Saturday, February 16, 2013

Hands Off My Foreskin! Dr. Martin Winckler on the Care of Baby Boys

By Martin Winckler, M.D. © 2013
Lire en Français ici. Translated to English by Nicolas Maubert and Danelle Frisbie for DrMomma.org with Winckler's blessing. Dr. Martin Winckler is a general practitioner and author in France. Read more from him at his website, MartinWinckler.com  



Many young mothers today are very worried because their mother, or their mother-in-law, or their doctor, told them they must 'clean' the glans (head) of the penis of their baby boy, and that to do so, you must retract (i.e. roll back) the foreskin like a turtleneck. In reality, however, this should not be done. The practice of retraction only causes problems and has no benefits.

What follows is an article interview printed in the L’Arbre à bébé Association's November 2005 issue. For this interview I answered some questions on the delicate topic of proper penile care and retraction that I am now sharing here with you.




Question One: 

What is your position regarding foreskin retraction, as a physician and as a parent? Do you retract your own patients? Do you retract your own sons for 'cleaning?'

Answer: 

I have never retracted the foreskin of a boy. Not any one of my patients, nor any of my five sons. (I believe if I asked them what they think of foreskin retraction they would look at me like something was wrong with me to have such strange ideas!)

Very early in my career, in the early 1980s, while reading the work of pediatrician Aldo Naouri, I had the notion that the practice of retraction was not only unnecessary, but aggressive for everyone -- starting with those most concerned (the boys), but also for their parents. The act itself is aggressive because once you touch a little boy’s penis, an erection is induced. Not all mothers [or fathers] are going to be comfortable with this, and we understand why. Boys will often smile or laugh that it tickles and very quickly we find that parents prefer to leave that area alone to care for itself.


Question Two:

What do you think of the arguments commonly used by proponents of retraction (that retraction will prevent adhesions, phimosis)?

Answer: 

Phimosis is the condition in which the orifice of the foreskin is too tight to allow the glans to leave when the boy is erect. So it can not interfere with boys until the age at which they are likely to have intercourse. However, most studies that have been done on the subject show that any amount of retraction, 'just a little' or a lot, has no medical function, neither for hygienic purposes, nor to prevent phimosis, which is an uncommon condition to begin with. It used to be said that retraction was necessary to fight against adhesions and to 'clean up' anything under the prepuce. However, preputial secretions are as normal as vulvar secretions in the little girls. There is nothing wrong with them whatsoever. Never have we suggested that we 'clean' the vulva of our daughters with a cotton swab, yet I have seen mothers try to pass a cotton swab under the foreskin of their son because a doctor told them to do so!

Quite simply, the foreskin is self-cleaning. The orifice of the foreskin is tight at birth on purpose to prevent dirt (bacteria, viruses, etc.) from creeping into it. Retraction (a dilating force) is then entirely unnatural. And it hurts! Retraction causes tears and can cause paraphimosis (having the foreskin stuck in a retracted position behind a swollen glans) which itself is an emergency. This induced paraphimosis is actually much more common than true phimosis.

A common scenario: A mom wanted to retract a boy (usually in the bath). The manipulation resulted in a retraction after erection. Suddenly, the foreskin 'turtlenecks' (squeezes) the glans, which then swells and turns purple. The child yells. And in a warm bath, it gets worse. [Vasocongestion takes place, leading to more blood flow, a throbbing erection, and tighter constriction.] In short, parents call the doctor and then one of two things happen. Either the doctor panics and sends the child and his parents to the emergency room, or the doctor understands what has just happened solves it very simply:
1) Do not pull the foreskin forward after retraction and paraphimosis (it does not work).  
2) You must first empty the warm water bath. Then pour somewhat cooler water (but not iced/cold water) on the penis. The cooler water deflates the penile engorgement.  
3) Then gently squeeze the swollen glans (head) of the penis. As the penis deflates, the foreskin will start to roll back down over the glans by itself.  
I saw dozens of situations like this one early in my career. It was always among boys whose mothers had a slight obsession of making sure their son was 'clean,' or among those whose parents had conscientiously felt pressure to retract following the advice of a relative or highly invasive physician. So much so that their little boy was retracted three times each week - so often that these little boys begin to develop anxiety when their mothers approached them to change or 'clean' them. The more mothers touched their boys' penises in this fashion, the more young children became angry, the more it hurt, the more retraction became torment, until they developed paraphimosis. And then parents call for help. In short, it is a vicious cycle.

Very quickly I started to pass along the message to young parents that they should not even touch the foreskin. Leave it alone. And with this advice, over the years, I began to see less and less paraphimosis among my patients. There were now more and more happy little boys who tugged on their own foreskin, laughing, without anxiety. And I saw more and more mothers delighted with the fact that they did not have to handle their son's penis - in fact, they did not have to do anything for its care. I have not had any little boys need surgery on their penis during my career as a general practitioner, and I saw very few boys ever in need of surgery during medical school, because in my district, no doctor was a fan of retraction.

Question Three: 

At what age should I be worried and consider surgery for a boy whose foreskin does not retract?

Answer:

It's simple: you should never worry because there is no reason to worry. Foreskin retraction is a cultural practice [in a few nations], and does not take place at all in other countries. Still, there are no more cases of phimosis or 'problems' among those nations where foreskin retraction is unheard of. Retraction by someone other than a boy himself serves no purpose at any age. And yet, all parents of little boys can testify that fiddling and tugging on the foreskin are commonplace practices among infants and toddlers (up to eight to ten years old). This self-exploration causes no problems. Quite simply, the foreskin is not meant to be retracted by anyone other than the owner himself - it serves as a sheath to the glans in this way, a protector from outside invasion. As a child grows, the foreskin lengthens and softens over time. With puberty and masturbation, the foreskin opens on its own. It stretches along the penis little by little, allowing for erections to take place without cause for concern. By the time the hormones of puberty are in full swing, the vast majority of boys have already retracted their own foreskin and eased the preputial orifice open.  Even if their prepuce was tightly closed in childhood, they do not have phimosis, and this is evident as young adults. So small is this concern that these boys do not even know the word 'phimosis!' In rare cases when there is a real issue, it is at puberty that this is discovered, not before. If a 'problem' arises before puberty, it is likely paraphimosis, because a boy is being retracted - see above.

Throughout my career as a general practitioner [~30 years in 2013] I have only had to circumcise one single man, aged 22 years, who had developed untreatable phimosis that was the result of brutal retraction as an infant and child that left tight foreskin scarring on his penis. This started to bother him at puberty - not before. And, in fact, it was the way he was treated as a baby and child that caused the inflammation that resulted in his phimosis - not the other way around. He had to be circumcised as a result of improper care by those who did not know any better. When we repeatedly tear the foreskin at an age of development, it does lead to scarring, and this in turn tightens the foreskin over time, causing the problems we then blame on foreskin (rather than improper care).

Question Four: 

What is your advice to a mother who does not know what a pediatrician will do to her baby during a check-up? What should she do if a physician suggests that she retract? How should she handle guilt-trips pushing improper care?

Answer:

Retraction is a problem that exists merely because it is a matter of culture-based opinion and not a factual issue of prevention or health. Again, there is no evidence that retraction has even the slightest benefit, but its disadvantages are medically obvious.

Doctors do not exist to dictate their personal opinions onto parents, and there should be no guilting of mothers who consciously decide they will not 'mess with' the penises of their sons. In fact, I find these mothers to be the ones who are the most mentally stable and emotionally healthy. Would a mother okay the circumcision of her son just to please a physician who tells her it is 'cleaner?' Of course not. The same goes for retraction. If a doctor talks about such things, tell him that you will leave your child to figure things out for himself, and if a problem arises down the road, you will deal with it at that point. Above all, do not let a physician who is suggesting retraction use your child for their demonstration.

Just as there is zero justification in performing vaginal exams on infant and young girls, so also is there never justification to retract and examine the inside of a baby boy's or child's penis when there is nothing wrong. Doing so is not alright for girls, and it is not alright for boys. The only time a physician should be handling your child's genitals (gently!) is if the penis or vulva in question has a visible abnormality that requires examination. If this is not the case, then hands off!

- Martin Winckler, M.D.



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8 comments:

  1. I remember when I was about 5, my mother and a neighbor that was a nurse, decided that they should hold me down and try to force my foreskin back, because the nurse had told my mother that it needed to be done to clean it. I was screaming with so much horror and pain, but they just continued. That is the first time I ever remember women touching my penis. I am a gay man, and believe that I was born gay, but I don't think this expeience helped, at all.

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    1. Your story is heartbreaking! You must have felt so betrayed by your mother, and I'm sure you still do. Like I tell people, the child experiences things like circumcision, and forcing back a nonretractile foreskin as a sexual assault. It makes no difference to the child that the person has some kind of degree. Nurses are given credit for knowing about such things, but the only thing most RNs are taught about this topic is how to assist in performing a circumcision. They usually have to take personal responsibility for learning anything such as care of an intact child, and very many don't.

      Have you ever spoken to your mother about that event? If not, she may feel guilty about it, or at least be hoping that you don't remember it. Perhaps some time you can ask her about it, in a noncontrontational way. If she regrets it, it may help you deal with it better.

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    2. Not quite the same as I am female but when I was around 3 I was held down by my mother for the doctor to examine me , I remember screaming and struggling. as neolani says to a child it is no different to someone abusing them.
      I hated that doctor from then on and have never gotten on with my mother.

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    3. To the female Anonymous poster, this story is breaking my heart, too. I'm wondering if you could talk to your mom about this incident? I was so angry and my mom for some things that happened to me as a child, only to find out later there was a medical reason why things happened, but my perspective as a young child prevented me from processing the events. Still upsetting for me, yes, but when I was able to have an adult understanding, it did help, some. Made it less like a personal attack, and I was able to detach from the fear and helplessness I felt as a child and let those feelings go (mostly). We can't erase our past, but we get to write our futures, and reinterperate our past with new understanding. I hope this helps. My heart goes out to you and the original poster who was held down by his mom and nurse. No doubt they thought they were doing the best thing for you, but clearly they didn't, and created a traumatizing situation for you. So sorry, and know that there are many moms right now reading your stories and their hearts are breaking forthe children that you two were and what you went through. Sending love out to you today...

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  2. I wonder what Dr. Winckler says about the practice of forcing back a foreskin remnant, on a circumcised boy, that has reattached itself to the glans. My children are all adopted, including four sons, born between 1983 and 1993. My first, third and fourth sons came to us intact and stayed that way.

    When we got our second baby, at four weeks old, I wasn't even 100% sure what had happened, at first. I had only seen one noncircumcised baby at that time, and that was my first son who, I later learned, had a shorter than average foreskin. My new baby had attached skin that covered most of his glans and, for a moment, I thought perhaps he hadn't been circumcised. Unfortunately, that wasn't the case. The social worker I had told that we didn't want the baby circumcised had made sure it was done before he let us have him.

    I took him to our pediatrician. When the diaper came off, he said "whoever has been taking care of him hasn't cared for his circumcision properly". Before I had a chance to think, he started pushing and pulling on the baby's penis, while the baby literally shrieked in pain. The ped said, "Poor kid. This is almost as bad as going through circumcision again." My son is 27 now. I can still picture his little face, that day, and I'm still in tears, writing this!

    I was given instructions to push back the foreskin remnant each day and put ointment on it, so that it didn't get stuck down again. Every time I touched his penis, no matter how gently, he screamed. The front part of it stayed separated but the back part always started to stick back down, hours later.

    One day, I started thinking about the fact that my first son's foreskin had just barely become 100% retractile, and he had just turned three (which, incidentally, is on the young side of the average range, for that to happen). I wondered if my new son's foreskin remnant would loosen on it's own, like an intact foreskin does. I also figured that, even it meant he would need some kind of local procedure to free adhesions when he was older, that would be far better than for him be hurt repeatedly while he was little. I put ointment on it one last time and left it alone. Within 24 hours, it stuck back down and all the redness went away and it never hurt him again. After that, during his bath, I just cleaned under the loose part very carefully, to avoid disturbing the attached part. When he was about two and half, it loosened spontaneously (which, again, I think is quite early).

    Since then, I have found that my son's situation is very common in circumcised babies, and that most have also been further traumatized. I have been suggesting that parents of circumcised boys not try to retract a fused, partial foreskin, rather than keep trying to break adhesions, over and over. Everyone who has done so and told me about the results has had the same experience as mine with my son.

    I do believe that an unattached fold of skin on a circumcised boy should be rinsed under, periodically. Intact foreskins cover completely and prevent anything dirty from getting under them, but a cut edge quite easily gets everything from diaper lint to fecal matter from a really full dirty diaper under it. It's quite a bit like fingernails. The unattached part collects dirt easily, but only an injury results in dirt under the attached part.

    I had hoped by this time, well into the 21st century, all Americans but those with a religious motive would have abandoned this harmful practice. In the meantime, though, I wish we would at least stop needlessly inflicting further injury on circumcised babies by tearing back foreskin remnants that have gone back to being attached.

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  3. Perfect timing - it is definitely very much a cultural practice in Poland, and just today there was an article on one of the websites for parents recommending that they do it unless they want to harm their baby boys. Reposted this article in response - I hope you don't mind. Thanks so much for a clear, respectful and informative post!

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  4. Thank you for this article. My older son is circumcised and he developed a scalding staff infection, and also, during the procedure the doctor accidentally cut him. :-( He was in the hospital for the first 2 weeks of his life, all because of a stupid circumcision. Worst mistake I've ever made concerning my kids. My second son was NOT circumcised because of this, and many other reasons. I have no idea how to care for his penis. Some people tell me to pull it back, some say just leave it. He had some discharge in his diaper around his penis area, and his pedi suggested that it was probably irritated and to gently just pull back enough to expose the little hole and pat it with a wet cloth. So I've been doing that. I don't pull it hard at all, I pull it so I can see the tip better. He has a lot of skin (that's what his pedi said). So now, I'm second guessing this suggestion...... I won't be touching it anymore, I'm just going to leave it. I'm happy I don't have to because I don't want to have to do it when he's older anyways.. Its weird to me.

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  5. How does one deal with a dr saying they need to 'see' his peehole by retracting? (i panicked and kept saying not to retract not even a little) i changed pediatricians but need to figure this out

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