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Doctors Opposing Circumcision
Physicians Guide to the Normal (Intact) Penis

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Most American medical schools have not yet included information about the prepuce in their curricula, so most American medical doctors are ignorant of the most basic information regarding the prepuce of the human male. Drs. Thomas J. Ritter and George. C. Denniston were aware of this deficiency and addressed the problem by including an appendix for physicians in their highly informative landmark book, Doctors Re-examine Circumcision (2002). This file, provided for the enlightenment of physicians, contains that appendix. Used by permission.



Physicians Guide to the Normal (Intact) Penis

The material in this appendix has been requested by numerous American physicians because there is so much misinformation on this subject in the medical literature.

Introduction
The foreskin of the human male’s penis should not be removed at birth except in rare instances. In Finland, where the circumcision rate is zero at birth, the risk of needing the foreskin removed later is one in sixteen thousand, six hundred sixty seven (1/16,667), an extremely rare event!1 The prepuce is invariably normal and almost never requires removal.

The prepuce is an integral part of the human penis, as it is of all mammalian penises. This highly specialized region of mucous membrane and skin has several important functions. All of the reasons given to justify removal have turned out to be invalid. The risk of myriad complications far outweighs any alleged “benefits.” And no one else has the right to remove an important part of someone else’s body.


Care and Development of the Intact Penis
Proper hygiene for the intact male is extremely simple. Here are the basic rules.

1. Leave the Foreskin Alone!2
The major function of the foreskin during the early years is to protect the glans (head) and urinary opening. If the infant can urinate there is usually nothing to worry about.

2. Never permit anyone to retract the foreskin.
While it remains attached, the foreskin is the skin of the glans. It is there to protect the glans. Retraction can tear the attachment, producing pain, scarring, and disfigurement. When left alone, separation occurs naturally.

If a young man is unable to retract this foreskin as a teenager, it is still, although less common, perfectly normal.

3. When the child can fully retract his own foreskin comfortably, he may begin to do so in the tub or shower.
A little clear water, running over the retracted prepuce and exposed glans, is all the hygiene that is necessary. Let us look at these rules in more detail:

Leave the foreskin alone
The intact penis has a glans penis that is an internal organ. It is still fully covered with skin, and, at birth in 96% of male infants,11 the foreskin is incapable of full retraction without damaging the penis.

During intrauterine life, the foreskin completely covers and is inseparable from the glans penis. Before an infant is born, the process of separation from the glans begins, foreskins are still not fully retractable at puberty; a few continue to be non-retractable at the age of 17 years.

Never Permit Anyone to Retract the Foreskin
This warning is given to mothers and to anyone caring for a male infant. Numerous nurses and doctors, having failed to understand the normal penis, have been known to retract the foreskin forcibly.3 When this is done, the beautiful mechanism that protects the glans is threatened, and the skin is literally torn off the rest of the organ. The infant or child screams and scarring of the glans and prepuce results. Mothers need to warn doctors, nurses, and others, before an intact child is examined, not to retract. If forced retraction does occur, it may be treated with a topical steroid rather than circumcision.4

Forcible retraction of the prepuce by medical personnel has been cause for successful legal action.

Let the child Retract His Own Foreskin
Let the child retract his own foreskin over time, and, as it naturally becomes quite loose, hygiene will consist simply of running water over the glans and foreskin.


Prepuce “Problems” and How to Care for Them
“Patience and time! Patience and time!”5 A useful prescription for many penile problems.

Ammoniacal Dermatitis
If an infant develops a reddened foreskin, it may be an infection. Cutting through infected tissue to remove it is dangerous. More commonly, a reddened foreskin is ammoniacal dermatitis. Ammonia is produced by a specific bacterium in the infant’s feces, B. ammoniagenes. The ammonia causes the reddening, which may extend over the diapered area, and may include vesicles and papules with some excoriation. The lesions are stopped by treating the diapers with an antiseptic (mercuric chloride), which inhibits the ammonia-producing bacterium.6 Circumcision is contraindicated.

Allergy to Alkali in Soap
Another irritation of the foreskin may be stopped by discontinuing the use of soap. Simply wash the penis with warm water—nothing more—and with patience and time, the redness disappears.7 Circumcision is contraindicated.

Ballooning of the Foreskin
If, at any time during childhood, the opening remains small, while the urine stream is considerable, the foreskin may balloon, with urine under back pressure. This is normal, so long as urination is not markedly prolonged. Circumcision is contraindicated.

Decreased Urinary Stream
If the urine comes at as a mist, and urination is prolonged, steps may be taken to remedy the situation. A local anesthetic may be applied to the foreskin. After one hour, the foreskin is pulled forward until the urinary meatus is visualized. Then 1% hydrocortisone cream is sparingly applied six times a day for four weeks and once or twice a day for two weeks after that. Accompany this cream with gentle retraction, preferably by the boy himself. Circumcision is contraindicated.

Forced Retraction of A Tight Foreskin
(Paraphimosis)

Take care not to pull the still tight foreskin back beyond the base of the glans. If this is done, it acts like a tourniquet. Blood can get into the glans but it cannot easily get out. If this condition occurs, and is discovered promptly, the situation can easily be treated with gentle prolonged hand pressure using a well-lubricated glove, squeezing the glans gently until the blood is forced out of it, and the foreskin can be pulled over it.

Pinhole Opening in Foreskin
If one were to look gently for the opening in the tip of the infant foreskin, it is often found to be a “pinhole” in size. Yet, while the adult is still looking, and gently manipulating the penis, it is not uncommon for the infant to release a stream of urine. The size of the outlet becomes considerably larger than the visualized pinhole. This extraordinary disparity in the size of the opening, depending on whether pressure is applied from the outside or the inside, vividly documents the primary purpose of the foreskin at this time of life—that of protection, while still permitting function. The infant can urinate normally, but the pinhole opening is an effective part of the foreskin barrier.

Smegma
The white material that collects under the prepuce is called smegma. Smegma is formed as the result of a natural process. Skin is always renewing itself by sloughing off dead cells. Smegma is little more than those dead cells: like the material one obtains by scratching the forearm with a fingernail or collects between the toes. During childhood, smegma is a product of the process whereby the preputial space is formed.

In the child, smegma should be left alone. Much confusion arises while trying to determine when to retract the foreskin for cleansing.8 At such time as the child is able to retract his own foreskin comfortably, he can let water run over the penis. That is the full extent of hygiene required for a child’s and for an adult’s penis.

Smegma tends to increase at puberty. This is perfectly normal.


The Functions of the Foreskin
The foreskin has several useful functions: It serves to protect the infant glans and urethra form feces and other sources of infection. In the infant and in the adult as well, the protecting foreskin prevents the thin mucous membrane surface of the glans from thickening. Without protection, the glans adds numerous layers of cells with consequent loss of sensitivity. When this thickening occurs around the urethral meatus, it produces meatal stenosis, or narrowing, a common complication of circumcision, often requiring further surgical intervention to open it.9 In addition, meatal ulceration with scarring is also common.

The foreskin eventually separates from the surface of the glans. During erection, the penile shaft elongates, becoming about 50% longer and the separated foreskin covers this lengthened shaft. It develops to accommodate the penis, which is capable of a marked increase in diameter and length. Removing the foreskin leads to tightness, discomfort, and even penile curvature.

In addition to its function in normal erection, the foreskin makes masturbation, now recognized as completely normal activity, easier and much more pleasurable.

The foreskin makes it easier for the male to enter the female. During entry, the foreskin slides back, as nature intended. This function may be compared to the rolling on of a condom. No one tries to pull an unrolled condom on. The friction is too great.

The foreskin has complex nerve endings, described by Taylor, which give a degree of sexual pleasure not experienced without it.10 Some twenty small concentric, circumferential ridges, collectively called the frenar band, carry specialized nerve endings back and forth across the corona of the glans, producing pleasure. One man, who had a circumcision after he had become sexually active, said: “Stimuli that had previously aroused ectasy now have relatively little effect.”

An intact foreskin, properly cared for, is a pleasure that all humans have a right to enjoy.


Intact Children Require Parental Protection:
“Leave my son alone!”

American parents with intact sons must realize that they may have difficulty while their sons are growing up in protecting them from mutilation. Sometimes doctors have difficulty protecting their own sons. In America today, parents of intact sons must remain alert.

The foreskin can cover the glans completely without ever being retractable. Though rare, this is perfectly normal. Many men prefer this to circumcision. Of course, it is more usual for the tip of the foreskin to gradually enlarge, and for the remaining attachment points between the foreskin and the glans to dissolve. By puberty, many boys have a fully retractable foreskin, which can easily be pulled back so the glans is fully exposed. There is no constriction, because the foreskin is now a wide channel.

At puberty, many boys cannot fully retract their foreskin. This is no cause for alarm. It is perfectly normal. By age 17, most boys can retract, but even then, non-retractability is not sufficient reason to circumcise.


Excuses that Doctors Use to Circumcise
Around 1860, doctors suggested that circumcision would prevent masturbation. As soon as that absurd idea was dismissed, they found another excuse. And so it continues…

Hygiene
Most Americans have rarely seen an intact penis. If they have, it has been the penis of an infant whose foreskin normally extends well beyond the tip of the glans and is gathered tightly around it. They have difficulty imagining that this foreskin, if left alone, will enlarge and expand with normal growth to become a loose-fitting arrangement during childhood. They scarcely realize that any intact male can gently pull his foreskin back and look as though he were circumcised. At that point, cleansing is identical for the circumcised and the intact.

Cancer of the Penis
Another excuse has been that circumcision prevents cancer of the penis. This type of cancer occurs in one in one hundred thousand (1/100,000) men. Who could reasonably suggest that circumcision should be done on all male infants to prevent this extremely rare cancer of the adult penis? For comparison, the risk of breast cancer is now about one in nine (1/9), yet no one suggests that we remove all female breasts at puberty to prevent his formidable disease.

Gairdner’s study was instrumental in stopping circumcision in Great Britain during the 1950s. His data showed there would be 15 infant deaths for circumcision per one hundred thousand circumcisions.11 Who wants to risk killing 15 infants to prevent one cancer of the penis in one older man?

Because of its rarity, is it not unethical to mention cancer of the penis as a “reason” for circumcising?

Urinary Tract Infection
Recently, the excuse for circumcising has been the alleged prevention of urinary tract infections. Thomas Wiswell, M.D., has claimed that 1% of intact boys get urinary tract infections. Even if we accept Wiswell’s facts, with which wiser doctors disagree, it is only 1% of intact infants who get urinary tract infections. No doctor should justify harming 100 infants to possibly protect one of them from an infection that is normally treated with antibiotics. All European doctors treat these infections without resorting to circumcision. In view of the extremely low incidence of urinary tract infection in the intact newborn, is it not unethical to mention UTI’s as a “reason” for circumcising?

Prevention of Sexually-Transmitted Diseases
(STDs)
In America, it is not customary for parents to decide how their children will conduct themselves sexually. Parents can neither predict, nor control, their children’s sexual behavior. Therefore, even if foreskin removal did prevent STDs, the intact young person might prefer to choose avoiding exposure.

The idea that circumcision might prevent STDs is ludicrous. Simply look at the incidence of STDs in a country (USA) that has a majority of its males circumcised! Rather, we should ask, can we prove that circumcision does not increase the risk of STD?

Cancer of the Cervix
An excellent paper by Terris demonstrates that there is no increased risk of cancer of the cervix in the partners of intact men.12 A physician in another study determined that the circumcision status of the partner (because the woman often did not know). (sic) No association between cancer of the cervix and circumcision status was found.13 In Europe, where circumcision is not performed, cancer of the cervix is not higher than in the U.S. Cancer of the cervix is simply another excuse for circumcision that has never been proven.

Do circumcision now, because it might have to be performed later
In Finland, the rate of post-neonatal circumcision is one in sixteen thousand six hundred sixty-seven men (1/16,667).14 This figure demonstrates how incredibly normal the foreskin is, and provides some indication of the vast number of unnecessary, indeed, contraindicated circumcisions still being done in the United States.

Phimosis
Phimosis is a normal condition of the human prepuce in young males. The word comes directly from the Greek and means “muzzling.” Its English definition is “A tightness or constriction of the orifice of the prepuce, arising either congenitally or from inflammation, congestion, etc. and making it impossible to bare the glans.” This, of course, is precisely what the prepuce does during the early years of life. The ending, “-osis,” according to Webster’s International Dictionary, means a suffix signifying “condition, state, process.” A condition of muzzling. Perfectly normal.

Dr. Peter Lord, Secretary of the Royal College of Surgeons, says, “…Phimosis does not occur with a healthy foreskin. A high proportion of small boys are not able to retract their foreskin until six, and sometimes later. ..no harm at all in leaving it unretracted at that age, unless of course there is recurrent infection [see Balanitis]. Usually by age five or six the little fellow is sufficiently interested in his anatomy to have done some exploring and to have found that he can retract. If, however, he falls into the hands of the School Doctor, or the District Nurse, he may be referred to the Surgeon with a view to circumcision for phimosis.15

Paraphimosis
Para comes from the Greek and means “associated in a subsidiary capacity.” Paraphimosis refers to the situation where a constricted prepuce is retracted, baring the glans. The constricted prepuce acts like a tourniquet on the penile shaft. With constriction, swelling of the glans occurs and gangrene could ultimately result, unless it is promptly reduced, as described in the section titled, “Forced retraction of tight foreskin.”

Balanitis
Literally, “inflammation of the acorn” or glans penis, diagnosis of balanitis requires redness, swelling and pus. Beware of the diagnosis of balanitis, which is not really balanitis, but simply irritation (redness) and normal smegma. Balanitis does not cause phimosis, and no single pathogen is involved. Usually a boy suffers only one episode.16 Balanitis may be treated by bathing in hot water, local washing, or like other infections—with antibiotics. In the case of candidal balanitis, Acidophilus culture is indicated and fungicides may be used.17 Balanitis has often been used as an excuse to circumcise.

Balanoposthitis
Inflammation of the glans and prepuce. Treatment consists of diagnosis of the offending organism(s), and appropriate antibiotic therapy, not removal of the organ.

Preputial Stenosis (Balanitis Xerotica Obliterans)
This rare disease of unknown etiology, which rarely occurs before age 5, exists only when there is cicatrization of the preputial orifice with histologic changes of balanitis xerotica obliterans (BXO). It is characterized by a thick, white fibrous ring around the prepuce, and by pale gray, parchment-like skin. There is thinning of the epidermis and replacement of the dermis with dense collagenous tissue infiltrated with chronic inflammatory cells. The epidermis separates easily from the dermis.18 This condition can be progressive. Since, in the adult, the likelihood of the progression of the disease to involve the anterior urethra may be increased by circumcision, since spontaneous regression may occur, and since the changes of BXO have been reversed by the local application of corticosteroids,19 it would be well to consider conservative treatment before resorting to circumcision.20 21

Preputial Adhesions
Under normal conditions, preputial adhesions do not exist. The prepuce is not adherent to the glans; the prepuce is the skin of the glans, initially attached just as tightly as the skin on one’s finger.

At approximately 17 weeks gestation, cells in the area of separation between the future foreskin and the glans initiate the process of creating the preputial space. They begin to form microscopic balls comprising multiple layers of cells. As these whorls of cells enlarge, cells at the center are cut off from nutrients; they die and create a space. Some boys will not have a fully retractable foreskin until after puberty.

The preputial space will inevitably become complete without outside interference. When a doctor begins a circumcision, he will usually take a probe, and run it around in this partially formed space, disrupting the attachments between the two organs, the prepuce and the glans. Now adhesions can truly form because raw surfaces remain on both organs after this disruption.

Redundant Foreskin
Sometime in the infant, the foreskin may seem excessive beyond the tip of the glans. This is perfectly normal because the entire organ is going to grow and change. In the boy, this so-called extra skin will begin to serve one of its most important functions. It slides down to cover the enlarging shaft of the penis during erection.

Hypospadias
Hypospadias refers to the urethral opening not existing at the tip of the glans, as it usually does, but below the tip, somewhere along the underside of the penis. This condition arises during a failure of normal development. Circumcision is contraindicated in such cases because urologic surgeons currently use the foreskin to make the repair.

Since it is virtually impossible to make the diagnosis until a circumcision is underway, or until time permits normal unforced retraction of the foreskin, circumcision should never be contemplated until the diagnosis can be made without risk of harming the child (through forcibly retracting the foreskin).

Further, since the prepuce may be required for repair and, since the concern here is with preserving the prepuce, repair of hypospadias, a cosmetic operation, should not be undertaken until the male is of age and able to give his fully informed consent. While urinating from the underside of the penis may be inconvenient, it should be his choice to put up with the inconvenience, rather than have an operation that severs sexually responsive nerves, and leaves him without a fully functioning prepuce during his adult life.

Chordee Without Hypospadias
The penis is bent downwards. This is usually an isolated skin chordee, but may be due to a congenitally short urethra. Circumcision is contraindicated because the foreskin is needed in the current technique of repair.

Anesthesia
Since all reasonable scientists now recognize that circumcision causes much pain, one would expect the widespread use of anesthesia. This is not happening.

Using anesthesia does not justify performing a circumcision: 1) It usually is not that effective; 2) Harm and pain, persist long after any anesthesia has worn off.


Complications of Circumcision
One example of a circumcision complication is ulcerative meatitis. Dr. Leonard Marino, in 25 years of practice as a pediatric urologist, stated that 25% of his patients were intact. None of these ever needed surgery for meatal stenosis, a sequelum of ulcerative meatitis. In contrast, 75 of his circumcised patients required surgery to enlarge the urinary meatus. The accompanying symptoms were dysuria, frequency, hematuria, meatitis, meatal stenosis, urinating more than a single stream. Each patient usually had 4 or more of these symptoms together.22

P. Freud writes, “It is astonishing how few articles on this frequent and important disorder have been written and how little the condition is known.”23 It is generally recognized to occur only when the glans is exposed., i.e., in circumcised boys or in intact boys whose prepuce does not completely cover the glans. Ulcers form along the border of the urethral meatus, and the antero-posterior diameter of the meatus is shortened. Urination is very painful and usually requires topical anesthesia to prevent urinary retention. A scar forms after healing. Meatomy is often required. It is now generally recognized that the narrowing of the meatus is secondary to the thickening of the surface layers of the glans following circumcision.

Psychologic Complications
Settlange has stated, “Concern for the psychologic development and future mental health of the child requires that the events in the neonatal as well as any later stage of development be managed in such a way as to keep tension in the child within tolerable limits.”24 During the performance of unanesthetized surgery, these limits may be exceeded. Preston comments: “One cannot argue that structure and function are intimately related, and at the same time shrug off with equanimity the fretful, circumcised newborn, his glans swollen and cynanotic for three to five days.25

The patient has experienced, according to experts, “excruciating pain, the perinatal encoding of his brain with violence, an interruption of maternal-infant bonding, the betrayal of infant trust, and must suffer the risks and effects of permanently altered normal genitalia. In addition, he has lost his basic human right to a sexually intact and functional body.”26


The Etiology of Circumcision
In case the reader is wondering why all these bizarre excuses have been advanced to permit circumcision to continue, we offer our best explanation (hypothesis): Circumcision produces circumcisers. The loss of this normal body part is, in some instances, so profound that the person who has lost it is unwilling to admit that anything is wrong. If he becomes a doctor, he may not hesitate to perform circumcisions.

Another hypothesis goes further: Some who have been circumcised cannot stand that someone else might go through life intact. If that person is a doctor, he sees to it. If he is a father, he may insist that his sons be circumcised. A recent analysis stated that the most important factor associated with the decision to circumcise was whether or not the father was circumcised.27

We have the greatest admiration for those fathers and those physicians who, while circumcised themselves, say “No” to having their sons and patients circumcised.



  1 Wallerstein, E. Circumcision: An American Health Fallacy. New York: Springer Pub. Co., 1980

  2 Spock B, Rothenberg MB. Dr. Spock’s Baby and Child Care, 6th Ed. New York: Simon & Schuster, Inc., 1992

  3 Preston EN. Circumcision and genital hygiene. Amer J Dis Child. 140: 969, 1986 [PubMed]

  4 Jorgenesen ET, Svensson A. The treatment of phimosis in boys, with a potent topical steroid cream. Acta Dermato-Venereologica (Stockholm). 73;55-56;1993 [PubMed]

  5 General Kutuzov. quoted in War and Peace by Leo Tolstoy

  6 Cook JV. The etiology and treatment of ammonia dermatitis of the gluteal region of infants. Am J Dis Child. 22:481-492, 1922

  7 Birley HDL, Walker MM, Luzzi GA, Bell, Taylor-Robinson D, Byrne M, Renton. AM. Clinical features and management of recurrent balanitis; association with atopy and genital washing. Genitourin Med. 69: 400-403, 1993 [Full Text]

  8 Krueger H, Osborn L. Effects of hygiene among the uncircumcised. J Fam Pract. 22:353-35, 1986 [PubMed]

  9 Freud P. The ulcerated meatus of male children. J Ped. 31:131-141, 1947 [Full Text]

10 Taylor, J. The prepuce: what exactly is removed by circumcision? Second International Symposium on Circumcision; 1991 [Abstract]

11 Gairdner D. Fate of the foreskin. Br Med J. 2:1433-1437, 1949 [Full Text]

12 Terris M, Wilson F, Nelson JH. Relation of circumcision to cancer of the cervix. Am J Obstet Gynecol. 117:1056-1066, 1973

13 Stern E, Neely PM. Cancer of the cervix in reference to circumcision and marital history. JAMWA. 17:739-740, 1962 [Full Text]

14 Wallerstein E. Circumcision: An American Health Fallacy, 1980

15 Lord P. Personal communication

16 Escala JM, Rickwood AMK. Balanitis. Br J Urol. 63:196-197, 1989 [Full Text]

17 Waugh MA. Clinical presentation of candidal balanitis—its differential diagnosis and treatment. Chemotherapy. 28 (Suppl 1):56-60, 1982

18 Robbins S. Pathological Basis of Disease. W B Saunders, p. 1208

19 Catterall RD, Oates JK. Treatment of balanitis xerotica obliterans with hydrocortisone injections. Brit J Vener Dis. 38:75-77, 1962

20 Tan HL. Foreskin fallacies and phimosis. Annals Acad Med Singapore. 14:626-630, 1985 [Full Text]

21 Rickwood AMK, Hemalatha V, Batcup C, Spitz L. Phimosis in boys. Br J Urol 52:147-150, 1980 [Full Text]

22 Mario LJ. An emphatic vote against circumcision. Contemp Peds. p 14, Nov 1989

23 Freud P. The ulcerated urethral meatus in male children. J Peds. 31;131-141, 1947 [Full Text]

24 Settlage CF. Psychologic Development, in Nelson WE (ed) Textbook of Pediatrics, ed. 9. W B Saunders, p. 60, 1969

25 Preston EN. Whither the foreskin? A consideration of routine neonatal circumcision. JAMA. 213:1853-1858, 1970 [Full Text]

26 Milos MF, Macris D. Circumcision: a medical or human rights issue? J Nurse-Midwifery. 37:87S-96S, 1992 [Full Text]

27 Brown MS, Brown CA. Circumcision decision: prominence of social concerns. Pediatrics. 80:215-219, 1987 [Abstract]



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