Circumcision and Socio-Sexual Aspects
Erectile function is a complex process in which the foreskin plays no important role [Lue, 1998]. Control of penile erection resides in the hypothalamus, cerebral cortex and spinal cord. Erection is a neurovascular event involving sensory, motor and autonomic nerves, neurotransmitters, penile cavernosal structures and penile blood circulation and hormones. Just as the rest of the penis, the foreskin contains sensory nerve endings, but the foreskin is not needed for arousal [Lue, 1998; Schoen, 2007e]. There is no evidence that the extra complement of nerve endings owing to the presence of a foreskin has any effect on sexual pleasure. Nor is there any evidence for speculative nonsense as to whether circumcision deletes afferent projections to particular neurones in the brain. In fact the scientific research evidence does not support such speculation.
The Badger study in Australia:
As far as attitudes and sexual behaviour are concerned, perhaps the first, albeit small and restricted, but interesting survey of circumcised versus uncircumcised men and their partners was conducted by University of Sydney biomedical scientist James Badger [Badger, 1989b; Badger, 1989a] (who used to regard himself as neutral on the issue of circumcision, but would now appear swayed by the evidence into adopting a ‘pro’ stance, not surprisingly for any scientist who follows the research findings). His study involved responses to a questionnaire placed in clinics of the Family Planning Association in Sydney. This led to 180 participants (79 male, 101 female) who were aged 15-60. The women were mainly (50%) in the 20-30 year-old age group cf. 25% of the men, more of whom (33%) were aged 30-40. It found that:
• 18% of uncircumcised males underwent circumcision later in life anyway.
• 21% of uncircumcised men who didn't, nevertheless wished they were circumcised. (There were also almost as many men who wished they hadn't been circumcised and it could be that at least some men of either category may have been seeking a scapegoat for their sexual or other problems. In addition, this would no doubt be yet another thing children could "blame" their parents for, whatever the decision was when their child was born.)
• No difference in sexual performance.
• Slightly higher sexual activity in circumcised men.
• No difference in frequency of sexual intercourse for older uncircumcised vs. circumcised men.
• Men who were circumcised as adults were very pleased with the result. The local pain when they awoke from the anesthetic was quickly relieved by pain killers (needed only for one day), and all had returned to normal sexual relations within 2 weeks, with no decrease in sensitivity of the penis and claims of "better sex". (Badger's findings are, moreover, consistent with every discussion the author has ever had with men circumcised as adults, as well as an enormous number of email messages received from many such men. The only cases to the contrary were a testimonial in a letter sent to the author from a member of UNCIRC and a very brief email message that didn't say why.)
• Women with circumcised lovers were more likely to reach a simultaneous climax - 29% vs. 17% of the study population grouped across the orgasmic spectrum of boxes for ticking labeled "together", "man first", "man after" and "never come"; some ticked more than one box. (Could the superior response involve psychological factors? ... Could it be that more circumcised men have a better technique? ... Or could other factors be involved?)
• Women who failed to reach an orgasm were 3 times more likely to have an uncircumcised lover. (These data could, however, possibly reflect behaviors of uncircumcised males that might belong to lower socio-economic classes and/or ethnic groups whose attitudes concerning sex and women may differ from the better-educated groups in whom circumcision is more common.)
• A circumcised penis was favoured by women for appearance and hygiene. (Furthermore, some women were nauseated by the smell of the uncircumcised penis, where, as mentioned in another section earlier, bacteria and other micro-organisms proliferate under the foreskin.)
• An uncircumcised penis was found by women to be easier to elicit orgasm by hand.
• An circumcised penis was favoured by women for oral sex (fellatio).
A survey of 5,000 men aged 16-49 (78% circumcised, 19% not, 3% "don't know") was subsequently conducted by Badger. This was open to all, and so included men who were anti-circumcision activists and those who were not. Circumcision had been performed at birth in 72%, before puberty in 12% and after puberty in 16%. Of those who said someone else decided for them to be circumcised, only 16% said they were unhappy to be circumcised; 46% were happy and 38% didn't care. Overall only 11% said they would not circumcise any son(s).
These findings are consistent with later studies.
The US National Health and Social Life Survey:
As far as performance during sex is concerned, the National Health and Social Life Survey (NHSLS) of 1,410 men in the USA found that uncircumcised men were more likely to experience sexual dysfunctions [Laumann et al., 1997]. This was slight at younger ages, but became quite significant later in life and included finding it twice as difficult to achieve or maintain an erection. It was also discovered that circumcised men engaged in a more elaborate set of sexual practices, i.e., enjoyed a more elaborate sexual lifestyle, and their female partners were more pleased with the esthetics of a circumcised penis over an uncircumcised one. Not surprisingly, in view of the findings above, circumcised men received more fellatio. However, they also masturbated more, a finding that contradicts the purported wisdom in Victorian times that circumcision would reduce the urge to masturbate. (In fact, as described in detail, with references, earlier, this is largely a myth, having little common currency at the time [Morris et al., 2006a]). Of course, circumcision would have prevented smegma and itching, so stopping males scratching their genitalia, a behavior that would have offended polite Victorian sensitivities.)
As noted in other studies, circumcision rates were greatest among whites and those who were better educated, reflecting their exposure to and ability to evaluate and respond to scientific information about circumcision [Laumann et al., 1997]. There was little difference between different Christian religious groups. The study also noted that the men’s female partners found the circumcised penis to have greater esthetic appeal.
Australian survey of men:
A telephone-based survey of 10,000 men in Australia found circumcised men had fewer sexual difficulties for a month or more in the previous year [Richters et al., 2006]. This was greatest in men over 50, in whom 27% of uncircumcised, but only 15% of circumcised, men reported difficulty keeping an erection [Richters et al., 2006]. Physical pain during intercourse was also less common among circumcised men. (This contradicts part of the anti-circumcision mantra that claims the penis is an 'internal organ' [!] and the "lubrication" [?!] under the foreskin produces a gliding action during penetration. It is always good to compare such claims with scientific research findings, which, like most other claims of the anti-circumcision movement, are not supported, in fact here contradicted, by the evidence.) The Australian study observed no difference in premature ejaculation, nor masturbation. The circumcised men had significantly more liberal sexual attitudes, just as found above in the US study. Although this study, unlike the one in the USA, found uncircumcised men received as much fellatio as the circumcised, this finding did not indicate what type of penis women preferred. This presents an opportunity for further research in Australia such as conducted in the US and described in the next paragraph.
Australian survey of parents:
A survey in 2007 of parents who were having their sons circumcised in a circumcision clinic in Melbourne found that the most common perceived benefit was hygiene (96%) [Xu & Goldman, 2008]. Other reasons were family tradition (57%), medical benefit (36%) and esthetics, with 14% believing it improved sexual performance/enjoyment as an adult and looked better to women. The most common concern was pain (79%), apparently not realizing that circumcision can be completely pain-free when the Russell method is used (see section “the procedure itself”). Many parents (41%) thought more information should be made available to parents prior to the birth so as to help in decision-making. Those who had earlier sons circumcised were more likely to get subsequent sons circumcised earlier (P = 0.02).
A US survey of new mothers:
In a survey of new mothers in the USA, hygiene and appearance were the two major reasons for choosing to have their newborn son circumcised [Williamson & Williamson, 1988]. There was a strong correlation between their son's circumcision status and the woman's ideal male partner's circumcision status for intercourse. Thus by being circumcised they thought that their sons would likewise be more attractive to a future sexual partner (with the implication that they would be at an advantage in passing on their, and therefore the mother's, genes to the subsequent generation). Their own preference thus affected their choice for their sons.
In this US study, 92% said the circumcised penis was cleaner, 90% said it looked "sexier", 85% it felt nicer to touch and 55% smelled more pleasant. Even women who had only ever had uncircumcised partners preferred the look of the circumcised penis. Only 2% preferred an uncircumcised penis for fel1atio, with 82% preferring the circumcised variety. Preference for intercourse for circumcised versus uncircumcised was 71% versus 6%, respectively; manual stimulation, 75% versus 5%; visual appeal, 76% versus 4%.
What then is sexier about a circumcised penis? Quite likely it is that the glans is exposed in both the erect and un-erect state.
Canadian survey of mothers:
In Canada the reasons mothers gave for getting their infant boys circumcised were health or hygiene 44.4%, to be like their father, siblings or peers 35.6%, religion 17.3% and other reasons 2.7% [Canada, 2009]. Calculations by Jake Waskett in Manchester, UK, found that by analysing the data in this survey there is a strong, significant (P = 0.013) positive correlation between the mother saying she received enough information about circumcision and the circumcision rates.
In Korea circumcision occurs at age 12. It is regarded as a "rite of passage" into adulthood and it is believed that it enhances sexual function [Oh et al., 2004]. Most (73%) Korean males aged 10-59 think circumcision is necessary, with only 7% believing it is not [Oh et al., 2004]. For parents 91% considered circumcision necessary, with only 2% considering it unnecessary [Oh et al., 2002]. Improved penile hygiene was the principal reason in 78% of men [Oh et al., 2004], 82% of parents [Oh et al., 2002], and 63% of men [Oh et al., 2004], and 81% of parents [Oh et al., 2002] thought circumcision would prevent genital infection of the sexual partner. Mothers were most in favor, as were parents of higher socio-economic status [Oh et al., 2002]. Males also considered that circumcision improved erectile function, prevented premature ejaculation, and enhanced growth of the penis [Oh et al., 2004].
A review of 13 studies of acceptability of male circumcision in populations that do not traditionally circumcise in 9 sub-Saharan countries indicated a mean acceptability of 65% among men, 69% among women (for their male partner(s)), with 71% of men and 81% of women being in favor of circumcision for their male children [Westercamp & Bailey, 2007]. The data were quite consistent across population groups. In Botswana infancy was preferred as the best time, while in most other countries age 8-16 was preferred [Westercamp & Bailey, 2007]. Similarly, a study in rural Tanzania of 5,354 schoolboys (mean age 15) found that despite its low prevalence, attitudes to male circumcision were positive [Weiss et al., 2008b]. Interestingly, inconsistencies were noted between self-report and clinical examination of circumcision status in this study. In Botswana, 92% of mothers of newborn baby boys said they would have their boys circumcised if the procedure was made available in a clinical setting [Plank et al., 2009]. The main reason was to prevent future HIV infection. 85% said that the boy's father must participate in the decision.
The gold standard in epidemiology is the randomized controlled trial. Two of these have now been published.
One, in Uganda, involved 4,456 sexually-experienced men aged 15-49. It found no difference in sexual satisfaction or clinically significant function between the 2,210 randomized to receive circumcision and the 2,246 who remained uncircumcised over the 2 years of the trial [Kigozi et al., 2008]. At 6 months, difficulty with penetration was seen in 1.4% of circumcised men and 0.6% of uncircumcised men, pain on intercourse 0.6% of circumcised and 1.2% of uncircumcised men. At 12 months and 24 months these were all identical between each group. Sexual satisfaction in circumcised men was 98.5% at enrolment and 98.4% at 2 years, and in uncircumcised men was 98.0% and 99.4% in at these times.
The other, in Kenya, involving 2,784 men, found a similar decrease in sexual dysfunction in both the circumcised and uncircumcised groups (from 23.6% and 25.9%, respectively, at baseline, to 6.2% and 5.8%) two years later, no doubt due to increased sexual experience over this period for these young (18-24 year-old) men, as well as the general counselling they received as part of the study [Krieger et al., 2008]. The baseline rate of sexual dysfunction was, moreover, almost identical to that reported in the British National Survey of Sexual Attitudes and Lifestyles (NATSAL) of 24% [Mercer et al., 2005], and similar to that of studies in the USA [Laumann et al., 1999] and globally [Nicolosi et al., 2004]. At the 24 month time-point of the trial, 64.0% of the circumcised men reported that their penis was "much more sensitive" and 54.5% rated their ease of reaching orgasm as "much more". These findings flatly contradict claims by the anti-circumcision movement that circumcision decreases sensitivity and sexual experience. In the trial, more than 99% of men were "satisfied" with their circumcision and the rate of this increased with time. A large and increasing proportion of the men reported having sex more often compared to before they were circumcised. Risky behavior was decreased in the circumcised men and they found it easier to apply a condom. Although penile sensitivity was increased, this was not associated with premature ejaculation.
In Africa, women preferred men who were circumcised because they considered they were at less risk of STI [Nnko et al., 2001]. The foreskin was also regarded as a source of a bad smell and men too thought it was cleaner to be circumcised. Increased sexual pleasure to both partners was also stated [Nnko et al., 2001]. For example, women from tribes that do not practice circumcision report deriving greater sexual pleasure from circumcised men [Moses et al., 1998]. Female preference is for the circumcised penis in partner(s) and son(s) [Bailey et al., 2002; Kebaabetswe et al., 2003; Lagarde et al., 2003; Scott et al., 2005] and after information this increased to ~90% [Kebaabetswe et al., 2003]. Most men, including those who were uncircumcised, preferred circumcision [Kebaabetswe et al., 2003; Lagarde et al., 2003; Rain-Taljaard et al., 2003; Mattson et al., 2005; Scott et al., 2005]. Men who preferred to remain uncircumcised were concerned about pain and cost rather than losing their foreskin [Mattson et al., 2005].
A randomized controlled trial, involving 455 women aged 15-49 years, of the effect of male circumcision on female sexual satisfaction found that the overwhelming majority (97%) reported either no change (57%) or improved (40%) sexual satisfaction after their male partners had been circumcised [Kigozi et al., 2009a]. The authors concluded that male circumcision has no deleterious effect on female sexual satisfaction.
Young adults stated that circumcision reduces friction during sexual intercourse, enhances the sexual pleasure of both partners, and likened the presence of a foreskin to wearing a condom in that it reduced sensitivity [Kebaabetswe et al., 2003].
Circumcision is rare in the Dominican Republic. Amongst men aged 18 to 50 years acceptability, although initially only 29%, increased to 67% for themselves and 74% for their sons once they had attended an information session that explained the benefits [Brito et al., 2009]. The main reasons were finding out that circumcision improves hygiene and did not decrease sexual pleasure. Younger men (aged under 30) were more likely to accept circumcision.
Chinese survey of men:
China has a low rate of circumcision, there being an absence of any history of circumcision amongst the majority Han population. A study published in 2009 reported that the circumcision rate was 19.9% amongst men aged 16 to 68 (mean 32 years), being higher amongst Muslims, whose minority population numbers 20 million [Sullivan et al., 2009]. The acceptability of circumcision amongst Chinese men is, moreover, lower than amongst African men, with only 39.1% of 530 uncircumcised men willing to get circumcised to protect themselves from infection and 45.5% willing to consider it to protect their partner [Sullivan et al., 2009]. Among Chinese MSM, however, there is a movement towards wanting to be circumcised [Sullivan et al., 2009].
Indian survey of mothers:
A survey of women in Mysore, of whom 78% were Hindus (who traditionally do not embrace circumcision), 18% were Muslims (who do), and 4% were Christians, found that after they were informed about the risks and benefits of male circumcision, 81% said they would definitely have their boy(s) circumcised if the procedure were offered in a safe hospital setting, free of charge, and 7% said they would probably get it done, with only 1% saying they would not have their boy(s) circumcised [Madhivanan et al., 2008]. Thus circumcision was highly acceptable amongst this broad range of mothers in India.
Of 116 parents of Pacific Islander boys aged 8-18, 89% felt that circumcision should be performed, mainly for reasons of hygiene and culture [Afsari et al., 2002]. The age at which most Pacific Islander males are circumcised is between 6 and 10 years of age.
Thus research has demonstrated consistent high rates of satisfaction in men after circumcision. After becoming informed the willingness of uncircumcised men to get circumcised, as well as of parents to have their male children circumcised is high.
Many surveys have been carried out by women's and men's magazines over the years, and all report a preference by women for a man with a circumcised penis. One in Sydney by the magazine Men's Health (July 2001 issue) found that only 16% of women preferred the uncircumcised penis, 46% preferred the circumcised, and 31% didn't care (6% had never seen an uncircumcised penis and 1% had not seen a circumcised penis). A preference for the "cut" penis was reported in a survey by a female columnist of her female friends [Murray, 2008]. Comments they made were that "uncircumcised penises look like alien life forms", that they look "like a woolly mammoth or something from the Stone Age", that "the foreskin just gets in the way, especially during fellatio", that "a cut penis gives both him and her more pleasure", that "for those with their tackle intact, they're likely to smell more", and that the old adage "cleanliness is next to godliness ? goes for sex-godliness."
Questionable ‘research’ by anti-circumcision activists:
A "preliminary" survey by lay anti-circumcision activists of women "recruited through ? an announcement in an anti-circumcision newsletter", not surprisingly, found the opposite [O'Hara & O'Hara, 1999]. The authors acknowledged this "shortcoming". They also state "this study has some obvious methodological flaws" and that "it is important that these findings be confirmed by a prospective study of a randomly selected population of women." Thus bias arising from the seriously flawed study design causes this particular study to lack credibility and it should be ignored. Moreover, others have obtained findings that are the complete opposite, e.g., in one study that found a preference by women for the circumcised man the respondents remarked that circumcised men enter the woman more easily and cause less trauma [Bailey et al., 2002].
Another flawed study was conducted in Korea. This examined masturbation, rather than a male's typical sexual expression, namely vaginal intercourse, and confused "sexuality" (in the title of the article) with "male sexual response" [Kim & Pang, 2007]. The various flaws, including poor study design, and the authors' statement that all men in Korea are circumcised, then giving a tally of circumcised men that exceeded the n value of the cohort, makes one wonder about the thinking of the authors, not to mention the source of the uncircumcised men! These serious errors and other deficiencies in their study has led to it being criticized severely [Willcourt, 2007].
Movies and television:
In the visual arts, for scenes involving the naked male it is quite plausible that American producers of erotic films and publishers of photographic works choose circumcised men, or at least uncircumcised men whose foreskin is smooth and free from loose, wrinkled skin, as the latter lacks visual appeal, especially to those who are not used to seeing an uncircumcised penis. Societal attitudes, at least in the USA, are reflected in the entertainment industry, such as TV shows.
With apologies for introducing anecdotal material, a few examples are nonetheless potentially illuminating.
For example, the character "Elaine", in an episode of the TV sitcom Seinfeld, set in New York, stated that "[the uncircumcised penis] looks like an alien!"
Similarly, in an episode of Sex in the City, also set in New York, one character recoiled in shock on seeing her new boyfriend was uncircumcised. It was clear that the quite sexually experienced 30-something women in this show were unused to the foreskin, describing it as resembling a Shar Pei (a dog breed with excessive rolls of skin). The new boyfriend's status had been bothering him anyway so he got circumcised, and liked his new look and improvement in sex so much he dumped the new girlfriend so he "could take the doggy for a walk", i.e., try it out on other women around town. The moral: "You can take the Shar Pei out of the penis, but you can't take the dog out of the man".
In the TV cartoon series 'South Park' the boys were alarmed to hear a new baby was going to be circumcised, thinking the penis was going to be cut off. Later when told it made the penis bigger they all wanted it. (Being set in America's heartland it is certain they already were circumcised (and didn't know what it was) - that is if one can apply this kind of rationale to cartoon characters!) These illustrations involve of course actors or characters who are following a script, and is therefore not scientific by any means, but do reflect thinking and behaviors in these US settings.
The hit TV series ‘House’ has also had some apt segments concerning the uncircumcised penis. One episode included a brief attendance at the clinic by a young Asian man who had decided to circumcised himself using box cutters ... obviously not to be advised!
In the 2009 movie Year One the Moses character wants every male to get circumcised, stating "It's a really sleek look" and "I think this is going to catch on".
The topic also comes up in the TV shows Ally McBeal, Married with Children, Absolutely Fabulous, the Meet the Fokkers movie, the Rugrats movie, and the Howard Stern radio show. In all cases the message about the circumcised penis is positive. In the Meet the Fokkers movie the foreskin, saved from the ritual circumcision ceremony of the now grown-up son, is accidentally dropped into the fondu during a dinner party. This would never happen in a Jewish family since it is the custom to bury the foreskin soon after the circumcision, not save it as a memento.
The topic also comes up in ‘Ally McBeal’, ‘Married with Children’, ‘Absolutely Fabulous’, the ‘Meet the Fokkers’ movie, the ‘Rugrats’ movie, and the Howard Stern radio show. In all cases the message about the circumcised penis is positive.
In a program on channel 4 in the U.K. on May 14, 2009, entitled Extreme Male Beauty the presenter decided to exhibit a variety of male organs, including his own, through an aperture in a screen, to a fairly large audience of young women, who were asked to comment on a number of aspects and then list preferences. Even though it was clear from the subsequent conversation that many of the girls had no experience of circumcision, at least 45% of the group expressed a preference for the circumcised penis, one girl waxing lyrical about the subject. And this in the U.K. - a country where circumcision is relatively uncommon, actively discouraged, and where news media coverage is usually of a negative nature.
For more on accounts of circumcision in popular culture see: http://www.circlist.com/preferences/circtv.html
Women’s preferences and sexual satisfaction:
As mentioned above, the gold standard of epidemiological evidence is the randomized controlled trial. One, involving 455 women, found that the overwhelming majority (97%) of women reported either no change (57%) or improved (40%) sexual satisfaction after their male partners had been circumcised [Kigozi et al., 2009a]. The authors concluded that male circumcision has no deleterious effect on female sexual satisfaction, and that it might, moreover, have social benefits in addition to the established health benefits. Speculation about any possible adverse effect on female sexual satisfaction was dispelled.
As also noted above, in Africa, women preferred men who were circumcised [Nnko et al., 2001; Westercamp & Bailey, 2007], one reason being because they considered they were at less risk of STI [Nnko et al., 2001]. The foreskin was also regarded as a source of a bad smell and men too thought it was cleaner. Increased sexual pleasure to both partners was also stated [Nnko et al., 2001]. For example, women from tribes that do not practice circumcision reported deriving greater sexual pleasure from circumcised men [Moses et al., 1998]. Female preference is for the circumcised penis in partner(s) and son(s) [Bailey et al., 2002; Kebaabetswe et al., 2003; Lagarde et al., 2003; Scott et al., 2005; Westercamp & Bailey, 2007] and, after information about benefits and risks was provided, this increased to ~90% [Kebaabetswe et al., 2003]. Most men, including those who were uncircumcised, preferred circumcision [Kebaabetswe et al., 2003; Lagarde et al., 2003; Rain-Taljaard et al., 2003; Mattson et al., 2005; Scott et al., 2005]. Men who preferred to remain uncircumcised were concerned about pain and cost rather than losing their foreskin [Mattson et al., 2005].
A study from Mysore in India found that most women (mainly Hindu) with uncircumcised sons would definitely have them circumcised if the procedure was offered safely and free of charge [Madhivanan et al., 2008].
A survey of women in Spain who had experienced sexual intercourse with the same partner before and 2 months after circumcision found no difference in general sexual satisfaction, pain during vaginal penetration, desire, and vaginal orgasm [Cortés-González et al., 2008]. A slight decrease in vaginal lubrication was, however, stated by some women (being adequate for 78% of women before, compared to 63% after their partner had been circumcised).
In Australia, as detailed above, the surveys by Badger are notable. They show that most women prefer the circumcised penis. And in the USA, as also mentioned above, a large majority of women preferred the circumcised penis for sexual activity [Williamson & Williamson, 1988]. In this survey, 90% said it looked "sexier", 85% it felt nicer to touch and 55% smelled more pleasant. Even women who had only ever had uncircumcised partners preferred the look of the circumcised penis. Only 2% preferred an uncircumcised penis for fellatio, with 82% preferring the circumcised variety. Preference for intercourse was 71% for the circumcised variety compared to only 6% for the uncircumcised, manual stimulation was 75% vs 5%, and visual appeal was 76% vs 4%.
Courtney Bee, a writer for the National Examiner in Los Angeles states, in a criticism of the withdrawal of Medicaid funding by 16 states in the USA, stated "Get it together Medicaid. Making the next generation of men into an army of wrinkled elephant trunks is no way to govern a nation. Our forefathers fought hard so that American men would have the sculpted penile curves of a Ferrari, and denying them that right is simply unconstitutional" (http://188.8.131.52/x-1961-Sexual-Health-Examiner~y2009m1d14-Health-plans-cut-circumcision).
A study in Sydney, Australia, of gay men found no differences between the circumcised and uncircumcised in participation in insertive or receptive anal intercourse, difficulty in using condoms, or sexual problems such as loss of libido [Mao et al., 2008]. Comparing those who had been circumcised in infancy with those circumcised later (because of phimosis or parental wishes), the latter were slightly more likely to practice receptive anal sex (88% vs 75%), to experience erectile difficulties (52% vs 47%), and were slightly less likely to practice insertive anal sex (15% vs 23%). Rather than this being due to circumcision perse, it was suggested that the differences reflected preferences that existed prior to circumcision, these having arising from foreskin pathologies such as phimosis.
Thus societal attitudes clearly favour the circumcised penis.