B.M.J. Rejected Paper 01/2208
See also : The Importance of Monitoring Boys for Frenulum Breve and is the BMJ biased
The Value of Routinely Monitoring Boys for Phimosis Before Puberty
131 word ABSTRACT
The usual medical approach of monitoring and early prevention is of particular relevance to the subject of foreskin conditions. After monitoring and educating a group of boys for 7 years, Jacob Øster measured a 1% incidence of phimosis among adolescents. This is the lowest incidence recorded in the available medical literature. It appears an incidence of 1% can only be expected after 7 years monitoring and education. Interviews and correspondence show that young men with phimosis commonly experience embarrassment and distress during puberty and in early relationships. Boys must be monitored before puberty. Apart from allowing persistent problems to be treated in good time, monitoring provides a very practical education which will stimulatinge awareness and promote the simplest, cheapest form of treatment: the self manipulation which will often stretch a phimosis.
848 word TEXT
Our culture's health care usually emphasises monitoring and early prevention, except concerning the foreskin. Here, normal practice has become obscured and even overwhelmed by the debate for or against routine circumcision. It seems, routinely monitoring boys for foreskin conditions, is a practice which was last urgently recommended by Bokström in 1944, (who measured an incidence of 4.1% for phimosis among 20,361 army conscripts), and Schöberlein in 1966, (who measured 8.8% among 3,000 young men of 17 years old and over). 
In 1967 a revolutionary study showed that phimosis was not necessarily an indication for circumcision. After seven years annual monitoring and education of 1,968 schoolboys, Jacob Øster  recorded phimosis "with a diminishing incidence throughout the years, from 8% in 6-7 year-olds to 1% in 16-17 year-olds." (If we include his statistic for "tight foreskin" in the older group this gives 2.4%). Øster`s is the lowest recorded incidence for phimosis among adolescents in a reliable statistical survey in the available medical literature. Other studies record an incidence ranging between 3% and 14%. 
It is remarkable that since its publication, Øster`s is the only medical study whose statistics on phimosis among adolescents are ever quoted, (in the familiar European languages).  Øster wrote "Phimosis is seen to be uncommon in schoolboys, and the indications for operation even rarer if the normal development of the prepuce is patiently awaited." His conclusions on spontaneous retraction are widely recognised. 
It is astounding that neither Øster nor any subsequent writer has pointed out a correlation between his low statistical measurement and his seven years education and monitoring. It appears that an incidence of 1% can only be expected after seven years monitoring and education.
Beauge  reports that many young men with phimosis were helped by the instruction which he gave on foreskin retraction. This stands to reason, then young men with phimosis are often unaware of the possibility of retraction. Whether this is simply because their foreskin is impossible to retract or as a result of avoiding potential pain or difficulty, the sufferer has grown used to himself with the foreskin forward and does not possess the necessary initiative to attempt a self regulation of the problem. It is clear that education and monitoring stimulate awareness, and this promotes the self manipulation which is often necessary to stretch a phimosis.
Interviews and correspondence concerning the sexual experience of young men with phimosis  show the importance of early monitoring. Phimosis or an inability to freely retract the foreskin, in its pathological form is caused principally by either the phimotic ring and/or frenulum breve. There are numerous degrees and combinations of frenular-phimotic conditions each causing specific physiological effects, and because these conditions are less elastic and do not stretch to the same extent as the surrounding foreskin, the physiological effects become more pronounced during erection.
Some conditions are infibulating, some are mildly irritating, others are extremely painful. By definition all involve some restriction on the freely retractable foreskin with inevitable behavioural limitations during masturbation. After questioning several hundred 18 - 22 year olds with phimosis, Beauge  described the truly "conditioned" methods of masturbation used by men with phimotic ring.
Beauge added "From the interviews it appears that the great majority of these subjects are virgin, and that among those who have had sexual experience, many have failed, with difficulty in penetration, pain and loss of erection". Phimosis commonly causes embarrassment and distress during puberty and in early relationships, inhibiting a normal and healthy physical expression of natural desires and emotions. This can become especially disturbing in those cases who are not even aware of the possibility of retraction, due to a displacement of the actual problem and the consequent disorientation. 
Clearly there are far greater problems with phimosis than has been generally recognised, however, when confronted at their origins, most complex problems reveal a simple solution: in accordance with our cultures usual modern principles of monitoring, education and early prevention, boys must be monitored before puberty.
In order to monitor, with respect to the saying 'The fortunate foreskin of an infant boy will usually be left well alone by everyone but its owner', the boy himself must be asked to retract his own foreskin. If response is not forthcoming or if the attempt is unsuccessful, it would be exemplary of modern attitudes to first describe the possibility of foreskin retraction and then give the boy a little time to digest the idea before offering any further advice. This in itself would be a big first step for many boys, showing due respect for the youngster`s privacy, at the same time as demonstrating the maturity of an enlightened culture to discuss such problems openly.
Apart from allowing persistent problems to be treated in good time before puberty, routinely monitoring boys for foreskin conditions has special value as an early preventative measure. Monitoring provides a very practical form of education. This will not only dismiss the possibility of boys growing up in ignorance, but also it will stimulate the most natural (and cheapest) method of treatment: self manipulation and stretching.
(1) Encyclopedia of Phimosis Statistics: https://www.male-initiation.net/statistics.html
(2) Øster J., Further Fate of the Foreskin Archives of Disease in Childhood (BMA), April 1968;43:200-203.
(3) Twelve Studies since 1980 quoting and misquoting Øster https://www.male-initiation.net/library/medicus/refs_oster.html
(4) Beauge M., Traitment Medical du Phimosis Congenital de L'adolescent Thesis for the University Diploma of Andrology. Faculty of Medicine, Saint-Antoine University. Paris V1. University Year 1990-1991 translated by Dr. J.P. Warren http://www.cirp.org/library/treatment/phimosis/beauge/
(5) The Passages to Manhood: Part Three "Adult Initiations" case histories compiled by R. Stuart https://www.male-initiation.net/passages.html#adult