Effectiveness of non-surgical foreskin restoration

(NSFR) to regain prepuce function and increase

positive body image.
AUTHOR: Andrew M. Smith, NREMTa

ABSTRACT
a National Registry of Emergency Medical

Technicians
OBJECTIVES: The survey objectives
were to determine the effectiveness of email: andrew.smith4@loop.colum.edu
non-surgical foreskin restoration and
KEY WORDS:
assess the need for future studies.
non-surgical foreskin restoration, circumcision,
METHODS: Participants included mitosis, tissue expansion, coverage index,
circumcised males (n = 238) that are keratinization, de-keratinization
either restoring their foreskin (n = 199)
or have already restored their foreskin ABBREVIATIONS:
(n = 9). The survey was available via NSFR––non-surgical foreskin restoration
w w w. k w i k s u r v e y s . c o m a n d t o SFR––surgical foreskin restoration
whomever had access to the Internet. CI––coverage index
The unique URL to complete the
FINANCIAL DISCLOSURE: The author has
survey was propagated through the use
no financial relationships relevant to this article.
of Facebook foreskin restoration
groups, and foreskin restoration FUNDING: There was no financial expense
forums on the Internet. Female needed to conduct this survey.
participants were urged to not partake
in the survey, and were filtered
through the use of an initial CONCLUSIONS: NSFR is a safe and
questioning of the participants effective means to regrowing a prepuce
biological gender. with proper education and technique.
However, unlike the name suggests, the
R E S U LT S : T h e m a j o r i t y o f
foreskin will never be restored to its
participants have reported increased
original condition. The multitude of
sexual pleasure and positive body
specialized nerves and frenulum cannot
image as a result of non-surgical
be regrown but the many functions that
foreskin restoration. The faux prepuce
were lost can be regained. Despite the
has regained multiple functions that
amount of time required, the benefits
were lost because of circumcision,
of non-surgical foreskin restoration
including increased sensitivity of the
seem to be worth such an endeavor.
penis, gliding motion of the inner and
outer foreskin, protection of the glans,
and natural lubricant for sexual
intercourse and masturbation.
SUMMARY:
As of 2007, approximately 30% of the
world’s men are reported to be
circumcised, either because of religious
influence, cosmetics, perceived health
benefits, or medical necessity. (WHO,
and UNAIDS. "Male Circumcision
Global Trends and Determinants of
Prevalence, Safety and
Acceptability." (2007): Web.) Per the
results of this survey, 89% of
participants were circumcised as a
neonate (birth-1mo) through infancy
(1mo-1yr). Although circumcisions
may not be remembered later in life, it
is very clear that the procedure has
negative impact because 87% resent
being circumcised. 88% were
circumcised because of their parents
decision, while 7% decided to get
circumcised themselves for various
reasons, 2% of which chose to do so
for cosmetic reasons. Per the results of
this survey, 238 participants from
around the world have decided to
u n d e rg o n o n - s u rg i c a l f o r e s k i n
restoration, or have already done so. As
of Friday, January 29, 2016
(01/29/2016), there is a combined total
of 15,300 active members registered
w i t h r e s t o r i n g f o r e s k i n . o rg a n d
foreskin-restoration.net.
Non-surgical foreskin restoration is a
process with a variable amount of time
needed for completion, and its success
depends on many factors. New skin is
formed by the process of tissue
expansion, which is “the controlled
overstretch [of skin] to grow extra skin
for defect repair”. 2 In simpler terms,
when multiple cells are the same type
they form what is called tissue. New
skin cells are grown when the over-
stretching of skin induces mitosis,
which is when a cell divides and
creates an identical copy of itself. The
copies of the cells become a part of the
original tissue 3, which in the case of
NSFR is the skin sheath of the penis.
Non-surgical foreskin restoration,
because of the process of mitosis, can
create a near-perfect match of the
original skin, minus the specialized
nerves that were present in the original
foreskin. Dependent on the presence of
the inner foreskin (mucous membrane)
cells on the penis of the restoring
person, and the foreskin restoration
technique (manual tugging, inflation,
tension device), the cells that make up
the inner foreskin can duplicate by
mitosis, which results in a regrown
mucous membrane. Upon regrowing a
sufficient amount of skin to cover the
glans of the penis, de-keratinization of
the mucous membrane can occur.
Increased moisture retention in the
inner foreskin aids in the process of de-
keratinization, as well as rehydration of
the mucous membrane tissue, which
increases sensitivity of the skin. The
gliding motion caused by the inner and
outer foreskin moving against each
other is also regained as a function.
5,6,15 Since starting foreskin restoration
or having completed restoring their
foreskin to their desired goals, 87% of
participants feel better about their
penis, 82% report a more sensitive
glans, 75% report more pleasurable
sex, 84% report more pleasurable
masturbation, 93% say their new
foreskin is easy to clean, 8% say that
their foreskin smells bad, 78% feel
they are more "whole", 75% feel more
normal, and 1% feel that restoring their
foreskin was a mistake. (Figures 28-30)
A major concern with any procedure,
whether surgical or not, is safety.
Fortunately, non-surgical foreskin
restoration by tissue expansion is
relatively safe. 7 However, it appears as
though more information regarding
foreskin restoration needs to be readily
available, specifically pertaining to
safety and how to properly use tension
and inflation devices. The majority of
participants (75%) will stop a restoring
session in order to investigate the cause
of pain, while 25% of participants will
either sometimes or never stop to
investigate because of pain. 5 (2%)
participants have visited a hospital,
doctor, urgent care centre, or any other
medical facility or professional
because of injuries that have occurred
while restoring. A torn circumcision
scar was experienced by 11 (5%)
participants, and the formation of
stretch marks were experienced by 49
(24%) participants. (Figure 21-24) It is
unknown whether or not the use of oils
or skin moisturizers plays a role in the
prevention of torn circumcision scars
or stretch mark formation. Of the
participants using manual tugging and
or taping techniques, 20% have had
difficulties learning the techniques.
17% of participants using tension and
or inflation devices have had
difficulties learning how to properly
use their respective device. (Table 21)
In light of all the benefits, there is,
unfortunately, one significant drawback
to NSFR - the length of time required. 8
The percentage of participants that
have started restoration more than 1
year ago as of 2015 is 60%. More
specifically, 36% of participants
surveyed have been restoring for 2-4
years, 9% for 5-7 years, and 15% for 8
or more years. On average, 26% of
participants spend 6 or more hours per
day and 6 days per week restoring their
foreskin. 29% of participants have
stopped restoring because too much
time was needed, while 54% are just
taking a break. (Figure 14, Tables 11-20)
Non-surgical foreskin restoration,
unlike the name suggests, doesn't
actually restore the foreskin to its
original condition. The thousands of
specialized nerves cannot be regrown,
however the many functions that were
lost can be regained. Despite the
amount of time required, the benefits
of NSFR seem to be worth such an
endeavor, for 99% of participants
would recommend foreskin restoration,
and 65% are satisfied with their current
results. (Figure 30)
INTRODUCTION:
A significant amount of function and
sensitivity of the penis is lost as a
result of circumcision.19, 25-26 The inner
Figure 1. The erect intact penis. 6
foreskin (mucous membrane) dries and
keratinizes over time, and the frenulum
is removed * , seen in Figures 1 and 2.
The glans penis changes color, dries
out, and skin becomes tough. 21 The
many specialized nerves that were
present in the foreskin are also lost. 9
Dysfunctions of the penis such as
erectile dysfunction (ED), and painful
erections are reported to be a
consequence of circumcision. 10,11
Foreskin restoration, both surgical and
non-surgical, are ways in which the
attempt to regain function and
sensitivity of the penis and reduce
dysfunction and pain can be pursued.
The first documented case of surgical
foreskin restoration dates as far back as
1898, and was performed in Canada.
The procedure included reconstruction
of the frenulum and narrowing of the
existing foreskin on a patient that had a
circumcision that left enough skin to
cover the glans. In 1990, the successful
*The removal of the frenulum is dependent on the type of circumcision performed, and skill level of the
surgeon.
† CI means Coverage Index, which is the measurement of the amount of skin covering the glans penis.
Figure 2. The erect circumcised penis. 6
SFR using scrotal skin grafts was
completed. The patient reported delight
with the results, which suggests that
SFR can increase positive body image.
While no severe complications are
reported as a result of SFR, the
formation of scars is inevitable and the
color and texture of the new foreskin
does not match the existing skin of the
penis. 12,13 Another option available,
however, is non-surgical foreskin
restoration by skin expansion.
A closed survey was released with the
objectives of determining the:
• effectiveness of NSFR.
• necessary time investment of NSFR.
• safety of NSFR.
• current and desired CI. †
• techniques used for NSFR.
• body-image of the participant.
• perceived benefits of NSFR.
BACKGROUND:
Pediatric and adult male circumcision

Figure 3. Common circumcision procedures. Illustration by Kagan McLeod and Jonathon Rivait. 14
is one of the most dated surgical
procedures and is a widely debated,
controversial topic. This is because of
the fact that circumcision removes the
prepuce (foreskin), which has multiple
sexual and non-sexual functions. As of
2007, approximately 30% of the
world’s men are reported to be
circumcised, either because of religious
influence, cosmetics, perceived health
benefits, or medical necessity. 1 Given
the prevalence of circumcision and its
notoriety, it is important to also spread
awareness about effective non-surgical
options for those persons wanting to
regain the majority of prepuce function
and sensitivity.

DEFINITIONS:
Circumcision is a surgical procedure,
most commonly performed on
newborns, that removes the foreskin of
the penis. The amount of skin or
removal of the frenulum is not
regulated and varies from case to case.
Circumcision results in the glans penis
being exposed and the formation of a
ring shaped scar around the remaining
skin sheath. There are many ways in
which circumcision can be performed,
however the most common types are
Gomco clamp, Mogen clamp, and
Plastibel, seen in Figure 3.

Prepuce (foreskin) is a continuation of

the skin sheath of the shaft of the penis
that covers the glans penis. The
frenulum is a highly vascularized tissue
 that connects the foreskin to the glans

Figure 4. Sensitivity of the intact and circumcised penis. 4

penis. 1 The inner foreskin contains
smooth mucosa and ridged band
tissue, both lined by cells similar to
those found in the mouth, vagina, and
esophagus. Meissner’s corpuscles are
concentrated in the ridged band of the
foreskin, as seen in Figure 4. 9 The
foreskin also protects the glans penis
so it remains moist. 15

Non-surgical foreskin restoration

(NSFR) is the process of using tissue
expansion to induce mitosis, resulting
in skin growth on the shaft of the
penis. There are many techniques and
devices that aid in this process, the
most common of which are as
follows:

• Manual tugging of the skin.

• Dual Tension Restorer (DTR).
• TLC Tugger & TLC-X

From left to right: DTR, TLC-X, TLC Tugger.

 Figure 5. Comparison between keratinized and non-keratinized tissue. 16

Keratinization (cornification) is the

process of epithelial cells losing
moisture and converting into horny
tissue * , forming the Stratum
corneum, as seen in Figure 5,
Diagram A. This process is different
from the formation of hairs, nails, and
horns and can be described as a soft
cornification. 17 It takes place on the
remaining inner foreskin of the
circumcised penis because the
epidermis is responding to rough
usage 18 , causing a hardened layer of
cells to form, as seen in Figure 5,
Diagram A. The glans penis does not
keratinize, however its color and Figure 6. . Figure 7.

texture changes 21 , as seen in Figures

6 and 7. epidermis renewing itself with the use
of stem cells present in the basal layer.
De-keratinization is the opposite of The renewal of the epithelial cells
keratinization and is the process of the occurs continuously throughout a

* Horny tissue is resemblant of tough fibrous material.

lifetime. When enough new skin is
regrown to cover the glans penis and
form an inner layer of skin (inner
foreskin), the rough and drying
environment no longer exists and de-
keratinization of the mucous
membrane can occur without the
renewal of horny tissue. Similarly,
when artificial protection is provided,
most commonly with the use of a
retaining device, de-keratinization can
occur.
SURVEY OBJECTIVES:
Education plays an important role in
any society, especially when it is
involved in the prevention of harmful
occurrences and the introduction of
beneficial processes. The objectives of
the survey were therefore to:
1. Establish trends relating to the
physical and emotional effects of
male circumcision.
2. Determine the effectiveness of
non-surgical foreskin restoration
in regaining prepuce function and
increasing positive body image.
3. Evaluate the average amount of
time necessary for results. *
4. Assess the need for additional
surveys or studies.
* Results of NSFR are subjective in relation to the survey.
METHODS:
Creation of the survey and data
collection
The survey was created using an online
survey creator, www.kwiksurveys.com.
The author created a list of 40 multiple
choice questions, ranging from
objective to subjective based, and 9
matrix (table) selection questions with
objective and subjective based
questions and answers. The decision to
solely use multiple choice questions
instead of also including response type
questions was so that the survey could
be as accurate as possible for the type
of medium being used to gather the
results. The survey was created and
propagated to the public on January 29,
2015 (01/29/2015) through the use of
social media (Facebook, online forums,
etc.) and ran for a total length of 34
days (1 month and 3 days), closing on
March 3, 2015 (03/03/2015).
Target population
The desired sample size was in the
range of 10,000 - 24,000 participants
that have been circumcised, however
the sample size obtained was 238 male
participants and 17 female participants.
The optimal sample size could not be
achieved due to lack of funding.
Responses came from Australia (9),
New Zealand (2), Romania (1), Spain
(1), France (2), United Kingdom (7),
Germany (4), Sweden (2), Norway (1),
Argentina (1), Colombia (1), Mexico
(3), United States (174), and Canada
(15). There is a total of 223 responses
that had locations tracked. Presumably,
the missing tracking on the remaining
15 responses is because of the Internet
browser security settings of the
participant. There was no age
requirement for participation in the
survey. Female participants were urged
to not partake in the survey, and were
filtered through the use of an initial
questioning of the participants
biological gender. If the participant
disclosed their gender to be female,
they were not allowed to participate in
the survey. No other personal identifier
besides gender was used to determine
eligibility for participating in the
survey. Tables 1-3 show the different
population groups that were surveyed.
Data management
Data was stored on the server owned
by KiwkSurveys. Data was download
in the form of a Comma Separated
Values document (CSV), Portable Data
File (PDF), and Excel Spreadsheet, and
is being stored on The Author’s
computer’s solid state drive.
Personal data
Each participant took part in the survey
in anonymity. IP addresses were
obtained to allocate the location of the
participant, which was done through
KwikSurveys. The IP addresses were
not disclosed to The Author. By taking
part in the survey, the participant
agreed to allow the sharing of the
collected data.
RESULTS:
Data was collected over 34 days from
29th of January to 3rd of March 2015.
Tables 1-3 summarize the different
population groups and their ages.
A total of 238 men participated in the
survey of which 59 stopped completing
the survey at various questions.
A total of 17 women attempted to
complete the survey but were not
allowed to do so since they identified
as “female”. It is unknown if any
female participants selected “male” in
order to trick the survey algorithm to
allow participation of the survey.
Data was therefore collected from a
total of 255 people of various ages,
genders, and locations, analyzed from
238 eligible participants, of which 179
completed the survey to its full extent.
Circumcision
There was an overall prevalence in
neonatal circumcisions and prevalence
declined as age group increased, as
seen in Table 4.
Table 1 - Sexual orientation by age

Table 2 - Ethnicity by age

Table 3 - Religion by age

Table 5 - Reason for circumcision
Reason circumcised
Parents decision, non-religious
Parents decision, religious
Parents decision, medical
Parents decision, emergent medical
Personal decision, religion
Personal decision, cosmetic
Personal decision, medical
Other
The majority of circumcisions were
performed because of the participant’s
parent’s decision to do so, being at
88%. A few participants decided to get
circumcised on their own accord for
various reasons, as seen in Table 5.
Resent of circumcision
The majority of participants resent
having been circumcised (87%),
whether it was their own personal
decision or their parents. There are
multiple factors that seem to influence
the resentment of circumcision,
ranging from mild to significant, which
are as follows:
• Age group when circumcised
• Reason for circumcision
• Coverage index
• Insulted for being circumcised
n %
144 65.16
20 9.05
23 10.41
8 3.62
2 0.9
4 1.81
9 4.07
11 4.98
Age group when circumcised
The age of the participant when the
circumcision was performed does not
seem to have significant influence on
resentment of circumcision. However,
even in younger age groups resentment
is present despite presumed lack of
recollection of the procedure.
Resentment is the majority in each age
group. (Figure 8)
Reason for circumcision
The reason the participant was
circumcised seems to play a significant
role in determining the likelihood of
resentment. Of all the parental
reasoning for circumcision, religious
influence creates resentment in the
most number of participants. Following
thereafter is a parental decision
influenced by medical reasons not of
emergent nature. The reasoning with
the least amount of resentment are
those made by the participant
themselves. However, it is worth
Figure 8 - Trends of age group when circumcised and resentment

noting that the majority of participants
resent circumcision regardless of
making the decision on their own
accord. Resentment is the majority no
matter the reasoning for circumcision.
(Figure 9)
with a low CI are more likely to resent
circumcision than those with a high CI.
Similarly, participants with a high CI
are less likely than those with a low CI
to desire a high CI upon completion of
NSFR. (Figure 10)

Coverage index Insulted for being circumcised

Coverage Index (CI) seems to have Participants that were insulted for
significant influence on the prevalence being circumcised have a higher
of resentment as well as the desired CI chance of resenting circumcision than
upon completion of NSFR. Participants participants that were not insulted.

Table 6 - Resentment and being insulted for circumcision

Insulted! ! ! Not insulted

Resentment n % n %

Yes 26 11.87 164 74.89

No 1 0.46 28 12.79
Figure 9 - Trends of resentment and cause of circumcision

Figure 10 - Relationship between CI and resentment

Resentment is the majority regardless Coverage index

of if the participant was insulted or Nearly all participants were at a CI 1-3
not. (Table 6) upon starting NSFR. This means that
the majority of participants had a tight
Table 7 - Coverage index
Before NSFR! ! Current !! ! Desired

CI n % n % n %

1 136 61.54 9 4.07 0 0

2 52 23.53 34 15.38 0 0

3 32 14.48 78 35.29 1 0.45

4 0 0 34 15.38 3 1.36

5 0 0 19 8.60 3 1.36

6 0 0 16 7.24 9 4.07

7 0 0 18 8.14 30 13.57

8 0 0 11 4.98 66 29.86

9 1 0.45 1 0.45 37 16.74

10 0 0 1 0.45 72 32.58

circumcision before pursuing NSFR. • Sexual pleasure before NSFR

The average CI before NSFR is 1.6.
At the time of participation in the
survey, participants were all at various
CI’s, the average of which is 4. This
means that the majority of participants
currently have regrown enough
foreskin to cover the corona of the
penis when not erect.
Desired coverage index
There are multiple factors that seem to
have significant influence on the
desirability of a CI, which are as
follows:
• Resentment of circumcision
• Insulted for being circumcised
• CI before NSFR
• Pain and dysfunction before NSFR
Resentment of circumcision
Seen in Figure 10, participants that
have resentment for circumcision
desire a higher CI upon completion of
NSFR. Resentment seems to have
significant influence on the desirability
of a CI.
Insulted for being circumcised
Having been insulted for being
circumcised increases the number of CI
that the participant desires and
decreases the range of CI to choose
from. Those that were not insulted
desire a CI from a range of 3-10, while
those who were insulted desire a CI
from a range of 6-10. The majority of
Figure 11 - Trends in being insulted and desired CI

Figure 12 - Influence of CI before NSFR on desired CI

Table 8 - Influence of pain and penile dysfunction on desired CI
Painful erections! ! Painful sex! Erectile dysfunction

Desired CI n % n % n %

1 0 0 0 0 0 0

2 0 0 0 0 0 0

3 0 0 0 0 0 0

4 1 2.00 1 3.13 0 0

5 0 0 0 0 1 1.53

6 1 2.00 0 0 2 3.10

7 6 12.00 8 25.00 13 20.00

8 14 28.00 3 9.41 19 29.23

9 8 16.00 4 12.50 8 12.31

10 20 40.00 16 50.00 22 35.50

participants not insulted desire a CI of participants with erectile dysfunction

8, while the majority of insulted
participants desire a CI of 10.
CI before NSFR
The desired CI upon completion of
NSFR, as seen in Figure 12, is
influenced by the CI number that the
participant had before NSFR. Those
with a lower CI before NSFR seem to
desire a higher CI than those with a
higher CI before NSFR.
Pain and dysfunction before NSFR
Painful erections or sex and erectile
dysfunction seem to have significant
influence on the desirability of a CI.
98% of participants experiencing
painful erections or pain during sexual
intercourse desire a CI > 5. 100% of
desire a CI > 5. (Table 8)
The percentage of participants that
have experienced painful erections or
sexual intercourse or erectile
dysfunction and are desiring a C-10 is
higher than the overall percentage.
However, the desire for a C-10 and C-8
are in the majority whether or not pain
or dysfunction was experienced.
Sexual pleasure before NSFR
Enjoyment of sexual intercourse seems
to have moderate influence on the
desirability of a CI. Participants that
enjoyed sexual intercourse before
NSFR are 52% more likely to choose
CI-8 than CI-10, while those who did
not enjoy sexual intercourse are 64%
Figure 13 - Influence of sexual pleasure before NSFR on desirability of CI

Table 9 - Referrals of NSFR

more likely to choose CI-10 than CI-8.
This suggests that lack of enjoyment of Medium n %
sexual intercourse before NSFR results
in the desire of a higher CI. (Figure 13)
Television 5 2.4
Non-surgical foreskin restoration
Seen in Table 9, the majority of Radio 1 0.48
participants were informed about
NSFR through the Internet. This Friend or colleague 10 4.81
suggests that additional means of
reaching the population that is eligible Family member 7 3.37
for NSFR might be necessary.
Internet 165 79.33
However, many participants have
informed various people about their Social media 6 2.88
plans of NSFR of which the majority
are the spouse or partner. Following Other 14 6.73
thereafter are the friends of the
participants. Approximately 1/4 of
 Figure 14 - Time investment of NSFR

Table 10 - Who participants inform of NSFR

participants informed no one of their
Informed n % NSFR plans. (Table 10)

Nobody 51 24.52 Investment of time

The majority of participants spend an
Spouse or partner 95 45.67 average of 6 hours or more 6 days per
week on NSFR, as seen in Figure 14.
Mother 23 11.06
Spending less than 1 hour on NSFR
seems to be steadily low across-the-
board, dipping even lower for
Father 12 5.77
participants that restore 6 days per
week. As the number of days per week
Sibling 17 8.17 spent on restoring increases, so does
the number of hours per day. However,
Other family
member
23 11.06 participants that restore 7 days per
week spend considerably less time
Friend or colleague 75 36.06 daily on NSFR than those who take at
minimum one day of rest.
Online friend 77 37.02
There are multiple factors that
influence the amount of time spent on
Other 17 8.17
 Table 11 - Trends in average time spent for NSFR and employment status

Employment status Hrs/day Days/week Longest break from NSFR

Employed >6 6 < 1 month

Unemployed <1 6 1-2 months

Student <1 7 < 1 month

Retired <1 6 < 1 month

NSFR, ranging from mild to part, the days per week spent on NSFR
significant, which are as follows: are equal between all employment
statuses. However, students are
• Employment status spending on average 1 day more on
• Religious faith NSFR than others. Similarly, the
• Education longest break taken from NSFR is
• Marital status equal between all employment statuses
• Resentment of circumcision with the unemployed taking 1 month
• Current CI more of break time than others. (Table 11)
• Desired CI
• Current age Religious faith
• NSFR technique Religious faith seems to have
• Use of retainer * significant influence on the
participant’s investment of time in
Employment status NSFR. Those with religious faith spend
Employment status seems to have far less time on NSFR than those who
moderate influence on the participant’s are non-religious or have other
investment of time in NSFR. Spending religiousness or spiritualness. The most
6 or more hours is the majority for frequent amount of time taken as a
employed participants, break from NSFR is less than one
less than 1 hour for the unemployed, month regardless of religious faith.
students, and the retired. For the most (Table 12)

Table 12 - Trends in average time spent for NSFR and religious faith

Religious faith Hrs/day Days/week Longest break from NSFR

Religious 1 5 < 1 month

Non-religious >6 6 < 1 month

* A retainer is a NSFR device used to hold the regrown skin
Other 4-5 5 over the glans penis. < 1 month
Table 13 - Trends in average time spent for NSFR and education

Education Hrs/day Days/week Longest break from NSFR

No education 4-5 5 < 1 month

Nursery - 8th grade 4-5 5 7-8 months

Some high school <1 2 < 1 month

HS diploma or eq. >6 5 1-2 months

Trade/technical cert. >6 5 < 1 month

Some college >6 6 < 1 month

Professional degree >6 6 1-2 months

Associate’s degree 1 6 < 1 month

Bachelor’s degree <1 6 < 1 month

Master’s degree 4-5 5 < 1 month

Doctoral degree 4-5 5 1-2 months

Education some level of college. Graduating from

Education seems to have significant
i n f l u e n c e o n t h e p a r t i c i p a n t ’s
investment of time in NSFR. Those
with either one of the two lowest or
highest levels of education spend 4-5
hours per day 5 days per week.
However, those with nursery school –
8th grade education have taken a 7-8
month break from NSFR either on one
high school or earning the equivalent
increases the amount of hours spent per
day up until either an Associate’s
degree or Bachelors degree has been
earned. With the exception of
participants that have only completed
some high school, the average days per
week spent on NSFR is between 5-6.
(Table 13)

or more than one occasion. Otherwise

the longest break taken from NSFR is
in the range of less than 1 month – 1-2
months. Participants that are either still
in high school or have only completed
some level of high school spend less
time on NSFR than those who are
either still in college or have completed
Marital status
Marital status seems to have moderate
i n f l u e n c e o n t h e p a r t i c i p a n t ’s
investment of time in NSFR.
Participants that are currently single,
either never married or divorced,
spend the same amount of time on
Table 14 - Trends in average time spent for NSFR and marital status
Marital status Hrs/day
Single, never married >6
Separated 2-3
Divorced >6
Widowed 1 2
Married or partnership >6
Table 15 - Trends in average time spent for NSFR and resentment of circumcision
Resentment Hrs/day
Yes >6
No 2-3
NSFR, which is the most time spent of
all marital statuses. Participants that
are separated spend 1 day more and 3-4
or more hours less on NSFR than those
who are married or in a domestic
partnership. Widowed participants
spend the least amount of time on
NSFR. (Table 14)
Resentment of circumcision
Resentment of circumcision seems to
have moderate influence on the
participant’s investment of time in
NSFR. Those with resentment spend
3-4 or more hours per day and 1 day
less per week than those without
resentment. The longest break taken
from NSFR is the same regardless of
resentment. (Table 15)
Days/week Longest break from NSFR
7 < 1 month
6 < 1 month
7 < 1 month
3-4 months
5 < 1 month
Days/week Longest break from NSFR
5 < 1 month
6 < 1 month
Current coverage index
Current CI seems to have mild
i n f l u e n c e o n t h e p a r t i c i p a n t ’s
investment of time in NSFR. Those
with the lowest and highest CI, CI-1
and CI-10, spend 6 hours or more per
day 7 days per week on NSFR. Those
with a CI-2 spend on average 2 days
less on NSFR than those with a CI-1.
Those with a CI of 2–8 spend between
5-6 days per week on NSFR.
Participants with a CI-9 spend the least
amount of time on NSFR. The longest
break taken from NSFR is less than
one month for the majority of CI’s.
However, those with a CI-7 have taken
a break of 1-2 months, and those with a
CI-9 have taken a break of 5-6 months.
(Table 16)
Table 16 - Trends in average time spent for NSFR and current coverage index

Coverage index Hrs/day Days/week Longest break from NSFR

1 >6 7 < 1 month

2 >6 5 < 1 month

3 <1 5 < 1 month

4 4-5 6 < 1 month

5 >6 6 < 1 month

6 4-5 5 < 1 month

7 4-5 5 1-2 months

8 2-3 6 < 1 month

9 <1 3 5-6 months

10 >6 7 < 1 month

Table 17 - Trends in average time spent for NSFR and desired coverage index

Coverage index Hrs/day Days/week Longest break from NSFR

3 >6 7 9-10 months

4 2-3 6 1-2 months

5 1 3 3-4 months

6 1 5 2-4 years

7 4-5 6 < 1 month

8 >6 5 < 1 month

9 2-3 6 < 1 month

10 >6 5 < 1 month

 Table 18 - Trends in average time spent for NSFR and current age
Desired coverage index
Desired CI seems to Age Hrs/day Days/week Longest break from NSFR
have moderate
< 12 4-5 5 1-2 months
influence on the
participant’s investment 12-17 >6 7 < 1 month
of time in NSFR. The
amount of hours spent 18-24 >6 6 < 1 month
on NSFR decreases as
the desired CI increases, 25-34 <1 6 < 1 month
up until the desired CI
35-44 4-5 6 < 1 month
is 5, from which point
the hours spent 45-54 1 5 < 1 month
increases. However,
those with a CI-9 spend 55-64 >6 5 < 1 month
2-3 hours per day on
NSFR. The days per 65-74 2-3 5 < 1 month
week don’t seem to be
> 75 4-5 5 1-2 months
majorly influenced by
the desired CI. The days
per week spent rotate between 5 and 6, 12-17 spend 7 days per week, 18-44
with the exception of those with a CI-3 spend 6 days per week, and 45 and
who spend 7 days per week and those older spend 5 days. The youngest and
with a CI-5 who spend 3 days per oldest age groupings have taken a 1-2
week. Participants that desire a CI of month break and those aged 12-74
3–6 have a wider variety of time taken have taken a break from NSFR of less
as a break from NSFR, while those than a month. (Table 18)
with a CI of 7–9 have taken a break of
less than 1 month. (Table 17) NSFR technique
The technique chosen for NSFR seems
Current age to have moderate influence on the
Current age seems to have mild participant’s investment of time in
i n f l u e n c e o n t h e p a r t i c i p a n t ’s NSFR. Those that solely use the
investment of time in NSFR. However, manual tugging or taping technique
there are very distinct trends for the spend 2-3 or more hours per day and 1
days spent per week and the longest day per week less than those using both
break taken from NSFR. The hours manual tugging or taping and device or
spent per day seem to have no distinct inflation techniques together. Those
pattern. As the age of the participant that solely use devices or inflation
increases, so does the amount of days spend 1 day more than those solely
per week spent on NSFR. Those aged using manual tugging or taping, and
Table 19 - Trends in average time spent for NSFR and NSFR technique

NSFR technique Hrs/day Days/week Longest break from NSFR

Manual tugging or taping 2-3 5 < 1 month

Device or inflation 2-3 6 < 1 month

Both >6 6 < 1 month

Table 20 - Trends in average time spent for NSFR and use of retainer

Use of retainer Hrs/day Days/week Longest break from NSFR

Never >6 6 < 1 month

Rarely 4-5 7 < 1 month

Sometimes <1 5 < 1 month

Frequently >6 5 < 1 month

2-3 or more hours per day less than
those using both manual tugging or
taping and device or inflation
techniques together. The longest break
taken from NSFR is less than 1 month
regardless of the techniques being
used. Participants using both
techniques of NSFR spend the most
NSFR. Those that occasionally or
frequently use a retainer spend 5 days
per week on NSFR, while those that
rarely or never use a retainer spend 6-7
days per week on NSFR. (Table 20)
N S F R techniques
There are two
Figure 15 - NSFR techniques

amount of time on NSFR. (Table 19) divisions of

techniques
Use of retainer used for
The use of a retainer seems to have NSFR, which
mild influence on the participant’s are manual
investment of time in NSFR. Those tugging,
that never use a retainer spend the w h i c h
same amount of hours per day as those includes the
who frequently use a retainer, however use of taping,
spend 1 day more per week on NSFR. and devices, which includes the
Participants that rarely use a retainer use of inflation. As seen in Figure 15,
spend the most days per week on the majority of participants use both
Figure 16 - Usage of manual tugging or taping
Figure 17 - Satisfaction of manual tugging or taping
manual tugging techniques and
devices in NSFR.
Manual tugging or taping
Seen in Figure 16, the number of
participants that either never use or
often use a manual tugging or taping
method is nearly mirrored. The
majority of participants (75%) have
never used methods 3-5 or taping or T-
taping. Inversely, the majority of
participants (35%) often and
occasionally use method 2 and the
squeeze-stretch technique. The number
of participants either barely or
occasionally using methods 1-5 is
fairly level. Few participants no longer
use methods 1-5 and many participants
no longer use taping or T-tape methods.
Satisfaction of tugging or taping
Seen in Figure 17, the majority of
participants (79%) strongly like and
like methods 1-2, with the satisfaction
of technique decreasing rapidly after
method 2 and slowly declining from
thereon. However, from tape to T-tape,
another rapid decline in satisfaction of
technique is seen. The neutrality of
satisfaction is fairly level across-the-
board. Very few participants have
strong dislike or dislike for the
majority of manual techniques, with
3% of participants strongly disliking
Figure 18 - Usage of devices
Figure 19 - Satisfaction of devices
the tape and T-tape techniques, and a
total strong dislike and dislike
percentage of 4.
Devices
Seen in Figure 18, the majority of
participants (95%) own the DTR and
eith er u s e it s o lely, o f ten , o r
occasionally. Following thereafter at
86% is the often, occasional, and sole
use of homemade devices. The third
most owned and used device is the
TLC-X, with 64% of participants either
using it solely , often, or occasionally.
Staying within the TLC family of
devices, the TLC Tugger is the fourth
most owned and used device with 59%
of participants using it often or solely.
However, the TLC Tugger is the device
most commonly owned and not used.
The majority of participants (99%) do
not use or own the MSC. Following
thereafter is the MP with 3% usage and
97% of participants owning the device.
The CAT II Q is second device most
commonly owned and not used.
However, the CAT II Q has the same
often or solely usage as the TLC-X.
Satisfaction of devices
The satisfaction of a device seems to
somewhat correlate with the usage of
the device, as seen in Figure 19. The
majority of participants (96%) strongly
like and like the DTR. Following
thereafter is the strong like and like of
 Table 21 - NSFR technique usability
homemade devices at 85%. The TLC- Tugging/Tape Devices/Inflation
X is the third device most strongly
Difficult n % n %
liked and liked at 57%. ~25% of
participants that own the TLC Tugger Yes 41 22.28 36 20.00
strongly dislike or dislike the device,
making it the most disliked device. No 142 77.17 143 79.44

Inflation use and satisfaction Attainability of NSFR technique

44% of participants that use devices
also use inflation. Seen in Figure 20,
the majority of participants (70%)
strongly agree and agree that inflation
is a very effective NSFR technique.
However, the majority of participants
are neutral about inflation being more
effective than other NSFR devices. The
majority of participants (62%) do not
use inflation as their sole NSFR
technique.
Seen in Table 21, the majority of
participants (77% & 79%) had no
difficulty learning NSFR techniques
for either tugging or tape or devices or
inflation. This suggests that NSFR
techniques are generally easy to learn.
Use of retainer
Seen in Table 22, out of the majority of
participants (60%) that use or have
used a retainer, they either rarely
(23%) use a retainer, sometimes (43%)
use a retainer, or always (34%) use a
retainer whenever they are not using

Figure 20 - Satisfaction of inflation

Table 22 - Trends in use of retainer and NSFR technique Table 23 - NSFR safety
Both Manual Device Total
Safety n %
Wear retainer n % n % n % n %
Extremely 125 60.39
Never 38 32.8 16 48.5 29 50.9 83 40
Safe 74 35.75
Rarely 17 14.7 2 6 9 15.8 28 13.5
Neutral 8 3.86
Sometimes 36 31 9 27.3 8 14 53 25.5

Always 25 21.5 6 18.2 11 19.3 44 21.2

other NSFR techniques to stretch the participants experiencing it. 2% of

skin of the penis.
Safety and health concerns
Seen in Table 23, the majority of
participants (96%) consider NSFR to
be a safe means of foreskin restoration
if properly educated. 60% of
participants feel NSFR to be extremely
safe, and 36% feel NSFR to be safe.
Leaving 4% of participants at a neutral
standing in the matter of safety.
Seen in Table 24, the most prevalent
complication is the formation of stretch
marks on the skin of the penis, which
24% of participants have experienced.
Tearing of the circumcision scar is the
least likely to occur, with 5% of
participants have visited a hospital or
other medical professional or facility
because of injuries caused by NSFR.
69% of participants have not
experienced any medical complication
as a result of NSFR.
There are multiple factors ranging from
mild to significant that influence the
perceived safety of NSFR, as well as
the occurrence of any complications
that arose while restoring, which are as
follows:
• Education
• Desired CI
• Technique used
• Difficulty learning technique

Table 24 - NSFR complications Education

Yes! No Education seems to have moderate
Complication n % n % influence on the safety of NSFR. Those
with a higher level of education have
Torn scar 11 5.31 196 94.69 fewer occurrences of complications.

Stretch marks 49 23.67 158 76.33 The formation of stretch marks does
not seem to be related to education.
Hospital visit 5 2.42 202 97.58 The percentage of participants with
stretch mark formation in each
Figure 21 - Safety and complications related to education
educational division were relatively
similar, within the range of 21-30%.
Similarly, tears of circumcision scars
are unlikely regardless of education,
with 5-8% of participants in each
education division tearing their
circumcision scar. It appears as though
those with graduate or doctorate school
education have the least likely
possibility of tearing their circumcision
scar. However, this could be due to the
small sample size of participants that
have claimed graduate or doctorate
education.
The least likely complication is that of
hospital visits, with 2% of participants
having to had visit a hospital, doctor,
urgent care or any other medical
facility, or a medical professional
because of injuries that have occurred
while restoring. (Figure 21)
Desired CI
Desired CI seems to have varied
influence on the safety of NSFR.
Moderately; 42% of participants that
have experienced a torn circumcision
scar desire a CI of 10 upon completion
of NSFR. Likewise, the majority of
participants (37%) that have had
stretch marks form also desire a CI of
10 upon completion of NSFR.
Mildly; one participant from each CI
desire group between 6 and 10 have
had to visit a hospital, doctor, urgent
care or any other medical facility, or a
medical professional because of
injuries that have occurred while
restoring. This suggests that injuries
needing medical attention are
uncommon and not particularly related
to desired CI. (Figure 22)
Figure 22 - Safety and complications related to desired CI

Technique used occur that requires medical attention

The technique used seems to have
moderate influence on the safety of
NSFR. Participants that solely use
devices and those that use devices and
manual techniques seem to have a
higher chance of tearing their
circumcision scar or having an injury
(~6-7%).
Stretch mark formation occurs more
with participants that either use devices
only or use both manual techniques
and devices (~20-27%). (Figure 23)

Figure 23 - Safety and complications related to NSFR technique used

Figure 24 - Safety of NSFR related to difficulty learning technique
Difficulty learning technique
Difficulty learning NSFR technique
seems to have mild influence on the
safety of NSFR. There is a wider
difference between the occurrence of
complications with participants that
had difficulty learning manual
techniques or devices than with those
that had no difficulty learning how to
use a manual technique or device. Of
the participants that had difficulty
learning manual techniques or how to
use a device, ~7-8% have torn their
circumcision scar, ~30-34% have had
stretch marks form, and ~6-7% have
had to visit a hospital, doctor, urgent
care or any other medical facility, or a
medical professional because of
injuries that have occurred while
restoring. Of the participants that had
n o d i ff i c u l t y l e a r n i n g m a n u a l
techniques or how to use a device,
~5-6% have torn their circumcision
scar, ~23-25% have had stretch marks
form, and ~1.5% have had to visit a
hospital, doctor, urgent care or any
other medical facility, or a medical
professional because of injuries that
have occurred while restoring. (Figure 24)
Satisfaction of results
4% of participants have completed
their foreskin restoration, leaving 96%
of participants still involved in the
NSFR process. Of which, a hiatus from
NSFR has occurred because (a)
participant was made fun of (4%), (b)
pain was too much to bear (5%), (c)
restoration techniques were too
difficult to learn (10%), (d) participant
could not obtain a NSFR device
because the lack of available funds
(12%), (e) NSFR goals have been
reached (14%), (f) participant not
seeing enough results to their
satisfaction (26%), time demands of
 NSFR is too high (29%), and (g)
participant is taking a brief hiatus from
NSFR (54%).
However, the majority of participants
(44% & 21%) are either satisfied or
extremely satisfied with their results.
22% of participants are neutral, and the
minority of participants (11% & 2%)
are dissatisfied or extremely
dissatisfied with their results.
There are multiple factors ranging from
mild to significant that influence the
satisfaction of results, which are as
follows:
• Coverage index
• Technique used
• Medical complications
• Sexual function
Figure 25 - Influence of CI on satisfaction of NSFR results
Coverage index
Coverage index seems to have
moderate influence on the satisfaction
of results. As seen in Figure 25, of
those participants with a CI of 1-3
before starting NSFR, 65% are
satisfied with their results, 13% are
dissatisfied, and 22% have a neutral
standing. The only participant with a
CI of 7 before starting NSFR has
reported satisfaction of current results.
47% of participants with a current CI
of 1-3 are satisfied with their current
results, 20% are dissatisfied, and 34%
have a neutral standing. 65% of
participants with a current CI of 4-7 are
satisfied with their current results, 14%
are dissatisfied, and 22% have a neutral
standing.
54% of participants with a desired CI
of 4-7 are satisfied with their results,
Figure 26 - Influence of NSFR method on satisfaction of results
12% are dissatisfied, and 35% have a
neutral standing. 55% of participants
with a desired CI of 8-10 are satisfied
with their results, 19% are dissatisfied,
and 27% have a neutral standing.
Technique used
The NSFR method used seems to have
mild influence on the satisfaction of
results. As seen in Figure 26, of those
participants that use a device as their
primary NSFR method, 52% are
satisfied with their current results, 16%
are dissatisfied, and 32% have a neutral
standing.
Of those participants that use manual
techniques as their primary NSFR
method, 55% are satisfied with their
current results, 14% are dissatisfied,
and 30% have a neutral standing.
Of those participants that use both
manual techniques and devices for
NSFR, 73% are satisfied with their
current results, 11% are dissatisfied,
and 15% have a neutral standing.
Medical complications
Medical complications seems to have
mild influence on the satisfaction of
results. As seen in Figure 27, the
majority of participants with a medical
complication (54%) as a result of
NSFR are satisfied with their current
results, 15% are dissatisfied, and 31%
have a neutral standing.
Of those participants with a torn
circumcision scar as a result of NSFR,
27% are satisfied with their current
results, 27% are dissatisfied, and 46%
have a neutral standing.
Of those participants that have had
stretch marks form as a result of
NSFR, 61% are satisfied with their
Figure 27 - Influence of medical complications on satisfaction of results
current results, 10% are dissatisfied,
29% have a neutral standing.
Of those participants that have visited a
hospital or other medical professional
or facility because of injuries caused
by NSFR, 40% are satisfied with their
current results, 40% are dissatisfied,
20% have a neutral standing.
Sexual function
Sexual function seems to have
moderate influence on the satisfaction
of results. As seen in Figure 28-29,
positive sexual function as a result of
NSFR leaves more participants
satisfied with their results than those
that have negative sexual function.
Of those participants with a gain in
glans sensitivity, 79% are satisfied with
their current results, 10% are
dissatisfied, and 11% have a neutral
standing. 0.00% of those with no gain
in sensitivity are satisfied with their
current results, 60% are dissatisfied,
and 20% have a neutral standing.
Of those participants with a gain in
sexual pleasure, 83% are satisfied with
their current results, 6% are
dissatisfied, and 11% have a neutral
standing. 0.00% of those with no gain
in sexual pleasure are satisfied with
their current results, 67% are
dissatisfied, and 33% have a neutral
standing.
Of those participants with a partner
that had a gain in sexual pleasure, 86%
are satisfied with their current results,
5% are dissatisfied, and 9% have a
neutral standing. 33% of those with a
partner that had no gain in sexual
pleasure are satisfied with their current
results, 33% are dissatisfied, and 33%
have a neutral standing.
Of those participants with a gain of
masturbatory pleasure, 73% are
Figure 28 - Influence of positive sexual function on satisfaction of results

Figure 29 - Influence of negative sexual function on satisfaction of results

satisfied with their current results, 9%
are dissatisfied, and 18% have a neutral
standing. 40% of those participants
with no gain in masturbatory pleasure
are satisfied, 20% are dissatisfied, and
40% have a neutral standing.
Of those participants with a partner
that is more attracted to the participant,
84% are satisfied with their current
results, 9% are dissatisfied, and 6.3%
have a neutral standing. 44% of those
participants with a partner that is either
less attracted to or has had no gain in
attraction to the participant are satisfied
with their current results, 28% are
dissatisfied, and 28% have a neutral
standing.
Figure 30 - Enjoyment of sex and masturbation before and after NSFR

Figure 31 - Painful sex before NSFR and increased pleasure after NSFR

Seen in Figures 30 and 31, the majority
of participants that enjoyed sexual
intercourse and masturbation before
NSFR reported an increase in sexual
(73%) and masturbatory (68%)
pleasure. As well, 16% of participants
that enjoyed sexual intercourse and
masturbation before NSFR reported no
increased sexual pleasure, 17%
reported no increased masturbatory
pleasure, 11% are neutral regarding
increased sexual pleasure, and 15% are
neutral regarding increased
masturbatory pleasure.
Additional satisfactions
Seen in Figure 32, 87% of participants
have experienced a gain in positive
image of their penis, 3% have not, and
10% are neutral. 93% of participants
agree that their faux foreskin is easy to
clean, 0.00% disagree, and 7% are
Figure 32 - Satisfaction of NSFR

neutral. 8% of participants agree that effective, 12% disagree, and 22% are
their faux foreskin smells bad, 75% neutral.
disagree, 17% are neutral. 32% of
participants are uncomfortable not Recommendation of NSFR
wearing a retaining device while not Seen in Figure 33, 178 participants
restoring, 41% are not uncomfortable, would recommend NSFR, leaving 1
and 27% are neutral. 78% of participant not recommending NSFR.
participants feel more “whole”, 3%
disagree, and 19% are neutral. 74% of
participants feel as though their Figure 33 - NSFR recommendation
endeavors were successful, 12% feel
unsuccessful, and 14% are neutral.
75% of participants feel more normal,
5% disagree, and 21% are neutral. 1%
of participants feel as though NSFR
was a mistake, 98% disagree, and 1%
are neutral. 88% of participants feel as
though NSFR was worth the time, 11%
disagree, and 2% are neutral. 78% of
participants feel as though devices are
effective, 4% disagree, and 18% are
neutral. 67% of participants feel as
though manual techniques are
Figure 34 - Condom usage before and after NSFR
Condom usage
Seen in Figure 34, before NSFR, the
majority of participants (62%) did not
partake in usage of condoms during
sexual intercourse. Of those
participants, 8% are now more likely to
use condoms since starting NSFR, 57%
are not, and 35% are neutral.
Of the participants that always used
condoms before NSFR (15%), 38% are
now more likely to use a condom since
starting NSFR, 14% are not, and 48%
are neutral.
Of the participants that were neutral on
condom usage before NSFR (15%),
21% are now more likely to use a
condom since starting NSFR, 26% are
not, and 53% are neutral.
Discussion and limitations
It seems that regardless of the reason a
participant has been circumcised, the
majority still resent the procedure.
Furthermore, it is very telling that even
those participants that chose to be
circumcised resent having done so.
However, it is important to note that
the participants in this study were
sampled primarily from Internet sites
for men that are presumably already
unhappy with their circumcision.
Otherwise, the participants from those
sites would most likely not be pursuing
NSFR. Sites and forums pertaining to
NSFR were used for data collection
because this study focused on foreskin
restoration. It was not the intention to
collect data from primarily, presumably
unhappy participants. Future studies
with a broader sample size of
circumcised participants that are not
pursuing or aware of NSFR is
necessary for better evaluation on
resentment of circumcision.
Furthermore, those future studies
would need to assess a participant’s
education on the foreskin and its
functions. It is assumed, but not
proven, that the participants in this
study are aware of the purpose of
foreskin because they are pursuing
NSFR to regain lost functions. It is
only possible to truly resent the loss of
foreskin if its purpose is fully
understood. For future studies, it would
be beneficial to dive deeper into the
reasons why a participant is resentful
of circumcision. This paper makes
connections between resentment and
demographics, reason for circumcision,
CI, and emotional bullying of
circumcision, but it does not
definitively connect a participant’s
resentment as a direct causation.
Legitimate reasons for resentment can
only be obtained from the participant
themselves.
Anecdotal and observational
indications of physiological changes of
the glans penis (drying, toughening,
change in coloration, loss of sensitivity,
etc.) have traditionally been attributed
to keratinization. However, there is no
evidence currently to suggest
additional keratinization of the glans
penis after circumcision. Regardless,
full or partial loss of the frenulum,
which is dependent on the circumcision
performed, and decrease in sensitivity
of the coronal ridge decreases sexual
sensitivity. The glans penis is most
sensitive to vibrations, specifically in
the coronal ridge and frenulum/
underside of the glans. 22-24 There is
also little evidence proving major
differences in glans sensitivity between
circumcised and uncircumcised
participants. So while the absence of
foreskin does not seem to have a huge
impact on glans penis sensitivity, the
other functions that are lost decrease
sexual sensitivity. It can be assumed
that any increase in glans sensitivity, as
reported by participants, is either
purely psychological or a result of new,
unfelt sensitivity because of de-
keratinization of the mucous
membrane. Future studies on the cause
of coronal ridge desensitization, and if
NSFR re-sensitizes the coronal ridge,
should be considered.
One sexual function of the foreskin
that is said to be lost is the gliding
motion. This study does not ask the
question of if a gliding motion is
regained or felt by a participant. There
are currently no studies indicating how
many circumcised and uncircumcised
men experience a gliding motion.
Human prepuce: some aspects of
structure and function 27 states that,
“The tight frenulum helps to retain the
obliquely placed loop of retracted
prepuce in position. The inner lining of
the projecting tubular part has the
structure of the outer layer and adds to
the thin gliding skin when retracted.”
However, the statement referencing the
gliding skin does not have any relation
to the gliding motion during coitus.
Future studies indicating how many
men (circumcised, uncircumcised, and
restoring) and their partners experience
a gliding motion during coitus are
necessary. It would also be interesting
to determine if using a retaining device
to protect the glans or any remaining
foreskin, instead of using a device or
manual technique to stretch the skin, is
enough to increase positive body image
and sexual sensitivity and pleasure.
Sensibly, participants with a lower CI
before beginning NSFR desire a higher
CI upon completion. There were many
strong connections made between
desired CI and the reasons for such a
d e s i r e d C I . H o w e v e r, a m o r e
straightforward approach to
understanding the reason for a
participants desired CI is necessary for
future studies.
There are many influences in daily life
that can hinder the amount of time
available to devote to NSFR.
Surprisingly, participants that are
employed spend more time on NSFR
than those that are either unemployed
for whatever reason or a student.
Participants that are non-religious
spend more time on NSFR. For future
studies, it would be interesting to see if
there is a connection between
circumcision and losing faith in a
participant’s religious belief.
Prevention of sexually transmitted
diseases is one of the most frequently
discussed reasons in favor of
circumcision. Participants that did not
always wear a condom before NSFR
were still unlikely to wear a condom
since starting NSFR. Similarly,
participants that always wore a condom
were even more likely to use a condom
since starting NSFR. This suggests that
NSFR does not seem to have a huge
role in the decision making regarding
condom usage during coitus. Which
further suggests that circumcision as
well has little impact on the usage of
condoms. What is more alarming
though is the high percentage of
participants that do not use condoms
during coitus. This suggests that
increased public education regarding
safe sex practices might be necessary.
However, the slight increase in
participants that are now more likely to
not use a condom during coitus since
starting NSFR when they originally
always used a condom before NSFR
suggests an increase in sexual pleasure
or sensitivity.
Based on the responses of participants,
despite the high occurrence of stretch
mark formation, NSFR seems to be
fairly safe with proper technique and
education. However, controlled and
monitored studies are necessary to
confirm the actual safety of NSFR. For
future studies, it would be beneficial to
have further information collected on
how and why a participant had a
medical complication and what the
prognosis was. As well, data needs to
be collected on the use of topical
creams and oils or dietary supplements
that aid in the NSFR process, and on
how to properly use a NSFR device or
technique. Granted, there are resources
available on the Internet that explain
how to use a device or technique,
however legitimate studies that can
determine correct and safe ways to use
a technique or device are necessary. All
future studies would be beneficial in
that they can help design an effective
and safe, possibly individualized plan
for those that wish to pursue NSFR. At
the very least it would help get
information to personal healthcare
providers so that they can properly
assist their patients with NSFR.
Currently there are no statements
regarding NSFR made by the American
Academy of Pediatrics (AAP), Center
for Disease Control (CDC), or Child
Protective Services (CPS) in their
recent guidelines on circumcision.
Furthermore, there are no studies
regarding NSFR mentioned in those
guidelines. Learning about the attitudes
and motivations of men undergoing
NSFR is important in the decision
making process of persons considering
circumcision. Before allowing a person
to make a medical decision, on behalf
of another person or themselves, it is
the responsibility of the medical
professional to discuss all possible
outcomes of such a decision. It is of
upmost importance that the findings of
this study are made available to
persons making the decision on
circumcision.
Literature review
There are few articles that study the
sensitivity of the glans penis. In one
study, Fine-touch pressure thresholds
in the adult penis 4 , “Adult male
volunteers with no history of penile
pathology or diabetes were evaluated
w i t h a S e m m e s - We i n s t e i n
monofilament touch-test to map the
fine-touch pressure thresholds of the
penis. Circumcised and uncircumcised
men were compared using mixed
models for repeated data, controlling
for age, type of underwear worn, time
since last ejaculation, ethnicity, country
of birth, and level of education.” This
study came to the conclusion that “the
glans of the circumcised penis is less
sensitive to fine touch than the glans of
the uncircumcised penis.” However the
major difference in sensitivity was seen
in the coronal ridge. There is currently
no evidence to suggest that after
circumcision the glans penis becomes
further keratinized than it already is.
However, Alex. L. Hodgen, M.D.
states in his publication in the
Maryland Medical Journal, Volume 37,
that “...after circumcision, the head of
the [penis] and any remains of the
mucous membrane becomes
toughened, the head fading from a
purple hue to about the color of
ordinary skin, and any remnants of the
mucous membrane from red to the
general color of the [skin].” 21 The
Frenular Delta 26 offers a postulation
to such occurrence in that, “(1) as
circumcision interrupts this venous
circuit and (2) as superficial veins are
not restored in the great majority of
preputial remnants, the change in the
color of the glans from a venous purple
in genitally intact males to the pink tint
of the penile shaft in circumcised
males is due to a dramatic change in
skin circulation in the circumcised
penis.” Future studies determining the
legitimate cause of color change and
toughened skin, and if the possible
change in circulation changes the
sensitivity of the penis are necessary.
In another study, How does male
circumcision protect against HIV
infection 20 , “Histological observations
were carried out on samples of penile
tissue obtained from 13 perfusion fixed
cadavers of men aged 60-96 years,
seven of whom had been circumcised.”
This study came to the conclusion that
“the epithelia [of the glans is] equally
keratinised [compared to
uncircumcised participants]. In
circumcised participants only the distal
penile urethra is lined with a mucosal
epithelium.” However, this study falls
short on being able to report the
sensitivity of the glans penis, sensibly
because there were no living
participants in the study. It also does
not note the condition or treatment of
the glans penis while the cadaver was
alive. As well, it is unknown if the
embalming or decomposition of the
cadavers played a role in the studies
findings. The authors of this paper state
that the glans does not keratinize,
however they do not offer alternative
explanations as to why the glans
changes color and texture.
Future studies need to be conducted on
living persons, measuring the
keratinization and sensitivity of the
glans penis after circumcision, and any
possible connections between
keratinization and rougher
environments that the glans penis
endures. As well, future studies are
needed to explain if the glans penis
recovers its color and texture as a result
of NSFR, and if those changes are
associated with a change in sensitivity,
whether physiologically or
psychologically.
Conclusions
This study shows that the majority of
circumcised participants, regardless of
the reason for their circumcision,
resent being circumcised and have
chosen to pursue NSFR so that they
may regain prepuce function. NSFR is
a safe and effective means to
regrowing a prepuce with proper
education and technique. However,
unlike the name suggests, the foreskin
will never be restored to its original
condition. The multitude of specialized
nerves and frenulum cannot be
regrown but the many functions that
were lost can be regained. Regardless,
the majority of participants are
satisfied with their results and report
increased body image and sexual
function. Despite the amount of time
required, the benefits of non-surgical
foreskin restoration seem to be worth
such an endeavor.
ACKNOWLEDGMENTS
The Author would like to thank Juan
Andrés Alzate, Glen Davis, and Greg
Hartley for thoughtful discussions and
helpful suggestions.
Conflicts of interest:
The Author of this paper declares that
he has no conflicts of interest.
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