Safe Female circumcision
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Dr. Sit Elbanat Khalid Mohamed Ali
Obstetrician Gynecologist
Khartoum University - Sudan

Introduction :
The prepuce is a common anatomical structure of the male and female external genitalia of all human and non-human primates; it has been present in primates for at least 65 million years, and is likely to be over 100 million years old, based on its commonality as an anatomical feature in mammals Certain cultures have excised the prepuce from children to conform to societal standards, while other cultures accept the complete external genitalia as normal. The motives for circumcision in preliterate cultures are difficult to define, but include rites of passage, blood sacrifices and cultural markings. Ritualistic, childhood genital surgery has become popular in the last several thousand years, making the prepuce the most vilified normal anatomical structure of the human body. Rather than acknowledging the prepuce as normal anatomy, some contemporary physicians consider the penile and clitoral prepuce (or clitoral hood) to be dangerous and unhealthy. However, before theoretical justifications for circumcision can be considered, a complete understanding of the normal anatomy and function of the prepuce is required. This paper reviews the embryology, anatomy and function of the prepuce.
Overview :
The prepuce is an integral, normal part of the external genitalia that forms the anatomical covering of the glans penis and clitoris. The outer epithelium has the protective function of internalising the glans (clitoris and penis), urethral meatus (in the male) and the inner preputial epithelium, thus decreasing external irritation or contamination.The prepuce is a specialized, junctional mucocutaneous tissue which marks the boundary between mucosa and skin; it is similar to the eyelids, labia minora, anus and lips.
Ritualistic circumcision involves the involuntary removal of normal, healthy genital tissue from infants and children for religious, societal or theoretical medical benefits. Although the amount of genital tissue removed is variable, the penile prepuce is removed in nearly all male circumcisions, and the clitoral prepuce is removed in a grade 1 female circumcision.
The clitoral prepuce develops similarly to that in the male. The prepuce of the clitoris forms independently of the urogenital and labioscrotal folds, which form the labia minora and labia majora, respectively. The clitoral prepuce is formed by a cellular lamella which grows down on the dorsum of the clitoris and is fused to the clitoris in the fetus.
Some authors state that the clitoral prepuce is formed by a splitting of the urogenital folds around the clitoris, with development of the prepuce superiorly and the clitoral frenulum inferiorly. However, this theory is discordant with earlier studies and has not been explicitly proved. The urogenital groove on the ventral surface of the clitoris prevents circumferential preputial development and results in the hoodlike appearance of the clitoral prepuce. The urogenital groove of the clitoris eventually regresses and develops into the labia minora. In the female, there is no mesenchymal proliferation in the prepuce to form a dartos muscle layer. Physicians can allay parental fear of normal, intact external genitalia by explaining normal development and maturation.
Innervation of the prepuce:
The female prepuce has somato-sensory innervation by the dorsal nerve of the clitoris and branches of the perineal nerve (including the posterior labial nerves. Autonomic innervation of the prepuce arises from the pelvic plexus. The parasympathetic visceral efferent and afferent fibres arise from the sacral centre (S2-S4), and sympathetic preganglionic afferent and visceral afferent fibres from the thoracolumbar centre (T11-L2). The parasympathetic nerves run adjacent to and through the wall of the membranous urethra.
Although the sensory and autonomic innervation of the penis and clitoris are similar, there is a remarkable difference in their encapsulated somato-sensory receptors. Sensory receptors can be classified as mechano-receptors, e.g. Meissner's corpuscles, Vater-Pacinian corpuscles and Merkel cells; and nocio-receptors (free nerve endings)]. A multitude of names have been used to describe these encapsulated receptors, e.g. Krause, Dogiel, genital corpuscles, Endkalpsen and mucocutaneous end-organs, but the term corpuscular (encapsulated) receptors will be used here to include all of these mechano-receptors. Most of the encapsulated receptors of the prepuce are Meissner corpuscles, as they contact the epithelial basement membrane.
In females, the glans clitoris and the inner plate of the prepuce have corpuscular receptors on their oppositional surfaces. The glans clitoris also has a much denser concentration of Vater-Pacinian corpuscles than either the glans penis or the male prepuce. The fused common epithelium of the clitoris and the inner plate of the prepuce are reported to have intraepithelial nerves. Merkel cells mediate tactile sensations, and are found in glabrous skin ; they have been reported in the clitoris and can be identified in the male prepuce.
Mucosal epithelium (inner plate of the prepuce):
The epithelium of the clitoral prepuce is fused in the fetus and has intraepithelial nerves. The fused inner plate of the male prepuce/glans has also been reported to have intraepithelial nerves.The clitoral prepuce has only a dermal component with fewer elastic fibres than the male prepuce. The inner layer of the male and female prepuce has occasional sebaceous glands and sweat glands.
The preputial sac:
The preputial sac contains desquamated squamous epithelial cells similar to other mucosal cavities such as the oral cavity or vagina. This white, creamy material may collect under the prepuce of the clitoris and is called (smegma clitoridis) .
Preputial coverage of the glans:
There is variability in the preputial coverage of the intact glans penis and clitoris. Some adult men have the glans penis completely covered by the prepuce while others have only partial coverage of the glans. In a similar manner, the glans clitoris can be partially or completely covered by the prepuce; this merely represents anatomical variation.


1 - The Female Prepuce ((Clitorial Hood )) .
2 - Female Genital Anatomy and Sexual Dysfunction.
3 - Clitorial Un hooding.
4 - Medical Studies .
5 - Personal reports.
6 - Female Circumcision: “Prohibition or Allowance?”
Islamic & Medical Perspective.
7- Female Circumcision Negligence and Abuse.
8- Stabilizing female Circumcision .
9 - A Candid Interview With Dr. Royal Benson, III
A Surgeon Who Has Performed Hundreds Of Clitoral Unhoodings—On His Surgical Method And Related Issues.
10 –The Proper Way Of Safe Female Circumcision.


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