Rabbi Avi Billet, Mohel in South Florida

A Skilled Operator

noreply@blogger.com (A.B.) — Fri, 01 Jun 2012 15:51:00 +0000

Many of the people involved in yesterday's bris are medical people. The baby's mother, and both of his grandfathers (to name three). One grandfather was sandak, and the other (the oral surgeon) was standing alongside watching carefully.

Both had very complimentary things to say (full disclosure: they both know me forever and this is the third bris I've done for the family), but my genuine impression was that they were impressed.

The sandak grandfather told me twice how much he enjoyed watching me work.

The "watchful" grandfather told me "I can recognize when a person is good at his craft. There is another mohel, I won't tell you who, who takes too long, has the baby crying too much, and there's too much blood."

It happened that the baby yesterday barely cried, which was unique. However, I appreciate the fact that I can work relatively quickly and that things can go as smoothly as they did yesterday.

It's not always the case - things do sometimes happen - but the smooth and easy days are the ones that are the most enjoyable.

Getting Around Florida

noreply@blogger.com (A.B.) — Sun, 20 May 2012 22:21:00 +0000

On Friday I was in Gainesville for a bris.
Today (Sunday) I was in Orlando for a bris.

One-day trips are fun - the trip in and trip out require me to be at the top of my game (so to speak), because it is much harder to make follow up visits to these distant places. I wrote about the limited time span and attention I give the baby here.

But in these last two trips (as in other cases I have not blogged about - or mentioned in this context), I rechecked the baby either an hour after the bris, or right after the bris, and found that he could be left with either a tiny bandage or NO bandage, and everything worked out beautifully.

No bleeding and simple care instructions for parents are the best results I could hope for.

I thank God these experiences went so smoothly.

And, as always, I am grateful to the parents who put their trust in me, who seek me out even though I am not local.

Books About Bris

noreply@blogger.com (A.B.) — Wed, 16 May 2012 03:22:00 +0000

Three years ago, the seforim blog posted about Milah Books and Manuals, most of which are in Hebrew and have spanned all kinds of ranges of subject matter and target audiences. The blog post may be of interest to some people. So here is the link.

There are very few books about Bris Milah written in English. Most of the books don't have much information about the process or what parents and baby go through in their experience. The book published by Artscroll (written in English? - ;) ) is entirely dedicated to the ceremony itself (and the laws leading up to determining exactly when the bris should take place) and symbolism of the mitzvah and ritual, but nothing about post-care or what to look for in the months following the bris.

In a practical sense, the book is ~~worthless~~ not helpful. Anything the book tells you that parents need to know in advance of their son's bris will be told to them by their mohel. And hopefully the mohel will also provide information as to how things will look in the coming days, weeks and months.

This blog was created in an effort to fill that void. Maybe one day I'll publish what I've put together here. All in good time.

Bris: Not Barbaric

noreply@blogger.com (A.B.) — Mon, 07 May 2012 03:02:00 +0000

Someone sent me a message on Facebook which said something along the lines of "What kind of person harms the integrity of the genitals? How do you live with yourself?" As I have mentioned here, this is not the forum to respond to the anti-circumcision people. This is a pro-bris website. So I choose to ignore (as in, not respond) to comments like this, because they serve no purpose. But in the event that an anti circumcision person comes across this discussion, I will try to explain here what I believe you (the anti-circumcision person) might not be able to understand.

Before I do, however, I want to bring an analogy, and let us see if this makes any sense. There are numerous studies out there that debate the efficacy of breast augmentation surgery (the outcomes are more unanimously against - as in, because the procedure is unhealthy). I am not talking about when a reduction is necessary for health reasons. I am talking about when a woman takes her naturally grown (no matter the size) healthy breasts and has an elective surgery in which silicone (or some other foreign object) is placed inside the body. I understand that there may be an emotional side to some of these decisions, where one's self image or femininity is negatively affected. But it's not always the case. And, at least the way society paints the picture, this is a common procedure that people do electively. And while people may cry out saying "You shouldn't do this to yourself!" the fact is that this doesn't stop the myriads of women who go under the knife for a look that they think is more attractive [it probably attracts more attention, but many will debate if it's actually more attractive]. I recognize, of course, that this is a choice that "adults" make about their own bodies – and this is very different than a choice made by adults about someone else's body, particularly that of an infant. I will address this below.

As most of my audience are those looking for information regarding mohels and brisses and how to have the best kind of experience when having a bris, the question is a non-issue. I have addressed the "barbaric" question before.

And, out of respect for my intended audience, I will answer this question in the simplest way I can.

"Intactivists" and those who obsess over their anti-circumcision campaigns have a little too much time on their hands. [I addressed my specific issues with them as relatedto the proposed circumcision ban in San Francisco in 2011, which was later thrown off the ballot by a judge (not because of my article).

Suffice it to say, easily 95% of the circumcised male population don't give any thought to it, and most are glad it was taken care of when they were babies. Ask most adults who opt to circumcise as adults (for whatever reason) and they will usually tell you "I wish I had it done when I was a baby, so I wouldn't know what it feels like and I wouldn't remember it."

Why is it not barbaric and how can I live with myself?

The objective medical community has the following perspectives on circumcision (some contradict one another, because opinions vary)

Circumcision is unnecessary
Circumcision is beneficial and brings down the percentage possibilities of developing certain illnesses and diseases
It is a simple "nothing" of a procedure
Because it heals so quickly, it is really not a big deal.
It removes sensitive nerve endings that might make intercourse a different experience as an adult.
It doesn't change the experience (of #5) all that much
Having a circumcision (done properly) may or may not give the baby long term trauma. Babies tend to get over it rather quickly and live normal lives with or without having been circumcised.

This last note would indicate what everyone knows to be true. A circumcision (done properly) does not alter one's life. The organ functions the same – in some cases (ie phimosis, severe webbing, etc) it functions better, and it can still do its jobs without incident. It can not even be compared to barbaric acts such as whipping or punishing amputations. A hand without a finger is not the same hand. A penis without a foreskin functions in the same way as it did before the foreskin was removed.

On the subject of trauma, I honestly believe that anyone who, as an adult, claims to "remember the trauma" of the experience as an infant, is LYING – pure and simple. They have trauma as an adult, for whatever psychological reason. But this has nothing to do with a memory of the experience.

So, How can I live with myself after being the agent behind foreskin removals?

Because I am a professional who is hired by parents to do this. With the exception of people I know personally (and even then I don't usually), I do not solicit clients. They find me. They call me because they are looking for this service to be provided, and I provide the service. I do not seek out babies to "mutilate."

Most people are happy and emotionally invested in the circumcision taking place. This is what they want.

My mohel teacher was once asked to speak at a bris when I was training. In his speech, he said, "What gives us the right to do this? How do we know the baby agrees with what we're doing? When we ask him, he cries. Maybe he doesn't want anything to do with it!" Rabbi Sasson answered his own question saying, "When a father brings his own son to the bris, he is demonstrating that he 'agrees' with what was done to him. That this is what he has wanted all along for himself." The baby, after all, is his own flesh and blood.

The mitzvah of bris is one Jews who observe Mitzvot (or even just this mitzvah), have been doing for thousands of years with a pretty good track record, and not much complaint until the advent of the original Reform movement (though Reform has largely accepted bris – there is a very large Reform Berit Milah Board), and the last couple of decades of anti-circumcision (Israelis) and anti-establishment secular (very very unaffiliated) Jews in different pockets around the world.

For every one anti-bris Jew, I am sure there are thousands of Jews who are of the other opinion and find the practice to be a very very very strong tradition, one that does not lend itself to much, if any, dissatisfaction or disgust with it.

I have also found this to be the case with non-Jewish people who circumcise for either religious or cultural reasons. They want it, and have no second thoughts about it being "barbaric."

A number of years ago, I wrote a dvar Torah for Parshat Lekh Lekha, which concluded with these two paragraphs:

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 [see Genesis 17]. 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 to arrive at the unstriking conclusion that the covenant with God is what keeps us going. In the words of Rav 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.

This is what drives me, and why the role I play is an honored one in the Jewish community.

Denuding the Shaft

noreply@blogger.com (A.B.) — Mon, 07 May 2012 02:02:00 +0000

I have written about this before, in the context of a discussion about arrogant mohels, and in the context of a bad story I was told by a baby nurse I worked with, and I hinted to it when I recounted a conversation I had with a urologist-grandfather with whom I worked directly. And I mentioned here why I would personally do my research in this regard were I to look for a mohel myself. Alas, being a mohel, I knew who was going to circumcise my sons.

But now I am calling it what it is.
Because I had a conversation today with a woman who recounted vivid details of her son's bris 5 years ago. She kind of laughed it off "because he's fine now" but I could tell that the trauma of her experience (not to mention her son's experience - my GOD!) is something she still carries with her. And I would readily admit that if a person has an emotionally difficult reaction to the bris - this is normal. A woman is post-partem, her baby has surgery, he cries during the bris, etc. It's not easy. But in a normal case, most people can talk about "how I (the parent) did not do well the day of the bris.. But, when I saw everything was fine, and everything happened exactly the way the mohel said it would, and the baby was calm after the bris" and leave it at that.

But when the mohel does a tremendous disservice to the baby, causing a terrible loss of blood, and making the penis look horrifically unlike how it should look after the bris, on account of a BAD JOB - this information needs to get out. The problem is: No One Talks About It

It does not matter that the urologist grandfather I mentioned above said "The penis is a very forgiving organ." This means that somehow, when it heals, things tend to work out nicely. That does not excuse poor choices made by a mohel.

The Skinny

The penis as an organ does not change in size in any significant way from birth until a child is at least 10. shaft may get a little fuller from newborn to age 3, but the real major changes come with the onset of puberty. This is why even when there seems to be skin (ie membrane) climbing on the edge of the glans in a youngster, puberty will likely remedy that aesthetic inconsistency.

Many years ago I had a conversation with a mohel (who is probably 35 years older than I) about what is the proper amount of skin to remove in a bris. We were discussing longer term consequences, and different scenarios were raised, which mostly stem from the fact that every baby has a different size and shape penis (the ingredients are the same, but the amounts are different from baby to baby): some have a very long shaft, some have a very short one; some have a very pronounced glans, some have a glans that is hardly distinct from the rest of the shaft; some seem to have all-glans-no-shaft, and some have a more ratio-d proportion of shaft to glans; the angle of the glans (dorsal and ventral sides) change from baby to baby.

What is "Denuding"?

He asked me, "How do you know how much to skin to remove if the shaft is longer or shorter?" I told him that I mark the edge of the foreskin where I see the edge of the glans pre-circumcision. He laughed and said, "And you follow the mark?" I affirmed. [He didn't believe me.] He said, "What happens when you see that you undershot?" (It could happen that in the prep-room I will underestimate how much skin is to be removed, usually on account of the fact that the skin is so maleable and it literally can shift from second to second.) I told him that when it happens (as it does every now and then) I will leave myself a little cautionary room to take a little more off the dorsal side, because, as every mohel knows, taking a little more off the dorsal side is OK. This is where the penis is most forgiving. But I will still follow my mark on the ventral side. I don't want to risk denuding the shaft.

He said, "When the organ is smaller, you want to take off as much skin as you can. Otherwise the penis will sink into itself. When the organ is longer, you want to take off the absolute minimum because otherwise, you'll end up denuding the shaft." [He told me that it sounds contrary to logic, and it does seem that way, but while I don't completely agree with him, I do agree that there is basis to the argument.]

I had a similar conversation recently when a mohel colleague (much closer to my age, though I think I've been working a few more years) asked me my opinion regarding if its better to leave more or less of the original shaft skin. I told him that the reason I use the marker is to ideally leave the baby with as much of his original shaft skin as possible. We are removing the FOREskin, not ALL of the shaft-skin.

I told him what the older mohel told me, which parts I agree with, and which parts I disagree with. Mostly I think there isn't necessarily a one-size-fits-all. Every baby needs to be "diagnosed" for the best angled and planned bris the mohel can give him. Leaving him as much original skin, and less "scar tissue," than he should have to deal with.

All this is why the mohel I mentioned in the opening tale did a tremendous disservice to the family in question. He did not inform them of his method of doing bris. He did not share any information with them.

And they too did themselves a disservice by not doing more research. That "everyone uses him and we therefore thought everything would be OK" does not justify a lack of research.

This is a violation of rule #10, 7, 6, 5, 4, 2, 1

From my conversation, I know exactly what the man did. He wrongly estimated the end of the foreskin (did not mark), he grabbed the foreskin and ended up taking ALL of the shaft skin, and he did NOT use a shield. Thank God he did not amputate the glans! But he also left right after the bris (he flew in from NY to do their bris in a different state), and did not give ample instructions or leave an adequate bandage that made everything palatable to see afterwards. The mother described the "bloodiest diaper. It was a horror."

NO ONE SHOULD EVER HAVE AN EXPERIENCE LIKE THAT!

No mohel is an expert from the get-go. But every mohel should have a decent sense of the proper precautions to take to avoid disaster. And every mohel, with time, hopefully gets better and becomes more efficient at what he is doing.

But the denuding of the shaft is wrong, as at least a minimal amount of skin should remain climbing up the shaft from the scrotum and from the belly. The remains of the membrane will fill in the rest of the shaft with time.

DON'T LET THIS HAPPEN TO YOU OR YOUR SON! MAKE SURE YOU KNOW WHAT PRECAUTIONS THE MOHEL TAKES TO MAKE SURE HE REMOVES THE RIGHT AMOUNT OF SKIN AND PROTECTS YOUR SON'S GLANS.

BE INFORMED, TAKE CHARGE, AND DON'T BECOME THE VICTIM OF A FOOL MOHEL WHO SHOULD NOT BE PRACTICING (on account of his not marking or using a shield), WHO CARES MORE ABOUT HIS STATS (AS IN, HOW MANY BRISSES HE'S DONE - a number he apparently shared with the mother) THAN ABOUT EVERY BABY UPON WHOM HE HAS PERFORMED A BRIS.

A List of Brisses

noreply@blogger.com (A.B.) — Mon, 23 Apr 2012 22:13:00 +0000

My brother sent me this photo (taken with a smart phone - as I think the shadow indicates) of a list that is described as part of a "letter [which] lists twenty-one people circumcised by Moses Mendel Seixas between 1775 and 1796."

I hope the short list of a 21 year period is indicative of a small Jewish population at that time - and not the particular skills of the mohel in question. Although I am quite curious as to what the word that seems to say "dead" after 3/4 of the dates would indicate.
Were they written later by someone seeking the people he circumcised, or by some record keeper? Were they written by the mohel as a result of his work? Did he circumcise stillborns or infants who did not survive?

Or does it mean something else entirely? If anyone knows, please let me know!

Another Article on Metzitzah

noreply@blogger.com (A.B.) — Thu, 12 Apr 2012 00:12:00 +0000

This time in the Jewish Press

The author is the same Dr. Gary Gelbfish, whose article I posted over here.

In it, he sort of responds to this article by Dr. Daniel Berman (I have not linked to this article until now)

Essentially, he suggests that a complete panel of physicians gather to weigh in on their perspectives to the rabbis - with facts and opinions about the efficacy of mixing the germs and bacteria of the mouth with an open wound (knowing what we know about all these things)
- so the rabbis can become educated about the risks in question (even if available "statistics" don't indicate an epidemic - high probability of "risk" is nothing to hush under the rug) and issue perspectives (as did the Rabbinical Council of America) for their constituents to follow. [If they can't rule on end-of-life issues or niddah questions without understanding how the body works, the same logic should apply to blood, bacteria, herpes, and neonatal immune systems.]

I have mentioned Dr. Berman in the past, simply because he is the author of this article, which does terrible injustice to his medical credentials.

Say what you will about the failedmessiah blog, but his take on Dr. Berman's perspective (at the end of this post) - how do I say this? - I couldn't have said it better myself.

News Monitor: Metzitzah and Herpes

noreply@blogger.com (A.B.) — Tue, 10 Apr 2012 15:02:00 +0000

This from the Jewish Week.

There are those who may call the Jewish Week all kinds of names, and may disagree with their slanted approach (and I will include myself in this category, for some stories). But I don't think they are off on this one. I think sensible people want to protect babies, and don't believe that any part of the bris should "possibly" put the baby in danger (with the exception of the Biblically mandated circumcision itself - which is only done on healthy babies, and, when done properly, is a safe procedure - with a very good track record).

Every time I have read an article written by a physician advocating "metzitzah with direct-oral-contact" as "a safe procedure" the article has been wholly unscientific and very very tainted by the doctor's "hashkafa" (Jewish perspective) as dictated by his emotions and religious beliefs, rather than by medical realities.

BTW, in the article, they quote one of these doctors as having claimed that "the baby had a rash" before the bris. Were that the case, any responsible mohel would not have gone ahead with the circumcision. A rash on the genitals (as opposed to on the tush) is not "normal" and a responsible mohel will wait at least until the rash goes away before doing the bris.

How to Find a Mohel

noreply@blogger.com (A.B.) — Tue, 10 Apr 2012 14:44:00 +0000

Like the medical field in general, the Bris Milah field prides itself on reputation building and reputation maintenance. While people may appreciate how nice you are, most people really (should) want to know if you do a good job. And the way they find out is by asking their friends who have had similar experiences, "Who did you go to? Were you pleased with the experience?"

No matter what the other person's experience, it is important to interview the person you may be interested in hiring. Just as every doctor has a personality and a style that needs to work for you, this is certainly the case for every mohel.

People find a mohel either by word of mouth, through a physician referral (or mohel referral, if your first choice is not available), or on the Internet - through a Google search followed by research through various websites, most likely including the website of the mohel you end up choosing.

If you've done this before and had a good experience, you will likely call your mohel again.

If you did not have a good experience
- which could be a personality or style clash, or you were not pleased with circumcision results, or follow up, you will likely look elsewhere. [While I simply don't have numbers because I don't know when people are pregnant again (though I know of some people in the earlier years who did not call again), I can say with certainty that in the last five or six years - during which time my own efficiency standards have significantly improved - I have been called on many occasions by those who had a previous experience they were unhappy with (with a different mohel), for any of the reasons just described. The feedback I have generally gotten was "you're the first mohel we would call again!"]

It is therefore important to know what will be important to you in the experience you are looking to have, what questions you need to ask (see here as well (and an anecdote here)), and what answers you are hoping to hear.

Some Mohels have their way of doing things but are flexible per your input. Some are not. If you have an open conversation, you'll likely find common ground. The most important thing you need to have is confidence that you've made the right choice.

You need to be comfortable with your choice, and this comes from your trusting your mohel.

I like to have pre-birth conversations (when applicable because I am called in advance of birth), pre-bris conversations, and follow up after the bris, both in Person and over the phone. I make a very concerted effort to avoid the problems and concerns I hear about from many parents who have shared their bris experiences and stories with me (again - from their experiences with certain other mohels).

These are not, to be sure, problems which exist across the board - many mohels do a fine job the first time, and have wonderful reputations. I am talking about the "fell between the cracks stories" which generally amount to long-term aesthetics, and any post-bris (un)forgettable moments such as the need to do another bris because it wasn't done properly the first time (not to mention hospital trips).

Sadly some people laugh about these things in retrospect, but this is no laughing matter. Many people never talk about these things because they think it is embarrassing to discuss. Stories like these need to addressed, because people have the right to know what they are possibly getting themselves into. No mohel bats 1.000%. No human being is perfect or does a perfect job every time (and one who claims to have never had a "bad story" is likely not telling the truth). But even in the circumcisions that do not come out "perfectly" there is, thank God, a significant margin allowing for human error. As a urologist recently told me, "the penis is a very forgiving organ" when it comes to post bris aesthetics. But all precautions to avoid taking off too much or too little, as well as the removal of excess mucosal membrane, need to be accounted for. There is a certain aesthetic we are looking for, and it should be achieved as closely as possible, and after the most minimal passage of time from the actual bris, if not at the bris itself.

The bottom line is this. When you do proper research, know what to ask, and have an idea of what kind of experience you're looking to have, you'll make the right decision. [If you don't, join the ranks of the "Top Ten Mistakers"]

You need to be concerned about and inquire regarding the Mohels sterile technique (see here as well), another item not to be taken for granted.

Lastly, assuming all cosmetic results are the same (though they aren't, and believe it or not doctors who perform circumcisions generally produce the worst cosmetic results - except pediatric surgeons and urologists), remember that "mohel" is a specialist title that describes your resident expert in question much more than do titles of "Doctor" or "Rabbi." Find your man based on his Mohel track record.

I wish for you and your baby to have not only a great experience at the bris, but the cosmetic results you and he will be pleased with for a lifetime.

A word about this blog

noreply@blogger.com (A.B.) — Mon, 02 Apr 2012 01:27:00 +0000

As it says at the top of the page, this blog consists of my "Observations, thoughts" and discussions of "issues related to Bris Milah." Of course everything is from my perspective, based on the things I have learned, studied, been taught, and experienced through my years of training and hands-on practice as a mohel.

Over the two and half years I've had this blog, the audience has been expanding – and for that I am grateful. Grateful that I can play a role in educating people about bris milah, and that the perspective I have to offer (which, of course, is not the only perspective out there) has an audience.

On account of the sensitive nature of this blog, I have chosen to heavily monitor the comments that come through. To bring a few examples:

This is a pro-bris blog, not a pro-circumcision blog. Comments from those who are anti-circumcision have no place here.
This is a blog which shares information to educate or to inform people what is out there, what to ask about and what to look for when hiring a mohel – wherever you may find yourself and whomever you may be hiring. Comments from those who claim that all mohels are the same and give the same services in terms of personality, sterility, cleanliness, and resulting bris look have no place here. That presumption is simply not true.
This is a blog in which I share some information about my personal practices as a mohel. I am happy to explain details people have questions about in this regard. I have studied many halakha sources (though certainly not everything out there – who has?), I continue to converse with mohel colleagues, and I turn to great rabbis and poskim for questions that come my way that are of a more complicated nature – for which I need guidance. This is not the forum for me to justify these to those who think otherwise. I am certainly available to engage in a dialogue of this nature by email, and would welcome such an opportunity.
There are times when a news item addresses the practice of bris milah – such as the proposed ban in San Francisco of Summer 2011, stories that come out of Israel, or the Metzitzah story that came out of NY in March 2012. I may report these objectively, or I may offer my own commentary. Of course, in doing so I am offering my opinion. Comments are welcome on the stories, of course, and I am happy to answer direct questions. But I can no longer respond to Anonymous postings in the blog – sometimes the blog back-and-forth give-and-take does not lend itself to the same kind of response that can come in email format, when I can actually talk to the person addressing me instead of at the person.

I am really not interested in having every conversation in which I engage posted on the internet. Email is a much better forum for some discussions - if you would like to engage in conversation (or debate), feel free to email me.

If a reader would like a different perspective to be voiced here, feel free to write an essay, email it to me, and I will be happy to post your opinion under your name.

Looking forward to future dialogues.

Nissan - When one Perk is Irrelevant

noreply@blogger.com (A.B.) — Sun, 01 Apr 2012 15:37:00 +0000

Every day at shacharis someone will ask me "Are you working today?" meaning, "Do you have a bris?"

The reason they are asking is because when a mohel is present in shul on a day when he is performing a bris, since it is considered to be a Yom Tov/holiday for him, the "tachanun" prayer is omitted in celebration of the special occasion. After all, who needs to beseech God with supplications when such good news is taking place? [That's not exactly the thought process, but it's a start.]

Anyway, the custom is for the entire Jewish community to omit Tachanun during all of the Hebrew month of Nissan on account of the fact that 20 days of the month (Biblically speaking) have a special event attached to them. The rabbis taught, once more than half the month is free from tachanun, we'll just apply the celebrations to the entire month..

During Nissan, bris or no bris, I am reminded "we don't need you."

I got it.

Milah U'Priah B'Vas Achas

noreply@blogger.com (A.B.) — Sun, 01 Apr 2012 06:01:00 +0000

The title refers to removing the foreskin and the membrane below it in one action. There are different ways to do this:

My teacher, Rabbi Mordechai Sasson, would often grab the foreskin with his fingers and remove all of the membrane along with it, alleviating any need to tear the membrane or otherwise remove it.
Others accomplish the same task with the help of an instrument called a "hemostat"
Still others do what Rabbi Sasson did, except they only remove part of the membrane. The remaining membrane is then torn apart with the fingernails (which can be gloved, if the gloves are thin) and folded back beyond the corona of the glans. This third approach does not completely remove the membrane as do the first two methods described.

I recently had someone ask me why I follow the second approach listed, especially in light of my training. Following the advice of one of my teachers, who is of the opinion that the fewer things needed to be done to a baby (as in "cut once" as opposed to "cut and then tear") the better, I have opted to act in accordance with the approach advocated by Rabbi Moshe Feinstein in his responsa on this subject. The most clear cut analysis is in YD 3:98 (as noted below), in which he quotes this - from the Geonic Period:

תשובות הגאונים שערי צדק חלק ג שער ה סימן ו

רב האיי ז"ל. (גם זו הועתקה) דע כי זה החוק יש בבבל מהיו' שנים רבות: שמושך המוהל את הערלה ומפסיק הקליפה התחתונה בידו כדרך שהם יודעין עד שהיא נפסקת, ומאבד אותה עם הערלה, וחותך אותה בבת אחת. ואם אינה נסדקת ונפסקת באצבע או בצפרנו, יהיה לו סרן הנקרא בלשון ערבי מדור ופוסק בו וחותך הכל בבת אחת ושפיר דאמי. ואין ראוי לחתוך בשני פעמים, אבל ראוי להיות מילה ופריעה בבת אחת וכשנעשות שתיהן יצא. +(שבת קל"ג קל"ז, י"ד רסד ג' ד')+ עד הנה.

Rabbi Feinstein even writes that when he first discussed this topic he had not yet seen (or known about) the passage I just reproduced above (knowledge of which I only have from reading Rabbi Feinstein's letter), but since his halakha analysis brought him to the same conclusion, it is clear that it is a proper practice to remove the foreskin and membrane together.

Every person has the ability to educate oneself about the methods out there, and choose what works best for you. You can hire a mohel telling him exactly what you want him to do, and see if he will accommodate your wishes based on his comfort level. And if it doesn't work in either direction, don't hire the man. But by no means get upset because he has his way and you have yours. And both are fine, produce fine circumcisions, and leave baby no worse for wear with either method - it is merely a question of whether one believes one way is either better than the other, more halakhically advocated, or more vs. less painful to the baby.

I do believe other things - more globally - are worth getting upset over in the process of bris milah, such as the stories that come my way when talking to people I have just met about their experiences when they had their sons circumcised in different places and with different mohels. Thank God, most people do not have stories like these, and they are fairly uncommon, but I hear enough firsthand stories to know that they happen: mohels damaging babies, babies who lose a lot of blood and/or need to go to the hospital post-bris, of mohels who operate without gloves and who make a huge mess.

Essentially, as Phil Sherman has said it here (last paragraph), any mohel story that causes another Jew to pursue the doctor route before the baby's eighth day of life, or to choose the doctor over the ritual completely, or to forego the bris altogether, is cause enough to be upset over the disregard being fomented towards this mitzvah.

HAVING SAID ALL THIS, I AM PRODUCING THE FOLLOWING RESPONSUM FOR THE BENEFIT OF ALL THOSE INTERESTED IN THIS SUBJECT.

To the best of my knowledge, Rabbi Moshe Feinstein had three responsa on this subject. YD 1:155, 3:98, and 4:40. I am indebted to an anonymous commenter for pointing out this last one, which I am producing below, preceded by my translation of it, and commentary embedded between the "quotation indentations." Some of the points made by Rav Moshe which highlight my position have been emphasized in bold.

*******************

On the topic of Milah and Priah at the same time, and using anesthesia on the baby (numbing) at the time of circumcision. This response is the last big response that Rav Moshe wrote in his own handwriting. During this time, his vision was deteriorating (it should not happen to anyone), and after this response, the writing of which was very difficult for him, he only wrote short response. 15 Elul 5744, New York To [many superlatives] Rabbi Shabsi/[tai?] Frankel, etc.
It's surprising about the letter the Rabbi wrote, which is dated 16 MarCheshvan 5743, because it has been more than 1 year and 8 months since it was written, and in all this time, I have seen the illustrious rabbi a number of times, and he never mentioned anything about the letter he had written. Nonetheless it has appeared. And now that the letter has been found, and it's a matter of Torah, I have the responsibility to respond. In particular because it is a matter that is halakha l'mayseh (quite relevant) and on the topic of the mitzvah of bris milah, which is very important, as the Talmud Nedarim (31b) explains.
1. Is there a concern when the foreskin and the priah membrane are removed at the same time with a knife of "changing the way the mitzvah is fulfilled"?
[Answer] What the rabbi has seen in Americathat the cutting of the foreskin, [along with] the membrane that is a thinner skin – the mohel did this in one cut with his knife. This is done through the insertion of a blunt thick needle [a probe], which he uses to separate the thin skin, which is the membrane, from the glans.

Rav Moshe is describing the method used by many mohels to separate the membrane from the glans in order to assist in the removal of the membrane, which would otherwise remain stuck to and coating the entire penis when the foreskin is removed.

The two skins [foreskin and membrane] were then attached, and he excised them together in one action. I was asked this question in 5714 (1954), and my answer was published in YD I:155, that according to the law there is no difference: not in the cutting of the foreskin or the cutting of the membrane with regard to what they use to do it.The mitzvah of milah is to remove the two skins that cover the glans (to the edge of the corona), which are the foreskin and the membrane. The definition of priahis "revealing," as Rashi explained at the end of Rabbi Eliezer D'Milah (Shabbat137b, s"v para). And there is no difference as to how this is accomplished.But, since the membrane is thin and attached to the glans, and it is impossible in practical terms, to cut it in a simple cutting of the foreskin, and it even can not [be cut] by itself [meaning, when the foreskin has already been removed and the membrane alone remains] unless one tears it with fingernails to fold it back from on the glans; and because it is so thin there is no need to cut it, rather they just fold it back beyond the corona, and it sticks to the skin of the shaft in that spot and becomes part of the shaft.

Rav Moshe is describing the third method I described at the beginning of this posting.

It is not part of the skin of the foreskin - which is thicker – for were one to do the same thing with the foreskin, to fold it back and have it stick below the corona, it would be quite clear that this is the original foreskin stuck back there. And maybe, when the circumcision is done this way [folding back extra foreskin] he did not fulfill the mitzvah of bris milah because it will look like it was never cut, because the skin is still there, except that it has changed its location on the organ.
The mitzvah is to circumcise yourselves (Genesis 17:10), which means to completely cut off all that is recognized as that skin. And every word "Milah" at the end of parshat Lekh Lekha and Tazria refers to a cutting.
This implies that for the foreskin itself, a real cutting is required. But the membrane, which is a thin skin, which gets stuck and becomes part of the shaft itself and can no longer be recognized, it is good enough if it was not cut and was just folded back and set below//beyond the glans in the shaft – even though it gets stuck there and we are aware of it.

While technically speaking Rav Moshe is obviously correct, in practical terms, I have examined many babies (in the dozens), whose parents had a concern that they did not look circumcised. In very few cases it was because not enough skin was removed. In most of the cases, not enough membrane was removed, too much was folded behind the glans, beyond the corona as Rav Moshe describes, and it became a very puffy and unsightly ring of skin which climbed its way on the glans giving the baby an uncircumcised-look. It is this concern that causes me to leave behind as little membrane as possible in most circumstances, and to leave a little more for the babies who need it to fill in the shaft.

It's also possible that it's a "Halakah L'Moshe MiSinai," [namely] that the foreskin needs to have a complete excision, and none of it whatsoever should remain on the organ, not even on some other part of the organ (relocated), but this would not be the case with the membrane.

It is not a Halakha L'Moshe MiSinai that the membrane needs to be completely removed

There is a difference between the membrane and the foreskin, and there is a difference to the law from the decree of the Torah, from the law from Sinai, since this is what was the practice "l'mayseh" [for] many generations.

The practice for many generations was to remove the entire foreskin, and either to remove the membrane or to leave some of it behind.

Nonetheless,this is certainly not to suggest there is a mitzvah to specifically leave the membrane on the body, even in some other place [ie relocated to below the glans]. It is certain that if a mohel removed the membrane, leaving nothing behind, there is nothing lacking in the [fulfillment of] the mitzvah. If he's not adding pain to the baby.

On this last comment, the question becomes one of perception: what is more painful to the baby - a hemostat and one cut? or a cut and a grab and tear of the membrane? Jury is out on that one...

And what it says in the Midrash Shochar Tov (and in Midrash Tehillim 35:2 it only mentions [a mitzvah done with] fingernails regarding using them to reflect the light at havdalah, but the text in Yalkut Shimoni Tehillim 723 it mentions fingernails for priah) it says fingernails are for priah, this is not meant to establish an obligation to do it this way.

In other words don't use conflicting midrashim which ascribe different purposes for the fingernails, in order to determine a halakha related to fingernails and their use in a bris.

It's only because it was the practice of mohels in all the generations with fingernails, because that way was easier to do, and it also healed better than when [priah was] done with a knife. That's why it was done with fingernails.

This idea of it being done with the fingernails "in all generations" means that "If after the foreskin is removed there is still a membrane on the penis, the best way to remove that membrane is with a fingernail and not a knife." The knife, in that specific circumstance, is too big, too dangerous, and can't do as good a job, or as quick a job, as a fingernail. Of course, if the membrane is gone, it is a moot point. [Hmmm... but what if a mohel has more than just a knife available to use, such as a hemostat which might grab the membrane better than a fingernail...?]

But if one sees that that the membrane is also excised with the knife, it is simple, in my humble opinion, that he is yotze [has fulfilled the mitzvah properly].And this is true even if it was done in two acts – cutting the foreskin and cutting the membrane.
And even on shabbos, two [separate] acts are permitted, even when there is a greater expert who can do them both [milah and priah, that is] in one act [of cutting]

I see. Doing it in two acts is permitted, even if a "greater expert who can do both in one act" is available. So the "greater expert" is the one who can do both in one act!

And this expert I refer to is one who is an expert in the simple cutting of the foreskin – that he can excise all of the foreskin along with some of the membrane, because this makes it much easier for the person doing priah to grab the membrane.
But many mohelim are not able to do this: when they remove the foreskin they get nothing of the membrane. And then to go back with the knife and cut part of the membrane is extremely difficult, and they need to find a way to begin the cutting of the membrane, which is really a thin/delicate skin.
The second guy, the one standing by to cut the membrane, needs to do it with his fingernails and not a knife, because it is difficult to ascertain that he will only cut the thin membrane with the knife [and not, chas v'shalom, a part of the glans], unless he says he is an absolutely expert mohel. And even then we don't rely on him.

What if he is not using a knife, Rav Moshe? What if he is using a hemostat and blunt-ended scissors to cut the membrane - in which the safety concern that a knife raises is removed with this blunt instruments?

But in the first place, one should hire a mohel who can assure that when he removes the foreskin he also touches the end of the membrane, so that the priah will be relatively easy to do, with as little pain to the baby as possible.
But with regard to the fulfillment of the mitzvah of milah, there is no distinction in the cutting of both skins together, because if both [meaning neither] skins are not removed from the organ, it is nothing [IOW, not even considered a bris], whereas if both skins are removed from the organ it is a fulfillment of the mitzvah of milah.
The one distinction is that the foreskin needs to be removed completely from the organ, but with regard to priah, when it is moved off the glans and placed [still attached] below the corona there is that distinction because that can be done with the membrane but cannot be done with the foreskin.

[Even in this last point I wonder, because I have been in the operating room observing a reconstruction of the penis where the entire organ needed to be drawn out of the webbing that held it inside the scrotum, and the doctor needed to use the foreskin to reconstruct the penis. In other words, what was once the foreskin is now part of the scrotum, and most of us would never notice it or know it were we to see it. Does this mean this child is not considered circumcised? His penis looks 100% circumcised... For his sake I hope it's fine, because taking away that now-part-of-his-shaft foreskin would destroy his penis.)

[I included the rest of this - which does not translate the entire answer - simply because the point is a good tag to this posting about numbing.

2. The reason we don't use anesthesia on the baby before the circumcision
With regard to what Rav Shlomo Zalman Auerbach wrote on 23 Cheshvan 5743 that in the act we are careful not to change a practice, even if [the old practice] is not a preferred way to do it.
He said [for example]:
We do not change how metzitzah is done, even though nowadays we have better mediums [tools] which are much easier and better than [classic] metzitzah, and we also do it on shabbos, even though it contains the issue of [it being] melakha.

It seems from here that Rav Shlomo Zalman was of the opinion that a tube for metzitzah was a better method than the mouth, and that doing metzitzah on shabbos is a melakha! He allows the old ways (no pipette and doing it on shabbos) as a nod to the days of old. But his personal view of the more ancient practices is that "they are not better."

And he also said that the reason we don't use anesthetic on the baby to prevent him from feeling discomfort, is because we don't want to do any changes in how this mitzvah is done, even though it would seem there is no real suspicion because there is no indication [that this is changing the mitzvah.]
But, you should know, that the real reason we don't use anesthetic is because anesthesia is not healthy for babies. It's also not good for older people. But the older people take the anesthesia because they specifically request it, because they'd much prefer to be numb [and deal with the risks that come with anesthesia] than to feel the pain of having skin removed without numbing. But the choice we make for children is most influenced by our concern for their wellbeing….

שו"ת אגרות משה יורה דעה חלק ד סימן מ

בעניין מילה ופריעה בבת אחת והרדמת התינוק בשעת המילה

תשובה זו היא התשובה הגדולה האחרונה שכתב מרן זצ"ל בכתי"ק. בתקופה זו הוכבדה עליו הראיה ל"ע, ולאחר תשובה זו, שכתיבתה עלתה לו בקושי רב כתב רק תשובות קצרות.

ט"ו אלול שדמ"ת נוא יורק

מע"כ ידידי היקר חביבא דנפשאי הרב הגדול מעוז ומגדול מהר"ר שבתי פרנקל שליט"א שלום וברכת כתו"ח טובה לעולם.

הנה לפלא שמכתב כתר"ה שנכתב זמן הכתיבה עליו ט"ז מרחשון תשמ"ג, לא בא לידי ולא ראיתיו עד ט"ז תמוז שדמ"ת, שהוא יותר משנה ושמונה חדשים משנכתב. וגם במשך זמן הארוך הזה נזדמן שראיתי את כתר"ה איזה פעמים, ולא הזכיר מהמכתב ששלח. אבל הכי עכ"פ אירע זה. ועתה כשנמצא המכתב והוא בדברי תורה הרי יש עכ"פ החיוב להשיב, ובפרט שהוא לדבר הלכה למעשה ובמצוות מילה החשובה ביותר כדאיתא בנדרים (ל"א ע"ב).

א. אם יש לחוש כשחותכין את עור המילה והפריעה בבת אחת בסכין, משום שינוי בדרך קיום המצווה

הנה מה שראה כתר"ה בכאן אמעריקא, שחיתוך עור הערלה, והפריעה בקרום עור הדק, עשה המוהל בחיתוך אחד בסכינו. ע"י מה שמתחילה תחב מחט גס בלא עוקץ, והפריד אף עור הדק שהוא עור הפריעה מעל הגיד, והיו שתי העורות מדובקים וחתכם יחד בבת אחת. הנה כבר נשאלתי ע"ז בשנת תשי"ד, ונדפס באג"מ על יו"ד ח"א סימן קנ"ה מה שהשבתי, שבעצם לדינא ליכא חילוק לא בחיתוך הערלה ולא בהפריעה במה יעשו אותו. דהמצווה דמילה היא שיסירו מעל הגיד שתי העורות שעליו שמכסין העטרה, שהן עור הערלה ועור הפריעה. דפירוש פריעה הוא גילוי, כדפרש"י בס"פ ר"א דמילה (שבת קל"ז ע"ב ד"ה פרע) וליכא חילוק איך יעשה זאת. אבל כיוון דעור הפריעה רך ודבוק בגיד, ואי אפשר במציאות שייתחתך בסתם חתיכת עור הערלה, ואף לא לבדו, אלא בקריעה בצפורנים לקולפו מעל הגיד. ומאחר שהוא דק ביותר אין צורך לחותכו, אלא קולפין אותו מעל העטרה, ומניחין אותו מתחת לעטרה ונדבק לבשר הגיד שמתחבר שם, ונעשה מהגיד עצמו.

ולא שייך בעצם לעור הערלה עצמה שהוא עב, ואם יעשו בו כך, שיקלפו אותו ויניחו אותו מתחת לעטרה יהיה ניכר וידוע שהוא בשר הערלה שנדבק כאן. ואולי כשימול כך לא יצא המצווה דמילה, דהוא כלא נחתך, מאחר דהוא עדיין על הגוף אך ששינה מקומו. והמצווה נאמר המול לכם (בראשית י"ז, י') שתרגומו הוא למגזר לכון כל דכורא, שפירושו לחתוך. וכן תורגם על כל לשון מילה שבס"פ לך ובפרשת תזריע שהוא לשון חיתוך. וא"כ מסתבר שבעור הערלה צריך דוקא חיתוך ממש. אבל עור הפריעה שהוא עור הדק, שהוא נדבק ממש ונעשה כעור אחד עם הגיד ולא ניכר כלל, סגי אף שלא חתכו ממש אלא דקלפו מעל הגיד והניחו תחת העטרה על גוף הגיד, אף שנתדבק שם וידעינן מזה.

וגם אפשר שהוא הלכה למשה מסיני, שהיתה שבעור הערלה צריך דוקא חיתוך ולא ישאר ממנו כלום על הגיד, אפילו במקום אחר מהגיד, ובעור הפריעה לא נאמר זה. שלכן איכא חילוק לענין זה בין עור הפריעה לעור המילה, ואיכא חילוק לדינא מגזירת התורה מהלכה מסיני. ואף שלא הוזכר זה שייך לומר כן, מאחר שכן היו נוהגין למעשה כל הדורות.

עכ"פ זה ודאי שליכא ענין מצוה להניח דוקא עור הפריעה על הגוף, אפילו במקום אחר. וודאי שאם מוהל אחד חתך גם את עור הפריעה ולא הניח כלום, ליכא חסרון בהמצווה - אם רק אינו מוסיף יסורין להתינוק. ומה שבמדרש שוח"ט (במדרש תהלים מזמור ל"ה פסוק ב' הוזכרו צפרניים רק לגבי להסתכל בהם אור ההבדלה, אבל בנוסח המובא בילקוט שמעוני לתהלים סי' תשכ"ג אי' צפרניים לעשות בהם פריעה) הוזכר שבצפרניים עושים פריעה, אינו לדין לחיוב לעשות כך דווקא. אלא מחמת שדרך המוהלים בכל הדורות היתה בצפרניים, שכן הוא יותר נוח לעשות וגם להתרפאות באופן יותר טוב מכשהיה זה בסכין, שלכן נעשה בצפרניים. אבל אם אירע שנחתך בהסכין גם עור הפריעה, פשוט לע"ד שיצא. והוא אף שהיה זה בשני מעשים (חיתוך הערלה וחיתוך עור הפריעה), ואף בשבת יכולין לעשות זה בשני מעשים אף כשאיכא לקמן אומן גדול שיכול לעשות בפעם אחת.

והנה האומן הגדול שכוונתי לו, הוא כשהוא אומן באופן סתם חיתוך הערלה - שיכול לכוין לחתוך כל עור הערלה ומשהו מעור הפריעה, שיהא נוח לעושה הפריעה לאחוז במקום הפריעה. אבל הרבה מוהלים אין יכולין לכוין כן, ולא חתכו אלא את עור הערלה ולא נגעו כלל בעור הפריעה. ולחזור לחתוך בהסכין מקצת מעור הפריעה הוא דבר קשה מאוד, וצריכין להשתדל שימצא דרך איך להתחיל לחתוך את עור הפריעה שהוא דק מאוד. וצריך השני שהוא הפורע לעשות הכל בצפרניים ולא בסכין, משום שקשה לכוין שלא יחתוך בסכין אלא עור דק כזה, אם לא דאומר דהוא מומחה גדול, ואף באופן זה לא היו רשאין לסמוך עליו. אבל לכתחילה צריך ליקח למוהל את מי שיכול לכוין כשחותך הערלה ליגע בסכינו משהו בתחילת עור הפריעה, כדי שיהא מעשה הפורע בקל ובמיעוט הצער לינוקא. אבל לענין קיום מצות מילה ליכא חילוק בחיתוך שני העורות, דאם לא סילקו את שני העורות מהגיד אינו כלום, ואם הסירו שני העורות מעל הגיד קיים מצוות מילה. אך שאיכא חילוק - דעור הערלה צריך לחתוך כולו מעל הגיד, ולענין הפריעה, כשהסיר והניחו למטה תחת העטרה איכא חילוק, דעור הערלה אסור ועור הפריעה מותר, כדלעיל.

ב. הטעם שאין מרדימים תינוק לפני המילה

ובדבר מה שכתב הגאון הגדול מהר"ר שלמה זלמן אויערבך שליט"א בכ"ג מרחשון תשמ"ג לכתר"ה, שבמעשה נזהרים מלשנות מן המנהג אפילו בדבר שאין בזה עדיפות עצם המצוה. והביא שאין משנים ענין המציצה, אף שאיכא בזמננו אמצעים יותר קלים ויותר טובים ממציצה, וגם עושין בשבת אף שאיכא ענין מלאכה. וגם הביא ממה שאין עושין תרדמה להתינוק שלא יצטער התינוק, והוא מפני שאין רוצים לעשות שום שינוי במצוה גדולה זו אף שלכאורה ליכא שום חשש, בדליכא הכרח. אבל ידע נא כתר"ה שמה שאין עושין תרדמה לתינוק הוא משום שלא טוב כלל סמי התרדמה לתינוקות, ואף לא לגדולים. אך לגדולים נותנים סמי תרדמה מפני רצונם, שעדיפא להו עשיית התרדמה מהצער הגדול שיהיה לו לחתוך בשרו בלא תרדמה. אבל לקטנים עושים כפי היותר עדיף להם לבריאותם. ואף כשיש צורך לקטן כזה, דצריכים לעשות איזה ניתוח שיש לחוש שיבכה בקול גדול שיטריד בזה את הרופא שיוכל להתעלם עי"ז במלאכתו בעשיית הניתוח, צריכין ליתן סמי תרדמה. אבל בלא זה אין נותנין סמי תרדמה, שאין זה דבר טוב לרפואת האדם. ולכן אין נותנים סמי תרדמה לעשיית מילה דקטן. ולא מצד שיש איזה חששות בדין לקיום המצוה, ואף לא לסודות המצוה, כשלא ידעינן משום תקלה ומשום חשש. דעיקר דבר המצוה ואף הסודות ידועים לחכמי הדור.

Rabbi Kaminetzky Clarifies His Statement

noreply@blogger.com (A.B.) — Sun, 01 Apr 2012 03:18:00 +0000

See here where Rabbi Kaminetzky "clarifies" what he said in the comments I noted here.

Having read the Rosh Yeshiva's brother's book about the response to his (Rav Nosson Kaminetzky's) book "Making of a Godol," I can only surmise that the zhulikehs are at it again.

I love the 3500 years line. It follows along with the "2000 years of a perfect record" which appears here.

The link will do the best justice - here is part of it. One of the commenters claims that the Jewish Week, which orginally quoted Rabbi Kamenetzky, lied. But the Rosh Yeshiva never said he was misquoted. He just clarified what he was quoted as having said.

"The practice is indeed time honored and is followed by the majority of the Orthodox Jewish community today around the world, as it has been for thousands of years.
To my knowledge, it has not been proven that the practice leads to contraction of illness. The halacha is extremely sensitive to health concerns and it is wrong to insinuate that Jews who are very particular in the care of their children would be engaging in a practice for thousands of years which is inherently dangerous.
We have a sacred responsibility to protect our children from danger and that responsibility is paramount. However, in the absence of an inherent danger from our performing mitzvos or following our traditions, we must follow them. In my view, there has been no demonstration of an inherent danger associated with Metzitzah B’Peh.
The statement that, “I don’t think there is a response to them,” referred specifically to those who allegedly said it would be invalid to use a tube where there are demonstrable health issues present as to either the Mohel or the child.
Similarly my comment that in my community “as far as I know they do metzitzah with a tube,” refers to a case where a health concern has been established and was in no manner intended to suggest that I believe that it should be universally adopted.
In no way should what I said be misconstrued as supporting the curbing of, or outside interference with, Metzitzah B’Peh. In fact, we have very effectively self-regulated the practice over the past 3500 years."

Postponing a Bris

noreply@blogger.com (A.B.) — Thu, 29 Mar 2012 23:53:00 +0000

I was asked recently about jaundice, and whether it might delay a bris.

In my experience, jaundice rarely causes a bris to be delayed.

In simple terms, a delay of a bris will come about if a baby has a condition, which, if untreated, could bring about the baby's death. Typically if the baby needs to go on antibiotics to treat something (as opposed to as a preventive measure), the bris will be delayed.

For very small babies, see this posting

For a systemic issue, we'll typically wait 7 complete days (7 twenty-four hour periods) from the time the danger passes and the baby is medically cleared.

For something which is not systemic, or even regular physiological jaundice that DOES cause a delay, the bris can be done as soon as the specific issue heals or is resolved.

Being Up Front and Straight

noreply@blogger.com (A.B.) — Thu, 29 Mar 2012 20:59:00 +0000

This posting is designed to address all the concerns that have been brought to my attention by a Mr. Anonymous who comments on some of the postings of mohelinsouthflorida.com, bringing up questions and "challenges" that are irrelevant to the post at hand.

If you want to have a conversation, feel free to call or email me. If you want to comment or ask a question that is on topic - that furthers the point in any direction - such a response will be approved. Inasmuch as you are looking for consistency, I ask the same for the conversations here.

Parents looking to hire a mohel have different reasons for choosing the one they end up hiring. I'll leave you to judge which of these seem good, fair and which are coming from a mixed-up sense of priorities.

He has an excellent reputation
I saw him do my friend's son's bris
When I asked for prices, he had the best rate
I can relate best to him
He did my bris, so it's great that he can do my son's bris too
He has a long beard, which indicates how pious he is
He does a wonderful service
I don't know what results he gets in the circumcision, but man is he funny!
People seem to like him
The baby doesn't cry when he does the bris
He is a really frum mohel
He wears a big hat

If I were to hire a mohel (were I not a mohel), the following would be my priorities (not in any specific order):

Is the mohel an observant Jew?
What is his track record with babies? Is there any history of botched circumcisions, or babies having to go to the hospital post-bris, or needing touch-ups down the road?
Does he operate using a sterile technique?

Here is why these questions cover it all:

Is the mohel an observant Jew?

If so, he needed to undergo a training program that assured he is an expert in bris milah laws. It is fair to assume that he is God-fearing (or was at the time of his training, because why else would he go into this field?), and he is aware of the steps of a bris that are mentioned in the Talmud: milah, priah, and metzitzah. How he does each of these, Jewish law wise, is a matter of semantics.

Milah - does he circumcise using a double-edged knife, a single-edged knife, a scalpel blade, or scissors? As the law says that the foreskin needs to be removed and can be done so with just about anything (that will not leave a splinter), even though it mentions some customs and the prevalent custom of using a knife, the specific cutting item need not matter as long as it is done quickly.

Priah - does he use a hemostat or have an incredible method for grabbing the foreskin and membrane together - removing them both at once, or does he do priah with his fingernails separately? Both methods have adequate sources in Rabbinic tradition. What we are looking for is the end result that the membrane is not going to climb back on the glans.

Metzitzah - does he use a sterile pipette, put his mouth directly on the baby, or offer for the father to do it? (of course, the direct mouth on baby approach would be a concern addressed by the sterile technique question). All methods have adequate rabbinic sanctioning. The mohel's view on the need for metzitzah would determine whether it is to be done on Shabbos.

What is his track record with babies? Is there any history of botched circumcisions, or babies having to go to the hospital post-bris, or needing touch-ups down the road?

A guy who does not adequately estimate where the edge of the foreskin is, who consistently takes off too little or too much skin, who leaves behind skin tags that need to be readdressed by a urologist - most often for aesthetic reasons, may want to consider finding a different line of work.

[Obviously no one is perfect. But someone who has consistent issues, and more often than infrequently, in which results after healing leave an unsightly circumcision, has a real problem. Obviously people are not talking about the issues with their friends. It is important for concerns of this nature to be discussed by potential clients as long as they avoid personal ad hominem attacks and they address the specific point "We needed our son to have corrective surgery after a bris done by so-and-so." Unfortunately, people do not tend to talk about the aftereffects of the bris on their son's penis.]

Does he operate using a sterile technique?

If he does, I know no part of the bris can possibly cause my son to get an infection. A person who does not wear sterile gloves when operating, or who puts his mouth on the baby's open wound, opens the door to possible negative results which are completely avoidable, and which, frankly, are inexcusable.

Metzitzah Follow Up - Common Sense from a Highly Respected Rabbi

noreply@blogger.com (A.B.) — Wed, 28 Mar 2012 20:07:00 +0000

See the comments of Rabbi Shmuel Kaminetzky in this article from Vosizneias

The following quote is a direct cut and paste from the middle three paragraphs of the article:

When asked if there were those who believe that metitza cannot be performed using a tube, R’ Kaminetzky stating unequivocally, “Nobody holds likes that” and expressed disbelief when told that there are rabbis who insist that metitza must be done by mouth saying, “I don’t think there is any response to them.”

R’ Kaminetzky expressed surprise that any Mohel would perform metitzah b’peh, given the links between the practice and transmission of certain diseases to infants, saying that under the circumstances, performing metitzah b’peh would run counter to halacha.

“Chas V’shalom, if [children are] getting sick [from oral suction, you] wouldn’t do it,” under Jewish law, ruled R’ Kaminetzky, saying that since the act of doing metzitza via a sterile tube is completely risk free, the suctioning should clearly be performed in this fashion.

See the update - as per 3/31/2012

So.... Do you use a Clamp?

noreply@blogger.com (A.B.) — Tue, 27 Mar 2012 04:43:00 +0000

I get this question a lot, and I think it's time to clarify what the tools of the trade are. I have blogged about the different methods utilized in bringing about the coveted circumcision result.

Here I will simply distinguish between the largely rabbinically approved, lauded and recommended device which is called a מגן - a Magen - a shield (in Hebrew). And the "Mogen Clamp" developed by the mohel, Rabbi Harry Bronstein in the 50s (or thereabouts).

Here is a link to photos of shields. (here too - though you get the full gamut of supplies) The basic gist is that a shield is a solid metal plate (once made of silver, but now more often made of steel) with a thin slit that divides the shield in half.

The foreskin is grasped with the thumb and index finger, and the shield is applied so that only the foreskin is drawn out - while the glans remains protected below the metal, and the foreskin is excised along the shield.

The Clamp - AKA the "Mogen Clamp" or the "Bronstein Clamp"

I include the following photo to contrast the Gomco Clamp (on the top), to the Mogen Clamp. The Gomco Clamp is more often used by physicians in hospitals, particularly as the device of choice in routine circumcisions. There are those who use the Mogen Clamp in hospitals as well. Both devices (if used) should only be used by those who know how to use them very well, as the potential dangers of each could be quite disastrous.

Having said all that, here are two photos of the Mogen Clamp, one which is in the closed position, while the other is.... open! Note the clamping arm which closes the device, crushing the foreskin, killing all the bloodcells, and essentially amputating the skin pre-incision.

Rabbi Bronstein created this clamp, as the story goes, in order to provide an alternative to those looking to have a traditional bris without all the bleeding. The plan backfired because most rabbis felt that the pain involved in the clamping mechanism was much worse than anything mandated by the circumcision itself. Not only that, but the Talmudic requirement for there to be blood at the bris is incontrovertible.

I will add that the potential irreversible danger that is posed to the glans should it get caught during the clamping is a thought I don't want to ever entertain as a possibility - and believe me I have heard my share of bad stories, which I prefer not to write about.

MOST TRADITIONAL MOHELS (AND I INCLUDE MYSELF IN THIS CATEGORY) - MOSTLY ORTHODOX MOHELS - WILL ONLY USE THE PLAIN SHIELD, WITHOUT AN OPTION FOR A CLAMPING MECHANISM. WE KNOW HOW TO DEAL WITH THE BLEEDING, TO KEEP IT TO A MINIMUM. AND, WITH PROPER TRAINING AND A LITTLE COMMON SENSE, THE GLANS IS NEVER NICKED IN THE PROCESS.

THERE ARE SOME ORTHODOX MOHELS WHO USE THE "MOGEN CLAMP" - EITHER CLOSING THE CLAMPING ARM COMPLETELY, PARTIALLY, OR NOT AT ALL. SOME WILL SHAVE DOWN PART OF THE INSIDE OF THE CLAMP TO ALLOW FOR A LITTLE MORE BLOOD CIRCULATION AND TO PREVENT THE COMPLETE CRUSH THAT A REGULAR CLAMP MIGHT OTHERWISE GIVE.

As a parent, you have the right to decide what method you want at your son's bris. Have a discussion with your mohel. If you want either method, either be prepared to fight for it (and possibly to switch mohels if he can't accommodate you) or be ready to give in to what he is comfortable with. I personally only operate with the traditional shield. I don't even own a clamp. And I know mohels who only use a clamp, and wouldn't know what to do if they were asked to do a bris with a traditional shield. And some mohels are comfortable using both devices - utilizing either method.

Which works for you? Talk it over with your spouse, and make sure to discuss with your mohel if it is not made clear what his method is...

The Father's Role

noreply@blogger.com (A.B.) — Tue, 27 Mar 2012 00:16:00 +0000

Bris milah qualifies as one of the commandments incumbent upon a specific individual (in this case the baby's father) who can opt out in the event he feels unqualified or inadequately trained to perform it.

He can't shirk the responsibility completely, but he can hire someone else, in this case a mohel, to serve as his agent to accomplish the mitzvah on his behalf. Which most fathers opt to do. [here's a story of a father who opted to do the bris]

What is the father's role at the bris?

He should show up.
He must appoint the mohel as his shaliach/ agent to fulfill the mitzvah on his behalf.
He says the blessing on bringing his son into the covenant - להכניסו בבריתו של אברהם אבינו - l'hakhneeso bivreeso shel avraham avinu.
He usually produces his son's name for the person who announces the baby's Hebrew name.

Many fathers speak after the ceremony. Either before or during the celebratory meal.

It is always a good idea to be supportive of the baby's mother, who is often (though certainly not always) going through a rough ordeal with the bris and all.

Be there for her, and try to leave the sarcastic remarks at the door. Unless of course you can't control yourself. But she probably already knows that about you. ;)

In Talking to a Urologist

noreply@blogger.com (A.B.) — Tue, 20 Mar 2012 14:56:00 +0000

At today's bris, the mohel was actually the baby's grandfather, a Urologist by profession. I served as the facilitator and the bandager, setting things up and taking care of the baby afterwards [see here, where I describe what is done when I play this role, in the context of a father who "blanked" in the heat of the moment].

Just a few observations from a Urologist who has been around the block a few times, with whom I chatted for a few minutes afterwards.

1. When I opened the diaper at the bris, he spontaneously said, "Wow. You already marked it!" He told me afterwards that he always marks the foreskin when he does a surgery (which I would have assumed anyway), and he's never seen any other mohel who did this. I personally know of a couple of mohels who do mark the baby - but I still can't figure out what it isn't a more common practice. For the sake of the baby!

2. Personal observation is that mohels generally do a better job than physicians who do circumcisions. This may be because we are not averse to taking off a little more skin than a little less skin. [I'll add from my own experience watching doctors circumcise that some doctors are of the opinion that any minimal amount of skin removed from the tip constitutes a circumcision. We are looking for the glans to be completely cleared - which is why we estimate a little more skin to be removed.]

3. At the same time, if a repair will be in order, it is always better to have removed less skin than more. [which is really why you want it done right the first time.

4. It is better to take off more skin at the top (the dorsal side) than on the ventral side.

5. At the same time, the "penis is a very forgiving organ. It has a way of working things out as it heals and grows."

When I asked him what are the kinds of cases he generally sees, when "touch-up is required," he mentioned that some people leave over too much membrane and it either becomes a little unsightly or develops skin tags. [I take care of these at the bris, when necessary, in order to avoid these problems down the road.] These are not a big deal to repair, but - [again, I ask] wouldn't it be better to get it right the first time.

He told me of the worst case he ever dealt with (over 20 years ago), which was when a mohel amputated the glans [which should never happen - it's a very simple precaution (see approach #2) with the use of a shield]

And he even told me of a certain mohel (did not mention name) who should not be in the business. Too many "not good" stories. Not that the man is not a nice person. On the contrary - but he's like the caterer who can't cook a proper dish. He should not be in this business.

Very enlightening.

A Circumcision for Conversion

noreply@blogger.com (A.B.) — Tue, 20 Mar 2012 05:37:00 +0000

Here I explain my personal philosophy regarding my role as mohel for conversions and an alternative those looking for my services might want to consider. Here is my previous post on this subject - along with earlier links to related topics

I get calls and emails from people across the spectrum of Judaism: Orthodox Jews, Conservative Jews, Reform Jews, unaffiliated Jews, Jews by birth, Jews by choice, "Messianic Jews." I also get calls from those who identify themselves as "non-Jews."

While I am not picky about my clientele per se, I do try to distinguish between "circumcision services" and "bris services." While both obviously include a circumcision, the former is without a ceremony and without blessings. It is not meant to serve as a fulfillment of the Jewish "bris" and it is typically requested by those who are not Jewish.

The "bris services" are for Jewish babies, born of Jewish mothers, who are Jewish either through matrilineal descent - a line of Jewish mother after Jewish mother - or through a conversion I might have officiated over myself, were I in the business.

Due to the unfortunate reality of the manifold kinds of conversions out there, some of which do not demand very much from the converts in question, I try to shy away from them. Rarely do I perform circumcisions for the sake of conversion, and I have difficulty providing a "bris" for those mothers whose conversions I cannot personally qualify - simply because I do not have enough information about the process, the rabbi, the bet din, the method, etc.

[There are some mohels who will accept every case without question - will always do the circumcision, and may or may not tell you afterwards that your son's circumcision was for the sake of conversion and that should your child one day want to pursue his Judaism, he'll need to go the mikveh, etc. This translates to a question of whether, up front, your mohel accepted your Jewish status - either he did or he did not, either he was up front with you about it or he was not, as well as misinformation possibly being provided as to how others will perceive your son as a Jew longer-term.]

I am not interested in playing games. So this is what I offer:

If you are either adopting a non-Jewish baby or you (the mother) have converted to Judaism through a program I can not adequately verify or approve of (for other outside reasons), I can circumcise your baby as long as the following is understood.

1. The circumcision is a "Circumcision alone." You are hiring me as a specialist, to do the circumcision in a gentler atmosphere than a hospital, to perhaps come to your home and to follow up with your son later. Same great care as I give for brisses, but under a different name.
2. I will not recite blessings.
3. Should your baby ever want to pursue a Jewish existence, he may have to undergo a conversion process (See next paragraph for how it would relate to his circumcision). A Reform rabbi will probably not require the conversion, especially if the baby's father is Jewish. If the mother's conversion was Conservative, the Conservative rabbi would likely not require anything more to be done.

But if the child wants to pursue an Orthodox Jewish life, or even to move to Israel, the conversions in question will be subject to scrutiny. SO HERE IS HOW TO TURN A CIRCUMCISION INTO A BRIS IN A MEANINGFUL WAY FOR THE INDIVIDUAL --- when the person in question is ready for such a conversion or a new level of acceptance of Jewish life, all he needs to do vis-a-vis the bris is have a mohel do "hatafat dam bris" in the presence of the Bet Din (Rabbinical court) who will certify his conversion. This is a minimal procedure, hardly invasive, which draws the tiniest speckle of blood from the circumcision scar to signify and symbolize the blood of the covenant.

If done by parents with their rabbi (separately from my role) it can be quite significant for them.
If done by the individual himself when he reaches a certain level of maturity and appreciation for the significance of the commitment he is undertaking, the "hatafat dam bris" ceremony takes added meaning.

This is not a question of judging or mistreating. This is about a standard that I try to adhere to.

I thank you for your understanding.

[With regard to Hatafat Dam - If you hire a mohel to do this, it might be appropriate to compensate him for his time - especially if he traveled to you. But the medical attention needed for this is nothing in comparison to at a full bris. He may have a "price" and he may insist on your giving NOTHING (this is my practice when people bring a baby to me), but $150-$250 is suitable compensation for the service in question. Unlike a bris which may require multiple visits, the hatafat dam is a one-time episode that does not require follow-up.]

A Medical Opinion Piece about Metzitzah (plus some logical arguments)

noreply@blogger.com (A.B.) — Thu, 15 Mar 2012 19:42:00 +0000

I will talk about this piece after the following interlude, but if you don't want to read what I have to say, either click the link or scroll down to where I have reproduced this opinion piece of Dr. Gary Gelbfish in the Jewish Week, dated March 13, 2012

I just got off the phone with a mohel colleague - we talk about the trade every now and then, on the phone, online and on Facebook! Young mohels... so in touch with technology :)

After sharing this article with me, he argued that people going snowboarding/skiing, or driving unsafely on a highway are all risks that people take, but we don't ban the activities. Therefore, perhaps one can make the argument that metzitzah is a risk people take.

I am not going to go into the probabilities and start making mathematical equations. To live life and avoid danger we don't shut ourselves into a corner. We face the world, do the best we can and hope for the best. But snowboarding and skiing is generally safe when done in a safe manner - and besides, it's a choice individuals make for themselves. Can I put myself at risk in choosing to participate in this activity?

A baby has no such luxury. Please excuse the image I am about to present. The parallel would be that if I am circumcising myself, I can choose to have someone do metzitzah on myself. Baby has no say in the matter.

I've also heard the argument proposed that "Saliva has antiseptic qualities. Isn't your first instinct to suck your finger when you cut it?" [Regardless of the fact that saliva does not have antiseptic qualities...] Again, the logic does not follow. Even if I do suck my finger when I cut it (I don't - I clean it under a sink and put pressure on it, but whatever), I don't have my friend suck my finger. So the only parallel which would work is (and again, please excuse the image) "When I do a bris on myself, I do the metzitzah." RIDICULOUS!

Furthermore, the fact that a parent may choose to drive unsafely on a highway - with kids in the car - is also not parallel to the risk posed by a metzitzah on the mouth situation.

In comparing the circumstances - On one hand you have a parent driving putting himself and his child in danger, and on the other hand you have a parent who puts a not-yet-built-up-immunities baby in a situation where a simple lesion in a mohel's mouth can be fatal [remember - you don't know if you'll be in a car accident, but you do know the mohel's mouth will touch the baby]:

Choice: Drive more carefully, use seatbelts, get a safer car – do what you can to live your life in a way that minimizes risk. Driving a car is something everyone does every day.

Choice: Either make the mohel test for herpes before each time he does metzitzah, or do metzitzah with a tube – do what you can to live your life in a way that minimizes risk. No one allows strangers to put their mouths on others' open wounds ANY day.

Does the parent have the "right" to make a potentially dangerous choice for one's child? Technically, yes. But society has the right to say, "This is unacceptable in our community. There is a limit." Can a parent utilize corporal punishment? Yes. A parent has that right. But society limits it. You want to spank your kid? A potch on the tush? A slap on the wrist? OK. You start whipping or breaking bones, however, and the police are going to get you. There's a difference between tolerable and intolerable, between technical rights and completely "endangering the welfare of a child."

I am always grateful that the bad metzitzah stories are few and far between. We definitely live in a time in which our knowledge of medicine, infection, etc is light years ahead of where it once was, and we don't see trends of babies dying.

I guarantee you, however, that if babies were dying left and right, it wouldn't be tolerated. We would hear people saying things like the Chasam Sofer, "In light of recent events, we have decided to allow a tube to minimize risk to babies." Why would it take more babies dying to bring about a conclusion like this?

We want to nip it in the bud.

WITH THIS AS A BACKGROUND, ENJOY DR. GELBFISH's OPINION PIECE. IT SOUNDS VAGUELY FAMILIAR [Although there is one error. He says the Talmud advocates MBP - which is not accurate. The Talmud says nothing about the Peh - the use of the mouth. The Talmud mentions Metzitzah as part of the procedure - though as I have pointed out here, the Talmud does not say how to do it, as the meaning of the term is vague, and it indicates that Metzitzah was a medical suggestion to keep the baby out of danger (which we would completely disagree with today), much more than it was a religious requirement. Other than this nuance, it is a well thought out piece.]

In Debating Bris Controversy, Know The Medical Facts

Gary A. Gelbfish

Tuesday, March 13, 2012

The debate about ritual circumcision with metzitzah b’peh (direct mouth-to-wound oral suctioning by the mohel) is complex, as it involves halachic, historical, social, medical, technical and potential regulatory components.

My personal interest and experience in ritual circumcision is long standing. I studied to be a mohel in Israel and was certified as a mohel by the Israeli Rabbinate in 1983. I have performed many circumcisions, mostly on babies of family members, and occasionally on children and adults from the former Soviet Union. Furthermore, as a vascular surgeon for the past 22 years, I have frequent interaction with infection and wound healing issues.

My first interaction with probable disease transmission from metzitzah b’peh (MBP) was in 1998, when an infant in my wife’s pediatric practice was treated for herpes infection of his genital area soon after a bris that included MBP. The latest case of an infant death in New York attributed to herpes associated with MBP is deeply disturbing to any parent, mohel, rabbi or public health official. Clearly we need to discuss MBP and at least entertain potential changes in ritual practice.

For those in a position to influence the debate, I present the following medically related points.

Transmission of herpes via MBP does occur in some cases. This has been amply established by multiple case studies reported in the medical literature and many unreported cases. These cases showed herpes in the genital area soon after a bris that included MBP; with little probability of a source for the infection other than the mohel’s mouth. While the frequency of such infection is difficult to quantify, it must be noted that medical case literature most often under-reports the frequency of unusual disease presentations prior to a widespread awareness of the disease having emerged amongst medical practitioners.

Even if we did not have these case reports, the potential for infection is totally consistent with what we know about herpes virus transmission, via oral contact. Would any sensible adult knowingly kiss a person infected with herpes, especially with an open wound? In our modern society, we accept this line of reasoning without question, yet somehow in the MBP discussion, arguments are presented which inexplicably imply that this logic somehow does not apply to a newborn. To the contrary; newborns may be at even greater risk since they are known to be relatively immune compromised.

In the 19th century, even before the widespread acceptance of Pasteur’s Germ Theory of Disease, there were many reports of children with genital syphilis and tuberculosis attributed to MBP. At the time, this generated significant halachic debate and led many rabbis to restrict MBP, most notably Rabbi Moshe Schreiber (the Chasam Sofer), who ruled that MBP could be accomplished by instrumental suction or a gauze/sponge. Ample evidence exists that in many European cities, the custom of many Orthodox communities was changed as a result.

Over time and with the essential elimination of syphilis and tuberculosis as a risk factor, MBP has had resurgence amongst some elements of the Orthodox community. We seem to have forgotten what was obvious to many over a century ago — that communicable diseases can be spread via MBP.

The herpes virus is a relative newcomer to the known pantheon of communicable diseases, most frequently associated in adults with oral and genital lesions. Is there any reason, however, to postulate that it behaves in some special way during a bris? Do we really need additional case studies to reconfirm the medical paradigm of infection transmission?

Herpes infection in a newborn may lead to lifelong infection, chronic neurological impairment and, at times, death.

The Talmud recommends MBP as beneficial to the health of the baby, consistent with ancient Greek and Roman medical theory. However, based on the current mainstream medical understanding of wound healing and infection prevention, there is no known medical benefit to MBP; certainly none that would outweigh its currently observed potential for harm.

A person may not be aware that he is infected with herpes, and virus shedding from the mouth surfaces may at times, occur without obvious oral sores. This is why we cannot expect caring and well-meaning mohels to be able to solve this problem by not performing MBP when they know themselves to be ill. To lessen the incidence of transmission we may construct an elaborate public health system to track and ensure that our mohels are “disease free” via frequent, perhaps monthly physical exams, blood and salivary immunoglobulin tests and perhaps viral cultures. Even if effective, are our mohels willing to accept this burden or are we willing or able to impose this on them?

From a technical standpoint, the goal of MBP is to apply suction and draw out blood from the wound. It can be easily demonstrated that suction may be equally accomplished via a sterile tube or to an even greater extent with a mechanical apparatus that does not involve any oral contact.

In order to have a sound and effective dialogue, we need to first accept the obvious — that MBP does entail a certain, yet at present, unquantified, risk of herpes transmission, and when transmission does occur, the results can be catastrophic. If this truism is accepted, rabbis and communal leaders can then productively discuss the other issues that may be pertinent and come to a conclusion.

Some of these questions are: Is the practice based on strict halacha or is it a less restrictive “minhag” (custom)? Are the origins of this practice and the historically attributed medical benefits relevant today, considering current medical knowledge that disavows the benefit of MBP and instead documents potential harm? Does the perceived threat to the “mesorah” (Jewish tradition) that any change in ritual practice would potentially cause, justify the risk of significant harm to the occasional newborn? What role, if any, should governmental regulation have?

I hope that medical misinformation will not cloud the discussion.

Gary A. Gelbfish is a practicing surgeon and certified mohel.

Metzitzah - an explanation for non-Jews in light of recent news stories

noreply@blogger.com (A.B.) — Mon, 12 Mar 2012 02:14:00 +0000

When the story in the Daily News came out, I honestly thought it was shoddy reporting. The information provided would never stand in a court "A baby died 6 months ago, says the unnamed spokesperson, from complications from herpes allegedly transmitted by an unnamed mohel to an unnamed baby of an anonymous family."

I was interviewed for an article, from a mohel's perspective, and the article in question found its way to the Huffington Post, among a whole host of blogs. Many of those involved have made disgusting and unwarranted comments about me, mohels in general, and Judaism. I will not give those comments the dignity of a response.

I have seen the story be re-translated in a number of venues – as news and in opinionated-blogs (everyone is entitled to an opinion), so I am writing here to make a few clarifying remarks and to explain metzitzah to a non-Jewish audience in particular.

Those who view mohels as pedophiles are completely in the wrong. It's the same as saying a Gynecologist assaults women. No mohel touches a baby unless he has been hired by the baby's parents, and they have called him based on his experience and reputation.

In addition, the circumcision is done with a metal blade. The mouth is not used to perform the circumcision. It's utilization in the ritual will be described below – and you will see where the mouth's role was developed, how I believe it is utilized wrongly, and how it can be included in the ritual in a safe manner that could satisfy the desires and sensibilities of all persons involved [see the very end of this posting].

My comments on metzitzah (until this point - see here here and here) have been towards those looking specifically for a bris. But this latest news has brought metzitzah to the fore again, and it cannot be ignored.

*****************************************
We live in a country made up of arguably the most religious population in the world, with a media that is the most anti-religious in the world. An unhealthy cynicism and hatred of people of faith makes discussions surrounding religious practices difficult to be heard for their merits.

For example, it is very important to people that President Obama is a Christian (as opposed to a Muslim), but heaven forfend that the nature of his religious practice, actual beliefs, etc be subject to scrutiny. On the other hand, Sarah Palin and Rick Santorum have been ripped apart for their beliefs, and the fact that Mitt Romney is a Mormon is also "problematic." Even in JFK's time, many made a big deal over his Catholicism. All of this may play a role in defining a personal ideology, may or may not effect political decisions, and should be a universal question in any and all candidates. Either we make a big deal about religion always, or we do not ever.

There are religious practices which seem odd to outsiders in general, and may even seem out of place to the practitioners and adherents themselves. Why does water – applied in a specific place and under the instruction of a specific individual – turn a person into a Christian? How does emergence from water – in a specific place and with a rabbinical court present or nearby – turn a person into a Jew?

Why does wine play such significance in different ceremonies?

Why do we put so much stock in the archaic form of wedding ceremonies?

Religions have rich histories, and adherents to the ways of their religion do what they can to follow their traditions – sometimes when they understand them, and sometimes even when they don't understand them.

In Judaism, there are reasons for just about every practice imaginable. That people do not always know the reasons for the things they do speaks more of their education than for Judaism's lack of answers.

Over the last two centuries the Reform and Conservative movements have spent much time putting ancient practices to scrutiny, and in many cases, rejecting the ways of old in favor of newer ways, sensitivities, sensibilities, realities and modernity.

While one can argue the benefits of such an approach, these innovations are not universally heralded as a boon to Judaism. Sometimes it is in fact to Judaism's detriment.

The ancient practice of Bris Milah, ritual circumcision, has been put to much scrutiny. It's Biblical sources are in Genesis 17 and Leviticus 12 – in both cases Abraham and his descendants are enjoined to circumcise their sons on the eighth day of a baby's life.

Regardless of what one thinks about circumcision – whether it is a right of the parents, of the child, whether it has medical benefits or does not have benefits – most doctors will tell you that the procedure itself, when done properly on newborns (and it is one of the most common surgical procedures done in the United States today), is not dangerous, it has a very quick healing time, and it does not change a baby's growth and development in any way. In many cases, it may even be quite beneficial to the baby, taking care of a problem he might have otherwise had to take care of himself when older – such as a bad case of phimosis, or speeding up a necessary reconstructive surgery which may have been overlooked had the parents not been looking to have a circumcision done.

All arguments to the contrary are generally made by circumcised individuals who, as adults, wish they had a foreskin. Making this an obsession is an unfortunate result of people having too much time on their hands.

While there are certainly methods of circumcision which are barbaric and should be outlawed, and while there are certainly operators who should not be allowed to circumcise, this is not sufficient reason to ban the practice. Circumcision is done for religious, social, medical, and even asthetic reasons. And when done in a quick procedure by an experienced operator, the pain is minimal and the healing quick.

The Talmud is the transcription of the Oral Law of Judaism – the tradition handed to Moses at Sinai along with the Five Books known as the Torah. Observant Jews look to the Talmud as the guide for all of Jewish law, as, in addition to being the basis for most matters of civil law and holiday practices, it is also the source turned to first to address contemporary questions of business and medical ethics.

The discussion over organ donation and the definition of the end-of-life for such purposes, for example, begins in the Talmud.

When it comes to the Jewish practice of bris, the Talmud describes in clear terms what the steps of the bris are: milah – excision of foreskin, priah – removal of the mucosal membrane, and metzitzah – which Maimonides described as the drawing out of deeper blood.

It is metzitzah which is the subject of debate and controversy, simply because it is not clear a. how the word is best defined (and therefore what the action is), and b. what purpose it is meant to serve.

The Hebrew word metzitzah can mean to squeeze, compress, drain, or suck. If it is any of the first three terms, metzitzah can be easily understood by everyone. The best way to bandage an open wound is by compressing it, done now with gauze, thereby drawing blood away from the incision spot, allowing the bandage to be immediately applied in order to achieve stasis. This is standard first-aid procedure and has an excellent track record for achieving the desired result. If, however, the term means "suck," then the Talmud is suggesting that the best way to bring about this result is through creating a vacuum at the incision spot, and drawing the blood away through the power of the mouth. We will revisit this point in a moment.

The next question to be addressed is what is the purpose of the metzitzah? Is it a required part of the procedure, a ritualistic remnant that is beyond our comprehension? In other words, is it a part of the "mitzvah" – an essential element of the fulfillment of the commandment to circumcise? Or, was it instituted for health reasons, as advice or as a strong suggestion as to how to best achieve stasis?

If it's the former, those who follow the Talmud's instructions to carry out Jewish law to the "t" will continue to do metzitzah (method subject to debate). If it's the latter, perhaps metzitzah ought to be abolished. Modern science and medical knowledge gives no credence to placing a mouth, laden with all its bacteria, on any open wound, especially that of a newborn.

At the same time, we must recall that knowledge of the "germ theory" is little over one hundred years old. Historians will tell you that President James Garfield more likely died at the hands of his doctors than at the hand of the bullet shot into him. His body had formed a cyst around the bullet, by no means leaving him comfortable, but also preventing his wound from being fatal. His doctors sticking their fingers in his body to try to get the bullet out is what brought on the infection that took his life.

There is one caveat. In addition to what has been said until now, the Talmud says that if milah (removal of the foreskin) is done without priah (removal of the membrane) it is as if the circumcision was never done. In other words, it would need to be revisited; the child would need to undergo another circumcision

While it does not mention metzitzah as being a factor which, were it not done, would cancel the bris and cause a revisit, it does say that a mohel (ritual circumciser) who does not perform metzitzah is to be removed from his post. The reason? He has put the baby in danger through skipping the metzitzah step.

It doesn't take a degree in rocket science to see that this last explanation gives every indication that metzitzah is to be regarded as a medical necessity from the Talmud's perspective. This would imply that if the medical reality changes, we need not follow it. There are many bizarre medical suggestions in the Talmud which are not taken literally today – they are clearly a reflection of the medical knowledge of the time when the Talmud – the oral discussions that had carried on for centuries – was finally recorded to avoid its being lost forever.

And yet, the Talmud says that a mohel who does not do metzitzah is to be removed from his post. This is a statement that many people take quite seriously. On the one hand, I think that metzitzah is unnecessary, on the other hand, according to the Talmud, if I don't do metzitzah I am no longer fit to be a mohel. What to do?

Let us consider that metzitzah means to compress, squeeze, or drain. Would anyone argue that metzitzah is not be done? On a fresh wound that requires immediate attention, it is the best way to go. Put enough pressure, and bleeding stops. But if metzitzah means to suck, every sensible person would say it should not be done – should be abolished, in fact.

OK. We revert to the latter discussion – is metzitzah a requirement, part of the mitzvah or was the Talmud making it a medical mandate?

This is the source of the debate and the controversy over the years. The rabbinical authorities throughout the centuries have been split on the matter – some saying it is part of the mitzvah, to varying degrees of obligation; others have said it was a medical necessity, subject to the scrutiny of medical knowledge changes.

For close to a thousand years, metzitzah through suction was the method recorded in rabbinic literature (though surprisingly, the method of metzitzah is not described in the major codes of Jewish law - such as Maimonides and the Shulchan Arukh). And it makes sense. Bandages of yesteryear were nothing like what we have today. And the Hippocratic method of medicine advocated sucking blood out of wounds in various instances – particularly from poisons, to remove toxins, and sometimes through the use of leeches. Mohels doing this was no different than what everyone else was doing.

That babies may have died in the last millennia from circumcision was not a particular fact people would have noticed. For hundreds of years, 1 out of 3 babies was not expected to survive very long – mortality of infants was accepted as a fact of life. While there were incidents recorded in different towns, where a number of babies died post bris, it was only in the last 200 years when people particularly took notice and blamed it on the mohel. And they were usually right.

Science has evolved, medicine has evolved, and we know things now that were not known 150 years ago.

The problem, and the source for the story that became known in the first week of March 2012, is that there are people in the Jewish community who still believe that despite all the evidence suggesting otherwise, metzitzah is part of the mitzvah, meaning it must be done, and that the only acceptable method of doing metzitzah is by putting the mouth on the baby.

Before I continue, I would like to point out that there are many people who follow this latter method, and despite this being the case, it is surprisingly rare to hear a story like this, of a baby dying as a result. The number should be zero – zero babies dying from herpes contracted during the circumcision. The fact is that the herpes from brisses cases are quite uncommon, but unfortunately, the number is not zero.

To give you a sense of how even bright people will go against all of their sensibilities in this matter, I bumped into an old acquaintance from my camp days who is now a cardiologist. When he asked me what I do, and I mentioned I am a mohel, we got to talking and the subject of metzitzah came up. I asked him his opinion, and he said "My family's custom is to do it with the mouth directly on the baby." When I asked him how his medical knowledge jives with this practice, he said, "It doesn't." Then why do you still do it? "Because it's our family practice."

I understand that people might feel this way – which is why I have advocated that if a family insists it be done this way, let the father take the responsibility and do it himself. Why have a mohel, who deals with many many babies, be the conduit for the sharing of bacteria? [I know, this sounds quite archaic and wrong. But I am trying to explain the convictions and beliefs of people, and where they are coming from – even if they, were they to think for a moment, would see how wrong it is. The problem is that many don't even think about the possible repercussions.]

The alternative, in light of the Talmudic pronouncement that a mohel who does not do metzitzah is to be removed from his post, is to do metzitzah in an alternative way. There are those who accomplish the metzitzah through the simple application of gauze.

And there are those, such as myself, who view the metzitzah as a remnant of a ritual – which certainly had importance once upon a time – which can be accomplished with the power of the mouth through the utilization of a method that is harmless to the baby, no different than the application of an additional gauze pad.

Using a sterile glass pipette (first invented in the late 1800s) stuffed with a sterile gauze pad, is the method I utilize because:

the vacuum pressure can be achieved with the power of the mouth,
it fulfills the obligation according to those who think metzitzah means sucking with the mouth,
it avoids the removal from one's post (as mohel) advocated by the Talmud for not doing metzitzah,
it avoids any transfer of body fluid from mohel to baby and vice versa,
while most importantly it is an act which is harmless to the baby on the one hand (because the glass and gauze are sterile) and so meaningful, on the other hand, to those who view metzitzah as part of the mitzvah.

If you read any of my writings about bris and the sterile technique I advocate in the public ceremony that surrounds the ritual circumcision of Jewish babies, you will know where I stand. I advocate that:
• mohels be held to higher standards in their sterile techniques
• no aspect of the circumcision procedure (beyond removal of the foreskin which is biblically mandated) should possibly put the baby in danger
• babies' lives are far more important than any religious convictions a mohel may personally carry

Remember that every mohel who performs a bris does so because parents have called him and hired him to perform the circumcision on their behalf. Mohels have a responsibility to inform parents of what they intend to do.

More importantly, parents must be informed, and must make sure that when they hire a mohel to do a bris, that he performs the metzitzah (and other aspects of his circumcision technique) in a sterile manner that conforms to their sensibilities.

Mohels who will not comply will quickly be out of business.

And if parents take the bull by the horns, metzitzah with direct oral contact can become a thing of the past, and we will finally move past the days when we hear stories of babies contracting herpes and dying from the bris.

The Plot Thickens... Still No Information

noreply@blogger.com (A.B.) — Tue, 06 Mar 2012 04:47:00 +0000

Link 1: From the Jewish Week

Link 2: Failed Messiah Blog

We'll see what information comes forward. [I have received a confirmation of the death claim from a different source not quoting the original Daily News article.]

The Wine

noreply@blogger.com (A.B.) — Mon, 05 Mar 2012 23:35:00 +0000

We use wine at the bris for the blessing over wine and to sanctify the ceremony.

There is a custom to give some of the wine to the baby after the ceremony.

I don't know how this custom came to be, but it is clearly stated in Jewish law discussions that when a bris takes place on a fast day, when the mohel, sandak and/or person reciting the blessings are fasting, that the wine (over which the blessing for wine is recited) is tasted by the baby. [This goes into a different discussion about a bracha l'vatala – a wasted blessing – which we try to avoid saying. Once the blessing is recited over the wine as part of the ceremony, someone needs to drink it.]

On regular fast days, the baby's mother is usually not fasting on account of her recently giving birth, so she can be the one to drink if she is present or close by. But if the bris is on Yom Kippur or Tisha B'Av, the mother does participate in the fast – leaving the baby as the closest available candidate to drink the wine.

Some will say in shock, "You mean you actually give the baby wine?"

Yup. Not a lot. Very little, in fact. But the sweetness of the wine makes it easy for the baby to handle, and the low-alcohol content helps soothe the baby.

I have seen many a smile light up on the faces of those watching the baby cry, as the wine touches his lips and he stops crying, and does the cutest lip-smacking you have ever seen in your life.

How is it given to the baby?

As far as how it is administered, I have found dipping a clean gauze pad in the wine and putting it in the baby's mouth to suck on to be the best way to go (I usually use two – to alternate between the different dippings and moments when we give the wine to the baby). Some people dip the pacifier in the wine, but very little wine is retained on it in the process.

There are some mohels who dip their pinky in the wine and put it in the baby's mouth. The wine does its job, and the pinky stays in for the baby to suck on. If your mohel does not wear gloves, it might be worth asking him how he gives the baby the wine. [In other words, if you don't want your mohel putting his finger in your baby's mouth - no matter how "clean" it might be, better have this discussion in advance!]

What kind of wine is to be used?

Kosher (of course), sweet, low-alcohol content. Think Concord Grade (Kedem, Kesser, Manischevitz, etc)

I've had fathers bring in wines like Merlot and Cabernet Sauvignon, to my chagrin. These wines may be good for wine connoisseurs, but babies hate them!

It is certainly appropriate to have good wine during the celebratory meal afterwards. But when we're trying to give a little bit of it to the baby to calm him post-bris, the sweet stuff is the way to go.