Presentation on theme: "Circumcision and the Foreskin"— Presentation transcript:
1 Circumcision and the Foreskin Presented byCraig GarrettColoradoNOCIRC.orgNational Organization of Circumcision Information Resource CentersColorado Center
2 Outline Global context & history Information Gap Anatomy and Functions of the ForeskinDevelopment and Care of the Intact PenisConservative TreatmentThe Procedure: Types, Pain, ComplicationsSocial & Medical IssuesEthicsAdditional Resources
3 Mother-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
4 Global Perspective Worldwide: Rare: Common: 25% circumcised, 75% intactRare:Europe, South America, & most of Asianever adopted circumcisionUK, Canada, Australia, New Zealandabandoned circumcision during 1950s-1980sCommon:Muslim countries & Israelparts of Africa (along with female cutting)USA, Philippines, S. KoreaGreen portions: circumcision very rare, Red: non-religious circ common, Orange: religious circ common
5 How 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 hospitalcircumcision became 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; but became a “cultural norm”
6 Current Trends in U.S. Peaked in 1970s – about 90% About ~55% nationwide (2010)1971 AAP: no absolute medical indicationAdvent of the InternetImmigrationMedicaid dropping coverage18 states (36%) do not pay2011: South Carolina & Colorado dropped coveragedata from 2010/2011, courtesy of circumstitions.comimage from: mgmbill.org/statistics.htm
7 Information Gap Many parents' decisions are preconceived1 Lack of informed consent:Details 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
12 Fine-touch Sensation 2007 study of 150 men Semmes-Weinstein monofilament testingCONCLUSION: 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.
15 Protection 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
16 Natural Infant PenisFused to glansTight outletOverhang
17 Two Processes Lead 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
18 Age 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.
19 Care 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 isn’t necessary)Replace the foreskin back over the glans
20 Phimosis 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
21 Foreskin 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!
22 Pain 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
23 Pain 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
25 Initial Steps Baby on “Circumstraint” board Separating the foreskin from the glansDorsal penile nerve block
26 Gomco Clamp Procedure Pulling through baseplate Dorsal crush Dorsal slitInserting bellDevice assembledRemoving bellGomco result
27 Plastibell Procedure Applying ligature Plastibell procedure DOES involve cuttingRing stays in place 5-8 daysPlastibell result
28 Post-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
29 Circumcision RisksA “safe and quick” procedure? Risks “rare and minor”?Complication 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 until years laterApprox. 1% of boys will need corrective surgeryNo national system for collecting data
31 Other Complications Post-operative infection including MRSABlocked urethra (esp. Plastibell)Post-operative bleedingdangerous in newbornshidden by absorbent diapers
32 Catastrophic 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
33 Other Possible Side Effects NewbornDifficulty breastfeedingFussinessInterference with mother-infant interaction/bondingExcessive sleepingAdultTight or uncomfortable erectionsCurved penisHairy shaftSexual dysfunction especially in older menErectile dysfunction & delayed ejaculationPTSD
34 Medical 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
35 Rethinking the Medical Arguments Unscientific start of circumcisionNot 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.
36 Potential 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
37 Amer. Academy of Pediatrics (2012) AAP: “benefits outweigh the risks”, “parents’ choice”Failed to quantify risks (benefits > ???)Downplayed and dismissed risksEmphasized reduction in HIV, but…Failed to show such effect in U.S.No discussion of foreskin itselfNo description of anatomy or functionMisrepresented findings and conclusion of SorrellsNo discussion of patient’s perspective or preferences
38 Response to AAP statement March 2013: International group of 38 physicians from 16 European countries responded:no compelling health arguments in favor of circumcisioncircumcision can have serious long-term urological, psychological and sexual consequencescircumcision of underage boys conflicts with good medical practicecircumcision conflicts with children’s rights and the doctors’ oath not to do harm
39 Cultural, not Medical Parents’ motivations: Social concernsPersonal “preference”What they have heard from family or friends: “hygiene”Not recommended by medical organizations1AAP stopped short of “recommending” circumcisionSome neutralSome actively discourage it1.
40 Social 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 cultures (i.e. 75% of the world)O’Hara study: women who experienced both prefer intact
41 Ethical 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 boys who are not circumcised do not choose to get circumcised as adults