after conducting extensive research on the topic, I've found the intactivists make a more compelling case.
Since the 1800s, proponents of circumcision in the US have pointed to health as the main reason parents should have their infants circumcised. Back then, circumcision was medically touted as a method of reducing a boy's urge to masturbate, which was believed by the Puritans of New England to be the cause of illnesses. There's a pretty clear medical consensus these days that this isn't the case, but the tradition lingered and foreskin became associated with a new host of ailments.
In December of 2014, the US Centers for Disease Control and Prevention released a draft endorsing infant male circumcision. This mirrors a 2012 statement by the American Academy of Pediatrics which links circumcision with the decreased transmission of HIV, STDs that can cause cancer, and urinary tract infections. However, both statements were called out by the international medical community by and large as lacking on a scientific and ethical basis.
When it comes to medical recommendations about circumcision, there is an undeniable cultural bias that is persistently reflected in the scientific literature. Most medical societies in developed nations—except for the American ones—agree that in environments where hygienic conditions allow men to wash themselves regularly, any health benefits circumcision might offer cease to outweigh the risks. "The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are questionable, weak, and likely to have little public health relevance in a Western context," states the critique of the AAP's stance on circumcision led by Danish epidemiologist Morten Frisch.
The European scientists did find that circumcision can result in reduced UTIs, but only by about 1 percent. They cite the AAP's own estimates of the risk of complications from circumcision to conclude that "1 case of UTI may be prevented at the cost of two cases of hemorrhage, infection, or, in rare instances, more severe outcomes or even death." A UTI is no picnic, but I'm sure it beats a penile hemorrhage.
Logic is often no match for religious zealots, or those on the other end of the spectrum: "circumfetishists."
This isn't a new stance either—scientists have been arguing against circumcision on the basis of health benefits since the 1970s. But logic is often no match for religious zealots who think masturbation is a sin, as well as those the other end of the spectrum—circumfetishists. Most egregiously, one Australian man named Brian Morris has been plaguing circumcision-related research for the past decade, lying about his scientific credentials and publications, submitting criticisms of circumcision research in which he disproportionately cites himself, and "issuing misstatements faster than they can be checked and refuted." I can't speak to his motivation for doing this, but one circumcision watchdog site observed him linking to circumcision erotica.
Aside from the scientific debate, there is a parallel ethical debate which revolves around the issue of consent. Even if medical science could irrefutably prove health benefits from circumcision, many intactivists contend that performing a preventative surgery on a child is unethical; the decision to circumcise should only be made for children in medical emergencies, or voluntarily by adults such as is the case with cosmetic surgery and other body modifications. This view rubs up against religious views that circumcision is necessary to protect children from their sexual impulses, which could distract them from God.
"I think that children should be protected from having their genitals modified because they don't understand what's at stake," says Brian Earp, an ethics researcher at the University of Oxford. "In general we should consider legal adults competent to modify their own bodies." He raised the point that removing the breast buds of infant girls could prevent breast cancer, but nobody would seriously recommend doing that in a medical setting.
Earp says he became interested in the ethics of circumcision after the city of San Franciscio considered banning infant circumcision in 2011, and more so in 2012 when a local court in Germany ruled that child circumcision was illegal, even with parental consent, after a botched circumcision involving a four-year old Muslim boy. "While the court held that religious circumcisions in fact are to be deemed illegal because they violate the child's right to physical integrity and self-determination, it differentiated such acts from instances when a circumcision is medically necessary," the ruling reads. Similar legal measures have been considered in Finland, Denmark, and Sweden.
Religious dictates aside, the main ethical consideration parents use to have their baby boys circumcised in the US is the pop cultural belief that in doing so they are somehow protecting their kids from future locker room harassment. But studies show this isn't actually a problem—if guys are going to have their penises made fun of for any reason, it will probably be the size, not whether or not they're circumcised.
But locker rooms are one thing—what about the room where it really matters: the bedroom?
Think about what a foreskin does, biologically: In a non-erect penis, the foreskin covers the shaft completely, hanging over the tip and making it effectively an internal organ. When its gets hard, the foreskin secretes lubrication that allows the skin to slide back and forth against the shaft. When it gets really hard, the top part of the foreskin flips inside out, exposing a really sensitive part called the frenulum and the head of the penis, which is almost always otherwise covered. Some liken the function of a foreskin to that of a lip or an eyelid, as it protects the mucosal membrane beneath.
Circumcision removes about 15 square inches of skin containing about 20,000 nerves (as an adult), makes the penis an external organ with the head constantly exposed, disables the frenulum, the lubricating function, and its gliding mobility, and even dulls the color of the penis—and that's if the procedure goes well.
"Overwhelmingly, men who have foreskins like them and want to retain them, whereas men who have never had a foreskin assume it's useless," Earp says.
Largely absent from the scientific and medical literature is research on the sexual benefits of foreskin for men; there's almost a complete void when it comes to how male circumcision impacts sex from a female partner's perspective. A 2015 paper by Jacobs and Arora claims that foreskin has basically no effect on sexuality, but it cites likely biased sources connected with Brian Morris, and, as Earp points out in a critique published in the American Journal of Bioethics, the research they cite relies mainly on a pair of clinical trials that were carried out—not on infants—but on adult men who were voluntarily circumcised.
But even absent a basis for comparison or any compelling research, intactivists contend that the loss is dire.
"The effects of adult circumcision, whatever they are, cannot be simply mapped on to neonates," Earp says.
Likewise, the big question for the folks over at Foregen is if they can map the function of adult foreskin back onto someone who was circumcised as a neonate.
Clopper, whose friends call him "foreskin guy," has been a vocal intactivist ever since his college rugby team went to Scotland. "We'd get really drunk and naked and do really stupid things. Not gay things, just weird things," Clopper says, which was when he noticed that his Irish counterparts weren't circumcised, prompting a debate over which penile format was better."I said, 'I think being circumcised is better so I'll do my own research.' Now that I know that having the entire penis is better, it seems insane that I felt otherwise," Clopper says. Ever since his initial foray into circumcision research, he's connected with several other men who also feel they have been robbed of one of nature's coolest biological functions, and are pissed about it. "It's really a brainwashing," he says. "Once they realize what they lose—and the internet's a huge help—that's where the outrage comes from."
The biomedical technologies that would enable a procedure like this to be conducted safely are still theoretical at best, but Foregen founder Vincenzo Aiello of Rome, Italy, says he plans to have a procedure patented and cleared for clinical trials within five years.
"The peripheral nervous system can regenerate. The only obstacle to getting this to work is getting the new nerve endings to connect to the severed ones," Clopper says. "We are able to graft entire limbs to amputees right now. We're doing the same thing using the same exact technology but on a smaller scale with a bigger market."
"Now that I know that having the entire penis is better, it seems insane that I felt otherwise."
The process Clopper described would involve taking a donor foreskin and decellularizing it, or 3-D printing a new cellular skeleton, then "reseeding the decellularized matrix" with stem cells matched to the recipient. "They'll pick up on the cellular signals and grow into the full tissue," Clopper says. They completed their first animal experiment in December of 2013 at the University of Bologna's School of Veterinary Medicine in Italy. "Foreskin has proved exceptionally fruitful as a regenerative agent, making the likelihood of real foreskin regeneration in vivo, on a living male, all the better," the website claims.
Though the science may be theoretically possible, it's definitely not there yet. Perhaps the greatest challenge, even beyond the theoretical stem cell science, is the piece that involves grafting or regenerating peripheral nerves; nobody can do that yet, and the first people to figure it out probably won't use it for foreskin.
When I asked Aiello about the exact details of the procedure, he said he couldn't tell me because he wanted to protect his future patent, but I got the feeling that he still had some conceptual track to lay. After all, Aiello is a mosaic artist, not a scientist. That said, plenty of startup founders know nothing about the technology that powers their products when they go into VC meetings. Currently, he is working on a sculpture project that he described as an anatomical depiction of the adult foreskin, which he expects to be highly controversial.
The Foregen team admits that "the main obstacle in achieving foreskin regeneration is aligning the overwhelming demand for a cure for circumcision with the correct scientific personnel." Aiello told me the biomedical researchers who have agreed to work with Foregen so far have done so on the condition that he doesn't name them. "I think they are a little bit scared for many reasons. They don't want to be remembered in history for regenerating the foreskin. It's basically a taboo."
Aiello estimates that Foregen, a nonprofit registered in the US and Italy, has raised about $100,000 to date from private donors, mainly Americans, and intends to crowdfund the rest. But this is a negligible amount compared to what will be needed to set up a clinic if and when the procedure makes it through clinical trials. "We'd like to do everything in four years, but we don't know if this will be possible because the bureaucracy makes the entire process very slow," he says.
Regardless of whether or not Foregen meets their quotas, the main variable that will impact the prevalence of infant circumcision in the United States and beyond in coming years is the culture. If present trends are any indication, that culture is shifting in favor of foreskins. What's needed now to confirm that this is indeed the most beneficial path—health-wise, ethically, and sexually—is unbiased research collected to this end that could formally influence the recommendations of respected medical bodies and perhaps even local law.
When I asked Earp how to achieve this, he shrugged. "It would be great if there was some dispassionate researcher somewhere who was just curious about the effects of circumcision."
Correction: This post was updated to clarify how often Brian Morris's research criticism cites his own work, changing "mostly" to "disproportionately." The post was also updated to clarify that the city of San Francisco considered, not proposed, a 2011 proposal for a circumcision ban.