Your Uncircumcised Son:
Expert Medical Advice for Parents
by: Paul M. Fleiss
Increasing numbers of American parents today are protecting their sons from routine circumcision at birth, but as their boys grow up, they often find themselves at odds with doctors who cling to old-fashioned opinions and hospital routines.
I often receive calls from distraught parents who say that a doctor insists that their little boy needs to be circumcised because there is something wrong. When they bring their son into my office, I almost always find that there's nothing wrong with the child's penis. Occasionally there's a slight infection, but that can be quickly cleared with an antibiotic cream. In all my years of practice, I've never had a patient who had to be circumcised for medical reasons.
When a doctor advises that your son be circumcised, it's usually because he or she is unfamiliar with the intact penis, misinformed about the true indications for surgical amputation of the foreskin, unaware of the functions of the foreskin, and uncomfortable with the movement away from routine circumcision.
Doctors can be psychologically challenged by the sight of an intact boys. They may see problems with the penis that do not really exist. They may try to convince you that the natural penis is somehow difficult to care for. They may cite "studies" and "statistics" that appear to support circumcision.
Probably the only problem you will encounter with a foreskin is that someone will think that he has a problem. The foreskin is a perfectly normal part of the human body, and it has very definite purposes, as do all body parts, even if we do not readily recognize them. There's no need to worry about your son's intact penis. WHAT TO SAY WHEN THE DOCTOR SAYS TO CUT
Below is a list of some of the things that doctors have said to parents in an attempt to convince them to agree to a circumcision. After each incorrect statement, I've given you the medical facts to help you understand what your doctor may not know about the intact penis and its care, and what you need to know to protect your child from unnecessary penile surgery. If you ever find yourself in a situation where a doctor suggests that your child should be circumcised, the best thing that you can say is simply: "Leave it alone." Your son's foreskin should be cut off in order to facilitate hygiene.
My experience as a pediatrician has convinced me that circumcision makes the penis dirtier, a fact that was confirmed by a study recently published in the British Journal of Urology
.1 For at least a week after circumcision, the baby is left with a large open wound that is in almost constant contact with urine and feces--hardly a hygienic advantage. Additionally throughout life the circumcised penis is open and exposed to dirt and contaminants of all kinds. The wrinkles and folds that often form around the circumcision scar frequently harbor dirt and germs.
Thanks to the foreskin, the intact penis is protected from dirt and contamination. While this important protection is extremely useful while the baby is in diapers, the foreskin provides protection to the glans and urinary opening for a lifetime. At all ages the foreskin keeps the glans safe, soft, and clean.
Throughout childhood, there is no need to wash underneath the foreskin. Mothers used to be advised to retract the foreskin and wash beneath it every day. This was very bad advice indeed. When the foreskin becomes fully retractable, usually by the end of puberty, your son can retract it and rinse his glans with warm water while he is in the shower. Your son's foreskin is too tight, it doesn't retract. He needs to be circumcised.
The tightness of the foreskin is a safety mechanism that protects the glans and urethra from direct exposure to contaminants and germs. The tight foreskin also keeps the boy's glans warm, clean, and moist, and when he is an adult, it will give him pleasure. As long as your son can urinate, he is perfectly normal. There is no age by which a foreskin must be retractable. Don't let your doctor or anyone try to retract your son's foreskin. Optimal hygiene demands that the foreskin of infants and children be left alone. Premature retraction rips the foreskin of the penis open and causes your child extreme pain. There is no legitimate medical justification for retraction. The child's discomfort is proof of that.
Do NOT let your doctor or anyone else try to retract your child's foreskin. Your son's foreskin is "adhered" to the glans. It must be amputated.
The attachment of the foreskin and glans is nature's way of protecting the undeveloped glans from premature exposure. Detachment is a normal physiological process that can take almost two decades to complete. By the end of puberty, the foreskin will have detached from the glans because hormones that are produced in great quantities at puberty help with the process. There is no age by which a child's foreskin must be fully separated from the glans.
Some misguided doctors might suggest that the "adhesions" between the foreskin and the glans should be broken so that your son can retract his foreskin. This procedure is called synechotomy. To perform it a doctor pushes a blunt metal probe under the foreskin and forcibly rips it from the glans. It's as painful and traumatic as having metal probe stuck under your fingernail to pull it off. It will also cause bleeding and may result in infection and scarring of the inner lining of the foreskin and the glans. The wounds that are created by this forced separation can fuse together, causing true adhesions. There is no medical justification for this procedure because the foreskin is not supposed to separate from the glans in childhood. If any doctor suggests this procedure for your son, firmly refuse, stating, "Leave it alone!" Your son's foreskin is getting tighter. It no longer retracts. Something is wrong. He will have to be circumcised.
Sometimes, in childhood, a previously retractable foreskin will become resistant to retraction for reasons that are unrelated to impending puberty. In these cases, the opening of the foreskin may look chapped and sting when your son urinates. This is not an indication for surgery any more than chapped lips. This is just the foreskin doing its job. If the foreskin were not there, the glans and urinary opening would become chapped instead. Chapping is most often caused by overly chlorinated swimming pools, harsh soap, bubble baths, or a diet that is too high in sugar, all of which destroy the natural balance of skin bacteria and should be avoided if chapping occurs. The foreskin becomes resistant to retraction until a natural and healthy bacterial balance is reestablished.
You can aid healing by having your son apply a little barrier cream or some ointment to the opening of the foreskin. Acidophilus culture (which can be purchased from a health food store) can be taken internally and also applied to the foreskin several times a day to assist healing, and should be given any time a child is taking antibiotics. Your son's foreskin is red, inflamed, itching, and uncomfortable, It has an infection and needs to be cut off.
Sometimes the tip of the foreskin does become reddened. During the diaper-wearing years, this is usually ammoniacal dermatitis, commonly known as diaper rash. When normal skin bacteria and feces react with urine, they produce ammonia, which burns the skin and causes inflammation and discomfort. If the foreskin were amputated, the inflammation would be on the glans itself and could enter the urethra. When the foreskin becomes reddened, it is doing its job of protecting the glans and urinary meatus.
Circumcision will have no effect on diaper rash. Change your baby's diaper more frequently and use a barrier cream until the rash clears. Harsh bath soaps can also cause inflammation of the foreskin. Use only the gentlest and purest of soap on your child's tender skin. Resist the temptation to give your child bubble baths, because these are harmful to the skin. Never use soap to wash the inner foreskin because it is mucous membrane just like the inner lining of the eyelid.
Foreskin infections are extremely rare, but if they occur, one of the many simple treatment options is antibiotic ointment along with bacterial replacement therapy. (Acidophilus culture). We don't amputate body parts because of an infection. Most infections of the foreskin are actually caused by washing the foreskin with soap. Leave the foreskin alone, remembering that it doesn't need any special washing, and infections will be unlikely to occur. Your son is always pulling on his foreskin. He should be circumcised.
I can assure you that, whether circumcised or not, all little boys touch and pull on their penis. It is perfectly normal. Intact boys pull on the foreskin because it is there to pull on. Circumcised boys pull on the glans because it is that is all they have to pull on. Little boys sometimes will adjust the position of their penis in their underpants. They will sometimes explore the interior of the foreskin with their fingers -- a perfectly normal curiosity and nothing to worry about. It is important for parents to cultivate an enlightened and tender congeniality about such matters, otherwise they risk transferring unhealthy attitudes to their children.
Sometimes a boy will pull on his foreskin because it itches. All parts of the body itch occasionally. Even a circumcised boy has to scratch his penis. Just as you don't worry every time your child scratches his knee, so you should not worry when he scratches his penis. If the itch is caused by dry skin, then have your son avoid using soap on his penis. Treat the foreskin as you would any other part of the body.
If the real fear is masturbation, calmly remind yourself of the simple, natural fact that all children will explore their bodies, including their genitals. Touching the genitals gives children a pleasant feeling and relaxes them. Classic anatomical studies demonstrate that the foreskin is the most pleasurably sensitive part of the body. You can congratulate yourself for having protected your child from a surgical amputation that would have permanently denied him normal sensations. Your son's foreskin is too long, it should be cut off.
There is tremendous variation in foreskin length. In some boys, the foreskin represents over half the length of the penis. In others it barely reaches the end of the glans. All variations are normal. The foreskin is never "just extra skin" or "redundant." It is all there for a reason. Your child should be circumcised now because it will hurt more if it has to be done later, or worse when he is an adult.
This excuse is tragically wrong and has resulted in a very serious crisis in American medical practice. It is based on the false notion that infants and young children do not feel pain. Babies can see, hear, taste, smell, and feel. In fact babies feel pain more acutely than adults, and the younger the baby, the more acutely the pain is felt. If an adult needed to be circumcised, he would be given anesthesia and postoperative pain relief. Doctors almost never give babies either of these. The only reason doctors get away with circumcising babies without anesthesia is because the baby is defenseless and cannot protect himself. His screams of pain, terror, and agony are ignored. In any event, this all too common excuse is merely a scare tactic, one with tragic consequences for any baby forced to endure a surgical amputation without the benefit of anesthesia. Your son is having anaesthesia for another operation, we'll just go ahead and circumcise him.
Most parents are never told that their son is in danger of being circumcised during a tonsillectomy or surgery for an undescended testicle. It would never occur to them. If your child is going into hospital for any reason, be certain that you tell the physician, surgeon, and nurse that under no circumstances is your child to be circumcised. Write "No Circumcision" on the consent form, too. Then if your child is circumcised against your wishes, remember that you have legal recourse. Your son has cysts under his foreskin. He needs to be circumcised.
During the period when the foreskin is undergoing the slow process of detaching itself from the glans, sloughed skin cells (smegma) may collect into small pockets of white "pearls." These are not cysts. Some doctors mistakenly think that the smegma under the foreskin is an infection, even though it is white rather than red, is cold to the touch, and is painless. As the foreskin proceeds with detachment, the body will do its job, and those pearls will pass out of the foreskin all by themselves. These collected pockets of cells are nothing to worry about. They are simply an indication that the natural process of detachment is occurring.
In all my years of practice, I have never had a patient who had to be circumcised for medical reasons. Your son has a urinary tract infection (UTI) and needs to be circumcised to prevent it from happening again.
The belief that the foreskin is slightly increases the chances of a boy having UTI is highly controversial and, more importantly, unproven. Members of the medical profession in Europe do not accept it. Medical research proves that UTIs are most often caused by internal congenital deformities of the urinary tract.2,3,4 The foreskin has nothing to do with this. Even if it could be proven that circumcision slightly reduces the risk of UTI, it is an absurd proposal because UTIs in boys are extremely rare and are easily treated with antibiotics. Breastfeeding, too, helps prevent UTIs. Child-friendly doctors advocate breastfeeding not penile surgery. Your son sprays when he urinates. Circumcision will correct this.
In almost every intact boy, the urine stream flows out of the urinary opening in the glans and through the foreskin in a neat stream. During the process of penile growth and development, some boys go through a period where the urine stream is diffused. Undoubtedly, many of these boys take great delight in this phase, while mothers, understandably find it less amusing. If your boy has entered a spraying phase, simply instruct him to retract his foreskin enough to expose the meatus when he urinates. He will soon outgrow this phase. Your son's foreskin balloons when he urinates. He needs to be circumcised or else he will suffer kidney damage.
Ballooning of the foreskin during urination is a normal and temporary condition in some boys. It results in no discomfort and is usually a source of great delight for little boys. Ballooning comes as a surprise only to those adults who have no experience with this phase of penile development. It certainly does not cause kidney damage; it has nothing to do with the kidneys. Ballooning disappears as the foreskin and glans separate and the opening of the foreskin increases in diameter. It requires no treatment. Your son caught his foreskin in the zipper of his trousers; we will have to cut it off.
There have been rare cases where a boy has accidentally caught part of the skin of his penis in the zipper of his trousers. This is painful and can cause a lot of bleeding. Cutting off the foreskin, however, is illogical in this situation. By cutting across the bottom of the zipper with scissors, the zipper can easily be opened to release the penile tissue. Any laceration in the skin can then be closed with either sutures or surgical tape, depending on the situation. The proper standard of care in this situation is to minimize and repair the injury, not make to worse by cutting off the foreskin and creating a larger and more painful surgical wound. Your son has phimosis. He needs to be circumcised to correct this problem.
Phimosis is often used as a diagnosis when a doctor does not understand that the child's foreskin is supposed to be long, narrow, attached to the glans, and resistant to retraction. Some doctors use prescribing steroid creams for phimosis, but this is unnecessary in children, since the foreskin does not need to be retracted in young boys. The hormones of puberty will do the same thing at the appropriate time that a steroid cream is doing prematurely. In adults who have a foreskin that is securely attached to the glans or a foreskin with such a narrow opening that the glans cannot pass easily pass through it, steroid creams are a conservative therapy. This is if the adult wants a foreskin that fully retracts. Many males don't, preferring a foreskin that remains securely over the glans. It is purely a matter of personal choice, one that only each male can decide for himself. Your son has paraphimosis and must be circumcised to prevent it from happening again.
Paraphimosis is a rare dislocation of the foreskin. It is caused by the foreskin being prematurely retracted and becoming stuck behind the glans. The dislocation can most often be corrected by applying firm but gentle pressure on the glans with the thumbs as though you were pushing a cork into a bottle. To reduce the swelling, an injection of hyaluronidase may be effective. Doctors in Britain have also reported good results from packing the penis in granulated sugar.5 Ice packs work well, too. Your son has BXO and will have to be circumcised.
Some doctors equate phimosis with an extremely rare skin disorder called balanitis xerotica obliterans (BXO) which is also called lichen scherosus et atrophicus (LSA). BXO can appear anywhere on the body, but if this disorder affects the foreskin, it may turn the opening hard, white, sclerotic, and make retraction almost impossible. BXO is usually painless and progresses very slowly. Many times it goes away by itself. To an experienced dermatologist, there is no mistaking BXO, but a diagnosis must be confirmed by an biopsy. The good news is that BXO can almost always be successfully cured with steroid creams, carbon dioxide laser treatment, or even antibiotics. Circumcision should be considered only after every other treatment option has failed. Just as we do not amputate the labia of females with BXO or the glans of circumcised boys with BXO, it is logical that we should not amputate the foreskin of intact boys with BXO. Your son needs to be circumcised or else he won't enjoy oral sex as an adult.
I'm afraid that doctors really have said such inappropriate things to parents. Such a statement is evidence of ignorance of the normal functions of the foreskin ad sensations of the intact penis. Classic anatomical investigations have proven that the foreskin is the most richly innervated part of the penis. It has specialized nerve receptors that are directly connected to the pleasure centers of the brain. Your intact son is far better equipped to enjoy all aspects of lovemaking than his circumcised peers.
The myth that American women prefer the circumcised penis, in my opinion, demeaning to women. It may be true that American women of a certain generation and social background were more likely to be familiar with the circumcised penis than the intact penis, but this was the result of the mass circumcision campaigns of the 1950s not personal preference. I suspect that what women prefer in men is more related to the personal qualities of consideration, gentleness, sensitivity, warmth, and supportiveness. It is very unlikely that circumcision increases a male's capacity to develop these qualities. Your son needs to be circumcised so that he looks like his father.
A child is a mixture of both his mother's and his father's genetic heritage. He doesn't need to look like his father, nor will he ever look like his father in every way. Each child is a unique gift, and that uniqueness should be cherished. The idea that a boy will be disturbed if his penis does not look like his father's was invented to manipulate people into letting doctors circumcise their children. It has no basis in medical fact.
There are no published reports of an intact boy being disturbed because part of his penis was not cut off when he realized that part of his father's penis had been cut off. When intact boys with circumcised fathers express their feelings on the matter, they consistently report their immense relief and gratitude that they were spared penile surgery. They express sadness, as well, for the suffering their dads experienced as infants.6
Occasionally, a circumcised father will state that he wants his child circumcised because he think that it will create a bond between him and his son. It is a wonderful thing for a father to want to establish such a bond, but circumcision cannot accomplish this worthy goal. If a father wants to establish a lasting and meaningful bond with his son, the very best way, and perhaps the only way, he can achieve this is by spending quality time with him and by showing him much affection.
Sadly, some fathers who have been circumcised have an unhealthy attitude may look for any excuse to schedule the child for circumcision. Putting a child in a position where he fears that part of his penis is going to be cut off is abusive. When fathers demand that their son be circumcised, I suspect that they are desperately trying to justify their own circumcised condition. The emotions that some fathers feel when they are forced to confront the fact that part of their penis is missing can be so disturbing that they will do anything to block them out.
A father who forcibly circumcises has son will not win his son's gratitude, affection, trust, or love. I am aware of instances where such events have permanently destroyed the father-son bond and changed a son's love for this father into rage and bitter resentment. In situations where the father suffers from an unhealthy attitude about his son's normal penis, I think it is best for everyone concerned--especially the son--for the father to receive compassionate psychological counseling to help him overcome his problem. All children deserve the safest, most nurturing, and most loving home possible.
When physicians realize the important functions of the foreskin, they'll realize that just about every problem with it can and should be solved without cutting it off. Cutting off part of the body--especially part of the penis--is an extreme measure that should be reserved for the most extreme of circumstances. The only legitimate indications for cutting off any part of the body, including the foreskin, are life-threatening disease, life-threatening deformity, or irreparable damage. These situations are extremely rare.
The best advice for care of the intact penis is simply to leave it alone. The intact penis needs no special care. Let your boy take care of it himself, and when he is old enough, he will enjoy taking care of his own body. After all, it is his business. Just relax and avoid worrying about your son's intact penis. Remind yourself that the foreskin is a natural and healthy part of the body. If European boys grow up healthy and unconcerned about foreskins, so can your son. NOTES
1. R.S. Van Howe, "Variability in Penile Appearance and Penile Findings: A Prospective Study
," British Journal of Urology
80, no. 5 (November 1997): 776-782.
2. J. Winberg, I. Bollgren, L. Gothefors, M. Herthelius, and K. Tullus, "The Prepuce: A Mistake of Nature?
" The Lancet
8638, no. 1 (March 1989) 598-599.
3. S. M. Downs, "Technical Report: Urinary Tract Infections in Febrile Infants and Young Children
." The Urinary Tract Subcommittee of the American Academy of Pediatrics Committee on Quality Improvement, Pediatrics 103, no 4 (April 1999): e54.
4. M. A. Gill and G. E. Schutze, "Citrobacter Urinary Tract Infections in Children." Pediatric Infectious Disease Journal
18, no. 10 (October 1999): 889-892.
5. R. Kerwat. A. Shandall, and B. Stepheson, "Reduction of Paraphimosis with Granulated Sugar", British Journal of Urology
82, no. 5 (November 1998): 755.
6. Rosemary Romberg, Circumcision: The Painful Dilemma
(South Hadley, Mass.: Bergen & Garvey, 1985). FOR MORE INFORMATION Organizations
If your physician or health care provided ever recommends that your child be circumcised, get another opinion from a physician. We have a list of foreskin-friendly doctors here.
Doctors are encouraged to contact and join:
Doctors Opposing Circumcision (DOC) 2442 NW Market Street, #42, Seattle, WA 98107. 360-385-1882. Fax 360-385-1948. faculty.washington.edu/gcd/DOC Another resource especially for nurses:
Nurses for the Rights of the Child, 369 Montezuma #354, Santa Fe, NM 87501. 505-989-7377. www.cirp.org/nrc For information about alternative bris for Jewish parents:
Circumcision Resource Center. Ronald Goldman, PhD, PO Box 232, Boston, MA 02133 617-523-0088. www.circumcision.org One of the best sources of information on the Internet:
The Circumcision Information and Resource Pages. www.cirp.org Books
Denniston, G. C., F.M. Hodges, and M.F. Milos. Eds. Male and Female Circumcision: Medical, Ethical, and Legal Issues in Pediatric Practice
. Kluwer Academic/Plenum Press, 1999.
Goldman, Ronald. Circumcision: The Hidden Trauma
Illingworth, Ronald S. The Normal Child: Some Problems of the Early Years and Their Treatment
. Tenth Edition. Churchill Livingstone, 1991.
Ritter, Thomas, and George C. Denniston. Say No to Circumcision!
Second Edition, Hourglass, 1996. Books of special interest to Jewish parents
Goldman, Ronald. Questioning Circumcision: A Jewish Perspective
, Vanguard, 1997.
Hoffman. Lawrence A. Covenant of Blood: Circumcision and Gender in Rabbinic Judaism
. University of Chicago Press, 1996.
Weiner, Kayla. Jewish Women Speak Out: Expanding the Boundaries of Psychology
. Canopy Press, 1995. Important medical journal articles
DeVries, C. R., A. K. Miller, and M. G. Packer. "Reduction of Paraphimosis with Hyaluronidase
48 (1996): 464-465.
Fleiss, P. M., F. M. Hodges, and R. S. Van Howe. "Immunological Functions of the Human Prepuce
." Sexually Transmitted Infections
74 (1998): 364-367.
Jorgensen, E. T. and A. Svensson. "Problems with the Penis and Prepuce in Children: Lichen Sclerosus Should Be Treated with Corticosteroids to Reduce Need for Surgery
," British Medical Journal
313 (September 14, 1996): 692.
Nolan, J. F. T., J. Stillwell, and J. P. Sands, Jr. "Acute Management of the Zipper-Entrapped Penis." Journal of Emergency Medicine
8 (1990): 305-307.
Shaw, Angus. "Africa to Address AIDS at Conference." Science
(September 10, 1999).
Van Howe, R. S. "Circumcision and HIV Infection: Review of the Literature and Meta-analysis
." International Journal of STD & AIDS
10 (1999): 8-16.
Van Howe, R. S. "Does Circumcision Influence Sexually Transmitted Diseases? A Literature Review
." British Journal of Urology International
83, Supplement 1 (1999): 52-62. Paul M. Fleiss, MD, MPH, is assistant clinical professor of pediatrics at the University of Southern California Medical Center and is in private practice in Los Angeles, California. He is the author of numerous scientific articles published in leading national and international journals.
[This article was previously published in Mothering Magazine
, Number 103, November/December 2000: Pages 40-47.]
by: Darlene Owen(Posted with author's permission)
I wouldn't say that I'm fanatical about it or anything, but I do have a very strong opinion about it, and am completely against it. I strongly believe in genital integrity for both, females and males.
I'm talking about circumcision.
I had never given it much thought before, until as a nursing student I actually saw a circumcision performed on a two day old, male infant. After witnessing the procedure, I began to question this very unnecessary procedure, and tried to reason what I can only describe as torture that was carried out on that innocent little baby who had no voice, no one to help him.
Witnessing that circumcision led me to educate myself as much as I could on the topic, and question a lot of the myths surrounding circumcision, and discover the actual truths.
I grew up like everyone else with the very wrong mis-conception that circumcisions were "no big deal", and were "cleaner, healthier" etc.
I was in my second year of nursing and looking forward to my clinical rotation in Labour and Delivery since it was the area I was most interested in, and knew most likely would be the career path I would take in nursing.
It was my second day on the unit, when the nurse I was following and observing, informed me that I would be helping her to assist a doctor that morning with a circumcision.
My nurse and I set up for the procedure and talked about what was to be involved. My nurse made it sound as though it was a very minor procedure and quite simple really.
I went with the nurse to the mom's room that was having her son circumcised that morning. The nurse asked the infants' parents if they had any questions, both parents simply replied, "no". If only they knew what their poor little baby was in for.
The nurse asked the parents if they wished to be present during the circumcision and watch the procedure performed. Neither parent was interested, so we then headed with the baby in her arms to the "procedure room", which was simply... the nursery.
The nurse unswaddled the calm, sleeping baby, and proceeded to undress him. The baby began to fuss a little since it was a little cold in the room, and I'm sure he didn't appreciate being unwrapped and removed from his warm, cozy blankets.
The nurse then layed the now naked infant down on a hard plastic body board and strapped down his arms and legs. The baby was crying very hard now, trying to fight having his arms and legs strapped down in such a straight unnatural position for a newborn.
The doctor then walked in, and was very friendly when the nurse introduced me and informed him that I was a nursing student who was joining them that morning to observe. While the doctor was talking to me, he seemed impervious to the now screaming infant. I wasn't even really hearing the doctor at that point, all I kept thinking was, 'Someone please unstrap that poor little guy, and pick him up and comfort him already.' The doctor saw my obvious distress and smiled and said, "Oh, don't worry about him, he just doesn't like being on the board, he's in no real distress." 'No real distress'? Really? This tiny little newborn was screaming and no one was responding to his cries. He was literally being ignored. I was not impressed so far.
The doctor then draped the infant in surgical drapes which covered his abdomen and legs but exposed his penis. The doctor using a swab, rubbed a solution on the infants' penis explaining what the solution was, and that it works to cause an erection on the infant so that he can grasp his penis easier.
The doctor then grabbed the infants now erect penis with forceps and proceeded to force a sharp instrument into the opening of the penis. The infant was of course screaming the most horrid cry I have ever heard come from an infant. The nurse was proceeding to give him sugar water, which she claimed "helped soothe the baby". This little guy seemed as though he could care less and was choking and gagging on the liquid. He just kept screaming. At times his scream didn't even come out, he was screaming so hard. I felt weak in the knees and had to fight very hard to hold back the tears forming in my eyes.
The doctor had forced the sharp scissor-like instrument into the opening of the baby's penis and was now forcing it open to tear away the foreskin from the glans of the penis. He then grasped the skin with another type of forcep and proceeded to cut at the foreskin. The doctor was talking away and explaining each step, I wasn't even listening. I could not believe the unbelievable distress this baby was in, and no one seemed to care really. I then asked the doctor if he had used any freezing or anything. He simply replied, "No, it's too risky to use on little guys like this." WHAT? So, basically this doctor was hacking skin off of this poor little infants' most sensitive organ, and the infant was experiencing every cut? I remember feeling so disgusted and said to the doctor, "This is barbaric." The doctor said, "Well, that's your opinion, but some parents prefer their boys be cut." All I could think of was, 'Why? Who really cares?'
When the doctor was finished the procedure, the nurse took the now exhausted infant and applied Vaseline and gauze to the infants' very raw, bleeding penis. The infant was no longer crying, but had such a look of shock on his little face. He had just experienced the most horrific pain he will probably ever experience in his entire life.
I was at a loss for words.
The truth about circumcision is that it is not medically necessary.
It is not cleaner.
Studies have proven again and again, that it has no direct relation on cancer etc. as was once thought.
It is also a very painful procedure. The baby does feel it, experience it.
There have been studies that demonstrate actual MRI changes within an infants brain after a circumcision has been performed.
As for those who claim "it looks better", my response is, "Really? Based on who's decision?" A penis with a foreskin is how the penis is supposed
to look. The foreskin has a function
, it providess protection of the very sensitive glans (head) of the penis, and it provides ease during intercourse. During intercourse, the penis moves within its foreskin, preventing rubbing or friction of the vagina, which makes intercourse far more pleasurable for both the man and woman.
Many people will respond in outrage over female circumcision, yet still consider circumcision of males 'the norm'.
Many parents aren't properly informed of the procedure. It IS
a very serious procedure with very many real risks involved. In my experience as a post partum nurse, many parents who were led to believe it was a 'minor' procedure and observed their sons' circumcision, were sickened just as I was at the actual pain and distress it caused their infant. I have had many patients who, after witnessing their first son's circumcision, decided immediately that they would not get any other boys they may have circumcised. Many parents told me that they wished they had known just how painful it would be for their son, that they would not have even considered it if they had known what is actually involved.
As for the argument that many men want their son to look like them, my answer is, Why? It is a stupid argument. Why can't parents simply teach their son that their son's penis is 'normal and healthy', that 'daddy had his normal, healthy functioning skin of his penis removed surgically, unnecessarily'. I also always say to those people, "Really? Well, watch an actual circumcision and see if you still feel that way afterwards." I have yet to see any parent watch a video, or view an actual circumcision procedure, who is not completely against the idea afterwards.
An uncircumcised penis is very easy to keep clean. There is no special care required. The saying goes, "Clean only what is seen".
As for worrying about the son's foreskin not retracting, and needing a circumcision later in life. That actually only occurs in a very, very small number of males. However, even if the male does need the surgery later in life, he will be put to sleep for the procedure and will not feel it. He will also be managed comfortably with pain medication. A newborn doesn't have any of those benefits. A newborn is awake for it, will feel it, and doesn't receive any pain medication.
Ask any grown male if he'd get his penis circumcised while awake, with no freezing, and I guarantee you'd hear a very loud resounding "NO!" Yet, many men will put their newborn son through it. Doesn't make much sense does it?
I realize that at one time it was considered the norm. Now however, with all of the education about it, I can not understand why parents still proceed to put their tiny little newborn son through such a horrific experience.
I am proud to say that I am an intactivist, and the proud mom of two gorgeous, healthy, intact boys.
Original article can be found here
Circumcision and Adult Penile Sensitivity & Sexual Dysfunction: A Review of the LiteratureWritten by: Teri Mitchell, RNC, BSN, LCCE, IBCLC, SNMQuestions? firstname.lastname@example.org
New parents in the United States (US) are often presented with the option of whether they would like their newborn son to be circumcised, or if they would like him to remain intact
(uncircumcised). This offer typically comes from the mother’s obstetrician, who has the most contact with the parents before the baby’s birth and who often performs the surgery. The advertised risks of the procedure are limited to the more immediate risks, such as bleeding, infection, injury to the penis, and scarring (American College of Obstetrics and Gynecology [ACOG], 2008). While the potential long term benefits may be offered, such as decreased risk for urinary tract infections, penile cancer, and acquisition of sexually transmitted diseases (Binner, Mastrobattista, Day, Swaim, & Monga, 2002), the long term risks are not included in the discussion when counseling parents on the risks and potential benefits of non-therapeutic neonatal circumcision. In effort to best serve our youngest and most vulnerable patients, healthcare providers should include all potential short-term and long term risks and benefits when providing information to parents considering elective surgery for their newborns.
Since newborn males are many years from sexual maturity, it may be easy for parents and providers to overlook the potential impact of circumcision on penile sensitivity and sexual function during adulthood. However, for the future man himself, this will likely be an important aspect of his life. One topic that has not been included in circumcision educational materials provided by ACOG (2008) is whether or not neonatal circumcision has a correlation with penile sensitivity or sexual dysfunction later in the baby’s life. I believe this is an important topic because parents deserve to be fully informed before giving consent for their newborn boys to be circumcised. The purpose of this paper is to review the literature in order to answer the question: Do circumcised men experience decreased penile sensitivity or greater sexual dysfunction than intact men?Background and Significance
Circumcision is the surgical amputation of the prepuce of the penile glans. Cold and Taylor (1999) published a detailed explanation of the structure and function of the prepuce. The prepuce plays an important role in sexual function:
The prepuce is primary erogenous tissue necessary for normal sexual function. The complex interaction between the protopathic sensitivity of the corpuscular receptor-deficient glans penis and the corpuscular receptor-rich ridged band of the male prepuce is required for normal copulatory behavior. The increased frequency of masturbation, anal intercourse, and fellatio reported by circumcised men in the USA may possibly be due to the sensory imbalance caused by circumcision. Clearly, amputation of the prepuce causes changes in sexual behavior in human males and females (Cold & Taylor, 1999, p. 41).
This loss of sensory function in the circumcised penis was an important factor in the rising popularity of the surgery in the US, for non-religious reasons (Gollaher, 1994).
Circumcision has a history dating back as far as historians can measure, with Alexander Badaway’s reports of carvings depicting circumcision in Egyptian tombs in 2400 B.C. (as citied in Gollaher, 1994). The reasons for the ritual are highly varied and dependant on the cultural group and the beliefs of the time (Gollaher, 1994). What was once restricted to establishing a covenant with their creator among the Muslim and Jewish faiths, became an encouraged medical practice in the US during the second half of the 19th century (Gollaher, 1994).
Gollaher’s (1994) report chronicled the history of circumcision in the US. In the late 1800’s and early 1900’s, paralysis, insomnia, digestive abnormalities, epilepsy, hernias, scoliosis, insanity, promiscuity, homosexuality, nocturnal enuresis, nightmares, spermatorrhea and masturbation were believed to be cured by circumcising the male with the said affliction. All of the listed indications were believed to be caused by masturbation. The list of seemingly unrelated indications increasingly grew during this era (Gollaher, 1994).
Masturbation became the priority reason for circumcision (Darby, 2003). The premise was that by inflicting pain on and removing the most highly sensitized tissue from the penis, would stop boys and men from using their penis for any other activities besides procreation (Darby, 2003). Physicians specifically promoted the surgery to be performed without anesthesia in order to act as a punishment and leave a painful imprint on the male who was guilty of the prohibited act of sexual self-pleasure (as cited in Darby, 2003).
“Circumcision in male neonates is the most common surgical procedure in the United States. Throughout the rest of the world, except for religious reasons, it is performed infrequently” (Wang, Macklin, Tracy, Nadel, & Catlin, 2010). In the US, today’s parents are choosing circumcision for a variety of reasons not related to religious beliefs or potential medical benefits (Binner et al., 2002). The most prominent reason for choosing circumcision is so that the child will have the same surgical outcome as the child’s father (Binner et al., 2002). We have come to a time in history when researchers are attempting to validate indications for circumcisions that are aligned with the current beliefs and health concerns of today’s society (Gollaher, 1994), while parents are perpetuating the cycle of the procedure for reasons of aesthetics (Binner et al., 2002).
It is important to remember that the reason why circumcision became popular in the US was because it was known to decrease penile sensation (Darby, 2003; Gollaher, 1994). The topic of circumcision as it relates to penile sensation and sexual dysfunction is important to nurses because expectant and new parents may inquire about the potential risks and benefits. Healthcare providers should consider the historical, cultural, ethical, and medical aspects of non-therapeutic neonatal circumcision when providing information to parents and should encourage an informed independent decision. Methods
Academic Search Complete, CINAHL, and Medline databases were used to search the terms circumcision
, premature ejaculation
, and sexual dysfunction
. Limits placed on the search included English language and publication dates ranging from 2002 to 2012. Articles with titles related to the topic of interest were obtained and the abstracts were reviewed. Abstracts that met the inclusion criteria were included in the review. The inclusion criteria consisted of a) published in the preceding 10 years b) quantitative research design c) penile sensitivity, ejaculatory time, erectile dysfunction, orgasm difficulty, or dyspareunia as outcome criteria d) male subjects e) circumcised and intact group assignments. Excluded articles included those that examined the outcomes before and after adult circumcision. These articles were excluded because the premise for this review is to offer informed consent to parents of newborn boys. Furthermore, the outcomes for men circumcised as adults may be different than those circumcised earlier in life, especially in terms of glans keratanization secondary to the loss of the protective sheath of the prepuce (Cold & Taylor, 1999).
Six articles were found that met the inclusion criteria. No systematic reviews were found on this topic in the past 10 years. Each article was outlined in the accompanying Evidence Summary Table
, which presents the design, sample description, variables, findings, and limitations of each study. No further statistical tests were run on the data beyond what was presented in each study individually. FindingsPenile Sensitivity
Two studies were identified that attempted to objectively measure penile sensitivity, by measuring the “small and large axon fibers” (Bleustein, Fogarty, Eckholdt, Arezzo, & Melman, 2005, p. 774) and the “fine touch pressure thresholds” (Sorrells et al., 2007, p. 864).
Bleustein et al. (2005) operationalized the measurements by using a series of instruments to determine sensitivity upon touch (Semmes-Weinstein monofilament evaluator), vibration (Bio-thesiometer), spatial perception (tactile circumferential discriminator), and thermal thresholds (Physitemp NTE-2A Thermal Sensitivity Tester). The measurements were taken on the dorsal glans of both the circumcised and intact groups. An additional measurement was taken in the same location among the intact subjects with the prepuce covering the glans, for the vibration, pressure, and spatial measurements only. This sample was comprised of men who sought care at a urology clinic, of which 77% had diagnosed erectile dysfunction. Among the 63 circumcised and the 62 intact subjects, there was not a statistically significant difference reported. (Bleustein et al., 2005).
Sorrells et al. (2007) employed strict exclusion criteria to avoid as many conceivable extraneous variables as possible. This study created a 19-point map of penile sensitivity, operationalized by using the Semmes-Weinstein monofilament evaluator. This was the same instrument used to measure sensitivity to touch by Bleustein et al. (2005). A power analysis was conducted and the study was adequately powered. This study contained 163 subjects (68 intact and 91 circumcised) who were volunteers from the community, without a long list of penile or systemic pathologies. Sorrells et al. (2007) found that the circumcision scar (prepuce remnant) was the most sensitive location among circumcised men, particularly the ventral scar. Among intact men, the study concluded that 18 of the 19 locations were more sensitive than the circumcised group. Sorrells et al. (2007) reported that “Five locations on the uncircumcised penis that are routinely removed at circumcision were more sensitive than the most sensitive location on the circumcised penis” (p. 867). While a significant difference was not found in the two location measurements done by Bleustein et al. (2005), the 19 location map created by Sorrells et al. (2007) showed significant differences between circumcised and intact subjects. Premature Ejaculation
Three published studies measuring premature ejaculation (PE), which were conducted in the last 10 years, were reviewed. According to Waldinger et al. (2005), “Premature ejaculation is probably the most prevalent sexual complaint of men” (p.492). This condition is:
characterized by: (i) ejaculation which always or nearly always occurs prior to or within 1 minute of vaginal penetration; (ii) inability to delay ejaculation on all or nearly all vaginal penetrations; and (iii) negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy (Waldinger, McIntosh, & Schweitzer, 2009, p. 2888).
Waldinger et al. (2005) and Waldinger, McIntosh, and Schweitzer (2009) conducted the same study, only changing the way in which intravaginal ejaculatory latency time (IELT) was operationalized. Waldinger et al. (2005) instructed the subjects to use a stopwatch to measure and a journal to record their sexual encounters during a 4 week period. Waldinger, McIntosh, and Schweitzer (2009) used a blinded timer with a hidden electronic record to obtain the same measurements. Both studies obtained a sample containing heterosexual couples from five countries; the Netherlands, United Kingdom, Spain, Turkey, and the US. Both studies claimed “exactly the same” (Waldinger, McIntosh, & Schweitzer, 2009, p.2891) findings. Waldinger et al. (2005) and Waldinger, McIntosh, and Schweitzer (2009) both reported that men from Turkey had statistically significant shorter IELT compared with the rest of the sample. However, the results from Turkey were not included in the final findings because all Turkish men (Turkish n=130; sample n=500) in the Waldinger et al. (2005) study and all but two Turkish men (Turkish n=124; sample n=474) in the Waldinger, McIntosh, and Schweitzer (2009) study were circumcised. Upon exclusion of this data, there was no significant difference found in IELT among circumcised and intact men in either study (Waldinger, McIntosh, & Schweitzer, 2009; Waldinger et al., 2005).
The most recent study, used surveys to assess PE among a sample obtained from a primary care setting (Tang & Khoo, 2011). The surveys were pretested and deemed reliable. Subjects were operationalized as having PE if their survey score fell into the PE or Probable PE categories. Tang and Khoo (2011) found that circumcised men were nearly five times (OR 4.88) more like to report PE than intact men. This finding was both statistically and clinically significant, considering that PE may be the most frequent sexual complaint among men (Waldinger et al., 2005) and may cause significant personal distress (Waldinger, McIntosh, & Schweitzer, 2009). Orgasm Difficulty
Frisch, Lindholm, and Gronbaek (2011) sought to explore the outcomes of circumcision in Denmark, where 95% of the population is intact. The study examined several factors that are potentially linked to circumcision. Information was gathered from a questionnaire. The study concluded that, while there was no statistically significant difference among intact and circumcised men reporting only occasional orgasm difficulties, there was a statistically significant difference between the groups when reporting frequent orgasm difficulties. Circumcised men were more than 3 times (OR 3.26) more likely to report frequent orgasm difficulties than intact men (Frisch, Lindholm, & Gronbaek, 2011).
Interestingly, while not the topic of this paper, this study found several statistically significant differences in sexual satisfaction and experiences among women with circumcised partners and women with intact partners. Women with circumcised partners were two to three times more likely to report overall sexual dysfunction (OR 3.26) and frequent orgasm difficulties (OR 2.66), as well as eight and a half times more likely to report dyspareunia (OR 8.45) than women with intact partners (Frisch, Lindholm, & Gronbaek, 2011). This is an area that warrants more research to fully understand the impact of circumcision on the sexual partners.Strengths and Limitation
All the subjective measurements of sexual function found highly significant differences, as did the studies with more stringent controls of extraneous variables. The studies varied greatly in the measurement outcomes and data collection methods, with exception of IELT.
While the Bleustein et al. (2005) study did not find a difference among the groups, the sample was taken from a urology clinic. The subjects could have had extraneous variables that impacted the study findings. For example, men seeking care at a urology clinic may have characteristics or health conditions that differ from the general male population. The Bleustein et al. (2005) findings are not generalizable beyond a population of men who seek care at a urology clinic. This study had an inadequate power and a small sample size as well (Bleustein et al., 2005). The Sorrells et al. (2007) study had higher power, extensive controls, and a more thorough examination of penile sensitivity. Sorrells et al. (2007) also provided comprehensive findings of penile sensation by location, including the locations lost due to circumcision. Interesting to note, Cold and Taylor (1999) reported that “The only point of the body with less fine-touch discrimination than the glans penis is the heel of the foot” (p. 37). The most highly innervated region of the penis is the prepuce, which is removed during circumcision (Cold & Taylor, 1999). Sorrells et al. (2007) argue that sensitivity of the glans is of lesser importance because the glans is not amputated during circumcision.
While the objective measurements analyzed by Waldinger et al. (2005) and Waldinger, McIntosh, and Schweitzer (2009) did not show a statistically significant difference in IELT among the groups in question, Tang and Khoo (2011) found that circumcised men are much more likely to report a shorter ejaculatory time than desired. Regardless of objective measurements, subjective reports demonstrate the desire for longer ejaculatory time among circumcised men. This raises the question: Is there a characteristic unique to circumcised men that lend them to report a need for longer ejaculatory time in order to experience full sexual satisfaction? Do men who report premature ejaculation also have a shortened IELT, upon objective measurement? This is certainly an area in need of further research.
Another limitation to note is that all the men or couples in the study had to volunteer to participate in the studies. Quantifying findings as personal as penile sensitivity and sexual function is certainly threatened by the characteristics of the type of individuals who are willing to participate (selection bias), the impact of having this aspect of one’s life evaluated (evaluation apprehension), and the expectations of the researchers (experimenter expectancies). The researchers did not disclose their own circumcision status, their feelings about their status, the circumcision status of their own sons, or their bias for or against the procedure. Implications of Findings/Recommendations for practice
The body of evidence on this topic demonstrates that circumcised men are more likely to report greater sexual dysfunction. Objective measurements examining limited variables did not show any difference between the groups, but more extensive objective measurements with tighter controls did show a significant difference between circumcised and intact men. More research is needed to combine subject reports with objective measurements. Researchers need to be sure to include objective measurements of the prepuce in their studies, since that is the removed part.
Over the last 150 years, the healthcare profession has lost sight of normal male anatomy and the outcomes circumcision. “Historically, reduced penile sensitivity was not an unintended side effect of circumcision” (Frisch, Lindholm, & Gronbaek, 2011, p. 9), but today’s nursing schools do not teach the important historical roots, function, and importance of the prepuce, in this writer’s experience. Today’s providers in the US are not taught alternatives to circumcision when an intact male is in need of competent medical care for a condition of the prepuce. The result is providers who are providing ill-informed data to parents attempting decide if they want their son circumcised, a culture that views males with natural anatomy as abnormal, and a lack of intact friendly
providers for parents with intact sons.
Normal sexual function must be considered when discussing circumcision with individuals weighing the pros and cons of the surgery for themselves or their children. The prepuce serves many important functions throughout the span of a male’s lifetime, including normal reproductive behaviors (Cold & Taylor, 1999). Omitting the possibility that circumcision may impact the sexual experience of the individual denies parents the opportunity for fully informed consent on the behalf of their sons.
Future practice should include more research, re-evaluation and alteration of informed consent and patient education materials, and more comprehensive education of healthcare providers in the academic setting.
American College of Obstetricians and Gynecologists (2008). Newborn circumcision
. [Brochure]. Washington, D.C.: American College of Obstetricians and Gynecologists.
Binner, S., Mastrobattista, J., Day, M., Swaim, L., & Monga, M. (2002). Effect of parental education on decision-making about neonatal circumcision. Southern Medical Journal, 95
(4), 457-461. Retrieved from http://ehis.ebscohost.com.ezproxy.baylor.edu/ehost/pdfviewer/pdfviewer?vid=4&hid=121&sid=83be1044-47f9-4e1f-ab62-a08205bba187%40sessionmgr111
Bleustein, C.B., Fogarty, J.D., Eckholdt, H., Arezzo, J.C., Melman, A. (2005). Effect of neonatal circumcision on penile neurologic sensation
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Darby, R. (2003). The masturbation taboo and the rise of routine male circumcision: A review of the historiography. Journal of Social History, 36
(3), 737-757. Retrieved from http://ehis.ebscohost.com.ezproxy.baylor.edu/ehost/pdfviewer/pdfviewer?vid=4&hid=121&sid=65948ec5-a06c-4b12-8353-6ca93bd7ea71%40sessionmgr113
Gollaher, D. (1994). From ritual to science: The medical transformation of circumcision in America. Journal of Social History, 28
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written by: Larissa Black
Ryan McAllister Ph.D. is the creator and director of NotJustSkin.org
. He’s also a writer frequently featured on Examiner.com
, and currently he’s the intactivist world’s newest YouTube sensation.
At first glance McAllister looks like your average approachable guy next door. In his video presentation Child Circumcision: an Elephant in the Hospital
, he is dressed in casual attire. His relaxed posture and his gentle voice have a way of setting you at ease. He addresses his audience the same way he might address a friend at the dinner table, with compassion, humor, and blatant honesty. Only minutes into his lecture you inevitably find yourself hanging on his every word.
“I’m going to talk with you about circumcision,” he explains. “I’m calling it the Elephant in the Hospital because it’s this huge thing that happens, as far as I see, in our culture but we have very little discourse about it. It’s performed between five hundred thousand and a million times each year in the U.S. almost entirely on infants within the first three days of life. It’s completely unnecessary and I believe, based on my research, entirely harmful to children.”
Over a span of thirty-three minutes time, McAllister goes on to examine:
-The most common rationales used to defend infant circumcision
-The history of circumcision in the U.S.
-Comparison of female and male genital cutting practices and attitudes
-Surgical and post-operative complications of circumcision
-Functions on the foreskin
-Ethical issues involving informed consent from medical professionals
-Commercial use of infant foreskin
-The flawed science behind the commonly cited studies used to promote circumcision
-Roadblocks to ending this cultural practice
This powerful video, which was taped as part of a university course on human sexuality, has to date topped 2,600 hits on YouTube and over 550 likes on Vimeo. It’s been lighting up Facebook pages worldwide ever since its release in July 2011. Already this presentation has proven a valuable resource in the education of expectant parents who struggle with the circumcision decision. “I have heard from parents that they've chosen not to circumcise children because of it,” says McAllister.
Expectant parents aside, who did Ryan McAllister intend to reach with his message? “Everyone really,” he responds. “I think it's an issue for us to address as an entire society. I would like parents, medical professionals, others who care about children, and academics from the many relevant disciplines (gender, bioethics, critical theory, anthropology, medicine, etc.) to be thinking critically about this practice we have in mainstream U.S. culture of cutting children.”
Why does McAllister feel so passionate about routine infant circumcision in particular? “I believe that adults who interact professionally with children have a critical professional responsibility to bring a very high ethical standard to that work. And even more so with medical professionals, who also have a bioethical imperative to found their work in the needs of the children they serve.”
He goes on to discuss why he finds the practice of routine infant circumcision so troubling. “When I have spoken with medical professionals who perform or have the power to stop this procedure, what I've often heard is a discourse that, instead of being founded in the child's needs, generally lacks any reference to the child's needs. Take, for example, the conversation I mention in my lecture with Dr. Landy, the Chair of Obstetrics and Gynecology at Georgetown University Hospital. When a physician of that esteem tells me that she knows that this elective surgical procedure on a minor doesn't make sense medically, I say that gives her an ethical mandate to stop performing the procedure. However, she said that her department will not "be a beacon of light", that they will not stand out by ceasing to perform circumcision. The reason she gave is essentially economic -- that they want to provide circumcision as a service to parents so that birthing mothers don't choose another hospital in which to give birth. And I am deeply troubled by this reason.”
In addition to all the overwhelmingly positive feedback McAllister has received on his presentation, it’s clear his message has also ruffled some feathers. An attorney representing Georgetown University Hospital issued a letter disputing McAllister’s use of statements made by the Georgetown University Hospital Chair of Obstetrics. McAllister responds: “I have asserted that I am accurately representing my notes from the meeting, and I asked the hospital administration for a meeting to discuss the ethics of their practice of circumcision.”
To date, they have not responded to his request, but according to McAllister that’s not necessarily a bad sign. “My hope is that they will resolve to end the practice because it contradicts the fundamental bioethical principles of non-malfeasance and beneficence -- principles I would hope they aspire to as an institution. As it stands, consciously or unconsciously they're putting the physicians who work at their hospitals under institutional pressure to perform unnecessary surgery on minors -- which, when you look at it, is hard to defend ethically.”
Infant circumcision is only one of many issues McAllister hopes to address. “There are many other elephants in obstetrics -- places where standard practice is directly in conflict with both peer-reviewed research and the well-being of birthing women and newborns,” he points out. “I hope to draw attention to those elephants as well, as the current state of affairs mis-serves women, newborns, their families, and physicians.”