Just wanted to post this for others if they ever need to send a similar letter.
"Dear Dr. W:
On 18 July 2011 you provided care for my son’s 6-month well child visit. I found you to be warm, caring, and helpful, and I want to thank you for the professionalism you showed during the visit.
There was one aspect of the visit that concerns me. My son is intact, and during the check of his genital area, you attempted to manipulate his foreskin backwards towards the shaft while asking, “Are there any adhesions?” This was despite my holding my son’s penis with my fingers and repeating, “No retraction!” three times or more. We had already discussed the fact that my son’s urine stream flows straight and freely prior to the genital exam. I am concerned that even with this level of vigilance from his mother, my son was still in danger of forcible retraction or manipulation at the hands of his doctor. I can only assume that other intact boys have their foreskins retracted or manipulated during well-child visits.
In virtually all intact male infants, the foreskin is adhered to the glans by way of synechiae, which are the normal physiological attach points of the foreskin to the glans in the infant. This attachment is similar to the way that the fingernail is adhered to the nail bed, or the way a kitten’s eyes are fused shut at birth. In virtually all males, the synechiae will naturally desquamate over time, and the foreskin will naturally separate from the glans. There is no specific age by which desquamation should or must occur, and wide variation exists from toddlerhood to the teenage years. In a very small percentage of adults, the foreskin never becomes retractable; if this occurs and if the adult male would prefer a retractable foreskin, non-surgical alternatives exist to loosen the synechiae and induce retraction. However, because virtually all males will become retractable by adulthood, the risks of routine premature retraction or manipulation of the fused foreskin of all boys outweigh any possible benefit to the very small percentage of males who would not have otherwise become retractable on their own with time and who would prefer to be.
Premature retraction or manipulation of any kind of the fused foreskin backward toward the shaft of the penis can cause tearing of the synechiae. This tearing apart of the tissues causes pain, opens a wound, can introduce pathological bacteria into the delicate area between the foreskin and the glans, and can cause the development of scar tissue and true adhesions. Adhesions are a pathological consequence of forced or premature retraction or manipulation of the fused foreskin, when scar tissue adheres the foreskin to the glans at the site of tissue damage from the forced retraction or manipulation. The infant foreskin that has not been manipulated or retracted does not have adhesions, only synechiae, and there is no reason for anyone, including a medical provider, to check for their presence. Similarly, there is no medical reason for a boy’s foreskin to be retracted for “cleaning.” Like the vagina, the intact penis is a self-cleaning organ. The first person to retract a boy’s foreskin should be the boy himself, never a care provider. After a boy has become retractable, it is sufficient for him to retract himself during bathing and rinse with water or wash, if desired, with mild soap and water.
I have enclosed a copy of current guidelines for proper care of the intact penis from the American Academy of Pediatrics and the American Academy of Family Physicians. I have also included several educational brochures for your education and possible dissemination to parents of your intact patients. I have included digital links for some of these brochures below, so that they can be printed with high-quality materials for dissemination; for the rest I can provide a digital file if you desire. I would appreciate if this topic could be reviewed and shared with all doctors and practitioners at XYZ pediatrics.
I would be happy to discuss this topic with you if you have any questions or concerns. I can be reached on my cell at ###. Thank you again for the care you continue to provide to my children.
Encl: 1. “Care of the Uncircumcised Penis” from AAP; http://www.growingchildpediatrics.com/pdf/UncircumcisedPenis.pdf
2. “Circumcision” from FamilyDoctor.org, AAFP; http://familydoctor.org/online/famdocen/home/men/reproductive/042.printerview.html
3. “The Development of Retractile Foreskin in the Child and Adolescent” from Doctors Opposing Circumcision; http://www.doctorsopposingcircumcision.org/pdf/2008-03retractileforeskinleaflet.pdf
I'd be happy to hear any suggestions for improvement!
ETA: I posted the final letter a few posts down. It wasn't shorter, but I tried to use more neutral/supportive language. I figure that if the doctor is interested in learning, she'll read it.
Edited by Pirogi - 7/20/11 at 6:48am