Saturday, May 11, 2013

Circumcision at 5 years: how your doctor gets to lie and collect a check

One of the supposed benefits of circumcision is the "prevention of phimosis". It is true that phimosis is a condition of the foreskin which may require circumcision, but circumcising babies to prevent circumcision is what I call "prevention by obliteration": any part of the body that is removed won't develop any condition or pathology - but won't serve any functions to the body anymore.

Phimosis occurs when the foreskin cannot retract behind the glans. This condition will make hygiene and sex more complicated, some times even making penetrative sex impossible. Severe cases of phimosis may require circumcision. Milder cases may respond to steroid creams, stretching exercises and stretching devices.

The big confusion however is that there are two different kinds of phimosis:

  • physiological phimosis, which is normal and generally resolves itself in time; and 
  • pathological phimosis, which requires some treatment.

Let's look deeper into this. At birth, the foreskin and the glans are usually sealed by the "balanopreputial membrane". This is absolutely normal - this is physiological phimosis. This membrane prevents the foreskin from retracting. Parents of an uncircumcised child do not need to retract his foreskin to wash the penis, and in fact, retracting the foreskin would be painful and harmful.

As the child grows, this membrane desquamates to allow retraction. This can occur in months - or in many years. We will look more into this shortly.

If after puberty, the child cannot retract the foreskin, then we may have a case of pathological phimosis. This often occurs because a ring of skin on the foreskin will not expand enough to allow the glans to glide through. While some men may go their lives without ever retracting their foreskins, some will simply have issues because of this and won't be able to have normal sexual lives. Phimosis during adulthood is also a risk factor for penile cancer. So it's better to try to resolve phimosis after puberty.

One important variable here is the age of retraction. A 1999 study by Cold and Taylor shows a graphic of the age of retraction - referring a 1968 study by Jakob Øster. It shows that at 6 to 7 years, approximately 60% of the boys still present adhesions (in other words, they cannot retract the foreskin yet). At 10-11 years, close to 50% of the boys still present adhesions. At 14-15, approximately only 10% of the boys still present adhesions. As we approach 17 years, only a very small percentage will still present adhesions. That means that, left uncircumcised, most boys will be able to retract their foreskin before they are 17 years old.
Incidence of preputial adhesions in various age groups, after Øster

As you can see, there are a lot of details in understanding what is phimosis and when phimosis becomes a problem. But hospitals and doctors often use the ignorance of parents to their benefit, by turning a natural condition into a pathological one.

I often hear parents who during childhood "had to" circumcise the child that they tried to keep intact, because he "had phimosis", the son was traumatized, and discouraged they have decided that any future son will be circumcised at birth.

This, however, is the result of a lie.

The other day, as I was reviewing the website of the Cincinnati Children's Hospital, base of some of the researchers in the trial of Gomco vs. Mogen clamp, I ran into an interesting information.

First, I have to admit that their page on circumcision provides some more information than most other clinics do.  For example, this page dedicates one paragraph to the role of the foreskin. While this paragraph is very incomplete (it does not explain at all the sexual function of the foreskin), at least it says that the foreskin "protects the sensitivity of the glans".

On their section on benefits they also admit that the risks of UTIs, phimosis, balanitis and penile cancer are all low. Very low. And they don't even try to talk about prevention of STDs. I'm honestly surprised, this page seems more honest than most other hospitals.

However, I also found a referral guide, and this is their guide for circumcision:

Elective circumcisions (outside the newborn period) are performed around 6 to 12 months of age. Therefore we recommend evaluation at age 6 months. 
Neonates who were circumcised at birth should be seen seven to 10 days later in the primary care physician's office. At this visit, the infant should be checked for the development of adhesions between the glans and the foreskin. These adhesions should he lysed in the office at that time. Children with adhesions that cannot be lysed in the office, or with a sub-optimal initial circumcision, may be seen at age 6 to 12 months for possible surgical revision.  
Children who are uncircumcised should not have their foreskin retracted until 3 to 4 years of age. If adhesions still exist when the child is 5 years old, offer the option of circumcision or recommend waiting until puberty to see if the adhesions resolve spontaneously.

This is the key part: "If adhesions still exist when the child is 5 years old, offer the option of circumcision or recommend waiting until puberty to see if the adhesions resolve spontaneously." From the graphic, over 65% of the children at age 5 still present adhesions! That means that 65% of the uncircumcised children are at risk of being referred for circumcision at age 5 unless their parents have enough understanding to know that this is not a pathological condition.

Let's be clear. Diagnosing phimosis on a child is almost always fraud. Retracting the foreskin of a 5 year old child is unnecessary and potentially dangerous, as it can cause pain, bleeding, wounds inside the foreskin, infections and additional adhesions (as wounds inside the foreskin due to forceful retraction may become scar tissue binding the glans to the foreskin!).

Now you know how they do it.

And since we are going at it now, is the AAP Policy on Circumcision any better?

The 9th page of the Technical Report states that:

Parents of newborn boys should be
instructed in the care of the penis
at the time of discharge from the
newborn hospital stay, regardless of
whether they choose circumcision or
not. The circumcised penis should be
washed gently without any aggressive
pulling back of the skin.24 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

There are several things wrong with this. The use of soap, particularly antibacterial, scented and stronger soaps, on the foreskin and penis in general, may disrupt the pH of the foreskin and damage the beneficial bacteria, causing irritation and infections. It is actually recommended to use just warm water to rinse the penis.

The parents of the child DO NOT need to retract the foreskin at any age. Only the child himself should retract the foreskin, and that only when he becomes able to do it comfortably.

Now, I'm especially concerned with this: "Most adhesions ... spontaneously resolve by age 2 to 4 months". This is definitively not supported by the graphic by Cold and Taylor. It's only at 17 years of age that most males will resolve their adhesions. This sentence regarding 2 to 4 months will make many people wrongfully think that the inability to retract a child's foreskin is a pathological condition that merits immediate surgical intervention.

In one occasion someone argued that this document is written for health professionals, not for the typical parents. It is my opinion that even if it is written for health professionals, it should provide more information as this is the one chance to educate them.

So now you know how your doctor gets to lie to you, injure your son and collect a check.


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