Sunday, January 31, 2010

What Will It Look Like Before and Afterwards?

I try to leave graphic images out of this blog, so I will do my best to explain here what the penis looks like before and after the bris.

BEFORE

Take a look at your baby! Now you know how it looks before the bris!

Just kidding.

The uncircumcised shaft of the penis looks like an inverted hourglass. It is thinner as it hits the scrotum, and thinner at the tip, but significantly fatter in the middle. The reason for this is because the glans, the part of the penis which is revealed after the circumcision, is hidden underneath the foreskin. Were you to slowly (and gently) pinch the tip of the penis, you'd see the "bump" in the middle of the shaft move it's way towards the scrotum. Let go of the tip of the penis, and the bump will slide back to its natural position. That bump is the outer edge of the glans - usually the 1/3 or midway point of a baby's penis.

THE FORESKIN

The foreskin (a.k.a. "prepuce") is an outer coating which covers the glans. It covers around half of the shaft. As only the foreskin is removed during circumcision, when the glans is revealed, one can easily see (contrary to popular culture's 'complaint') that the penis is not "smaller" - it just looks different.

[While I won't put the photo in the actual blog - I believe you can get the idea of what this all means when you look at this photo of a circumcised banana.]

AFTER

Before you read this section, understand that most circumcisions do not necessarily turn out exactly the same. All babies are different, and may have different "surprises" under their foreskins, which are not usually detected until after the circumcision itself.

For example, every baby has a differently shaped glans. Thus the first thing you see will look different from child to child.

Secondly, some babies have a minimal mucosal membrane underneath the foreskin, which might completely come off as well during the circumcision. Others have much more membrane with a significant amount left over after the bris, even if it is no longer coating the glans. Still others have significant tissue webbing, which would be undetected until the foreskin is removed. Depending on the extent of the webbing, it may need to be removed separately after the circumcision.

THREE SECTIONS

After the circumcision, one can usually identify three distinct sections on the circumcised penis.

SECTION #1: THE GLANS is the first things you see. It is the tip of the penis, and it almost looks like an army helmet - were the shaft to be standing upright.

A kosher bris consists of the farther rim of the glans being completely revealed, visible, and distinct, with no skin tags attached to it, and nothing hampering its distinct view.

It is usually a very deep, dark, raw RED COLOR (though it is sometimes PURPLE).

SECTION #2: THE MEMBRANE may or may not be completely removed in the bris process. If some of it remains, it may be slightly swollen, and may seem a little puffy below the glans.

Like the glans, it is typically a dark RED COLOR, though it does not usually have the same deep color of the glans. It will also look raw.

If the Membrane is completely removed, the area below the glans will look empty, but there will usually be a gap of a couple of millimeters between the glans and...

SECTION #3: The SPOT OF THE INCISION. This is the spot on the skin itself where the foreskin ended - or at least where the mohel estimated the foreskin ended. Ideally, the incision mark will be fairly close to the glans - but depending on the size of the baby's shaft, the mohel may have found the need to remove more or less skin in order to avoid future problems which may come from the glans falling back into the shaft and/or scrotum.

Dr. Neil Pollock - a very busy circumciser in Vancouver, has detailed information about this on his website. Feel free to read through the information he has - it can be found here [Start with the "Parents Guide to Circumcision" and move on from there!]

WHAT YOU WILL SEE

Aside from the dark red colors and the swelling, the scab tissue which sometimes develops in the area will typically be of a yellowish/ greenish hue. This is normal.

It is not advisable to pick at this, or to rub it as it will only cause the penis to bleed. A warm bath is good and promotes healing. Otherwise, like any scab, it is best to put bacitracin on it for a few days and then stop using ointments when the danger of infection is gone and it just needs to continue healing on its own.

Monday, January 18, 2010

The Ceremony and the Honors

The baby starts off with his mother in a private room. The room changes depending on the venue - it could be a bedroom in an apartment or house, an office or bridal room in a synagogue or catering facility - any place which gives the baby breathing room and an intimate environment where baby’s mother can nurse or otherwise feed him after the bris.

The mohel may or may not prepare the baby prior to the bris. If the baby is “prep”ed by the mohel, the baby can be brought out when he is ready. Otherwise he should be brought out when the mohel calls for him.

For information on how to choose people for the following honors, see the end of this section.

The baby is brought into the room where the bris will take place by a “kvatter” couple. The couple consists of a male and female who are either married to one another or are mother/son or father/daughter or brother/sister. Their role is to be the medium passing the baby from his mother to his father.

After he is passed to kvatter, the mother can go to her “spot” for the bris. Some mothers prefer to stay in the back or in a different room. Some like to be right up front. If you have a rabbi, speak with him about what is best for you based on your tradition. There also tend to be different protocols for home circumcisions versus synagogue circumcisions.

In many traditions, the baby is next placed on the chair of Elijah, the “kisei shel Eliyahu.” Some verses are recited, paying tribute to a staunch defender of the covenant of Bris Milah, Elijah the prophet. Note how he makes an appearance here, similar to the one he makes at the Passover Seder.

The baby is handed to the father who first appoints the mohel to be his messenger to do the bris. This helps the father fulfill his obligation to be the actual person performing the circumcision.

(In Jewish law, a person can appoint a messenger, a “shaliach,” to perform certain commandments on one’s behalf. Other examples include sending someone to donate your charity money, or giving and accepting Jewish legal documents.)

Depending on the family custom, the father’s blessing might be recited now (Sephardic or Middle Eastern tradition).

The father places the baby on the sandak’s lap, where he will be held during the actual circumcision. The sandak honor is considered the highest one can bestow upon a person at the bris.

At the moment of circumcision the mohel recites a blessing and then the father recites a blessing (Ashkenazic tradition), and the congregation responds accordingly.

After the circumcision is over and the baby is bandaged and wrapped up, he is held by another honoree, who is sometimes called the “standing sandak.”

While the baby is held, two blessings are recited by the rabbi, mohel or an honoree, who is holding a cup of wine. After that another paragraph is recited in which the baby is officially given his Hebrew name.

Mazal Tov!

PICKING THE HONOREES

The rules: All participants in the bris ceremony should be Jewish.

Every other absolute rule is in bold. Anything else is a suggestion or might change based on the venue - ie home versus synagogue. Usually the honorees are all male, save in the kvatter component.

The kvatter: The kvatter is a married couple unless they are a male/female team as described above. Some people have the custom to give this honor to a couple who as yet do not have children, with the hope that in the merit of participating in this event they will be blessed to have a child. If all your married friends and relatives have children, then the honor can be given to any married couple. Some people give it to a great aunt and uncle.

What about having more than one “kvatter”?

No problem. Some people have unmarried siblings (aunts and uncles to baby) or other friends they’d like to get involved. My rule is simple: “Women first, then men. Let the last woman hand the baby to her husband (the first man).”

Elijah’s Chair: This honor can be given to anyone. Some give it to a rabbi, some to an uncle, some to a dear friend. If this is not your first son, many people try to give honors to individuals who were not honored at the previous bris.

Sandak: The sandak must be male. He is usually the baby’s grandfather or great-grandfather. There is a custom, once past the first bris, to use a different sandak for every subsequent bris of your children. A person may be sandak many times – but for only one of your sons. Some Sephardic traditions re-use sandaks.

Blessings and Naming: Should be read by someone who reads Hebrew fluently. In a traditional ceremony, the one who recites the blessings is an observant Jew. In many cases, the rabbi or the mohel will recite the blessings as the default honoree.

Holding the baby/Standing Sandak: This honor can be given to anyone. It is often split - one person for the blessings, and one for the naming. When there are two grandfathers, this is usually when one or both get involved. If one was the regular sandak, the other will typically fill this role. If a great-grandfather was the regular sandak, the grandfathers might split the baby-holding.

Instructions for After-Care

While there is still a bandage

* Before every diaper change, wash your hands with soap and water
* Prepare a gauze pad with a generous heap of A&D ointment on it.
* Open the diaper, wipe as normal – do not touch the gauze or bandage.
* Before closing the new diaper, reach under the gauze to hold the wrapped bandage in place, then gently remove the gauze pad.
* If the gauze pad sticks, either leave till next diaper change or apply a small amount of baby oil to spot that sticks, then remove.
* Replace with new gauze pad, placing center of the gauze over the glans, pinching the sides of the gauze so it forms a tent over the penis. (Take care not to pinch or squeeze the glans)
* Close diaper.

Once bandage is off (typically after the last time I see the baby)

* First twenty fours hours, apply polysporin/bacitracin on gauze as above
* After twenty four hours of no bandage, apply polysporin/bacitracin directly (no gauze) for two to three full days, at every diaper changing (you can dispense it directly and rub it in with your finger, or dispense onto a Q-tip and apply with the Q-tip)
* After the three or four day period, ointments should no longer be applied as the bris needs to finish healing on its own.
* Baby can bathe the following evening (24+ hours) after the bandage comes off.

Monday, January 11, 2010

Bris v. Circumcision

No - it's not one of those landmark Supreme Court cases.
But it is a question that comes up a lot: What's the difference between a circumcision and a bris? Isn't a bris just a souped up circumcision?

It is true that a bris contains a circumcision as part of its process, but a circumcision alone does not a bris make.

Circumcision

Male circumcision is the removal of some or all of the foreskin (prepuce) from the penis. (I got the concise definition from wikipedia, though the page has graphic images I don't recommend for the sensitive...)

Bris

A Bris includes the circumcision (though it would more accurately remove all of the foreskin), but also has ritualistic components as well as religious significance that is extremely important for the history and continuity of the Jewish people.

This is not the forum to respond to anti-circumcision people - so don't expect that here.

Do a google search of "anti-circumcision" or "against circumcision" and you will find hundreds of websites and millions of hits. This is not our issue. I assume you are looking to circumcise your son, just don't know if it would be better to do it with a doctor in the hospital or with a mohel in a bris ceremony.

A Medical Circumcision...

...consists of either an operating room procedure or an office procedure. Depending on who does it and how much pride the person takes in the outcome, and in his/her relationship with the baby and his family, you can get all kinds of different outcomes.

Doctors will use all different kinds of methods - some which produce excellent cosmetic results, some which produce shoddy results.

In cases where parents sign a waiver allowing hospitals to take care of the circumcision, unless they request otherwise, there is a good chance that a medical student will be operating, for the first time, on their baby.

Local anesthetic may or may not be used, and depending on the method of choice, the baby might be in a degree of discomfort for between 7 to 30 minutes.

Cosmetic results will differ based on the skills of the operator. A doctor who does many of these procedures will usually have it down to a science and should produce wonderful cosmetic results. Otherwise, you are at your own risk.

I have been inside operating rooms in which the surgeon took pride in his work, took the time, marked the foreskin, and made a clean and even incision, gently and carefully, all around the circumference of the glans.

I have also been in the operating room when the child in question was put "out" for a hernia operation, and the choice was made to do the circumcision at the same time, while the baby was under general anesthesia. In my own observation, while the doctor may have taken all the time in the world to do the hernia properly, the circumcision was an afterthought, and was treated as such. No mark, quick snip (forgive me), and a suture job afterwards that was not to my satisfaction. Argument: "It's only a 'circ.' What's your problem?" My problem is that it isn't "only" a circ.

A Bris...

... takes much less time. Depending on the operator, he may use a bronstein (Mogen) clamp or a Traditional Jewish shield, but will usually finish the procedural (circumcision) component in under a minute.

A bris requires the entire foreskin to be removed, as well as the mucosal membrane beneath the foreskin to be completely removed from the circumference of the glans. In addition to being the fulfillment of the requirement, this will inevitably produce a more asthetically pleasing result.

Not that we're doing this for asthetics.

The circumcision carries with it the promise made by God to Abraham in Genesis 17 that He will be the exclusive God for Abraham's descendants (defined in Genesis 15 as those who descended to Egypt, and ultimately experienced the Exodus and Revelation at Sinai - the Children of Israel) if they bear the mark of the covenant in their male offsprings' flesh.

For the Jewish people, this prospect of being "the firstborn of God" (see 4:22) is highly significant.

The Bris Ceremony makes reference to Biblical defenders of the faith, who outwardly defended the covenant and the concept of circumcision - Abraham, Pinchas, and Elijah the Prophet. It includes prayers to God on behalf of the operator (mohel), the father of the baby, the sandak (who holds the baby during the bris), and, most importantly, the baby - that he should experience his circumcision with minimal pain and discomfort and that he should heal speedily.

There is symbolism in the blood that emerges from the incision (compare this to the blood on the doorposts (12:7-13) that was used to effect the "Passover" event)

There are blessings that are recited invoking God, the covenant, and national significance for all the Jewish people.

The baby is given his name in ceremonial fashion, with a cup of wine - just as we have for kiddush on Sabbath and holidays, and at other important ceremonies such as a wedding.

And, perhaps most significantly, friends and family gather together to celebrate the arrival of the baby, the continuing of a tradition, and the continuity of the Jewish people.

I conclude with the words I've already written in this posting

The doctor v mohel question is for a different discussion - it has been addressed in the second half of this posting.

Tuesday, January 5, 2010

The Traveling Mohel

Welcome to my blog about bris/t milah, and about being a mohel!

I hope you find the content of the blog informative and helpful in the research you are doing to find the right mohel for your son.

This entry is more of an advertisement than a traditional "blog" (since when can a blog be categorized as "traditional" anyway? There were no blogs in "Fiddler"!)

Whether you live in a place that has many mohels, or a place that has zero mohels, I invite you to consider engaging my services as your son's mohel, for a number of reasons:

1. I will speak with you about every aspect of the bris: logistics, details, family sensitivities, etc., to make sure you are 100% comfortable and emotionally prepared for the roller coaster that is the day of the bris. I am available on the phone almost always, and if you leave a message, I will get back to you quickly.



2. I am the world's biggest stickler for creating and maintaining a sterile field and sterile environment for the bris. There is no compromising in making sure the ultimate care is taken to assure nothing negative - such as an infection - will result from the bris.



3. You will not find a more easy-going and time-giving mohel. I make sure you know everything you need to know, and everything you want to know as far as what I am doing or need to do or as far as how to take care of your baby when I am not around.



4. You get full details about how to care for the baby, what you will see, how long things take to heal



5. I check the baby mmediately after the bris and a few hours later. The efficiency with which this is done assures your son has the most aesthetically pleasing circumcision, and that he requires the most minimal care on your part by the time my role is finished. You do not have to deal with bandages that are on long term, and you do not have to take off any bandages or deal with any bleeding. This is a full service operation.



6. The cost to you can be within your budget. Most mohels who put a price on the bris will charge between $400 to $1000. When I travel longer distances (more than 50 miles from my home - or by plane), I only ask you to cover the travel expenses. The rest, as always, is up to you.

I am quite serious about the offer to travel - even great distances. Check out my other site http://www.travelingmohel.com/


So. Whether you (or someone you know) live(s) in a remote area and need a mohel (recommendations are always appreciated!), or you want a mohel who suits your needs best and most identifies with the Judaism you practice, we should have a conversation. Even if it won't be me, I can help you make sure you find the right person, and give you information that will help you make sure you know "exactly" what is going on, and that you are taking charge of your son's entry into the mark of the covenant.