Category Archives: circumcision

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

Toward Understanding: Circumcision Terminology

There’s an issue in conversations about male circumcision today. Well, there are a lot of issues, such as the complete shutting down of opposing viewpoints and slinging of ad hominems and cyber bullying. But the one out of the dozens of issues that I want to address in this post is terminology.

The United Nations’ official term “Female Genital Mutilation” (FGM) refers to the cultural practice that involves removing part or all of a girl or woman’s clitoris, clitoral hood, and labia, and sometimes sewing her vagina closed [1] (see Footnote 1). It’s a horrific practice, and so “mutilation” seems fitting. However, they discovered that when discussing the practice with natives and trying to educate them about how harmful the practice really is, the term “mutilation” is so emotionally-charged that it tends to shut down conversation entirely and do more harm than good in advancing their anti-FGM cause (see Footnote 2). Thus, when conversing with natives and educating them about the harms of the practice, the WHO advocates the use of the emotionally neutral and anatomically accurate term “Female Genital Cutting” (FGC). [1]

A very similar thing is happening in online conversations about circumcision. I would like us to advance toward a better understanding of each other and an improved ability to communicate effectively, and this may be one small part of that.

I apologize if this makes your eyes glaze over.

Terms for the Penis

If a penis has been circumcised, there are a number of terms used to describe it. The most common are “circumcised” and “cut.” People who are very against circumcision often use the term “mutilated.” Obviously, that’s intentionally inflammatory and offensive to males who are circumcised. Circumcised men sometimes refer to their penis as “clean” or “clean-cut.” Obviously, that’s offensive to males who are not circumcised. Therefore, I recommend the terms “circumcised” and “cut.”

If a penis has not been circumcised, there are also a number of terms used to describe it. The most common is “uncircumcised.” I’m going to take a slight rabbit trail for a moment. My children are not vaccinated. Anti-vaxxers often take offense at the term “unvaccinated” because, they argue, “you can’t un-vaccinate a child.” To me, this has always demonstrated a profound misunderstanding of the English language. If I am “unlicensed,” that doesn’t necessarily mean I once was licensed but now am not (that would be “de-licensed”). It simply means I am not licensed. The English prefix “un-” simply means “not.” Ergo, “unlicensed” means “not licensed,” “unvaccinated” means “not vaccinated,” and “uncircumcised” means “not circumcised.” So this whole argument doesn’t make any sense to me, but in the same way that anti-vaxxers often take offense at the term “unvaccinated,” people who are opposed to circumcision often take offense at the term “uncircumcised.” My children are not vaccinated and I use the term unvaccinated. I don’t understand the offense at the terms “unvaccinated” or “uncircumcised.” In fact, I think it’s stupid in both situations. But I’m going to respect that opinion by not using the term “uncircumcised” in conversations where people opposed to circumcision might be involved.

Another term for a penis that is not circumcised is “intact.” This is the term those who oppose circumcision most often use. However, it’s insulting to circumcised males because the term was first used in animal husbandry to mean an animal that has not been neutered or castrated. Thus, using the term “intact” for a man who is not circumcised implies that a man who is circumcised has been castrated and/or emasculated. For this reason, some men take offense to the term. In fact, an acquaintance of mine calls himself “intact” even though he’s circumcised. So in conversations with people from both groups, I recommend against the use of the term “intact.” Other terms used include “natural” and “normal,” which are also obviously insulting to circumcised men and intentionally inflammatory; and “anteater,” which is obviously insulting to men who are not circumcised and intentionally inflammatory. The only completely neutral term* I can find that isn’t highly medico-lingal, and which people on both sides use, is “uncut.” So that’s the term I recommend.

Two completely neutral medico-lingal terms are “prepucal” and “aprepucal.” The “prepuce” is the foreskin, so a “prepucal” penis is one that has a prepuce and an “aprepucal” penis is one without a foreskin. However, I thought these terms were too difficult to catch on with non-medical persons.

Therefore, I recommend “circumcised” or “cut” versus “uncut.”

Terms for People

People who support circumcision typically use the terms “pro-circumcision,” “pro-circ,” or “PC.” People opposed to circumcision call them “pro-cutters.” Although the term is technically somewhat neutral, it is always used in a derogatory way, so it’s considered offensive by pro-circs. People opposed to circumcision also call them “pro-mutilators,” “pedophiles,” “child abusers,” “child molesters,” etc. For obvious reasons, I recommend avoiding those terms as well and sticking with “pro-circumcision,” “pro-circ,” or “PC.”

People who oppose circumcision call themselves “intactivists,” which is a combination of “intact” and “activist.” Pro-circs sometimes call them “intactonuts” or “intactic*nts,” which are obviously offensive, so I won’t use those terms. Because the term “intactivist” comes from the offensive use of the word “intact,” it could be argued that “intactivist” shouldn’t be used, either. However, “anti-circumcision activists” is too long and pro-circs most often use the term “intactivist” anyway, so I recommend “intactivist.”

A somewhat neutral term is “PPC” or “pro-parental-choice.” This refers to people who support a parent’s right to choose whether to circumcise, even if they disagree with their choice. Typically, intactivists believe that circumcision is evil and should be completely abolished, so it will be very rare for you to find an intactivist who is also PPC. Therefore, PPC typically only refers to people who are neutral on circumcision or are pro-circ. I have yet to meet a person who actually believes that circumcision should be mandated, but most intactivists believe that circumcision should be legally prohibited.

Conclusion

To help us move toward a better understanding and more fruitful conversations on the topic of circumcision, I recommend the use of emotionally neutral terminology, including “uncut” versus “cut”/”circumcised” and “intactivist” versus “pro-circ”/”PC.” You don’t advance your cause by insulting the other side, and anyone can see that you’re being a jerk. If you really care about helping boys to live healthier, fuller lives, you should consider reaching their parents in the most effective way possible.

 

*Well, I thought it was completely neutral. I’ve seen it used almost exclusively in a positive light. But just today, after writing this but before publishing it, I discovered that there are even people opposed to that term as well. At any rate, it’s still the least offensive term I can find.

 

Footnote 1

A brand new and exceedingly rare version of this involves removing only the clitoral hood, but this is not a traditional practice [1]. Because removing only the hood is similar to removing only the foreskin in the man, it is accurate to call it “female circumcision.” However, this is distinct from the practice of FGM, which has never traditionally involved only the hood but rather has always involved some degree of harm to the clitoris and almost always removal of some portion of the labia minora. Some may argue that female circumcision can also be performed for genuine medical reasons such as the treatment of clitoral phimosis [2].  However, in that case, if you read the entire study, you’ll find that the treatment involves cutting a slit in the hood, not removing the entire clitoral hood. Therefore, the only accurate use of the term “female circumcision” is in reference to a new, rare practice that is most common in Egypt and is only one small part of traditional FGM.

 

Footnote 2

From Reference [1]:

“The language used to describe these practices remains controversial and requires careful ethical consideration. The term ‘Female Genital Mutilation,’ formerly adopted by the United Nations (UN) calls attention to the gravity of the harm caused by FGC practices. ‘Female Genital Mutilation (FGM)’ is the terminology used within campaigns to end these practices by anti-FGC advocates from practicing countries of origin and the western world. FGM terminology positions the practice of FGC as an extreme human rights violation. This term is often perceived as inflammatory, judgemental and stigmatising, particularly for women previously exposed to the practice who do not view their bodies, or the bodies of their daughters, as mutilated [3]. The implication within this terminology is that FGC is practiced as an act of intentional violence against female children, adolescents and women. Those who do not understand FGC as such an act, but as a valued cultural tradition, may experience the language of “mutilation” as alienating [7,911]. The delicate challenge of reconciling respect for cultural values associated with these practices and addressing their perceived harmful effects on health is evident in this discrepancy between the intent and impact of language.

” ‘Traditional women’s practices,’ ‘Traditional health practices,’ and ‘Initiation,’ are some of the preferred terms identified by individuals who subscribe to the socio-cultural benefits from these practices. Chalmers & Omer Hashi [10] as well as Vissandjée et al. [7] conducted focus groups with overall 600 women from different practising countries living in Canada which revealed “circumcision” to often be the preferred terminology. Several other authors have also identified “circumcision” as an alternative term, yet this term has been argued to trivialise the procedure, falsely attributing to FGC the legitimacy afforded to male circumcision within the West [12,13]. “Female Genital Cutting (FGC)” and “excision and infibulation” have been identified as more neutral, ethically sensitive terminology [4,6]. For the purpose of this chapter, we will use FGC as a term comprising procedures which alter the female genital organs for cultural or non-therapeutic reasons.”

References

[1] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4012131/

[2] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4721030/