Friday, September 14, 2012

The history of forced retraction of the foreskin and the dangerous advice of the AAP

From the AAP Policy Statement on Circumcision 2012, Technical Report:

The noncircumcised penis should be washed with soap and water. Most adhesions present at birth  spontaneously resolve by age 2 to 4 months, and the foreskin should not be forcibly retracted. When these adhesions disappear physiologically (which occurs at an individual pace), the foreskin can be easily retracted, and the whole penis washed with soap and water.25 (Camille CJ, Kuo RL, Wiener JS. Caring for the uncircumcised penis: what parents (and you) need to know. Contemp Pediatr. 2002;19(11):61–73)

From: and also from

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

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

What happened to Ethan is a clinically unnecessary injury and utterly inexcusable. Ethan's parents have exactly the right instincts, and with good reason. But to understand why, the reader needs some background.

The history of forcible foreskin retraction In the mid-19th century, many British and American doctors were hoping to convert childbirth and infancy into medical opportunities, thereby marginalizing their ancient competitors—midwives and doulas. Thus the medicalisation of childbirth and infancy began in earnest.

Around the same time, other physicians promoted the notion that irritation or stimulation of sensitive tissue, like genital mucosa, caused disease to appear in a distant part of the body. They invented, for instance, the old locker-room myth that masturbation causes blindness. They called their pre-germ disease theory 'reflex neurosis'.

Of course this theory was false, but as well as conveniently blaming and shaming the patient for causing his own health problems, reflex neurosis spawned a whole breed of pseudo-medical interventions for children, including circumcision, clitoridectomy, and forced foreskin retraction. Aggressive cleaning, drying—even amputation—of sensitive, erogenous, genital tissue was, according to this theory, a way to discourage bodily exploration, thwart disease, and simultaneously promote 'moral hygiene'.

Especially widely publicized was the notion that a build-up of smegma, a protective secretion both boys' and girls' genitalia naturally produce, might cause unwanted stimulation, then termed 'irritation'. This stimulation might draw a child's attention to his penis (or her clitoris)—so goes the theory—which he or she might then touch. Even casual genital exploration by the child was thought to cause tuberculosis, insanity, blindness, idiocy, hip malformation, unusual hair growth, and dozens of other conditions.2 As late as the 1930s, some doctors advised parents to tie scratchy muslin bags, especially made for the purpose, on the hands of boys and girls, to prevent even inadvertent genital contact during sleep.

Parents were also advised to retract their boy's foreskin and scrub out any 'dangerous' secretions regularly, or have the boy circumcised so these could not possibly accumulate. Throughout the 20th century in all English-speaking countries, forced retraction for genital cleaning became standard medical practice. Millions of living, intact Anglo men, it is safe to say, were forcibly—and painfully—retracted as children.

An Australian medical historian recently published the following observation about the invented and erroneous myth of the need for rigorous infant male hygiene. He notes the irony that females only narrowly escaped similar treatment:

To appreciate the scale of the error, consider its equivalent in women: it would be as if doctors had decided that the intact hymen in infant girls was a congenital defect known as 'imperforate hymen' arising from 'arrested development' and hence needed to be artificially broken in order to allow the interior of the vagina to be washed out regularly to ensure hygiene.

—Dr. Robert Darby, A Surgical Temptation, The Demonization of the Foreskin and the Rise of Circumcision in Britain.


 Care of the foreskin Proper infant hygiene, for both girls and boys, is actually astonishingly simple:

'Only Clean What Is Seen.'

This means the boy (or girl) needs only warm water, gently applied to the outer, visible, portions of his or her genitalia. No soap is needed. No intrusive or interior cleaning of the genitalia of either gender is ever needed or desirable. Aggressive interior hygiene is destructive of developing tissue and natural flora, and is harmful as well as painful.

At birth the penis is anatomically immature. The foreskin is connected to the glans by a natural membrane, the balano-preputial lamina (translation: 'glans-foreskin layer'). This membrane is apparently nature's method of protecting the highly nerve-supplied and erogenous foreskin of the developing penis from irritation by faeces, the ammonia in urine, and invading pathogens.4 Although very different in structure, it can reasonably be thought of as the male's hymen, protecting the sexual organs during the years when they are not needed for sexual purposes. This membrane may take as long as 18 years or more to disappear naturally, allowing retraction.

Numerous studies have shown that the mean age for natural foreskin retraction without pain or trauma is around 10 years.5 Some men never seee their glans until they are in their 20s. Any age is normal; there is no need to see the glans prematurely. Indeed, pre-adolescent boys, like pre-adolescent girls, need no internal cleaning whatsoever, and to suggest toddlers need to be retracted at each bath, or should be taught to do so themselves, is antique, 19th-century, medical superstition.

Culture influences medical training Male doctors born in America from the 1930s to the 1980s were almost invariably circumcised at birth. Consequently, they have no personal knowledge of the foreskin—a normal and highly specialised component of male anatomy. They are dependent upon whatever information they received in their medical training—from circumcised professors. Many American medical textbooks exported to Australia were written by circumcised doctors and lack even an illustration of normal male anatomy.6 Medical practitioners so minimally trained are unlikely to provide accurate information on proper care of a body part they do not possess and attend only occasionally.

(Anecdotally we at D.O.C. know there is an element of psychological compulsion attending the foreskin. Intact boys are a novelty to Anglo doctors who, in the USA especially, are mostly circumcised themselves or partnered with someone who is. The impulse to examine the child to explore what the doctor himself lost, or sees only rarely, seems irresistible even when there is no evidence of disease or infection.)

Better medicine vs hygiene hysteria A few modern English-language medical books correctly describe normal penile anatomy as Europeans understand it, and warn against tampering. Unfortunately, of the 40-odd medical, nursing, and parent-advice books the staff of D.O.C. has surveyed, only four give the proper advice. Mostly they parrot 19th-century pre-germ hygiene hysteria.
One reference text, Pediatrics,7 notes the correct timetable for foreskin retraction:

'The prepuce is normally not retractile at birth. The ventral [lower] 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.'
And Roberton's Textbook of Neonatology8 warns:

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

Avery's Neonatology,9 issues an identical warning:

'Forcible retraction of the foreskin tends to produce tears in the preputial orifice resulting in scarring that may lead to pathologic phimosis.'

Similarly, Pediatrics10 notes that phimosis or paraphimosis is '…usually secondary to infection or trauma from trying to reduce a tight foreskin…' And they add, 'circumferential scarring of the foreskin is not a normal condition and will generally not resolve'.

And even the American Academy of Pediatrics (who formerly discouraged breastfeeding and encouraged regular forced retraction of intact boys) has now changed its policy [1999]:
'Caring for your son's uncircumcised penis requires no special action. Remember, foreskin retraction will occur naturally and should never be forced. Once boys begin to bathe themselves, they will need to wash their penis just as they do any other body part.'11

 [circumcision diaries note: indeed, from 1999 to 2012 the AAP went from a correct advice, to a poorly written potentially dangerous paragraph which suggests that the foreskin should be retractable after the 4th month and that parents should retract it once it becomes retractable - no word of how they would figure out when this happens, I assume parents would have to probe until it retracts if they were trying to follow such a poor advice. This should NOT be done. ]

So what will happen to little Ethan? Ethan's parents have every reason to be angry and concerned. Ethan's unnecessary forcible retraction risks, or has created, one or more fully avoidable outcomes, some of which may not become obvious for years. All will remain a worry: 

″ Premature forcible foreskin retraction is uniquely painful because the foreskin is among the most densely nerve-supplied structures of the male body. Research shows that pain alone holds later psychological consequences.15

″ Likely the child now has an 'iatrogenic' (physician-induced) infection, caused by unnecessary tampering. Invariably forcible retractions are performed without surgical gloves or proper antisepsis, and the open wound becomes an immediate portal for disease.

″ His infection may worsen, leading to urethral ulceration, and, perhaps to urinary stenosis (blockage). Indeed, septic genital tampering is the likely cause of many avoidable urinary tract infections, themselves then used to justify post-neonatal circumcision.

″ The raw, bleeding surfaces, formerly separated by a natural membrane, might now grow together, causing unnatural adhesions or skin bridges that may, or may not, eventually dissolve.

″ His infection may leave scar tissue, which renders the foreskin inelastic, complicating adult hygiene and normal sexual functioning.

″ This inelasticity may create pathologic phimosis, an unnatural tightness of the foreskin opening, which might not fade with time and, ironically, may require medical intervention.16

″ The child with an inelastic foreskin may suffer periodic paraphimosis emergencies, or trapping of the foreskin behind the glans' corona when retracted. His glans may become strangled, trapping blood and causing swelling, which then must be released by hand.

″ The child may now endure painful nocturnal erections because of his compromised foreskin (four or five involuntary nightly erections are normal at all ages for both genders). This may interfere with necessary REM sleep and might even create sexual dysfunction in adulthood.

″ The child may become understandably reluctant to have any adult touch his genitals or bathe him.

Forcible retraction and circumcision You might already have sensed the connection between the historical marketing of circumcision and forcible foreskin retraction. Teaching youthful and trusting parents that an intact boy needs thoroughgoing internal hygiene at each bath helped to market circumcision, as it implied amputation might free the parents of this burden, unpleasant for them; painful for their son. Better—goes the argument—the immediate acute pain of circumcision than the periodic pain inflicted by parents over the years. And when the forcible retraction by parents did cause infection, or scar tissue, or adhesions, phimosis, or other problems, it was easy to blame the parents for inadequate hygiene or failing to choose circumcision, the 'sensible' option, to begin with.

Indeed, there is much anecdotal evidence that forcible retraction in the 20th century became a sort of retribution for non-compliant Anglo parents who declined circumcision for their newborn. The two, circumcision and forced retraction, have always been closely allied, and both create work for medical professionals, while leaving the intact boy alone to develop normally holds no economic benefit whatsoever. The false 'either-or' choice presented to parents for over 140 years has always been retraction and cleaning—or circumcision. The easy and more ethical European or Asian solution—leaving the child's genitals entirely alone—has only rarely been recommended in Anglo medical practice.

Post-neonatal circumcision A tendency to misidentify the normal connective foreskin membrane of toddlers and young boys as an abnormal 'adhesion' also leads to unnecessary post-neonatal circumcisions. Millions of older toddlers in the US, UK, Canada, Australia, and New Zealand have endured painful, unnecessary, and psychologically challenging post-neonatal circumcision, with or without anesthesia, based on this ignorance.

Misdiagnosis of the child's normal connective membrane is also the origin of the circumcision marketing mantra that 'he'll only need it later'. It is the direct source of many a family's story of their Uncle Bruce's painful circumcision at age six, of which he is only too happy to remind everyone. The implication is that circumcision is best done at birth, when, in truth, normal genitalia do not need fixing at any age, and never did.


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