CAUTION: This blog post contains medical images of penises suffering medical conditions. It is not for the squeamish.
Maybe
you're an intact male who was born in America and were, up until this
point, blissfully unaware that circumcision is deeply ingrained in North
American culture, and having anatomically correct genitals carries
social stigma. (Your blogger didn't know his penis was a "problem" until
his junior year in high school.)
Maybe you're a
European male visiting the United States for a job or study abroad, and
you come from a country where having a foreskin is simply as plain as
having lips, eyelids and a nose.
But now you're doctor is telling you you need to get circumcised.
You
came in for a cough, but for whatever reason the doctor asked you to
take off your pants because he wanted to see your dick. He takes one
good look at your intact member and he says "Oh, you got it bad. We need
to schedule you for a circumcision."
The question is, do you?
There are a few considerations that you need to get out of the way
before you entertain this thought any further, particularly if you are
an intact male living in North America.
In America, "Whole Penis" is a Medical Condition
America and Europe are different in many ways. One of the biggest
differences between both continents is in the way we view circumcision and anatomically
correct male genitals. Whereas circumcision, particularly the routine
circumcision of infant males, is a common, culturally ingrained practice
in the United States, it is rare or virtually not practiced in Europe,
except among Jews and Muslims.
Perhaps due to Judeo-Christian roots, people in both continents share a
taboo surrounding nakedness, so they are unaware of each others'
practices. People in Europe often believe that circumcision is limited
to religious groups, such as Judaism and Islam, and generally believe
that their American counterparts hold male circumcision in the same
regard. In great contrast, people in America believe anyone who's anyone is circumcised. It
often comes as a shocking surprise to people in either country, when
they find out the truth; Americans are surprised that the rest of the
English-speaking world does not circumcise, and Europeans are horrified
to find out that in America, male newborns are often circumcised.
You do WHAT?
It is no surprise, then, that American and European physicians hold
different views when it comes to male genitals and circumcision. What
they learn in medical school concerning male genital development is
vastly different; while European physicians are taught to regard
unaltered male genitals as nature made them as healthy and normal,
American physicians are taught to look at the same genitals as aliens
from another planet. While in Europe, physicians are taught to look at
the foreskin as an intrinsic part of the male organ, akin to labia in
female organs, in the United States, the physicians are taught to treat
the presence of a foreskin as a superfluous growth, like some sort of cancer or tumor.
Indeed, some hospitals will list the presence of a foreskin alongside
other medical problems.
This picture was taken at an American hospital. Notice that being uncircumcised
is a "problem," along side hearing loss and poor growth and weight gain.
To Europeans, penises in American textbooks may appear strange, as they
are depicted as circumcised, as if this is they the human penis appears
in nature. To Americans, the pictures of penises in European textbooks appear to be "Ew, gross!" The foreskin, if mentioned at all in American textbooks, is often described as "that loose piece of flesh at the end of a penis, which is removed in circumcision." Whereas
European textbooks present the penis as-is and moves on, American
textbooks must describe various reasons why circumcision is performed,
and why parents ought to make a "decision."
In short, when it comes to knowledge of basic male anatomy, Americans aren't getting the full package.
So intact males beware; unless a North American physician has actually taken the time to study how the natural
male organ works, s/he will know little to nothing with how to deal with
a man who's organs remain as nature gave them to him. Some
physicians will see having a foreskin as a problem in and of itself.
They see the foreskin as a tumor and will prescribe circumcision upon
seeing it. The only thing they ever learned in medical school regarding
the foreskin is that it must be removed.
Circumcision is Deeply Ingrained in North American Culture
It's
a relatively new phenomenon that began only about a century ago, but
male circumcision has become deeply ingrained in American culture. The
phenomenon of male circumcision in America has evolved over the decades.
It started as a way to prevent masturbation, because masturbation was
thought to be the source of physical and mental disease. Then it turned
into a status symbol, where being circumcised meant you were born into a
family that could afford to go to the doctor, and not being circumcised
meant you came from a poor family. Other associations were made with it
too, including being "unhygienic" and "dirty."
In
recent years, the rate of male infant circumcision has fallen from about
80 to 90% in the 1980's, to about 56%, according to the CDC, but the
overall number of adult males circumcised from birth continues to be
about 80%, so there is an overwhelming compulsion to continue to see
male circumcision as "normal," and having intact genitals as foreign and
alien, sometimes even as "dirty," "diseased" and/or "undesirable," so
intact males need to be aware that in America, having intact genitals
carries social stigma, and doctors may be trying to push their bias that
all men need to be circumcised on them.
Religious Conviction to Circumcision
For
some, the compulsion to stigmatize anatomically correct male genitals
is religious in origin. Particularly for adherents of Judaism,
circumcision, particularly male infant circumcision, is seen as divine
commandment. Adherents of Islam often see male circumcision as a good
Muslim virtue, although this is not a requirement (not all Muslims
circumcise), and it is not mentioned once in the Quran. Some adherents
of Christianity see male circumcision as desirable, as it was commanded
to Abraham, although it is stated in the New Testament that circumcision
profits the Christian nothing. (See Galatians 5) On the front, doctors
who advocate for circumcision may state that they do so because of the
so-called "medical benefits" it supposedly affords, but in actuality,
they may be cloaking a religious conviction which disallows them from
saying anything negative about circumcision, and only highlighting all
the "benefits" of it.
Circumcision is a Moneymaker
Hey.
Everybody has to make a living. We all need to eat somehow. Used car
salesmen make their living selling used cars. Companies spend millions
of dollars on infomercial campaigns trying to convince you that you
absolutely need to buy their product. In America's for-profit medical
system, doctors may try to convince you that you absolutely need the
service they offer, the drug they push, the surgery they specialize in.
In America, some doctors make their sole living on convincing males,
and/or their parents, that they need circumcision. In a culture that's
already geared toward having a circumcised penis, some men, having
endured the social stigma of having intact genitals, happily oblige.
"It is difficult to get a man to understand something, when his salary depends upon his not understanding it." ~Upton Sinclair
So the first thing to consider when a doctor tells you you need to be circumcised is, "Is my doctor biased?"
Is your doctor actually fully educated as to how the intact penis works?
Does he himself have a personal bias in favor of circumcision?
Does s/he have a religious conviction in favor of circumcision?
Does your doctor make a great part of his living by prescribing circumcision and isn't actually interested in solving your problem?
If you're in North America, chances are he or she is, and it would be wise of you to seek a second opinion.
Standard medicine dictates that surgery
should be used as a last resort, and only where alternative, less invasive methods of treatment have failed.
If
your doctor hasn't even bothered trying to treat your problem in other
ways before resorting to surgery, this should be a good indicator that
you probably need to see another doctor.
It
is best to seek a doctor that you know for sure is interested in
preserving your body, taking care of your problem conservatively, and
isn't trying to push his or her bias that all men should be circumcised
on you. Such doctors will be known as "foreskin friendly," or "intact
friendly" doctors hereafter. In the future, we will compile a list of
doctors who have their knowledge of anatomically correct male genitals
up-to-date.
Intact Male's View of Surgical Treatment
The
goal of this website is to promote anatomically correct male genitals,
to spread awareness, and to help intact males realize there's nothing
wrong with having organs as nature meant them to be, and to build
confidence. However, this is not to say that problems don't occur, and
that corrective surgery is never necessary. We want to promote having
intact genitals, but we also acknowledge that there may be cases where
surgery may be inevitable.
One of the greatest goals of
this website is to spread education and awareness about anatomically
correct male genitals, and this includes problems that could occur with
them, and what methods of treatment are available, including, when needs
be, surgery.
The view of this website is that although
surgery is a valid method of treatment when there is medical
indication, it should be treated as a very last resort when all other
methods of treatment have failed, or when a male individual is able to
weigh the pros and cons and make an informed decision. Some males may
decide that surgery is the best treatment for them, and may want to
forgo alternative treatment, and that's OK too, so long as they are
fully informed, and they're the ones making that decision.
How do I know I actually need surgery?
Let's begin to address this question by stating some facts.
First
and foremost, attention must be brought to the fact that empirical
evidence shows that problems of anatomically correct male genitals which
require surgical correction are extremely rare.
According
to the current medical literature, only about 1% of intact males, if
not less, ever develop problems that require surgical treatment.
The
fact is that about 70% of males are not circumcised globally, and there
is simply no epidemic of "problems," no mob of men banging down the
door at urologists' offices demanding to be circumcised.
In
the United States, doctors may use any and every alibi as a reason to
circumcise, including the mere presence of the foreskin itself.
Intact
males need to be aware that medical indication for circumcision is
already quite rare, and that if a doctor is calling for him to be
circumcised, without any medical indication, without any tests, without
trying other methods of treatment first, this should raise a red flag.
Let's Begin By Talking About What is "Normal"
Part
of the problem here is that the foreskin has been absent from the
American psyche for so long that a lot of people don't actually know
what is "normal," because we've been conditioned to think that being
circumcised should be "normal" by default, and that there is a problem
otherwise.
In an intact male, the foreskin usually
covers the head of the penis when it is flaccid, bunching up at an area
called the acropostheon.
The
part of the foreskin that bunches up and hangs over the glans (head of
the penis), is called the "acropostheon," colloquially known as the
"overhang." Some people think this part of the penis is so important so
as to warrant special attention, so much that they created a website
dedicated to it. You can visit the website
here.
The foreskin does not always cover the glans completely, however. Some foreskins are shorter than others.
In
some penises, the head of the penis protrudes from the acropostheon.
How much the foreskin covers the glans varies from penis to penis. The
degree to how much the head of the penis is covered is called "coverage"
in some circles.
How much "coverage" do you have? A
"Foreskin Coverage Index" has been created, showing the different
degrees of "coverage" that men may have. Visit the website
here.
In most penises, the foreskin retracts to reveal the glans when the penis is erect.
Some may need a little "help," however...
So
now that we've established a benchmark of "normality" for intact guys,
let's talk about problems that may warrant surgical intervention.
Phimosis
By
far, the most common "problem" in intact males is the inability to
retract the foreskin to reveal the glans, often called "phimosis." It is
said that about 10% of men will develop problems retracting their
foreskin, and about 1% may actually need surgical treatment. The word
"phimosis" originates from the Greek word
phimos (
φῑμός)
which means
"muzzle". Today, "phimosis" is a vague blanket term
that refers to any condition where a male can't retract his foreskin, but it
actually refers to a specific medical condition. Oftentimes, what
doctors call "phimosis" may not even be a problem at all.
Writing
off a male with a non-retractile foreskin as having "phimosis" is
problematic for many reasons. For one, it refers to an actual medical
condition caused by a pathological condition, which we'll get into shortly. For another, a non-retractile foreskin is actually a normal stage
of development in an intact male's life. A male may be too young to be
said to be having any kind of "problem," and even when a male's foreskin
can't retract, it doesn't necessarily mean he has a medical problem.
In
order to understand when the inability to retract the foreskin is a
problem, I think its necessary that we understand what the normal stages
of development are for males with anatomically correct genitals. Sadly,
this is information that American doctors don't learn, and even in
European countries, isn't talked about. In this post, we will talk about
the normal stages of development for intact males, what phimosis is,
what it isn't, when there may actually be a problem that requires
medical attention, how doctors should be assessing the problem, and
when doctors should be offering patients surgical treatment. I have
included references to medical literature that readers can use to
confirm the information I present here.
What are the normal stages of development?
At Birth
Typically, when a baby boy is born, the foreskin is long with a narrow tip.(1)(2) Retraction is not possible in
the majority of infants because the narrow tip will not pass over the
glans penis.
Moreover, it is normal for the inner mucosal surface of the
prepuce to be fused with the underlying mucosal surface of the glans,
or head of the penis,(1)(2)(4)(5) by
means of a membrane called synechia, also known as the balano-preputial
membrane or balano-preputial lamina,(1) further preventing retraction. This attachment forms early in fetal
development and provides a protective cocoon for the delicate
developing glans.(6) It is normal for the foreskin to be non-retractable in infancy and early childhood.(6)
Retraction of the Foreskin
In normal development, the foreskin
usually separates from the glans and becomes retractable with age.(4) As
the infant matures into a boy and the boy into a man, the tip of the
prepuce becomes wider, and the shaft of the penis grows, making the tip
of the prepuce appear shorter. The membrane that bonds the inner
surface of the prepuce with the glans penis spontaneously disintegrates
and releases the prepuce to separate from the glans. The prepuce
spontaneously becomes retractable.
In order for retraction to occur, the foreskin must have
separated from the glans and the opening of the foreskin must have
widened to allow it to slip back over the glans. Throughout childhood
and adolescence, there is a release of hormones. As hormone levels rise,
the fiber-dense tissue of the prepuce is replaced with a more elastic
tissue. A boy will begin to explore his genitals as he grows, and as time
passes, the elastic tissue will allow the opening of the foreskin to
widen. This can happen at any age but it is not common in young boys.
The amount of time it takes for a boy's
foreskin to become fully retractable varies from boy to boy; this
process can take many years for some boys, and yet minutes for others.
In some boys, the foreskin may not be retractable until after
puberty.(7)(8)(9) This is an entirely normal stage of development and
should not be diagnosed as any kind of "problem."
When Does Retraction Happen?
According to the experience of doctors
and researchers in cultures where circumcision is
uncommon, retraction happens at varying ages, and a non-retractable
foreskin rarely requires treatment. Observations from doctors in
Denmark, and Japan and other countries indicate that spontaneous
loosening usually occurs with increasing maturity.(7)(8)(9)(10)(11)(12)
Non-retractability is considered normal for males up to and including adolescence. The
process whereby the foreskin and glans gradually separate may not be
complete until the age of 17.(4) A Danish survey (2005) reported that
average age of first
foreskin retraction is 10.4 years.(13) Marques et al (2005) reported
that 99% of boys can retract their foreskins by age 14.(12)(14)(15)(16)
One may expect 50% of 10-year-old boys; 90% of
16-year-old boys; and 98-99% of 18 year-old males to have a fully
retractable foreskin. Treatment is seldom necessary.
A 1999 study by Cold and Taylor shows that at 6 to 7 years,
approximately 60% of the boys had natural adhesions. At 10-11 years,
close to 50% of the boys still had adhesions. At 14-15, approximately
only 10% of the boys had adhesions. As they approach the age of 17, only
a very small percentage of boys will have adhesions. That means that,
left uncircumcised, most boys will be able to retract their foreskin
before they are 17 years old.
Foreskin Retraction as Observed in Children in Other Countries
Jakob Øster, a Danish physician who conducted school examinations,
reported his findings on the examination of school-boys in Denmark,
where circumcision is rare.(7)
Øster (1968) found that the incidence of fusion of the foreskin with
the glans penis steadily declines with increasing age and foreskin
retractability increases with age.(7)
Kayaba et al. (1996) also investigated the development of foreskin
retraction in boys from age 0 to age 15.5, and they also reported
increasing retractability with increasing age. Kayaba et al. reported
that about only 42% of boys aged 8-10 have fully retractile
foreskin, but the percentage increases to 62.9% in boys aged
11-15.(8) Imamura (1997) reported that 77% of boys aged 11-15 had
a retractile foreskin.
Thorvaldsen and Meyhoff (2005) conducted
a
survey of 4000 young men in Denmark. They report that the mean age of
first foreskin retraction is 10.4 years in Denmark.(13) Non-retractile
foreskin is the more common condition until about 10-11 years of age.
Current medical literature indicates that the foreskin is
non-retractable in the majority of males until they begin to approach
puberty. Until a boy begins to reach sexual maturity, non-retractability
of the foreskin is a normal part of growing up.
Readers, are you catching this?
If
a male is under 17, having a foreskin that does not retract is not a
"problem," and perfectly normal, and he is still too young to be
diagnosed with "phimosis."
So when is "phimosis" a problem?
Given the empirical facts stated above, it is already mistaken to assume
that just because the foreskin cannot be retracted to reveal the head
of the penis, a male has some sort of pathological condition. As
evidenced by the facts given above, the great majority of male children
who have anatomically correct genitals will have foreskins that cannot
be retracted, and it is a mistake to assume that all children undergo
this transitory "illness" where they can't retract their foreskins, akin
to the mumps, measles or chicken pox. Girls do not begin to menstruate
until the onset of puberty, and they are not considered to be suffering
any sort of medical condition until then.
Preputial Stenosis
Non-retractability of the foreskin may pose a problem if it continues
well past puberty, but unless it meets certain criteria, it still can't be considered a medical problem that needs surgery.
Typically the foreskin has dilated to allow
retraction as a result of the release of hormones. In a small percentage
of males, the production of these hormones is insufficient, and the
foreskin fails to dilate, resulting in a condition known as "preputial stenosis,"
or, a narrow foreskin. This is a physiological problem and can't technically be called "phimosis." This condition may make hygiene and sexual
intercourse difficult, if not impossible, but not always. In older men
that have bad hygiene habits and who smoke regularly, having a
non-retractile foreskin can increase the chances of developing penile
cancer.
In some males, the end of the foreskin may fail to dilate, resulting in a
narrow foreskin opening that makes foreskin retraction difficult or impossible.
This condition is often diagnosed as "phimosis," but unless the presence of
certain pathogens is not detected, it isn't "true" phimosis as we will describe below.
Having
a narrow foreskin that does not retract (preputial stenosis) is not
necessarily a problem. Some men go their entire lives without ever
seeing the head of their penis; it does not hurt them to masturbate, and
sexual intercourse is not a problem. Some men may see help in becoming
able to retract, but some do not, and unless this is causing them pain
or problems with intercourse, it's not an actual problem that
necessarily needs remedy.
How do you treat "preputial stenosis?"
Assuming
that a male who has a narrow foreskin actually wants to be able to
retract his foreskin like most males, a doctor could provide stretching
exercises that will remedy the problem. It depends on the extremity of
the narrowness of the foreskin; there are different degrees. Some men
may choose to take the time to stretch their foreskins, some men may
choose to simply get it over with and get circumcised. In most cases,
stretching should work.
It
must be remembered that a narrow foreskin, is not necessarily a problem
if the male is not experiencing pain or discomfort during sex. A male
with a narrow foreskin may feel he is fine just the way he is and it's
not a problem.
If you are reading this, you think you might have preputial stenosis and you're interested in stretching out your narrow foreskin, visit My Phimosis Journey, a very informative blog about a man who chose to go through with stretching out his narrow foreskin over getting circumcised.
"True Phimosis"
There is another reason why the foreskin may not be retractable in a
male, and that is because he has suffered an infection with balanitis xerotica obliterans,
or BXO for short. In this case, the tip of the foreskin has become scarred and
indurated, and has the histological features of a pathological
infection. The foreskin of a male who has suffered an infection with BXO
will have developed a fibrotic ring, which makes retraction difficult
or impossible. It is this pathologically induced non-retractability
which can be correctly termed "phimosis."
To differentiate between the normal stages
of development, and even the physiological state of a foreskin which
has failed to dilate as a result of lack of hormones, from
pathologically-caused non-retractability, doctors have invented the term
"true phimosis." It is this non-retractability
caused by pathological infection with BXO that can actually be
considered "phimosis" and an actual problem.
In "true phimosis," the end of the foreskin has resulted in a fibrotic ring caused
by an infection with balanitis xerotica obliterans, otherwise known as BXO.
Can "phimosis" be cured? How Do I Know I Need Surgery?
It is estimated that 2% of males go their entire lives without their
foreskins ever becoming retractable. How this condition can be
treated
will depend on what the actual problem is. The physiological condition
where a foreskin has failed to dilate as the result of a lack of
hormones, otherwise known as "preputial stenosis," tends to respond to
steroid cream therapy, coupled with stretching exercises and/or
stretching
devices. As mentioned earlier, if a narrow foreskin isn't necessarily
causing pain or problems with sexual intercourse, a man may decide to stay the way he is.
Non-retractability as a result of a BXO infection, however is different,
as this is caused by a resulting fibrotic ring at the end of the
foreskin, which is scarification that may or may not respond to steroid
cream treatment or stretching exercises. It is non-retractability caused
by BXO infection that can be genuinely considered a problem which may
call for corrective surgery.
It should be noted that non-retractability of the foreskin as a result
of BXO infection occurs in less than 1% of males. Additionally, it
should be noted that even when a case of "true phimosis" may require
surgical correction, it does not always entail a complete removal of the
prepuce. There are procedures that can correct phimosis which can
preserve the foreskin and its functions. Surgical methods range from the
complete removal of the
foreskin (circumcision) to more minor operations to relieve foreskin
tightness, such as a "dorsal slit" (AKA "superincision") a "ventral
slit" (AKA "subterincision") and "preputioplasty."
If treatment should
be necessary, it should not be done until after puberty and the male
can weigh the therapeutic options and give informed consent.(9)
How should a genuine case of phimosis be diagnosed?
In order to correctly determine that there is a real problem occurring
in a male, a learned doctor will begin by ruling a few things out.
-
If, for example, a child hasn't reached puberty yet, and because
non-retractability is common for this age group, the doctor should
consider that the child may be experiencing normal stages of
development.
-
If, for example, a child hasn't reached puberty yet, but he was able retract his foreskin previously, it may be probable that the child may have experienced an infection with BXO.
-
If, for example, an adult male who has already gone through puberty
still has a non-retractile foreskin, the doctor needs to determine if
this is a physiological problem caused by a lack of hormones (preputial
stenosis), or if it is a pathological problem as a result of infection
with BXO (AKA "true phimosis").
Because non-retractibility of the foreskin can be both a normal stage of development, and
a pathological problem, it can be very easy for doctors to make an
inadvertent, or even deliberate misdiagnosis. Particularly in countries
like the United States, where circumcision is a perceived norm, and
doctors may not be educated in the differences between normal stages of
development and phimosis as a pathological condition, it can be very
easy for doctors to say that a child or adult male is suffering a condition that may
require surgical correction, where in fact, there is actually none.
For a correct diagnosis, a doctor who is knowledgeable about the
difference between normal stages of development and non-retractability
caused by BXO infection will correctly have the male analyzed for signs
of lesions of BXO. Then, and only then, can a doctor properly make the
diagnosis that a male is suffering a medical problem, and that the person may need surgery to correct the problem.
Because non-retractability in adult males is rare, and "true phimosis"
(pathologically induced non-retractability) even more rare, there is a
high probability that a diagnosis for "phimosis" may actually be false,
especially in younger males, where non-retractability of the foreskin is a
part of normal development.
Readers Beware: The Doctor May Have Actually GIVEN You Your Problems
Problems with the retraction of the
foreskin may either be the result of a lack of hormones, the result of
an infection with BXO, or, they could be iatrogenically induced. (E.g.
actually caused by the doctor himself.)
It has been widely recognized by the
medical profession
for most of the 20th century that normal male infants have foreskins
which are incompletely separated from the epithelium of the glans.(17)
The foreskin cannot be retracted without tearing the fusion and
adhesions which are commonly present between the inner foreskin and the
glans penis in normal
stages of development.
In English-language medicine, there is
an absence of proper knowledge of the foreskin and its development in
the medical curriculum. According
to McGregor et al (2005), physicians often have
difficulties distinguishing between this normal, natural state of the
penis in neonates and pre-pubecent boys and pathological
phimosis caused by BXO.(17)(18) Spilsbury et al (2003) suggest that
doctors may be likely to confuse the aforementioned conditions with
pathological phimosis.(19) In America, doctors may be predisposed to seeing the presence of a foreskin as inherently problematic.
Unaware of the harmless nature of the
normal, natural
state of the penis in neonates, and the presence of
adhesions in infants and pre-pubecent boys, and unaware that this can be
damaging, doctors have been known to forcibly attempt to retract
the foreskin in healthy, developing children, just to see if it
retracts, tearing natural
adhesions and/or ripping the foreskin in the process. Furthermore, they
have been known to erroneously instruct parents that a child's foreskin
needs to be retracted in order to "clean under it," arguing that they
will develop infections otherwise.(20) (!!!)
Premature, forcible retraction of the foreskin is an extremely painful,
serious, and potentially permanent injury(17). It can damage the glans
and mucous inner tissue of the foreskin. Forcibly retracting a child
could result in iatrogenically induced phimosis, where the raw, open
wounds of ripped adhesions could heal and fuse together, or where a
forcibly dilated foreskin could develop scarification, resulting in a
fibrotic ring similar to the one caused by BXO infection. Additionally,
this can result in a complication known as "paraphimosis," where the
narrow foreskin strangles the penis trapped behind an enlarged glans,
thereby necessitating surgical intervention.
Adhesions such as this one occur whenever raw wounds heal together.
This happens in circumcised males when the raw circumcision wound
adheres to the glans, or in intact males where raw wounds caused by forcible
retraction heal together and become fused. Surgery is needed to cut these loose.
Paraphimosis happens when the foreskin gets trapped behind the glans
as a result of forced retraction. Forcibly trying to retract the foreskin in a
child or young man whose foreskin fully retracted can result in injury.
For this reason, all respected medical organizations recommend that the
foreskin not be forcibly retracted in children and youths, not even for "cleaning."
It must be noted here that these problems rarely present themselves in
countries where circumcision is rare or not practiced. There is simply
no epidemic of foreskin problems in countries where male children aren't
circumcised. These problems tend to suspiciously present themselves in
countries where circumcision is common, and diagnosed by doctors who
happen to specialize in child circumcision. Children may have been
circumcised to correct "problems" that either never existed, or whom
were given their problems by ignorant doctors to begin with.
It is harmful and misleading to tell parents that a child's foreskin
must be forcibly retracted. In children whose foreskins are still
adhered to the glans, or where the foreskin has not dilated to allow the
glans, this can be a harrowing experience. Forcibly retracting a
child's foreskin "to clean under it" is the equivalent of cleaning out a
girl's vagina with a pipe cleaner. Surely, a doctor who would instruct
parents to clean out their child's vagina would be dismissed as a
lunatic. Medical associations advise not to forcibly retract the foreskin
of an infant, as this interferes with normal penile development, and may
result in scarring or injury.(21)(22).
Camille et al (2002), in their guidance for parents, state that "[t]he
foreskin should never be forcibly retracted, as this can cause pain and
bleeding and may result in scarring and trouble with natural
retraction."(23)
Simpson & Barraclough (1998) state that "[n]o attempt should be made
to retract a foreskin in a child unless significant separation of the
subpreputial adhesions has occurred. Failure to observe this basic rule
may result in tearing with subsequent fibrosis and consequent
[iatrogenically induced] phimosis. ..."(24)
The American Academy of Pediatrics cautions parents not to retract their
son's foreskin, but suggest that once he reaches puberty, he should
retract and gently wash with soap and water.(25) The Royal Australasian
College of Physician as well as the Canadian Paediatric Society
emphasize that the infant foreskin should be left alone and requires no
special care.(26)
Summary on Phimosis
The facts, which are well-documented in medical literature, speak for themselves.
A foreskin that is adhered to the glans and/or will not retract is a
normal stage of development in all healthy male children in infancy. The
belief that a foreskin that is "tight" and will not retract is a
problem in male infants implies that all human male children are born
with some kind of birth defect, congenital
deformity or genetic anomaly akin to a 6th finger or a cleft.
In the great majority of males, the foreskin separates from the glans
and becomes retractable as they approach puberty, without the aid of
medical or surgical intervention.
A foreskin that will not retract in older males is rare, and may or may
not be a pathological problem. In order to determine the cause of a
non-retractile foreskin, a knowledgeable doctor who understands
anatomically correct male genitals, the normal stages of development of
healthy males, and true pathological problems of male genitalia, must
run the correct analyses in order to detect the presence or absence of
pathological lesions; then, and only then, can the doctor determine
whether there is an actual problem, and whether or not it can be remedied with conventional medicine or by
means of surgical correction.
A narrow foreskin is not necessarily a case of "phimosis," but instead a condition known as "preputial stenosis." A narrow foreskin that will not retract is in itself not a problem, if the male is comfortable with himself and his condition does not cause him pain or difficulty with masturbation or sexual intercourse. A narrow foreskin that is not the result of a pathological condition responds well to stretching exercises, and if it is a problem, can be alleviated without surgery.
Even when a genuine case of phimosis that necessitates surgical
intervention presents itself, circumcision, or the full excision of the
foreskin is not always called for; there are surgical interventions
which will correct phimosis while preserving the foreskin and its
functions.
Intervention to hasten the retraction of the foreskin in otherwise
healthy, prepubescent males may actually cause iatrogenically induced
problems. The forced retraction of the foreskin may itself cause
non-retractability. Forcibly dilating the foreskin causes scar tissue to
form, which may result in a fibrotic ring at the end of the foreskin.
Breaking the natural adhesions which occur between the glans and the
foreskin during normal stages of development may cause new adhesions to
form between the glans and the foreskin, becoming fused as the raw
wounds of the broken adhesions heal together. Forcibly pulling back
naturally narrow foreskin over the glans in otherwise healthy children
may result in paraphimosis, where the narrow foreskin catches behind the
glans, preventing the foreskin from returning to its neutral position
covering the glans, ironically necessitating the need for surgical
intervention.
Conclusion
It is a shame that there is a gap in medical knowledge between the
United States and other English-speaking countries. The information
presented here is well-documented knowledge that all doctors need to
know. This is the information that a doctor needs to be giving to
parents of a male child. Anything other than this is misinformation or
an outright lie.
American medical curricula is either omitting information, teaching
outdated information, if not outright teaching misinformation. Efforts
need to be made to bring English-language curriculum on the
foreskin, the natural stages of development and genital pathology up to
date. Doctors need to educate themselves and stop dispensing erroneous
and dangerous advice to parents. They need to learn to differentiate
between the normal stages of development in human males, and actual
pathological phimosis.
Doctors who diagnose
"phimosis" in a perfectly healthy male are either uneducated when it
comes to the foreskin and natural stages of development, or may in fact
be committing medical fraud, deliberately inventing a misdiagnosis in
order to justify surgery in a healthy, non-consenting minor, and/or
collecting medicaid funds intended for actually medically necessary
surgery.
Until American medicine undergoes this long-needed overhaul, long-term
visitors to the United States ought to be warned that doctors in America
are often inadvertently, or quite deliberately misinformed about
anatomically correct male genital anatomy, and that visiting American-trained doctor could be hazardous to their health.
Disclaimer:
The
information presented on this blog should not be taken as medical
advice. A male who is suffering a problem, or believes he may be
suffering a problem should seek the counsel of a foreskin-friendly
doctor. Intact males should beware of the bias and predisposition that
American doctors have against the foreskin, and in favor of male
circumcision, and should seek a second opinion if the doctor is pushing him to get circumcised.
References:
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2. Spence J. On Circumcision. Lancet 1964;2:902.
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4. Øster J. Further fate of the foreskin: incidence of preputial
adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child
1968;43:200-3.
5. Catzel P. The normal foreskin in the young child. (letter) S Afr
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