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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.
Embryology:
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.
Contents
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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