Letter to Mr. Keenan, AAP

Maurice E. Keenan, MD / President of the Executive Committee
of the American Academy of Pediatrics
16 Bristol Road
West Newton, MA 02165
617/244-6000
FAX 617/232-9376

I have been told by COPAM, at the AAP, that the Executive Committee will be choosing the committees that will recruit the next Task Force on Circumcision. This task force, however, will only cover part of the problem: circumcision. One of the main reasons why circumcision exists in this country is because doctors don't learn alternative treatments of penile ailments. I am suggesting to your committee that the new task force be called the Task Force on PENILE CARE AND Circumcision (or something to that effect). As it stands, whether the statement comes out for, against or neutral on circumcision, doctors in this country will remain ignorant on treatment of penile problems unless education is ALSO addressed.

In my opinion, this document should combine guidelines for treatment of penile ailments and a circumcision policy. Attached is a model of this new approach which I call the Task Force Report on Penile Care and Circumcision. I don't expect you to adopt each and every view expressed in my model, however, the inclusion of alternatives to circumcision in the AAP's next statement would make this document more objective and balanced. (See Section 2 of model and Detailed version of Section 2)

Richard Americus DeSeabra
Director, NORM of NYC, a support network for men damaged by circumcision

Task Force Report on Penile Care and Circumcision (A MODEL)

1. Section on Care of the Uncircumcised (Intact¹) Penis - The Task Force Report on Penile Care and Circumcision should begin with something similar to the AAP's brochure Care of the Uncircumcised Penis that includes function and anatomy of the prepuce. In this section, there can be advice for circumcised fathers with intact boys and how differences might be explained.

2. Section on Treatments for Various Ailments - Circumcision is a drastic treatment for simple ailments of the penis. Alternatives for these ailments are implemented internationally. The Task Force should educate physicians as to the alternative treatments for: phimosis, paraphimosis, UTIs, ammonia dermatitis, allergy to soap, decreased urinary stream, BXO, eczema, balanitis and balanoposthitis (see treatments attached). A POLICY STATEMENT WITHOUT THESE TREATMENTS IS NOT A BALANCED STATEMENT.

3. Section on Circumcision - In light of the above, less invasive and cheaper treatments that preserve the erotogenic, mobile and protective functions of the prepuce, the AAP should declare that circumcision is a radical and obsolete solution for simple problems. Mention should be made of the possibility of severe damage to the penis and even death. Mention should also be made that clamp circumcisions will remove mucosal tissue, sever or obliterate the frenulum (a highly erotogenic genital part) and restrict natural mobility of shaft skin. Finally, the Task Force should mention the possibility of breast-feeding failure, psychological sequelae and the chance that a son will desire to restore himself in the future. Circumcision should be discouraged even if there are boys in a household who are already circumcised. The AAP should encourage doctors to learn the simple techniques mentioned in the treatment section above and discourage patients from circumcising.

4. Section on HIV/Cancer Awareness - Penile cancer is extremely rare and men are more likely to develop male breast cancer than penile cancer. Males are also more likely to die from circumcision itself than from penile cancer. Also, medicine has shown that the development of cervical cancer has to do with behavior and not a spouse's body part. America is one of the nations with the highest AIDS rates and has the highest population of circumcised men, demonstrating that amputation is not effective prophylaxis. The AAP should recommend that physicians dispel any parental fears about the foreskin causing cancer or AIDS. Physicians should also be made aware of the inflammatory effect that even the mention of these diseases may have in the doctor/patient dialogue. Spurious assertions of a link between circumcision status and HIV or cancer are not sufficiently convincing to warrant inclusion in a public document of this kind.

5. Section on Guidelines For Physicians Who Are Ritual Circumcisers - At a time when the ritual circumcision of girls is becoming illegal, it is inappropriate for ritual circumcisions, male or female, to take place in any hospital setting. The AAP should encourage physicians who are Muslim or Jewish ritual circumcisers to perform these rituals out of hospitals and clinics and in the homes of or the temples of the children undergoing the ritual.

6. Section on the 1989 Task Force Report on Circumcision - The nullification of the 1989 Task Force Report should be made clear. (Nullification would be proper based on the fact that Edgar Schoen had, and still has, a predisposition to favor circumcision, writes sentimental poetry about genital chic, engages in pro-circumcision activities and still uses his title as '89 Chairperson to misconstrue the AAPs recommendations on circumcision in the press).

7. Section on Continuing Education - This section would inform doctors on continuing education resources (cassette tapes, videos and web pages) that will give them more detailed information on the care of the intact penis, anatomy and function of the foreskin and medical treatments of penile maladies.

The AAP must take a responsible leadership role in educating pediatricians as to the proper care of the penis. A guidelines approach to the new Task Force Statement including the following treatments would be more objective and balanced. Whether the statement comes out for, against or neutral on circumcision , there are still the alternative solutions to simple penile problems to which doctors and parents must be made aware.

Phimosis - A normal condition of the human prepuce in young males. A high proportion of small boys are not able to retract their foreskin until six, or even after puberty. Usually by the age of five or six boys are sufficiently interested in his anatomy to have done some exploring and to have found that he can retract. If the prepuce is still unretractable in adulthood, mild stretching of the preputial opening can be recommended in order to relieve the problem. Other methods such as a balloon catheter or a dilater can enable a physician to stretch the preputial opening.

Paraphimosis - May easily be treated with gentle, prolonged hand pressure using index finger and thumb, squeezing the glans gently until the blood is forced out of it, and the foreskin can be pulled over it. Can also be solved with manual stretching of tight tissue after puberty.

UTIs - Treatment consists of diagnosis of the offending organism(s), and use of appropriate antibiotics, not removal of the organ.

Ammonia Dermatitis - May be stopped by treating the diapers with an antiseptic (mercuric chloride) which inhibits the ammonia-producing bacterium. Frequent diaper changes.

BXO (Balanitis xerotica obliterans) - This condition exists only when there is cicatrization of the preputial orifice with histologic changes of balanitis xerotica obliterans (BXO) a rare disease of unknown etiology, which rarely occurs before age 5. This condition 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. Premature and forced retraction of the prepuce may cause this condition. 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, it would be well to consider conservative treatment before resorting to surgery. As a last resort this condition can be resolved with removal of only the inflicted area. A radical circumcision, or complete denuding of the glans, need not take place.

Allergy to alkali in soap - 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.

Eczema - This condition is characterized by a scaly rash at the tip of the prepuce, and by a constant itching. Hydrocortisone cream is recommended.

Treatment of Balanitis - Beware of the diagnosis of balanitis which is not really balanitis, but simply irritation (redness), and the presence of normal smegma. Balanitis does not cause phimosis, and no single pathogen is involved. Usually a boy suffers only one episode. Balanitis may be treated by bathing in hot water and local washing, or like other infections - with antibiotics. In the case of candidal balanitis, fungicides may be indicated.

Balanoposthitis - Treatment consists of diagnosis of the offending organism(s), and use of appropriate antibiotics, not removal of the organ.

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 birth, a space has begun to form between the prepuce and the glans, the preputial space, and the process of creating this space is not yet complete.

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. These minute spaces coalesce, eventually becoming the preputial space. This process is completed by age 3 in 90% of boys, but it may take until puberty for some boys to have a fully retractable foreskin.

When premature and forced retraction of the prepuce takes place by uninformed physicians or parents, adhesions can truly form, because raw surfaces remain on both organs.

Redundant Foreskin - Sometimes 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 an erection. It is normal for foreskins to vary in length.

Ballooning of the foreskin - This is normal, so long as urination is not markedly prolonged.

Footnote

Please put (intact) by the word uncircumcised. Parents who choose not to circumcise their sons prefer this term. And besides, is semantically incorrect; that means a woman with breasts would be unmastectomized. The term uncircumcised makes the surgery seem normal which, ona global level, it clearly is not.

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