Protecting Children From Forced Foreskin Retraction
See below to empower yourself at the doctor’s office
SOME medical textbooks are getting intact care right!
Avoiding retraction injuries: Correct pediatric foreskin care
On average, the prepuce (foreskin) naturally remains fused to the glans (head) of a child’s penis until the onset of puberty. Yet in U.S. culture, misinformation persists suggesting a much younger expected age for foreskin retractability. This puts children with intact (not circumcised) penises at risk of iatrogenic injury from forced retraction.
Forced retraction is the act of someone other than the child pulling back the foreskin in an attempt to expose any part of the glans. It often causes pain, bleeding, and scarring. (It also happens to be the first step in circumcising a baby.) Tearing the foreskin away from the glans before it has naturally separated introduces infection risk, because it exposes the area and any resulting wounds to environmental pathogens. When an adult instructs or coerces a child to retract their own foreskin before it has naturally separated from the glans, this is also forced retraction.
Forced retraction is unnecessary and harmful, yet it happens regularly in doctors’ offices and hospitals around the U.S. The nonprofit organization Your Whole Baby receives hundreds of forced retraction complaints annually from parents. Many incidents happen during routine health exams. It is likely that far more go unreported, as some parents are unaware that the practice is dangerous and not evidence based.
Complications requiring corrective surgery can result from forced retraction. As the number of children with intact penises in the U.S. continues to increase, it is important for healthcare providers to familiarize themselves with current foreskin care information.
At what age does foreskin become retractable?
The most recent research demonstrates wide variance in the onset of retractability. Some healthy children won’t have retractable foreskin until their late teens, while others will be able to retract before puberty. This table summarizes findings from several studies:
The foreskin separation process
The protective foreskin is formed from the outermost layer of glans tissue between 10 and 16 weeks’ gestation. Its inner surface typically remains fused to the surface of the glans after birth. [7] As Cold and Taylor describe, “The fused mucosa of the glans penis and the inner lining of the prepuce separates gradually over years, as a spontaneous biological process.” [8] The process should not be interfered with or rushed. This shared epithelial membrane (sometimes incorrectly referred to as “adhesions”) releases on its own over time with hormone production and self-exploration.
The prepuce is a highly innervated, touch-sensitive body part, and retraction primarily serves a sexual function. [9-11] Still, there is a pervasive misconception that caregivers must regularly “exercise” a child’s foreskin back from the tip of the glans in order for it to eventually become retractable. A 2018 survey of nearly 200 U.S. pediatric urologists found that the majority of those who offered foreskin care guidance to guardians recommended regular retraction of young children. [12] Results from a 2020 survey of 83 U.S. pediatric residents found half had not received education on foreskin care, yet it was common for respondents to advise guardians to retract. [13]
Attempts at forced retraction are invasive, and can hinder the natural separation process if wound adhesions and inelastic scar tissue develop from ripping the fused membrane. [14] A very small fraction of people reach adulthood with foreskin that is not fully retractable, which is not itself a problem in the absence of pain or other concerns. [15]
Phimosis & paraphimosis
The natural state of childhood non-retractability is often termed “physiologic phimosis,” but it is not a condition requiring treatment. “The majority of referrals to pediatric urologists for circumcision constitute developmentally non-retractable foreskin rather than true [pathological] phimosis,” [16] a condition that can result from forced retraction. Unnecessary treatment places strain on healthcare systems, yet such foreskin-related experiences are far too common in the U.S.
Paraphimosis, a medical emergency where the foreskin becomes stuck behind the glans, often results from an adult’s attempt to retract a child’s prepuce; thus many pediatric cases are avoidable. [17,18]
Adults sometimes express concern that a child’s foreskin is “too tight” if its opening does not allow visualization of the meatus (urinary opening at the tip of the glans), but this is a developmentally normal, protective function of the foreskin’s intertwined smooth muscle and elastic fibers. [8,14] Ballooning, spraying, and smegma pearls under the foreskin are also normal, transient aspects of foreskin development. [19,20]
How to clean an intact child's penis –
“When intact, don’t retract! Only clean what is seen!”
“Soap irritates mucosal tissue and dries it out . . . Don’t wash your baby’s foreskin with soap . . . just rinse the outside of the penis gently, from body to tip, as you would wash a finger.” (Dr. Adrienne Carmack, board-certified urological surgeon) [21]
“The uncircumcised penis requires no special care. . . . It is important not to retract the foreskin forcefully for any reason. Some parents feel the need to pull the foreskin back to ‘clean under it.’ Since the . . . inner foreskin and the glans are initially fused, there is no space to clean.” (The Canadian Urological Association) [22]
Once the foreskin has become naturally retractable, its owner can simply pull back the foreskin and rinse with water — no soap — when bathing/showering. This step can be suggested to the child if their foreskin is retractable before puberty, but should not be required, as it may cause discomfort.
Zealous genital hygiene regimens and use of some hygiene products have been linked to irritation, inflammation, dermatitis, and balanoposthitis. [23,24] In a 1996 study, 90% of adults with irritant dermatitis-associated balanitis and/or posthitis experienced full symptom resolution after replacing soap with emollient cream and reducing frequency of penile washing. [25]
Statements on forced retraction
The American Academy of Pediatrics states that as children grow and gain awareness of their own bodies, they generally figure out how to retract on their own, “but foreskin retraction should never be forced. Until the foreskin fully separates, do not try to pull it back. Forcing the foreskin to retract before it is ready can cause severe pain, bleeding and tears in the skin.”[26]
The Canadian Urological Association informs caregivers that an infant’s inner foreskin is typically fused to the glans, naturally preventing retraction. Forced retraction “may lead to cracking and bleeding of the foreskin tip. Over time, this may cause scarring of the tip making retraction impossible.”[27]
Summary of intact penis care
Never pull a child’s foreskin back toward their body to “clean” under it, to “stretch” it, or for any reason, including catheterization. Catheters can be inserted safely without retraction when the foreskin is fused to the glans of the penis. [28]
The foreskin is fused to the glans of the penis, sometimes through puberty.
The only person who should EVER retract a child’s foreskin is THE CHILD.
Forced retraction is painful and can cause bleeding, infection, scarring, and other complications.
Thank you for taking time to learn more about best practices for care of the intact penis!
References
[1] Hsieh T.F., Chang C.H., Chang S.S. (2006). Foreskin development before adolescence in 2149 schoolboys. Int J Urol, 13(7), 968-70. doi: 10.1111/j.1442-2042.2006.01449.x. Authors found that 8.2% of subjects ages 6-7 years old had fully retractable foreskin. This number increased to 21% by ages 9-10, and to 58.1% for children ages 12-13.
[2] Ishikawa, E., & Kawakita, M. (2004, May). Preputial development in Japanese boys. Hinyokika Kiyo, 50(5), 305-8. Retrieved from https://pubmed.ncbi.nlm.nih.gov/15237481/. Researchers found “the incidence of having a retractable prepuce gradually increased with age from 0% at age 1 year to 77% by the age of 11 to 15 years” and concluded that “forced retraction or circumcision is unnecessary for phimosis . . . with or without balanoposthitis.”
[3] Kayaba H., et al. (1996). Analysis of shape and retractability of the prepuce in 603 Japanese boys. J Urol, 156(5), 1813-5. https://doi.org/10.1016/S0022-5347(01)65544-7. Authors found that 42% of subjects ages 8-10 had fully retractable foreskin; compared to 62.9% of children ages 11-15.
[4] Thorvaldsen M.A., Meyhoff H. (2005). Patologisk eller fysiologisk fimose? [Phimosis: pathological or physiological?] Ugeskr Læger, 167(17), 1858-62. PMID: 15929334. Researchers found that the mean age at which children could retract their foreskin was 10.4 years.
[5] Wang, M. H., Wang, Z. X., Sun, M., Jiang, X., & Hu, T. Z. (2006). [Analysis of shape and retractability of the prepuce in 1,015 Chinese boys aged from 0 to 18 years old]. Zhonghua nan ke xue = National journal of andrology, 12(3), 249–250. Researchers found that 64.09% of study participants ages 0-3 had non-retractable foreskin. Percentages of children with non-retractable foreskin decreased progressively by age group, with a low of 7.66% in participants ages 11-18. The authors concluded that “the prepuce will separate from the glans progressively [until] adolescence, so it's unnecessary to perform circumcision” for a non-retractable foreskin in the absence of other concerns.
[6] Yang, C., Liu, X. & Wei, GH. Foreskin development in 10,421 Chinese boys aged 0–18 years. (2009). World J Pediatr 5, 312–315. https://doi.org/10.1007/s12519-009-0060-z. Researchers found “the incidence of a completely retractile foreskin increased from 0% at birth to 42.26% in adolescence” and concluded that “incomplete separation of foreskin is common in children.”
[7] Cunha, G.R., Sinclair, A., Cao, M., & Baskin, L.S. (2020). Development of the human prepuce and its innervation. Differentiation; research in biological diversity, 111, 22–40. https://doi.org/10.1016/j.diff.2019.10.002
[8] Cold, C.J., and Taylor, J.R. (1999). The prepuce. BJU Int. 83 Suppl. 1:34-44. doi: 10.1046/j.1464-410x.1999.0830s1034.x
[9] García-Mesa, Y., García-Piqueras, J., Cobo, R., Martín-Cruces, J., Suazo, I., García-Suárez, O., Feito, J., & Vega, J. A. (2021). Sensory innervation of the human male prepuce: Meissner's corpuscles predominate. Journal of anatomy, 239(4), 892–902. https://doi.org/10.1111/joa.13481
[10] Sorrells, M.L., Snyder, J.L., Reiss, M.D., Eden, C., Milos, M.F., Wilcox, N., & Van Howe, R.S. (2007). Fine-touch pressure thresholds in the adult penis. BJU international, 99(4), 864–869. https://doi.org/10.1111/j.1464-410X.2006.06685.x
[11] Taylor, J. R., Lockwood, A. P., & Taylor, A. J. (1996). The prepuce: specialized mucosa of the penis and its loss to circumcision. British Journal of Urology, 77(2), 291–295. https://doi.org/10.1046/j.1464-410x.1996.85023.x
[12] Li, B., Shannon, R., Malhotra, N.R., Rosoklija, I., & Liu, D.B. (2018). Advising on the care of the uncircumcised penis: A survey of pediatric urologists in the United States. Journal of Pediatric Urology, 14(6), 548.e1–548.e5. https://doi.org/10.1016/j.jpurol.2018.05.024
[13] Malhotra, N.R., Rosoklija, I., Shannon, R., D'Oro, A., & Liu, D.B. (2020). Frequency and Variability of Advice Given to Parents on Care of the Uncircumcised Penis by Pediatric Residents: A Need to Improve Education. Urology, 136, 218–224. doi: https://doi.org/10.1016/j.urology.2019.09.057
[14] Carmack, A., & Milos, M.F. (2017). Catheterization without foreskin retraction. Canadian Family Physician, 63(3), 218–220. Retrieved from https://www.cfp.ca/content/63/3/218.long
[15] Doctors Opposing Circumcision. (2017). Phimosis and Balanitis. Retrieved from https://www.doctorsopposingcircumcision.org/for-professionals/alleged-medical-benefits/phimosis-balantis/
[16] Van Howe R. S. (1998). Cost-effective treatment of phimosis. Pediatrics, 102(4), E43. https://doi.org/10.1542/peds.102.4.e43. In a related article, Van Howe mentions that true pathological phimosis/preputial stenosis occurs in less than 2% of people with penises, and that the incidence is similar for intact and circumcised penises.
[17] Bragg B.N., Kong, E.L., & Leslie, S.W. (Updated 2022). Paraphimosis. StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK459233/
[18] Choe J. M. (2000). Paraphimosis: current treatment options. American family physician, 62(12), 2623–2628.
[19] Babu, R., Harrison, S.K., & Hutton, K.A.R. (2004). Ballooning of the foreskin and physiological phimosis: is there any objective evidence of obstructed voiding?. BJU International, 94: 384-387. doi: https://doi.org/10.1111/j.1464-410X.2004.04935.x
[20] Burleigh, A., & Lam, J. M. (2017). A mobile yellow nodule under the foreskin of a toddler. Paediatrics & child health, 22(8), 459–460. https://doi.org/10.1093/pch/pxx154
[21] Carmack, A. (2015). The Good Mommy’s Guide to Her Little Boy’s Penis. Adrienne Carmack.
[22] Canadian Urological Association. (2014). Foreskin Care for Boys. Retrieved from https://www.cua.org/system/files/PIB/PIB15_en.pdf.
[23] Jain, M., Ansari, F., Agarwal, N., & Mittal, A.K. (2023). Morphological Patterns of Balanoposthitis and their Correlation with Final Etiological Diagnosis. Indian Dermatology Online Journal, 14(2), 187–194. doi: https://doi.org/10.4103/idoj.idoj_197_22
[24] Margesson, L.J. (2004), Contact dermatitis of the vulva. Dermatologic Therapy, 17: 20-27. doi: https://doi.org/10.1111/j.1396-0296.2004.04003.x
[25] Birley, H.D., Walker, M.M., Luzzi, G.A., Bell, R., Taylor-Robinson, D., Byrne, M., and Renton, A.M. (1993). Clinical features and management of recurrent balanitis; association with atopy and genital washing. Genitourinary Medicine, 69(5), 400–403. doi: https://doi.org/10.1136/sti.69.5.400
[26] American Academy of Pediatrics. (2007; updated 2017). Care for an uncircumcised penis. Retrieved from https://www.healthychildren.org/English/ages-stages/baby/bathing-skin-care/Pages/Care-for-an-Uncircumcised-Penis.aspx
Empower yourself to prevent forced retraction at the doctor's office
The saying "Knowledge is power" holds true when it comes to being an advocate for your child and protecting them from harm. The more you know and understand about natural, whole penis development from infancy to puberty, the more confident you will feel talking to, and sometimes disagreeing with, your child's healthcare provider.
It is important that you understand proper intact care so that you feel comfortable and confident discussing this topic with your child's doctor. Many American doctors will direct you to retract your child's foreskin to clean or bathe. Your doctor may also try to forcibly retract your child during well visits.
These tips will be helpful in keeping your baby or older child protected from forced retraction.
Use the Your Whole Baby Intact Friendly Doctor List to find a doctor in your area. If there is not a doctor in your area or one that fits the needs of your family, be sure to ask the doctor to specifically describe care of the foreskin before they examine your child. Find out if the doctor encourages manipulation of the foreskin in any form. (This list is meant to guide you in finding a great doctor for your family, but you still need to be vigilant and ask about their practices. For example, sometimes a parent will recommend a doctor who is great with newborns, not realizing that they push retraction at the preschool age.)
Share or print this webpage with any doctor who might examine your child to help ensure the office is well versed in care of the intact penis.
Ask your doctor to read and sign an Intact Care Agreement.
Prior to your young one’s diaper being removed by a medical professional, inform them that they may not manipulate your child’s foreskin in any way. Stand right next to your child to ensure that no manipulation occurs.
Establish a “look, but do not touch” policy where during visits the doctor may use only their eyes to examine your child’s penis. Stand in close proximity to ensure this is followed.
You might also consider establishing a more cautious “diaper on” policy. Ask that your child’s chart indicate that the diaper is to remain on during visits unless the child has an issue with the genital area that requires examination. In this case, be sure to remind the doctor not to retract the foreskin and stand close by to ensure this is followed. For visits where the diaper area is not a concern, be sure to remind the medical professional before they begin the exam that child’s diaper is to stay on.
Do not go into the appointment assuming that your doctor wouldn’t attempt to retract your child’s foreskin. A good portion of the complaints we receive about forced retraction are about doctors who had not previously tried to manipulate the child’s foreskin. Be on guard. Assume the doctor will try to retract and act accordingly before the situation is one that can’t be reversed.
Be brave. Doctors can be intimidating. They can try to make you doubt yourself. Speaking up and being assertive can make your hands and your voice shake, especially for a new, first-time parent. Know that the information you have is correct. If you are bullied, it is due to the insecurity and ego of the doctor and not something you are doing wrong. You know your child better than anyone and are your child’s #1 advocate. It is your role to protect your child’s body.