Foreskin restorers: insights into motivations, successes, challenges, and experiences with medical and mental health professionals – An abridged summary of key findings

Abstract

Demographically diverse surveys in the United States suggest that 5–10% of non-voluntarily circumcised American males wish that they had not been circumcised. Similar data are unavailable in other countries. An unknown proportion of circumcised males experience acute circumcision-related distress; some attempt to regain a sense of bodily integrity through non-surgical foreskin restoration. Their concerns are often ignored by health professionals. We conducted an in-depth investigation into foreskin restorers’ lived experiences. An online survey containing 49 qualitative and 10 demographic questions was developed to identify restorers’ motivations, successes, challenges, and experiences with health professionals. Targeted sampling was employed to reach this distinctive population. Invitations were disseminated to customers of commercial restoration devices, online restoration forums, device manufacturer websites, and via genital autonomy organizations. Over 2100 surveys were submitted by respondents from 60 countries. We report results from 1790 fully completed surveys. Adverse physical, sexual, emotional/psychological and self-esteem impacts attributed to circumcision had motivated participants to seek foreskin restoration. Most sought no professional help due to hopelessness, fear, or mistrust. Those who sought help encountered trivialization, dismissal, or ridicule. Most participants recommended restoration. Many professionals are unprepared to assist this population. Circumcision sufferers/foreskin restorers have largely been ill-served by medical and mental health professionals.

Full text

ARTICLE
Foreskin restorers: insights into motivations, successes,
challenges, and experiences with medical and mental health
professionals –An abridged summary of key findings
Tim Hammond
1
✉, Lauren M. Sardi
2
, William A. Jellison
2
, Ryan McAllister
1
, Ben Snyder
3
and Mohamed A. B. Fahmy
4
© The Author(s), under exclusive licence to Springer Nature Limited 2023
Demographically diverse surveys in the United States suggest that 10–15% of non-voluntarily circumcised American males wish
that they had not been circumcised [1,2]. Similar data are unavailable in other countries. An unknown proportion of
circumcised males experience acute circumcision-related distress; some attempt to regain a sense of bodily integrity through
non-surgical foreskin restoration. Their concerns are often ignored by health professionals. We conducted an in-depth
investigationintoforeskinrestorers’lived experiences. An online survey containing 49 qualitative and 10 demographic
questions was developed to identify restorers’motivations, successes, challenges, and experiences with health professionals.
Targeted sampling was employed to reach this distinctive population. Invitations were disseminated to customers of
commercial restoration devices, online restoration forums, device manufacturer websites, and via genital autonomy
organizations. Over 2100 surveys were submitted by respondents from 60 countries. We report results from 1790 fully
completed surveys. Adverse physical, sexual, emotional/psychological and self-esteem impacts attributed to circumcision had
motivated participants to seek foreskin restoration. Most sought no professional help due to hopelessness, fear, or mistrust.
Those who sought help encountered trivialization, dismissal, or ridicule. Most participants recommended restoration. Many
professionals are unprepared to assist this population. Circumcision sufferers/foreskin restorers have largely been ill-served by
medical and mental health professionals.
IJIR: Your Sexual Medicine Journal (2023) 35:309–322; https://doi.org/10.1038/s41443-023-00686-5
SURVEY HIGHLIGHTS
Q14: 25% of respondents were aware by age 12 of harms they
attributed to circumcision (6.5% by age 7).
Q15: 43% of respondents became aware of restoration after
stumbling across it on the internet.
Q16: 16% began restoration before the age of 19; 34% between
ages 20 and 29.
Q20: Length of time spent on restoration ranged from less than
6 months to more than 11 years.
Q25: Before starting restoration, 65% reported feelings of
circumcision-related dissatisfaction or distress.
Q27: 22% reported engaging in sexually compulsive behavior as
a coping mechanism for their sexual dissatisfaction and/or
emotional distress.
Q29: 69% of restorers reported that restoration increased their
sexual pleasure.
Q31: Most partners either supported (46%) or were neutral
(45%) about respondents’restoration efforts.
Q32: 25% reported that restoration improved their relationship
(mostly sexually) and <6% stated it had worsened their relation-
ship, with the majority saying it had no effect on the relationship
either way.
Q37: 67% said they would be “very interested”or “somewhat
interested”in restoration methods involving regenerative
medicine.
Q41: Only 13% of respondents sought help from a medical or
mental health professional.
Q42: 57% of those who sought no help believed the
professional would not be knowledgeable or supportive.
Q44: Of those who sought professional help, 25% reported
that the professionals were unsympathetic, dismissive or
ridiculing.
Q45: 69% believed professionals are insufficiently aware of or
compassionate toward circumcision sufferers/foreskin restorers;
64% believed professionals are unaware of foreskin anatomy or
circumcision harm.
Q47: 83% believed that medical and mental health profes-
sionals should receive special training on the issues of circumci-
sion distress and foreskin restoration.
Q48: 87% of restorers would recommend foreskin restoration to
others.
Q51: Over 60 birth countries were represented by respondents;
mostly from the US, Canada, the United Kingdom, Australia, and
Germany.
Received: 18 October 2022 Revised: 21 February 2023 Accepted: 27 February 2023
Published online: 30 March 2023
1
Independent Researcher, Your Sexual Medicine Journal https://www.nature.com/ijir/.
2
Quinnipiac University, Hamden, CT, USA.
3
Certified Sex Therapist, Minneapolis, MN, USA.
4
Al-Azhar University, Cairo, Egypt. ✉email: timemail50@gmail.com
www.nature.com/ijir
IJIR: Your Sexual Medicine Journal
1234567890();,:

Q55: Most respondents reported being born into Christian,
Jewish or Muslim families; however significantly fewer still
identified with those religions (Q56).
Q58: Restorers identified their sexual orientation as straight
(47%), gay (33%), bisexual (19.5%), and ~1.5% identified them-
selves as transgender women.
INTRODUCTION
Non-therapeutic (i.e., ritual, cultural) genital cutting of male and
female children (MGC, FGC) has been practiced by a range of
human societies since ancient times, often in parallel ceremonies,
servicing various functions including socio-functional (e.g., age-
group bonding, maintenance of intergenerational hierarchies),
religious/mythological, gender-normalizing, and (other) practical
and symbolic purposes [3,4] pp57 & 101, [5] p105].
In recent times, such non-therapeutic practices, typically carried
out on a non-voluntary basis on minors, have become partly
medicalized in some high-prevalence countries (e.g., FGC and
MGC in Malaysia, MGC in the United States), meaning that they are
practiced by health professionals despite divergence from the
canonical purpose of surgery: “diagnostic or therapeutic treatment
of conditions or disease processes”[6]. Wherever FGC is a
common practice, MGC is performed in the same communities,
but not vice versa (i.e., many communities practice only MGC). The
United States is one of a minority of countries globally with low-
prevalence FGC but high-prevalence MGC.
An estimated US annual incidence of in-hospital non-therapeu-
tic newborn penile circumcision is 1.2 to 1.3 million [7,8], with
religious ceremonies and private clinics likely increasing the
incidence to 1.5 million [9]. Consequently, from 1960 to 2010, 60
to 75 million childhood circumcisions likely occurred, plus an
unknown number of adult circumcisions. It is unknown what
percentage of those individuals experience circumcision distress
involving resentment (or regret, after adult circumcision). Con-
servatively, if even one-tenth of 1% of those are assumed to
experience circumcision distress sufficient to motivate them to
regain their bodily integrity, there could be 60,000 to 75,000 active
or potential/willing foreskin restorers currently in the US.
Prospectively, based on the same assumption, 12,000 to 15,000
males are born and circumcised each year who may develop
sufficient circumcision distress to pursue or be open to pursuing
foreskin restoration, a gentle but time-consuming non-surgical
method of skin expansion that approximates the functions of the
original prepuce (i.e., glans protection, gliding function through
tissue motility, lubrication and sexual pleasure).
According to a nationally representative Foregen/YouGov
survey, more than 5 million US men could be interested in
foreskin restoration if a quicker, less tedious restoration method
involving regenerative medicine became available [10].
The earliest circumcision reversal procedures occurred in the
Hellenistic period to assist either the circumcised, or those born
with deficientornoprepuce(aposthia), to cover their bared
glans to gain social respectability in Greek society [11]. Surgical
foreskin restoration attempts occurred in the 1960s through
1990s [12–14], however, no study has systematically evaluated
the efficacy of any reconstructive procedures [15]. A more
detailed history of foreskin restoration, including previous
studies of foreskin restorers, is available in the Unabridged
Supplement to this article (Sections “The Long Historical Search
for Wholeness”–“Prior Research on Restoration Motivations and
Results”).
Contemporary non-surgical foreskin restoration employs gentle
skin expansion to regrow remaining penile shaft skin forward over
the glans using commercial devices. For example, one consists of a
stainless steel weight that affixes to penile shaft skin, allowing
gravity to create tension, while another consists of a conical device
covering the glans that secures penile shaft skin between silicone
components (Fig. 1A–D).
A distinct subset of circumcised males has been identified that
experiences distress over their circumcised condition [16,17],
some of whom seek foreskin restoration. We aimed to survey this
population to understand participants’restoration motivations
and goals, communications with others, and their lived
experiences.
METHOD
An Institutional Review Board approved all research for data collection
(Protocol #04421, Quinnipiac University). Participants were provided an
informed consent page prior to starting the survey, noting that they were
free to stop any time, and that further participation implied on-going
consent.
To reach this geographically dispersed, distinctive population, we
employed targeted sampling methods. While this provides important
qualitative insights into a hard-to-reach understudied community, due to
non-random recruitment our results cannot be generalized beyond the
sample obtained (e.g., to all foreskin restorers or to circumcised males in
general).
In addition to asking commercial restoration device manufacturers to
email their past customers with a survey invitation and to post news of the
survey on their websites (e.g., American Bodycrafters/ForeskinRestoratio-
n.info, TLC Tugger.com), we posted news of the survey to online
restoration forums (e.g., Reddit.com/r/foreskinrestoration, r/Circumcision-
Grief), restoration support groups (e.g., National Organization of Restoring
Men, 15 Square), and genital autonomy organizations (e.g., Doctors
Opposing Circumcision, Intact America).
Participants
The survey, in English, Spanish, German, and French, launched 22
June 2021 and remained open for 100 days. 1790 fully completed and
331 partially completed surveys were submitted by participants from 60
countries. We report only results from the fully completed surveys.
Most respondents were born in the United States (n=1298, 72.51%),
Canada (n=107, 5.98%), the United Kingdom (n=87, 5.64%), Australia
(n=60, 3.35%), Germany (n=41, 2.29%), or France (n=26, 1.45%).
Ages ranged from 18 to 60+, with Christianity as the majority parental
religious affiliation (n=1322, 73.85%) and Agnostic/Atheist as
the majority current participant affiliation (n=512, 28.60%).
Most participants identified as White (n=1658, 92.63%) and as
Straight/Heterosexual (n=839, 46.87%), followed by Gay/Homosexual
(n=589, 32.91%) and Bisexual or Pansexual (n=350, 19.55%). Although
all participants were born with a penile phallus and almost all identified
as males/man, a very small minority identified as Transgender (n=27,
1.51%), Intersex (n=3, 0.17%), or Non-Binary/Fluid (n=75, 4.19%).
Complete demographic information is available in the Unabridged
Supplement (Sections “Participants”and “Demographics”).
Survey construction
An online survey tool was developed containing 49 qualitative questions
regarding motivations, successes, challenges, and experiences with
medical and mental health professionals. The survey also contained 10
demographic questions. Survey questions were generated from inquiries
used by the lead author in previous surveys, many of which were
motivated by decades of the lead author’s listening to the lived
experiences of circumcision sufferers and foreskin restorers in support
groups and online communities. All precisely worded questions are
presented in the Unabridged Supplement (Sections “Survey Questions”–“-
Research Question 3. What Were Restorers’Experiences with Medical/
Mental HealthProfessionals, or Why Didn’t They Reach Out?”). Participants
were also given an opportunity to upload up to five restoration progress
photos and were advised that by doing so they consented to the
possibility of the photos being used in published survey findings.
To help participants accurately identify and report adverse physical
impacts from MGC, images of intact penile anatomy and common
circumcision outcomes (Fig. 2a–e) were included.
To estimate how much glans coverage respondents had pre-restoration,
and the coverage they sought, respondents were directed to the Coverage
Index chart [18].
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To deepen our understanding of the various ways that unwanted
circumcision and the desire for foreskin restoration can impact one’ssexual
health, we utilized Dailey’sCircles of Sexuality (Supplementary Fig. S5). These
circles, which are explored in greater detail in the Discussion section, involve
the experiential spheres of sensuality, intimacy, sexual identity, sexual health
and reproduction, and sexualization. We acknowledge that, for some, the
experiences of circumcision and foreskin restoration are limited to one
sphere, but for many others, their experiences overlap multiple spheres in
complicated ways that are, as yet, not fully examined or understood.
RESULTS
1
Research question 1. What motivates people to seek/pursue
foreskin restoration?
To assess motivations for restoration, participants were first asked
if they experienced any sense of resentment for having been
circumcised without their consent as a child (Q6), to which 83.85%
responded in the affirmative. When asked if they experienced
regret (Q8), this question did not apply to the majority of
participants (94.64%), but of the remaining respondents who
freely chose to be circumcised as an adult (~6%), 80% of those
responded that they immediately regretted their decision and still
regret it.
Next, when asked about the severity of their circumcision (Q9)
using the Coverage Index chart, 37.93% of participants self-
reported a C-1 severe circumcision (e.g., no tissue mobility when
erect, causing skin tightness and/or pain); 55.64% disclosed a C-2
to C-3 moderate circumcision (e.g., enough loose tissue when
erect to only glide along the shaft but not the glans/head); and
6.42% reported a minimal C-4 circumcision (e.g., enough loose
tissue when erect to partially or completely pull over the glans/
head).
Participants were then asked about physical damage (Q10) and
sexual, emotional and self-esteem injuries (Q11–Q13). Fifteen
distinct types of physical harms were reported by participants
(Q10), which are detailed in Table 1and are given greater
meaning within the context of the Circles of Sexuality as described
in the “Discussion”section.
Participants were then asked their age at first awareness of
circumcision harm (Q14, Table 2) and source(s) of this first
awareness (Q15). The majority of respondents reported being
aware of circumcision harm between ages 13–19 (n=540,
30.17%), with some respondents who became aware between
ages 7–12 (n=331, 18.49%) and others who reported becom-
ing aware before age 7 (n=116, 6.48%). Notably, the majority
of participants (91.62%) first became aware of their harm from
various sources and were not influenced by the intactivist
movement (i.e., political activities and resources dedicated to
Fig. 1 Foreskin restoration devices. Row 1: APenile Uncircumcising Device/PUD; BProduct as worn Row 2: CTLC Tugger; DProduct as worn
with optional strap.
1
Note that any results totaling more than 100% are the result of
participants’ability to select more than one response for that
question, specifically regarding Q1, Q5, Q7, Q10-13, Q17, Q24, Q25,
Q27, Q33, Q34, Q40, Q42, Q45, Q57 and Q58.
T. Hammond et al.
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IJIR: Your Sexual Medicine Journal (2023) 35:309–322

opposing/ending medically unnecessary childhood genital
operations). Only 8.38% reported intactivism as a source of
awareness of their harm.
Motivations
The bulk of participants (69%) reported starting foreskin restora-
tion between ages 20 and 49–with a clear majority (34%) starting
in the 20–29 age range–while almost 15% started the process
after age 50, and almost 8% starting around age 18 or 19.
Surprisingly, almost 8% of respondents stated they began
restoring before age 18, with one participant admitting “I started
restoring in elementary school.”
Most participants’motivations for seeking restoration (Q17,
Table 3) were: increased glans sensitivity (79.83%); enhanced
sexual pleasure (78.16%); and protecting the glans from the outer
environment (74.97%).
Research question 2. What were/are their restoration
experiences and results?
Participants’restoration goals were queried (Q18). A precise
percentage breakdown for each type of coverage goal appears in
the Unabridged Supplement (Section “Personal Experience”,
Table S5), however, a deeper examination of the types of
coverage goals, and possible rationale for each, appears herein
under the “Discussion”section. For restoration stage at time of
survey (Q19), 76% reported their restoration was ongoing. One
participant submitted a photographic series documenting his
5-year progress from a CI-3 to CI-9+(Supplementary Fig. S4).
a) Frenulu
m
Left: Intact
(
adult circu
m
Right: Abla
t
during infa
n
b) Glans pe
Left: Moist,
(protected b
y
Right: Dry,
k
(unprotecte
d
c) Meatal s
t
Left: Intact
(Due to me
a
environmen
t
penis loses
p
post-circum
c
d) Tissue d
a
Left: Tight
e
(no skin mo
b
Right: Pro
m
e) Other an
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n
Center: Ski
n
Right: Devi
c
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(
preservable
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m
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t
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t circumcisi
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foreskin).
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u
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u
a
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t
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o
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rotective for
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ision at a yo
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.
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ans.
Fig. 2 Types of Circumcision Damage. a Frenulum (b) Glans penis (c) Meatal stenosis (d) Tissue damage (e) Other anomalies.
T. Hammond et al.
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Table 1. Physical, sexual, emotional/psychological, self-esteem damage attributed to circumcision motivating respondents to begin foreskin restoration (Q10–Q13).
Physical Sexual Emotional/Psychological Self-esteem
Response option Response
percent
Response option Response
percent
Response option Response
percent
Response option Response
percent
Dry, keratinized glans 72.74% insensitive glans 62.68% frustration 58.94% felt less whole 59.22%
Partial/total loss of foreskin 64.30% excess stimulation needed
to achieve orgasm
47.88% anger 51.28% felt inferior to those with an
intact foreskin
55.25%
Partial/total loss of frenulum 57.77% delayed orgasm (I can’t
come when I want to)
28.10% dissatisfaction/distress over my
condition
46.93% felt mutilated 49.55%
Pubic hair drawn onto shaft 49.55% none 21.34% human rights violated 45.87% felt damaged 47.21%
Scarring (prominent) 44.75% premature orgasm (I come
too quickly)
13.63% betrayal by doctor 37.99% felt abnormal/unnatural 40.45%
Scrotal webbing 44.36% scar is numb 9.83% betrayal by mother 36.76% ashamed/fearful to let others
(esp. partners) see my penis
25.25%
Skin tone variance 43.85% erectile dysfunction
(untreated)
9.11% betrayal by father 34.25% body eudysmorphia
(persistent concern about a
true defect in my genital
anatomy)
23.46%
No shaft skin mobility, or
tight, painful erections
40.89% scar is painful 6.20% body violated or raped 32.74% none 21.90%
Scarring (uneven) 29.89% erectile dysfunction
(treated with medication
or devices)
5.47% embarrassment 30.50% other 1.01%
Skin tag/s 24.19% circumcision scar bleeds
during sex
2.40% shame 28.77%
Shaft curvature (any
direction) when erect, not
due to recent injury
20.84% scar is too sensitive 2.35% none 20.61%
Meatal stenosis 18.38% Other 9.50% alexithymia (trouble identifying
or expressing feelings and/or
emotions)
16.31%
None 7.60% thoughts of revenge or doing
harm to my circumciser
15.31%
Skin bridge/s 5.75% suicidal thoughts 13.07%
Gouge/s on the glans 3.52% spiritual trauma 9.66%
Device injury to glans 1.79% thoughts of revenge or doing
harm to parent(s)/ guardian
who consented to my
circumcision
8.32%
Other 2.12% recurrent nightmares 6.59%
betrayal by religious
circumciser
2.79%
betrayal by tribal elders 0.84%
other 6.76%
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The 18.83% of respondents who abandoned restoration were
asked why (Q24), with top responses being: too much trouble/too
difficult (39.76%); didn’t reach desired result/abandoned hope
(24.33%); and lost patience (21.96%).
When asked about pre-restoration feelings (Q25), top responses
were: dissatisfaction/distress (65.47%), depression (33.46%),
and hopelessness (31.4%). When asked if restoration had
changed those feelings (Q26) 74.82% reported some easing or
elimination.
Among prior coping behaviors for distress (Q27) participants
cited smoking, alcohol/drug use, self-harm, compulsive eating, or
compulsive sexual behavior (i.e., increased number/frequency of
sexual encounters to compensate for poor quality sexual experi-
ences). The most common coping behavior was sexual compulsivity
(21.96%) with the next most prevalent being alcohol use (10.45%).
When asked about restoration’s effect on those behaviors (Q28)
almost two-thirds (61.55%) reported those behaviors were
decreased or eliminated entirely.
When asked about changes in penile sensation from restoration
(Q29) most (69.11%) reported increased pleasure.
Interest in regenerative medicine for foreskin restoration (Q37)
revealed 67% were either somewhat or very interested, especially
if economically feasible.
Research question 3. What were restorers’experiences with
medical/mental health professionals, or why didn’t they reach
out?
When asked if respondents knew other restorers (Q38) 32.29%
said yes and 67.71% said no.
When questioned about which non-professionals participants
had spoken with (Q40), respondents said: no one (30.39%); a
partner/significant other (49.66%); friend(s) (41.47%); family
(17.49%) and someone else (6.20%).
When asked about which professionals they had spoken with
(Q41), responses yielded: no one (86.76%); medical professional
(e.g., urologist, primary care physician, plastic surgeon) (8.99%);
mental health professional (e.g., psychologist, psychiatrist) (4.47%);
sexologist/sex therapist (1.01%); spiritual counselor (0.28%), or
someone else (0.39%).
Reasons for not speaking with professionals (Q42) included: felt
hopeless/didn’t think professionals would be knowledgeable or
supportive (56.95%), embarrassment (39%) or feared ridicule
(30.53%).
Gender of the professionals spoken with (Q43) was 62.02%
male. Participants noted the professionals’attitudes (Q44,
Table 4).
Top responses about obstacles to seeking professional help
(Q45) included: professionals insufficiently aware/compassionate
toward restorers (69.94%); professionals insufficiently aware/
compassionate toward MGC sufferers (69.39%); and professionals
insufficiently educated/knowledgeable about foreskin anatomy/
functions or about circumcision harm (64.41%).
When asked if professionals need to become familiar with
circumcision distress and foreskin restoration issues (Q46), 92.63%
responded affirmatively. When asked if professionals need special
training to work with foreskin restorers (Q47), 82.85% responded
yes. A majority would recommend restoration to others (Q48 &
Supplementary Table S6).
When asked about sexual orientation/gender identity (Q58),
participation by gay and bisexual men combined was 51.9%. A
very small proportion of respondents identified as transgender
women (1.45%) or intersex persons (0.17%).
DISCUSSION
Demographics
As noted in the “Methods”section, most respondents selected
their birth country (Q51) as the United States. This is unsurprising
since the US has the highest rate of non-therapeutic, non-religious
neonatal MGC [19], compared to the other Anglophone nations
previously mentioned that also share a history of MGC, which
began during the Victorian era (i.e., as part of anti-masturbation
campaigns [5].
As in previous surveys, the representation of gay and bisexual
men was significantly higher than in the general population.
The reason for this is uncertain. It is possible that gay and
bisexual men (i.e., men who have sex with men and thus for
whom male genital anatomy plays a distinctive role in sexual
attraction and experience) might be more attuned to questions
around bodily autonomy, including with respect to penile
anatomy, specifically, as well as voluntary vs. non-voluntary
Table 3. Motivations for seeking foreskin restoration (Q17).
Response option Response percent Response count
To enhance sexual pleasure 78.16% 1399
To increase glans/head sensitivity 79.83% 1429
To improve aesthetics or appearance 73.30% 1312
To hide circumcision scarring 32.63% 584
To protect the glans (penile head) from the outer environment 74.97% 1342
To resolve anger, resentment, or negative emotions over my circumcision 46.65% 835
To improve body image and/or increase self-esteem 63.46% 1136
To regain sense of control over my body 54.25% 971
Suggestion or recommendation by significant other, friend, relative 3.58% 64
Other (Please specify; 100 character limit) 3.97% 71
Table 2. Age at first awareness of circumcision harm (Q14).
Response option Response
percent
Response count
I don’t recall/not
applicable
5.53% 99
Before age 7 6.48% 116
7–12 18.49% 331
13–19 30.17% 540
20–29 23.85% 427
30–39 7.09% 127
40–49 4.64% 83
50–59 2.79% 50
After age 60 0.95% 17
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modifications thereof.
2
For example, gay/bisexual respondents
reported that awareness of adverse effects they experience from
MGC is heightened during sexual activity with circumcised or
intact partners, either of which can amplify feelings about their
own genital loss.
Some individuals who were assigned male at birth (i.e.,
transgender or intersex persons) may feel victimized by binary
gender-based normalizing surgery [21,22], which may be
compounded where MGC is culturally endemic.
Effects of non-therapeutic childhood penile circumcision on
transgender respondents may be illustrated with the following
sampling of comments:
“I’m trans, I need that flesh…”
“My surgeon used the restored tissue to create a sensate
clitoral hood”
“Yep, transgender woman restoring her dick, wild right?”
Attempts by the lead author to glean more information about
the transgender experience by contacting transgender activists
and professionals during the survey period and prior to
publication of this paper went unanswered. However, since
foreskin restoration can be beneficial to some transgender
women in helping to reach their goals for gender-affirming
surgery, further research across non-heterosexual and non-
binary identities or orientations is needed to understand
experiences of circumcision harm, dissatisfaction, distress, and
engagement with foreskin restoration in this distinctive
population (Supplementary Section “Transgender Women and
Intersex Persons”).
With respect to religion, current reported religious identity/
affiliation of participants was markedly lower than their
reported religion-of-rearing, especially among Jewish, Christian
and Muslim respondents (Supplementary Sections “Partici-
pants”and “Religious identification”). Participants frequently
cited the role of circumcision in these religions as a factor for
their abandonment of religion. Further research is merited into
the degree to which childhood circumcision may have any
lasting negative impact over time upon adult religious identity
or allegiance.
Research question 1. What motivates people to seek/pursue
foreskin restoration?
Circumcision of the newborn or young child (i.e., on a smaller
organ that has not fully developed) is a delicate procedure that
risks widely variable experiences of harm. The concept of harm is
understood differently in different disciplines and spheres of life.
Moreover, application of the concept varies from individual to
individual (i.e., what one person experiences or interprets as an
enhancement or a harm may not be recognized as such by
another). From a medico-legal perspective, however, it is notable
that bodily surgeries are considered harmful per se, such that they
can only be justified, if not by one’s own consent, then by
circumstances of medical necessity (i.e., necessary to avoid an
even greater harm). As a result of litigation brought by an
individual who was subjected to successful but needless nasal-
sinus surgery, a California court ruled that “Even if a surgery is
executed flawlessly, if the surgery were unnecessary, the surgery
in and of itself constitutes harm”[23]. In addition to this legally
recognized intrinsic harm, non-therapeutic child circumcision also
risks contingent harm, for example via surgical complications. Due
to inadequate data, however, the American Academy of Pediatrics
(AAP) has twice acknowledged that the precise risk and full extent
of such complications are not known [24] p 390, [25] p e772]
3
.
Because the inner foreskin firmly adheres to the penile glans at
birth, and only separates slowly with maturity (Box 1), neonatal
MGC disrupts this developmental process by prematurely and
traumatically separating these structures, resulting in further
variation in outcome and injury (Box 2).
Physical damage–in addition to the destruction of the prepuce
itself–can include excessive skin removal causing tight, painful
erections; meatal stenosis [30]; prominent or irregular scarring;
numb, hypersensitive, or painful scars; unsightly scar pigmenta-
tion; unaesthetic and/or painful skin bridges; gouges in and/or
toughening of the penile glans; and an array of other issues
[31–33].
Physical harms (Q10, Table 1). As mentioned in the “Results”
section, almost 20% of participants reported meatal stenosis.
Previous studies have estimated that the rate of meatal stenosis,
due to exposure of the urethral meatus through removal of its
protective preputial covering, occurs in 5–20% of neonatally
circumcised males [30,34,35], and is a permanent condition
Table 4. Attitudes toward foreskin restorers among medical or mental
health professionals from whom help was sought (Q44).
Response option Response
percent
Response count
Sympathetic or helpful 33.65% 70
Neutral or nonjudgmental 29.33% 61
Unsympathetic, dismissive,
ridiculing, unhelpful
25.00% 52
Attitudes varied because I
went to more than one
professional
12.02% 25
2
A peer reviewer has asked us to elaborate, and we do so briefly here.
While heterosexual males may be visually familiar with penile
aesthetics through partially-mediated experiences (e.g., watching
pornography; seeing male genitalia in changing rooms at some
distance), gay/bi men likely have broader and/or less-mediated
experiences with circumcised and intact penises in the context of
intimate interpersonal encounters, allowing for multi-modal
comparisons (i.e., via sight, touch, smell, taste and even sound). In
addition, concerns around bodily autonomy may be of heightened
significance for gay/bi men in relation to such matters as what may be
done to one’s body–vis-à-vis threats of medical or psychological
“conversion therapies”, arrest or imprisonment under sodomy laws,
hate-motivated violence, and so on. As such, long-standing
LGBTQ +concepts of body ownership and bodily autonomy may
foster a deeper awareness, understanding, and/or sensitivity to issues
that lie at the intersection of sexuality and human rights [20]. For
further analysis, see Unabridged Supplementary Section “Gay/
Bisexual men”.
3
Although numerous immediate and short-term complications have
been documented [26,27], there is no universally accepted definition
among professionals of what constitutes a circumcision
“complication”, especially in the un(der)-investigated long-term.
Nevertheless, a systematic review concluded that neonatal penile
circumcision complications are likely more common than is typically
surmised [28]. Many complications are never recorded because they
become evident only as the penis develops. An analysis of
medicalized MGC found a complication rate of 4% and that adult
complications are not greater than infant complications [29].
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unless remedied through surgery. Participant comments about
physical harm included:
“Didn’t know why mine was different colors and had a
bad scar”
“Extreme pain with every erection”
“Pain and bleeding during sex”
Physical harms can adversely affect sexual experiences and self-
esteem, leading to emotional issues and ultimately mental health
and quality of life challenges.
Sexual, emotional/psychological harms and effects on self-esteem
(Q11–Q13, Table 1)
Circumcision and the five circles of sexuality: Circles of Sexuality
[36] and Supplementary Fig. S5] is a well-established theoretical
construct of multiple overlapping facets of human sexuality used
by sexuality researchers, educators, and therapists.
Most respondents reported multiple undesired effects from
circumcision, which were often motives for restoration. One
respondent reported frustration from glans discomfort when it rubs
against garments. This can be understood not only in the sexual
health and reproduction circle, but also in the sensuality circle with its
effect on sensory experiences with his penis; the sexual identity circle
when considering his feelings of frustration toward his penis and how
it impacts his overall sense of gender; and the intimacy circle as we
consider impacts on his feelings and challenges of sharing his body
with partners. The sexualization circle may also apply, insofar as these
outcomes, relating to adult sexual life, are ultimately the result of a
non-consensual (and medically unnecessary) intervention performed
onhissexualorgansasachild.
First circle: sensuality. This involves internal physical, cognitive,
and emotional experiences with sexuality and experiences of
sexual response. Participants described how these disruptive
sensations directly impacted their experiences.
“Irritation and discomfort from meatus and urethra hole
rubbing against clothing”
“Orgasm is a bodily function. It’s not supposed to be very
difficult to do. The less satisfying it is, the more you seek that
satisfaction. It’s not supposed to be an exercise in frustration”
“I was careless to be rough with my penis because I had to be
rough to feel pleasure”
Others identified struggles with masturbation, needing exces-
sive lubricant and feeling decreased pleasure. Still others
described painful sensations accompanying erection from tigh-
tened shaft skin, painful tearing, and bleeding.
In relation to FGC, it has been theorized that cutting of the vulva
causes neural network reorganization which then modifies
sensory perception [37]. Analogously, it has been proposed that
MGC results in changes within a male’s somatosensory cortex
[38,39]. In both cases, the brain and spinal cord likely respond to
genital cutting as they would to any loss of neural targets or
inputs: by rearranging neural networks which, in turn, affect neural
signaling to target structures and modify sensory perception. This
can help us better understand how genital cutting may modify
sexual sensation or experience in persons with different sets of sex
characteristics. However, the role of gendered social attitudes (e.g.,
boys should be stoical, unfeeling; girls are delicate, emotional)
may inspire different responses to a child’s genital injury (i.e.,
female sexual deprivation is often viewed negatively, while male
sexual deprivation is often viewed as positive, harmless or
emphatically denied), which may in turn differently influence
individuals’sensation schema (i.e., what they pay attention to,
whether they notice certain bodily sensations, how they interpret
what they feel or are socially permitted to speak about, and so on)
[40–44].
Box 2. Tissue loss from circumcision
(for corresponding references see Unabridged Supplement)
In a cadaver study, the mean surface area of the prepuce when unfolded was
46.7 cm
2
[120]. A later study of excised tissue from newly circumcised men reported
the inner and outer adult penile preputial surface area ranged from 7.0 to 99.8 cm
2
[133]. A landmark study of the prepuce found that “[T]he mean length of prepuce…
covered 93% of the mean penile shaft”concluding that newborn circumcision often
removes “51% of the mean adult penile shaft”, typically ablating 1/3 to 1/2 or more
of the penile skin that “is more than most parents envisage from pre-operative
counseling.”[134].
Regardless of sex, the prepuce is “a specialized, junctional mucocutaneous tissue
which marks the boundary between mucosa and skin [similar to] the eyelids, labia
minora, anus, and lips …The unique innervation of the prepuce establishes its
function as an erogenous tissue”[76], making it essentially “the functional end”of
the penile skin [135]. “The penile prepuce has a highly organized, dense, afferent
innervation pattern that is manifest early in fetal development”[136]. Afferent
neurons, typically associated with specialized sensory receptors, are nerve fibers
responsible for bringing sensory information from the outside world into
the brain.
“Ridged bands”on the inner mucosal surface of the penile prepuce, the peaks of
which are rich in Meissner’s corpuscles [134], make that surface the most sensitive
part of the penis, both to light touch stimulation and sensations of warmth and
movement, while the ability of the penile prepuce to re-cover the glans during
sexual activity likely mediates excessive stimulation, thereby playing a valuable role
in controlling ejaculatory reflex [137–142]. Stimulation of the ridged bands is
virtually assured by interactions between the penile prepuce and the coronal ridge
of the penile glans [143], as well as by vaginal or rectal walls.
Regardless of sex or gender, genital cutting effects are highly individualistic.
While “it’s hard to study subjective sexual experiences using scientific instruments”
[144], the undeniable anatomical and physiological consequences of penile
circumcision will affect sexual experience to various degrees.
Box 1. Foreskin: form follows function
(for corresponding references see Unabridged Supplement)
All human and non-human primate species, regardless of sex, possess a genital
prepuce, an evolved structure that “is likely to be over 100 million years old”[76
p34]. Human penile and clitoral prepuces are undifferentiated in early fetal
development, emerging from a genital tubercle capable of penile or clitoral
development [77].
At birth, the inner penile foreskin is firmly adherent to the penile glans (head).
They separate slowly as the penis matures, sometime between birth and
adolescence [78–82]. Widespread medical ignorance of this normal developmental
process leads to over-diagnosis of phimosis and needless circumcisions [79, 83]
despite the existence of more cost-effective and tissue-sparing treatments
[84,85].
Functioning with other external genital structures, the human prepuce offers
integral coverage for the glans penis and clitoris, internalizing each and “decreasing
external irritation and contamination”[76]. The penile prepuce protects the urinary
opening from abrasion, which exits the penile, but not the clitoral glans [86].
Secretions from the inner mucosal prepuce offer immunological defense against
pathogens [76,87]. “Langerhans’cells (LCs) are a specialized subset of antigen-
presenting cells in the epidermis of the skin and mucosal tissues of the vagina and
foreskin. They provide a barrier against entry of pathogens, thereby protecting
against disease. …LCs are not efficiently infected with HIV-1 and do not transmit
virus to T cells”[88].
The penile prepuce “…is highly dynamic and biomechanically functions like a
roller bearing during intercourse, “unfolding”and gliding as abrasive friction is
reduced and lubricating fluids are retained”[89]. The penile prepuce cushions and
lubricates during sexual activity, particularly during intromission [90, 91 p7].
The densely innervated frenulum, often ablated during newborn circumcision but
usually spared in adult circumcision, is highly sensitive to light touch and has been
called a male “G-spot”[92,93].
The human penile prepuce is a long-evolved, complex, and functional organ with
a unique structure possessing many beneficial physiologic attributes [91 pp vii, 1,
35, 37, 44, 51, 53, 54, 101].
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Second circle: intimacy. This involves experiences with emotional
closeness, vulnerability, and trust. Preliminary research on a possible
association between circumcision and alexithymia (difficulty
identifying/describing feelings) reported that “circumcised men
had age-adjusted alexithymia scores 19.9 percent higher than intact
men”[45]. In the present study, 16.26% of respondents attributed
alexithymia to their unwanted circumcision (Q12).
Other respondents discussed experiences with how altered or
reduced sensitivity, or sensory irritation to the exposed glans,
impacted the sensuality circle in ways that indirectly affected the
sexual response cycle and intimacy.
“(When I) got my first hand-jobs, they were painful, realized it’s
because of the lack of skin - but didn’t link that to the
insensitivity yet”
“Performed sexually too fast to feel”
“Masturbated more, made love less”
Within the intimacy circle, several respondents identified
complaints that sexual partners had about their circumcised
bodies, including difficulties achieving orgasm, dryness, chafing,
and struggles with penetration.
Third circle: sexual identity. This circle addresses self-knowledge
and sexuality, including sexual orientation, gender identity, and
sense of self in relation to one’s own sexual experiences. Many
participants identified feeling inadequacy in various respects due to
circumcision. Others felt that their penises were mutilated and
deformed, which they associated with decreased sexual self-esteem.
“My first time having sex was senior year of college. I had other
opportunities prior, but could never get myself to do it because
I was so worried that the girl would think something was
wrong with my penis. (I had a prominent skin bridge)”
“Avoiding sexual activity for many years because of shame and
self-esteem over how my circumcision looks”
“I feel alone, because very few people have any empathy for
my situation and [they] believe that circumcision was for my
own good”
“I just want to be whole. I can’t express how much pain this has
brought me”
Fourth circle: sexual health and reproduction. This involves
biological factors of sexual anatomy and physiology, contra-
ception, reproduction, and the sexual response cycle. Respon-
dents described suffering that ranged from pain during erection
and penetration to insufficient sensation to maintain arousal and
achieve orgasm. One participant noted that due to the over-
whelming sensory challenges from his circumcision, his lack of
sensual experience interrupted the sexual response cycle. He
described coping by:
“Avoidance of sexual encounters to avoid worsening negative
thoughts about myself and the fact that thanks to my
mutilation it is basically just a hose for urine and not worth
anything more”
Fifth circle: sexualization. This involves power and influence with
regard to sexuality.
Respondents expressed feelings of violation and disempower-
ment by a circumcision imposed on them without their consent.
Many expressed resentment about lack of control over such a
powerful decision with lifelong impacts on sexual health,
experience of their bodies, sense of masculinity and sexual
identities, and relationships with partners. They directed anger at
parents, doctors, society, culture, and religion. Respondents
attributed feelings of anxiety and depression to circumcision.
“I felt unwhole. Robbed. I was angry for years. I still am”
“Considered removing penis to end pain and suffering”
“I’ve had suicidal thoughts, anxiety, and depression, which I
partly attribute to it and is now sometimes triggered by it”
Since a circumcised individual cannot participate in sexual
activities involving foreskin manipulation “…these individuals
must rely on a narrower range of physical acts that conform to the
contours of their penis.”[46] p5].
In varying and multifaceted ways, experiences of circumcised
respondents are sexual because they expand concepts of human
sexuality beyond physiological response, anatomical and neuro-
logical function, injury, and the sexual response cycle, allowing
for an expanded examination of sexual implications of circumci-
sion.
We agree that “…even the smallest prevalence of these severe
complications is significant given that the procedure in question is
by definition medically unnecessary”[17] p6], and especially given
the exceedingly high incidence of neonatal circumcisions
performed each year in the US and globally.
Sources of first awareness of harm (Q15). Common sources of
awareness of harm included: wife, girlfriend, sex with intact men,
researching circumcision for newborn son, and variations on “I
simply googled uncircumcision at age 12.”The intactivist
movement (i.e., political activities and resources dedicated to
opposing/ending medically unnecessary childhood genital opera-
tions) was not a major source of awareness of harm (8.16%).
Rather, for those who engage(d) in it, activism is/was a vehicle for
validating, expressing and healing the distress that was present
from an early age.
Lasting circumcision trauma: suffering, grief, and suicide. Our
survey responses suggest that circumcision is a cause of male
body-loss grief. As suggested by others, the traumatic effects of
foreskin loss can last a lifetime [47] p751, [48], and circumcision
may be properly understood as an Adverse Childhood Experience
[49]. Suicide and suicidal ideation related to circumcision grief is
increasingly being discussed by men and reported in the media
[50–53].
One researcher found among his interviewees that repeatedly
observing effects of their circumcision when bathing, urinating or
during sexual activity often stirred symptoms of post-traumatic
stress disorder. He concluded:
“The process of grieving for a lost foreskin closely parallels the
experiences of those who have suffered amputation, rape, body
dysmorphic disorder”[54] back cover].
Follow-up research evaluating 22 men seeking therapy for
circumcision grief found:
Therapists were reluctant to accept that the grief was real, were
unaware of foreskin functions, denied circumcision had physical or
psychological sequelae and minimized patient grief …[55] p109].
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As one author observed about FGC “For the majority of girls and
women, the psychological effects are more likely to be subtle,
buried beneath layers of denial, mixed with resignation and
acceptance of social norms”[56]. The same may reasonably be
true for the majority of circumcised boys and men in high-
prevalence societies where questioning of the norm is socially
discouraged.
Our findings echo another review of neonatally circumcised
males that “revealed a ‘discovery’theme, previously noted as well
within the literatures on intersex and (endosex) female genital
operations”[17] p6] wherein those affected become aware, later in
life, of adverse physical and psychosexual phenomena associated
with having their genitals surgically altered as children without
medical indication or their consent.
Research question 2. What were/are their restoration
experiences and results?
Restorers reported diverse goals, reflecting various motivations for
starting restoration. For some tightly circumcised respondents it
was sufficient to achieve enough slack skin for more comfortable
erections and masturbatory experiences.
For those whose chief complaint was a dry, keratinized or
desensitized glans, or who suffered constant discomfort from the
exposed glans rubbing on clothing, partial or total glans coverage
while flaccid was a reasonable goal.
Others whose unprotected meatus (urinary opening) was
persistently irritated from the friction of clothing may have sought
greater glans coverage (with overhang) to prevent such irritation.
For still others, attaining the maximum amount of gliding action
for comfortable penetration and reduced friction during inter-
course could explain their goal of total glans coverage (plus
overhang) when erect.
Regardless of coverage goals (Supplemental Table S5), restora-
tion was commonly associated in this sample with one or more
benefits including: increased moisturization and re-sensitization of
the glans, increased sensory input and sensual pleasure relating to
the interactive gliding motion of the pseudo/ersatz foreskin,
improved self-image by appearing to be intact, psychological and
self-esteem benefits from having reclaimed their bodies, and
improved sexual and/or intimate relationships.
Most respondents reported that their negative feelings were
somewhat eased or eliminated completely by restoration. Those
who had identified prior negative coping behaviors stated that such
behaviors were decreased or, in some cases, eliminated entirely.
Most restorers committed significant time, effort, and money to
regain their bodily integrity, especially absent any professional
monitoring or support (Supplement Section “Personal Experi-
ence”). Some (18.83%) had abandoned restoration due to difficulty
and frustration with the process, with over half of those spending
less than one year attempting to restore.
At time of survey, >75% were continuing restoration either on a
consistent or intermittent basis, while 5% of participants said they
had met their goals and satisfactorily completed their restoration.
Reported duration of time spent restoring ranged from less than
one year to over five years. One respondent uploaded a pre-
restoration photo and final photos of his 16-year restoration
journey with self-captioned commentary about the positive
effects restoration had on his marital relationship (Fig. 3). While
pride in one’s restoration was not a survey question, his
testimonial, among many others, exemplifies how restorers in
this sample often felt more confident in their bodies.
Research question 3. What were restorers’experiences with
medical/mental health professionals, or why didn’t they reach
out?
86.76% of the respondents did not consult any professional (Q41)
because in the words of one participant:
“…male genital mutilation isn’t taken seriously”
Of those who sought restoration help from a medical or mental
health professional, 25% reported that those professionals
trivialized or dismissed their concerns or reacted with ridicule.
Fairly typical participant responses included:
“Brought it up with doctor once but they were unsupportive”
“Asked primary once. Unhelpful and felt like they were
laughing at me for it.”
Ignorance of circumcision suffering is exemplified by this
physician who remarked: “I have never seen an adult with PTSD
from a neonatal circumcision. Nobody has ever told me that they
regret a circumcision.”[57] para26]. Beyond ignorance, many
professionals are simply unprepared to deal with circumcision
sufferers and foreskin restorers, which reinforces mistrust among
these patients, as captured in these comments:
“In many cases I find that I know more than most
‘professionals’”
“Medical doctor caused it. I didn’t trust them to discuss
reversing. Still don’t.”
Lack of understanding and support for MGC sufferers and
foreskin restorers among professionals and the general public is
viewed by some as a reflection of circumcisionism:“the hegemonic
view that genital circumcision is a normative and acceptable
practice”[58,59] & Box 3] as well as holding false beliefs about
unaltered genitalia and the consequences of childhood genital
modification [1].
Overall, restorers believe that the professional community is
insufficiently educated about concerns of MGC sufferers and are
ill-prepared to offer foreskin restorers the understanding and
assistance needed to support them on their restoration journey
[60]. This could explain why the restoration community remains
rather isolated from medical and mental health professionals.
Do participants recommend foreskin restoration? As noted earlier,
while pride in one’s restoration was not a survey question, many
respondents seemed to feel more confident in their bodies, which
may be why most respondents (86.7%) said they would recommend
foreskin restoration to others (Q48) (Supplemental Table S6).
Among reasons for selecting “yes”in response to the recom-
mendation question:
“It gives you a sense of taking back some control of your body”
“If circumcision bothers you and you can do something about
it, why not do it?”
“It’s the only option besides surgery, suicide, or giving up and
suffering through life”
“Restoration works. It is both physically and emotionally
healing”
Some reasons for responding “no”:
“Takes too long”
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“It doesn’t work. Circumcision should be outlawed as a barbaric
practise”
“Severed nerve endings are irreplaceable.”
Among reasons for selecting “unsure”:
“While I don’t doubt it works for some, I’m unsure since it didn’t
work for me”
“It’s a long slow process which can get depressing when results
aren’t seen regularly. Methods and devices are bulky and hard
to use comfortably in day to day work”
Fig. 3 One respondent’s restoration. Top: Pre-restoration (2004) Bottom: Post-restoration (2020).
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Participants were generally enthusiastic about what they
accomplished with restoration and are willing to offer encourage-
ment and support to others.
Survey limitations
As one of the first empirical studies exploring the attitudes,
motivations, and experiences of foreskin restorers, we used
targeted sampling to reach this distinctive population and did
not survey non-restoring circumcised people (as a potential
comparison group).
Because only descriptive data is gathered and reported, no
correlational conclusions or causal inferences are drawn. We did
not measure psychological (e.g., trauma-related) responses
through standardized instruments and relied solely on participant
self-responses (i.e., as an initial means) to explore qualitative
experiences, self-understandings and interpretations, and perso-
nal meaning-making frameworks and narratives in relation to
long-term phenomena associated with circumcision, along with
motivations for uncircumcision. Future research could explore
outcomes using a longitudinal study pre- and post-restoration and
could incorporate psychometrically validated, quantitatively-
based self-report measures.
A limitation to generalizability is that it was not possible to
randomly sample from the total population of foreskin restorers;
rather, our sample was recruited primarily through online forums
and anonymous contacts of individuals who had purchased
restoration devices.
Because we did not conduct a systematic qualitative analysis of
open-ended responses, comments we selected are meant to
highlight quantitative data, but should not be interpreted as being
representative of all response data.
Reframing circumcision
Complex experiential harms reported by respondents suggest that
the current debate over “benefits vs. risks”of circumcision (i.e.,
third-party utility calculations based on probabilistic/anticipatory
health benefits vs. estimated risk of surgical complications) is
insufficient to determine whether circumcision will be helpful or
harmful to any specific child and the adult they become. Surgical
complications are not the only harms. Future discussions about
newborn/childhood circumcision should be expanded to account
for the full range of lived experiences of persons who have come
to face what is, to them, a troubling realization: namely, that a
healthy, normal, sensitive part of their penis was removed without
their consent and without medical necessity. Therefore, a more
productive formula might be “potential advantages vs. inherent
disadvantages”of circumcision.
The very existence of a global foreskin restoration community
amplifies the question of who should be allowed to authorize such
childhood surgery: the person whose penis it is, or their parents/
guardians. According to the American Academy of Pediatrics
Bioethics Committee, physicians, at a minimum, “have legal and
ethical duties to their child patients to render competent medical
care based on what the patient needs, not what someone else
expresses”[61], emphasis added]. This suggests that, regardless of
parental expressions of a preference to have their child genitally
modified, doctors behave unethically–and potentially illegally–if/
when they perform a genital surgery on a child patient who does
not, in fact, need it.
According to the World Health Organization (WHO), among
numerous other supranational medical and legal bodies, all
human beings, including children, have a fundamental right to
bodily integrity. The WHO affirms that this right is violated, in the
case of FGC, by any medically unnecessary genital cutting,
regardless of motivation or how superficial (i.e., even if not
physically harmful). Since the right in question is a human right,
the same conclusion must apply to MGC. Consistent with this, it is
increasingly acknowledged by ethicists and legal scholars that
non-therapeutic infant penile circumcision violates the rights of
the child [32] and Supplementary references 156, 160, 191, 195,
196, 203–207].
CONCLUSION
Foreskin restorers constitute an under-recognized and under-
studied, yet not insignificant, population of patients who system-
atically seek to undo the surgeon’s work. Our survey results
provide insights into lives of these individuals, most of whom
identify as men, along with a small percentage who identify as
intersex persons or transgender women. Collectively, participants
reported suffering numerous physical, sexual, emotional, and
relational injuries associated with their circumcisions. Most did not
feel comfortable speaking up about their difficulties outside of a
small number of trusted individuals, if any, and the minority who
sought medical or professional help were unlikely to receive
informed, sympathetic care. Such reticence is reinforced by
experiences of marginalization and/or well-founded fears of being
misunderstood, unsupported, not being taken seriously, or worse,
being ridiculed by family, friends, or the very health professionals
from whom one should be able to expect compassionate
assistance.
Our findings offer insights into how foreskin restorers have
been ill-served by medical and mental health professionals.
Accordingly, in the Unabridged Supplement to this paper (Section
Box 3. How is circumcisionism manifested?
(for corresponding references see Unabridged Supplement)
A review of academic literature and intactivist websites reveals what some genital
autonomy advocates believe to be examples of circumcisionism:
●Calling unmodified genitals, or the entire person, “uncircumcised”(rather
than intact), implies “that circumcised is the default state of human males
(question: is unmastectomied the universally accepted default state of
human females?)”[182];
●Scientifically supported information about foreskin anatomy and
functions is easily accessible online [135,183–185], yet most US medical
textbooks depict the penis as circumcised by default and do not discuss
preputial anatomy or physiology [186];
●Physicians routinely misdiagnose the naturally adherent prepuce in
young boys as “pathological phimosis”to justify needless insurance-paid
circumcisions [79,83];
●Aggressive marketing of newborn circumcision in US hospitals, where
94% of mothers are solicited for circumcision and the average number of
in-hospital solicitations is eight [187], has prompted a consumer
protection initiative “Don’t Ask. Don’t Sell®.”[9] (in Abridged) & 24 (in
Unabridged Supplement)];
●Newborn circumcision is financially profitable for physicians, hospitals,
device manufacturers, insurance providers and others [188];
●Circumcision advocates consider the intact newborn foreskin to be of no
value (or a potential health hazard), yet after excision the tissue gains
immense value to commercial bio-tissue and cosmetic firms [4]
p123, 189];
●Many US physicians ignore proven cost-effective non-surgical prophy-
laxis and treatment methods that preserve bodily integrity [84];
●Personal biases heavily influence circumcised male physicians and
female physicians with circumcised sons [190];
●The AAP–among the only professional medical bodies in the world to
defend and promote newborn circumcision–was internationally criticized
for medical ignorance over its “culturally biased”2012 circumcision
policy statement [191];
●An AAP Circumcision Task Force member publicly repeated that “no one
knows the function of the foreskin”before invoking his and his wife’s
personal predilections for the circumcised penis [192];
●Ethical and human rights concerns regarding genital cutting of newborn
males are routinely disregarded [193–197];
●Seeking breast reconstruction after medically necessary, consentual
mastectomy is considered reasonable, yet seeking foreskin restoration
after medically unnecessary, non-consentual circumcision is often
ridiculed [198].
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“Recommendations”), we propose detailed recommendations for
future research to better understand the long-term adverse effects
of non-voluntary, non-therapeutic genital cutting upon those
assigned male at birth, along with indirect effects on their
partners; to ascertain the various ways in which these effects
manifest themselves; to improve medical education; to improve
professional services to circumcision sufferers and foreskin
restorers; and to better inform parents about potential adverse
impacts of childhood MGC, all with a view to ultimately reduce its
incidence to the point that non-therapeutic newborn male
circumcision is no longer considered to be within the standard
of care by physicians and hospitals.
DATA AVAILABILITY
The datasets generated during and/or analyzed during the current study are available
from the corresponding author on reasonable request.
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ACKNOWLEDGEMENTS
TH wishes to acknowledge the late R. Wayne Griffiths, who guided TH on his own
restoration journey, assisted him with the co-founding of the National Organiza-
tion of Restoring Men (NORM), conducted the first organized survey of 240
foreskin restorers in 1995, and whose early efforts inspired TH to undertake this
current larger-scale survey. The authors also express their gratitude to the more
than 2100 respondents who courageously stepped forward to share their lived
experiences on this intensely private matter by submitting completed or partially
completed surveys.
AUTHOR CONTRIBUTIONS
This investigation was conceived by TH who developed the survey questionnaire based
on decades of listening to the lived experiences of circumcision sufferers and foreskin
restorers. He assembled and managed the team of co-authors and contributed
significantly to the overall manuscript. LS acted as Principal Investigator, obtained IRB
approval from Quinnipiac University, authored the Methods and Result sections, and
contributed significantly to the Discussion section. WJ, as statistician, contributed his
skills to analyze survey findings, and along with LS authored the Methods and Results
sections. RM contributed conceptual knowledge and data analysis and organized the
overall presentation flow. BS, as a certified sex therapist, authored the Discussion
section relative to sexual impacts. MAB as a physician and author of medical textbooks
on male genitalia and thecomplications of circumcision, providedmedical review of the
section on penile anatomy, physiology, and circumcision complications. All authors
were responsible for the review and editing of the final manuscript prior to submission.
COMPETING INTERESTS
TH is the author of two related surveys of circumcision sufferers and is co-founder of the
nonprofit charity the National Organization of Restoring Men. TH knew the owners of two
restoration device companies and asked for assistance to promote this survey to past
customers. Anonymized email lists were supplied to TH at no charge and no promotional
promises were made to the companies. LMS has written numerous articles about ethical
and human rights implications of circumcision; WAJ has performed statistical analyses and
published papers about circumcision; RM appeared in documentaries and videos and has
written about the ethics and effects of circumcision; BS appeared in a circumcision
documentary for US parents; MABF has published medical textbooks on normal and
abnormal prepuce and the short- and long-term physical effects of penile circumcision.
The non-profit organization Doctors Opposing Circumcision underwrote the subscription
cost (<$300) of the online survey software used in this research.
ETHICAL APPROVAL
This study received Institutional Review Board approval (Protocol #04421) from
Quinnipiac University in Hamden, CT, USA, and followed all ethical standards to
ensure proper protection of participants and their data.
ADDITIONAL INFORMATION
Supplementary information The online version contains supplementary material
available at https://doi.org/10.1038/s41443-023-00686-5.
Correspondence and requests for materials should be addressed to Tim Hammond.
Reprints and permission information is available at http://www.nature.com/
reprints
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author self-archiving of the accepted manuscript version of this article is solely
governed by the terms of such publishing agreement and applicable law.
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