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.
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
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.
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?
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 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:
1. Gairdner D. The fate of the foreskin: a study of circumcision. Br Med J 1949;2:1433-7.
2. Spence J. On Circumcision. Lancet 1964;2:902.
3. Deibert GA. The separation of the prepuce in the human penis. Anat Rec 1933;57:387-399.
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 Mediense Tysskrif [South Afr Med J] 1982 (13 November 1982) 62:751.
6. Wright J.E. (February 1994). "Further to 'the further fate of the foreskin'". The Medical Journal of Australia 160 (3): 134–5. PMID 8295581. http://www.cirp.org/library/normal/wright2/
7. Øster J. Further fate of the foreskin: Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child (published by the British Medical Association), April 1968. p. 200-202.
8. Kayaba H, Tamura H, Kitajima S, et al. Analysis of shape and retractability of the prepuce in 603 Japanese boys. Journal of Urology, 1996 Nov, V156 N5:1813-1815.
9. Warren JP: NORM UK and the Medical Case against Circumcision. In: Sexual Mutilations: A Human Tragedy; Proceedings of the 4th Intl Symposium on Sexual Mutilations , Denniston GC and Milos MF, Eds. New York, Plenum, 1997) (ISBN 0-306-45589-7)
10. Celsus. De medicina, vol 3. Harvard University Press, Cambridge, p 422
11. Celsus. De medicina, 6.18.2. In: Spencer WG (ed and trans) (1938) Celsus. De medicina, vol 2. Harvard University Press, Cambridge, p 269
12. Hodges FM. Phimosis in antiquity. World J Urol 1999;17(3):133-6.
13. Thorvaldsen MA, Meyhoff H.. Patologisk eller fysiologisk fimose?. Ugeskr Læger. 2005;167(16):1852-62.
14. Marques TC, Sampaio FJ, Favorito LA (2005). "Treatment of phimosis with topical steroids and foreskin anatomy". Int Braz J Urol 31 (4): 370–4; discussion 374. doi:10.1590/S1677-55382005000400012. PMID 16137407. http://www.brazjurol.com.br/july_august_2005/Marques_ing_370_374.htm.
15. Denniston; Hill (October 2010). "Gairdner was wrong". Can Fam Physician 56 (10): 986–987. PMID 20944034. PMC 2954072. http://www.cfp.ca/content/56/10/986.2.long. Retrieved 2014-04-05.
16. Huntley JS, Bourne MC, Munro FD, Wilson-Storey D (September 2003). "Troubles with the foreskin: one hundred consecutive referrals to paediatric surgeons". J R Soc Med 96 (9): 449–451. doi:10.1258/jrsm.96.9.449. PMID 12949201. PMC 539600. http://www.jrsm.org/cgi/pmidlookup?view=long&pmid=12949201.
17. McGregor TB, Pike JG, Leonard MP (April 2005). "Phimosis—a diagnostic dilemma?". Can J Urol 12 (2): 2598–602. PMID 15877942.
18. Metcalfe PD, Elyas R. Foreskin management. Survey of Canadian pediatric urologists. Can Fam Physician 2010;56:e290-5.
19. Spilsbury K, Semmens JB, Wisniewski ZS, Holman CD (February 2003). "Circumcision for phimosis and other medical indications in Western Australian boys". Med. J. Aust. 178 (4): 155–8. PMID 12580740. http://www.mja.com.au/public/issues/178_04_170203/spi10278_fm.html.
20. Osborn LM, Metcalf TJ, Mariani EM. Hygienic care in uncircumcised infants. Pediatrics 1981;67:365-7.
21. "Care of the Uncircumcised Penis". Guide for parents. American Academy of Pediatrics. September 2007. http://www.healthychildren.org/English/ages-stages/baby/bathing-skin-care/Pages/Care-for-an-Uncircumcised-Penis.aspx.
22. "Caring for an uncircumcised penis". Information for parents. Canadian Paediatric Society. July 2012. http://www.caringforkids.cps.ca/handouts/circumcision.
23. Camille CJ, Kuo RL, Wiener JS. Caring for the uncircumcised penis: What parents (and you) need to know. Contemp Pediatr 2002;11:61.
24. Simpson ET, Barraclough P. The management of the paediatric foreskin. Aust Fam Physician 1998;27(5):381-3.
25. American Academy of Pediatrics: Care of the uncircumcised penis, 2007
26. Royal Australasian College of Physicians. (2010) Circumcision of Infant Males.
