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.

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