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Doctors Opposing Circumcision
Forced Retraction

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WARNING TO PARENTS:
FORESKIN RETRACTION OF INTACT BOYS — AN EPIDEMIC
(And ease of hygiene for your child)

In my capacity as the Executive Director of this international physicians’ non-profit, I field around three anguished complaints each week from parents of intact (not circumcised) boys whose foreskins were forcibly retracted by ignorant medical practitioners. Premature, forcible, foreskin retraction (PFFR) is a much more painful, serious, and potentially permanent injury than most parents imagine. It is also epidemic in English-language medicine (though apparently not elsewhere). I speculate that only one in 1,000 cases in N. America comes to our attention. Indeed many parents have no idea their child was injured or why. That might mean as many as 150,000 cases in the USA each year, but no one knows for sure.

Here is a typical incoming email. (For reasons of HIPAA protection of our parents, this complaint is a composite, details changed, but it is very typical).

“Dear Mr. Geisheker,
I have read on a mothering website that you handle complaints about retracting the foreskin of little boys. We kept our boy, Ethan, now six months old, uncircumcised because we know it is unnecessary, painful and risky. Last week during a routine doctor visit, and before I could stop him, our pediatrician, Dr. ‘Paul,’ peeled my son Ethan’s foreskin back all the way. It happened so fast there was nothing I could do.

“Ethan screamed instantly, cried for hours, and has been restless and fussy ever since. There are now small circles, like cracks, around his foreskin, which ooze blood. His whole penis is red and swollen. Ethan is now unusually fussy as soon as his diaper is wet, and we think it must sting when he urinates. He screams when we change him or the diaper touches his penis. It just breaks my heart to hear him. He had no problems at all before this doctor visit.”

“Dr. Paul told us that we must pull Ethan’s foreskin back this way every day or at least at every bath, to prevent what he called ‘adhesions’ and to clean out the smegma that builds up there. He said that if we don’t, our boy will need to be circumcised for sure.”

“Is all this necessary? I can’t believe you need to hurt a boy to keep him clean. It makes no sense to me and I am very angry at what happened to Ethan. He was a very happy baby before this.”

“Please help us.”
Signed,
Sad Mom of Beautiful Ethan

*  *  *  *

What happened to ‘Ethan’ in this composite anecdote (my three cases each week all have similar heart-breaking details) is an unmitigated, inexcusable disgrace, indefensible medical malpractice, and a clinically unnecessary (and illegal) injury to the child. ‘Mom of Ethan’ has exactly the right instincts, and with good reason.

Forced retraction is only rarely defensible. Inguinal hernia, undescended testicle, hydrocele, and varicocele can all be addressed without forcible retraction. The penis should be repositioned for any necessary intervention with sterile tape, not by inserted hemostat. Catheterization can be done by 'feel,' without retraction. Only in the instance of significant hypospadias or epispadias (congenital malposition of the urethral opening) might retraction be necessary and even then only if it is unavoidable collateral damage for which there should be specific follow-up care.

[D.O.C. follows up all such complaints with a footnoted 10-page letter to the physician or nurse, detailing the correct medical protocol, and if the parents agree, a formal complaint to their state licensing authority we are only too happy to file.]

But to understand what really happened to Ethan, and why, the reader needs a little background.

In the mid 19th century British and American doctors were hoping to ‘pathologize’ childbirth and infancy, converting these natural events into diseases, thus marginalizing their ancient competitors — midwives and doulas. They invented and marketed the notion that irritation or stimulation of sensitive tissue like genital mucosa caused disease to appear in a distant part of the body. They called this pre-germ disease theory ‘Reflex Neurosis.’

This was elaborately concocted puritanical nonsense and fraud, of course. But as well as conveniently blaming the patient for causing his own health problems, reflex neurosis spawned a whole litany of pseudo-medical interventions including circumcision, clitoridectomy, and forced foreskin retraction. Any amputation, desensitization, drying, or aggressive cleaning of sensitive genital tissue was, according to this theory, a way to discourage genital exploration and thus thwart disease.

Especially widely-promoted was the notion that a (wholly imaginary) build-up of smegma, a protective emollient both boys and girls naturally produce, might cause irritation. This could draw a child’s attention to his penis or her clitoris, so goes the theory, which he or she might then touch. This stimulation was thought to cause the child to develop tuberculosis, insanity, blindness, idiocy, hip injuries, unusual hair growth, and 20 other conditions. (Yes, this is the exact source of all those modern locker-room jokes.) Thus parents were advised to regularly retract their boy’s foreskin and scrub out this ‘dangerous’ substance, or circumcise the boy so it could not possibly accumulate. Doctors advised parents, as late as the 1930’s, to tie fingerless mittens on girls before bedtime, to prevent inadvertent ‘touching.’

This pre-germ theory — patently bizarre, cruel, stupid, even perverted — has not yet died out. It still lingers, in various watered-down versions, passed around among generations of physicians and nurses ‘folklorically,’ who then teach it to parents. While you read this, (and I wish I were just kidding) likely someone at the Mayo Clinic is forcibly retracting a hapless little boy or advising the parents to do so at each bath. A family medical ‘advisor’ sponsored by the Mayo Clinic and on the shelf in 2007, urges as much.

The genuine, proper, (European, Asian, or pre-1860) infant hygiene is astonishingly simple to explain and easier to follow, and this comes from a kindly member of our international physicians’ organization:

“ONLY CLEAN
WHAT IS SEEN

…by which this sensible pediatrician means the boy (or girl) needs only warm water gently applied to the outer, visible portions of his or her genitalia, and only the very mildest soap if any. No intrusive or interior cleaning of the genitalia of either gender is ever needed or desirable, and aggressive hygiene is destructive of developing tissue and natural flora, and is harmful as well as painful.

BASIC MALE ANATOMY
At birth the penis is anatomically immature and still developing. The foreskin adheres to the glans, (the little firefighter’s hat at the end) because of a natural connective membrane, the balano-preputial lamina. This membrane or synechia is apparently nature’s method of protecting the highly nerve-supplied portion of the maturing penis from feces, the ammonia in urine, and other irritants and pathogens. This membrane can take as long as 18 years or more to disappear allowing retraction. The mean age for natural foreskin retraction without pain or trauma is 10.4 years.1 Some men never see their glans until they are in the 20’s. Any time is normal, there is no need to see the glans early, and rushing the timetable for retraction is not necessary or desirable as no special hygiene is needed. Indeed, pre-adolescent boys need no internal cleaning whatsoever, and to suggest toddlers need to be retracted at each bath, or should be taught to do so themselves, demonstrates stunning ignorance and cruelty.

NO SPECIAL CLEANING WAS EVER NEEDED
Let us think like evolutionary biologists for a moment. If such cleaning were actually necessary, would any of us exist? Surely our forefathers would have died of infection in childhood, long before they could reproduce. Our primate predecessors were unlikely to head down to a nearby river every day to scrub their childrens’ genitals, and evolution would quickly eliminate those who needed such care. Only those not needing genital cleansing would have survived. We are those survivors.

In reality, urine, in the absence of a urinary tract infection, is a sterile liquid. The foreskin of infants, toddlers, pre-school and elementary school boys is flushed out with this sterile liquid at every urination. No further cleaning is necessary.

The mucosal genitalia, like the mucosal eyes and mouth, are self-cleaning and self-defending, and it could not possibly be otherwise. Moreover, mid-19th century British and American boys (and girls) did not suddenly develop filthy genitals which needed aggressive hygiene after their ancestors, for hundreds of generations, survived nicely on benign neglect.

Male doctors, who were born in America in the 1930s, 1940s, 1950s, 1960s, and 1970s, are almost invariably men who were circumcised at birth. Consequently, they have no personal knowledge of the foreskin—a normal component of male anatomy! They are dependent upon what ever information they received at medical school or what they can learn from medical textbooks. The medical textbooks, in many instances, are written by circumcised doctors and contain incorrect information. As a result, the public is most likely to receive incorrect information on foreskin care from medical practititioners.

The notion that little boys or girls need aggressive genital hygiene is medical delusion and invented fraud. A few modern English-language medical books, mostly from outside the USA, have this anatomy and the related hygiene correct. Unfortunately, of the 40-odd medical, nursing and parent-advice books we at D.O.C. have surveyed, only FOUR give the proper advice. The rest regurgitate 19th century puritanical folklore, a sad commentary. Consider: in 2006 D.O.C. conducted a survey of medical students, residents and physicians at an American Academy of Family Practice, AAFP, medical convention. Of the 113 we surveyed, exactly THREE (2.6%) understood this basic anatomy. Some of these young medically trained parents-to-be clung to laughable myths directly traceable to the pseudo-medical frauds of the 1860’s. (Which makes one wonder: what else in 21st century training about medical care for children is based on folklore rather than world-class science or bioethics?)

One medical text, Avery's Neonatology, (2005:1088) correctly suggests one reason why these ‘misdiagnoses’ of the boy’s natural membrane occur:

“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.”

Notes Pediatrics, a reference text by Rudolph and Hoffman:

"The prepuce, [or] foreskin, is normally not retractile at birth. The ventral surface of the foreskin is naturally fused to the glans of the penis. At age 6 years, 80 percent of boys still do not have a fully retractile foreskin. By age 17 years, however, 97 to 99 percent of uncircumcised males have a fully retractile foreskin. Natural separation between the glans and the ventral surface of the foreskin occurs with the secretion of skin oils and desquamation of epithelial cells, [or] smegma.”

Roberton's Textbook of Neonatology also warns:

“Forcible retraction in infancy tears the tissues of the tip of the foreskin causing scarring, and is the commonest cause of genuine phimosis later in life.”

Avery's Neonatology, issues a further warning :

'Forcible retraction of the foreskin tends to produce tears in the preputial orifice resulting in scarring that may lead to pathologic [i.e., in this case, iatrogenic, or physician-induced] phimosis.”

Similarly, Osborne's Pediatrics notes that phimosis or paraphimosis is “usually secondary to infection or trauma from trying to reduce a tight foreskin…” Moreover, they later state, “circumferential scarring of the foreskin is not a normal condition and will generally not resolve.”

And even the American Academy of Pediatrics, (those who formerly discouraged breastfeeding and encouraged daily forced retraction of intact boys) has now changed its tune:

“...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 AAP bulletin, "Care of the Uncircumcised Penis").

WHAT WILL HAPPEN TO LITTLE ETHAN?
Ethan’s unnecessary forcible retraction risked, or has created, one or more fully avoidable outcomes, some of which may not become obvious for years. His parents have every reason to be angry and concerned:

  1) Premature forcible foreskin retraction is uniquely painful as this is the most densely nerve supplied structure on the male body. Research shows that pain alone holds psychological consequences.
  2) Likely the child now has an ‘iatrogenic’ (physician-induced) infection, caused by unnecessary tampering. Invariably forcible retractions are performed without surgical gloves, betadine, or other antisepsis, and the open wound becomes an immediate and lingering portal for pathogens.
  3) The infection may worsen to urethral ulcer and stenosis, interfering with urination. Indeed, septic genital tampering is the likely cause of many avoidable UTI’s, (urinary tract infections) themselves used to justify circumcision.
4) The raw, bleeding surfaces, formerly separated by a natural membrane, might now fuse, causing unnatural adhesions which may eventually dissolve ––but may not.
  5) The infection may leave scar tissue which renders the foreskin inelastic, making adult hygiene and normal sexual function difficult.
  6) The inelasticity may create phimosis, an unnatural tightness of the foreskin to the glans which will not fade with time and may require medical intervention.
  7) The child with an inelastic foreskin may suffer periodic paraphimosis emergencies, or trapping of the foreskin behind the glans corona when retracted, as the glans may become strangled and ischemic (deprived of oxygenated blood) unless iced down to shrink the swelling.
  8) The child may now endure disturbing nocturnal erections (4 or 5 usually pleasant occasions each night, lifetime, is normal at all ages for both genders) which interfere with necessary REM sleep and might even create sexual dysfunction at adulthood.
  9) The child may develop painful skin bridges which may never resolve.
10) Commonly the child will become understandably reluctant to have any adult touch his genitals or bathe him. He can hardly be blamed for that.

FORCIBLE RETRACTION AND CIRCUMCISION
The attentive reader will have already sensed the connection between the historical marketing of circumcision and forcible foreskin retraction. Teaching youthful and trusting parents that their boy needs aggressive hygiene at each bath helped to market circumcision as it implied amputation might free the parents of this yucky task, unpleasant for them; painful for their son. Better, goes the argument, the immediate acute pain of circumcision rather than periodic pain inflicted by parents over the years. And when the forcible retraction by parents did cause UTI, or scar tissue, or adhesions, phimosis, or other infection, it was easy to blame the parents for inadequate hygiene or failing to choose circumcision, the ‘sensible’ option, to begin with.

Indeed, there is much anecdotal evidence that forcible retraction in the 20th century became a sort of punishment for non-compliant parents who declined circumcision at birth. The two, circumcision and forced retraction, have always been closely allied, and both create work for medical professionals while leaving the intact boy alone to develop normally holds no economic benefit whatsoever. The false binary choice presented to North American parents for over 140 years has always been retraction and cleaning — or circumcision. The easy European or Asian solution –leaving the child’s genitals entirely alone – has almost never been recommended in English-language medical practice.

POST-NATAL CIRCUMCISION
Failure to correctly identify the normal connective foreskin membrane of youth and to misdiagnose it as an artificial, unnatural ‘adhesion’ needing surgical attention is another, widespread, medical fraud. Literally millions of older toddlers in the US have endured painful and destructive forced retractions –or worse – post-natal circumcision with or without anesthesia– based on this ignorance. It is the genesis of the circumcision marketing mantra that ‘he’ll only need it later’ and the source of every family’s story of their Uncle Ernie’s painful circumcision at age 6 years he is only too happy to remind everyone of, (and which was 99.99% likely to have been an outright fraud).

A medical historian writing in 2005, notes the following about the invented and erroneous suggestion of need for aggressive male infant hygiene, and the irony that females (narrowly) escaped similar treatment:

“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 Darby, A Surgical Temptation, The Demonization of the Foreskin and the Rise of Circumcision in Britain, Univ. of Chicago Press, 2005:235.)

IMMEDIATE FIRST AID FOR FORCIBLY RETRACTED INTACT BOYS
Not all boys develop the problems we list, and millions of boys have eventually recovered from the physical results of forcible retraction by or on doctors’ orders, though no offending medical professional should take credit for the recuperative powers of children. (Of course millions did NOT fully recover and bear permanent, lifelong problems they may not even recognize as an injury.) Moreover, we do not yet fully understand the psychological effect of systematic and unjustified pain imposed on a boy’s genitals by his guardians and caregivers.

But if your child has been forcibly retracted, you MUST protect the now raw surfaces and take immediate steps to prevent unnatural reattachment of these surfaces no longer separated by a normal membrane. That membrane of birth once ripped apart will never grow back to then begin slowly dissolving on its own, original and natural, timetable. It is important to apply 4x/day Vaseline to the glans and inner foreskin for several weeks until the damaged tissue heals. This may prevent unnatural adhesions, (there are no guarantees) and importantly, may keep the child’s foreskin from becoming scarred and inelastic.

The best method, of course, is to forbid forced retraction before it occurs, by making your wishes known in advance in no uncertain terms, in writing, with a copy of the AAP guidelines (or maybe this essay) in your hand and made a formal part of your child’s chart. Better to momentarily irritate –or educate– your family physician or nurse than to injure your son for life. D.O.C. has diaper (nappie) stickers we urge parents to use. They say “I’m Intact; Don’t Retract!” This prompts a non-threatening discussion with the Anglophone medical professional.

But if you are ignored and your child is forcibly retracted despite your warning, –it can happen in seconds– you should report the offending rogue physician or nurse to your state medical society, supplying all the details. Or contact our physicians’ group to help you. There is no charge for our intercession though donations are appreciated.

If your provider understands this medicine correctly and respects your child’s natural anatomy, please share his or her name with us. We are always on the lookout for well-educated, ethical, ‘foreskin-friendly’ physicians and nurses to whom we can refer, with confidence, when parents of intact children inquire.

Remember—you have no duty to massage the ego of a poorly-educated medical ‘expert.’
Protect your child instead!

John V. Geisheker, J.D., LL.M.
Executive Director, General Counsel,

On behalf, and at the instructions of,

Dr. George C. Denniston, M.D., M.P.H., President
Doctors Opposing Circumcision
2132 Westlake Ave. N. Suite #150
Seattle, WA 98109
tel +1. 206. 465. 6636

Reference

  1. Thorvaldsen MA, Meyhoff H. Patologisk eller fysiologisk fimose? Ugeskr Læger 2005;167(17):1858-62. Available at: http://www.ugeskriftet.dk/portal/page/portal/LAEGERDK/UGESKRIFT_FOR_LAEGER/TIDLIGERE_NUMRE/2005/UFL_2005_17/UFL__2005_17_44785

See also: The Development of Retractile Foreskin in the Child and Adolescent

See also: Penile hygiene in the intact non-circumcised male



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