Saving Our Sons: May 2023

Catheterization Without Retraction

By Adrienne Carmack, M.D. board-certified urologist, in practice in Texas, and author of The Good Mommy's Guide to Her Little Boy's Penis and Marilyn Fayre Milos, R.N. Executive Director of Genital Autonomy America, California.

Catheterization Without Retraction
Canadian Family Physician. 2017 Mar; 63(3): 218–220.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5349724/

Over the past century, numerous boys born in Canada and the United States have been circumcised. (1) However, this trend is changing, with neonatal circumcision being performed less commonly than in years past. (2,3) Because of these historical practices, many physicians and nurses have limited experience treating patients with intact foreskins and engage in ill-advised procedures such as premature foreskin retraction for purposes of “hygiene” or catheterization. Premature retraction of the foreskin can lead to tearing of healthy tissue, which is painful and increases the risk of preputial scarring and infection. (4–6) We describe a method for catheterization in which premature retraction of the foreskin is not necessary.

Technique

The foreskin should first be gently manipulated to determine if the meatus can be easily visualized. Pressure used for this should be gentle to avoid tearing of tissues, similar to the amount of pressure that would be used when spreading the labia to visualize the meatus of a girl. If the natural attachments of the foreskin to the glans (head of the penis) remain, the foreskin should not be forced back to expose the meatus.

If the foreskin can be gently moved such that the glans and meatus can be seen, catheterization can be performed under direct vision using a sterile technique. The foreskin should never be retracted past the point where it has already naturally separated. (7)

If the meatus cannot be seen, the genitals can be prepared and draped in a sterile manner without retraction. The catheter can then be lubricated and gently inserted through the foreskin opening and guided into the meatus, much like an intravenous catheter is guided into a vein by feel. Gentle pressure with the thumb along the dorsal aspect and the fingers along the ventral surface of the penis can keep the catheter from slipping between the glans and inner lining of the foreskin into the preputial space (Figure 1).

When catheterization is being performed for the purpose of collecting a urine specimen, the foreskin should also not be forcibly retracted. In both boys with an intact prepuce and girls, the initial urine obtained during catheterization should be discarded, as this will contain preputial and periurethral flora. The latter urine should be saved for culture. (8)

Discussion

An understanding of the normal anatomy and development of the foreskin illustrates why the technique of catheterization without retraction is an important skill for health care practitioners. Physiologic phimosis is the normal state of young boys. (9) This finding is characterized by a closed preputial outlet with the inner mucosa of the foreskin beginning to evert through the preputial opening, which is healthy with no scarring. The glans cannot be seen without retraction. This is in contrast to pathologic phimosis, in which the glans and meatus can often be seen, as the scarred ring of the preputial orifice is held open and no mucosa is visible at the preputial outlet. (10)

In a Danish study, 8% of healthy boys aged 6 to 7 still had complete physiologic phimosis preventing visualization of the meatus, and only 23% of boys this age had fully retractable foreskins. (11) In a Japanese study, 84.3% of boys aged 6 months to 1 year had a tight ring preventing any retraction, and this decreased gradually with time to 40% at ages 1 to 2 years, 28% at ages 3 to 4 years, 20% at ages 5 to 7 years, 16% at ages 8 to 10 years, and 8.6% at ages 11 to 15 years. (12)

The term phimosis is Greek and means “a muzzling.” Physiologic phimosis simply means the foreskin cannot be retracted and the glans is “muzzled.” Ballooning during urination is a common finding and part of the normal developmental process of foreskin separation. (10) It occurs because the opening of the immature foreskin is not yet lax enough to accommodate a full urine stream or passage of the glans through it. The foreskin and glans separate naturally as the child develops, has erections, and manipulates his foreskin. When a young boy manipulates his foreskin naturally, he tends to pull his foreskin away from his body, not toward it, as is done with retraction. As he gets older and more curious, he begins to pull his foreskin toward his body as well. (10) In most boys, physiologic phimosis resolves naturally by the end of puberty. (11)

The foreskin and glans are connected by the balanopreputial lamina, a membrane similar to the synechial membrane that connects the nail bed and the fingernail. The balanopreputial lamina is sometimes called the synechia. This membrane and the small preputial opening prevent retraction in boys with normal physiologic phimosis. The attachment might be forcefully disrupted, just as the fingernail can be torn from the nail bed, but this causes pain, is unnecessary, and can lead to infection, scarring, adhesion formation, or iatrogenic phimosis. There is no functional need for the glans to be exposed, and there is a protective effect of having the foreskin attached to and covering the glans.

Because the foreskin protects the glans penis and urethral meatus, premature exposure of the glans, as occurs after circumcision, commonly leads to meatal stenosis, in which a substantial part of the circulatory system in the glans penis is damaged (the frenular artery), and the glans tissue is exposed, denuded, and inflamed, which can lead to ulceration and subsequent scarring of the urethral opening. This inflammation and ulceration are caused by disruption of the normal attachment between the glans and foreskin, the absence of the protective foreskin, interruption in the normal circulatory system, or blisters from ammonia burns. (13–15) The blisters and ulceration at the opening of the urethra are caused by contact of urine-soaked diapers with the urethral meatus, which is no longer protected by the foreskin.

Retracting the foreskin of a prepubescent boy with physiologic phimosis, although still a common recommendation by many health care practitioners, has been shown to increase problems such as scarring and infection. These might result in iatrogenic pathologic phimosis and lead to a higher likelihood of circumcision being performed at a later date. (16) If the prepuce is unable to retract, there is nothing to clean under. The foreskin should not be retracted for cleaning until the foreskin has naturally separated and the child can do this himself. In fact, the owner of the foreskin should be the first person to retract his foreskin. Forceful retraction causes microtears that can lead to pathologic phimosis. (10)

An additional danger of premature retraction is paraphimosis, a condition in which the retracted foreskin becomes stuck behind the glans penis, cutting off circulation and leading to ischemia and possibly penile gangrene if not treated promptly. Retracting the foreskin and cleansing with soap, commonly believed to be important for proper hygiene, not only exposes the child to the risks of premature foreskin retraction, but also to the risks of infection such as balanitis, which has been shown to be associated with the use of soap on the delicate mucosal tissues of the male genitalia. (17) Soap dries out mucosal tissue and should never be used on the glans or inner foreskin. The foreskin should be left alone until it demonstrates the ability to retract. (10) Once this is possible, foreskin care is simple: retract (gently and only to the extent possible), rinse, replace. Warm water and fingertips adequately clean the tissue.

Besides false beliefs about hygiene, one of the main reasons boys are subject to premature foreskin retraction is that many health care professionals believe that the foreskin must be retracted to obtain a clean specimen for urine culture. Fortunately, this is not the case. With proper technique, as described above, urine specimens can be obtained from boys with intact foreskins without exposing these patients to the risks of premature foreskin retraction. Although the focus of this article is on a technique for catheterization, it must be remembered that catheterization is an intervention that carries risks. The risks of catheterization include discomfort and introduction of bacteria into the urinary tract, which could lead to infection. Indications for catheterization include the need to monitor urine output for medical management, emptying the bladder in patients who are unable to do so, introducing contrast material for imaging procedures such as a voiding cystourethrogram, and obtaining a urine specimen for analysis in patients who are unable to provide one.

If a patient can reliably void into a collection container, catheterization for monitoring urine output can be avoided. Patients who cannot empty their bladders have the options of clean intermittent catheterization, indwelling urethral catheterization, and suprapubic catheter placement. Other options for collection of a urine specimen for analysis and culture include a midstream voided sample and suprapubic aspiration, and these should be considered when determining the optimal approach for specimen collection.8 Suprapubic aspiration is significantly more painful than urethral catheterization in premature male infants (P < .001). (18) Contamination is possible with catheterized samples as it is with voided samples.19 This suggests that catheterization for urine specimen culture should be reserved for those patients who are unable to provide a voided specimen into a clean container, and suprapubic catheterization should only be used if previous efforts to obtain a specimen have resulted in contamination.

Conclusion

In boys with intact prepuces and physiologic phimosis, catheterization without retraction minimizes potential long-term problems and is an effective technique. Understanding how to catheterize without direct vision of the meatus and discarding the initial urine if culture is desired allow this procedure to be performed with high validity and minimal risk of iatrogenic problems for the child.

References

1. Weiss H, Polonsky J, Bailey R, Hankins C, Halperin D, Schmid G. Male circumcision. Global trends and determinants of prevalence, safety and acceptability. Geneva, Switz: World Health Organization, Joint United Nations Programme on HIV/AIDS; 2007.

2. Maeda JL, Chari R, Elixhauser A. Circumcisions performed in U.S. community hospitals, 2009. Rockville, MD: Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality; 2012. Available from: www.hcup-us.ahrq.gov/reports/statbriefs/sb126.jsp. Accessed 2015 Jun 15.

3. Fetus and Newborn Committee, Canadian Paediatric Society Neonatal circumcision revisited. CMAJ. 1996;154(6):769–80. [PMC free article] [PubMed]

4. Kaplan GW, McAleer . Structural abnormalities of the genitourinary tract. In: Mac-Donald MG, Mullett MD, Seshia MMK, editors. Avery’s neonatology. Pathophysiology and management of the newborn. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005. p. 1088.

5. Roberton NRC. Care of the normal term newborn baby. In: Rennie JM, Roberton NRC, editors. Textbook of neonatology. 3rd ed. Edinburgh, UK: Churchill Livingstone; 1999. pp. 378–9.

6. American Academy of Pediatrics . Newborns: care of the uncircumcised penis. Guidelines for parents [pamphlet] Elk Grove Village, IL: American Academy of Pediatrics; 1984.

7. Lacroix LE, Vunda A, Bajwa NM, Galetto-Lacour A, Gervaix A. Catheterization of the urethra in male children [video] N Engl J Med. 2010;363(14):e19. [PubMed]

8. Schaeffer AJ, Schaeffer EM. Infections of the urinary tract. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walshurology. 9th ed. Philadelphia, PA: Saunders-Elsevier; 2007. pp. 238–9.

9. Smeulders N, Wilcox DT. Urology. Disorders of the kidney and urinary tract. In: Rennie J, editor. Rennie & Roberton’s textbook of neonatology. 5th ed. London, UK: Churchill Livingstone–Elsevier; 2012. p. 949.

10. McGregor TB, Pike JG, Leonard MP. Pathologic and physiologic phimosis. Approach to the phimotic foreskin. Can Fam Physician. 2007;53:445–8. [PMC free article] [PubMed]

11. Oster J. Further fate of the foreskin. Incidence of preputial adhesions, phimosis, and smegma among Danish schoolboys. Arch Dis Child. 1968;43(228):200–3. [PMC free article] [PubMed]

12. Kayaba H, Tamura H, Kitajima S, Fujiwara Y, Kato T, Kato T. Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol. 1996;156(5):1813–5. [PubMed]

13. Canning DA, Nguyen MT. Evaluation of the pediatric urology patient. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh urology. 9th ed. Philadelphia, PA: Saunders-Elsevier; 2007. p. 3215.

14. Elder JS. Abnormalities of the genitalia in boys and their surgical management. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh urology. 9th ed. Philadelphia, PA: Saunders-Elsevier; 2007. p. 3749.

15. McGrath K. The frenular delta. A new preputial structure. In: Denniston GC, Hodges FM, Milos MF, editors. Understanding circumcision. A multi-disciplinary approach to a multidimensional problem. New York, NY: Springer; 2001. pp. 199–206.

16. Metcalfe PD, Elyas R. Foreskin management. Survey of Canadian pediatric urologists. Can Fam Physician. 2010;56:e290–5. Available from: www.cfp.ca/content/56/8/e290.full.pdf+html. Accessed 2017 Feb 2. [PMC free article] [PubMed]

17. Birley HD, Walker MM, Luzzi GA, Bell R, Taylor-Robinson D, Byrne M, et al. Clinical features and management of recurrent balanitis; association with atopy and genital washing. Genitourin Med. 1993;69(5):400–3. [PMC free article] [PubMed]

18. Badiee Z, Sadeghnia A, Zarean N. Suprapubic bladder aspiration or urethral catheterization: which is more painful in uncircumcised male newborns? Int J Prev Med. 2014;5(9):1125–30. [PMC free article] [PubMed]

19. Lau AY, Wong SN, Yip KT, Fong KW, Li SP, Que TL. A comparative study on bacterial cultures of urine samples obtained by clean-void technique versus urethral catheterization. Acta Paediatr. 2007;96(3):432–6. [PubMed]

Related Reading

Urine Samples and Catheter Insertion for Intact Boys: http://www.drmomma.org/2011/12/urine-samples-and-catheter-insertion.html

Using a Catheter Without Retraction: My Nurse Did It, and So Can Yours! http://www.savingsons.org/2013/01/using-catheter-without-retraction-my.html

How the Foreskin Protects Against UTIs: http://www.drmomma.org/2009/12/how-foreskin-protects-against-uti.html

UTI and Circumcision Resources: http://www.savingsons.org/2014/11/uti-resource-page.html

My son committed suicide due to circumcision

By Caroline Lowbridge
For BBC News
Read more by Lowbridge

Alex sent his mother an email before committing suicide, to let her know his reasons in detail.

"It quickly became apparent that what had just happened was a catastrophe... I died in 2015, not now."

Lesley Roberts was stunned as she read the devastating final email from her beloved son Alex Hardy.

The email had been timed to arrive on 25 November 2017, 12 hours after he killed himself. Less than an hour before the email arrived, Lesley had opened her front door to find a police officer standing there, explaining her son was dead. Alex was an intelligent and popular 23-year-old with no history of mental illness. Lesley could not understand why he would have wanted to take his own life. His email explained how the foreskin of his penis had been surgically removed two years before. This is commonly known as circumcision, but Alex had come to believe it should be regarded as "male genital mutilation". He never mentioned this to his family or friends when he was alive. Lesley did not even know her son had been circumcised. In the following months, she tried to find out more about circumcision. Why had it affected Alex so badly, and why did he feel killing himself was his only option?

Lesley said her dreams came true when she became a mom to Alex in July 1994.

Alex was the eldest of Lesley's three sons and had been very much longed for, having been conceived after fertility treatment. Lesley says her "dreams came true" when she became a mother in July 1994. "He was everything I could have wished for," she says. "Gorgeous, easygoing, and adoring of his younger brother Thomas who arrived following more treatment almost three years later." He also adored his baby brother James, who was born when Alex was 13.

The walls and windowsills of Lesley's home in Cheshire are covered in photos of all of them. Alex sailed through his education and was particularly gifted at English, so much so that his old school established the Alex Hardy Creative Writing Award in his memory. "Alex was passionate about history but as his English teacher I saw in him a true talent for writing," says Jason Lowe, who is now head teacher at Tarporley High School.

Alex was an intelligent child and breezed through school.

It was while on a school skiing trip to Canada, aged 14, that Alex fell in love with the country. He had enjoyed skiing as a child and the trip reignited his passion. So, when Alex reached 18, he decided to defer university and live in Canada for a year. "He fell in love completely with Canada and made so many friends and got a promotion at work," says Lesley. "After one year he rang me and said 'Mum, I'm deferring my place for university'. The same thing happened after year two." Two years turned into three, then four, and by the time of his death Alex had been living in Canada for five years and had obtained residency. "He was known as the 'super-smart Brit' with impeccable manners," says his mother. "The super-intelligent guy from the UK who helped people with their Canadian residency applications."

Alex was an avid skier and snowboarder, but said he found physical activity painful after being circumcised.

Lesley visited her son several times, both alone and with his brothers and stepfather. They were a close family, but Alex did not tell any of them he was secretly suffering with a problem with his penis. "I had issues with a tight foreskin," he eventually wrote in his final email, "but from my late teens it created issues in the bedroom as it meant my foreskin would not retract over the glans as intended which caused some awkward moments."

In 2015, still silently suffering, Alex consulted a doctor in Canada. He was given steroid cream to stretch his foreskin, but went back to the doctor after just a few weeks because he did not think the treatment was working. The medical name for Alex's problem is phimosis. It simply means his foreskin was too tight to pull back from the head of his penis, or the "glans" as Alex referred to it in his email. This is perfectly normal for boys in the early years of their life. As boys get older, their foreskin usually starts to separate from the head of the penis.

Lesley says that Alex was "intuitive, empathetic, gentle, kind, witty, quirky, unassuming, and caring."

Phimosis does not always cause problems, but if it does, problems can include difficulty urinating and pain during sex. In England, the NHS advises topical steroids and stretching techniques - and circumcision as a last resort. Over in Canada, where circumcision is more common, Alex was referred to a urologist. "He immediately suggested circumcision," Alex wrote. "I asked about stretching and he completely lied to my face and said it would not work for me. "I was mostly trusting as I felt he was the expert who knew best in this regard so with a pinch of salt I accepted it."

Lesley has since read online reviews of this urologist which have made her question his competence. One patient said she had been unable to work since having surgery for kidney problems, and he had "destroyed" her quality of life. "I'm a mother of three young children who are scared every day I will die as they see me suffering in so much pain," she wrote. "I can see how he misdiagnosed others, botched surgeries, and ruined lives," said another review. "He's dangerously incompetent." Another review of Alex's urologist read: "They left a surgical instrument in my bladder but I only got notified three months later. Run away before you get hurt!"

Lesley says she misses Alex's "big sparkly eyes, his grin, his sense of humor, and his bear hugs."

Lesley, who was "horrified" by these reviews, has asked for the urologist to be investigated. She has been told an inquiry is ongoing. The College of Physicians and Surgeons of British Columbia told the BBC it "cannot disclose the existence of a complaint against a physician, and only may do so if the complaint leads to formal discipline". "I will wish with my last breath and with all of heart that my darling son had run away," says Lesley.

Much to his regret, Alex was not able to research the urologist - or circumcision - properly at the time because his laptop was broken. He had tried researching the topic in a public computer space but felt uncomfortable, and also felt it was "too much of a taboo" to discuss with friends. So Alex booked what he believed was a minor procedure and had the surgery in 2015, at the age of 21.

Alex adored his little brother.

In the email to his mother, Alex explained, in great detail, the physical problems he had suffered afterwards. He described experiencing constant stimulation from the head of his penis, which was no longer protected by his foreskin. "These ever-present stimulated sensations from clothing friction are torture within themselves; they have not subsided/normalized from years of exposure," he wrote. "Imagine what would happen to an eyeball if the eyelid was amputated?" "He was in so much pain that it hurt to do normal physical activity," says Lesley. "He was a keen skier and snowboarder so you can imagine the pain he was in."

What is lost to male circumcision.
Informational cards for distribution at Etsy.

Consultant urological surgeon Trevor Dorkin, who is a member of the British Association of Urological Surgeons, advises his patients that the head of their penis will be more sensitive after circumcision. However, this sensitivity usually reduces. "I always say to guys 'it's going to feel more sensitive to start with' because all of a sudden you haven't got this protection over the head of the penis and it will feel different," says Mr Dorkin, who has carried out more than 1,000 circumcisions. "But in the vast majority of the cases the man adjusts to that, the brain adjusts to that, it adjusts to the signals that are coming back through the nerves from the head of the penis."

Alex also wrote about experiencing erectile dysfunction, and burning and itching sensations, particularly from a scar which sat where his frenulum was removed. The frenulum is a band of tissue where the foreskin attaches to the under surface of the penis. Some men refer to it as their "banjo string". "It's one of the more erogenous zones so it's thought to be important in sexual function," says Mr Dorkin. "The foreskin, the head of the penis and the frenulum is a very, very sensitive area. "But again when you do circumcision sometimes the frenulum is not preserved and it doesn't necessarily have an effect on overall sexual function and enjoyment."

Men take part in the Silent Survivors Stand during Genital Integrity Awareness Week in Washington D.C.

But Alex felt his frenulum had been important. "Through its absence I can certainly verify it is the most erogenously sensitive area of the penis and male body overall," he wrote. "If someone were to amputate your clitoris you may begin to be able to understand how this feels." He wrote about experiencing cramps and contractions in his muscles and "uncomfortable" sensations which extended deep into his abdomen. Lesley does not know whether or not Alex had sex after his circumcision. "Where I once had a sexual organ I have now been left with a numb, botched stick," he wrote. "My sexuality has been left in tatters." He asked: "Nature knows best - how can chopping off a section of healthy tissue improve nature's evolved design?"

Lesley did not know her son had been circumcised until after he died.

Like many people, Lesley admits she knew very little about the foreskin or circumcision before her son died. "I didn't know anything apart from I believed it was a very routine surgery," she says. The foreskin is sometimes dismissed as a "useless flap of skin", but Mr Dorkin says it does have a purpose. "It covers the head of the penis," he says. "In terms of what's it for, it provides a bit of protection to the head of the penis. It's thought to have some sort of immunological function perhaps." Circumcision rates vary a lot depending on where you are in the world and which culture you grew up in. According to the World Health Organization, 95% of men are circumcised in Nigeria but only 8.5% of men in the UK are.

Who in the world is circumcised? Figures from the World Health Organization.
Learn more at Medical Professionals for Genital Autonomy.

Most of the men circumcised in the UK are either Muslim or Jewish, as circumcision is regarded as an important part of their religions. According to the 2011 census, Muslims accounted for 4.8% of the population in England and Wales, while 0.5% were Jewish. People who question circumcision are sometimes accused of being anti-Semitic or Islamophobic, but Lesley stresses her son was neither. "For me, this has nothing to do with religion at all. I respect all people of faith or indeed no faith, as Alex did," she says. In Canada, where Alex had moved to, an estimated 32% of men are circumcised. Alex felt male circumcision has been normalized to the extent that most people do not question it, while female circumcision has become known as female genital mutilation (FGM) and is now illegal in many countries.

The most common forms of male and female genital cutting.

He felt male circumcision should be known as "male genital mutilation" - a view shared by a growing anti-circumcision movement. "If I were a female (in Western nations) this would have been illegal, the surgeon would be a criminal and this would never have been considered as an option by doctors," Alex wrote. "I do not believe in championing one gender over another but I feel strongly that gender equality should be achieved for all." Campaigners for "genital autonomy" believe it is wrong to circumcise a baby or child - whether they are male or female - because the patient cannot give consent, and these campaigners regard circumcision as a human rights issue.

Alex was the oldest of Lesley's three sons.

Having lived with an intact penis for 21 years, Alex believed men circumcised as babies or young children would "tragically never be able to fully comprehend what has been taken away". He estimated he had been stripped of 75% of the sensitivity of his penis. However, experiences of men circumcised as adults differ dramatically. Some report a significant loss in sensitivity and greatly reduced sexual pleasure. Some report being less sensitive but say there is no change in their overall enjoyment of sex. Some are happy with their decision to get circumcised. Some, like Alex, deeply regret having it done.

Alex celebrated his 21st birthday whale watching with his mom.

Alex sought further medical help following the circumcision as well as psychological help, but never shared his problems with his family or friends. "I was with him during those two years and I think I would be lying if I said I didn't think something wasn't right," says Lesley. "I did say 'Is something bothering you? Are you OK?' and he would absolutely reassure me that he was." Lesley, who used to be a teacher, now hopes to go into schools and speak to young men about sharing their problems, even if they are very personal. "I think we all know that men don't particularly tend to talk about their problems in the same way that girls do but I think circumcision is very much a taboo subject," she says. "Alex was reserved. He certainly wouldn't have said 'I've got a tight foreskin and it really hurts'. And he didn't. And I didn't know." Only a week after Alex died, a friend opened up to Lesley about his own circumcision. "He told me he wouldn't normally have mentioned it but he had a circumcision as an older man, 10 years ago, and he was in constant daily pain," says Lesley. "It just seems it's more common than you think."

Dr. Trevor Dorkin, urologist and member of the British Association of Urological Surgeons, warns his patients of the risks before he will perform circumcision surgery.

Mr Dorkin says serious problems following a circumcision are rare, but not unheard of. "You do hear of horror stories where a circumcision has been done poorly and there's damage done to the head of the penis itself," he says. Sometimes too much skin is taken and this can result in what's known as "burying" or shortening of the penis, where it gets pulled back into the body. "Surgeons at the end of the day are human and there is potential for human error and technical error during any operation," he says. "One of my mentors told me every case is a tricky case, that's got to be your approach to surgery. You never take anything for granted in surgery."

Circumcision always has risk, but it is especially great when performed upon an infant. Adult circumcision has real and lasting consequences, but when done to a fully informed (which Alex was not) consenting adult, it is not as life-threatening as infant circumcision.

There have been cases of children and men dying after being circumcised. Four-week-old Goodluck Caubergs bled to death after a nurse circumcised him at his home in Manchester, while one-month-old Angelo Ofori-Mintah bled to death after being circumcised. Since 1995 at least 1,100 boys have died in South Africa after ritual circumcisions. Some penises fall off after becoming infected and rotten, while some have to be amputated. In Canada, where Alex was living, newborn baby Ryan Heydari bled to death after being circumcised by a doctor in Ontario. Recently there have been reports of two babies dying within weeks of each other after home circumcisions in Italy, and a two-year-old boy died after being circumcised at a migrant centre in Italy.

Complications of infant circumcision, via Stanford University School of Medicine.
See Also: Death from Circumcision

"I'm not qualified to say that circumcision is always bad, because it isn't," says Lesley. "It certainly was in my son's case and I think we need more research. We need to look into the risks, what can really go wrong, and we need to be more aware of them." If circumcision is necessary, Mr Dorkin says it is important to tell patients about potential complications. "Particularly when you are doing the operation in a guy who is in his late teenage years or early adulthood, it's a very sensitive area and sexual function is important, so you have to explain the risks to them," he says.

As a child, Lesley says Alex was "gorgeous, easy going, and adoring of his younger brother, Thomas."

"Alex said he was not made aware of all the risks," says Lesley. "If he had, I feel sure he would not have had the surgery. "Alex wasn't alone. I now know he wasn't the only one that this has happened to. And that can't be right." The UK charity 15 Square, which tries to educate people about circumcision, says Alex is not the only man to have killed himself after being circumcised. "It happens more frequently than people realise," says chairman David Smith. There are no statistics on men who have killed themselves after being circumcised.

Alex died over a year ago but his story has not been told until now. An inquest into his death was held in the UK but it was not reported by the media. Lesley, who is normally private and reserved like her son, only agreed to share Alex's story because it was his dying wish. "If the following information can benefit anybody then it has served its purpose," he wrote. "I did not feel comfortable raising the issue when I had a choice, so if my story can raise awareness to break this taboo within society regarding men's health then I am happy for release of my words. "Alex said in his letter 'We stand on the shoulders of those who came before us'," says Lesley. "This is the last thing I'm doing for my precious son."

Alex asked his mother to share his story after he left this earth.

*******

If you were cut against your wishes at birth, or misled to believe the amputation of your prepuce would benefit you as an adult, there is hope through restoration, and support in many men's groups today. MenMatterToo.org/men

Related Resources:

NORM.org

Saving Our Sons Community

RestoringForeskin.org

RestoringTally.com

SOS Men

The Intact Network

Restoration resources and reasons circumcised men are restoring today.
Informational cards for distribution at Etsy.

What was so difficult in keeping my son intact was not that my son would feel different in a locker room, but that I would feel different from him. I would then have to accept that I'm an amputee from the wars of a past generation. - father in "Circumcision: The Hidden Trauma"

A Father's Regret

By Ryan B.

I am full of regret.

I am a father, and I allowed my son to go through the same trauma I experienced.

I had a natural and loving hesitation -- I asked the doctor, "Does it have to be done?"

His answer should have been, "NO!"

Instead it was an explanation of how it was "simple, painless, and healthy."

I consented, and I saw the raw, bleeding, open wound on my son.

He had adhesions for many years that would tear, bleed, and become infected. He almost constantly had pain, discomfort, and infections...

Please, research the benefits of keeping your children intact and don't risk walking down this road we were forced to travel.

MORE MEN SPEAK

MenMatterToo.org/men

SOS MEN'S GROUP

Further stories from parents who are Keeping Future Sons Intact:
DrMomma.org/2010/05/i-circumcised-my-son-healing-from.html

YEAST Q&A

QUESTION: Can yeast be passed back and forth between adults, and cause a problem for an intact man?

ANSWER:

Yes -- anything flora/microorganism related easily goes back and forth from one partner to another. However, this is not limited to intact adults. There are many 'yeasty' non-intact men who also pass yeast 'infections' back and forth between themselves and their partner.

Yeast lives naturally on all humans, on all mammals, and everywhere in nature. It is normal (and even healthy) to have some. The problems becomes when yeast spores overgrow. This is easier done on some people than others, depending on a variety of factors (diet being one, and how someone baths/showers/or cares for their body is another).

Many people are under the mistaken belief that they should use soap on the genitals to decrease yeast - this is counter productive and tends to disrupt flora. Or, it could be that things were disrupted from a young age when parents used soap on a child, or a child eats a hearty amount of processed (and sugary) non-foods. A child may grow up thinking they "smell" if they don't use soap -- but this is solely because the flora of the genitals became disrupted in the first place. In their healthy, natural, clean state (i.e. washed regularly with simply warm water), the human genitals are able to maintain their own balance.

Babies who are in diapers also have the perfect environment for yeast to flourish -- warm, moist, with a sugar-rich diet (human milk or a substitute - necessary and very important for human infant brain and body growth, but with the potential to nourish yeast as well). A youngster can get into a cycle of feeding yeast (processed, sugary foods and drinks), supporting the habitat in which it grows, and then well-meaning parents do things to try and over clean (soaps, scrubs), or apply things to the diaper area that they hear of in parenting threads (cornstarch, powders, flour, lotion, essential oils, human milk, etc.), and make the situation worse. Thankfully, these cycles are easy to break free from, but it takes the willingness to step back and be more hands-off while the body rebalances.

Some simple ways to make the body less likely to experience yeast overgrowth:

1) Showers under warm water only (no soap, not even 'natural' soap on the genitals).

2) Warm baths in epsom salt (and a little boron salt if desired - another anti-fungal natural mineral) -- 2 cups plain epsom salt (no perfumes or oils added), 2 Tablespoons boron (Borax is the most commonly sold refined brand of natural boron).

3) Air dry - go underwear free at home when it is practical to do so (if you live in a private place, even being in the sunshine nude is healing for the body, and sunlight plus fresh air aids the skin and genitals in rebalancing microflora).

4) Use only 100% cotton underwear of your chosen type - not too tight against the skin; not those with lining that is non-breathable.

5) Increase whole food plants in the diet (and items like garlic, lemons, onions, ginger root, turmeric root, black seed oil, d-mannose powder, apple cider vinegar, also help to re-balance gut and genital flora). Smoothies or juicing vegetables and fruits makes this easy.

6) Decrease processed non-food items and sugary items as much as possible. Dairy is also another culprit for many who have gut (intestinal) and yeast disturbances - switching to a nut-milk is one alternative, for example.

7) Clotrimazole on the outside of the genitals when there is external yeast overgrowth. If internal in the vagina, use treatment options that are 7 days in length vs. the 1-3 day treatment options that tend to leave behind some of the stronger yeast spores to regrow. Clotrimazole will be cheapest at your local store pharmacy aisle in any generic version they stock.

8) Calmoseptine on the outside when yeast causes raw skin, redness, rash, chaffing, irritation -- this is also antifungal and healing for the skin. It can also be used preventatively (say when traveling, or when swimming in a chlorine pool or bacteria filled lake). Using Calmoseptine FIRST, before clotrimazole is applied for the first time, is the best course of action to most rapidly heal a yeast related rash on babies, children, or adults. The skin needs to be on its way to healing first, preventing further issues, before 'treatment' starts with clotrimazole for the fastest, most effective remedy. Apply Calmoseptine first, ideally after an epsom salt bath. Wait 4-6 hours, and then continue with the course of suggestions above and clotrimazole. Doing so allows exterior yeast issues to be remedied within 24-48 hours. Internal yeast overgrowth, or that which recurs often, is more complex and requires more of the above changes and/or treatments to remedy. Calmoseptine can be found behind the counter at most pharmacies (call to ask which pharmacy has a tube in stock near you), or on Amazon. No prescription is needed.

Intact Care Resource Page

further resources on caring for your intact child

Intact: Healthy, Happy, Whole

an intact living community

Saving Our Sons Community

an advocacy group

Raising Boys

a mainstream group for those raising boys today

May the Foreskin Be With You! Star Wars - Intact Style!

By Erin Dutra
Director, Intact Rhode Island

I have to admit, I have never actually watched an entire Star Wars movie, but my husband is an avid Star Wars fan, so naturally our kids are too. Over the past few years of making Star Wars Halloween costumes and planning Star Wars birthday parties, I've grown familiar with the characters and become a little more into it than I ever would have expected. I find some of the characters cute - (have you seen an ewok? Adorable!) - and I become a little excited when I see a Yoda shirt or R2-D2 lunchbox in the store.

My son was born on Star Wars Weekend (an event I only know because of my husband: "May the 4th be with you!" and "Revenge of the 5th"). So in honor of my son's birthday, I decided to create a fun, pro-intact meme that fit with the Star Wars theme to share on Facebook. My original idea was, "Your little Jedi needs his whole lightsaber" ...and then several other ideas started to surface. Soon, I was cracking myself up with witty slogans - I may not be a true Star Wars fan, but I'm clearly a true nerd!

Once I had a handful of graphics created, I could not choose just one for my son's birthday, so I declared the entire week leading up to May the 4th "Intact Rhode Island's Star Wars WEEK." It has been so much fun seeing the response these graphics (and the accompanying informative links) have received. Over the course of the past week they have reached tens of thousands of individuals on Facebook and Pinterest, and have been shared by hundreds. Clearly, there are a lot of Star Wars fans out there, and many of them support leaving babies intact!

I think it's awesome that so many people, who may not otherwise be interested in learning about the benefits of remaining intact and the detriments of circumcision, will be intrigued by fun Star Wars images popping up in their newsfeed and will discover some important information in the process.

Learn more from Erin and her Star Wars Fun Family at Intact Rhode Island.

If you have an Intact Star Wars themed photo you'd like to share, send to SavingSons@gmail.com and we'll include it here as well. ツ

May the Foreskin Be With You

via SOS' WA chapter, Intact Washington

My face when someone says they are circumcising...
Baby Yoda • IntactBaby.org/research

Baby Yoda via IntactBaby.org

When you tell them to research the foreskin, and then watch them discover the truth about circumcision.
Baby Yoda • IntactBaby.org/research

via SOS' MI chapter, Intact Michigan

"May the FORESKIN be with you!"
~Ginger's little sweetie of Intact Wyoming

Christina's cutie, of Intact Iowa, plays in the May 4th sun in his Rumpkinz May the foreskin be with you cloth custom!

Mandi of Intact Michigan writes,
"I tried snapping a picture while my son was awake, but this little guy is a mover and a shaker, so I had to wait until he passed out. May the foreskin be with you!"