The Danger of Arrogance

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

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

Mild Problems

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

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

Different Problems

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

Too little

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

Too much

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

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

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

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

Bigger Problems

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

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

The DANGER of ARROGANCE

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

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

Methods ALL Mohels Should Employ

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

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

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

The Arrogance

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

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

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

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

I repeat (and add):

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

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

Different Types of Mohels

There are many excellent mohels in this country. There are many fine mohels as well.

In Israel these differences are marked by the title "Mohel Mumcheh" (מוהל מומחה) (expert) and the standard "Mohel Musmach" (מוהל מוסמך) (certified or ordained to be a mohel). The differences between them vary and depend upon certain qualifications such as advanced study and examination, and years and volume of experience.

Just to bring an example, on this list of certified over 350 mohels in the Jerusalem area, very few of them are "experts." It's kind of like going to the top doctor who is less accessible when just about any other doctor will do the same job for you.

Trifecta: Ceremony, Care (Results), Complications (a.k.a 'The Triple C')

These three components will help you determine the kind of mohel you want. Unless a mohel is right out of mohel school, any experienced mohel has done hundreds, if not thousands of procedures. So you need not worry about your son being horribly damaged. As a pediatric surgeon I know has said, "We fix more circumcisions done by OBGYNs than anything else. With mohels, we'll usually hesitate to do anything to their work because they generally do a really good job. The worst case scenario, if anything, is a slight cosmetic touch up. Which is extremely rare and usually unnecessary."

Taking his lead, let's look to other criteria, because just about any mohel you will hear about is probably a fine, good, or excellent mohel whom you can trust your son's care to. A pediatrician I consulted with many times (particularly to determine if the bris needs to be delayed due to the baby's health) told me that many brisses he sees (in his neighborhood in NY there are many mohels so he saw the gamut of "results") look awful in the first few days, but they usually heal quite nicely and end up looking fine. [Before I moved to Florida, he called me to say how much he'd miss me and that I was the first mohel name he gave to clients who asked for a suggestion.]

Ceremony

• Do you want a simple ceremony? A flashy ceremony?
• Do you want the mohel to be the star of the show? Or do you want the baby to be the center of attention?
• Do you want your family involved? Do you want the mohel to do everything?
• Do you want to do the bris your way? The mohel's way? Guided by Jewish tradition? (These do not have to conflict)
• Do you have customs based on your family's most ethnic point of origin (as in North Africa, Middle East, or Eastern Europe - not North America, Middle America, or the Eastern Seaboard)?
• Do you want explanations of the ceremony? Significance explained, lessons taught, stories told?
• Do you want bare bones, no talking except what is written in the prayer book?

Care (and Results)

• Does the mohel see the baby before the bris? Does he make a follow up visit after the bris?
• Is he sensitive to the baby? Is he sensitive to the mother?
• Does he wear gloves and have a sterile technique - see here and here ?
• Does he put you at ease (see here too)? Is he preoccupied thinking only about what he has to do?
• Does he inform you how to care for the baby after the bris?
• Does he tell you what to do in an emergency situation?
• What is his track record? Was his work ever revisited by surgeons? (for most mohels the answer may be yes. This is a simple matter of statistics. Out of 100 brisses, at least one may have an issue. Either he won't tell you, or, and this may very well be the case, he does not know because the parents did not tell him about it)?
• How long does it take to heal and what are the cosmetic results like (in general)?

Complications

• What kinds of complications can or do arise after a bris?
• How does a mohel deal with them?
• What if aesthetics or other matters come up or become apparent a few months down the road? How does the mohel deal with these circumstances and questions?

My Pitch to You

• I was trained by the government supervisor in Israel, Rabbi Mordechai Sasson. Before retiring he was one the five "expert" mohels on the list linked above.
• The number of brisses I have performed is in the 4 digits - which is an explanation I likely won't be updating for awhile (will need to get to 10,000 for that!) - in my over 25 years as a mohel (updated this info in 2024, as my training ended in 1998)
• Many parents have called me to do a bris for them a second time (on a different son of theirs, of course), a third time, and even four times! Some sets of grandparents have watched me circumcise anywhere from three to a dozen of their grandsons. This may include babies from three or more (sets) of their own children.
• I am not flashy, I am very respectful, and I guarantee the highest standards of sterility in the care of your son.
• I recognize that every baby is different, not all babies have the same circumstance of anatomy - and underneath the foreskin there can be all sorts of hidden surprises which may often determine a different result. Not all brisses end up looking the same.
• I have (thank God) never had a baby go to a doctor or hospital due to bleeding issues after a bris while under my care.
• I have (thank God) never had a baby develop an infection as a result of the bris.
• I view my role very seriously, and come to a bris with a sense of trepidation over the seriousness of the moment and the Jewish, traditional significance attached to the bris.
• On an equal scale, I value the trust you put in me as a practitioner, to give your son the care he deserves for undergoing this procedure, in fulfillment of the commandment first given to Abraham and concretized by Moses on Mt. Sinai. (If not for these last reasons, I would never serve in this capacity.)

I hope your research brings you back to this site and look forward to talking with you when your son is born.