Talk:Forcible retraction of the foreskin

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[edit] Jake

Lo jake, I see you've taken interest in the article. Are you going to readd improved versions of what you removed soon? You've introduced a couple unecessary weasel words for things that are not disputed at all. Dabljuh 17:31, 14 January 2006 (UTC)

I'm working on it, Dabljuh. In some cases I can find no reliable sources for some claims, so I'm leaving them out altogether. What weasel words do you object to? Jakew 17:39, 14 January 2006 (UTC)
The RACP doesn't leave much doubt about a couple things:
The foreskin requires no special care during infancy. It should be left alone. Attempts to forcibly retract it are painful, often injure the foreskin, and can lead to scarring and phimosis.
Ok, so what do you want to do? Quote them? I've no objection to that. Jakew 19:32, 14 January 2006 (UTC)

No. Simply avoid weasel words. "It is" instead of "Some argue", when we have their statement, that says "it is", in the external links.

[edit] Title

"Early retraction of the foreskin" Weren't you before lecturing me on names? I think the correct description of the procedure is "Premature retraction" ("of the foreskin", but since we do not have any other "premature retraction" articles, the "of the foreskin" part is superfluous)

The retraction is *premature*, not early. Early is a bird. Premature means, it is *too* early. So I think the title should go back to "Premature retraction" ("of the foreskin", if you insist, I don't care about that much)

An alternative would be "forcible premature retraction". Dabljuh 19:02, 14 January 2006 (UTC)

As you say, 'premature' means too early. That is not NPOV. I've no objection to renaming it 'forcible retraction of the foreskin', though, which doesn't have this problem. Do you want to move the page or shall I? Jakew 19:26, 14 January 2006 (UTC)
The whole point about the concept of premature retraction is that it is too early. The canadians and especially the RACP stress that the foreskin should be left alone. There's no POV dispute here, calling it "early retraction" is just plain false, if you think NPOV would mean that we should give an equal number of arguments why premature retraction is great, then you've misunderstood what NPOV is about. Its about being neutral, and you can perfectly neutrally call this "premature" retraction, as it damaging, possibly traumatic and is medically counter-indicated by science. And well, just plain premature!
I am not sure "forcible/forced retraction (of whatever)" is wise, but if you find "premature retraction" unacceptable, but would find the former better, I leave it up to you. "early" is simply not correct. Dabljuh 19:39, 14 January 2006 (UTC)
Ok, it's moved. As for NPOV, no I'm not saying that we should give an equal number of arguments. I'm just noting that we shouldn't endorse one point of view. Jakew 19:46, 14 January 2006 (UTC)

[edit] Beg pardon?

"The Royal Australasian College of Physicians states that the first person to retract the boy’s foreskin should be the boy himself.[1]"

Nope. The RACP say it should be left alone during infancy, but they don't say the boy should be the first to retract. Furthermore, citing Wright is inappropriate, since he isn't the RACP. Jakew 19:59, 14 January 2006 (UTC)

Maybe I mixed that up. Who said that then?
Mmh... Noharmm?Dabljuh 20:44, 14 January 2006 (UTC)

Wright is one example, in the link above. Jakew 20:12, 14 January 2006 (UTC)

Can a source be found for the claim that it causes phimosis? The RACP statement only refers to it causing paraphimosis. Jakew 20:06, 14 January 2006 (UTC)

Attempts to forcibly retract it are painful, often injure the foreskin, and can lead to scarring and phimosis. [2]

Thank you. Added. Jakew 20:12, 14 January 2006 (UTC)

[edit] Too many sources?

I find there are too many sources directly in the article. It harms the read flow. Also, too many names. This is Wikipedia, not a scientific paper. Can we agree to move them to the end?

Wait, I got a better idea. give me a minute Dabljuh 20:21, 14 January 2006 (UTC)

We can remove the names but not the sources. In order to verify information, it must be clear what reference supports what statement. We could change it to Harvard-style citations, as I used in balanitis xerotica obliterans, but you may find it harder still to read.
Post edit conflict: ok, what's the idea? Jakew 20:24, 14 January 2006 (UTC)
Check it out Dabljuh 20:26, 14 January 2006 (UTC)
Ok, the diff isn't really useful. I rm'd the 1 section with the many names (figured it was confusing at best) and moved all sources to the end of their respective block. Dabljuh 20:28, 14 January 2006 (UTC)
I think it's worse this way, but not enough to edit war over it. I've made a few minor changes, as you can see. Jakew 20:29, 14 January 2006 (UTC)
Same. But here's an NPOV sensitive issue: The doctors that claimed to have "resolved" problems by premature, cough, forcible retraction. Do you also see the problem leaving them there like this? I mean, the RACP does state, with emphasis, that the foreskin should be left alone. I find it problematic to mention these doctors that claim to have resolved issues by the technique. Wouldn't it be more sensible to say "Some doctors have claimed success in treating a range of blah such as blah by blah"? Dabljuh 20:39, 14 January 2006 (UTC)
I don't really see the NPOV issue here. We're not saying that they were right to do so (or that they were wrong), only that they did any they reported solving (as opposed to actually solved) various things by doing so. We're giving the RACP the last word, but NPOV does not require us to silence anyone who takes a different stance from the RACP. Far from it. Jakew 20:53, 14 January 2006 (UTC)

Btw, I don't think you need to add inline links to sources when the source is one of two links in the references. Dabljuh 20:45, 14 January 2006 (UTC)

Hmm. There are at least two different RACP documents that are cited in the article. It's probably best to be specific. Jakew 20:53, 14 January 2006 (UTC)

[edit] NPOVization/Clarification

Alright: Is there an NPOV issue?

The section that I find questionable is this:

Forcible retraction happens in a variety of occasions. Most commonly known is the premature retraction by doctors, as described by Cooper, who reported resolution of a number of problems, including balanoposthitis, dysuria, and phimosis through retraction under anaesthesia. Others have reported similar success in treating older children.MacKinlay reported on successfully breaking the adhesions between foreskin and glans with topical anaesthetic, thus achieving full retractibility.

(links removed for readability)

Right now, it is just confusing. Are we supposing that Cooper and others are dumb fucks that tried to "cure" physiological phimosis and adhesions, or are we supposing that they, well aware and informed etc indeed did cure a couple of conditions by the method of therapeutic premature retraction? Dabljuh 21:03, 14 January 2006 (UTC)

Thanks for clarifying. We shouldn't judge Cooper et al on this, only comment that it happened. It looks to me as though some doctors (eg the RACP committee and others) think it's a bad idea, others think it's a good idea (when done in sterile conditions). Doctors tend to have lots of different views on what is good practice. I'm currently looking for more info. I've tried to NPOV the text as far as I can - what do you think now? Jakew 21:14, 14 January 2006 (UTC)

Its worse now, I think. Let me explain
The thing is, most of those reports were from the 1970-1990. here's a fun quote:
Between March, 1973 and November, 1980 we treated 161 patients in this way, achieving complete separation in 150 and partial separations in 11. Complications were severe trauma in 9 and slight discomfort in 15. 2 mothers fainted. Apart from the 4 failures, the procedure had to be repeated in 4 children and paraphimosis was recorded in 1.
I think it would not be NPOV to leave it at that. That would give the impression that premature retraction is (still considered) a valid technique to relieve certain conditions such as "phimosis" and "adhesions" in children. The conclusion is pretty clear: The doctors are examples of "stupid doctors" that tried to cure a normal and nonthreatening condition. Meaning, they were unaware of the physiological phimosis and the fused foreskin/glands. And went ahead anyway.
If there are modern doctors, that take modern data into account, are aware of the physiology of the intact infant penis, and dispute the RACP opinion, we can report them as an alternative opinion. But these really seem merely to be "stupid" docs that are not current, and stupid enough to post their reports on pubmed. Dabljuh 21:28, 14 January 2006 (UTC)
They date, in chronological order, from 1983, 1984, 1988, 1996, 1997, and 2005. Sorry if you think they're 'stupid', but that's just your POV. It's a relevant alternative POV, and it should be in the article. The fact that they had successful results suggests they weren't so stupid to me (though that doesn't belong in the article either, obviously). Jakew 21:35, 14 January 2006 (UTC)
I should add: doctors are generally unlikely to dispute a web page belonging to a medical organisation. They're often too busy treating patients. Jakew 21:38, 14 January 2006 (UTC)

I have changed the section in question. Tell me what you think of it. The problem is once more WP:NPOVUW, as it would indicate the opinions of these doctors was an equal to the opinion of the RACP. That would be undue weight. The RACP/CPS' opinion must be given as the current state of the art medical view, and minority views must be displayed as in contrast to this. Dabljuh 21:49, 14 January 2006 (UTC)

I've made a couple of minor changes, as that was incredibly POV. I'm quite happy with presenting the RACP etc position as mainstream, and I remind you that it was I who felt that they should have the concluding paragraph, but there is no reason to censor the views of others, especially when they have given empirical evidence for their claims (unlike the RACP etc). Jakew 21:56, 14 January 2006 (UTC)
You appear not to understand. Of course they have success with treating a condition that would have resolved itself anyway. We must judge them according to the mainstream view. If the mainstream says, infants have phimosis and adhesions and they resolve naturally, and that forcible retraction is absolutely bad, and we have doctors, that claim they treat phimosis and adhesions WITH forcible retraction, then we must explicitely say so. "A says X is bad, B says they treat Y with X", then it would be confusing, and most misleading, not to mention in the *same* block that Y is not a condition that requires to be treatet. Dabljuh 22:03, 14 January 2006 (UTC)
But we cannot judge without violating NPOV. That means we cannot say Y doesn't require treatment. We can, however, say that A, C, and D state that it doesn't require treatment. Jakew 22:12, 14 January 2006 (UTC)
What I mean is, the doctors using premature retraction as a means to resolve preputial adhesions and congenital phimosis are certainly not disputing the opinion of A C and D, they are very obviously just unaware of it. The notion that premature retraction has any medical indication has been wholly refuted, these sources are not evidence of someone stating an alternative opinion, they are merely evidence of people not aware of the current state of things. We don't have the case that we have all major medical associations purporting X, Y, Z, with a minority saying ~X ~Y and ~Z. We have the case of doctors that are simply ignoring, or are oblivious of X, Y, Z, and continue to perform their practice of ~X, ~Y, ~Z because they never learned or heard anything else. Dabljuh 22:18, 14 January 2006 (UTC)
We simply don't know whether they're aware of the evidence. Maybe so, maybe not. Additionally, phimosis and adhesions can be a problem in individual children, even though they evidence suggests that mostly they aren't. For all we know, some of these doctors may be extremely familiar with the relevant evidence, and so performed this because the conditions were severe and caused the child pain or something. We simply don't know. All we can do is to say that X, Y, and Z say don't do it, while A and B say it can be helpful.
More to the point, the RACP (etc) state that retraction can cause phimosis, balanoposthitis, adhesions, etc, and these doctors are clearly in dispute with that, since they're not only claiming, but showing empirical evidence, that it can actually resolve these problems. Jakew 22:29, 14 January 2006 (UTC)
What they resolved most likely was not pathological phimosis, but congenital phimosis. The RACP's statement means it causes pathologic phimosis, obviously. I'll clarify that. Dabljuh 22:44, 14 January 2006 (UTC)

Well, I'm happy with it now. You? Dabljuh 22:41, 14 January 2006 (UTC)

I think it's okay now. Spilsbury didn't use Cooper as an example, and neither should we, since we have absolutely no way of knowing whether this was the case. Other than that, I've altered the text to better reflect what Spilsbury actually said. Jakew 22:45, 14 January 2006 (UTC)

This sentence must get into the article:

"doctors, unaware of the harmless nature of physiological phimosis and adhesions in infants, doctors sometimes forcibly retract the foreskin just to see if it retracts"

Or some variation thereof. That is the main cause of forcible retractions, not diagnosing phimosis and treating it with retraction. Understand: they diagnose phimosis by *attempting* to retract - and if it does not retract, treat it - that means, in most cases (where they don't diagnose "phimosis") the foreskin is prematurely, forcibly retracted, but no treatment is given. I think it would'nt take long to find sources to back that up, if you require. I remember when I was a kid in the 80ies, we'd have a shitload of idiot doctors retracting our foreskins just to see if they work properly. Dabljuh 22:53, 14 January 2006 (UTC)

Something like this must be sourced and attributed. Firstly, we must not present a point of view as the correct one, and secondly extraordinary claims need extraordinary evidence.
I don't exactly find that to be an extraordinary claim. Why do you think has nocirc issued an intact care agreement? How about this? [3] [[User:Dabljuh|Dablju
That's not a reliable source, it's just an activist site. Will you please find a proper source for the claim? I've temporarily commented it out until it can be sourced. Jakew 12:01, 15 January 2006 (UTC)

- :The grammar needs fixing, btw. Correct grammar would be: "X states that some doctors, unaware of the harmless nature of physiological phimosis and adhesions in infants, sometimes forcibly retract the foreskin just to see if it retracts." Better still would be a short quotation. Jakew 23:03, 14 January 2006 (UTC)

Btw, this here is an interesting bit:

One boy had to undergo a repeated procedure because he failed to follow the advice regularly to retract his foreskin in the three weeks after the procedure. Only one boy had to undergo circumcision later because of fibrous phimosis.

So we have 1 case of phimosis (rate of 1:32) and 1 kid "failed" to do the "procedure". More likely, refused to do something that hurts him (but I'm speculating here). Dabljuh 22:55, 14 January 2006 (UTC) forgot to link it: You'll like the title: "Save the prepuce"

In fairness, all had phimosis beforehand, so that's a success rate of 38 in 39. Jakew 23:03, 14 January 2006 (UTC)
Well, true they were all *diagnosed* with phimosis, but how likely is pathological phimosis in 2-12 year olds? Given that the AAPS considers only BXO a reasonable medical indication for circumcision. Additionally I can postulate the hypothesis that the single case of (pathologic, if it ultimately was then) phimosis was caused by the procedure of premature retraction. Dabljuh 23:20, 14 January 2006 (UTC)
I came across a study fairly recently in which foreskins from childhood circumcisions were assessed histologically. Something like 30% had BXO. I'll try to find it. Jakew 12:01, 15 January 2006 (UTC)
30%? That does not sound credible, tbh. Btw, if you mind that sentence about (dumb) doctors retracting prematurely to check for phimosis, we can leave it out until some source reliable enough explains the practice in detail. But I would find it rather obvious from the context. Dabljuh 12:43, 15 January 2006 (UTC)
here is the abstract. "Of the patients with congenital phimosis, 82% showed inflammatory disease in the prepuce; 30% had LSA." Jakew 12:47, 15 January 2006 (UTC)
Interesting, but not convincing. Suppose all those pediatric patients were "tested" for congenital phimosis and various other infections, that would mean, all those patients have gotten their foreskin prematurely retracted. Which indeed would lead to inflammation of the foreskin, acquired phimosis, balano/posthitis etc, but not BXO.
All 115 boys ... underwent full-thickness biopsies of the foreskin that were examined by a single pathologist.
I remember reading recently that BXO is indeed very rare (LSA can occur on any part of skin of the body, and BXO is when it just happens to be on the foreskin) and often misdiagnosed by pediatrics, as only a dermatologist could identify BXO safely. Dabljuh 12:56, 15 January 2006 (UTC)
Pathologists are specialists in identification of such things. In cases of doubt, a dermatologist would likely take a biopsy and send it to pathology for identification. Secondly, if the foreskins had been retracted there would be no indication for circumcision. Identification of congenital phimosis implies that when tested, the foreskin could not be retracted. Also, BXO is thought to be very rare, but several authors have suggested that's because foreskin tissue is rarely sent to pathology after circumcision. See Balanitis xerotica obliterans#Etiology and epidemiology for more info. Lastly, you're not quite correct. BXO is probably LSA when it applies to the glans or foreskin, but nobody is quite certain. Jakew 13:21, 15 January 2006 (UTC)
You are certainly right. But I would like to point out, that the mere fact that they regarded congenital phimosis as something that requires treatment, somewhat discredits the whole study, when viewed in the light that the (modern) medical consensus does not regard congenital phimosis as something to be treated (And explicitely warns against attempting to "treat" it) Dabljuh 13:26, 15 January 2006 (UTC)
I disagree. Although congenital phimosis is frequently harmless, it can be a problem in some cases. The fact that 82% had an inflammatory disease is a clue that the boys were suffering pain. I very much doubt that any (competent) doctor would suggest that a painful condition should go untreated. Jakew 13:36, 15 January 2006 (UTC)

Here's the credits:

G. Mattioli , P. Repetto A1, C. Carlini A1, C. Granata A1, C. Gambini A2, V. Jasonni A1
A1 Department of Pediatric Surgery, University of Genoa and Gaslini Research Institute, Genova, Italy
A2 Department of Pathology, University of Genoa and Gaslini Research Institute, Genova, Italy
A3 Department of Pediatric Surgery, Giannina Gaslini and Clinical Institute, Largo G. Gaslini 5, 16100 Genova, Italy

No department of dermatology was involved. That casts additional doubt onto this study, that claims to determine BXO/LSA rates in infants. In addition to that, its an italian study, and the italians, tbh, do not exactly represent the current state of medicine. I would recommend dismissing the study as inconclusive.

On a sidenote: I have so far explicitely not added a "Phimosis/BXO" section to my version of the circumcision article as I am afraid I might treat the topic unfairly due to bias towards the overdiagnosis of phimosis. Since you're qualified, I would like you to write the section in question. Dabljuh 13:42, 15 January 2006 (UTC)

Never mind that then, lets overhaul the whole article as described here. Dabljuh 15:31, 15 January 2006 (UTC)
Ok. Looks to me like you just don't want to accept the findings, and you're willing to use whatever excuse you can think of. Were this not the case, you'd see pathology and realise that is the field of medicine specialising in tissue analysis and the diagnosis of disease from that basis. Furthermore, every expert on BXO strongly recommends biopsy and histological analysis, which unfortunately is rarely done, but is precisely what these guys did. But frankly I don't see much point in continuing this discussion now.
As I've explained before, I'm not interested in working on a POV fork of the circumcision article. If you'd like to work on the main article, I'm happy to assist. Jakew 15:36, 15 January 2006 (UTC)
Maybe you are right with your assessment. Still, the abstract does not contain enough information to correctly interpret and judge the study's methology for it's value, everything else is merely speculation. A BXO rate of 30% in normal infants is simply absolutely unrealistic. Dabljuh 16:06, 15 January 2006 (UTC)
That's just it: these aren't normal infants. They are boys with a problem. You've indicated above that you're biased towards overdiagnosis, so please make a conscious effort to overcome this. Now, what's so implausible about the idea that physicians, in a country familiar with foreskins, are correctly diagnosing phimosis in boys when it is actually a real problem, and then finding that such a problem is caused by BXO more frequently than had previously been thought? Jakew 16:15, 15 January 2006 (UTC)
Because that would contradict everything we know about BXO, about its occurance rates, about congenital phimosis and pathologic phimosis, about the near impossibility to diagnose pathological phimosis in infants, about the scientific consensus that circumcision is not a medical procedure and only indicated in very few cases. So, either they are wrong, or the AAP, CPS, RACP, AAPS, well, pretty much everyone else then. What is the unbiased way to judge this study? Dabljuh 16:27, 15 January 2006 (UTC)
Please would you give an example of what is 'known' about BXO and its prevalence, and how this study contradicts it. Also, please give an example of where the AAP etc state that therapeutic (as opposed to routine) circumcision is not a medical procedure. Please also give an example of the AAP etc stating that it is nearly impossible to diagnose pathological phimosis in infants. Jakew 16:42, 15 January 2006 (UTC)

First of all, the AAP does not exclusively represent the scientific consensus. The scientific consensus is within a range. But maybe we misunderstand each other: "That's just it: these aren't normal infants. They are boys with a problem." <- Exactly. But what *is* their problem? It is not described in the abstract. All that's said is: "115 boys, 55 with congenital phimosis, 45 with acquired phimosis, 13 with hypospadias, and 2 with recurrent chronic balanitis". How were they selected? Why did they investigate boys with congenital phimosis, as, in contrast to, how do infant boys get acquired phimosis? How is it diagnosed? Without information like that, I find it impossible to infer any statistical data on a general population, or in fact, just on anything. I fail to see any meaning in this abstract, without further details. Yesterday I have talked to two guys, one had a red hat, one had a blue hat. I infer that of all guys who have hats, 50% are red.

So what exactly are we *learning* from this study? Nothing, as far as I can tell, I must say with regret. Dabljuh 17:13, 15 January 2006 (UTC)

[edit] "Intact" vs. "Uncircumcised"

Incorrect use of Language? Yes, there certainly is! I don't feel that the choice of words is an issue of political correctitude, but rather a question of accuracy. Using the term "uncircumcised" to describe an intact, natural, normal penis perpetuates the typically American, myopic misconception that a penis with its foreskin surgically amputated is natural or normal, when the exact opposite is true. "Uncircumcised" clearly implies to the reader that the surgically altered penis is medically normal. Would one call a man with both arms a non-amputee? In countries where genital mutilation is uncommon, or even illegal, a circumcised or "cut" penis is unquestionably viewed as abnormal and unnatural. I think it all depends on how one wishes to see himself.--MrEguy 10:24, 15 November 2006 (UTC)

[edit] lack of diagrams

Without diagrams or images, it is hard to tell what the article is talking about. Jidanni 22:08, 18 October 2007 (UTC)