Thursday, July 30, 2015

Getting the Percentages Right

After a bris, I try to explain to parents what things will look like over the next few days, weeks, and months as the circumcision goes through its different stages of healing.

There is swelling, a reminder of what things look like before vs after, there are stages of healing, a couple of long-term reminders:  the Chubby Baby Syndrome and the Fusion Challenge.

I often comment about the importance of using a marker to indicate where the edge of the foreskin is before circumcising. When this is done in advance of the bris, and when the mark is actually followed during the circumcision, the incision can be very even and beautiful (to quote a colleague who loves to use the word 'beautiful' to describe his work).

But what are we marking? Why can't a rough estimate be sufficient?

There is a very definite point where the foreskin ends, and that spot is where the skin of the shaft lies naturally beneath the outer edge of the glans/corona. A "beautiful" circumcision has all of the foreskin plus the membrane beneath it removed at exactly that spot.

However, owing to the reality that most circumcisions are not accompanied by a complete removal of the membrane beneath the foreskin, there is a benefit to removing a little more than just the foreskin, because leaving MORE skin plays a significant role in the Fusion Challenge, and especially in the Chubby Baby Syndrome (I get many questions from mothers who ask about the need to pull down the skin over the longer term. Depending on how the circumcision goes, this is an issue for some people, or may never be an issue at all.)

So let's say there is 100% shaft skin to leave behind. A good mohel will actually leave between 88-95% of the original shaft skin, since the remains of the membrane will make a proper fusion with the shaft skin and fill in the remaining 5-12 percent of the shaft as needed.

Without using the marker, the chances of removing 50% or more of original shaft skin are not unheard of. And the incision has a decent chance of being significantly unbalanced - one side having more skin removed than the other (a little uneven is not bad - these things have a tendency to heal nicely nonetheless). This form of operating is a tremendous disservice to any baby.

Being educated about circumcision takes a lot of guesswork out of the process. Best of luck to everyone!

Sunday, July 19, 2015

The Good Ole Perks

A few years ago, there was a to-do in some Israeli newspaper or in the world of a sector of Jewish blogosphere over a Facebook post posted by a rabbi who announced he had shaved during  Sefiras Ha'Omer. He also mentioned that he is a mohel.

Why people made such a to-do is beyond me. The custom not to shave during Sefirah is just that - a custom. And the fact that he is a mohel gives him every excuse to shave on the day of a bris.

And, the same holds true for the mohel (and the father and the sandak) during the Three Weeks, and even the Nine Days. 

So if you want to have every excuse to shave during the three weeks, look into becoming a mohel. Get busy! And every bris should come your way so you should grow in your experiences and feel confident (and people should feel comfortable with you) so you can shave without hesitation during the Nine Days.

Or, you can be Sefardic. :/

Sunday, June 28, 2015

One of Our Favorite Topics - In the News Again!

A wonderful perspective about metzitzah is presented below.
Sadly it will be ignored by the right wing community that has turned this issue into dogma, that has equated this ancient and halakhically unnecessary practice with those that originate from Sinai.

In the end of the day, the practice is a Chillul Hashem.

It turns Jews away from Bris Milah, either completely, or opting for hospital circumcisions which are often before the eighth day of life.
It turns non-Jews into people who degrade Judaism and its practitioners.
And it is near impossible to justify in the realm of modern sensibilities (and there are halakhic alternatives!).

It's not as if there isn't history to metzitzah being problematic. And even right-wing rabbis coming up with an equitable solution which maintains metzitzah (for those that require it) while doing it in a way that is hygienic and antiseptic AND halakhically acceptable. (Even though if pushed most would probably admit that metzitzah is not a necessary component of bris milah, certainly not on the level of the circumcision itself).

I don't pay attention to those who says "It's time for the Jewish people to get with the times and stop circumcising their sons." These people are ignorant of the Covenant and our attachment to it. They often "think" they have a solution, which they call a Brit Shalom, but they have made up a ritual that ignores everything that is written in Bereshit 17 about Avraham's descendants and God.

Anyway, enough about this. Here's a link + the full text of the article.
****************************************************************************
http://www.thejewishweek.com/editorial-opinion/opinion/nyc-metzitzah-policy-insufficient

NYC Metzitzah Policy Is ‘Insufficient’
Tue, 06/23/2015
Special To The Jewish Week

As Jewish physicians we feel a special responsibility to speak out on health matters that uniquely affect the Jewish community. The policy recently adopted by the City of New York to respond to herpes simplex virus (HSV) infection risk as a result of a certain form of ritual circumcision is inadequate. For Jewish medical professionals to remain silent during this discussion would be, in our judgment, inappropriate.
HSV, which commonly causes “cold sores” and genital herpes, can result in death or permanent disability in newborns.
There have been multiple cases of newborn males with laboratory-confirmed HSV infection following out-of-hospital Jewish ritual circumcision. There is strong evidence that in the majority of these cases the infection was associated with metzitzah b’peh, in which the mohel places his mouth directly on the newly circumcised penis and sucks blood away from the wound (direct orogenital suction, abbreviated as DOS). This represents an ancient practice, but since the formulation of germ theory in the 1800s the overwhelming majority of traditional ritual Jewish circumcisions no longer employ this practice, instead using alternative methods of suction. Some members of the charedi community continue the practice of DOS.
Keeping a campaign promise, Mayor de Blasio has rescinded the requirement that parents give written consent prior to the performance of DOS on their newborns. Instead, when a baby contracts HSV following DOS, if the mohel is proven to have the same HSV strain as the infected baby by DNA testing, then the mohel will be banned for life from the practice. It can sometimes require multiple DNA tests to establish a match.
We think the policy is insufficient.
Circumcision is surgery and can transmit infection if not performed under antiseptic conditions. Oral contact with an incision by a person who is an HSV carrier, even if he is unaware of an open sore, risks transmission of HSV and other pathogens. Alternative means exist by which blood may be drawn from a circumcision wound such as a sterile glass tube or sterile gauze.
Several arguments have been voiced either in defense of DOS or to mitigate concern. The ones we, as physicians, are least qualified to respond to are theological. Genesis [17:10-11] instructs “every male child among you shall be circumcised. ...” The Babylonian Talmud states that “if a mohel does not perform suction, that is deemed dangerous and he is to be dismissed.” While defenders of DOS will invoke an interpretation of the Talmud passage to support it, the overwhelming majority of Orthodox rabbinic rulings — as well as those of the other religious streams — either deem DOS as being inconsistent with Jewish law and contemporary knowledge of hygiene or, at the least, acknowledge that removing blood by other means, such as with sterile gauze or a sterile glass tube, is preferable.
Additional arguments have been voiced in defense of DOS. The first is that, according to some New York infectious disease specialists, the link between HSV and DOS and newborn death or severe brain injury has “not been proven.” Those holding such view seem unpersuaded by the detailed analyses published by the U.S. Centers for Disease Control (CDC), which establish the link and the ratio of newborn infections of HSV type 1 v. type 2. Scientific evidence supporting the causal link between DOS and HSV was recently reviewed by six members of the Albert Einstein College of Medicine faculty in the Journal of the Pediatrics Infectious Disease Society. If individuals, however, are not persuaded by sound virology and epidemiology research, we would bet that no adult who understands the transmission of disease by microbes would consent to a human being’s putting their mouths upon a fresh surgical incision.
The second argument is the assertion that, if a mohel rinses his mouth with wine or an antiseptic mouthwash, the risk of HSV infection by DOS is eliminated. While prolonged exposure to alcohol in a laboratory Petri dish can indeed inactivate HSV, any claim that a dilute alcohol swish in the mouth, with its multiple nooks and crevices, will prevent HSV infection is fanciful.
The third argument is that the new NYC policy represents a reasonable compromise, protecting an individual’s right to practice his/her religion while employing the tools of public health to limit the spread of disease. But allowing some babies to suffer the consequences of HSV infection before taking any action against the offending mohel, who must be proven to be the culprit by DNA testing, is not a preventive public health measure. It is too little, too late. DOS violates a baby’s right to be protected from an obvious impending harm. The government has an overriding interest in protecting infants who cannot speak for themselves.
DOS ignores the teachings of modern medicine and the overwhelming consensus of modern rabbinic rulings. Behavior by mohelim and local politicians that ignores fundamental principles of hygiene, and abrogates their responsibility to protect innocent children, is shameful and simply wrong, despite their express desire to maintain ancient religious traditions.
The Jewish medical community should strongly affirm its respect for religious pluralism and sectarian particularism. It should dedicate itself to working with rabbinic leaders to make them aware of the unequivocal scientific and medical facts about the dangers of DOS and the urgency of using existing safe and acceptable alternatives. Moreover, we urge our political leaders to go on record supporting this approach.
This statement is from Dr. Edward R. Burns, executive dean, Albert Einstein College of Medicine, Bronx; Dr. Robert Goldberg, executive dean, Touro College of Osteopathic Medicine, Manhattan; Dr. Laura Gutman, associate clinical professor emeritus, Duke University School of Medicine, Durham, N.C.; Dr. Robert Gutman, consulting professor, Duke University School of Medicine; Dr. Edward C. Halperin, chancellor and CEO New York Medical College, Valhalla, N.Y.; and Dr. Allen M. Spiegel, dean, Albert Einstein College of Medicine.

Tuesday, June 16, 2015

The Shabbos Bris

I had a bris on Shabbos this past weekend. Shabbos brisses are not as common as other days of the week (though statistically, babies should be born more or less equally on every day of the week). Of course, a baby born on Saturday via c-section will not be having his bris on Shabbos anyway. 

What is Allowed for a Shabbos Bris?

The Mishnah on Shabbat 133a says the following:
משנה. עושין כל צרכי מילה [בשבת]; מוהלין ופורעין ומוצצין, ונותנין עליה איספלנית וכמון. אם לא שחק מערב שבת - לועס בשיניו ונותן, אם לא טרף יין ושמן מערב שבת - ינתן זה בעצמו וזה בעצמו. ואין עושין לה חלוק לכתחילה, אבל כורך עליה סמרטוט. אם לא התקין מערב שבת - כורך על אצבעו ומביא, ואפילו מחצר אחרת.
We perform all the needs of circumcision on Shabbos. We circumcise, uncover the corona, and draw out the blood; then place a compress and cumin on it. If he did not crush the cumin before Shabbos, he chews it with his teeth then applies it. If he did not mix together the wine and oil on Friday, he applies each one separately. We may not prepare a new bandage, but a rag can be wrapped around it. If it wasn't brought to the place of the Bris in advance of Shabbos, he can wind it around his finger and bring it [to the bris] - even from a different courtyard.
The key phrase is the first one: we do everything that is necessary for the bris itself, meaning the moment of the actual circumcision. Many things that are done during a circumcision are otherwise a violation of Shabbos: the instruments are muktzeh, causing a wound, marking where the foreskin is, etc/

What is Different At a Shabbos Bris?

The main difference is in the immediate aftermath of the circumcision. If the mohel notices that there are tzitzin she'einan m'akvin - portions of the skin or membrane that might be a little asthetically unpleasing but are not on the glans - they may not be removed/cleaned up on shabbos. If, however, these leftovers would render the bris unkosher, then they could be removed on Shabbos, in the immediate aftermath of the bris. 

Anything Else?

Once the circumcision instruments are used and no longer needed, they become muktzeh. If the mohel can leave his things in a safe place where they won't get misplaced or accidentally taken, he should do that, rather than take them home with him. 

Finally - an older mohel told me this one long ago - if the mohel is inconvenienced in any significant way, on account of his having to leave his family for shabbos for example, it is certainly appropriate for the bris family to make arrangements for where he'll stay (if he can't on his own), and compensate him for his travel, bris services, and time away.

Thursday, June 11, 2015

When Naming Your Baby...


Most of what is written here is true for both boys and girls. Owing to the nature of this blog/website, the essay is written in the masculine.

Aside from bringing children into this world, parents have the awesome responsibility of giving each child a name. Some names speak to the significance of the baby in the lives of his parents, or a reflection of his personality. Sometimes he is named for a loved one - depending on the family's custom, the honored name might be carried by a living person, or it comes from someone who is deceased.

Some people decide their baby’s name months in advance of his birth. Others wait for the inspiration to come after the baby is born.  

How does one choose a name?

 Honestly, every couple has to find a method which works for them. And they should agree upon the method and the name, and be happy with their decision. I have spoken to people months after a bris, asking “how is ___ doing?” only to be told that that is no longer his name. It didn’t feel right. Hopefully this is not the experience most people are having (in my experience it is very rare, but it does happen).

 Some Sefardic cultures honor a living grandparent by giving the first grandchild the name of that grandparent – either as a first name or as a middle name. In the book Yalkut Yosef, the author says the name of the paternal grandfather takes precedence over the maternal grandfather, but he also says such a preference is not binding. (Some parents come from different cultures – especially in a “mixed” Ashkenazic wife/Sefardic husband situation.)

If a child is to be named for someone who is deceased, the choice is relatively simple when the same name is being given. When the exact name is not being transferred to the child, it becomes more complicated (see below).

If parents are choosing a name they like, it’s a relatively simple matter as well.

It becomes a little more complicated when parents are looking to be “inspired.” But, like many important decisions in life (such as when you decide to get married), when you feel it’s right, you know it’s right.

Different Names For the Same Child

Some parents put a child’s Jewish name on a birth certificate. Others put an Anglicized version of the name (such as Samuel for Shmuel, Gabriel for Gavriel, Jacob for Yaakov) on the birth certificate. Others put a related name (Max for Mordechai, Dylan for David). Still others have completely different “English names” than their Jewish names. Rex Ryan = Moshe Aharon. My uncle’s name is Michael, but his Hebrew name is Binyamin.  

When Naming For Someone But Not Giving the Exact Name

My great grandfather’s name was Chuna – a Yiddishized diminutive of Elchanan. My parents wanted to give me the Hebrew form of the name, so my middle name is Elchanan. This kind of thing happens all the time.

Gramps was named Mottel – a Yiddish version of Mordechai. The parents loved Gramps, but don’t want to name their child Mottel. They might stick with Mordechai. If not, they’ll typically want to keep the initial, so they might opt for a modern name that begins with M: Matan, Matanya, Ma’or or a simple classic such as Moshe or Meir.

Sometimes a boy will be named with great grandma in mind. Her name was Mary. Mary sounds like Meir. Meir also sounds like Miriam. The Biblical Miriam was Moshe’s brother, another option. Or Grandma’s name was Rose. Rose becomes Reuven or Ronen, etc

Who Gets to Choose the Name?

The baby’s parents. No one else.

A Good Rule

A friend of mine told me that he accepts and welcomes all name suggestions from family (new baby’s grandparents, for example) until the end of the second trimester of the pregnancy. This is an excellent rule. The people who are not the parents get to have their say. Then the parents can decide what they will do.

A Story

In Rabbi Herschel Schachter’s book “Nefesh HaRav,” he recounts how the subject of his book, Rabbi Joseph B. Soloveitchik, was given his name Yosef Dov/Yusher Ber.

Rabbi Chaim Soloveitchik, the famous Brisker Rov, and grandfather of the new baby, came to speak with his daughter-in-law, the baby’s mother. He told her that according to the custom and the law she (as the mother) has every right to name the baby after whomever she wants, or in whatever manner she wants (the mother gets first rights, even over the father).

And he also told her that to date no one had been named for his father, the Beis HaLevi, Rabbi Yosef Dov Soloveitchik, who had died 11 years earlier.

It is important to interrupt this story with two fun facts: 1. R’ Chaim was known to be squeamish. He did not like to serve as Sandak. 2. It is a great honor for parents, if the baby’s grandfather serves as Sandak, holding the baby during the actual circumcision. In general, it is customary to honor a person whose character traits and Jewish life are honored and respected by the parents to be the Sandak.

R’ Chaim told her that if she would agree to name the child after his father, he would agree to be Sandak, even though it was a role he shied away from.

She agreed. Apparently having R’ Chaim serve as Sandak was more important to her than her own choices of names she may have conferred onto her baby. He was named Yosef Dov/Yusher Ber, just like his great grandfather.

The point of the story is not that R’ Chaim got his way. It’s that he knew he didn’t have to get his way. He wasn’t supposed to get his way. His daughter in law did not have to agree or listen to his suggestion. It wasn’t his call. And he was going to be OK with that – he just wouldn’t swallow his squeamishness and serve as Sandak if they chose to go a different route with the baby’s name. Which would have been fine. Someone else would have been the Sandak.

In Conclusion

It is certainly a wonderful honor to name a child either after a living person or after a deceased loved one or ancestor.

But the parents of the baby must never feel pressured to give their child a name they don’t want to give. Naming a child is a privilege afforded to parents, and as they bring the child into the world, they and they alone have the final say in the baby’s name.

Too many times have I seen the new parents compromise on the name they end up giving their child, against their own wishes, on account of the pressure they feel from their own parents.

If they choose to honor a loved one and give a child the name that has been in the family, that is beautiful. That is wonderful.

If they do not, it says nothing of their relationship with that deceased individual, or with the kin of the deceased.

All it says is that they wanted a different name for their child. And that they exercised their rights as parents to give him the name they wanted to give him.

I bless all parents and grandparents to love all of their children unconditionally. When your children choose to name your grandson using a name that is emotionally meaningful to you, be grateful. If they do not choose such a name, they are not being hurtful or malicious. They are giving their child the name they wanted to give their son. Your grandson will be loved by you all the same. It is not worth making any kind of protest. And hopefully you’ll live long enough that your grandchildren will never have a need to name anyone after you (unless you are Sefardic).

Wishing everyone much nachas…

Wednesday, June 10, 2015

When There is No Bris

Sometimes a baby is born with an anatomical condition that does not allow for a traditional bris.

Here are layman's terms for some of these circumstances. Understand that these situations are a result of how the baby develops in utero, and are not a reflection of anything wrong with the baby or his parents. In some cases, this kind of development is genetic.

Thank God we live in a time in which highly skilled surgeons can make a relatively easy job of fixing the baby's genitalia, so he will not only have a beautiful circumcision, but in cases where certain elements of functionality would have been a little off, the correction is nothing short of miraculous. In a different time, some of these babies would not grow up to become fathers.

1. No foreskin

If a baby develops without any skin covering the glans, there is nothing to remove. The only procedure is Hatafat Dam Brit - drawing a minimal amount of blood from where the foreskin would have been, just above where the glans begins (not from on the glans itself).

2. Hypospadias

This is the condition in which the hole of the penis - the urethra - is not where it should be. It could be a little off center on the tip of the glans. It could be below the glans. Or in more extreme (and very rare) cases, it could be anywhere on the shaft or even the scrotum. Depending on the severity of the case, reconstructive surgery would align everything properly and allow for a productive future. If the hole is on the shaft or the scrotum, a boy would always have to sit when going to the bathroom, and he would never be able to be a father. (If it's only a little off center, most surgeons would recommended leaving it alone).
In the event that surgery would be required here, the surgeon needs as much skin as necessary. If the plan is for there to be a circumcised look afterwards, the surgeon will know this and will produce that result. But anything a mohel might do in a classic circumcision would do more harm than good for the baby.
[In most surgery-required-hypospadias cases I've seen, the hole is at the bottom of the glans, at the spot where the frenulum is.]

3. Chordee

The natural position the penis takes when erect is upward. In simple terms, chordee prevents that, as internal tissue pulls the erection downward, and even makes a downward curvature.

THERE ARE OTHER CONDITIONS AS WELL, BUT THESE ARE THE MOST COMMON

So What Is Done With the Bris?

There is no bris. The circumcision will be taken care of during surgery. The best route is to find a Jewish doctor (ideally observant), who will say the proper bracha (blessing) and have in mind the fulfillment of the mitzvah. If the surgery is not done by a Jewish doctor, the circumcision can be turned into a "Bris" through Hatafat Dam Brit, after everything has healed.

What About Family and Friends Who Are Looking to Attend a Bris?

They should be understanding that the baby's best interests do not include a formal bris. They don't need to know all the details. Some people are embarrassed to discuss the baby's circumstance. But it's really nothing to be embarrassed about. No one has done anything wrong. And the baby will be fine. And everything will work properly after the surgery.

Parents will do well to inform their family and friends something along the following lines:

Dear Family and Friends
After consultation with doctors and mohels, we have determined that a formal bris is not in our son's best interest. He is fine. He will have a proper bris - הראוי לו ובזמנו - for his particular needs at the right time.
In the meantime, we will be naming him at such and such time and place, and we would be honored if you would join us then (or at a different time) when we have a fitting celebration for his arrival.

Tuesday, May 12, 2015

Doctor vs Mohel

No, it's not the fight of the century.

But it is a question which comes up a lot. So here is the simple answer, from a mohel, of course.

[Though see here for a Reform Rabbi's answer http://www.jweekly.com/article/full/15332/which-one-is-better-doctor-or-mohel/]

Every person must do research and find the best operator for your needs, and for your situation.

In an ideal world, the person you are hiring is an observant Jew, who understands the significance of Bris Milah, the covenant, and all the laws associated with the performance of a bris milah. Whatever character traits you'd like in the person might also be significant to consider, when thinking about what kind of representative you (especially the father, who is really hiring the person to perform this mitzvah in your place) want to fill your place in this very important mitzvah.

ANYONE WHO FILLS THESE ROLES TO YOUR DESIRES IS A GOOD HIRE. [Even better, if he uses a marker when operating...]

Other things to consider:

1. Specialist

Who does more procedures? Many doctors I know (they are usually observant Jews) highly recommend a mohel over a doctor. They have the attitude that the mohel is a specialist. This is his field. He is the expert. Being highly trained in a specific discipline, and specializing in this unique field, makes the mohel most qualified to do this. [Obviously if a doctor happens to also be a mohel, this will work to his advantage in some people's eyes. But honestly, the service a doctor/mohel and a mohel provide is the same thing with respect to the circumcision and the result, except perhaps in two areas as I'll note below]

2. Method

Most doctors are more comfortable using a clamp - such as the Gomco or the Mogen clamp. Do research on these items, to decide if they are right for you. Some mohels (usually on the very modern side, or in the Conservative and Reform movements) use the Mogen clamp or a modified Mogen clamp. Most traditional mohels use what is called in Hebrew a Magen (מגן), a traditional "shield" (which protects the glans and the scrotum) which does not have a clamping arm. THIS IS THE PROCEDURE I USE While no procedure is completely bloodless (a real bris is not supposed to be bloodless), the clamps are supposed to cause less bleeding. The traditional method may have a little more bleeding, but in the hands of a good mohel, it is absolutely nothing to worry about.
And, as Rabbi Cartun points out in the article I linked to above (here it is again), the speed in which a mohel operates is usually much faster than any physician.

3. Numbing

See here for a discussion about this. Most doctors will give the baby several injections to create a nerve blockage. While the baby might not feel the bris, the baby will feel the injections (and may feel them hours later as well). Some mohels recommend or provide a topical anesthetic. Depending on its strength, it may remove the pain of the actual circumcision.

4. How is baby held?

Numbing does not help the baby's discomfort at having his legs held down. Most mohels have the sandak holding the baby's legs, and letting go as soon as the procedure is over. Many doctors might utilize a circumstraint to hold the baby, leaving the baby in an uncomfortable position significantly before and sometimes after the procedure as well.

5. Track record and Touch-ups
Probably the most important question is "what is the track record?" While I don't have statistical evidence, I have spoken to pediatric urologists and pediatric surgeons who have told me anecdotally that they do many more touchups on circumcisions done by doctors than by mohels. [Don't trust me. Ask similar doctors that you may know.]
Doctors tend to take off a little less foreskin, which leaves the penis looking uncircumcised in many cases of touch-up necessity.
[Many "problems" disappear when the child gets out of diapers, and certainly by puberty. But for babies who need their circ to be revisited - it is worth asking people and doctors who has a better track record.]
A surgical marker could resolve this issue, but most mohels and doctors don't use one (though I do! :))

I guess it is clear that I prefer a good and experienced mohel over a doctor. Surprised?