Doctor Ignorance of Male Anatomy Harms Boys

*Written by John Geisheker, J.D., LL.M.

WHY DO FORCED RETRACTION INJURIES CONTINUE TODAY?

Simplest answer: Folklore -as well as a recognized failure of U.S. medical schools to teach fundamental gross anatomy of male infants. One medical text, Avery's Neonatology (2005), candidly suggests a feeble excuse:

"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."

There are, indeed, excellent foreign resources which describe the correct infant anatomy: (Øster, 1968; Kayaba, 1996; Cold & Taylor, 1999; Concepción-Morales, 2002; Ishikawa, 2004; Agawal, 2005; Thorvaldsen and Meyhoff, 2005; Agawal, Mohta, and Anand, 2005.)

...but U.S. medical providers continue to cling to and circulate Victorian myths among themselves.

A recent survey of U.S. medical books, for instance, revealed that only two out of 42 pediatric, nursing, neonatology, and urology texts as well as family health encyclopedias, detailed the correct (minimal) hygiene needs for male infants. The rest featured obsolete, misleading, and potentially injurious advice directly traceable to 19^th-century sources.

Many medical texts even depict males as naturally circumcised, thus eliminating a normal body part as if it never existed, and quashing any need to discuss the slow timetable for natural, unaided, foreskin-glans detachment. (Harryman, 2004).

At a national convention of family practice doctors in 2009, for example, only two out of 113 doctors and med students we polled understood the proper, minimal, hygiene needs of a male infant. This is very likely due to the fact that the doctors themselves are circumcised and so inherently see the foreskin as abnormal.

WHAT DOES FORCED RETRACTION HAVE TO DO WITH CIRCUMCISION?

The claimed necessity for foreskin retraction and cleaning is used to 'market' circumcision. Circumcision is touted as a one-time method for parents to avoid the (imaginary) chore of regular genital cleaning. Leaving the genitals of both boys and girls to develop naturally, as is the case in Europe, has not yet fully arrived in American medical training or clinical practice.

Many U.S. families have an anecdote of their Uncle Charlie's distressing circumcision as a young boy. Very likely, though, his circumcision was claimed to 'cure' a normal condition -the natural fusion of glans and foreskin. Or possibly, Uncle Charlie was forcibly retracted as an infant and developed true secondary phimosis due to inelastic scarring. For over a century such cases were used as a scare tactic to convince parents to choose infant circumcision. Doctors claimed, "He'll only need it later when it is more painful." In truth, phimosis is both over-diagnosed and easily treated without circumcision, with topical steroids and stretching exercises. And in any case, a boy, even one with the rare true but mild phimosis, does not need to see his glans, nor does his penis need internal cleaning, until adolescence.

WHAT ABOUT THE CONCERN FOR UTI, URINARY TRACT INFECTIONS?

Proponents of circumcision claim that intact boys have a higher incidence of UTI, (Wiswell, 1985-86) but even the absolute incidence is only 1%, one infant in 100, if that. And that 1% can be easily explained by 'septic genital tampering' of which forcible foreskin retraction is a glaring example. In several years of investigating parent complaints of forcible retraction, we have not found even a single case involving a physician wearing surgical gloves -not one. Many parents claimed that the practitioner was not even seen to wash his or her hands beforehand.

Such failures of simple antisepsis, -100,000 or more times each year- easily explain the entire claimed higher incidence of UTI in intact boys.

WHAT IF MY SON'S FORESKIN 'BALLOONS' WHEN HE PEES?

While the errant sprinkles might be annoying, ballooning is harmless and easily explained. Unfortunately, it often leads to poor medical advice to either circumcise or forcibly retract the boy. The inflation of the foreskin by urine is due to a simple fact of flow dynamics -if it is easier for the urine to inflate the partially detached but elastic foreskin than to flow outward, it will flow sideways. Intact boys sometimes pinch their outer opening closed so the urine inflates their foreskin. Because the sensitive nerve receptors of the erogenous foreskin like being stretched, boys no doubt enjoy the sensation, (as well as the reaction they get out of their parents.) This ballooning phase is transient, as eventually the outer opening will be wide enough to allow unimpeded flow, or the boy can be taught to pull his foreskin back gently to encourage the stream outward.

WHY NOT JUST LEAVE THE BOY'S PENIS TO DEVELOP ON ITS OWN?

Why not, indeed! Evolution has apparently provided a useful protection for boys, at a time when they are still developing. Penises, like vulvas, do not need internal cleaning in childhood. The balano-preputial lamina is very much like the female hymen, protecting the child's genitals from feces and other infection or injury at a time when the child does not need to procreate.

It cannot be the case that our primate ancestors bothered to scrub their offspring's genitalia when their time was better spent foraging for food. We are the evolutionary survivors who needed no such intrusive care -or none of us would be here.

A medical historian notes the following about the erroneous and invented English-language urge to scrub the genitals of young males:

"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.)

WHAT CAN BE DONE TO DISCOURAGE THIS INJURY?

Our child-hygiene advice to parents is amazingly simple: "Only Clean What is Seen!" The first person to ever retract the boy's foreskin should be the boy himself, as he will stop when it hurts. Our simple advice to medical practitioners may be found on a diaper/nappy sticker we supply parents. It warns, "I'm Intact! Don't Retract!" This prompts an exam-table discussion well worth having in advance of any injury.

The developing penis of a child, like his sister's vulva, is self-cleaning and self-defending, as it has been for tens of thousands of years. In evolutionary terms, it could hardly be otherwise. The most sensible parents are those who instinctively practice 'benign neglect,' largely ignoring their child's penis (and antique medical advice) and who insist that their son's medical providers observe a 'hands-off' policy.

Unfortunately, until this injury is fully abandoned, forever banished by reform from within U.S. medical education, parents will need to be on constant guard. They should NEVER leave their intact child's side during any medical exam. They should simply forbid, in advance, any retraction in unequivocal terms, and compose a signed letter to be inserted in the child's medical chart explaining their wish to protect their son. Parents must remain on guard to any medical professional's request or insistence to "just see the urethra" or any other manipulation of the foreskin.

It may be a pity to admit it -but until today's generation of intact boys grows up to be doctors, the education of medical practitioners must now come from observant parents with good natural instincts.

John V. Geisheker, J.D., LL.M.

George C. Denniston, M.D., M.P.H.

Mark D. Reiss, M.D.

Morris R. Sorrels, M.D.

of Doctors Opposing Circumcision, Seattle

Pediatric consultant: Robert S. Van Howe, M.D., M.S.

POSTS ON CIRCUMCISION

Myths about Infant Circumcision you Likely believe

More Circumcision Myths You May Believe: Hygiene and STDs

Circumcision: Social, Sexual, Psychological Realities

Circumcision Ethics and Economics

What Is the Greatest Danger for an Uncircumcised Boy?

Why Continue to Harm Boys from Ignorance of Male Anatomy?

Pro-Circumcision Culturally Biased, Not Scientific: Experts

Protect (All) Your Boys from Early Trauma

Circumcision’s Psychological Damage

References and Resources for this and previous post:

Agawal A, Mohta A, Anand RK. Preputial retraction in children. J Indian Assoc Pediatr Surg 2005;10(2):89-91.

Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1:34-44.

Harryman, GL, An analysis of the Accuracy of the Presentation of the Human Penis in Anatomical Source Materials, in Flesh and Blood, Perspectives on the Problem of Circumcision in Contemporary Society, eds. Denniston, Hodges, and Milos, Kluwer Academic/ Plenum Publishers, NY, 2004.

Ishikawa E, Kawakita M. [Preputial development in Japanese boys]. Hinyokika Kiyo. 2004;50(5):305-8.

Kayaba H, Tamura H, Kitajima S, et al. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol 1996;156(5):1813-5.

Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child 1968;43:200-3.

NOTES:

‘Gairdner's Error' concerns the erroneous notion, popularized by British paediatrician Douglas Gairdner in 1949, that an intact boy's foreskin should be fully retractable by age 2 to 3.[1] Gairdner was grossly in error, as Europeans and-better educated American physicians know. Modern research, multiple times since 1968, shows that the actual mean age for natural, normal, expected, non-traumatic foreskin retraction is 10+ years, and even late puberty is no indication of pathology.[2]

From Rudolph and Hoffman's Pediatrics:
"The prepuce, 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, smegma. At puberty, the secretions of specialized sebaceous glands, Tyson's glands, assist in completing the separation between the glans and the foreskin; in adulthood they protect and lubricate the glans penis and inner layer foreskin. No treatment is required for the lumps or smegma, and in particular, there is no indication ever for forceful retraction of the foreskin from the glans. Especially in the newborn and infant, this produces small lacerations in addition to a severe abrasion of the glans. The result is scarring and a resultant secondary phimosis. Thus it is incorrect to teach mothers to retract the foreskin." [3]

A recent issue of UROLOGY NEWS[4] describes the correct anatomy:

"...Typically, the prepuce is long with a narrow tip, and the inner surface of the prepuce is fused with the outer surface of the glans so retraction is rarely possible.

...The fused prepuce and glans separate and spontaneous retraction of the foreskin and uncovering of the glans is usually possible by puberty. 'Phmosis' is often used misleadingly to describe a normal, developmental, non-retractile foreskin, implying pathology, when in reality there is none. More appropriate terms such as 'non-retractile foreskin' should be used in its place."

Roberton's Textbook of Neonatology also warns: "leave it alone and "not to try and retract it":[5]

"All newborn males have "phimosis"; the foreskin is not meant to be retractile at this age, and the parents must be told to leave it alone and not to try and retract it. 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 similar warning of immediate and irrevocable damage[6]:

‘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 warns about permanent damage:

"[phimosis or paraphimosis] is usually secondary to infection or trauma from trying to reduce a tight foreskin..." "circumferential scarring of the foreskin is not a normal condition and will generally not resolve." [7]

Avery's Neonatology also notes the boy's normal and expected preputial membrane may endure, without worry, into late puberty --as it has for many tens of thousands of years. This is not some secret, but an important detail of fundamental gross anatomy understood in the Renaissance and which European-trained physicians know well.

A medical historian writing in 2005 notes the following about the invented and erroneous suggestion of a need for aggressive or intrusive infant male hygiene, and the happy accident that females historically 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.)

A leading neonatal text, Avery's Neonatology: Pathophysiology and Management of the Newborn, MacDonald (ed) Lippincott, (2005:1088) suggests one reason why these (charitably termed) ‘misdiagnoses' of the male child's natural and normal balano-preputial-lamina occur in English-language medicine:

"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."

References for notes: SHORT WARNINGS ABOUT FORCIBLE FORESKIN RETRACTION

1) The American Academy of Pediatrics:

"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. "

2.) Pediatrics, a reference text by Rudolph and Hoffman, details the typical timetable for the natural desquamation of the child's balano-preputial lamina, and warns:

"The prepuce, 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... in particular, there is no indication ever for forceful retraction of the foreskin from the glans. Especially in the newborn and infant, this produces small lacerations in addition to a severe abrasion of the glans. The result is scarring and a resultant secondary phimosis. Thus it is incorrect to teach mothers to retract the foreskin."

3.) Roberton's Textbook of Neonatology also warns:

"All newborn males have "phimosis"; the foreskin is not meant to be retractile at this age, and the parents must be told to leave it alone and not to try and retract it. 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."

4.) Avery's Neonatology issues a similar 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."

5.) Similarly, Osborne's Pediatrics notes that:

"[phimosis or paraphimosis] is usually secondary to infection or trauma from trying to reduce a tight foreskin..." "circumferential scarring of the foreskin is not a normal condition and will generally not resolve."

6.) Avery's Neonatology: Pathophysiology and Management of the Newborn, MacDonald (ed) Lippincott, (2005:1088):

"Because circumcision is so common in the United States, the natural history of the preputial development has been lost..."

7.) Darby --A medical historian writing in 2005 notes the following about the invented and erroneous suggestion of need for aggressive male infant hygiene:

"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.)

[1] Gairdner D. The fate of the foreskin: a study of circumcision. BMJ 1949; 2: 1433-1437

[2] Phimosis and Paraphimosis, Article Last Updated: Apr 11, 2006, Santos Cantu Jr, MD, Consulting Staff, Department of Pediatrics, North Central Baptist Hospital. Avaialable at: http://www.emedicine.com/emerg/topic423.htm

[3] Rudolph, AM, and Hoffman, MD, Pediatrics, Appleton and Lange, Norwalk CT & Los Altos CA, 1987, Eighteenth Ed., Chap 23.13.1 "Penis" at p1205.

[4] Urology News, Vol 14(6) NOV / DEC 2009

[5] N.R.C. Roberton, "Care of the Normal Term Newborn Baby", in Janet M. Rennie and N.R.C. Roberton (eds) Textbook of Neonatology, 3rd edn., Edinburgh, Churchill Livingston, 1999:378-9.

[6] Avery's Neonatology: Pathophysiology and Management of the Newborn, MacDonald (ed) Lippincott, 2005:1088

[7] Osbourne's Pediatrics, 2005, eds Osborne, DeWitt, First & Zenel, (Elsevier Mosby), at pg 1925.

[8] Urology News, Vol 14(6) NOV / DEC 2009