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Psychological Factors in Hypospadias Repair
Vol. 113, May Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1975 by The Williams & Wilkins Co.
PSYCHOLOGICAL FACTORS IN HYPOSPADIAS REPAIR MARY ROBERTSON AND DIXON WALKER*
From the Departments of Psychiatry and Surgery/Urology, University of Florida School of Medicine, Gainesville, Florida
ABSTRACT
Children undergoing hypospadias repair and their parents have anxieties related not only to the operation but to future expectations. These anxieties are expressed by children through their drawings and by parents through interviews. They are enhanced by the fact that the hypospadias defect is only noticeable to the parents and child and is kept as secret information. Other defects, such as cleft palate, are obvious and cannot be hidden. The anxieties associated with hypospadias appear to be different when compared to those associated with more obvious deformities. A congenital defect of the penis requiring hypospadias repair may result in psychological scarring before the operation, which may continue after full surgical recovery. At the time of operation the child has certain expectations and apprehensions. These expectations and apprehensions are related to the aspirations of the parents as well as the child's fears. In the case of a congenital defect of the penis the child may define his role as an inability to urinate like other boys, while his parents may define his role differently. Our study was undertaken to examine the psychological factors in hypospadias repair in relationship to the child undergoing an operation and to the parents. It was hypothesized that the anxieties of children with hypospadias differed from the anxieties of their parents. HISTORICAL REVIEW
Edelston has documented that hospitalization of children involves many factors. 1 Some of these factors existed prior to hospitalization and some are related to the hospitalization. The potentially serious consequences of children separated from their parents by the process of hospitalization have been described previously. i-s The event of hospitalization of infants or small children has the effect of producing crying, a form of mourning and, if uninterrupted, a serious depression. However, there are congenital defects that the child has had from birth and involve psychological factors unrelated to hospitalization. Gluck and associates report on the heavy psychological burden cleft palate children carry, as compared to a group of child guidance subjects.' A child with a congenital defect, such as hypospadias, is likely to experience separation anxiety, Accepted for publication August 2, 1974. Read at annual meeting of American Academy of ·Pediatrics, Chicago, Illinois, October 20-25, 1973. * Requests for reprints: Division of Urology, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida 32610.
as most hospitalized children do. In addition, as Gluck suggests of cleft palate children, the child carries a heavy psychological burden because of the congenital defect. This psychological burden may be related to his guilt feelings because he needs to be hospitalized for an operation or the psychological burden may relate to the child's awareness of the parents' anxieties which he may not understand although the patient recognizes that there is an anxiety in relationship to himself. He may not know what the anxiety is when the congenital defect is a defective penis rather than a defect such as a cleft palate which is apparent to everyone. PROCEDURE
Eleven boys between 2 and 11 years old admitted to the Shand's Teaching Hospital for repair of hypospadias were interviewed and tested. A comparison group of 11 boys with a cleft palate was also studied. The parents of both groups were interviewed, using an open ended interview, in which they were asked, "What worries you most about your son"? and "What else worries you"? Since children are less able to express the complexity of their anxieties, the Robertson Auditory Projective Test was administered to both groups. In this test auditory stimuli are used to elicit imagery. The subjects then report their imagery by drawing the picture they experience and by describing it. The children were also asked what they worried about and were encouraged to discuss any anxieties they experienced. The cleft palate population was examined at the cleft palate clinic. The hypospadias patients were seen in the hospital 1 day preoperatively. RESULTS
The results indicate that parents of children with hypospadias have maleness anxiety as the primary concern for their children (table 1). The anxieties surrounding the operation are minimal.
698
699
PSYCHOLOGICAL FACTORS IN HYPOSPAD!AS REPAIR
1. Comparison of anxieties expressed by parents of children undergoing either cleft palate or hypospadias repair
TABLE
Present Anxiety
Future Anxiety
(%)
(%)
7
100
42
10
40
90
No. Pts. Parents of cleft palate patients Parents of hypospadias patients
(All parents interviewed stated that the congenital defect and the surgical procedures were well explained by the surgeon.) The parents of children with a cleft palate expressed anxiety about the immediate adjustment of their children. "Will he speak alright?", "Will other children tease him?" The children's anxieties were not usually expressed directly but were projected into their drawings. The drawings suggest an inner awareness of anxieties related to the penis which the child often is unable to express in words (fig. 1). This anxiety, expressed in drawings, was a more prevalent way of expression of anxiety in children between 2 to 6 years old. the drawings of 30, 3 and 4-year-old in a non-clinical population, only 3 subjects drew phallic-like symbols.) Table 2 compares the types of pictures drawn by children with hypospadias to those drawn by children with a cleft palate. Almost all of the younger children with hypospadias express an inner anxiety in the pictures they drew. This concept is supported the high incidence of phallic symbols in their drawings and the absence of phallic symbols from children with a cleft palate.
TABLE
2. Comparison of symbols expressed in drawings
in Robertson. Auditory Projective Test No. Pts.
Phallic Symbols
Non-Phallic Symbols
11 11
13 1
2:1 49
Hypospadias patients Cleft palate patients
In cases of hypospadias the parents and children have a secret (fig. 2). That secret relates to an imperfect penis and is not shared with friends 01 relatives. The child's anxiety is in the present and centers on urinating and fear of separation from parents. The parents' anxiety is in the future centers around maleness. In cases of cleft palate parents and children have no secret and their anxieties are m the present (fig. 3). DISCUSSION
Children with hypospadias have certain logical factors. There is a secret and secrets become distorted until fantasy and reality are easily separated. The parent may view the secret as a defect in themselves or as punishment for past misdeeds. The child may perceive the secret as indication that there are a multitude of defects within him including his angry thoughts. Secrets are known in families, although they are usually discussed by family members. This in turn results in a variety of distortions of the secret, each family member thinking the secret is as
CH I LD ANXIETY PRESENT
A DUL T ANXIETY FUTURE
I. PROWESS ANXIETY 2.SEPARATION ANXIETY
I. POTENCY 2.FERTILITY
FIG. 2. Interrelationship of anxieties of parents and children undergoing hypospadias repair.
B
CH I l D
ADULT NO SECRET ANXIETY
PRESENT
FIG. 1. Sample drawings from children undergoing A, hypospadias repair and B, cleft palate operation.
FIG. 3. Interrelationship of anxieties of parents children undergoing cleft palate repair.
700
ROBERTSON AND WALKER
perceived by him or her. The more a secret is hidden the more anxious the family becomes that someone will find out the secret. The boy with a congenital defect of the penis may initially experience anxiety about the secret because he has to sit to urinate and he does not want to be discovered in what he may view as a feminine position for urinating. At a little older age as boys demonstrate their prowess at urinating certain distances, the secret may again be kept as the boy refrains from entering into competition with other boys. A secret kept is a secret that accumulates other anxieties that were not initially related to the secret. Hospitalization has been documented as often precipitating separation anxiety in the infant or small child but hospitalization in the case of a child with a defective penis also causes maleness anxiety in parents. Congenital defects, whether they are related to sexual prowess or to other factors, often elicit guilt feelings in parents and children. An operation is normally attempted when the child is 3 years old. Children do not separate easily at this age. Successive hospitalization reinforces the fears of the surgical events related to the penis and it reinforces anxiety about the separation from the familiar environment and from the family. The parents are anxious but their anxiety centers in the area of maleness anxiety. Will our son be impotent? Will our son be sterile? The child reflects these anxieties although not comprehending them, for children read anxieties well. Adults may not express their anxieties because they may feel
partially responsible for their child's condition unless an atmosphere of understanding and clarification is prevalent. The surgical procedures the parents learn about easily, the psychological factors relating to the child's condition they are less able to handle. It is their secret and secrets are relinquished reluctantly. REFERENCES
1. Edelston, H.: Separation anxiety in young children: a
2.
3.
4.
5. 6.
study of hospital cases. Genet. Psych. Monogr., 28: 3, 1943. Bowlby, J., Robertson, J. and Rosenbluth, D.: A two year old goes to hospital. In: The Psychoanalytic Study of the Child. Edited by R. S. Eissler, A. Freud, H. Hartmann and E. Kris. New York: International University Press, Inc., vol. 7, No. 5, pp. 82-94, 1945. Spitz, R. A.: Hospitalism: an inquiry into the genesis of psychiatric conditions in early childhood. In: The Psychoanalytic Study of the Child. Edited by R. S. Eissler, A. Freud, H. Hartmann and E. Kris. New York: International University Press, Inc., vol. 1, pp. 53-74, 1945. Gluck, M., McWilliams, B., Wylie, H. L. and Conkwright, E.: Comparison of clinical characteristics of children with cleft palates and children in a child guidance clinic. Perceptual and Motor Skills, 21: 806, 1965. Spitz, R. A. and Wolf, K. M.: The smiling responses: a contribution to the ontogenesis of social relations. Genet. Psych. Monogr., 34: 57, 1946. Bakwin, H.: Hospital care of infants and children. J. Pediat., 39: 383, 1951.
THE JOURNAL OF UROLOGY
Copyright© 1975 by The Williams & Wilkins Co.
PSYCHOLOGICAL FACTORS IN HYPOSPADIAS REPAIR MARY ROBERTSON AND DIXON WALKER*
From the Departments of Psychiatry and Surgery/Urology, University of Florida School of Medicine, Gainesville, Florida
ABSTRACT
Children undergoing hypospadias repair and their parents have anxieties related not only to the operation but to future expectations. These anxieties are expressed by children through their drawings and by parents through interviews. They are enhanced by the fact that the hypospadias defect is only noticeable to the parents and child and is kept as secret information. Other defects, such as cleft palate, are obvious and cannot be hidden. The anxieties associated with hypospadias appear to be different when compared to those associated with more obvious deformities. A congenital defect of the penis requiring hypospadias repair may result in psychological scarring before the operation, which may continue after full surgical recovery. At the time of operation the child has certain expectations and apprehensions. These expectations and apprehensions are related to the aspirations of the parents as well as the child's fears. In the case of a congenital defect of the penis the child may define his role as an inability to urinate like other boys, while his parents may define his role differently. Our study was undertaken to examine the psychological factors in hypospadias repair in relationship to the child undergoing an operation and to the parents. It was hypothesized that the anxieties of children with hypospadias differed from the anxieties of their parents. HISTORICAL REVIEW
Edelston has documented that hospitalization of children involves many factors. 1 Some of these factors existed prior to hospitalization and some are related to the hospitalization. The potentially serious consequences of children separated from their parents by the process of hospitalization have been described previously. i-s The event of hospitalization of infants or small children has the effect of producing crying, a form of mourning and, if uninterrupted, a serious depression. However, there are congenital defects that the child has had from birth and involve psychological factors unrelated to hospitalization. Gluck and associates report on the heavy psychological burden cleft palate children carry, as compared to a group of child guidance subjects.' A child with a congenital defect, such as hypospadias, is likely to experience separation anxiety, Accepted for publication August 2, 1974. Read at annual meeting of American Academy of ·Pediatrics, Chicago, Illinois, October 20-25, 1973. * Requests for reprints: Division of Urology, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida 32610.
as most hospitalized children do. In addition, as Gluck suggests of cleft palate children, the child carries a heavy psychological burden because of the congenital defect. This psychological burden may be related to his guilt feelings because he needs to be hospitalized for an operation or the psychological burden may relate to the child's awareness of the parents' anxieties which he may not understand although the patient recognizes that there is an anxiety in relationship to himself. He may not know what the anxiety is when the congenital defect is a defective penis rather than a defect such as a cleft palate which is apparent to everyone. PROCEDURE
Eleven boys between 2 and 11 years old admitted to the Shand's Teaching Hospital for repair of hypospadias were interviewed and tested. A comparison group of 11 boys with a cleft palate was also studied. The parents of both groups were interviewed, using an open ended interview, in which they were asked, "What worries you most about your son"? and "What else worries you"? Since children are less able to express the complexity of their anxieties, the Robertson Auditory Projective Test was administered to both groups. In this test auditory stimuli are used to elicit imagery. The subjects then report their imagery by drawing the picture they experience and by describing it. The children were also asked what they worried about and were encouraged to discuss any anxieties they experienced. The cleft palate population was examined at the cleft palate clinic. The hypospadias patients were seen in the hospital 1 day preoperatively. RESULTS
The results indicate that parents of children with hypospadias have maleness anxiety as the primary concern for their children (table 1). The anxieties surrounding the operation are minimal.
698
699
PSYCHOLOGICAL FACTORS IN HYPOSPAD!AS REPAIR
1. Comparison of anxieties expressed by parents of children undergoing either cleft palate or hypospadias repair
TABLE
Present Anxiety
Future Anxiety
(%)
(%)
7
100
42
10
40
90
No. Pts. Parents of cleft palate patients Parents of hypospadias patients
(All parents interviewed stated that the congenital defect and the surgical procedures were well explained by the surgeon.) The parents of children with a cleft palate expressed anxiety about the immediate adjustment of their children. "Will he speak alright?", "Will other children tease him?" The children's anxieties were not usually expressed directly but were projected into their drawings. The drawings suggest an inner awareness of anxieties related to the penis which the child often is unable to express in words (fig. 1). This anxiety, expressed in drawings, was a more prevalent way of expression of anxiety in children between 2 to 6 years old. the drawings of 30, 3 and 4-year-old in a non-clinical population, only 3 subjects drew phallic-like symbols.) Table 2 compares the types of pictures drawn by children with hypospadias to those drawn by children with a cleft palate. Almost all of the younger children with hypospadias express an inner anxiety in the pictures they drew. This concept is supported the high incidence of phallic symbols in their drawings and the absence of phallic symbols from children with a cleft palate.
TABLE
2. Comparison of symbols expressed in drawings
in Robertson. Auditory Projective Test No. Pts.
Phallic Symbols
Non-Phallic Symbols
11 11
13 1
2:1 49
Hypospadias patients Cleft palate patients
In cases of hypospadias the parents and children have a secret (fig. 2). That secret relates to an imperfect penis and is not shared with friends 01 relatives. The child's anxiety is in the present and centers on urinating and fear of separation from parents. The parents' anxiety is in the future centers around maleness. In cases of cleft palate parents and children have no secret and their anxieties are m the present (fig. 3). DISCUSSION
Children with hypospadias have certain logical factors. There is a secret and secrets become distorted until fantasy and reality are easily separated. The parent may view the secret as a defect in themselves or as punishment for past misdeeds. The child may perceive the secret as indication that there are a multitude of defects within him including his angry thoughts. Secrets are known in families, although they are usually discussed by family members. This in turn results in a variety of distortions of the secret, each family member thinking the secret is as
CH I LD ANXIETY PRESENT
A DUL T ANXIETY FUTURE
I. PROWESS ANXIETY 2.SEPARATION ANXIETY
I. POTENCY 2.FERTILITY
FIG. 2. Interrelationship of anxieties of parents and children undergoing hypospadias repair.
B
CH I l D
ADULT NO SECRET ANXIETY
PRESENT
FIG. 1. Sample drawings from children undergoing A, hypospadias repair and B, cleft palate operation.
FIG. 3. Interrelationship of anxieties of parents children undergoing cleft palate repair.
700
ROBERTSON AND WALKER
perceived by him or her. The more a secret is hidden the more anxious the family becomes that someone will find out the secret. The boy with a congenital defect of the penis may initially experience anxiety about the secret because he has to sit to urinate and he does not want to be discovered in what he may view as a feminine position for urinating. At a little older age as boys demonstrate their prowess at urinating certain distances, the secret may again be kept as the boy refrains from entering into competition with other boys. A secret kept is a secret that accumulates other anxieties that were not initially related to the secret. Hospitalization has been documented as often precipitating separation anxiety in the infant or small child but hospitalization in the case of a child with a defective penis also causes maleness anxiety in parents. Congenital defects, whether they are related to sexual prowess or to other factors, often elicit guilt feelings in parents and children. An operation is normally attempted when the child is 3 years old. Children do not separate easily at this age. Successive hospitalization reinforces the fears of the surgical events related to the penis and it reinforces anxiety about the separation from the familiar environment and from the family. The parents are anxious but their anxiety centers in the area of maleness anxiety. Will our son be impotent? Will our son be sterile? The child reflects these anxieties although not comprehending them, for children read anxieties well. Adults may not express their anxieties because they may feel
partially responsible for their child's condition unless an atmosphere of understanding and clarification is prevalent. The surgical procedures the parents learn about easily, the psychological factors relating to the child's condition they are less able to handle. It is their secret and secrets are relinquished reluctantly. REFERENCES
1. Edelston, H.: Separation anxiety in young children: a
2.
3.
4.
5. 6.
study of hospital cases. Genet. Psych. Monogr., 28: 3, 1943. Bowlby, J., Robertson, J. and Rosenbluth, D.: A two year old goes to hospital. In: The Psychoanalytic Study of the Child. Edited by R. S. Eissler, A. Freud, H. Hartmann and E. Kris. New York: International University Press, Inc., vol. 7, No. 5, pp. 82-94, 1945. Spitz, R. A.: Hospitalism: an inquiry into the genesis of psychiatric conditions in early childhood. In: The Psychoanalytic Study of the Child. Edited by R. S. Eissler, A. Freud, H. Hartmann and E. Kris. New York: International University Press, Inc., vol. 1, pp. 53-74, 1945. Gluck, M., McWilliams, B., Wylie, H. L. and Conkwright, E.: Comparison of clinical characteristics of children with cleft palates and children in a child guidance clinic. Perceptual and Motor Skills, 21: 806, 1965. Spitz, R. A. and Wolf, K. M.: The smiling responses: a contribution to the ontogenesis of social relations. Genet. Psych. Monogr., 34: 57, 1946. Bakwin, H.: Hospital care of infants and children. J. Pediat., 39: 383, 1951.