Thursday, October 29, 2009

Why we stand at a bris

The mishnah in Bikkurim 3:3 says that when the first fruits were brought to Jerusalem during the holiday season in the times of Temple, workers would stop what they were doing to greet those carrying the fruit.

Rabbi Ovadiah of Bartenura asks why they did this. While there is a custom/law to stand out of respect for scholars, the rule is inapplicable to workers who are busy at their trade. If one need not stand for scholars, one certainly should not have to interrupt work to stand for regular people carrying fruit!

He answers that we are not standing out of respect for the persons or for the fruits. We are standing because at the moment the actual mitzvah is being performed, it is beloved. Thus we stand out of respect for the loving feeling we have for the mitzvah at the time it is being fulfilled.

This is why there is also a custom to stand for the pallbearers who carry the deceased past us and [on the opposite end of the circle of life] to stand for those who carry a baby into his bris.

Those who participate in a bris know the joy of the moment, the special feeling in the room. Emotions run extremely high when those attending have a deep understanding of the special significance of the bris, and have a feeling that the mitzvah being fulfilled is indeed beloved to all who are present.

One way to express respect garnered from the love emotion is to stand when subject of that love, the item or person, passes by.

As this is certainly the case for the baby at a bris, and hopefully for the mitzvah being fulfilled through the baby, we have the custom to stand for the bris itself.

Wednesday, October 28, 2009

Funny story? You decide...

Part I

At a bris of a family I knew well, I knew one set of the baby's grandparents, who lived in my community, but not the other set of grandparents. When I met the mother-of-the-baby's father for the first time and figured out who he was in relation to the baby, I made the mistake of saying to him, "O! You must be the other grandfather."

I meant no harm - simply that I knew one grandfather already, and since the baby has another one, I've now identified him.

In a half-joking but half-extremely-serious tone he said to me, "The other grandfather? I am not the other grandfather! I am the baby's grandfather. There are two grandfathers. Neither one is the other."

At least he was fair to his mechutan (is there a word in English for your kid's in-laws?).

Even though I meant no harm, I learned my lesson. Now I tell the story of how I learned not to call any grandfather the "other grandfather."

Part II

At a different bris, the family kept on calling up "the baby's grandfather" to participate in the ceremony - except that there were four of them! Grandfathers, I mean.

Finally, when the last grandfather was called up to serve as the sandak, who holds the baby during the bris, as I was positioning the baby on his lap, I told him the story (Part I).

I said, "I once made a mistake, so I never call any grandfather 'the other' anymore."

Without missing a beat, he said, "Well there were a lot of mistakes made here. And that is why there are four grandfathers."

Tuesday, October 27, 2009

Bris Humor

Here is a quote from Rabbi Joseph Telushkin's "Jewish Wisdom," p. 141 (William Morrow, 1994)

“My friend Rabbi Jack Riemer of Miami likewise expresses great exasperation at the obscene jokes that frequently are told by people attending a circumcision. Turning the sacred ceremony through which a male Jewish baby enters the covenant into a source for ribald humor demonstrates how obscenity can desecrate the sense of the sacred. For if entering the covenant is turned into a source of jokes, then the covenant itself eventually will be treated as a joke.”

The sentiment is so true. (I only disagree in that I believe the boy enters the covenant when he emerges from his Jewish mother, as does a baby girl who will never be circumcised, when she emerges from her Jewish mother. The boy bears the mark of the covenant, the sign of the bris (אות ברית) at his circumcision.)

The covenant is critical to the definition of the Jewish people. If we disregard or make light of it, it will become meaningless.

At just about every bris at least one person will approach me to see if I've "ever heard this one." One of my colleagues likes to say, "I have respect for that joke, because it's older than you and me combined."

It is a rare occasion when someone tells a joke related to bris that I have not heard.

It is even more rare if the joke I am told is appropriate and worthy of being repeated.

Let us save our inappropriate humor for a night on the town, and minimally preserve our dignity when we have the chance to show the utmost respect for our tradition and heritage.

Why not?

Wednesday, October 21, 2009

What to Prepare for a Bris

Every mohel has a similar list of items you'll need for the bris and for caring for the baby after the bris.

Here is my list:
  • 2 pillows (to hold the baby before, during and after the bris)
  • 1 small wastebasket (for packagings, bandages, and the occasional dirty diaper)
  • 5 disposable diapers with wipes (in case baby soils more than his share...)
  • 5 hospital-style receiving blankets (not expensive blankets) (see previous)
  • 1 large tube of A&D Ointment (with the gold label) (NOT the "cream") (to lubricate the bandage)
  • 1 box of 25 individually wrapped 3"x3" gauze pads (to put on top of the dressing)
  • 2 tubes of polysporin (ointment) (or polybacitracin) (For after the dressing is removed)
  • 1 bottle of sweet kosher red wine (for the blessings which accompany the bris)
  • 1 kiddush cup (to hold the wine :) )
Italicized items can be purchased at any pharmacy, and the ointments can be generic


The setup of the room can be found at this link (or http://www.mohelinsouthflorida.com/2009/10/typical-bris-set-up.html)

Covenants in the Torah

In the weekly Torah portion, we have entered the territory in which most of the covenants between God and humans were forged.

The first covenant is forged using the rainbow as a sign: Genesis 9:12, 15
The rainbow serves as a reminder that all of humanity will never again be destroyed with water. This covenant is between God and all of humanity

The second covenant is made over the mark of circumcision: Genesis 17:10-11 (read the whole chapter!)
This is between God and Abraham's descendants and household (Abraham passes on the tradition of this covenant to his son in Genesis 21)

The third covenant is created through the Shabbat: Exodus 31:13-17
This covenant is between God and the Children of Israel.

The rainbow, circumcision and Shabbat serve as a sign (אות) of God's role and involvement in the world. Circumcision and Shabbat serve as a mark of the special connection the Jewish people have with God.

On one hand, this is a very cursory view of these covenants, but on the other hand, for the God-fearing believer, these are very deep concepts.

The rainbow is external - it is for all of humanity.
Circumcision (as a covenant) is a one time deal which is difficult when it happens, but you don't really notice it beyond that. It is for Abraham's descendants and his household, not as general as the covenant of the rainbow.
Shabbat is, for the uninitiated, more difficult, more taxing, more long-term commitments, and it involves the entire body, on a weekly basis, and is exclusively for the Children of Israel.

We go from very general to very specific. What does this say about God? What does it say about different peoples?

Monday, October 19, 2009

Sterility and Cleanliness - Can't Emphasize Enough

Circumcision as Surgery - An Observation

Today I accompanied a pediatric surgeon friend of mine to the O.R. where he performed a circumcision on a three month old baby.

Those who do circumcisions strictly for non religious reasons have many options for how to do it. They can do it in the doctor's office, in their home, in the hospital with local anesthetic, or in an Operating Room, under general anesthesia.

It is a different kind of experience, watching a procedure I knew so well, and a result I am so familiar with, done in a completely different way. Surgeons have the luxury of all the time in the world. There is no crying baby, no nervous mother who only wants the baby to stop crying and for the mohel to leave him alone. And just about any error in the course of the procedure can be corrected right away without anyone being the wiser.

Emphasis on Sterility

There is no compromising on the sterility of the procedure in the operating room. Sterile drapes are put all around the surgical field. All instruments have the same level of sterility as for open-heart surgery. The surgeon and his assistant do a full scrub before donning their surgical robes and sterile gloves.

And why should they act any differently? They have a responsibility to assure that the risk of infection is minimized under their watch. At all costs.

The beef

I understand that the nature of a bris makes the sterility degree of an operating room nearly impossible to achieve. And thankfully, the bris usually heals without complications and without problems.

But...
  • I see too many mohels operate without gloves.
  • I see too many mohels who wash their hands and then touch everything from the baby's clothes to a briefcase on the floor before starting the bris.
  • I see too many mohels operate after putting their "sterilized" instruments onto a laundered diaper cloth handed to them by the baby's mother five minutes earlier.
  • I see too many mohels who have no regard for sterility, and explain their ways by virtue of their unverifiable track record and their inability to change their ways after having done things this way for decades.

There should be no tolerance for anyone treating your baby and his fresh wound any differently than how a fresh wound would be treated by medical personnel in a doctor's office or under close to O.R. conditions. Mohels are not perfect, but they can be much better.

While infections are uncommon (rare), they should be non-existent. And infections in a baby which come from the bris can be life-altering if not deadly.

Sunday, October 18, 2009

Important Lesson I've Learned on the Job

Over the years, I have been privileged to serve as mohel for parents at all stages of parenthood. First timers, Second timers, etc. up to tenth-timers. I've worked with parents of twins (a number of times) and triplets (twice).

Thankfully, most births are without complication, or with minimal complication.

But I once had the sad role of being the mohel for a premature twin who lived only one day. (There is a custom to circumcise baby boys who do not survive, so their body may bear the mark of the covenant. You may or may not agree with it, but for the parents who lose a baby so soon after birth, this can be very comforting.)

And I've been the mohel for babies who came against all odds, after their parents experienced numerous miscarriages, or many years of infertility - treated and untreated.

I was once called to do the bris on a baby whose parents - both of them - are cancer survivors. I did not know this about them until after the bris. The husband/father gave the most emotionally packed speech I have ever heard at a bris, and I kid you not when I say there was not a dry eye in the room. Their friends and family all know their story, and they all celebrated the birth and bris of that baby in a way I hadn't seen and haven't seen since.

So here is the lesson:

You never know what people go through before having or in order to have a baby. One father put it to me this way: "People keep saying to us, 'why are you waiting? Don't you know it's better to have the kids closer in age?' We have one daughter, and we've had nine miscarriages. We'll take 'em when we can get 'em."

Obviously he won't say that to people. But it just goes to show that people can be really dumb in the things they say.

Those who are blessed to have babies, whether without difficulty, or with difficulty and with help, are truly blessed.

And those who seem to "wait" a long time before having their first, or their second, etc. - they are blessed in a different way (perhaps moreso) when they have their babies.

And those who don't have any children - you never know why it is so.

Wish those who become pregnant the best of wishes. And if they don't become pregnant, do what you can to help only when they reach out to you. Otherwise, don't say anything.

You have no idea what they're going through.

Tuesday, October 13, 2009

Why I Love Being a Mohel

People ask me all the time why I decided to become a mohel.

Have you ever known you wanted to do something so badly? Some people know they want to be doctors from a very young age. Some know they want to be laborers. Some are destined to become teachers or clergy.

The First Reason - Why I Became a Mohel

I grew up in a home and an environment in which Judaism was very important to me. As I entered adulthood, it occurred to me that a well-rounded Jew knows how to do a few things. [In other words, somebody shared this passage from the Talmud with me, from Hullin 9a:]

ואמר רב יהודה אמר רב תלמיד חכם צריך שילמוד ג' דברים כתב שחיטה ומילה ורב חנניא בר שלמיא משמיה דרב אמר אף קשר של תפילין וברכת חתנים וציצית

"And Rabbi Judah said in the name of Rav, a wise student needs to learn three things: how to write (some say this means 'to be a scribe' while others define it as 'to be literate'), how to ritually slaughter (to make kosher animals fit for consumption: inaccurate slaughtering renders even kosher animals such as cows, sheep, goats, chickens, ducks to be unkosher), and how to circumcise. Rabbi Chananya son of Shelamya said in the name of Rav: Even how to tie the knot of the tefillin, how to recite the blessing of the groom (to conduct a wedding), and how to tie tzitzit."

I had observed many circumcisions, and had gotten over the natural squeamishness that sometimes comes when watching such things without knowing exactly what is going on. It was the right time and the right place for me to train and learn this skill.**

Reason #2

I love meeting new parents. Whether this is a first baby or a tenth child (I've done brisses for both ends, and all points in between), the joy that accompanies the arrival of a new baby is a classic example of something that unites the human condition.

It is a privilege to be invited into the inner circle so early, and an honor to bring what I hope is perceived as a calming presence to what can be the stressful (and meaningful!) ordeal of the bris.

Reason #3 & #4

I love newborns.

#3 - To my mind, there is no better evidence to the existence of God than witnessing the miracle of birth. Obviously I don't watch actual births, but I do get to see the result of (hopefully) nine months of gestation, and the constant renewal of the miracle of life.

There is a tradition that God continues to renew the world every day. Seeing newborns on a regular basis is an affirmation of God's continued role in Creation.

#4 - Newborns are so innocent, so sweet, so delightful to behold. It is true that most of my job consists of bothering them, but I also get to calm them and soothe them. I enjoy sharing with new parents some tricks to calm a baby that I've picked up over the years: fast diaper change, how to swaddle, how to avoid the ever-threatening "soaking" the baby gives those who change his diaper, and positions for holding a baby that can be calming, and can remove discomfort.

Reason #5

I am personally very detail oriented and a bit of a perfectionist, qualities which serve me well in my capacity as a mohel.

These character traits help me: run a respectful and organized ceremony, maintain cleanliness throughout the procedure, leave my workplace as neat or neater than how I found it, give you full instructions for how to care for the baby after the bris, make sure the cosmetic result is as best as I can make it.

Conclusion

Yes, there are other reasons as well, but these will suffice for now.

Most of all, it is an honor and privilege to be a part of your family's joyous occasion, which I appreciate very much and do not take lightly. I am grateful that you have opted to explore utilizing my services, and I look forwarding to serving your family with graciousness and sensitivity.

Mazal Tov! Best of luck to you, your baby and your family.


[**I have learned the laws, but not practical application, of how to slaughter animals. The squeamishness is different, and I don't know if I ever will learn the practical skill. It seems the Talmud is saying that a person should also know limits: If you have not learned the skill, do not undertake to do the action... It is very important for every person to be careful not to undertake tasks they are not trained to do. This may seem obvious, but in our world we hear stories all the time of people who thought something was "easy to do" or "didn't require training, skill or guided practice" and ended up with disastrous results.
As for writing, tying tefillin and tzitzit, and knowing the blessing of the groom, I am proud to put a check mark next to all of those.]

Monday, October 12, 2009

The Danger of Arrogance

Before you read this, please note: I share this conversation with you not to scare you, but to help you become aware of the possibilities out there, and to know there are ways to avoid many of the problems discussed here. My suggestions appear at the end of this entry, so please make sure to read through to the end.

Over the weekend I had an interesting conversation with a pediatrician friend of mine. Our discussion drifted towards the topic of this blog (circumcision) and he shared with me some horrific stories of circumcisions that came to his attention after the fact, when there was a problem.

Mild Problems

In cases where the baby is a bleeder, or the mohel needs help in containing the bleeding, the baby either needs to be sutured (a couple of stitches), cauterized, or, in some cases, better pressure needs to be applied to seal the wound. In some cases, different products that are often used to help coagulation can also be applied to stop the bleeding, without the need for the stitches or cauterization.

Thank God, I have never needed to send a baby to the hospital: I ask about hemophilia in advance, and I was trained very well in the skill of bandaging.

Different Problems

There is a small margin of difference between removing too little skin and removing too much skin.

Too little

Pros: easily correctable, no long term damage, might not need a correction
Cons: Baby may look uncircumcised for a long time, may need to be corrected, Baby has to go through two procedures (One person told me a story of how his son had a second Bris because the first was considered meaningless.)

Too much

Pros: Baby will definitely look circumcised. There won't be a need for any cosmetic adjustments
Cons: circumcision scar will be enormous. Sex (as an adult) will be a less pleasurable (perhaps more painful) experience.

All in all, these are a matter of debate regarding the pros and cons. Obviously a perfect circumcision every time would be preferred. But as all mohels (like all doctors) are human and are by definition not perfect, the guarantee of perfection would be dishonest. Instead, we do the best we can.

Below, I will explain steps that can be taken to help avoid these problems.

[See this posting about the different methods for how to do a bris]

Bigger Problems

My pediatrician friend described to me examples of children he examined who had been damaged by the mohel. "Damage" does not refer to brisses which are not 100% cosmetically beautiful - those are common enough and are no cause for concern. The penis generally heals nicely and functions normally.

But when the glans is nicked in the process (through the removal of the foreskin, a bris exposes the glans to the edge of the corona), or cut or [shudder] amputated, this is real damage. If an artery that can not be controlled through simple mohel techniques is somehow cut, we have a real problem.

The DANGER of ARROGANCE

Most mohels are trained by expert mohels in Israel or the US. If they follow the instructions of their teachers and do not look for shortcuts to make the process quicker, they can do no damage to the babies on whom they operate.

But if they think they know better, and worse, declare that they are the only ones who know how to circumcise and that others do not do "kosher brisses" because of the methods they employ to protect the baby - this is not only arrogant. It is stupid.

Methods ALL Mohels Should Employ

To reduce the negative possibile outcomes of a bris significantly, there are two steps I highly recommend. Most mohels already do the first in one form or another. Very few do the second. They are:

1. Use a Shield - a device that protects the glans during the incision. Whether one uses a traditional shield, or a clamping device such as the Bronstein/Mogen clamp, if the glans is pushed out of the way when the shield or clamp is applied, it will not be damaged in any way by the circumcision. (There are FDA problems and halakhic (Jewish law) problems with some clamps)

2. Outline the edge of the foreskin with a marker before beginning the procedure - This will reduce the "margin of error" significantly, and will assure a significantly better chance of having a clean and even incision all around.

The Arrogance

If a mohel decides he can do a better job freehand (using just his fingers to hold the foreskin, and a knife to excise, without using a shield to guide his incision and protect the glans - see method 3 here), I maintain that he is a fool and should not be allowed to operate.

To suggest that "God wants it to be done this way" is arrogance of the highest order.

I am not suggesting that I know what God wants any better than someone else. As a Jew who believes in the Torah, I believe God wants us to circumcise our sons, and that there are a few other requirements as to what is supposed to take place during a bris.

But I also believe that we are to take every precaution to assure that the chances of danger to the child beyond the inherent danger of removing skin tissue (the definition of the bris circumcision) be reduced to an absolute minimum.

I repeat (and add):

EVERY mohel should use a device that guards the glans
EVERY mohel should mark the edge of the foreskin before beginning
EVERY mohel should wear sterile gloves
EVERY mohel should maintain a sterile field during the bris
EVERY mohel should not allow any part of his body to come in direct contact with the open wound during or after the bris.

With proper monitoring and education, we can minimize the negative bris stories as we take charge in taking good care of our sons.

Wednesday, October 7, 2009

The Inspiration of Bris

The commandment of "bris milah," to bear the mark of the covenant between God and the Jewish people, first appears in Genesis chapter 17.

In essence, Abraham seals a covenant with God, an agreement that has survived until this day. Abraham and his descendants agree that God will maintain and sustain the Jews as His "chosen people" (an oft misunderstood term) if the Jews bear the mark of the covenant, circumcising their sons on the eighth day as per God’s commandment.

The “bris,” as it is known, has its own ups and downs. Everyone is joyful over welcoming a new baby. But the milah (circumcision) causes pain during which a baby cries. Some people say to the baby, “This should be the only pain you ever know.” Others say, “It’s not easy being a Jew.”

The truth is, however, that while the baby’s health is certainly our number one concern, the bris itself is more about an affirmation for everyone in the room, than it is for the baby. By all rights, every person should stand up and protest, “How can you do this to a newborn?”

Of course we don’t do this. Because we know in our hearts that the circumcision is but a small sacrifice to make to get God to live up to His end of the deal. That a nation which has experienced downs, such as the Jewish people have experienced, can continue to experience ups – this is the hand of God as revealed as it can ever be. It is what our lives are all about, it is what our experience on this earth is all about.

We use Avraham’s model of a struggle-filled life (see Genesis chapters 12 through 16 to understand his struggles) to arrive at the unstriking conclusion that the covenant with God is what keeps us going.

In the words of Rabbi Joseph B. Soloveitchik, in his “Tribute to the Rebbetzin of Talne,” we live “to feel the presence of the Almighty and the gentle pressure of His hand resting upon my frail shoulders.” It is a struggle worth living when the Comforter is so great.

Monday, October 5, 2009

Typical Bris Set Up

The setup at a bris varies from mohel to mohel, and from tradition to tradition.

Standard Ashkenazic

In most Ashkenazic brisses (where the husbands family is of Eastern European or Russian descent), the setup will consist of two chairs and a table. Good lighting is always appreciated.

Depending on the mohel's preference, the table will be on either the left or the right of the chairs.

One chair is used by the sandak, who holds the baby during the actual circumcision.



The second chair will be demarcated as the chair of Elijah the Prophet. There is a widely observed custom to set aside a chair for Elijah the Prophet to bear witness to the ceremony, much as we set aside a cup for him at the Passover Seder.

[See other examples of this chair here]
Standard Sefardic
Those who descend from Spanish Jewry, North African and Middle Eastern lands will usually have the table and the Elijah Chair, and will use the Elijah chair twice - first to put the baby on Elijah the Prophet's "lap," and then for the sandak to hold the baby during the bris.
Additional Items
Some have the custom to light candles.
Some set up a dish with dirt in it, so the excised foreskin may be placed in it - a prelude to its being buried shortly after the ceremony.
Modern Ideas
In different circles (mostly non-Orthodox), where many mohels happen to be physicians and are more used to babies being "out of commission," a circumstraint might be used to contain the baby's movements.

I don't recommend this device.
Others opt to have the baby held on a table for the procedure.
Finally, it is recommended to put a tablecloth on the table and a wastebasket under the table in case there is a need to dispose of any waste-filled diapers, sterile packagings, or used bandages.

The "Afterthought" Question

Please note I have another post on this subject here

New parents have many things on their minds. (Thank you "Baby Blues" for putting it so nicely)

Before preparing for a bris, the first thing everyone is concerned with is the adjustment - getting life back to a semblance of "normal" routine. First-time parents need to get used to the reality of a new person in their lives, whose care they are responsible for, and whom they possibly (probably) love more than they even love each other.

Parents with other children need to deal with the adjustment of a new baby in the house, possible jealousy of siblings craving attention, as well as the needs of the new baby himself, even though they are "seasoned" parents.

A bris puts what could potentially be a very stressful burden onto parents of a newborn, with a very fast deadline: No more than seven days to prepare.

Those who work out as many details in advance of the birth, whether they know the baby's gender or not, are a step ahead. They know where the bris will take place, they know who will cater, they've made arrangements with a mohel.

And somehow in the middle of it all, "the" question gets lost in translation.

"What's the fee?" "How much will it cost?" Most mohels do not raise such a question on their websites.






The truth is, how can you put a price on a mitzvah of such intimate, personal, and national significance?

My answer to the question is simple: I can't, so I don't. It's up to you.

According to Jewish law, the actual commandment in the Torah, is for the father to do the circumcision himself. People ask me all the time, "Did you circumcise your own son?" You see, bris and mohel-ing is not like a medical procedure for which it is ill-advised to have a family member preside over the surgery - even if the family member is the top in his or her field.

For a bris, the father is supposed to do the surgery.

Yes. I circumcised my son. Thank God, I am in a unique position of being a father who is trained and knows how to circumcise.

Most fathers are not trained, however, and would prefer to put their sons' well-being in the hands of skilled practitioners. And even if they think they can do it, the baby's mommy will never allow it, so it's usually a moot issue.




"Come on, Rabbi. Give me a range."

I can do that, but I don't want you to feel pressure to "match up" to others who may be in a different financial position. Ask yourself what it is worth to you to have this taken care of by someone else, and that is an appropriate honorarium.

It is my practice to say "Thank you" - no questions asked.

Final two notes:

A. If you live in a relatively close proximity to my home or regular travels, I look forward to meeting you before the bris. I will always make at least one follow-up visit, and may come back two or three times, depending on your child's needs. All travel expenses are included in whatever remuneration is offered - and is, of course, most appreciated.

B. For those looking for a range, people generally offer anywhere between $0 and $1000. Most people settle somewhere in the middle range ($250 to $750).

Here is the link to this question in the FAQ section of my website.

It may or not be helpful, but it is the best I can give you. Parents of a new baby could be at very different stages in their lives - from barely newlyweds who have no money to wealthy CEOs having their last hurrah at age 40. Let each do according to their means.

I am truly honored to participate - the role of mohel is a reward in and of itself. The opportunity to help, and everything else, is a gift of God.

See part II of this discussion