By Paul M. Fleiss

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 up 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 boy. 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 the foreskin of your intact boy 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 circumcision. After each incorrect statement, I've given the medical facts to help you understand what your doctor may not know about the intact penis and its 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 experience 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 protective function 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 child's foreskin must be retractable. Do not let your doctor or anyone try to retract your child's foreskin. Optimal hygiene of the penis demands that the foreskin of infants and children be left alone. Premature retraction rips the skin 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.

-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 up to two decades to complete. By the end of puberty, the foreskin will have detached from the glans because hormones that are produced in great quantities 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 glans should be broken so that your son can retract his foreskin. This procedure is called synechotomy. To perform it, the doctor pushes a blunt metal probe under the foreskin and forcibly rips it from the glans. It's as painful and traumatic as having a metal probe stuck under your fingernail to pull if 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 be separated from the glans in childhood. If any doctor suggests this procedure for your son, firmly refuse, stating, "Leave it alone!"

-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 be chapped instead. Chapping is most often caused by ov erly chlorinated 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 urinary meatus.

Circumcision will have no effect on diaper rash. Change your baby's diapers 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 that is all they have to pull on. Little boys sometimes will adjust the position of their penis in their underpants. They will also 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 just as you would any other part of the body.

If the real fear is of masturbation, calmly remind yourself of the simple, natural fact that all children will explore their bodies, including their genitals. Touching their genitals gives children a pleasant feeling and relaxes them. Classic anatomical studies demonstrate that the foreskin is the most pleasurably sensitive part of the penis. 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's based on the false idea that infants and young children don't 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.

-Since your son is having anesthesia for another operation, we'll just go ahead and circumcise him.

Most parents are never told that their son is in danger of being circumcised during a tonsillectomy or surgery for a hernia or an undescended testicle. It would never occur to them. If your child is going into the hospital for any reason, be certain that you tell the physician, 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 do 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 these 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.

-Your son has a urinary tract infection (UTI) and needs to be circumcised to prevent it from happening again.

The belief that the foreskin slightly increases the chances of a boy having a 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 lacerations 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 it 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 are prescribing steroid creams for phimosis, but this is unnecessary in children, since the foreskin does not need to be retractable 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 still have a foreskin that is attached to the glans or a foreskin with such a narrow opening that the glans cannot 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 if 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 sclerosus et atrophicus (LSA). BXO can appear anywhere on the body, but if this disorder affects the foreskin, it may turn the opening of the foreskin 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 a 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 and 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 is, 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 as infants.6

Occasionally, a circumcised father will state that he wants his child circumcised because he thinks 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 affection.

Sadly, some fathers who have been circumcised have an unhealthy attitude and 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 sons 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 own penis is missing can be so disturbing that they will do anything to block them out.

A father who forcibly circumcises his 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 his 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 saf est, 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 the 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's old enough, he will enjoy taking care of his own body. After all, it's his business. Just relax and avoid worrying about your son's intact penis. Remind yourself that the foreskin is a normal and natural part of the body. If European boys grow up healthy and unconcerned with their 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 1989): 598-599.

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): e54.

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. Stephenson, "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.: Bergan & Garvey, 1985).

If your physician or healthcare provider ever recommends that your child be circumcised, get another opinion from a physician who understands the important functions of the foreskin, no matter how "urgent" the situation may be. 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: 415-488-9660.

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.

Another resource especially for nurses:
Nurses for the Rights of the Child. 369 Montezuma #354, Santa Fe, NM 87501. 505-989-7377.

For information about alternative bris for Jewish parents:
Circumcision Resource Center. Ronald Goldman, PhD. PO Box 232, Boston, MA 02133. 617-523-0088.

One of the best sources of information on the Internet:
The Circumcision Information and Resource Pages.

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, 1996.

Illingworth, Ronald S. The Normal Child: Some Problems of the Early Years and Their Treatment. Tenth edition. Churchill Livingstone, 1991.

O'Mara, Peggy, ed. Circumcision: The Rest of the Story. Mothering, 1993.

Ritter, Thomas, and George C. Denniston. Say No to Circumcision! Second edition. Hourglass, 1996.

Books of special interest for Jewish parents: Goldman, Ronald. Questioning Circumcision: A Jewish Perspective. Vanguard, 1997.

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. ******, and M. G. Packer. "Reduction of Paraphimosis with Hyaluronidase." Urology 48 (1996): 464-465.

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 Coricosteroids 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.

For more information about circumcision, see the following article in a past issue of Mothering: "The Case against Circumcision," no. 85.

Paul M. Fleiss, MD, MPH, is assistant clinical professor of pediatrics at the University of Southern California Medical Center and is in private pediatric practice in Los Angeles, California. He is the author of numerous scientific articles published in leading national and international medical journals.

From Mothering Magazine, Issue 103, November/December 103