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

New York - July 2,  1996

Dear Dr. Keenan,

     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)

Thank you for your attention. Always willing to help.

Yours Truly,


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

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

NORM of NYC, June 1996

1. Section on Care of the Uncircumcised (Intact*) 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.

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

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2. Section on Treatments for Various Ailments  (DETAILED)

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.
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