Presentation on theme: "Circumcision and the Foreskin"— Presentation transcript:
1Circumcision and the Foreskin Presented byCraig GarrettColoradoNOCIRC.orgNational Organization of Circumcision Information Resource CentersColorado Center
2Outline Global context & history Information gap Anatomy and functions of the foreskinDevelopment and care of the intact penisForeskin problems & conservative treatmentThe procedure: types, pain, complicationsSocial & medical issuesEthicsAdditional Resources
3Mother-Friendly Childbirth Initiative (MFCI) Developed by the Coalition for Improving Maternity Services (CIMS)Birth Network is based on the MFCITen Steps define a mother-friendly hospital, birth center, or home birth serviceStep #9: Discourages non-religious circumcision of the newborn
4Global Perspective Worldwide, circumcision is rare (~25%) Europe, South America, & most of Asia never adopted itUK, Canada, Australia, New ZealandAbandoned circumcision during 1950s-1970sCommon:Muslim countries & Israelparts of Africa (along with FGM)Philippines, South KoreaGreen portions: circumcision very rare, Red: non-religious circ common, Orange: religious circ common
5How Circumcision Began in U.S. Late 1800’s – sexually repressive Victorian eramultiple pseudo-medical claims“cured” paralysis, epilepsy, bedwetting, insanity, & many othersanti-masturbation hysteria: both boys and girlsCame to be associated with upper classbirth moved into hospitalbecame part of the hospital birth processRoutine, almost universal in late 1940s/50spushed by doctors or done without asking parentsgenerally right after delivery, without anesthesiaOriginal reasons debunked; new reasons put forth
6Current Trends in U.S. Peaked in 1970s – about 90% About ~55% nationwide (2009)1971 AAP: no absolute medical indicationAdvent of the InternetImmigrationMedicaid dropping coverage18 states (36%) do not pay2011: South Carolina & Colorado dropped coveragedata from 2009/2010, courtesy of circumstitions.comimage from: mgmbill.org/statistics.htm
7Information Gap Many parents' decisions are preconceived1 Lack of informed consentDetails of procedureRisksAlternative of not circumcisingFunctions of the foreskinConsideration of the child’s perspective & choiceLack of knowledge among caregiversAssumption: foreskin has no value1. "Report 10 of the Council on Scientific Affairs (I-99):Neonatal Circumcision" AMA Interim Meeting: Summaries and Recommendations of Council on Scientific Affairs Reports. American Medical Association. December pp. 17. Retrieved
12Fine-touch Sensation 2007 study Semmes-Weinstein monofilament testing CONCLUSION: Circumcision removes the most sensitive parts of the penis.Sorrells ML, Snyder JL, Reiss MD, et al.Fine-touch pressure thresholds in theadult penis. BJU Int 2007;99:864-9.
15Protection Foreskin protects against: uncomfortable abrasion against clothingcoldurine & feces in diaperProtects the delicate urinary openingup to 10% of circumcised boys will suffer from meatal stenosisInner foreskin contains immunologically active cellssimilar to other mucous membranes
16Natural Infant PenisFused to glansTight outletOverhang
17Two Processes Leading to Retractability #1: Separation of the inner foreskin from the glans#2: Loosening of the foreskin openingVariable timingSeparation vs. LooseningTypical age range: 2–16, average 10-11Process does not need to be rushedFactors:Boy’s own handling, erections, penile growth, hormones
18Age of Retractability Øster 1968 (Denmark) ~2000 boys, ages 6 -17 Percent fully retractable:50% by age 1097% by age 17CONFIRMEDKayaba 1996, Imamura 1997, Concepcion Morales 2002, Ishikawa 2004, Thorvaldsen 2005, Agarwal 2005, Ko 2007Øster J. Further fate of the foreskin: incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child 1968;43:200-3.
19Care of the Foreskin: It’s Easy! What NOT to do:Never forcibly retract a child’s foreskin!Tell grandparents, babysitters, day care, and doctorsCleaning before the foreskin is retractable:Wash the outside onlyAvoid bubble baths & other harsh chemicalsCleaning after the foreskin is retractable (“Three Rs”)Retract the foreskinRinse with clean warm water (soap not recommended)Replace the foreskin back over the glans
20Phimosis Inability of the foreskin to retract in a MATURE male Non-retractable foreskin is NORMAL in childrenOften misdiagnosed & inappropriately used to justify newborn or child circumcisionTrue (adult) phimosis can be treated without circumcisionSteroid cream, stretching, preputioplastySome men who have phimosis are not bothered
21Foreskin Irritation PREVENTION AND CARE: SYMPTOMS: Redness, swellingREMEMBER:Foreskin is doing its job!POSSIBLE CAUSES:Diaper rashChemical or mechanical irritationTransient “separation inflammation”Imbalance of bacterial floraInfectionPREVENTION AND CARE:Warm tub soaks, barrier cream, air dryingAvoidance of: soap, bubble bath, excessive chlorine, commercial wipes, detergent residue, etc.Replenish healthy bacteriaApply liquid acidophilus topically and take orallyAppropriate antimicrobial, if neededTeach hand washingTo replenish healthy bacteria: Apply liquid acidophilus topically and take orallyContrary to myth, the foreskin is not prone to infection!
22Pain and Pain Reduction CIRCUMCISION IS PAINFULBabies feel and remember painAAP 1999: recommend use of “procedural analgesia”Anesthesia does not eliminate the painOperator skill, pain of injections, post-operative painNot all doctors use anesthesiaGeneral anesthesia is required for children after the newborn periodolder babies cannot be effectively restrained
23Pain reduction methods INJECTION (NERVE BLOCKS)Subcutaneous ring block (best)Dorsal penile nerve block (DPNB)Only addresses dorsal nervesTOPICALEMLA creamSubcutaneousring blockPhoto courtesy of Dr. Larry Veltman
25Initial Steps Baby on “Circumstraint” board Separating the foreskin from the glansDorsal penile nerve block
26Gomco Clamp Procedure Pulling through baseplate Dorsal crush Dorsal slitInserting bellDevice assembledRemoving bellGomco result
27Plastibell Procedure Applying ligature Plastibell procedure DOES involve cuttingRing stays in place 5-8 daysPlastibell result
28Post-Operative Care Care of circumcised newborn: Follow physician’s instructionsPain reliefClean wound, change gauze, apply Vaseline (Gomco)Watch for bleeding, signs of adhesions and infectionConsole a newborn in pain (esp. during urination)Healing takes 7-10 daysCare of non-circumcised newborn:Clean outside of penisat baths and diaper changessimilar to rest of diaper area
29Circumcision RisksA “safe and quick” procedure? Risks “rare and minor”?Risk rates: 0.2% - 0.6% ? (conservative)HOWEVER…“A realistic figure is 2-10 percent.”Williams N, Kapila L. Complications of circumcision. Br J Surg 1993; 80:Rates do not include:Sexual harmsPsychological harmsSome complications do not manifest till years laterApprox. 1% of boys will need corrective surgeryNo national system for collecting data
31Other Complications Post-operative infection including MRSABlocked urethra (esp. Plastibell)Post-operative bleedingdangerous in newbornshidden by absorbent diapers
32Catastrophic Damage to or loss of the glans (head) Loss of the entire peniselectro-cauterizationsurgical mishapinfectionDeath2-3 per year reported in mediasome estimate 100 deaths in U.S. each year
33Other Possible Side Effects NewbornDifficulty breastfeedingFussinessInterference with mother-infant interaction/bondingExcessive sleepingAdultTight or uncomfortable erectionsCurved penisHairy shaftSexual dysfunction especially in older menED, delayed ejaculationPTSD
34Medical RationalesArgument: removal of the foreskin has potential medical benefits“risks of not circumcising”“no health benefits of having a foreskin”This framing pathologizes the foreskinFact: the foreskin is a normal body partParents are not provided a list of other body parts to remove from their newborn with “benefits & risks” of each
35Medical Arguments Unscientific foundation of start of circumcision Not medically necessaryA medical-benefits or "therapeutic" justification requires:benefits sought outweigh the risks and harmsonly reasonable way to obtain these benefits, andnecessary to the well-being of the child.None of these conditions is fulfilled for routine infant male circumcision.
36Potential Medical Benefits Reduction in UTIs (first year)UTIs are uncommon (1%) & treatableBaby girls have more UTIsReduction in Penile CancerRare (1 in 100,000), only affects elderly menReduction in Cervical CancerRelated to HPV, best prevented through safe sexReduction in STDs and HIVProblems with studies; safe sex (condoms) still requiredU.S. has high rates of circumcision and high rates of STDs
37Cultural, not Medical Not recommended by medical organizations1 Some neutralSome actively discourage itMost physicians: no compelling medical reasonParents’ motivations:Social concernsWhat they have heard from family or friends1.
38Social Rationales “fit in to society” or “he’ll get teased” circumcision rates have decreasedcommunal showering less commongood parenting can promote child’s self-esteem“a boy should look like his father”no scientific evidence to support this ideaeasy to explain differenceswhat if the father had lost a finger?“women prefer circumcised partners”not true in non-circumcising culturesO’Hara study: women who experienced both prefer intactsome women are intrigued & interested
39Ethical Considerations Newborn Circumcision:Medically unnecessaryRemoves healthy tissuePerformed without the child’s consentWhat would he choose if the decision was left to him?We can’t know for sure, but…Circumcision is irreversible, andMost men who were not circumcised as babies do not choose to get circumcised as adults