Sunday, August 6, 2017

Halakhah v. Hashkafah

Bris Milah is one of the more unique mitzvahs, in that while in the world of people who fulfill it the desired results are the same, the permutations in terms of how to get to those results are as varying as languages. Aside from the simple order of the ceremony, which varies from Ashkenazic, to Sefardic, to Yemenite and other Middle Eastern cultures, and is even different inside or outside the Land of Israel, every step of the bris has its own adherents, some of whom are militant in their hashkafah (worldview), even though the halakhah (Jewish law) is flexible and fluid - often focused much more on the result than on the method of getting there. Hashkafah is guided significantly more by method than by result.

When the Talmud discusses how a bris milah is performed, it mentions three stages - milah (excision of foreskin), priah (removal of mucosal membrane from the glans), and metzitzah (drawing of blood from circumcision spot, following the acts of milah and priah).

In order to do each of these properly, different surgical instruments and methods have been created or introduced over time to make the experience easier for the mohel, and, in consequence, for the baby.

All of these have been addressed before, but here are the links for the items utilized, presented in their order of use - each has its own "debate" attached to it, summarized as briefly as I can

NUMBING - to numb or not to numb, that is the question. There are those who argue it is forbidden. Those who argue it is obligatory. And those who say it is optional. (And those who argue that injections cause more pain to the baby than the circumcision, and that a topical cream does more for the parents than for the baby (who will cry anyway), as cream makes things more slippery (not a good ingredient for something precise as circumcision)

GLOVES - to wear or not to wear, that is the question. There are those who argue it is forbidden (never done before, chatzitzah). There are those who argue it is obligatory (sterility). And there are those who argue it is inconvenient (slippery, or can't do priah properly). See this article by Rabbi Aryeh Leibowitz, in which he weighs all the pros and cons. 

MARKER - to mark or not to... (OK. I won't use the joke anymore). I can't even present the side against this, because it is beyond stupid. Anyone who argues that marking the edge of the foreskin with a surgical pen is anti-tradition is a full-scale idiot. I've seen too many babies have either not enough, too much, or an uneven (right v left sides) amount of skin removed, a problem alleviated by just using a little common sense plus a marker.

PROBE - The probe is used to separate the membrane from the glans so the circumcision can more likely remove the membrane at the same time as the foreskin. Those who don't use a probe argue that it is painful. And then they stick their fingernails underneath the foreskin to accomplish the same job. 馃槕.

HEMOSTAT - The hemostat allows for two of the stages of Bris Milah to be accomplished in one action - what is known in Hebrew as 诪讬诇讛 讜驻专讬注讛 讘讘转 讗讞转.  Very skilled mohels often do this when they grab the foreskin with their fingers. Otherwise the hemostat grabs them together. Those who are against it are adamant that the two stages be done separately, AND that priah be done using fingernails - tearing the membrane and folding it beyond the corona, AND they argue that the hemostat is painful to the baby. Those who use it argue that there is an ancient tradition of doing Milah and Priah at the same time, AND that tearing the foreskin with fingernails (method of those who don't use a hemostat) is also quite painful, AND that NOT removing all of the priah membrane could cause problems for the child down the line, either as a child or an adult requiring corrective skin removal surgery. In other words, the pain argument is a question of quantity and degree against both sides (short term v long term e.g. corrections)

SHIELD - The use of the traditional Shield is a hallmark of most Orthodox mohels. It's purpose is to isolate the foreskin (what we are removing) from everything else that we don't want to touch (shaft, glans, scrotum, etc) Some who do not use it opt for a clamp, which accomplishes the same thing in terms of protection (when used properly) but it has its own halakhic, hashkafic and safety issues. Others who do not use the shield do the entire procedure freehand, putting everything near and dear to the baby's safety at risk. As to the clamp - I don't use it nor do I recommend it. I've written plenty of things against clamps in this website. As to the shield, those who argue to use it are concerned for the baby's safety and are doing their due diligence to protect the baby from an unfortunate mishap. Those who argue against it claim that it hurts the baby (see previous paragraph for cost/benefit ratio question), and that it's an innovation from 400 years ago (or so) that has no place in this ancient tradition.

KNIFE - The idea behind using a double edged knife is based on a "drasha" from the verse 讜讞专讘 驻讬驻讬讜转 讘讬讚诐. In general, the sharpest knife should be used, so the incision is as quick as possible. Using a double-edged knife is entirely a hashkafic issue, as the rules of bris say anything can be used to excise the foreskin (except a reed which could give the baby a splinter), "but the custom is to use a knife."

TUBE - Metzitzah, the third Talmudic stage of the bris, can be accomplished in a number of ways. The most common methods utilize the power of the mouth, while the less common method uses a sponge or gauze. The most common methods either have the operator putting his mouth directly on the open wound, or have a sterile tube serving as a barrier between baby and mohel. Both of these methods are halakhically "metzitzah b'peh (or b'feh)," while hashkafically, the tubeless method is deemed by purists to be the "only acceptable method." To those who are sterility conscious, the tubeless method is wholly unacceptable - potentially putting baby, and sometimes mohel, at risk of spreading an infectious disease. In this view, metzitzah should be done with a sterile tube.

This post is in response to a recent phone conversation I had with a new father in Florida who personally was interested in the circumcision taking place, but did not particularly care about methods - only results. His parents, however, who hail from a very right-wing Orthodox community in the Northeast, carry every hashkafic notion of bris in a manner that clearly views other methods as unacceptable. As a colleague of mine told me, "If people ask, you let them know that 'hiring me means you get this kind of service, and if you don't want that, hire someone else.'"

Not that I believe for one second that anyone wants any harm to come to a baby. However, a hashkafa that proclaims that achieving circumcision results using methods that don't conform to safety and sterility are IDEAL - when I have heard plenty of stories from people who had very negative consequences (hospital visits, infection, baby on antibiotics post bris) - troubles me personally and deeply.

My method, thank GOD, has a perfect track record in terms of no-infection post-bris. Because everything that needs to be protected is protected, and nothing is exposed to bacteria that could have negative consequences.

I certainly wish everyone well, and hope that everyone hires the right mohel for their purposes, with the best interests of their baby in mind. 

Wednesday, July 26, 2017

A Different Type of Busy

I don't know what triggers them specifically, beyond my existence, but every now and then my Facebook page is attacked by anti-circumcision activists, some of whom are respectful, some of whom are curious as to why we do what we do, some of who can not fathom how we don't view Brit Milah as a human-rights violation, and some of whom are vile human beings who spew filth and the most hate-filled language and invective towards me (as a representative of Brit Milah) and our backwards ways.

These latter people, some of whom go so far as calling me a pedophile, get blocked, banned, and their comments deleted. They don't call urologists and gynecologists sexual predators, so their comment in my direction is just disgusting. If no one ever hired me again for a bris, I would never see another foreskin (except on my own newborn son, I suppose) as long as I live. And I certainly have no interest in seeing my work once the healing process has completed and parents aren't asking me questions about it. (Though as long as they ask questions, it's in a professional capacity, and the physician parable remains...)

As for the rest of the people, if they have respectful comments and questions, I am happy to have the dialogue. Perhaps there is merit to trying to explain - in a respectful manner. Even though it takes time, and the conversation almost never convinces anyone of even the merits of our view.

Because the bottom line is this. People who have not bought into a. Judaism, and b. the Covenant (both of which are why we do this), as well as those who do not agree with the idea that parents who bring children into the world are allowed to raise them how they want, they don't accept that Brit Milah (which includes the act of circumcision, but is symbolically much more than a circumcision) isn't a human rights violation. 

They can argue that a child born of a Jewish mother is Jewish even without circumcision. This is certainly true. But try explaining to them the concept of 'karet' and you're viewed as a lunatic (so I don't - not worth it). They certainly don't understand why doing it this way is highly preferred over letting the child decide when he is 18. While I've met some people on FB who are disgruntled, in my personal dealings, everyone is happy their parents took care of it for them when they were babies (as per Torah law - Genesis 17 and Leviticus 12:3), so it's done and taken care of.

To these activitists, pro-circumcision views are irrelevant (not that we need them, because we're doing it anyway), and any perspective other than their own is unacceptable. One woman even said that circumcision is a form of Anti-Semitism (I can't make this stuff up!) 

They don't understand us. Period. One person told me there was a reason why Greeks and Romans outlawed circumcision. And I congratulated him on joining the ranks of the most evil people to ever inhabit this earth, who hated Judaism and (murdered) Jews on account of their being different, and for the acts they did which made them Jewish.

Most Jewish men I encounter give no second thought to their circumcision, and certainly don't obsess over how their lives would be different if they had their foreskin. Many are even proud of their circumcision, and even prouder that they had the opportunity to bring their sons into the mark of the Covenant as well. 

It's been an interesting week. But I look forward to focusing on the important work of bringing our Jewish boys into the mark of the Covenant. 

Sunday, July 16, 2017

The Pulitzer Prize-worthy photo that went viral

The first time I posted a picture that went viral on Facebook was, post-bris, after a mom put a creative Harry-Potter themed onesie on her baby.

This time - overwhelming those numbers - the photo I posted on Friday (2 days ago), has already been seen by over 100,000 people, has been shared over 500 times and has received over 1100 reactions, according to the stats I see through FB.

I did not do this bris - it took place in Israel - but the story is so heartwarming. The great-grandfather held his own brother during WWII, as his brother died. The baby was named for that brother - what a different position to be in! To have held and lost over 70 years ago, and now to hold for life!!!

Here is the post. Am Yisrael Chai!!!

Thursday, July 6, 2017

Tefillin at the Bris

Image result for bris photo
I don't know what's going on in this photo, but the person on the right is still wearing his hand tefillin
When davening leads directly into the bris, the baby's father (as well as the Sandak) will often ask me, "Do I leave my tefillin on?"

According to the Sha"kh (Y"D 265:10) "the custom was to not remove tefillin until after the Bris, because tefillin are a sign (讗讜转) and Milah is a sign (讗讜转)."

Yosef Weissberg, in his Otzar HaBris Vol 2, page 250, addresses many of the rules associated with Tefillin in conjunction with a bris. 

* The Sefardic custom in Jerusalem is that the father and the Sandak put on tefillin (or leave them on) for the Bris. If it's after davening, the Mohel leaves them on too. (This assumes the mohel davens with them, which is not always the case. Also, from experience with my first son, I'll note that I took off my hand tefillin, but left my head tefillin on, as the hand tefillin get in the way of doing a good job  - AB)

* In the book 讗讜转 讞讬讬诐 讜砖诇讜诐 (from Munkatch) concurs with my parenthetical comment about the mohel, but felt that the Sandak should keep the tefillin on. 

* There is another viewpoint (recorded by Ateret Tzvi, and reported as practice of Chozeh of Lublin and otehrs) not to keep the tefillin on for the Bris. This is also true for the Yemenite Jews - tefillin are removed. 

* A reason for removing the tefillin follows a similar reasoning for why we don't wear tefillin on Shabbos. Since Shabbos is an 讗讜转, we don't need tefillin that day. Since 诪讬诇讛 is an 讗讜转, we don't need to have another 讗讜转 around at the same time as we are introducing a new 讗讜转. 

* In the book 讻讜专转 讛讘专讬转, he doesn't recommend taking them off. But if one is not wearing tefillin, he should not put them on, as he looks like he's seeking an 讗讜转 when he is already partaking in the marking of a very special 讗讜转. 

* Rabbi Moshe Feinstein argued with the logic of most recent bullet point, because the new 讗讜转 is not on the person wearing the tefillin - it's on the baby! So if the tefillin are on - whether kept on, or put on in honor of the bris - this is not a contradiction. 

TO PUT IT SIMPLY, I ALWAYS TELL THE FATHER AND SANDAK WHO ASK, "IT'S UP TO YOU!"

Wednesday, July 5, 2017

Bris During the Three Weeks

For babies born yesterday and for the coming three weeks, any bris will be during the period which is called "Bein Ha'Mtzarim" in Halakha, or the "three weeks" in English. This period starts on the 17th of Tammuz and ends with Tisha B'Av.

As this is a time of mourning on the Jewish calendar, some rules of the bris experience are a little different than usual.

All of the following is recorded in Yosef Weissberg's bris Otzar HaBris volume 1, pages 289-291, where he has all the footnotes supporting the viewpoints presented.

The Baalei Bris (Father, Sandak, Mohel) may get a haircut in honor of the bris. Some are of the opinion that if the bris is during the week when 9 Av will be taking place, that haircut should be skipped. [In a footnote, he essentially argues that the same rule applies to cutting fingernails]

The Baalei Bris (see above) may wear "Shabbos clothes" to the bris. The woman who brings the baby into the bris - the female half of the Kvatterin - may also wear Shabbos clothes, though the male Kvatter may not.

The wine should be given to children to drink, or to the mother of the baby. But the one who makes the bracha during the bris ceremony should not have, and neither should the Baalei Bris (see above) taste the wine. [Though he doesn't specify, I assume this rule is actually during the 9 days, when the custom is to refrain from wine, except on Shabbos, and not from 17 Tammuz until Rosh Chodesh]

Everyone who is present for the mitzvah and therefore the meal are permitted to eat meat and drink wine as part of the "seudas mitzvah" celebratory meal. The wine used for bentching may also be consumed.

However, during the week in which 9 Av falls, one should limit the size of the guest list to relatives and enough to make a minyan. The exception to this rule is if the bris is on Shabbos - even on Shabbos which is 9 Av (for which the fast will be observed on Sunday) - then everyone can participate.

Monday, June 26, 2017

Another adorable shirt choice

Easily the best shirt I've seen on a baby post bris is the one that went viral on Facebook. 
(Last link is to my blog about it. This one is to the Facebook post)

Last week, a couple with a wonderful way about them (very chilled out), with a shared sense of humor bought the "perfect" shirt for their baby to wear to his bris. And here it is.

I've written about the tasteless kind of humor that some people think belongs at the bris. But I am not against the kind of humor that eases the natural tension in the room, and the kind that is totally appropriate.  This qualifies.
Image may contain: one or more people, stripes, closeup and indoor

Adorable.

And the bris was perfect.


Sunday, June 18, 2017

Recent travels

Thank God, some of my recent brisses have taken place out of state. Ever grateful for the traffic from travelingmohel.com and a reputation that is, thank God, growing, these brisses always turn out to be wonderful experiences.  They often include meeting Jews in further-away communities, who are, of course, grateful for the gift of their new baby. But who are also making a go of a Jewish life away from family, and sometimes, away from a mainstream Jewish community.

It's always a marvel how people manage in their own way, their own observance, their own approach to a relationship with God. And how, for all of these people, the question is never "should we do a bris?"

It is always, "Where, and when will the bris take place? And how can we make sure we have a mohel for the proper time?"

Kudos - God bless - and may you raise your children with joy.

Thursday, June 8, 2017

Comics about Bris

I was cleaning out some old files and I came across these - from my New York days when we would get the Jewish Week.

In general I don't like jokes about Bris as they are usually inappropriate and irreverent (as demonstrated in the second one). A colleague of mine likes to say to the person who tells a bris joke, "I have a lot of respect for that joke because it's older than you and me combined."

That said, enjoy?




Sunday, May 28, 2017

Baby Feeling Pain - Myths and Facts

I just came across this article on chabad.org, and thought I'd give a slightly different perspective on the question of whether the baby feels pain at the bris. The main reason for sharing the following perspective is because I prefer to be a realist and share truth, rather than paint a rosy picture, blaming realities on straw-men, and ignoring the facts-of-life.

I do agree with the article in that we've been doing this for a very long time, and when done right, most babies are fine shortly after the procedure is over. And certainly have no memory of it.

I've written about this subject before - you can search "pain" in my website (this link will do it for you if you're not on a computer or laptop) and you'll get my thoughts on this more spelled out.

But here is the brief version.

FACTS
Anything out of the baby's comfort zone causes a baby to cry. This may include: wearing a diaper, not wearing a diaper, being hungry, being handled for a diaper change, having legs pushed out of fetal position, any kind of pain.

MYTH
Babies nerve endings aren't developed so they don't feel pain.

FACT
Babies feel pain. However, they don't have a very long-term memory. When pain sensation ends, and especially if amicably distracted (otherwise comfortable, eating, etc), crying can stop.

MYTH
Babies are at their prime for clotting on day 8, so the 8th day is the best day to have a bris.

FACT
The 8th day is the best day for a bris because God said so. Clotting factor is irrelevant to pain.

MYTH
A bris is really pain-free because it is a mitzvah.

FACT
A bris is often less painful than a hospital circumcision because the hospital variety utilizes clamps that crush the skin and destroy tissue (from the clamping). Some mohels use a clamp too, so let the customer beware (fwiw, I don't use a clamp). The baby cries when being handled, so the longer he is exposed, subject to metal surgical instruments, and with his legs restrained from being in the fetal position, the more he will cry. Saying he doesn't feel the circumcision in a bris ceremony is a lie.

FINAL POINT
While I'll leave the debate of numbing for a different discussion (search for numbing is here), I think the main points to consider are DEGREE of pain-inducing contact, and the amount of TIME during which baby is subject to the same.

A mohel should not use a clamp, and should work neatly, efficiently, and should be done - start (separating membrane) to finish (bandaging) in 30 seconds. Less contact → less discomfort → less crying baby → happier everyone.

Thursday, May 25, 2017

Maybe My Kvatter "Rules" Are Wrong!


I find this depiction of a bris, in particular the description of who served as Kvatter, to be fascinating. And who was the baby? At the time he was the son of a prominent rabbi in Piotrkow. Now that baby is a former Chief Rabbi of Israel. Rabbi Israel Meir Lau. 
Image may contain: text

讛专讘 诇讗讜.JPG
Rabbi Lau
Image result for naphtali lavie
Naftali Lavie and Rabbi Lau shortly after liberation
The bris story was recorded by Naftali Lau-Lavie in his book, "Balaam's Prophesy"Image result for naphtali lavie

A Bris Milah Roundup

As most of what I've ever wanted to say about Bris Milah has already been recorded in this blog, the challenge is ever present to say something new, to couch something a new way, or to come up with new material that has not yet been addressed. As it happens, there are many sefarim (Hebrew books) written on the subject, so if I would either like to get esoteric, or start discussing out of the ordinary circumstances (such as what happens if the bris is on a pushed off fast day and the baby's father dies before the circumcision), those options are always available.

At the minimum I'm trying to blog once a month, so before May is lost, here goes.

I've gotten two more inquiries from physicians - I mentioned a previous one from two months ago here. And once again a physician (or two, or more?) wants to become a mohel and is having a hard time finding a mohel to train him.

One needs to be consistently busy to train others, and as I'm finding out, babies tend to come in spurts and seasons. I have about 12 babies lined up for brisses at the end of June through early August - and that's just the people who call well in advance! (And some of them may turn out to be girls, which will obviously lower the numbers)

In the news: Europe is going crazy again, couching their anti-Semitism in the guise of liberalism. Save the babies! Save the animals! From those nasty Jews!  (the title is mine, but that is the truth behind this latest assault)

I spoke to a father this week who had two very preemie twin boys. They will need a lot of time before they are ready for a bris. And as I write this I am waiting in an airport for my delayed flight to take me to a bris for another set of twins - though only the brother half will be having his bris.

Life goes on. Babies are born every day, and this blog continues to service people around the globe. Not sure why, but for the first time I know of, the hits from Israel outshine from even the USA - 3929 website visits from Israel in this week alone, compared to a meager 411 in the USA.

Germany, Brazil, UK and Netherlands are the next top visitors. I hope they're mostly Jews looking for information, rather than anti-Semites looking for fodder to fuel their anti-Semitism (see mention of Europe above).

That about does it! Looking forward to the summer and the many anticipated (and unknown to me) births which are coming. May the babies all be healthy, and may the boys have their brisses at the right time.


Friday, April 21, 2017

The Consultant, plus a word on safety precautions

I've had a few conversations this week with new parents who just had their baby circumcised. They are in New York area - I was not the mohel.

They had questions about what had happened in their son's bris. Mind you - this is pretty atypical. Most people have a wonderful, surprise-free experience, and all goes well. But life is sometimes accompanied by surprises and unexpected turns.

While the photos that were sent to me can't be shared on this blog, I will tell you that there's a reason that I pride myself on the circumcision looking as nice as possible hours after bris. There is often swelling, and not much we can do about that. But aside from the natural swelling, to have the circumcision look palatable to any observer is really an important goal. I've had many parents squeamishly look only to discover, "Hey. That actually looks good!"

The natural redness that is exposed through the act of circumcision is not a frightening vision - you just need to know what to expect.

But when things don't go exactly as they should, you need to understand EVERYTHING that has happened in the circumcision and in what direction a proper healing process should go.

Anyway, these parents had questions. In general, when I get these kinds of calls, while in some cases they are in fact talking to their mohel, in other cases, they don't want to talk to him because they either do not want to hurt his feelings or feel they do not have a sympathetic ear for their concerns. This is why I do believe that parents who do not know the mohel they are hiring should at the very least have a phone conversation in advance of the birth, to be sure they are comfortable with their choice of mohel. 

Some previous blog posts addressing these issues are linked here:
http://www.mohelinsouthflorida.com/2010/06/importance-of-trust.html
http://www.mohelinsouthflorida.com/2011/04/consultant.html

And just FYI - I take many precautions to avoid the issues that I have been consulted to share information. I always tell parents that without actually having examined the baby, my opinion is only worth so much (a picture is good, but it isn't the same).

It's hard enough for some people to circumcise. Should the experience be anything other than as smooth as possible? I don't think so. Here are a few precautions every mohel should be taking. If they are not doing these, I honestly think every parent should look elsewhere.

http://www.mohelinsouthflorida.com/2016/02/safety-precautions-what-you-need-to-know.html
http://www.mohelinsouthflorida.com/2015/07/getting-percentages-right.html
http://www.mohelinsouthflorida.com/2011/08/magic-of-marker.html
http://www.mohelinsouthflorida.com/2016/04/tools-of-trade-i-shield.html
http://www.mohelinsouthflorida.com/2016/04/tools-of-trade-ii-metzitzah-tube.html
http://www.mohelinsouthflorida.com/2016/06/tools-of-trade-viii-gloves.html

Monday, March 13, 2017

Perceptions, Perceptions

I should probably learn how to do circumcisions on adults (Rephrase: I know how to do circumcisions on adults. I should learn how to administer local anesthetics and how to suture). What is it about adult men who want to get circumcised, and rather than going the medical route, they seek out a mohel? I've gotten 3 requests this month alone.

Which brings me to the irony of other conversations I've had in the last few weeks. I blogged about one here. And I received another email (from someone out of state who had been in touch with me - no local mohel options available in that town): "we are going to go with a local pediatrician to perform the brit."

And then there was the doctor from a northeastern state who called me today asking if I could advise him on where to train to hone his circumcision skills. Seems he recently watched a bris performed by a certain mohel (he did not identify the mohel) and felt, as a meticulous physician, he could do a better job. And yet, he is turning to mohels to seek that training.

Then there is this article from the Atlantic (goes back to 2015) entitled "Why Non-Jews Are Choosing Jewish Circumcision Ceremonies."

Bottom line: Who is better - a mohel or a physician? A silly question gets a silly answer.

Each mohel - whether medical doctor or simply mohel-specialist - must be judged as a practitioner on his own merit. Either he is good at what he does, or he is not as good as the other guy. Either he works well under pressure or he does not. Either he delivers a beautiful cosmetic result or he does not. Either he is the right person for your family or he is not. Your preference for one type over the other boils down to your perception, but should really boil down to your research.

Make no mistake. Mohels have been doing this for a very long time - much longer than it became "in vogue" for circumcision to be widespread and for doctors to get in to the "circ-service" industry.

Feel VERY comfortable trusting a specialist. Feel free to call me to have a conversation. The doctor I spoke with today was grateful, and I trust you'll find our conversation pleasant and informative as well.

Thursday, March 9, 2017

Metzitzah in the News - Again

Is it a witch hunt? More like "which" as in, "which mohel is responsible for being irresponsible?"

http://nypost.com/2017/03/08/new-case-of-neonatal-herpes-caused-by-jewish-circumcision/

Seriously, this is beyond ridiculous. I have it on high authority that metzitzah is not even required today (Rabbi Herschel Schachter and his reporting on Rabbi Joseph B. Soloveitchik), let alone the permissibility of doing it without a barrier (Rabbi Moshe Dovid Tendler, who has told me it is forbidden to do metzitzah with direct oral contact - not that I was ever doing it that way anyway).

For those of us who are not abandoning the practice of Bris Milah, there is a very simple way to avoid these kinds of stories - completely sterile technique. No exceptions.


Thursday, March 2, 2017

Doing Research Properly

I got an email today from someone with whom I had been in contact for a little while about possibly doing her soon-to-be-born son's bris.

She apologized profusely, saying "my husband wants to try a doctor this time." This was followed by "Hope no hard feelings."

First of all - there are NEVER hard feelings when people are doing research and being open. You must do what you feel is best for your son and your family. And I support that.

However, you must also do RESEARCH and know what you are getting into, no matter who you hire for your son's bris.

This isn't a question of Dr. v. Mohel. A mohel, after all, is a specialist in this field. So being a Doctor doesn't make anyone better at circumcisions than a mohel.

What DOES matter, is how the circumcision is performed.

What METHOD is used

Whether the precaution of a marker is utilized

How much foreskin (see #5 there) and membrane is removed

And, of course, the follow up.

There are MANY fine mohels. There are MANY fine doctor-mohels. The questions every person must ask before hiring either one is, "Have I done my research? Do I know what I want for my son? Have I found the right mohel-specialist for the experience I want my son to have, and the experience I want to have?"

When the answer to all of these questions is YES, then proceed accordingly. Until that time, there is work to be done as a parent. Best of luck!!

Friday, February 10, 2017

Parental Vigilance

Dear Parents,
I can not emphasize this enough. (I've written about this before)

After the bris is over, and I am finished with MY job, YOUR job kicks in.

So let me explain to you what MY job is, so you understand what your job is and why your job is very important.

My job:
1. To get as even and aesthetically pleasing circumcision as possible. To achieve this I use a surgical marker to guide the incision
2. To make sure I take off the correct amount of foreskin, which actually has a small range of flexibility, and not to take off too much.
3. To make sure that beyond removal of foreskin there isn't an excessive amount of membrane left behind, which could give the baby the appearance of being uncircumcised.
4. To control the bleeding and make sure the baby is well on the road to healing and recovery post circumcision
5. To give you information about how things will look over the next few days and weeks
6. To give you instructions for after-care and what your job is over the next few days and weeks

Which leads us, most obviously to YOUR job
1. To follow the instructions for after-care (see 6 above)
2. To be in touch with ANY and ALL questions
3. To keep the diaper area as clean as you can during the healing process
4. Over the next few days, weeks, sometimes months, to avoid the Fusion Concern
5. To be aware of the Chubby Baby Syndrome

It boils down to this.
After circumcision, the body realigns the penis and restructures itself in the absence of the foreskin. Depending on how the circumcision goes, there may be a ring of leftover membrane between the incision spot and the glans, or there may be no membrane there at all. IN EITHER CASE, because the baby spends so much time on his back, and especially if he becomes chubby over time, the glans has a tendency to sink a little back into the membrane or the shaft and stay there, giving the baby a partially (as opposed to completely) circumcised look.

Which is where YOU come in.
Every time you change his diaper, every time you give him a bath, make sure that the glans is free and clear of anything that is below it. It really is a very simple massage every time his diaper is open, until time (could be weeks or even months) indicates that no intervention is required any more.

In simple terms - I met an adult recently whose parents did not take care of this when he was young. After a brief consultation I suggested he speak to a urologist, and he ended up having corrective surgery. This could have been avoided if his parents had been vigilant!


Tuesday, January 31, 2017

Being Prepared for Out of the Ordinary Circumstances

As much as possible, I try to meet the baby a couple of days before the bris. It gives me a chance to speak with his parents face to face, and it also helps prepare me in terms of what to expect with the technical side of the circumcision.

In other words, not all male anatomy develops in the same way.

In examining a baby recently, I noticed that the glans was extremely close to the body in its natural state, while when pushed on the two sides of the shaft to elongate the penis, the entire organ seemed to emerge. I have seen situations in which the entire penis was inside the body, requiring a reconstructive surgery to draw everything out - which I was later privileged to observe in the operating room, under the skilled hands of one of the finest surgeons I have ever seen in action. But this was not so extreme at all, as everything was external, it just seemed pulled by nature to be less prominent.

I explained to the parents what I needed to do - to be as precise as possible in marking the foreskin, to avoid this problem, and to see to it that everything looks right after the bris.

As luck would have it, the marking went perfectly, the incision was precise, and it looked like all was going to be smooth sailing. However, as sometimes happens, I noticed afterwards that there was extra membrane, necessitating this quick touch-up.

But it turned out to be so much more. What is often a tiny piece of membrane tissue turned out to be a significant amount of below the foreskin webbing. It kept emerging, causing me to realize what was pulling the glans almost into the belly itself. 

Thankfully, it seems this was it. When it was all removed, the baby looked like every other baby post-bris, and the internal issue he had that was pulling his penis, making everything so retracted, was resolved. 

As I told the father, if we hadn't taken care of this now, he may have developed phimosis or the inability to have a complete erection, with internal membranes pulling him away from being able to do what he'll need to do one day.

Baruch Hashem, a good ending and a happy story. It's a warning to mohels to be humble and to remember that not everything is "textbook" every time. It is also a reminder to parents that mohels must treat each case as if it is the most important thing he is doing now. I have seen cases similar to this one in which the circumciser erroneously removed ALL shaft skin because he thought that was what was required due to the unique anatomy.

Thankfully that wasn't the case here, wasn't the approach tried nor the results achieved (which were actually quite impressive)!

May we be blessed to deal positively with all new situations, and be guided to always fulfill the mitzvah of bris milah properly, including in non-textbook circumstancs.