A “Snip” in Time: Circumcision Revisited

The publication of an Italian study on etiology and interactions of frenulum breve, fren- ulectomy, and premature ejaculation, and the results of a popular Austrian sex study initiated a survey on this topic, accompanied by collecting a small sample of data in an urban practice environment in Germany. Since frenulectomy, for practical reasons, often leads to a complete removal of the prepuce, circumcision has come to the fore anew. Moreover, under the heading, “Ending a myth: male circumcision is not associated with higher prevalence of erectile dysfunction,” a recent study relating circumcision to sexual dysfunction has been published. In this chapter, an overview of research results as well as of psychological and clinical aspects of circumcision and associated subjects is given. There seem to be advantages of circumcision as to sexual dysfunction and premature ejaculation. Depending on etiopathology, some treatment options may require psycho- somatic reasoning.


Introduction and overview
While in northern European countries circumcision in males has no great tradition, the publication of an Italian study on etiology and interactions of frenulum breve, frenulectomy, and premature ejaculation (PE) [1] and the results of the popular 2011 Styrian Sex Study in Austria [2] initiated a survey on this topic, accompanied by collecting a small sample of data in an urban practice environment in Germany. The Styrian Sex Study of 2011 (n = 413) revealed high interest of Austrian male adolescents in circumcision, yet only 62% felt generally well informed (213). The Italian study at the Urological Department of Napoli University found a short frenulum (frenulum breve) that was treated by frenulectomy in 43% (59; n = 137) of patients with diagnosed PE. The authors observed diminishing of PE, and suggested that the treatment of premature ejaculation with frenulectomy could be used as first-line option. Since frenulectomy, for practical reasons, in practice often leads to a complete removal of the prepuce, a debate of this issue in the public has started which is long overdue. Moreover, under the heading, "Ending a myth: male circumcision is not associated with higher prevalence of erectile dysfunction" [3], a German study has officially confirmed what nobody in the field would seriously have put at question. In the study, rather a slight inverse significant correlation of satisfaction with erectile rigidity in circumcised men has been observed.
Sexual dysfunction issues are delicate issues, mostly multifactorial, and often associated with biographic aspects. Apart from vascular, neurological, and hormonal disorders (cf. [4]), etiology often involves psychosomatic factors. Psychogenic etiology has been implicated extensively; it can be traced back to Freud and his beginnings [5]. The differentiation between generalized and situational symptom formation has become highly important, since it points to biographical and relational aspects of which not only the latter have interactional functions. In practice more usual in female patients [6], who tend to relate dysfunction to their experiencing more often than males, psychosomatic sexual dysfunction can often be alleviated by psychotherapy. Moreover, the interconnections of hormones and psyche in females have been extensively explored [7], which has made psychosomatic reasoning of some dysfunction easier. This is not so much the case in somatogenic sexual dysfunction. Still, psyche is often involved in etiology, and it depends on etiology how to intervene. While in male sexual dysfunction often effective PDE-5 inhibitors [8,9] aim at somatic functioning, which is an intervention in its own right, they also have psychosomatic impact. This will be discussed in the subsequent text.
Psychotherapeutic interventions are helpful in many psychic disorders, which is true for psychogenic sexual dysfunction, too. At any rate, from a psychoanalytic point of view, there is not only a necessity of getting grip on the psychodynamics of a patient's disorder in order to find an adequate intervention but, from a general point of view, also a necessity of understanding why, for example, some measures are or are not taken by patients. Even when something seems the obvious thing to do, their personalities, attitudes, and cultural predispositions may or may not keep them from doing so. Certainly, this is not to say what the right thing to do is.
Psychosomatic aspects of sexual dysfunction in males, not only in the case of PE, have often been observed. Quite often, such aspects remain non-reported, or remain unconscious. Thus, they have to be inferred from biographies of patients. More frequently in psychotherapeutic practice, the dysfunction itself is not reported at first but only later in the therapeutic process. It is not rare to see an interactional etiology even before the symptom has been described. Sexual dysfunction very often has an interactional etiology and always interactional consequences. Although sometimes denied or trivialized, after all, potency is always a male issue. Anamnestic questionnaires can tell about that. Dysfunction does emerge, whether patients are circumcised or not. Yet, myths and beliefs of circumcision as a measure that might reduce potency gives an idea that there are fantasies of all kinds toward circumcision. Moreover, circumcision is not widespread in northern European countries (which are here referred to as European countries northern of the Alpes), and this survey is to reintroduce reasonable dealings with the topic.
Physiology and pathophysiology in penile erection can be viewed in many publications; detailed overviews of its mechanisms have been given [8], and contexts of psychosomatic interconnections have broadened the perspective (cf. [10]). Many publications have given elaborate overviews of clinical management of male sexual function (cf. [11]). Especially in PE, there are many research results and management approaches of which excellent surveys have been published (cf. [12]). As can be seen, the prevalence of PE in the world's middle-east region is less than half (12.4%) of the average (somewhere between 27.4 and 30.5%) in other regions of the world [12]. The question must be raised whether this is merely an artifact or not. Why, will be discussed further below. In the following chapters, a closer look at circumcision from different perspectives is to broaden the view of sexual dysfunction and PE. After public opinion aspects at first, psychological and clinical aspects of circumcision and associated subjects follow some practice study data. As in most research from non-exact sciences, such as the disciplines related to humanities, it has to be clear that anything dealing with psyche will sometimes be hypothetical, or even speculative. Aspects discussed below cannot be depicted in their entirety but only as consistent as possible. There may be arguments against some of them. Further research would be welcome at any rate.

Public opinion
Circumcision as a minor medical practice in northern Europe had not been a highly crucial topic in public opinion until 2012, when a German minor regional court verdict on circumcision without medical indication was published [13]. The verdict that would have prohibited circumcision solely on behalf of cultural, religious, hygienic, or aesthetic reasons and in favor of medical reasons only led to a broad debate in the public as well as to its overturn and to a regulation of law by the end of 2012, all the more legalizing circumcision, albeit with some minor requirements (overview in Ref. [14]). German-speaking media had only occasionally reported on this issue, yet discussions emerged on the Internet (in Austria, e.g., on net-doktor.at). In times of increasing genital surgery in women, for example, labioplastics [15], the so-called designer's vagina [16], and along the trend of increasing intimacy in public perception it might be true that also the northern European population took on body modification options that might have led to wishing to have the penile foreskin removed more often than before. Increasing parts of the European population, for whatever reasons cannot be discussed here, have come to favor total depilization of pubic hair, having intimate tattoos and piercings. On the one hand, in northern countries there has been a general rejection especially as to newborn and infant circumcision; on the other hand an ongoing trend in modifying one's body parts seems to have triggered more people's interest in influences from southern cultural regions, particularly the Jewish, Muslim, or American sphere. The impression that circumcision even in German everyday life is more frequent than assumed initiated taking a further look at the subject.

Practice study data
A spontaneous screening of patients' mothers (aged 23-43) in a German urban practice for integrative gynecological psychosomatics and psychotherapy of children and adolescents, asking for early child illness and medical intervention data, revealed that 60% (12; n = 20) of their sons (aged 5-14) had been circumcised. This seems to be a very high percentage that no one would have expected. Only 25% (5) of the patients were of Muslim migration families, 10% (2) were of German-American background. Out of five German patients' mothers who had their sons circumcised, two declared phimosis as the reason, and three ticked other reasons (e.g., aesthetic and hygienic) (cf. [14]). This being a small, non-representative sample may not carry statistical evidence, yet in the context of societal trends it hints at the current development of migration and on collective fantasies about aesthetics, hygiene, and sexuality. Before the start of the practice study, there had been an informal exchange with a German child surgeon and an Austrian urologist, the latter stating circumcision in Austria to have a much better reputation than in Germany, emphasizing that the rate of circumcisions in Austria definitely was increasing. Some counter-movements are certainly existent too, igniting the debate on circumcision every now and then. This has been the case in the US and in Germany in a debate on bodily integrity, in Germany rather with an emphasis on nature orientation. Some medical circles refer to self-imposed imperatives of nature orientation as "German frenzy of naturalness" [17]. However, a way too anxious labeling of circumcision as psychic trauma ought to be withstood; all too excessively the term trauma has been psychologically applied on any given medical event. Empathic presence of parents prevents children from traumatic experiencing of painful events (cf. [18,19]), and the cultural anticipation of an intervention is most crucial [20]. Not circumcision itself, but its handling in the family, their communication, and their emotions about it seem to be pivotal to dealing with it. Case studies have occasionally pointed that out (e.g., [21]).

Psychological aspects
From a historical mentality point of view, it is fair to state that in the majority of Europe's Christian occidental heritage countries, along the nineteenth and early twentieth century nature movement and the so-called youth movement [Jugendbewegung], as well as especially in Germany's experience of the Nazi Regime and the execution of genocide, there has come to exist a strong collective affect against violations of bodily integrity. In the course, recent popular reports on female genital mutilation practices have oddly transformed into some general equation with male circumcision, some of them revealing horrendous ignorance of anatomy. By that, any Jewish or Muslim family involuntarily came to be on the brink of general suspicion of executing violent educational modes. This has to be critically reflected since any reflex of demonizing circumcision is not only beyond reason; possibly it rather serves as a psychic displacement of general socio-political issues toward a minor medical issue. Reports of children's poverty in Germany show outrageous rates although the children's rights movement has long reached policy-makers. In a country with very high average incomes and high gross national product, this seems like oddly displacing societal issues toward a minor surgical operation.
Here, we elaborate on why mostly in northern European countries in public opinion circumcision still is often rejected or has an at least questionable reputation and why advocators of circumcision tend to be viewed as non-empathic, if not sadistic aggressors. Pondering these issues does not refer to the pros and cons of ritual infant circumcision; what is at stake here is the psychic fantasy about removing the prepuce in general. As said before, this tradition has especially been practiced regularly in Jewish, Muslim, and Anglo-American cultures. Interestingly enough, Judaism and Islam are the two world religions that are related to Christianity the most (cf. [22]). Cultural differences between the latter have first of all emerged from secularization, which has different concepts and facets. Whereas, for example, in secular Islamic countries, there has been a segregation of religion from worldly life and from the state-which is the laicist version-in Christianity secularization rather means having worldly life permeated by religion. Christian secularization is thus different from Jewish or Islamic secularization: it means religion is confounded with worldly life, and not worldly life averting religion [23]. The differences in countries conducting secularization have been large; for example, France, or the US, being strictly laicist whereas, for example, Germany is not.
The whole history of circumcision cannot be depicted here; recently, a concise and informing overview has been published [24]. The pivotal issue is whether specifically the Christian ambivalence of sexuality is responsible for even secularized northern European citizens so to reject and dismiss circumcision in general. Much of the uttered care in the debate on bodily integrity actually does not seem to play much of a role in, for example, tonsillectomy. This is why it can be useful to explore passed-by images and fantasies from the cultural sphere where they stem from. What might a circumcised male represent in the fantasies of people from these countries? He might have been fantasied as a sexually potent man. On a visual level, showing the glans penis in contrast to covering it may give a sexually aggressive, which means potent, impression. In flaccid state, the glans would be concealed in uncircumcised men until in erected state, so that the visual difference is physically entrenched in the circumcised organ. So it is the visual impression which is a factor and which finds its deposit psychic. Taking into consideration Norbert Elias' theory of a steadily increasing civilizational process in history [25], it is fair to say that in ancient times highly aggressive interactional behavior would be as common in everyday issues as in sexual issues. Psychic defense and coping mechanisms like, for example, sublimation would develop only late in human history as cultural-processing modes that were at the same time founding and requiring more complex societies. Taking into account the concept of educational modes [26] with ubiquitous infanticidal modes reaching back to ancient times, it becomes clear that-apart from the everexisting exceptions of small elite groups-in common dealings there would be quite a coarse and brutal daily routine. Sexual matters would not be excluded from that way of living. Neither phenomena of industrial society like the decrease in sperm count nor lack of testosterone in men are likely to have existed-again, with the exception of the ever-present single cases. The common perception of males will have been a perception of being coarse and brute, not like in supposable idealized artistic or religious depictions. Along the civilizational development, and along enlightenment and humanistic influences on everyday dealings, people became more structured, became tamer, and became more orderly, this of course taking its toll in loss of spontaneity and directness. The mental process of sublimation, for example, directing of libidinous energy toward socially acceptable goals [27], probably became more prominent in the western world only from the eighteenth century on (violent regressions in war as contra-directional tendency being its inherent, dialectic counterpart). So in different periods, different modes of personalities and their dealings with one another would exist, developing in a long process toward-relatively-more peaceful and equanimous personalities. With that, along the twentieth century even gender roles became blurred, so that only at the turn of the millennium to the twenty-first century, going along with post-feminism, females could enjoy the freedom struggled for endlessly. Last but not least, through reintroducing of further accentuation of female sexual stimuli (e.g., aesthetic surgery), males got to be perceived as more male, and masculinity is more required than before. Even movies and television tell about that trend (cf. [28]), so that the sexes, in terms of male-female differentiation, are tending to be relocated at classic concept (gender issues otherwise becoming even more important, what is not necessarily in contradiction to increasing male-female differentiation). Viewed from a psychobiological perspective, this is to be welcomed. Significantly, the current trend toward re-appreciating of male aspects in men goes along with the accentuation of female aspects in women. This can serve as a psychobiological rationale of the visual, psychic perception of males, and it might entail a new trend toward circumcision. Moreover, oriental habits and customs have encompassed each and every erogenous zone of the human body, while through the influence of Christian churches especially in western Europe such dealings have remained unusual [29]-even when there have been many changes. However, in ancient times, a circumcised penis would necessarily draw attention and trigger rejection or fascination, at any rate trigger reaction at all. It seems clear that the glans penis visible hints at the erectibility of the penis [24], fitting it out with more of a specific sexual note in contrast to an uncircumcised penis. The fact that in Christian-heritage art the penis is depicted smaller than it is in reality [30] is an indication of Christian disesteem, too. The point is, in psychic reality, what is called "the other" is often tainted with defect, that is, what has been unknown will trigger discontent; certainly a fact in the perception of difference in the circumcision debate (cf. [31]).
Perhaps more important than appearance, the issue of the presence of a so-called paternal principle might relate to it, that is, circumcision as a symbolic act of castration by the father. Seemingly odd, circumcision as a symbolic castration would differentiate the man from the boy. To be a man, one would have to go through circumcision first. By contrast, an uncircumcised man would be no more than a big boy who did not undergo incest taboo and some other rules and regulations that come along with the concept of Nom-du-Père, that is, the law-, or name-of-the-father (Lacan, cf. [32]). This concept of Nom-du-Père manifests itself in the actual cutting of the penile foreskin, this being an act of transforming the penis into a phallus. Apart from the ancient notion of the phallus symbolizing power, fertility, and death-defiance, the idea is to declare and maintain paternal parentage, which cannot be testified through human senses (cf. [33]). However, witness can historically testify maternal descent. Thus, maternal parentage is obvious and visible, and in the course of their development it has to be psychically dismissed by males. Accepting and overcoming it at the same time is pivotal to male identity development. So, roughly speaking, in order to become a man in their own right, males have to partially relinquish female lines of identification. What Freud on a macro-level described as renunciation of sensuality in favor of an advance in intellectuality in Judaism [34] on a microlevel finds its analogy in male development. This process is attested by circumcision, which leaves a visible trace of this process. It also testifies incompleteness and vulnerability of the male body, which in females is naturally symbolized by menstruation [23]. As can be seen, here we have a connection between Islam and Judaism, which is also true for the differentiation of the sexes and their symbolic order. As to such an order, in practice looking at today's northern European patient families, it is not far-fetched to state that quite frequently hardly any paternal principle has been established. Surprisingly enough, in terms of the sample data above, several young German-based mothers now seem to symbolically establish a paternal principle substitute by having their sons circumcised. This might be understood as a symbolic act of anticipating, or making up ritual, of their individuation toward manhood.
Last but not least, the myth of circumcision for deterring masturbation (which of course can be traced to a large amount of sources) might be a myth itself. Unconsciously, advocators of circumcision in history might have considered masturbation itself not so much of a problem, but might have considered masturbation with prepuce a problem. Why? Because it literally can be regarded as having sexual intercourse with oneself. It tends to an even more inert and uncreative handling of sexuality. Back in time, circumcision advocators might intuitively have figured out right that disturbances of the senses will be triggered even more through stimulating the penis with an artificial meatus, which the prepuce would be, tending to replace objectal stimulation through the anatomy of a sexual partner by subjectal stimulation through one's own anatomy. So what may sound far-fetched at first might have an unconscious foundation in grasping a real-life issue. This is not to say that masturbation is generally bad: as always in medical issues, dose makes the poison; it is but a secondary means of handling sexuality.

Clinical aspects
Although hardly any disadvantages of circumcision have been reported [35,36], every now and then, in medical publications invectives against it emerge, sometimes from a pediatric, sometimes from an alternative, rarely from a gynecological background. At the same time, in scientific urological and sexual medical journals more often than not, functional, hygienic, and sexual advantages after circumcision are reported. Apparently, increasing parts of medical circles consider circumcisions making sense on different levels. Facts and necessities of circumcision are regularly depicted there, as, for example, in balanitis, in lichen sclerosus, in preventing of infections of different kinds [37][38][39], of penile carcinoma [40,41], or in a possible decrease of cervical carcinoma in females [36,42,43], this even in traditionally noninvasive German complementary and alternative medical publications [44,45]. Claude Bernard's motto, germs are nothing, substrate is everything, seems to be reintroduced by now (quoted in [46]). Prognostically, a further increase of circumcisions in northern Europe is highly probable, not only for migration reasons but also for globalizing of aesthetic practices reasons. Whereas British pediatricians now tend to dismiss routine infant circumcision, American physicians keep on advocating it quite generally [47][48][49]. Nowadays, most clinicians would not remove an appendix or the tonsils prophylactically. A conservative, noninvasive stance may definitely be right, and experienced clinicians know very well when to intervene and when not. At any rate, it does not seem to be appropriate to make the prepuce a fetish and transform it into a signifier of health and happiness, as has often been done in northern Europe. Especially, anxiety of suture and of keloid scars seems to be in the way, although these are issues which have come to be handled well [50]. Of course, climate conditions play a role: the climate in northern Europe is not the same as it is in, for example, the Alpe-Adria region, let alone in the Mediterranean and further into more southern regions. Of course, hot and humid climates support generating of some bacteria and microorganisms. By 1962, research findings compared the small amount of germs in a circumcised penis to that of an uncircumcised penis with a condom on [51], something that would be conclusive to generations of Americans. Some facts are not well known in northern Europe as yet: inflammation of the glans penis is not a rare event particularly in uncircumcised boys. Significantly, urinary tract infections in boys tend to be more frequent-up to 10 times-in the uncircumcised [52]; the risk of cervical carcinoma as to hygienic standard in Israel is 3.8 per 100,000, in Germany 16 per 100,000 [45]. The team of Castellsague et al. has elaborated on this, and Rivet in her stock-check has given a distinct account from a family physician's point of view [42,43].
In the case of a female patient wishing for her partner's foreskin to be removed for hygienic reasons (cf. [14]), in a 2-year follow-up the couple confirmed refraining from relatively short cohabitation time periods of around 5-10 min they had before circumcision-except for when intended. Following that, the result was that after 2 years the patient's now-circumcised partner had gained more control of his sexual functioning. It must be added that in anamnesis, none of these issues had been issues at all, essentially since the patient had sought psychotherapy for different reasons. In retrospect, the couple had sexually been quite happy before, although the patient reported to have problems reaching orgasm every now and then. Following their statements, there had been a significant increase in satisfaction after circumcision. Subclinical as it may be the case points to an interesting hypothesis: female sexual dysfunction not only can have many facets in phenotype and in psychosomatic etiology aspects (cf. [6]) but, as to PE, female orgasm disorders well known in daily practice might at times be considered an artifact due to male PE. Complaints on cohabitation time periods of 1-2 min may be a disguised PE; here, possibly, a symptom of males is displaced toward females who present with orgasm disorders as an allegedly female issue [53]. At any rate, cohabitation time period in circumcised males is frequently assumed to be longer than in uncircumcised males. Although there has not been any consistent evidence so far, the Italian study might support the public opinion. Moreover, in a recent review on PE, the authors [54] put frenulum breve at anecdote category, oddly ignoring the Italian study. They attempt a hint at cultural differences in what qualifies as a symptom and what does not-what may generally be right but not applicable in all ways. In their review, PE is attributed to some patriarchal cultures, at the same time generally imputing low self-esteem to women from these cultures who will not tend to rate rapid ejaculation as premature but as a sign of male virility; that is why PE is not diagnosed. Rather, in some cases PE may not exist because of differing cultural scripts. What the authors seem to withhold is differing cultural scripts of sexual encounter which can be completely different. Such scripts can grossly differ from the majority of, say, western scripts. Scripts as subsequent oral or manual stimulation toward female orgasm, usually followed by a second, more lasting cohabitation act, have to be taken into consideration in order to approach reality proper. These are not even considered existent by the authors, let alone further examined. In orientalism, specific female vaginal or anal muscular techniques have been used to provoke rapid ejaculation in males. Multiple sexual acts are not only in opposition to PE functionally [55] but maybe even by definition, thus highly culturally dependent. Again, orientalism has produced different relations to bodily issues, such as sexuality [29]. This might confirm the data of low prevalence in the middle-east cited above [12] in a more appropriate way than coercing data into fitting culturally insensitive reasoning. Lately, a psychoanalytic account has been given of historical idealization, or special appreciation of sexuality in Islam in opposition to its perception in Christianity [56], which should be similar in Judaism. Of course, differentiations must be further examined (cf. [57]). All in all, psychogenic erectile dysfunction in general not only often has short duration [4] but especially in the case of PE is subjected to different cultural scripts that will influence, if not define, symptom formation.
Another case shows a male patient who presented with situative erectile dysfunction, with a more complex psychosomatic background. The patient had a history of fantasying about his urethra carrying residue of urine mingling with his sperm when ejaculating, something that in his opinion would be a hygienic problem. His idea was that fluids must not mingle. He reported that this idea had bothered him ever since he was sexually active. He had been circumcised at the age of 4, and he could not remember to have had any problems about it. In sexual situations with his partner and with ex-partners in the past, he felt disgusted that they did not share his view but even enjoyed active oral sex. He had been with his current partner for 2 years, and she had assured him not to have any problem with his theory of fluids, and as a biology student she was right, he admitted. During coitus, he usually felt like having to ejaculate prematurely which in reality he did not. However, he would mentally keep on being sexually excited while his erection would be waning. Only through further active stimulation by his partner would he be able to continue, which for him felt like starting anew. Such an interactional loop could take place several times a night. The therapeutic process led to joint understanding of the patient's fantasies behind the symptom, of his feeling of nausea over smegma, of his theory of fluids that revealed a strict dichotomy between good and bad, and the like. Moreover, it led to the conclusion that his psychogenic dysfunction was somewhat linked to circumcision. It was the patient himself who suggested to view his sexual mode of behavior as some kind of pseudo-premature ejaculation, and he referred to an uncircumcised friend of his who was under treatment with PE diagnosis. After having reported to him about his ideas of hygiene, the friend told him about having a smegma problem although applying steady hygienic measures. The patient remembered to have heard of such a problem a long time ago. In the process of time, it had added to no more than severe qualms about his selfconfidence, which took 3 years to be reestablished. What was surprisingly easy to handle was the erectile dysfunction he had since in his mind, he felt like uncircumcised. Still in the end, it was not so much bibliotherapy that accounted for an alleviation of his dysfunction but, apart from the ever-effective therapeutic alliance, it was his realizing of the fact that he had been circumcised which made him comfortable with himself. The points his partner had made, such as dryness of the glans, would make him easy with his genital in contrast to the friend of his who at his wife's behest would have to clean his penis twice a day. Through less than a few months period, his concept of hygiene was waning while his erection would come back, and his fantasy to ejaculate early lost its urge. If the patient had not been circumcised the case would have been different and have led to even more complex entanglement-given the patient would have had the same fantasies anyway. In a 1-year-catamnestic questionnaire, the patient reported of no more dysfunction during the act, and his partner and himself described cohabitation quality and quantity as excellent. What is even more significant is, there would not be any displacement of symptom toward dysmorphophobia, something that by all means might have been the case. In this case, as to psychosomatic symptom formation, the sexual dysfunction had been a highly limited and well-accessible symptom.
Even when some research is limited, one can examine sexual functioning and experiencing of patients. As to functioning, the point is that erection is controlled by mechanisms in the hypothalamus, cerebral cortex, and spinal cord. Most important is the neural control of erection, which is organized afferently and efferently. In afferent direction, infraspinal and supraspinal influences on the spinal erection center can trigger erection. In reflexogenic erection, afferences extend via the pudendal nerve toward the sacral erection center which sends out efferences via the plexus hypogastricus inferior. In psychogenic erection, sensory, visual, or acoustic stimuli or fantasies trigger erection, with the involvement of cortical centers. In efferent direction, stimulation of the autonomous nervous system triggers erection, influencing penile vessels. The parasympathetic nervous system is pro-erectile; the sympathetic is antierectile. Penile vessels are innervated by preganglionic neurons in the spinal cord. Innervation runs via the plexus hypogastricus inferior and cavernosi nerves toward the penile corpus cavernosum. From the sacral plexus on, the pudendal nerve innervates pelvic musculature; pelvic floor contraction intensifies rigidity. After all, erection can be described as a neurovascular event involving sensory, motor, and autonomous nerves. Cavernosal structures and blood circulation in the penis are involved, as are hormones and neurotransmitters. Apart from molecular signal transduction which has been depicted extensively [8], sexual experiencing plays another important role. It will find its deposit psychically, as psyche will have predetermined experiencing and with that nerve system parameters.
Penile nerve supply is essentially conducted by the compact twin dorsal penile nerves which emerge from under the pubic bone. Running toward the glans, the nerve fibers fan out. Interestingly, although by circumcision corpuscular receptors of touch are removed, a recent sensory testing study found no long-term implications for penile sensitivity in circumcised males and even challenges the image of the foreskin to be the most sensitive part of the penis [48]. It is rather that, due to circumcision, loss of sensitivity of the glans as a result of keratinization will handicap ejaculation. Circumcision can stifle PE induced by high stimulation in the glans, or induced by high friction of the prepuce when in rhythmic contact with the glans in uncircumcised males.
Treatment of PE can be difficult, still behavioral and pharmacological approaches, and combinations of these, have often proven helpful. While PDE-5 inhibitors sustain penile erection and facilitate further sexual acts, they may support overcoming of anxiety that often exacerbates PE ( [58], cf. [12]). Such additional effects are welcome in case of an indication of PDE-5 inhibitors. Some patients with psychosomatic involvement will benefit from a combination of pharmacotherapy and psychotherapy without too much of behavioral instruction. Psychodynamic examination of personal biography can produce good results. Still, behavioral approaches and cognitive therapy are useful, especially those that will reach both cognition and emotion in patients. Apart from well-known sexual behavioral therapy publications, it is interesting to see that behavioral therapy publications on depression and addiction have proven helpful ( [59,60] and generally, [61]), which points to psychodynamic similarities of these disorders to some type of sexual dysfunction, such as psychosomatic PE. Additionally, learning of relaxation techniques [62,63] can have strong effects on sexual behavior and experiencing.

Discussion
Were it not for some good reasons, one might consider the foreskin superfluous from the beginning: the idea of hygiene has a point in its own right. Yet, it may have protected the glans penis from brush and plants in ancient times. An ideology of naturalness should not overrule today's hygienic or medical aspects, though. PE, which is by no means a rare issue in men of heterogeneous age and descent, is now being treated more and more by use of selective serotonin reuptake inhibitors [SSRIs] (cf. [12]), such as dapoxetine, which is used as on-demand treatment. This means intervening in neurotransmitter metabolism, which some European patient groups tend to refrain from completely. A possible loss of libido has been discussed, yet with no clear conclusion. All in all, dapoxetine research results are remarkable and are open to debate. However, PE patients ought to be diagnosed thoroughly, and uncircumcised men ought to be counseled. It stands to reason that checking of physiological and psychological status should be first of all. Meticulously detailed anamnesis also of psychosocial biography is required, even via questionnaires quite analogous to those of different focus [64]. Instead of rapidly going for medication in times of high pressure, which seems to be the easiest option to some efficiency-oriented patients, an exact analysis of PE and related disorders will be most helpful. In PE, the frenulum breve study ought to trigger attention to circumcision as a possible first-line option, especially in case that a restrictive frenular band was not the rare anomaly but more usual than assumed while a sufficient one was the exception. It might as well be denied or trivialized, or be culturally experienced as normal. It may be that the frenulum interferes more with retraction of the prepuce than usually assumed. Especially as the prepuce is continuously retracted, which for reasons of hygiene has to be case, frequently reported minor tears can generate inelastic scar tissue and by further retracting of the prepuce generate even more tears and scars. Also, the size of the glans in relation to size and restrictiveness of the prepuce might generally be underrated as well. Further research is needed here.
Especially male patients do not tend to report voluntarily on pain, inflammation, or problems with the sexual act. They do almost only at request. Adolescent males will not easily admit to these problems, too. However, whereas in urological practices the elderly are by far the majority of patients, in Internet forums plenty of adolescents seem to appear with plenty of questions on genital function, dysfunction, and the like. While it has been confirmed that circumcision is not associated with higher prevalence of erectile dysfunction-as we have seen, the foreskin plays no important role in erectile function anyway [65]-PE has not been so much in public focus to date. In correspondence with the myth of circumcision to be a measure that affects potency or erection, it must be clear that there is still much information to be given to the northern European public. The fact that the Brookman May et al. study's authors declare their results to end a myth [3] is not for nothing: oddly telling, in the 2014 European Parliament election campaign, a German mock-party called Die Partei [66] even launched a poster which read, "Hände weg vom deutschen Pimmel!" ("Hands Off German Peter!"), ironically addressing western European bureaucratic standardization issues via the seemingly German anxiety of circumcision.

Conclusion
The sacredness of the female body in Judaism and Islam corresponds to circumcision in males, a cultural practice by which human incompleteness is written directly in the body. More important than tradition-which must always be questioned-is the aspect of symbolic order of the sexes that points to culturally dependent perception in general. Psychologically, anxiety might confirm circumcised males still to be fantasied as some sort of danger to the northern European Christian-heritage culture, even when this seems to be an ancient issue long ago. Still, ambivalence toward sexuality is a common topos in Christianity, whereas more openness toward sexuality in Judaism, in Islam, and in wide parts of Asia have been common. Due to its ethnic and cultural heterogeneity and its puritan heritage, the Anglo-American region seems to be somewhere in between.
As to the medical aspect of circumcision, no real adverse effects have been observed [36]. As to psychogenic PE, behavioral and pharmacological approaches should be augmented by detailed psychosomatic anamnesis. Circumcision may support alleviation in some cases. Generally, it seems that circumcision, in case it stands the test of time, will have to be dissociated from solely religious beliefs and unquestioned cultural traditions. Instead, a somewhat more reasonable approach would be useful in order to a get a grip on circumcision. Many gynecologists and urologists favor circumcision for good reasons.