Numbing

I once addressed the "numbing" question in a posting that covered a few topics.

Since it comes up every now and then, here are a few thoughts to consider.

Concerned parents have different attitudes about numbing the foreskin before the circumcision. Here are a few examples of things that have been shared either with me or between parents who discuss this in my presence:

• Babies have been circumcised for thousands of years without numbing. He'll be fine without it.
• If you can do anything which will ease his discomfort, we'd appreciate it.
• Babies nerve endings aren't developed as much. He doesn't feel it so much anyway.
• He feels something, but he cries every time we open his diaper.

The feelings run the gamut, but they are also tainted by a little bit of misinformation.

#1. BABIES FEEL PAIN. The "nerve endings aren't developed" argument is a load of hooey. To suggest that a baby doesn't feel pain is to assume that a baby only cries when hungry or when needing a diaper change. Give a baby a blood test and you'll hear cries of "bloody murder."

#2. ALL STUDIES OF THE PAIN BABIES FEEL DURING CIRCUMCISION ARE IN HOSPITAL PROCEDURES (with either 0 or local anesthesia) WHICH CAN TAKE BETWEEN 10 AND 45 MINUTES. A BRIS, ON THE OTHER HAND, TAKES A FEW SECONDS. In other words, while there is pain at a bris, the amount of pain is directly correlated to the amount of time the procedure takes place. Since the bris is done using a different method than the hospital procedure, the painful part is minimal, in comparison to the rest of the time which I define as "discomfort" (ie. let go of me, stop putting pressure on my circumcision wound, close my diaper, let me eat, etc.)

#3. INJECTIONS ARE MORE PAINFUL THAN THE BRIS. We know injections are sometimes important. But that doesn't mean that they are painless. Even if we can withstand the needle, there are some shots that hurt hours after adminstered. Typically injections for a circumcision are done in three places, around the circumference of the dorsal (belly) side of the penis, to create what is called a "penile block." It makes the baby relatively calm during the circumcision, but at the cost of three painful injections.

#4. TOPICAL ANALGESICS WORK FOR THE MOMENT OF THE BRIS, BUT DO NOTHING ONCE THE FORESKIN IS GONE. Essentially, the shaft of the penis will not have sensation, and the baby can be quiet in the moment the foreskin is excised. But when pressure is applied to the now-open wound, all bets are off. The baby will likely cry even if the area was numbed beforehand, simply because he is uncomfortable (see the end of #2 above).

MY PERSONAL FEELINGS

I think injections are good for the doctor in a hospital setting (assuming he is working with a newborn and is not using general anesthesia), because a hospital procedure - or any procedure that includes a clamp utilized for more than a few seconds - is long, arduous, and painful to the baby if the area is not numbed. But I don't believe injections are beneficial to anyone in the event a mohel is circumcising using a more traditional circumcision method/procedure.

I have no personal problem or objection to the use of a topical analgesic/numbing agent, as long as I know what it is and it has a decent track record. There are debates about EMLA cream, for example. A doctor I know recommended I introduce people to "ELAMAX," which can be obtained OTC at a drugstore (just ask for it). I used to carry a 30% lidocaine cream that I had made by a compounder, as per a prescription given to me by a doctor (email me if you'd like to see the article that introduced me to this idea - I can send you the pdf). But it became complicated to get to people or if I only saw the baby a few minutes before the bris it was not enough time to put it on, so it wasn't worth the hassle.

There are other issues to consider as well (if you really care, see Phil Sherman's discussion of this in Q14 on his FAQ page), so I don't raise the issue unless people ask.

Simply put, I have found that the "pain concern" is more of an issue for parents than it is for the baby. When the bris is over - more accurately, when I close the diaper and get the baby dressed - he is usually fine. When I am done, the discomfort is over. The "pain" is over as soon as the foreskin is removed. Some babies still need to eat, but some go right to sleep. A little bit of Manischevitz does wonders.

To quote one of my teachers, there are two mitzvahs for which God said "You will feel pain." One of them is Bris Milah (the other is fasting on Yom Kippur). But, he argues, we do not need to maximize the baby's pain. He is therefore an advocate for using the numbing cream. Which is why I won't object to the proper cream being used. I will add, however, that the speed in which we operate is its own form of anesthetic. The method we use is far less painful than a "clamp method." All told, the traditional Jewish method minimizes the baby's pain as much as possible by its quick and simple design.

I mentioned above that the pain concern is more of a parental one. One of my colleagues is fond of saying that the person who feels the most pain at the bris is the... baby's mother. Sometimes the father too. The best anesthetic, therefore, is to pour two shots of whisky. Give one to Mommy, one to Daddy, and the baby will be fine.

Putting Parents At Ease - More Considerations

Over the weekend, I attended a presentation/discussion in which one person mentioned her impression that bris turns some people off from Judaism. Almost as an aside she said "They think it is barbaric."

It wasn't my forum, so I kept quiet. I have a lot to say on the subject, but it's for a different place. My blog, for example.

Firstly, I don't believe the bris turns people off from Judaism. It's a big world out there. People who are unhappy with Judaism will find any excuse they want.

As far as circumcision being barbaric, that statement is a hard sell in the United States when over 60% of the newborn male population is circumcised - either routinely with a clamp (with or without a local anesthetic), in the O.R. under general anesthesia, or as part of a religious or holistic ceremony - and until relatively recently, over 90% of the newborn male population of this country was circumcised.

The American Choice

In American culture, people have all kinds of reasons for circumcising their sons. I learned about this recently when our son was born, when my wife and I were handed a pamphlet about circumcision which boiled the choices down to two: "to circumcise or not to circumcise; that is the question."

They have a number of reasons why people may opt to circumcise.
* Medical suggestions that urinary tract infections, penile cancer, and other penile illnesses (including STDs) are less common and the penis is less susceptible when circumcised.
* It is easier to clean.
* Family - father and brothers are circumcised
* Cultural - everyone else does it
* Aesthetics - You like the circumcised "look" better than not.
* And, of course, religious reasons.

Reasons not to circumcise include:
* It is healthy tissue which guards a very sensitive area of the body
* No medical benefits if the child is taught how to clean under the foreskin
* Why subject a child to such surgery, which may be unnecessary?

The "barbaric" nature of circumcision is not raised, even if people may personally feel it to be such.

Why Jews Circumcise Their Sons

While the religious reason is most obvious, the best verbal explanation I have heard of late was in the documentary "Partly Private" - a film made by a secular Israeli woman living in NY, who was researching whether or not to circumcise her as-yet-unborn son (they had circumcised his older brother, but were displeased with the experience).

When a number of her Israeli friends gathered to be a sounding board for her deliberations, one of her friends who had become observant said, "If you are deliberating circumcision because you think it is 'barbaric' - you are right. Don't circumcise. But if you have faith in God and understand that this is what God asked of the Jewish people, as this is a mark of the covenant He forged with Abraham, then this is not barbaric. This is an act of love: for your child, for your people, for your God."

He is so right. The reason we circumcise is FAITH.

But it's still BARBARIC, Right?

It really depends on your perspective.

Most medical authorities who deal strictly from a medical perspective (in other words, who do not have an agenda), will argue the benefits versus the risks, the pros versus the cons. Very few will call it a barbaric procedure.

Most people who call it barbaric have an agenda, have an obsession, and find it hard to not think about how life (read "sex") would be different if the parents had not chosen to "make the cut" on them.

And they'll usually show a picture of a red, screaming baby to show the kind of pain a baby feels when undergoing a circumcision.

Before we continue, it is important to understand that there are different kinds of circumcision procedures, and all kinds of situations that can make a baby cry and scream bloody murder.

Setting the record straight

Babies cry. They scream. They can be in all kinds of discomfort. And sometimes there is not much we can do to ease their pain.

Babies who have blood tests, shots, raw diaper rashes, or sometimes just have colic may very well be inconsolable. Would you not have your baby have the necessary blood test or innoculation just so your baby won't ever cry?

Sometimes benefits outweigh the downsides. And sometimes not.

There are some who will argue that babies nerve endings are underdeveloped and so they don't feel the circumcision.

This is a lie.

Babies absolutely feel pain. But they only feel the pain to which they are subjected - and that, only if nothing is done to numb them from the pain. Which brings us to two points worthy of consideration when considering the difference between what is known as "routine circumcision" and a bris (A circ in an O.R. is a completely different story, because once the baby is under general anasthesia, all bets of pain and discomfort are off.)

SPEED OF PROCEDURE and NUMBING

Click this line to read the article in which it appears: "A mohel does not usually use anesthetic, because his anesthetic is the speed with which he does the circumcision. "

Most routine circumcisions are done elaborately, painstakingly, with a clamp that crushes the skin in order to achieve hemostasis. Since the skin is essentially dead when it is excised, there is usually no bleeding by the time the last skin is removed. Kudos.

Meanwhile, the baby has been in excruciating pain throughout the procedure (which usually takes between 5 and 20 minutes), unless the circumciser has used a penile block (3 injections around the circumference of the penis, along the lower base of the abdomen), to numb the area during the procedure.

3 injections = 3 shots. If your kid screams during one shot, imagine THREE, even if their outcome is a numbing. The shots themselves are painful!

A good mohel is usually done with the procedure, start to finish, in between 5 and 10 seconds. That's less time than it takes to administer the injections. Yes, there is usually a little more blood at a bris (only a little), but the drawing of blood is (like it or not) a necessity for the procedure according to Jewish law. The covenant was forged over blood. (If you like movies, you can see how a covenant is forged over blood in Kevin Costner's "Robin Hood" when he swears to avenge his father's murder in the first quarter of the film - I used to have a link to youtube here, but the video was taken down.)

NUMBING [See this posting - in which I revised what I wrote below - AB, 2012]

I happen to be a fan of numbing the foreskin, but not with injections. I prefer a topical analgesic with a dose of 30% lidocaine + 70% acid mantel cream base, to be applied to the penis at least a half hour before the bris. It doesn't hurt the baby at all in its application, and it does the same thing for the small amount of time it is helpful. Most of the discomfort at the bris comes from being handled, not from the pain of the bris (proof is that the baby usually stops crying once he is no longer being touched).

And even without it, the bris speed is, as mentioned above, its own form of anesthesia.

In Conclusion

If I were not Jewish, would I circumcise my son? Knowing what I know about circumcision, I probably would. My wife would probably not, just because she would not want to subject the baby to a painful experience - even a fleeting one.

As we are Jewish, we agree that we do it because the Torah commands it of us.

I don't think it is a barbaric custom, and I think those who do it properly have a tremendous sense of satisfaction that the baby is well and that the chapter of bris is behind them.

Consider the method and you have your answer. (Clamps, injections, drawn out, hospital v home, physician, resident, mohel, surgery v bris)

And hopefully, if you call me, you'll find what you're looking for in a mohel and you'll uncover the answers to more questions through our conversations.

The Basic Information - All You Need to Know Consolidated

I get many phone inquiries months in advance of births. Sometimes the baby is a boy, and sometimes the parents don’t know yet. (Obviously those who know they are having girls don’t call!)

I am always happy to discuss all matters in advance of the bris. But for ease of reference, here is all the information you need (some of these links are at the top of the page as well).  Of course, any topic you'd like to research more can be found in the Topical Index.

This is the Process most go through to prepare for the bris before baby is even born (and continuing as outlined below)

If baby has been born and you haven't booked your mohel yet, stop everything and call ASAP: 516-850-9694  [Please make sure only ONE person from the family is hiring a mohel to avoid booking two people for the same job]

                

Here are the supplies you need for the bris, and for the aftercare.

If you want to consider procuring a numbing agent for the bris (most people don't), here is information about analgesics that might be helpful to you - speak with your pediatrician if you need a prescription.

                

Here are the honors you need to think about and assign for the bris ceremony

                

Here is a summary of what a classic bris ceremony looks like.     

                         

Here is a basic summary of what will happen to your baby in the course of thecircumcision, including the methods of circumcision generally used by mohels (I use #2, and I do not own any clamps).

                

Here are the instructions for post-bris wound care.

                

Here is an explanation of how things will look like in the few days and weeks following the bris.

                

Here is a long term care reminder for some babies, and another for babies who gather much baby fat over the next several months. 

Here is a link to the Honorarium page - guide to figuring out what the bris costs. It is different for everyone (there is much flexibility), but costs and considerations are explained here

I have written several letters, either directly to the new Mom, to the husband of that new mom, and even to baby's grandparents who forget their role. All those letters and more are linked here, including how to deal with the unique circumstance of where there is no bris.

In 2018, I penned this SOCIAL MEDIA WARNING, because I discovered that crazy people scour Facebook (and other platforms) to be disgusting towards people who are proud that they are bringing their baby into the Mark of the Covenant. 

Unrelated to Bris, here are two posts on Parenting Tips - which may be helpful to first time parents:

1. Tricks for Changing Diapers, Keeping Things Clean, and Calming a Baby

2. Feeding, Calming, Medicating?, Diaper Rashes, Thoughts on Sleeping

****************************************************
Update from 2016 - I am including links to the tools of the trade blog posts here - which will give you a great overview of all the things used at the bris, and how they are utilized.

SHIELD              TUBE               KNIFE              PROBE             HEMOSTATS 

MARKER              GLOVES             NUMBING

Doctor vs Mohel

No, it's not the fight of the century.

But it is a question which comes up a lot. So here is the simple answer, from a mohel, of course.

[Though see here for a Reform Rabbi's answer http://www.jweekly.com/article/full/15332/which-one-is-better-doctor-or-mohel/]

Every person must do research and find the best operator for your needs, and for your situation.

In an ideal world, the person you are hiring is an observant Jew, who understands the significance of Bris Milah, the covenant, and all the laws associated with the performance of a bris milah. Whatever character traits you'd like in the person might also be significant to consider, when thinking about what kind of representative you (especially the father, who is really hiring the person to perform this mitzvah in your place) want to fill your place in this very important mitzvah.

ANYONE WHO FILLS THESE ROLES TO YOUR DESIRES IS A GOOD HIRE. [Even better, if he uses a marker when operating...]

Other things to consider:

1. Specialist

Who does more procedures? Many doctors I know (they are usually observant Jews) highly recommend a mohel over a doctor. They have the attitude that the mohel is a specialist. This is his field. He is the expert. Being highly trained in a specific discipline, and specializing in this unique field, makes the mohel most qualified to do this. [Obviously if a doctor happens to also be a mohel, this will work to his advantage in some people's eyes. But honestly, the service a doctor/mohel and a mohel provide is the same thing with respect to the circumcision and the result, except perhaps in two areas as I'll note below]

2. Method

Most doctors are more comfortable using a clamp - such as the Gomco or the Mogen clamp. Do research on these items, to decide if they are right for you. Some mohels (usually on the very modern side, or in the Conservative and Reform movements) use the Mogen clamp or a modified Mogen clamp. Most traditional mohels use what is called in Hebrew a Magen (מגן), a traditional "shield" (which protects the glans and the scrotum) which does not have a clamping arm. THIS IS THE PROCEDURE I USE While no procedure is completely bloodless (a real bris is not supposed to be bloodless), the clamps are supposed to cause less bleeding. The traditional method may have a little more bleeding, but in the hands of a good mohel, it is absolutely nothing to worry about.
And, as Rabbi Cartun points out in the article I linked to above (here it is again), the speed in which a mohel operates is usually much faster than any physician.

3. Numbing

See here for a discussion about this. Most doctors will give the baby several injections to create a nerve blockage. While the baby might not feel the bris, the baby will feel the injections (and may feel them hours later as well). Some mohels recommend or provide a topical anesthetic. Depending on its strength, it may remove the pain of the actual circumcision.

4. How is baby held?

Numbing does not help the baby's discomfort at having his legs held down. Most mohels have the sandak holding the baby's legs, and letting go as soon as the procedure is over. Many doctors might utilize a circumstraint to hold the baby, leaving the baby in an uncomfortable position significantly before and sometimes after the procedure as well.

5. Track record and Touch-ups
Probably the most important question is "what is the track record?" While I don't have statistical evidence, I have spoken to pediatric urologists and pediatric surgeons who have told me anecdotally that they do many more touchups on circumcisions done by doctors than by mohels. [Don't trust me. Ask similar doctors that you may know.]
Doctors tend to take off a little less foreskin, which leaves the penis looking uncircumcised in many cases of touch-up necessity.
[Many "problems" disappear when the child gets out of diapers, and certainly by puberty. But for babies who need their circ to be revisited - it is worth asking people and doctors who has a better track record.]
A surgical marker could resolve this issue, but most mohels and doctors don't use one (though I do! :))

I guess it is clear that I prefer a good and experienced mohel over a doctor. Surprised?

Baby Feeling Pain - Myths and Facts

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

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

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

But here is the brief version.

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

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

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

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

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

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

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

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

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

When Bris is on a Fast Day (Tosafos insights)

In a much larger Talmudic discussion (Eruvin 40b) that involves the question of whether one must eat/drink after saying a blessing (instead of having someone else, such as a child drink), as well as the propriety of giving alcohol to children, Tosafos record two stories, which are instructive as to how people conduct themselves with reference to eating and drinking on a fast day.

I share because when there is a bris on a fast day (10th of Tevet, referenced below, is coming up), this information is instructive.

תוספות מסכת עירובין דף מ עמוד ב 
ומעשה היה בחופה בעשרה בטבת נתנו הכוס לתינוק לשתות [ומעשה היה בברית מילה ברבינו יעקב בר יקר שחל עשרה באב בא' בשבת והוא היה אב"ד וצוה להתפלל מנחה גדולה ורחצו ואכלו מפני שי"ט שלהן היה כדכתיב שש אנכי כו' והאי דלא מברכינן שהחיינו משום צערא דינוקא תוס' שאנ"ץ].

"It happened that there was a wedding on the 10th of Tevet (a fast day), and they gave the cup (of wine) to a child to drink (the word "Tinok" means baby - but sometimes refers to a child)."

"It happened that there was a bris with Rabbi Yaakov bar Yakar which fell on the 10th of Av which fell on Sunday (meaning it was the day they were observing the 9th of Av fast, pushed to Sunday). He was the Head of the Rabbinic Court. He instructed everyone to pray the early Mincha, and then to wash and eat, for it was a Yom Tov for them, as it says, 'I rejoice at the fulfillment of Your word...'

And the reason we do not say "Shehechiyanu" at a bris is because of the pain the child experiences."

When we say a blessing over wine on a fast day, we have the custom to give the wine to the child - which at a bris is the baby. This may or may not be the source for our giving wine to the baby at every bris anyway.

But the points we take from these tales for bris practices on fast days are the following:
1. The easiest person to give to drink on a fast day is the baby
2. A fast day which is pushed off, even a fast day as important as 9 Av, is a day when participants at the bris may eat. While this is not a common practice, it is mostly due to lack of awareness of the rules.
3. A baby does feel pain at a bris. This is not something we celebrate through the recitation of Shehechiyanu. [This is a confirmation that this mitzvah is one of the rare mitzvos in the Torah that has pain associated with it (the other being fasting on Yom Kippur). This is why numbing the baby is advocated, while some argue that the speed in which we operate serves as its own numbing.]

Milah U'Priah B'Vas Achas

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.

Rabbinic Standards, Synagogue Standards, Mohel Standards

This post will explore a few topics:
1. That parents decide who their son's mohel will be
2. There are different methods employed when circumcising
3. There are hashkafic (worldview) differences employed by some religious camps in their preference for method
4. While there are halakhic differences associated with the worldviews, and while people may have a preference for how things ought to be done, with extremely rare exception, no one will say the brisses as described below are invalid. (When they ARE invalid, assuming the correct amount of foreskin has been removed, the method of fixing a bris is called "Hatafat Dam Brit")
5. The Standards that some rabbis and synagogues have employed in determining how they want a bris performed under their influence/oversight

PARENTS DECIDE

You brought this baby into this world? He is your responsibility. You must do your research. You must learn about bris, you must know what will be happening to your baby, and you must ask the right questions so that you know the person you will be hiring to perform the circumcision/bris conforms to your sensibilities, sensitivities, and the way you live your life.
For example:
If you are worried about the pain your baby will experience, you should be asking about what numbing options the mohel offers, how fast he works, whether he uses a clamp.
If you are concerned about sterility, you must ask whether the mohel wears gloves, how he sterilizes his instruments, whether he does metzitzah with his mouth, with a tube, or with a sponge
If you are concerned about methods and safety, you have to ask about clamps, freehand, whether the mohel marks the foreskin with a marker

Baby's grandparents, your rabbi, your friends are certainly allowed to make recommendations to you. But the decision of whom to hire (unless YOU CHOOSE TO DELEGATE IT) is your decision to make. The choice you make might come in conflict with the standards delineated below (in the STANDARDS section), but don't balk if you are confident in your decision that the mohel you've chosen is right for you and your baby.

DIFFERENT METHODS OF CIRCUMCISION

As I have noted here, while there are a number of ways people can go about circumcising, mohels typically fall into one of three methods. Clamp, Shield, Freehand.

Within those groups, there are different styles.
Clamp-using mohels (NOTE: I DO NOT USE A CLAMP) will most often use a Bronstein/Mogen Clamp, and very rarely use a Gomco Clamp. In all likelihood, someone who uses a clamp will also employ the use of  a hemostat in order to achieve "Milah U'Priah B'Vas Achas."

Within the shield style, some will grab the foreskin with a hemostat, some will grab it with their fingers alone, sans-any other instrument.

The freehand mohel uses no instruments other than a knife, and does so because he thinks his method is least painful to the baby, and most reflective of the method utilized by mohels from over 1000 years ago.

And then there's metzitzah. Which is either accomplished through a sterile tube, through the mouth of the father (or mohel), or sidestepped completely.

HASHKAFIC DIFFERENCES

The differences in these approaches are largely "hashkafic," and with the exception of the use of the clamp (where there are significant halakhic objections), no one I know of actually disputes or questions the validity of the circumcision performed using a different method of grabbing the foreskin, doing metzitzah, or using a shield.

STANDARDS

Like any trade skill, a mohel develops a routine and system that works for him. When a mohel is asked to do a bris in the manner he is not comfortable doing, he can try to comply or he can say "I work best using the method I am used to. If you want me, this is the bris you get. You don't like that style, by all means, please call someone else."

When a rabbi is asked for a recommendation of a mohel, the rabbi (or his congregation) might have a set of standards for what they allow/don't allow. In my experience, some shuls use any or all of the following standards of operations:
A. Metzitzah may not be done with direct oral contact (out of concern for the transmission of any kind of disease), and may only be done with a sterile pipette (usually glass or one-time disposable sterile back of a syringe)
B. Do not allow a clamp (for Halakhic reasons)
C. Insist the mohel wear gloves.
D. Orthodox synagogues will likely insist on the mohel being an Orthodox Jew.

Hashkafically, some communities do not like the hemostat and they prefer metzitzah with direct-oral contact, but they do not call into question the validity of a bris performed with a hemostat (it is not viewed the same way that a clamp is viewed) or the metzitzah performed with a pipette. If they insist that the bris be performed without a hemostat (which most mohels use), they are essentially telling their constituents, "We have a very limited number of mohels we allow to perform a bris here. If these mohels work for you, great. If not, enjoy doing your bris elsewhere."

FINAL THOUGHTS

Most people will certainly agree that standards which protect the baby should be unquestioned.

This is why I think that the institutions/rabbis which insist there is ONLY ONE ACCEPTABLE METHOD OF PERFORMING BRIS MILAH do their constituents a disservice, as they are basically dictating to parents, "We don't trust your judgment about the mohel you've picked. You have to trust our judgment." Meaning, if the parents want a certain method, which happens to hashkafically differ from the rabbi's perspective (even while halakhically being extremely mainstream and acceptable), that IS OK. And the rabbi needs to be a little flexible. And a little more humble. Especially if he is not a mohel himself and does not know everything about Bris Milah. Preach all you want, but allow people to come to Judaism and decisions on their own terms.

My Standard Recommendation

On the rare case when I am unavailable, or when people from out of state ask me for a recommendation of a mohel closer to them, my own standard of recommendation and endorsement is for mohels who wear gloves. There's an element of hygiene and cleanliness that accompanies a glove-wearer (metzitzah with a tube, a standard of sterilizing) which I simply admire and support. But I do not invalidate mohels who do not fit my standards! If they do a good (or even great) job and people are happy with how they operate, and of course are pleased with the results, then blessings upon everybody!

Yes. There are some places where I feel it is important to draw a line (I think, for example, that the Gomco clamp is a torture device, and should never make an appearance at a bris). But there should also be a little bit of flexibility, especially when the bris is halakhically valid "lechatchila" according to virtually everyone, and the baby emerges with a fine circumcision and without danger of infection from the method employed on him.

In short, those who make standards for their institutions need to be very careful to be consistent, and must also be ready to explain to their constituents why certain mohels that everyone else hires might not be acceptable in their own synagogue.

There is an element of risk as well, because the family might opt to not do the bris in that facility altogether, and might be turned off from the institution which dictates to them how to live their lives.

Table of Contents - Caring for the Circumcision (practical information)

Caring for the circumcision 'wound'
Thoughts on NUMBING the foreskin
What to Prepare for the Bris
Instructions for After Care
What Will it Look Like Before and After
How I Explain How it will look - with pictures!
Photos of a Healing Bris
Looks Swell - No? - on swelling
Is Tylenol a solution for a cranky baby?
What I learned in the Operating Room
Knowing What to expect afterwards
Talking to a Urologist - observations about circumcision from a grandfather at a bris (see follow up to this story here: A Promise Fulfilled)
Long term Care Reminder
CHUBBY BABY Syndrome - How alot of baby fat is disheartening for a few months
Fusion Challenge
The Myth of Bleeding Vein

Repost X: Describing Tools of the Trade + Additional Thoughts on Some of Them

Following in the theme of the last few posts, this is a review of much of what I've written about the different surgical instruments and otherwise that are used for Bris Milah in our time. Above the line of asterisks are links to descriptions of each item and how it is used. Below the asterisks are expansions on some of the items, which are more "discussed" in some "Hashkafic" arenas surrounding Bris Milah  Though deeper "Hashkafic Dives" will be presented in the next "Repost"

This is presented in the order each item would be used

NUMBING

GLOVES             

MARKER              

PROBE 

Table of Contents - Bris Kit, How Bris is Done

Bris, How It Is Done - Mohel's Bag of Tricks

SHIELD          
TUBE               
KNIFE              
PROBE             
HEMOSTATS          
FORCEPS 

MARKER              
GLOVES             
NUMBING

Halakhah v. Hashkafah

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

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

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

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

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

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

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

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

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

PRIAH - This is a discussion of what Priah is, namely the removal of the mucosal membrane from covering the glans, and addresses the oft-cited clai of anti-circumcision people, that Avraham Avinu wasn't instructed to do Priah

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

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

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

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

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

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

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

Table of Contents - Parent Notes

Parents, Notes to
For Bris Prep
ALL you need to know, in one easy blog post (links)
Being Aware of What you Should Be Asking Your Mohel
Numbing - Should I? Or shouldn't I?
Why baby can't eat before the bris
Tricks for baby care from your local mohelinsouthflorida.com - especially good for first-time parents!
Important Reminders
TOP TEN - Don't Make These Mistakes! - you'll kick yourself afterwards!
Finding a Mohel in South Florida

Tricks and Tips I've Picked Up Along the Way
Tricks for Changing Diapers, Keeping Things Clean, and Calming a Baby

Feeding, Calming, Medicating?, Diaper Rashes, Thoughts on Sleeping

A Note to the New Mom

Dear New Mom

For the Daddy
Dear Husband
The Father's Role in the Bris
And... Should the Father DO the circumcision?
If You Choose to Do the Circumcision Under My Supervision (to set your mind at ease)
The Myth of the Bleeding Vein - a note for fathers who want to perform the circumcision

Dealing With Family

Dear Grandparents - a Note to Share with Grandparents, a reminder of boundaries
The Right to Choose Your Mohel - (Grandparents may have solicited input, but they don't decide)

Who Gets To NAME the baby - (Grandparents may have solicited input, but they don't decide)
When anatomical abnormalities cancel a bris, and what you tell your family
Bringing KIDS to a Bris?

He's Your Son Really

Don't Worry!!

My Gratitude and Your Responsibilities
Putting Your Mind at Ease
Putting Parents at Ease
When the Bris Turns out Poifect!
Daddy (and Mommy) Tricks For Your Baby's Care (unrelated to bris, and also good for baby girls!)

My attitude in working with you
Importance of Trust
It's All About the Baby

Important notes about post-bris realities

The sometimes TWO STAGES of a bris

Instructions for After Care
My Scare Tactic - to get you to listen to instructions!

Social Media Warning

So.... Do you use a Clamp?

I get this question a lot, and I think it's time to clarify what the tools of the trade are. 

The answer to the question, by the way, is NO. I don’t use a clamp.  Keep reading, to learn what it is and why some do use it. 

[The following links were added to the post below at a later date (based on when I blogged about them). While the links below address the "tools"/Bris Milah instruments that I use, what follows after the links is not addressed in the "SHIELD" blog post linked immediately below, so the remaining content of this blog post is still quite informative, even if you choose to follow the specific links that immediately follow]

The links to the specific "tools of the trade blog posts" are here - each which will give you a great overview of each item and how it is utilized.

SHIELD              TUBE               KNIFE              PROBE             HEMOSTATS 

MARKER              GLOVES             NUMBING

continuing the original blog post here....

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. 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.

THIS IS THE ONLY KIND OF SHIELD FOR THE GLANS THAT I USE. 

I DO NOT OWN ANY OF THE FOLLOWING DEVICES

FAQ - Frequently Asked Questions SUMMARY

Short answers to the following questions can be found here

The links will send you to longer answers to the questions categorized below...

MOST PRACTICAL 
* I'm a practical person and don't have time for all this. What do I need to know and do to prepare for a bris? You can start by utilizing all the "page" links at the top of the page, or you can go to this blog post which covers each essential thing you need to find, from the preparations for the bris to the longer term care instructions and things to note.

ABOUT THE MOHEL
* Anythoughts on how to find the right mohel? (Aside from calling the number on the right of the page? :) Seriously though -- Important to know what you're looking for and to ask the right questions, basically - do your research!! My own comparison of Billet vs the other guys
* What is your training? (read my mini bio on this homepage)
* Why did you become a mohel? What do you enjoy about being a mohel?
* Are you a doctor? No.  Does a mohel need to be a doctor? Read the second half of this post
* (or read this article from the jweekly of California)

PREPARING FOR THE BRIS - DETAILS AND MINDSET
* What do I need for a bris? Supplies
* What is the setup for a bris? Setting up the room
* What goes into preparing a bris party? What is an appropriate venue for a bris?

THE CEREMONY AND THE PROCEDURE
* How does the ceremony work? (General overview of the Ceremony)
* How is a circumcision done? Methods,
* What exactly happens in a circumcision? Before and After (note the link to the circumcised banana)
* Explain the honors of the ceremony: HONORS LIST (more detailed list of the honors) Kvatter, Kisei (Chair of) Eliyahu (Elijah the Prophet), Sandak
* What is metzitzah? As straight as I can give it to you, An Additional Thought, Is it a "Mitzvah"?
* How do you balance inclusion of family, friends and guests in the ceremony? Having Family and Friends Involved (includes honors list)
* What surgical instruments and supplies are used in a circumcision?  SHIELD              TUBE               KNIFE              PROBE             HEMOSTATS           MARKER              GLOVES             NUMBING

AFTER THE BRIS
* How do I care for my son after the bris? Instructions  Thoughts on Tylenol
* What will it look like? Before and After
* What can go wrong? Common issues  Correctable and Really Bad, Long term Care Reminder

MISCELLANEOUS
* How does it work if one of us (baby's parents) is not Jewish? A: If his mother is Jewish...  What Makes a Jew, Mohel's role in circumcising half-Jews (one Jewish parent) and non-Jews, When the mother is not Jewish
* What will the bris itself (circumcision - mohel's role) cost? Initial Thoughts   and    More straightforward
* How important is sterility really? One, Two,  Three
* Is there a difference between a bris and a circumcision? This topic,  Related conversation