Healthcare Provider/s of our son, ______________________
In providing health care for the above named person, I agree to the following:
1. This boy is not circumcised. He was left intact, on purpose, by his parents at birth, who refused the operation at that time, as they feel that it is not a medically indicated procedure for infants. They intend to keep him intact, and are informed on the proper (and wary of the improper) care of the intact penis.
2. The proper care of the intact penis is to "leave it alone" (Dr. Benjamin Spock and many others). His parents do not retract his foreskin, as it is unnecessary, and likewise will not allow anyone else to do so either. Only a very small percentage of babies and young children have foreskins that are retractable. In the majority, the foreskin is firmly attached to the glans (head) of the penis in much the same way as the fingernail is attached to the finger, and DOES NOT retract.
Furthermore, any retraction of the foreskin before natural separation has occurred, as early as age three, but as late as early adulthood, can cause irreparable damage through bleeding and the formation of adhesions. The ONLY person who may retract our son's foreskin is our son himself, once natural separation has occurred.
3. There is NO reason whatsoever to touch our son's penis during an exam: Not "to see inside"; not "out of curiosity"; not "to break adhesions (the attach points are synechiae, not adhesions)"; not "to see if the foreskin retracts"; not "to clean it", etc., etc.
I therefore agree that I will not touch your son's penis for any reason. If I genuinely have a concern about whether his urethral opening is "fine", I will bring this point up to his parents and they can decide if there needs to be anything done. If they DO decide that it needs to be looked at, only THEY, not I, will touch his penis.
4. The intact penis needs no special care, such as "irrigation" or "loosening of the foreskin". His parents wipe the OUTSIDE with soapy water at bath time (and rinse after with warm water), and with water or baby wipes at each diaper change. Any "cleaning" other than the afore-mentioned can cause infection, and problems which stem from infections. When his foreskin has naturally separated on its own, his parents will inform him of the proper care concerning retraction, and concerning cleaning; (i.e. to retract gently and wash the entirely exposed foreskin with warm water.)
5. As our son's parents, we have written this document as a preventative measure only, in response to a previous negative experience. It is not meant to single out any one person, but is meant to relay our wishes and concerns to all health care providers who see our son.
I have read the above information. I understand what I have read, fully, and agree to what is written herein. I will adhere to the above information, and know that, if I do not, it will be seen in the eyes of his parents, as purposeful abuse toward our son. If I sign it, I will receive a copy of this document. If I do not agree to all that is written here, I of course have the right not to sign this form, and this boy will not be looked after by me for his medical care.