Does Forced Retraction Cause Phimosis?

In short: No. Not only is there NO evidence that forced retraction DOES cause phimosis, there is actually POSITIVE evidence–cataloged on intactivists’ own websites–that forced retraction DOES NOT cause phimosis.

What are Adhesions?

The foreskin is naturally stuck to the glans by what we call “adhesions.” Virtually 100% of uncut boys have adhesions that prevent the foreskin from retracting. In fact, because circumcision often doesn’t remove the entire foreskin, adhesions occur in 45% [Van Howe, 2001] to 71% [Ponsky et al, 2000] of circumcised boys as well. Breaking the adhesions by retracting the foreskin before it’s ready—called “forced retraction”—is very painful and has no known medical benefits. In order to circumcise, these adhesions must be broken, but the boy receives highly effective numbing medicine beforehand [Shockley & Rickett, 2011]. However, there’s no numbing medicine in day-to-day life, and there’s no evidence that forced retraction is beneficial to the boy’s health. So… cut or uncut… don’t do it.

Why Do We Forcibly Retract?

Intactivists claim that Americans retract the foreskin because of cultural ignorance of proper care of the foreskin due to unfamiliarity with the foreskin thanks to the relatively low number of uncut males in our society—in other words, cultural ignorance. However, this argument is false. In reality, retraction of the foreskin even in infants is a hold-over from early 1900s medicine which has not yet been fully dropped, and this practice was common in Europe, as demonstrated by a landmark British Medical Journal article (archived in intactivists’ own websites in full text format) wherein the (anti-circumcision) author stated, “mothers and nurses are often instructed to draw the child’s foreskin back regularly” [Gairdner, 1949, p. 1435]. At that time, the American newborn circumcision rate was very low—lower, in fact, than the British newborn circumcision rate. Furthermore, in spite of the vast majority of American boys being circumcised, most physicians don’t know how to properly care for the circumcised penis, either, and thus retract the skin, breaking the adhesions, and causing pain [Ponsky et al, 2000]. It’s not cultural ignorance. It’s prehistoric medicine.

Does Forced Retraction Cause Medical Problems?

Intactivists claim that forced retraction causes tiny, microscopic tears in the delicate inner skin of the foreskin, causing infection and scarring. The scarring then allegedly results in phimosis, for which the treatment is often circumcision. So it’s considered ironic that “most” medically-necessary circumcisions are necessary only because the foreskin was not properly cared for in the first place. Intactivists make this claim as a matter of fact, so I believed it was actually based in fact. However, what I found was that their own sources say the exact opposite.

I wanted to have a primary source for articles like this, rather than a heavily biased secondary or tertiary source, so I searched all of the intactivist websites for all their articles on forced retraction in order to farm their resources. For their theory that forced retraction causes infections and scarring, they almost exclusively cited tertiary sources—predominately, old pediatric textbooks. (For those who don’t know, textbooks often don’t differentiate between theory and proven fact, so a textbook should never be taken as an authoritative source.) However, one article in Psychology Today actually provided a tertiary resource that was published in a medical journal. So I used the anti-circumcision online Circumcision Resource Library to look it up.

A Psychology Today Blog post, which originated from another blog post by a Ms. Cannon, instructs parents not to retract the foreskin and states that forcibly retracting the foreskin “tears the foreskin and the tissue… that connects it to the head of the penis, leading to scarring and infection” [Nervaez, 2011]. It provided no reference for the claim that retraction causes scarring, but for the instruction not to retract, it provides as its reference a 2002 article, which states, “Parents should be educated to avoid forcible retraction of the prepuce; the tearing that may result could lead to fibrosis [scarring] and subsequent true phimosis…” [Camille, Ramsay, & Wiener, 2002] For this claim, it provided a 1998 reference, which I followed, and which states, “True pathologic phimosis occurs when fibrosis, induration and scarring occur in the tip of the foreskin usually secondary to inflammation or trauma” [Simpson & Baraclough, 1998]. For this claim, it provided a 1980 reference [Rickwood et al, 1980], which I followed, and which turned out to be the primary source I’d been looking for.

The primary source was a study of phimosis in boys aged 4-11 years undergoing a medically-necessary circumcision for scarring on the tips of their foreskins, resulting in pathological phimosis. Cross-sections of their foreskins were compared to cross-sections of the foreskins of non-phimotic boys circumcised for religious reasons. Their histories of infection, forced retraction, and other foreskin or penile issues (even their fathers’ histories of phimosis in search of a potential genetic basis) were also gathered and compared. The authors discussed three previous theories from the 1950s-1960s of the causes of phimosis, that it is caused by forced retraction [Twistington Higgins, Williams, & Ellison Nash, 1951], or by repeated bacterial infection [Campbell, 1951], or by irritation caused by ammonia (present in urine) [Robarts, 1962]. Ultimately, they could find no correlation between phimosis and any of these theoretical causes and concluded, “There was little to support the contention that the condition is caused by trauma, or by ammoniacal [urine-caused] or bacterial inflammation of the prepuce…” and “Our data do not support previous contentions that it is due to forcible retraction, ammonia dermatitis or recurrent balanoposthitis [infection of the glans and foreskin].”

Interestingly, what they did find was that balanitis xerotica obliterans (BXO) was present in almost every case (20 of 21 specimens) [Rickwood et al, 1980]. This was similar to another British study by the same author, which found that 84% of pathological phimosis specimens had BXO [Shankar & Rickwood, 1999]. As I’ll discuss further in a later post, we don’t know the cause of BXO and therefore don’t know how to prevent it, and the treatment is typically circumcision. Perhaps if certain intactivists could get off their high horses and stop fallaciously insisting that the only cause of circumcision is forced retraction (due to its falsely alleged causal relationship with phimosis), we could get some real research done to find out what causes BXO, realizing that BXO may be the primary—or even the only—cause of phimosis. Then, perhaps we could prevent phimosis from ever occurring, and thereby prevent the most common cause of medically-necessary circumcisions. Personally, I believe this theory has significant merit because it has even been demonstrated in women, where the cause of clitoral phimosis (where the clitoral hood is too tight) has been demonstrated to be caused primarily by BXO and secondarily by surgical trauma [Flynn et al, 2015].

At any rate, the very interesting, but not completely surprising, part is that these secondary sources I found cited this primary source as evidence that phimosis is caused by trauma, specifically forced retraction, yet the primary source they’re citing says the exact opposite. In other words, the authors either didn’t check the sources they were citing or were intentionally lying.

Conclusion

So to sum up, there’s actually no evidence that forced retraction causes any medical problems whatsoever.

However…. That being said… It’s still painful to forcefully retract a boy, cut or uncut, so it’s probably best to just leave it alone.

 

References

Camille, C.J., Ramsay, L.K., & Wiener, J.S. (2002). “Caring for the uncircumcised penis: What parents (and you) need to know.” Contemporary Pediatrics, 11:61. http://www.cirp.org/library/hygiene/camille1/

Campbell, M. (1951). Clinical Pediatric Urology. Philadelphia: Saunders. Cited in: Rickwood, A.M.K., Hemalatha, V., Batcup, G., & Spitz, L. (1980). “Phimosis in boys.” British Journal of Urology, 52L147-150. http://www.cirp.org/library/treatment/phimosis/rickwood/

Flynn, A.N., King, M., Rieff, M., Krapf, J., & Goldstein, A.T. (2015). “Patient satisfaction of surgical treatment of clitoral phimosis and labial adhesions caused by lichen sclerosus.” Sexual Medicine, 3(4):251-255. doi: 10.1002/sm2.90. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4721030/

Gairdner, D. (1949). “The fate of the foreskin: A study of circumcision.” British Medical Journal, 2(4642):1433-1437. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051968/

Nervaez (2011). “More circumcision myths you may believe: Hygiene and STDs.” Psychology Today Blog. https://www.psychologytoday.com/blog/moral-landscapes/201109/more-circumcision-myths-you-may-believe-hygiene-and-stds

Ponsky, L.E., Ross, J.H., Knipper, N., & Kay, R. (2000). “Penile adhesions after neonatal circumcision [Abstract].” Journal of Urology, 164(2):495-496. doi: http://dx.doi.org/10.1016/S0022-5347(05)67410-1. http://www.ncbi.nlm.nih.gov/pubmed/10893633

Rickwood, A.M.K., Hemalatha, V., Batcup, G., & Spitz, L. (1980). “Phimosis in boys.” British Journal of Urology, 52L147-150. http://www.cirp.org/library/treatment/phimosis/rickwood/

Robarts, F.H. (1962). “Penis and prepuce.” In Surgery of Childhood, ed. Mason Brown, J.J. Chapter 39, pp. 1159-1181. London: Edward Arnold. Cited in: Rickwood, A.M.K., Hemalatha, V., Batcup, G., & Spitz, L. (1980). “Phimosis in boys.” British Journal of Urology, 52L147-150. http://www.cirp.org/library/treatment/phimosis/rickwood/

Shankar, K.R., & Rickwood, A.M. (1999). “The incidence of phimosis in boys [Abstract].” BJU International, 84(1):101-102. http://www.ncbi.nlm.nih.gov/pubmed/10444134

Shockley, R.A., & Rickett, K. (2011). “What’s the best way to control circumcision pain in newborns?” The Journal of Family Practice, 60(4):233-234. http://www.jfponline.com/specialty-focus/pain/article/whats-the-best-way-to-control-circumcision-pain-in-newborns/d9d56c4483f56e3d0f9b55d68dc49985.html

Simpson, E.T., & Baraclough, P. (1998). “The management of the paediatric foreskin.” The Australian Family Physician, 27(5):381-383. http://www.cirp.org/library/hygiene/simpson1/

Twistington Higgins, T., Williams, D.L., & Ellison Nash, D.F. (1951). The Urology of Childhood. London: Butterworths. Cited in: Rickwood, A.M.K., Hemalatha, V., Batcup, G., & Spitz, L. (1980). “Phimosis in boys.” British Journal of Urology, 52L147-150. http://www.cirp.org/library/treatment/phimosis/rickwood/

Van Howe, R.S. (2001). “Re: Penile adhesions after neonatal circumcision.” The Journal of Urology, 165(3):915. doi: http://dx.doi.org/10.1016/S0022-5347(05)66571-8. http://www.jurology.com/article/S0022-5347(05)66571-8/fulltext

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