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Frequently Asked Questionsconcerning theProper care of the intact (NOT circumcised) Boy |
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FAQ, presented by:
By Dr. George C. Denniston, MD, MPH
Dr. Mark D. Reiss, MD
Dr. Morris L. Sorrels, MD
Along with editorial contributions by the international physician members of D.O.C.
More and more North American boys are being allowed to keep their normal, natural penis the way nature designed it, and circumcision rates are dropping steadily. In the Western US the number of intact (not circumcised) boys is over 70% now and rising, with around 90% of boys kept intact in neighboring Western Canada. But because circumcision was once so widespread, both N. American physicians and parents have lost the ancient ‘folklore’ about how to care for a normal, natural, intact boy. This is especially true in the USA, the last country to impose routine infant circumcision on a majority of its children. One recent medical textbook on care of the newborn freely admits:
“Because circumcision is so common in the United States, the natural history of the preputial development has been lost, and one must depend on observations made in countries in which circumcision is usually not practiced.” (Avery's Neonatology: Pathophysiology and Management of the Newborn, by Mhairi G. Macdonald, Mary M. Seshia, and Martha D. Mullett (Lippincott Williams & Wilkins–2005, at page 1088).
The myth that boys need special penile hygiene, including forced retraction of the foreskin to clean the glans, was started by 19th century physicians who suggested that the child’s penis produced itchy substances which encouraged masturbation. As they believed masturbation caused insanity, blindness, tuberculosis, and a litany of other diseases (for which they could offer no other cure), these early physicians urged parents to employ aggressive, even cruel, hygiene. Those pre-germ myths became imbedded in English language culture and linger even today. They can even be heard in locker room jokes. As a result, our DOC physicians get regular complaints from parents of sons about antique advice given by well-intentioned but ill-informed medical professionals or older relatives. One medical historian points out how odd it is that boys alone were affected by this mythology:
“To appreciate the scale of the error, consider its equivalent in women: it would be as if doctors had decided that the intact hymen in infant girls was a congenital defect known as ‘imperforate hymen’ arising from ‘arrested development’ and hence needed to be artificially broken in order to allow the interior of the vagina to be washed out regularly to ensure hygiene.” (Dr. Robert L. Darby, “A Surgical Temptation: The Demonization of the Foreskin and the Rise of Circumcision in Britain” Univ. of Chicago Press 2005:235)
Thus in English-language countries, both medical providers and parents need updating in the proper way to care for the intact boy the way Europeans have understood it for centuries. Luckily this is amazingly easy—mostly, there is nothing to do –but do nothing.
We provide below some answers to common questions curious or concerned parents ask our DOC physicians all the time. We hope these provide some comfort and reassurance. Of course each child is unique. For highly unusual cases and special circumstances, we are able to recommend ‘foreskin-friendly’ medical providers in many parts of North America. Please email us in confidence and privacy if the discussion below does not assist you with your son’s situation, or you need the face-to face help of a medical provider in your region. Feel free to print out this text or portions of it, to present to your medical providers if you feel that is appropriate. We encourage you to do so.
* Was I foolhardy to leave my son intact?
* Does my intact (not circumcised) son require any special hygiene?
* Is it necessary to pull a boy’s foreskin back to clean it?
* Is it true my son’s foreskin should have been retractable by age 5?
* Should I retract my son’s foreskin just a little bit more each day?
* Does my son really need a circumcision to treat a foreskin infection?
* What if my son gets a urinary tract infection?
* Why does my son’s foreskin puff-out when he pees?
* Do the white bumps under my son’s foreskin indicate infection?
* Does my son’s overhanging foreskin need a ‘trim’?
* How do I stop my toddler from ‘fiddling’ with his penis in front of our guests?
* What should I tell my son to say if he is teased for being intact?
QUES: My doctor hinted darkly that my choice to keep my boy intact was foolhardy, and that I put him at risk for all sorts of problems, inability to retract the foreskin, infections, inability to replace the foreskin after it is retracted and other scary stuff. Was I foolish to leave my son intact?
ANS: NO. We physicians are embarrassed to admit that many of the problems intact N. American boys have are related simply to tampering by our colleagues. Countries where the boys are never circumcised have much lower rates of these concerns than English speaking countries, simply because most penis ‘problems’ are due to bad medical advice, unnecessary manipulation of the child’s genitals, and lack of respect for normal male development. Besides, circumcision itself creates a whole litany of problems for the child, not the least of which is that his normal sexual functioning has been diminished. You were wise to leave your son intact, and the risks of being left ‘normal and natural’ are grossly exaggerated.
QUES: Does my intact (not circumcised) son require any special hygiene or bathing?
ANS: Short answer: NO. The good news is that the intact boy requires NO special care whatsoever. He may be bathed exactly the same way as, and no more frequently than, his sister. In fact, vigorous or aggressive hygiene may damage natural emollients and substances that provide him protection against infection. For that reason, D.O.C. recommends against bubble baths or use of any but the mildest soap for either gender, and then only to the exterior genitalia. Warm water only, a tiny application of the very mildest soap, is all that is really needed, until puberty and even after. The genitalia of both genders is mostly self-cleaning.
QUES: I was told that a boy who was not circumcised needed to have his foreskin pulled back at each bath so that his glans could be scrubbed clean. Is this really necessary?
ANS: NO, not in the slightest, and it is very harmful. That myth is based on a 19th century pre-germ theory that the foreskin of a male child traps dangerous secretions that need to be cleaned out. In fact some of his normal secretions –lysozome and lysozyme, the same immune agents found in tears, for instance–– prevent infection. Moreover, the foreskin of a boy is not able to be retracted without tearing and bleeding which risk infection and permanent scarring. Forcible retraction is both harmful to your son and very painful; it is also expressly forbidden by the American Academy of Pediatrics, who say:
“...foreskin retraction should NEVER be forced. Until separation occurs, do NOT try to pull the foreskin back — especially an infant's. Forcing the foreskin to retract before it is ready may severely harm the penis and cause pain, bleeding and tears in the skin. " (From the American Academy of Pediatrics bulletin, "Care of the Uncircumcised Penis")
QUES: My pediatrician says my son’s foreskin should have been retractable when he reached age 5, and that he now has a condition the doctor called ‘phimosis.’
ANS: Your pediatrician is wrong, (by more than ten years), about the typical timetable for foreskin retractability. He or she may be confusing true phimosis (Greek for ‘trapping’) with normal anatomy for a child of that age. Only a careful examination of the tissue can detect the difference. His or her analysis is based on outdated clinical criteria from the 1940’s. That fast-track timetable for natural retraction has been systematically debunked, over and over, and is now considered fully obsolete. Careful and well-trained medical providers know that an ‘adherent’ foreskin, one that sticks to the glans, is a protective feature of the still-developing penis. The membrane that connects the foreskin to the glans is called the ‘balano-preputial lamina’ or BPL. The BPL is a normal, natural, protective and necessary part of your growing boy and may endure, without worry, into late puberty. The BPL protects the boy’s foreskin and glans from infection, mechanical irritation from clothing, feces and urine until puberty when the boy can care for himself. Clinical research shows that only 50% of ten year-old boys can fully retract their foreskins. At any younger age, many fewer can do so of course. In any case, there is no pressing need for anyone, including the child, to see his glans before adulthood.
QUES: I was told by my family practice doctor that I should pull my son’s foreskin back a little more each day, to break what he called the ‘adhesions’ that form there. He told me that if I did not do so, the child would surely develop phimosis and need either surgery or a circumcision. My son screams when I do this and it is very unpleasant for me and I am guessing, painful for him. Why is this necessary?
ANS: Daily foreskin retraction is not only NOT necessary, it is also very harmful to your child. Those ‘adhesions’ as your doctor erroneously terms them, are a natural protective membrane that should be left alone to develop as nature intended. That membrane is not a birth defect that needs repair or attention. Forcible retraction is, ironically, the commonest cause of iatrogenic (doctor induced) phimosis, an unnatural trapping of the glans by a foreskin that cannot be retracted because it has developed adherent scar tissue. Forced retraction of the child can also lead to adult sexual dysfunction. (See the more detailed section on forced retraction elsewhere in this website.)
QUES: My doctor says my eight year-old son has an infection of the foreskin or glans and needs to be circumcised or this will recur or get worse. Will this be necessary? It seems drastic just for one infection.
ANS: You have good instincts that circumcision is drastic care for a single infection. It is common for the foreskin or glans, which come in occasional contact with the pathogens in feces, to develop a mild irritation or infection. These usually resolve by themselves without any need for a doctor’s care. Even a lingering infection of the foreskin or glans should be treated no differently than any other infection—conservative measures used first, more aggressive measures later if early attempts fail. There are good topical ointments and antibiotics now available that may assist, if they are even needed at all. There is never a need to amputate normal, healthy, nerve-dense, sexually vital and protective tissue merely to address a transient infection.
QUES: My son has had several urinary tract infections. Our family doctor says it is because we did not have him circumcised. But that seems a harsh measure to us. What should we do?
ANS: The risk of a urinary infection in the first year of life is less than 1 in 100, but they do occur. Even so, you made the correct ethical choice when you kept your son intact. Treatment by antibiotics is usually all that is needed, same as would be true for girls (who, lifetime, get many more urinary tract infections than boys ever do.) Circumcision is NOT the ideal solution. It is possible for a child to have a congenital defect of the genitourinary system such as an incompetent connection between his kidneys and bladder, or bladder and penis, that might cause recurring infections. This can be detected by a specialized x-ray of the entire genitourinary system. But such anatomical anomalies are rare and unlikely, though not unknown. A ‘foreskin-friendly’ urologist could help you if your son’s infections indicate a more serious underlying problem which needs surgical correction. Circumcision, however, would do nothing to solve a genitourinary anomaly, and aside from being inappropriate medicine, may create problems, –including infection– of its own.
QUES: Sometimes my 4 year old son’s foreskin seems to swell up when he urinates, getting all puffy. He does not complain about it so it doesn’t appear to be painful. What is that swelling caused by?
ANS: Please don’t worry. Likely all you are seeing is ‘ballooning’ of your son’s foreskin, a natural and benign event. It is caused by the fact that when the membrane that connects the glans and the foreskin slowly dissolves, it leaves pockets, spaces where urine can migrate. When the child urinates, if the stream is powerful enough, or the child does not pull his foreskin back a tiny bit to help the stream stay straight, it can run backwards under the foreskin, inflating the spaces where the tissue has naturally detached. As urine is sterile, this is not a problem. Young intact boys have been known to amuse themselves by pinching off their preputial meatus (the foreskin opening where urine exits) to inflate their partially detached foreskins on purpose. This is harmless exploration, and as the foreskin is exquisitely nerve-dense, likely a pleasant sensation—though of course it might get messy!
QUES: My son has little white bumps under his foreskin. I am told that these might be a sign of infection. Should I be concerned?
ANS: Probably not. Very likely those ‘bumps’ are merely remnants of the dissolving balano-preputial lamina, or BPL, the membrane that connects the foreskin to the glans at birth which slowly dissolves over many years. The bumps are harmless. Unless the child has other signs of infection, –swelling, redness, discoloration, pain on urination, over-frequent urination– there is little to worry about. Those bumps will slowly dissipate, dissolve, and be shed naturally.
QUES: My child has an unusually long, overhanging foreskin. It sure seems like a lot of floppy skin he does not need. I am opposed to circumcision generally, but it seems like my son needs ‘a trim.’ Should I be concerned?
ANS: Infants commonly present with a foreskin that seems way too long for their penis. The child’s glans and internal structures may be withdrawn due to temperature changes, fear, or other stimuli, leaving a ’floppy,’ unfilled, foreskin. Moreover, that ‘redundant’ foreskin as it is mistakenly termed, will be needed at puberty when the internal structure of the child’s penis begins to develop and needs this overhanging tissue as a cover. That tissue is not redundant, extra, or unnecessary, no matter what anyone says and it is highly nerve dense and necessary to natural adult sexual functioning. Usually this tissue ‘disappears’ as the child matures and his internal tubular structure —the corposa cavernosa– grows and develops to fill it. If the child is circumcised to remove this tissue, he may not have enough skin to cover his growing penis when erections occur, or he may suffer tight, painful erections. There is NO SUCH THING as redundant, extra or unnecessary penile skin. Like the comparable tissue of females, it is all necessary and nature knows best.
QUES: My intact toddler likes to fiddle with his penis, and I find this socially embarrassing when he does it in front of guests and relatives. What should I do?
ANS: Some physicians speculate that the natural shedding of the balano-preputial lamina causes a ticklish sensatioin, that draws the boy’s attention to his penis. Others think the child’s natural exploration assists the process of dissolution of the balano-preputial lamina, much like the tendency children have to wiggle a loosening baby tooth with their tongue. One famous pediatrician says that a boy experiments with his penis “simply because it is there.” Whatever the reason, he’s doing himself no harm, possibly some benefit and you can safely ignore this behavior and it is best to do so. (Reacting noticeably may only increase his enthusiasm to show off.) Eventually a boy will figure out that, like attending a stuffy nose, penile experimentation is best left as private behavior, or he’ll just get bored and wander off to a new amusement.
QUES: I worry that my intact son is being teased by his circumcised friends. In fact he has already told me that he feels ‘different’ and wants to look like the other boys. I did not want him circumcised because I felt that nature designed the human body the way it is for a reason. What should I tell him?
ANS: Well, whatever you tell him should be age-appropriate. If he is old enough –perhaps age 10 and above– to understand human sexuality, you might reassure him that his adult sexual sensation will be far more important later than any momentary urge to look like others. Likely he will have privately discovered this for himself and you will merely be confirming his observations. If he is too young to understand the worth of his sexual sensation, you need only arm him with the confidence to assert that he is not missing anything; indeed, he has been allowed to keep something other boys have lost forever. Your son could be taught to defend himself by saying, (without hurting the feelings of circumcised boys), “My parents wanted me to make my own decision about circumcision.” In any case, in many areas of North America, and especially in other English speaking locales where circumcision once flourished, like the UK, Canada, Australia, and New Zealand, intact boys are now in the vast majority. Although that may not impress your son with his immediate peer group, it is worth pointing out to him that he is not alone. Eventually his adult sexual needs and sensation will overcome his youthful conformity concerns, and he will count himself very lucky to be intact indeed. Our advice is to wait the problem out and not give into to your son’s immature wishes to be circumcised, which he will come to deeply regret once an adult.
By
Dr. George C. Denniston, MD, MPH
Dr. Mark D. Reiss, MD
Dr. Morris L. Sorrels, MD
Along with editorial contributions by the international physician members of D.O.C.
