P R O T E C T
E X P E R T M E D I C A
L A D V I C E F O R P A R E N T S
B Y P A U
L M. F L E I S S
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 tis 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 experiece 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
doctor or anyone else
try to retract your
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 quanitities 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
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 chorinated
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
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
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
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 physicion, 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
Your son has a urinary
tract infection (UTI) and needs to be circumcised to prevent it from
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
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
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.
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
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):
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
If your physician or health care provided ever recommends that your
child be circumcised, get another opinion from a physician. For help
finding one in your area, contact:
National Organization of Circumcision Information Resource Centers
(NOCIRC) PO Box 2512, San Anselmo, CA 94979-2512. 415-488-9883 Fax:
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
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 Vanguard,
Illingworth, Ronald S. The Normal Child: Some Problems of the
Early Years and Their Treatment. Tenth Edition. Churchill Livingstone,
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,
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." Urology 48 (1996):
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.