*Written by John Geisheker, J.D., LL.M.

What is the most dangerous event facing an 'intact' (not circumcised) boy?

Aside from circumcision? A well-baby visit. Our physicians' international non-profit intervenes in over 100 cases each year of intact boys who were injured by a primary care provider. The injury is called 'PFFR,' or Premature Forcible Foreskin Retraction. We conservatively estimate the annual incidence in the U.S. at more than 100,000 cases. Ironically, many occur when a parent takes the child to a well-baby visit at 6, 12, or 24 months; but this injury might occur at any age. The children we have helped range in age from one week to 12 years.

Here is a typical email we receive:

Dear doctors: At a well-baby visit yesterday for my uncircumcised son Jonah, 18-months, the doctor pushed his foreskin back so hard I could see my boy's entire glans, which was oozing blood. The Dr. told me I must do this at every bath or my child "will need to be circumcised for sure." Jonah now screams when we change him, is restless, and seems to be in pain. Is this really necessary? It does not seem reasonable to hurt a boy in order to clean him. Please help us. Signed, .W., Puzzled in Peoria.

How could this injury possibly happen?

At birth, the penis is under-developed. The foreskin is fused to the glans (head) by a normal connective membrane, the balano-preputial lamina, (translation: glans-foreskin layer). The two are functionally an undifferentiated single structure. It takes many years for this membrane to naturally dissipate, a few cells at a time. The average age for full foreskin retraction without trauma is 10 years, with half of all boys at age 10 fully retractable, and half not yet so. At age 6, for instance, only 20% of boys are fully retractable (Øster et al., 1968-2005).

Typically this injury occurs when a poorly-trained physician or nurse tells the parent that the child has 'adhesions' (an unnatural tissue connection) which must be separated "for hygiene." He or she will then tear the foreskin from the glans by forcing it towards the abdomen, exposing the entire glans and destroying the boy's protective membrane. Some doctors insert a blunt metal probe or closed hemostat to "lyse the adhesions." Either way, this is intensely painful and for the child, as well as exposing him to infection, scarring, and even adult sexual problems.

What happens to boys who have been forcibly retracted?

The trauma of tearing the glans and foreskin apart before they separate naturally will cause intense pain, bleeding, swelling, and expose what was formerly a sterile, internal site to infection. The trauma and subsequent infection may create scarring all the way around the foreskin that will make it inelastic and thus difficult to retract in later life, when adult hygiene will actually be needed. This condition is called phimosis. In older children and adolescents, true phimosis is almost invariably due to forced retraction in with its resultant infection and scarring. (False diagnoses of phimosis are, sadly, commonplace, the clinician mistaking the natural membrane for claimed 'adhesions.')

Pediatrics, a reference text for doctors by Rudolph and Hoffman, warns:

"The prepuce, foreskin, is normally not retractile at birth. The ventral 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 ... in particular, there is no indication ever for forceful retraction of the foreskin from the glans. Especially in the newborn and infant, this produces small lacerations in addition to a severe abrasion of the glans. The result is scarring and a resultant secondary phimosis. Thus it is incorrect to teach mothers to retract the foreskin."

Where did the notion of forcible retraction originate?

The complete answer is a book-length story of medical ignorance, 'hygiene hysteria,' prudery, even outright cruelty—but a short synopsis is possible.

In the mid-19th-century, before doctors discovered germs, they devised a disease theory called 'reflex .' This theory held that stimulation, (then called 'irritation' or 'neurosis') of sensitive tissue, would cause disease to appear in a distant part of the body (the reflex). As the genitals are intensely sensitive tissue, doctors blamed disease even on innocent touching 'down there.' A refinement of this theory claimed that children touched themselves because smegma, the natural substance that both sexes produce, would sour, become itchy, and draw the child's to his (or her) genitalia.

Thus if a boy in 1870 contracted tuberculosis, he was accused of 'irritating' his penis. The solution? Aggressive, regular, internal cleaning -or circumcision. This medical theory was a perfect fit with the sexual mores of the Victorian era. Thus began a hundred-year tradition in English-language medicine of vilifying the genitals, both male and female, as the source not only of disease, but also a potential temptation to offend 'moral hygiene.' Doctors reasoned that rigorous cleaning, drying-up, desensitizing (with acid), or even amputation of genital mucosal tissue (i.e., circumcision) was both a medical and a moral imperative.

Reflex neurosis survived in English language medicine until well after germs were discovered in 1879. Even in the 1930s, some doctors were still advising parents to tie scratchy muslin bags on children's fists to discourage even inadvertent genital contact during sleep. An entire industry of 'anti- ' devices for children developed. (Hoag Levins, 1996).

In an influential article in 1949, a British pediatrician conceded the BPL membrane was normal anatomy, but suggested, erroneously, it should disappear by age three years (Gairdner, 1949). This abbreviated and inflexible timetable—to be fair, an incremental improvement on a theory that this membrane was a 'birth-defect'—thrives today, even though modern, evidence-based medicine has shown otherwise, numerous times since 1968: (Øster, 1968; Kayaba, 1996; Cold & Taylor, 1999; Concepción-Morales, 2002; Ishikawa, 2004; Agawal, 2005; Thorvaldsen and Meyhoff, 2005, Agawal, Mohta, and Anand, 2005.) To reiterate: we have known for over 40 years that it is normal for the foreskin to not retract in children.

It was once standard English-language medical practice (1870-1980) to forcibly separate the glans from the foreskin, either by the doctor or by the parents on doctor's orders, "a little at each bath." Mothers reported disliking this chore as they knew it was painful. (cite available) This pernicious practice is not yet dead, and many grandmothers (and doctors) still cling to it. The American Academy of Pediatrics' has issued a stern (if tardy) prohibition in recent years:

"Until separation occurs, do not try to pull the foreskin back—especially an infant's. Forcing the foreskin to retract before it is ready may severely harm the penis and cause pain, bleeding, and tears in the skin. "

... but this warning is widely flouted by many practicing clinicians.

Reflex neurosis lives on today in locker room jokes about blindness, insanity, and unusual hair growth caused by touching the genitals. But it also lingers as PFFR—premature, forcible, foreskin retraction.

–John V. Geisheker, J.D., LL.M.; George C. Denniston, M.D., M.P.H.; Mark D. Reiss, M.D.; and Morris R. Sorrels, M.D., of Doctors Opposing Circumcision, Seattle. Pediatric consultant: Robert S. Van Howe, M.D., M.S.

Note: References are listed in the next post, Why Continue to Harm Boys from Ignorance of Male Anatomy?