Monthly Archives: January 2015

When having your normal body is seen as problem: Medical facilities providing improper advice

The American medical community’s ignorance of the normal care of intact male minors’ genitals is evident, but few times we run into written evidence of how doctors fail to follow even American medical standards, providing instead misinformation that is likely to harm children.

Before showing the specifics, let me explain:

During fetal development, the glans and the foreskin of the penis start as a single structure, and later on start to separate by the dequamation of a membrane, called sometimes the balanopreputial synechia. Typically, at birth this membrane has not separated completely and the opening of the foreskin is tight, a condition that is called physiological phimosis, and which requires no treatment.

Note: the term “balanopreputial synechia” appears to be uncommon outside the intactivist community, but the membrane described by those words has been studied and known for a long time, described in 1933 as ”a layer of stratified squamous epithelium”, also referenced by MediLexicon as “glandoprepucial lamella“.

After a relatively long time, this membrane dissolves completely and the opening of the foreskin becomes more flexible, allowing for retraction of the foreskin in order to expose the glans, the head of the penis. This may happen at any time, it could be as early as a few months, or as late as 17 or 18 years of age.

Used with artist's permission.

Used with artist’s permission.


Read: Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish Schoolboys. Arch Dis Child 1968;43:200-3.

Typically physiological phimosis should be superated at least after puberty, as a sign of sexual maturity. Not being able to retract the foreskin before the sexual debut can sometimes make sex difficult.

See Leonard MP. Pathologic and physiologic phimosis: Approach to the phimotic foreskin. Canadian Family Physician 2007;53(3):445-448.

When a sexually mature individual cannot retract the foreskin, or the opening of the foreskin becomes scarred and does not allow the glans to come through, we are now talking of a pathological phimosis. This is not very common but not extremely rare either. Depending on the cause, pathological phimosis may be resolved through non invasive procedures (such as stretching, exercises, steroid creams, etc), or some surgical paths can be taken  such as preputioplasty, dorsal slit, synechiotomy, or circumcision (as an informed and consenting adult).
See: Orsola A, Caffaratti J, Garat JM. Conservative treatment of phimosis in children using a topical steroid. Urology. 2000;56:307–310.  [PubMed]
Nevertheless, some adults are not bothered by their phimosis and may choose not to do anything about it, even if that means keeping the glans covered during sexual relations.

Most medical organizations, including the AAP, agree that:

  • Having a non-retractable foreskin during infancy is normal
  • Trying to retract the non-retractable foreskin of a child (forceful retraction) causes pain, and may cause bleeding, scarring, infections, damage to the foreskin, and may even result in a iatrogenic phimosis (phimosis caused by intentional injury).

The myth that parents of uncircumcised (intact) children needed to retract the foreskin and wash the inside every day, was started in 1941 by Allan F. Guttmacher, who also promoted mass circumcision (Should the baby be  circumcised? Parents Magazine 1941 Sept;16(9):26,76-8]). Unfortunately this myth still persists, even in many members of the medical community, even when standards, policy statements and medical school books advice against it.

So think about this:

You have a 10 months old baby with a stomach problem. You take your baby to the ER. Upon examination, the doctors notice that your baby is not circumcised. The foreskin becomes their prime suspect. They check your baby for infections and find none. However, retraction is difficult and painful (as it should be at that age). They diagnose your baby with viral gastroenteritis AND PHIMOSIS, even though your reason for consultation had nothing to do with the penis.

And then they proceed to give you a care sheet, where their main concern is to tell you to RETRACT THE FORESKIN WITH EVERY DIAPER CHANGE and clean area with a q-tip, even before telling you about the actual care for the real problem (which was to provide motrin for fever and discomfort as needed, no dosage indicated).

Now, if you are an inexpert parent, you may go home to do just what they told you to do. And what you will find out is that retracting the foreskin is not easy and it causes pain every time, but they recommended it so that’s what you do. And if you keep doing it, you may notice some bleeding at times (ah, it’s the phimosis, you will say), and it may become progressively more difficult (due to scarring of the wounds caused by retraction), or the child will cry more every time (because he learns that diaper change means pain), and soon you may give up and just ask for a referral to circumcision, kicking yourself for ever trying to keep your baby uncircumcised.

We’ve seen it happen before. I’ve heard a mother share: “I tried to retract but no matter what I did it wouldn’t retract far enough“. When she learned the truth she felt abused and violated by the health providers, but it was too late for her child.

Today, we have a scan of a care sheet providing such misguided advice. Fortunately for this baby, the mother was educated enough to dismiss the recommendation.

Providing wrong information which results in harm to a baby should be denounced as malpractice.  If we can confirm the name and location of the facility that provided this care sheet, we will update this post to let you know.

Phimosis? Forced retraction?