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	ask the experts marilyn milos

Marilyn Milos, RN
Circumcision and Genital Integrity

• Doctor detached foreskin
• Female phimosis
• Jews and circumcision
• Possible effects of retraction
• Forceful retraction during infancy
• Micropenis
• World Health Organization decision to promote circumcision.
• HIV
• Swollen, red penis
• Intactivism
• Making routine circumcision illegal
• Doctor recommending circumcision after infection
• Questioning leaving a male 'intact'.
• Retraction of foreskin
• Surgery to correct hypospadia and cordee
• Husband wants to circumcise our son
• Special care for an intact son
• Circumcision statistics
• Advocating genital integrity

Our first son was born prematurely and had testicles that did not descend fully; he required surgery [when he was] three-years-old to attach one of them to the scrotum so that it would develop properly. After the surgery, the surgeon said that our son's foreskin was adhered and that he had detached it for him. This confused me, and we came to feel that we should have been asked before the procedure was done. Our son is now twelve-years-old and has not regularly retracted his foreskin. When he does, it is adhered in one area. Should we be concerned with his particular situation, given that his natural development was altered, or should we wait until after puberty and see what happens to the adhesion?

From reading your responses to other questions, it would seem that our eight-year-old, who also does not retract his foreskin and also has some adhesion, is normal, and we should do nothing for him.

The foreskin and glans (head of the penis) are normally attached by a common membrane (the synechia) at age three. The average age at which separation occurs is 10.4 years, so what your son's doctor did was wrong. And, yes, you should have been consulted before such an invasive procedure was performed. You are also correct about waiting until after puberty to see what happens with your son's foreskin. It is very likely that adhesions have formed, as they often do when two raw tissues heal next to one another—in this case, the foreskin and the glans. This is the result of the doctor's meddling, something parents now realize happens if they are not diligently protective of keeping everyone's, including the doctor's and the caregiver's, hands off a boy's foreskin. The latest journal articles on the issue reassure us that most adhesions will resolve on their own. If they don't and your son still has them at the end of puberty, the foreskin and glans can be separated after analgesia has been applied. Let us hope that won't be necessary.

If a boy's foreskin has not retracted before puberty, the hormones of puberty usually will complete the task. While just 44?50 percent of 10-year-olds have a fully retractile foreskin, about 98 percent of 18-year-olds do. So, relax and watch nature at work. You have two lucky sons and, for now, they need to enjoy an [untroubled] boyhood.

Our doctor told us that my daughter-six months old-has phimosis, and her opinion is to do genital cutting. What is your opinion? Must I do it and [if so,] when?

And, by the way, some people live their entire lives with a non-retractile foreskin. I happen to be one of them. I'll be 68 years old in a week, and I've never had a problem! There is always time to wait and see. As my mother used to say, "Never trouble trouble till trouble troubles you!" Potential problems are not real problems, and cutting a baby's body should not be done for potential reasons. Babies do not need to have pain and trauma introduced into their young lives. They need to be loved and protected. I have a sense that's what you're thinking, too.

I am six-months pregnant with a boy, and as a woman of Jewish heritage, I feel extremely torn on the circumcision issue. My entire family is expecting a Bris, and I am rather against the practice. Are any Jews not participating in circumcision these days? What advice might you have about addressing this issue with my family?

Leonard B. Glick, MD, PhD, author of Marked in Your Flesh: Circumcision: From Ancient Judea to Modern America (Oxford University Press, 2006). This book helps us to understand the infiltration of circumcision into western medicine. Len's e-mail is: quabbinbooks@gmail.com.

Ronald Goldman, PhD, is the author of two books, Circumcision: The Hidden Trauma and Questioning Circumcision: A Jewish Perspective. Ron's e-mail is: crc@circumcision.org.

Miriam Pollack, a Jew who is deeply rooted and steeped in her cultural and religious heritage, has spoken at several of my International Symposia on Circumcision, Genital Integrity, and Human Rights, basically discussing "redefining the sacred." E-mail this extraordinary woman at: m3pollack@comcast.net.

Mark Reiss, MD, is also active in protecting Jewish boys from circumcision. He heads a Bris Shalom group, working to connect Jews who choose to have a naming ceremony (without cutting) with a rabbi who will perform a Brit Shalom ceremony instead of a Bris milah. Mark's email address is: Mdreissmd@aol.com.

Eliyahu Ungar-Sargon made the excellent new documentary, Cut: Slicing Through the Myths of Circumcision, which has just been released on DVD. Eli's e-mail is: eliungar@mac.com. I'm sure he'll be happy to talk to you about his documentary.

Edward Wallerstein, my deceased teacher, authored Circumcision: An American Health Fallacy.

Also see www.JewsAgainstCircumcision.org.

An anti-circumcision website in Hebrew says, "A healthy newborn baby is the most perfect thing in the world. I did not circumcise my son and urge you to learn the subject before going for the cut. If you read Hebrew, please visit my website, which is dedicated to this issue: http://www.gonnen.org. Eran Sadeh, Israel (07.31.06)"

You are not alone in wanting to protect your baby from unnecessary pain and trauma. Jewish, Muslim, and Christian moms share your sentiments. As you can see, there are several wonderful resources for Jewish parents. E-mail NOCIRC at nocirc@cris.com for a packet of Jewish writings.

I know it's not easy to stand against harmful religious or cultural traditions, but know that you're not alone. Not everyone has the courage to lead the way, but when we do, others will have the courage to follow. Trust your instincts to protect your baby!

My 23-month-old intact son recently had his second grand mal seizure. While in the hospital, as part of the infection testing, he was given two catheters. For the first, I was comforting my son (in addition to being completely panic-stricken) and did not see the insertion of the catheter. For the second, I was alarmed to see that the nurse had completely retracted his foreskin. His foreskin had never been retracted. Will this cause harm to his foreskin? Is there anything I can do to prevent future problems?

Foreskin retraction is not necessary for inserting a catheter into the urethra of a male. The catheter can be inserted through the foreskin's opening and then inserted into the urinary meatus "by feel." The majority of health-care workers don't yet know this.

The risks of premature (forcible) retraction of the foreskin include the infliction of pain, trauma, infection, adhesions, and acquired phimosis. You can read about these risks at www.nocirc.org; click on the pamphlets on the homepage, and read pamphlet 6. If your son's foreskin bled or if he cried in pain, then damage was done. [This damage] may have occurred during the first retraction, and you would have known it if you had seen blood on his penis or in his diaper. If there was no blood or pain when your son's foreskin was retracted, it may have already been retractable, whether on its own or following the first catheterization.

Even if adhesions form, they often resolve on their own, so nothing needs to be done now. Your son's penis will be done developing at the end of puberty (18-25 years), and that's when he'll know if there is anything that needs attention. In the meantime, as long as there are no problems, rejoice in the fact that you've kept your son intact!

My stepson is six years old and uncircumcised. Without making this too long, I'll say that I'm pretty sure that his foreskin was forcefully retracted at some point during his infancy. His pediatrician had told their parents that this needed to be done in order to keep them clean. When I met him he was five and he was able to fully retract his foreskin. Tonight during a bath my husband noticed that my stepson can no longer retract the skin. He's not in pain, he's still able to pee, everything else is normal, he's just no longer able to retract the skin over the glans. My husband is concerned and asked me if it was normal (he knows I research these things like crazy). I shared what information I have with him regarding the fact that it never should have been forcefully retracted in the first place and that it has probably just returned to it's previous, normal state since my stepson doesn't ever retract it on his own. I also said that, from what I've read, as long as he's not in any pain or discomfort (which he says he's not), it's not anything to worry about. My husband calmed down a little, but I told him that I see if I could find any information on it. What do you think?

Your response to the situation is right on. There is nothing to worry about with a boy whose foreskin at age six is non-retractile. In fact, only 44-50% of ten year old boys have a fully retractile foreskin. About 90% of intact 15 year old boys have a fully retractile foreskin and 98% of 18 year olds are able to retract their foreskin. For the other 2%, a non-retractile foreskin is normal, although gentle stretching techniques work for those who want their foreskin to retract.

Please go to www.nocirc.org, click on "Directory," again on "Important Articles," and read the second, third, and fourth articles, and you'll learn more about the structures, functions, development, and care of the normal penis than most physicians learned in medical school. Also, click on the pamphlets on the first page and read them. Then, you'll be informed and know the importance of normal genitalia and be prepared to protect your intact stepson.

Please give me your expert advice. I have a one year old intact son. When he was born we were told by a geneticist that he had micropenis. Not knowing much about it, I researched it on the web. However, I noticed while cleaning his diaper area that there seemed to be quite a substantial "lump" beneath the foreskin where his penis would normally come through. It so happened that at three months he started ballooning while urinating and when I took him to the doctor I asked if it were possible that this "lump" was actually the remainder of his penis trapped underneath the foreskin—the doctor didn't seem to know. We requested to be referred to a pediatric urologist since our doctor was not familiar with the ballooning situation. When we saw the urologist he said to just apply enough pressure to release the trapped urine and then informed us that our son DID NOT have micropenis but instead trapped/hidden penis, in that it had retracted back into the pubic fat pad and would resolve itself once he started crawling/walking and losing the fat. However, he did tell us to retract the foreskin to stretch it and allow the penis to come through which I did not feel comfortable with after reading that this can cause damage and is unnecessary. When we saw the geneticist for a follow up appointment and told her what the urologist had said, she disagreed and insisted that he had micropenis. We were distressed at hearing this again and again made an appointment with the urologist. We informed him of what the geneticist had said and pleaded with him to check again. He did and again insisted that he did not have this condition and that "in actuality" it was a bit bigger in size than average. We are quite confident that this is the situation, however we are awaiting a second opinion just to confirm. We were also told that he does not have phimosis because it is possible to retract his foreskin (with some effort). At this time, however, he is still experiencing the ballooning—not all the time but every once in a while and I'm wondering how long this typically lasts. He has had it off and on since three months and is now almost 13 months. I am wondering if it is complicated more so because of the trapped penis condition and the extra foreskin flipping inwards and getting in the way. I really don't know if I should be retracting him or not or letting it resolve itself. A couple months ago he had redness on his foreskin and the penis tip and my doctor told me that he had an infection and that I would have to retract it and clean it with warm water in order to get rid of it. I did for a couple days but then didn't feel comfortable with it and left it alone. It seemed to get better but lately when I try to retract it a little to see if there's any redness around the edges of the foreskin or penis tip my son cries. I'm at a loss as to what I'm supposed to be doing or not doing! Please help! No one seems to know very much about either of his conditions and I feel lost in that we feel like we have no one to talk to.

First of all, if your son is urinating, his penis is functioning. Whether or not he has micropenis (and it sounds from what the urologist has told you that he does not), it does not matter at this point in his life. Your son's penis will not be done developing until after puberty, so you'll need to wait to see. Many males are "growers" not "show-ers," and what appears to be a small penis when flaccid becomes large when erect. This is normal for those males.

Ballooning with urination is a normal part of penile development in some boys, letting you know that the foreskin and glans are in the process of separating. It would be helpful for you to read three articles to help you understand the structures, functions, development, and care of the normal penis. Please go to www.nocirc.org , click on Directory and again on Important Articles, and read the second, third, and fourth articles. The latter two were published in Mothering magazine.

With regard to redness of the foreskin, it is usually caused by ammoniacal dermatitis (diaper rash) or other disturbance of the normal bacterial balance due to antibiotics, bubble baths, soaps or shampoos in the bath, highly chlorinated swimming pools, or hot tubs. Bacterial replacement to restore the foreskin to health is simple. Purchase some liquid Acidophilus culture from the healthfood store and apply a little directly to the foreskin with each diaper change (at least six times a day). The foreskin should appear normal by the end of the second day.

It is not necessary to retract the foreskin of your son and, in fact, retraction can cause problems. Just wash your son's penis like you wash his fingers and toes. Nothing special needs to be done.

 If you have additional questions, please feel free to call me at the NOCIRC office, 415-488-9883. I'll be happy to help.

I've heard and read in the media about the new World Health Organization study and decision to promote circumcision to prevent the spread of HIV in heterosexual males. I was appalled at the thought. Especially when you consider all the effort undertaken to prevent female and male mutilation. What is your take on this? Isn't a condom more effective? Got any good sound bytes I could offer to friends and family who bring this up around my decision not to circumcise my son?

The practice of circumcision is fear-based and excuses for circumcision always have been consistent with the dreaded disease of the day. HIV/AIDS, as an excuse to circumcise, is no different. If circumcision didn't prevent the spread of other sexually transmitted diseases, as promised during the sexual revolution of the 1960s, it certainly won't protect against this sexually transmitted disease, either. The US has one of the highest circumcision rates and one of the highest HIV/AIDS rates in the developed world; circumcision obviously does not prevent AIDS.

The spread of HIV/AIDS has been curbed in Thailand, Senegal, and Eastern Uganda, where governments have created aggressive educational campaigns about the danger of AIDS, highlighting the importance of safe sex and providing free condoms. These programs are successful without circumcision, which is not cost-effective and has known risks. Reduced penile sensation and a false sense of safety after circumcision could easily exacerbate the spread of AIDS by decreasing condom use. Education, not foreskin amputation, is a sane and successful approach to stopping the spread of AIDS.

For more information, see nocirc.org and click on Circumcision and HIV on the home page.

My son is 11 weeks old and intact. I was very happy about our decision not to circumcise him. Recently, I have read articles about new studies in Africa and New Zealand that conclude that uncircumcized males are three times more likely to contract sexually transmitted diseases. The articles appeared twice in the New York Times as well as a sidebar in Parents Magazine (February issue). What are your thoughts about this new research? Are there steps that intact males can take to lesson the risks of STDs (condoms etc)? I never thought I would regret leaving my little one intact, but am starting to feel as if my good intentions could put him at risk in the future. I would appreciate your take on this research. Thank you!

One fear-based excuse after another has been used to promote circumcision since it was introduced into western medicine during the mid-1800s to prevent masturbation (which, at the time, was thought to cause disease). The excuses for circumcision always have been based on the dreaded disease of the day, i.e., masturbation, germs, penile and cervical cancer, sexually transmitted diseases, urinary tract infections, and now HIV/AIDS.While circumcision is being touted as a way to stop the spread of AIDS in Africa, HIV/AIDS has successfully been curbed in Thailand, Senegal, and Eastern Uganda with aggressive educational campaigns about the danger of AIDS, the need for safe sex, and the importance of condom use. In Thailand, the government's program of "100% condom use, 100% of the time," providing free condoms for everyone, has been successful without circumcision, which is not cost-effective and has known risks. Reduced penile sensation and a false sense of security after circumcision could easily exacerbate the spread of HIV/AIDS by decreasing condom use. Circumcision hasn't prevented HIV in the USA, Israel, or Muslim countries. Circumcision is not promoted in Scandinavia because education is enough; so why isn't it enough in Africa? HIV policy should focus on what's been shown to work.

Your good intentions have protected your son from unnecessary pain and trauma and allowed him to maintain the protective foreskin, the wholeness of his body, and the fullness of his sexual experience. You can teach him about the importance of good hygiene and safe sex practices. Education, not amputation, is the rational approach to curbing the spread of HIV/AIDS. You need not regret your decision, you can rejoice in having made the right decision. One day, your son will thank you.

My 21-month-old son woke up from a nap yesterday with aswollen, red penis. He soon had a pussy discharge, which seemed tobother him, and then urinated without difficulty. We took him to the ER,where a doctor took a cursory look at him and diagnosed him withphimosis. He suggested circumcision before he suggested antibiotics orsteroid cream or any other non-invasive treatment. I have an appointmentwith a urologist tomorrow, and am concerned they will not respect ourfamily's decision about circumcising/not retracting our son. Both the ERdoctor and the receptionist of the urologist said we should have beenretracting the foreskin and cleaning, and that this is the cause of thephimosis. Everything I read before and after says this is not necessaryand can cause harm. Still, it seems obvious my son has an infection,and I do not want to put him in any further danger. He is on cephalexin,and after only two doses his penis went back down to a normal size. Wehave also used (at the doctor's suggestion) hydrogen peroxide and neosporin twicea day. He is urinating, has not had any fever, and is his usual playfulself. What should we do?

Your willingness to protect your child from unnecessary surgery is to be commended! It takes courage to stand firm when the first suggestion of medical professionals is surgery. Had you taken a daughter for care because of swollen genitals, no one would have suggested amputation. No one would have told you that you should have been retracting her foreskin (clitoral hood) daily to prevent infection. It is not uncommon for a two-year-old to pull on his foreskin and, in doing so, he may have torn the tissue that adheres the foreskin to the glans. This tissue will become separated on its own over time, with the help of the normal developmental process as well as self-manipulation. The swelling of the tissue -- the body's inflammatory response -- is normal and does not require amputation of the body part.

As an informed parent, you are also aware of the fact that you do NOT have to be trying to retract your son's foreskin. The intact penis and glans are normally attached and the condition of "phimosis," a normal developmental phase in infancy and childhood, cannot be diagnosed before the penis is fully developed, somewhere between 18 and the mid-twenties. At that time, a boy with phimosis can determine what he wants for his own penis. Gentle stretching works and is effective. The majority of the 2% of phimotic men live happily with their non-retractile foreskin, a variation on the theme.Sadly, most American physicians (probably themselves circumcised) did not learn about the normal penis in medical school. In fact, what they may have learned is intrusive and the very thing that often causes problems. Fortunately, some of today's younger physicians are beginning to learn about the structures, functions, development, and care of the normal penis.

I am delighted to hear that antibiotics are working for your son. Be sure give him liquid Acidophilus culture orally several times a day and dab some on his foreskin several times a day, too. The reason for this is because antibiotics kill all bacteria -- good as well as bad -- so, this is bacterial replacement therapy. It should continue for several days after the course of antibiotics is complete.

Hydrogen peroxide and neosporin both kill bacteria, which is what the antibiotics are doing. Hydrogen peroxide is a harsh and unnecessary treatment.

I am not a physician, so I cannot diagnose, treat, or prescribe. But, as a nurse, I can offer you the information provided to me by the urologist on our board of directors and the many physicians on ourmedical advisory board. These are physicians I have come to trust because they trust the normal, natural body and they deal with any problem that might occur by starting with the least invasive therapy. All agree that your instincts about protecting your son, just like your son's body, are intact. Continue with the course of antibiotics until it is finished and give your son Acidophilus culture internally and externally while he's taking the antibiotics and for several days afterwards, and your son should be just fine.

I recently had my second child, a son, whom I left intact. My husband and I both feel very strongly about protecting our children and not participating in what we believe to be mutilation. My question is, how can I help or get involved with trying to protect more babies? I am astounded that people still do this and that it is even legal. I am also amazed at how many people think I should just shut up, because it is none of my business. Shouldn't we protect all children, not just our own?

Your comments bring me hope! You are determined to protect your son and any other unborn boys. Circumcision is not legal. There are many legal documents both national and international that honor the rights of a child to protection, making a child safe in his person. Unfortunately, a circumcising culture is often not willing to recognize this fact of law, just as physicians, whose oath it is to "First, do no harm" are unable to uphold their own obligation, even to the most vulnerable among us.

When I began my work, 27 years ago, there were only a few of us working to protect the genital integrity rights of children. Today, the movement to end non-therapeutic genital cutting of non-consenting minors is growing. If you want to help, write to NOCIRC Headquarters at info@nocirc.org or NOCIRC, POB 2512, San Anselmo, CA 94979-2512. We'll send you guidelines on becoming a NOCIRC Center with information about how you can help. Thanks for your willingness to help us provide a voice for those not yet able to state their own wishes about their own body. We are protecting them from a primal wound and we are preserving their right to self-determination.

Is there a movement towards making routine circumcision illegal? And, if so, who (and/or what organization) is leading the movement?

There is a Bill to End Male Genital Mutilation in the U.S., which was first submitted to Congress on February 23, 2004. MGMbill.org is a non-profit organization, founded by Matthew Hess and based in San Diego, California, seeking to pass a law that will end the practice of male genital mutilation (circumcision) in the United States of America.

A doctor recently recommended circumcision after my 5 year old son developed a penis infection. He is unable to retract his foreskin. By what age is retraction considered necessary?

Your son's penis is normal. You'll be happy to learn that just 44% of 10-year-olds, 90% of 16-year-olds, and 98% of 18-year-old boys have a retractable foreskin. The last two percent, those with a non-retractile foreskin, are a normal variation on the theme. These males can stretch the foreskin, if they so choose, to make it retractable. Many appreciatethe way they are and don't want a retractile foreskin.

The doctor should have determined the cause of your son's infection and discussed it with you. When we understand the cause of infection, we canprevent future occurrences. If your son had an infection in his finger or toe, his doctor would not suggest amputating that body part. If a girl had a genital infection, amputation would never be mentioned. Why then do doctors recommend circumcision? Probably because they didn't receive adequate education about the structures, functions, development,and care of the normal penis or what to do when a problem occurs. Many doctors do not have a foreskin. Many have rarely seen one. This is an interesting time for parents with intact sons. They often know more about the normal penis than their son's doctor and they are having to educate the docs. When parents do educate their son's doctor, they help all the other boys who will be seen by that doctor in the future. I lookforward to the day when all physicians are educated and trust the body'sperfect design.

My husband and I are expecting our first and expect it to be a boy. We have been wrestling with the issue of circumcision. I always assumed it was 'normal' - when we got married I was suprised to find my husband was not circumcised. I have found your column informative - still a couple of questions remain in my mind. My husband recalls a painful memory as a youngster needing to go to the doctor because he had an infection from not 'cleaning himself' correctly and believed he could have been spared this pain had he been circumcised. Is this common? Second, sometimes during intercourse, his foreskin has apparently folded back, causing him pain. This troubles me and has made me question leaving a male 'intact'.

American women have begun to understand the foreskin's contribution to normal sexual relations. Sex with an intact male is considerably different than sex with a circumcised male. European women ask me howAmerican women can have foreplay without a foreskin to "play" with. That's an important question.When a functioning part of male genital anatomy is amputated, the mechanics of sex must be altered to compensate for the loss. The movements a circumcised male needs to make to achieve orgasm are /not /compatible with the movements a woman needs to reach orgasm. In addition, an intact male brings his own lubrication to intimacy, so the common complaint of American women about dryness and shafing with intercourse are not a problem for a woman with an intact sexual partner.

The foreskin, like the vagina, is self-cleaning. Problems of the foreskin usually occur during childhood when someone fiddles with the foreskin, attempts to retract it, or continuously and vigorously washes it. The foreskin of a child should be washed like the outside of any other body part. It should /not/ be retracted for cleaning. When the foreskin becomes retractable -- and the child should be first person to retract his own foreskin -- the boy can be instructed to pull his foreskin back while bathing, rinse it with water, and pull his foreskin forward again. Soap should not be used because it is an irritant. I have discussed other reasons for foreskin problems in previous answers to questions, or you can go to www.nocirc.org and click on pamphlet #3, "Answers To Your Questions About Your Young Son's Intact Penis" to read about the most common reason for problems, how to prevent them, and what to do should they occur. Also, click on "Directory" on the same site,
then click on "Important Articles," and read the two articles by Paul Fleiss, MD, both of which were published in Mothering Magazine.

I am not sure what you mean by your husband's foreskin "folding back." The foreskin's action is one of gliding, and it is normal for the foreskin to glide back and evert during intercourse. The inner lining of the foreskin, which is mucous membrane, is what comes into contact with the lining of the vagina, also mucous membrane. This constitutes normal genital functioning. However, there is a variation of this theme. About two percent of males have a non-retractile foreskin, which is normal for them and non-problematic. If retraction is not easy for your husband, it may very well be painful during intercourse. In this case, there is an easy solution, which simply requires gentle stretching of the preputial opening over a period of several weeks until it is wide enough to accommodate the glans. Just as a baby's head widens the cervix for birth, the glans (head of the penis) widens the preputial opening for retraction.

Your husband's problems with his foreskin are minor in comparison to the pain and trauma inflicted upon an infant during and after circumcision. Circumcision is a primal wound that interferes with the maternal/infant bond, disrupts breastfeeding and normal sleep patterns, undermines the successful completion of the child's first developmental task of establishing trust, induces post traumatic stress disorder, and denies a male his right to genital integrity and self-determination.

Your concern is fear-based. Using fear as a premise, we cannot cut off enough of an infant's body to ensure he won't have problems with it during his life. Your son needs you to respect his being and protect his body. I trust you will.

My 5 year old son's foreskin will not retract. The doctor recommended a steroid cream to thin and soften the skin, which we haven't applied yet because of what I have read in your columns. He has a white mucous build up under the foreskin. Is this a problem or will it just stay there for years until his foreskin can move back?

You will be happy to learn that your son is perfectly normal. About 44% of boys have a fully retractable foreskin at 10 years of age, 90% at 16 years, and 99% at 18 years. About 1-2% of adult males have a non-retractable, which is simply a variation on the theme. For those who want a retractile foreskin, they can use steroid cream to successfully achieve their goal, but thisshould never be done before the end of puberty, when the penis is done developing. Putting steroid cream on a 5-year-old for a non-retractile foreskin would be like putting steroid cream on the breast buds of a 5-year-old girl because her breasts aren't developed yet. The hormones of these children will be activated when the time is right and they will finish normal developmental tasks. Retractability should never be forced or hurried. If a boy is urinating, his penis is functioning and nothing needs to be done.

With regard to the while lump under your son's foreskin, it is not "mucous buildup," it is called a smegma pearl or cyst. It lets you know that the separation of the foreskin and glans is occurring as nature intended. The membrane that attaches the foreskin and glans, head of the penis, in the early years of a boy's genital development is called the synechia. As the cells of the synechia slough, the separation of the foreskin and glans begins. Sometimes the process begins at the tip of the penis and the sloughed cells (smegma) may never be noticed. In other boys, the cells are sloughed further back, white pockets form, and eventually the pockets coalesce to the tip of the foreskin. When the separation at the tip occurs, the body discharges the sloughed cells, just as sloughed vaginal cells are eliminated by the female body as new cells form.

Again, your son is perfectly normal and nothing needs to be done except to make sure everyone keeps their hands off his penis and to watch as he grows and develops as nature intended, without assistance. So, now you can relax!

My son is 1 1/2 and is scheduled to undergo surgery to correct hypospadia and cordee. He will need to be circumcised and the foreskin will be used to reconstruct his urethra. I am having doubts about the surgery, but do not want to wait until he is older when he would be more conscious, scared, etc . Three different
doctors are supporting the surgery. Is there any reason to question the necessity of this surgery. Thank you for helping us with this issue.

In the past couple of decades, we have come to realize that genital surgery may not be the best thing for infants and children. Adults who were born with ambiguous
genitalia, suffering shame, surgeries, and secrecy throughout childhood, have grown up and spoken out. They contend that they should have been left alone to make such decisions for themselves, rather than suffering the painful invasive surgeries in early life. Their organization, the Intersex Society of North America (www.isna.org) has a booklet that recommends against surgery for hypospadias.

You did not mention the severity of the hypospadias and chordee, which, of course, can be serious. If they are mild, perhaps waiting to see what happens would be
the wisest choice. There may also be a physician who is willing to spare your son's foreskin and do a less invasive surgery, if that's what is absolutely needed.

I understand that you have gotten three opinions. Sadly, reconstructive surgery is what most physicians learned in medical school. Since many physicians don't have a foreskin and learned nothing about the structures, functions, development, and care of the normal foreskin in medical school, they are oblivious to the importance of the tissue they so quickly suggest be amputated.

May I suggest you contact Paul Fleiss, MD, who has written two wonderful articles about circumcision for Mothering magazine, for yet another opinion. He is in Los Angeles, California,and his number is 323-664-1977. He's very willing to speak to parents on the phone.

I think you are very wise to still be asking questions. Surgery is irreversible, so you want to make sure that you are doing the right thing for your son.

Please let me know what happens. My best wishes to your son and his parents.

I'm not very much in favor of circumcision, but my husband wants our son to look like him. What do you suggest that I tell him?

Your question is a familiar one, somewhat specific to women in North America because they have a medical option about the care of their baby. Expectant mothers have protective instincts and know that cutting off any part of their normal, healthy baby is neither normal nor healthy. Your job, now, is to educate your husband. This is no easy feat. In order for your husband to understand your protective instincts and to acknowledge circumcision as a primal wound that interferes with maternal/infant bonding, disturbs breastfeeding, and undermines the baby's first developmental task of establishing trust, he's going to have to come to terms with what happened to him when he was too little to resist or escape a painful surgery. It's not easy for any man to recognize the harm that was done to him -- 20- to 40,000 specialized erogenous nerve endings amputated from his organ of power, pleasure, and procreation! In other societies, the phallus is revered, as in the fertility rituals upheld in Japan. Here, however, we do something different -- tragically different -- to the phallus, and the male to whom it is attached.

In the United States of America, we cut off the most erogenous part of the penis, and this was not done by mistake. During the mid-1800s, the foreskin of males and the clitoral hood (foreskin) and clitoris of females were excised to prevent masturbation. Doctors at the time thought that each person was born with a finite amount of energy and that over-exertion of that energy caused disease. So, doctors cut off the most erogenous tissue of male and female genitalia with the hope of preventing masturbation and over expenditure of nervous energy. Once the microscope was developed and the cause of disease was determined, circumcision was performed because of a fear of germs (early 20th century). From that point foreword, circumcision has been done out of fear. There was the fear of penile cancer (1930s) -- a rare disease of elderly men with a history of cigarette smoking and multiple sexual partners; fear of cervical cancer (1950s) -- because Jewish women had a low rate of cervical cancer until, during the sixties, they, too, became sexually active and contracted the HP virus responsible for sexually transmitted diseases; fear of sexually transmitted diseases (1960s & the sexual revolution) that circumcision didn't protect; fear of looking different than dad or boys in the locker room (1970s, when medical practices were questioned, e.g., tonsillectomies, radical mastectomies, episiotomies, circumcision, and when emotional excuses were adopted); fear of urinary tract infections (1980s with Wiswell's climb to fame through the use of methodologically flawed studies); and the fear of HIV/AIDS (1990s & 2000, due to Aaron Fink's assertion that circumcision would reduce the risk-- an experiment already performed in the USA, with the majority of males circumcised and the highest HIV/AIDS rate in the world. As we've proved, circumcision for the prevention of AIDS only produces circumcised corpses.).

So, in truth, fear is the coat rack and the excuses/myths of fear are what we hang upon it. It is fear that holds the practice up. Today, it is also fear of abandoning the dominant paradigm, the status quo, the current medical model, and the loss of dollars from a lucrative business.

Now, how do you educate your husband? First, may I suggest what one mother found effective with her husband. She went to www.nocirc.org (especially see "Important Articles" and NOCIRC Publications) and www.cirp.org and found specific articles that she wanted her husband to read. She printed out the messages that rang true to her. She enlarged them with her copy machine and printed them out. She took the enlarged text and attached it to the wall opposite the toilet of the family bathroom. That way, her husband was initiated to the information without confrontation. When sitting on the throne, he simply read the text. She changed the message several times over the next few weeks. Then, she began hearing her husband on the telephone with his friends, telling them about the issue. Not from Susan's words but from his own.

So, you need to feed your husband information carefully. He has his own primal wound to deal with in regards to this issue. Once you have him informed, you will be providing him with the best help you can give in his becoming a father -- he will become the protector! That's his job. And, you will have done yours.

Is any special care required for my intact son?

Your son's natural penis needs no special care. During the first few years of life, the inside fold of his foreskin is attached to his glans, very much the way the eyelids of a newborn kitten are sealed closed. The tissue that connects these two surfaces dissolves naturally over time -- a process that should never be hurried. The foreskin should never be retracted by force. During this period, immersion in plain water during the bath is all that is needed to keep the intact penis clean. Don't use soap on his penis because it will sting and it will destroy the beneficial bacterial flora that protect his penis from harmful germs.

The foreskin will become retractable when its inside fold separates from the glans (head of the penis) and its opening widens. If this hasn't happened prior to puberty, the hormones of puberty help to complete the process. Even if the glans and foreskin separate by themselves in infancy, the foreskin may not be retractable then because the opening of a baby's foreskin may be just large enough to allow for the passage of urine.

As a young boy, you'll notice that your son will pull his foreskin outward. This is normal and natural and no cause for concern; he won't hurt himself. The first person to retract your son's foreskin should be the child himself. Make sure his pediatrician understands that you do not want his penis touched or his foreskin retracted, and then watch closely to be sure your instructions are followed. Many doctors do not understand how to care for an intact penis because they weren't provided with this information in medical school.

Once your son discovers that his foreskin is retractable (a wondrous discovery for the intact child), he can easily learn to care for himself. Telling your son about retractability beforehand will keep him from becoming alarmed the first time his foreskin retracts.

The white emollient under the foreskin is called smegma. All mammals have this beneficial, necessary substance. Smegma moisturizes the glans and keeps it smooth, soft, and supple. Its antibacterial and antiviral properties keep the penis clean and healthy.

When your son is old enough to bathe himself, he can wash his penis when he washes the rest of himself. Simple instructions for rinsing his penis once the foreskin is retractable may be helpful.

• Gently slip your foreskin back
• Rinse your glans and the inside fold of your foreskin with warm water.
• Pat it dry if you like.
• Slip your foreskin forward, back in place over the glans.

When I began my work in 1979, the circumcision rate in the US was about 85%. The rate has dropped 30% in just 24 years, a remarkable feat for a grassroots movement. Rarely does social change occur so quickly. In the early 1980s, parents would ask me, "What should I tell my son when he asks why he's different than his circumcised friends?" Today parents ask me, "What can I tell my son when he asks why we let someone cut off a part of his penis when his friends are not circumcised?" We are coming to a time of "have" and "have not," and the boys without a foreskin are the ones who now are feeling deprived.

Just as it should have been important for parents of circumcised boys to teach their sons respect for individual differences, the same is true now. Raising an intact boy should include empowering him to compassionately respond to anyone who might ever tease him about being normal and whole. As my grandson said to me when we had this discussion before he started kindergarten, "Don't worry, Nana, even if a circumcised boy did tease me, I would never tease him back because he's been hurt enough already."

Mothering magazine has printed many informative articles on the subject of circumcision to educate parents. Two of these are excellent articles by Paul M. Fleiss, MD, "The Case Against Circumcision," which describes the structures, functions, development, and care of the normal penis and why it should not be altered, and "Protect Your Uncircumcised Son: Expert medical advice for parents," which explains the reasons doctors perform post-neonatal circumcision and why it is almost never necessary (both are available from Mothering as a reprint). Dr. Fleiss has also written one of the most valuable books ever published on the subject, "What Your Doctor May Not Tell You About Circumcision: Untold Facts on America's Most Widely Performed -- and Most Unnecessary -- Surgery (Warner Books, 2002), available in most book stores.

I suggest you provide your sister-in-law with Dr. Fleiss' two articles and his book, saying something like, "This is information I wish my mother had read before my brother was born. I know she did the best she could with what she knew at the time and I know you did, too. But I'm sure that this material would have made a difference, so I hope you'll take the time to read it before the birth of your next baby."