Frequently Asked Questions
1. Q. Do physicians recommend circumcision?
A. The American Academy of Pediatrics recently (August 27, 2012) modified their stance on circumcision for all babies born in the United States. Based on new research they found that the health benefits outweigh the risks. See here for an article in the New York Times on the issue. Most of the parents I encounter decide to circumcise for religious reasons. However, the fact that it is supported by the medical community is reassuring. See below for a recent article by Dr. Edgar Schoen (former chief of pediatrics at kaiser permanente in oakland) recommending in
2. Q. How is circumcision performed and is it dangerous?
A. Circumcision is a relatively minor procedure that is medically acceptable starting from within the first 24 hours of birth. It is performed with sterile equipment just as it would in a surgery room. Measures are taken to make sure that only what needs to be cut will come into range of the knife, protecting the baby from any harm. The use of special hemostatic medicines control the bleeding so that within minutes of the procedure the bleeding has essentially stopped. The baby will feel some pain at the moment of the incision but within seconds will be comforted with a topical anesthetic and the pain will subside.
3. Q. Do you inject anesthesia?
A. Injections of anesthesia are unnecessary and tend to increase the level of discomfort of the baby. A traditional bris is completed within the same minute that it begins. The greatest anesthetic is the time factor which allows the baby to be comfortably back in his mother's arms immediately after the bris. Injections of anesthesia to comfort the baby tend to have an opposite effect by prolonging the procedure and are at times ineffective at blocking the nerves. Furthermore, I apply a topical anesthetic immediately after the incision to numb the area. In the past I have offered to bring a pediatrician who can administer injections. However, after years of performing bris' in the presence of pediatricians, who have all agreed that anesthesia is not necessary due to the speed of the bris, I no longer offer this as an option.
3. Q. Isn't it better to have a trained physician perform the bris?
A. No, for many reasons. The method of performing the bris in hospitals is to use a device called the gomco clamp (see below) causing 10 minutes or more of pain to the baby as the device is placed tightened on the foreskin. When used in conjunction with injections, the pain will be less acute but the procedure will take even longer. Another method that has become commonly used in hospitals is the Plastibell. This procedure also has many steps causing it to take more time and seems to have an increased risk of infection. In contrast, a bris performed by a proficient mohel who is trained in the use of a Mogen is quicker and thereby less painful to the baby. Furthermore, a bris performed by a physician would often not be acceptable according to Jewish law, demanding further blood to be drawn in the future. Religiously observant urologists, pediatricians and gynecologists refer to a competent mohel, recognizing that the technique of the mohel far surpasses the procedure performed in hospitals.
See here for an article by Rabbi Ari Cartun as to the advantage of a mohel - http://www.jweekly.com/article/full/15332/which-one-is-better-doctor-or-mohel/
The lengthy procedure performed by physicians with the use of an anesthetic can be viewed here: Gomco, Plastibell. In contrast, the procedure performed by a trained mohel using the mogen takes less time from start to finish than just the injection of the anesthetic alone.
4. Q. Where can the Bris be performed?
A. A bris can be performed either in a synagogue or in one's private home. Some are more comfortable with a more private family setting, whereas others prefer to celebrate this special event together with friends.
5. Q. When should the Bris be scheduled for?
A. According to Jewish Law, a bris should be scheduled for the 8th day from the day of birth (including the day of birth). For example if a baby was born on Tuesday, the bris will take place the following Tuesday. Being that in Jewish Law the eve is part of the following day, if the the baby was born on a Thursday night the bris would take place Friday one week later. Under special circumstances where the baby isn't yet healthy enough to undergo a bris, the bris will be pushed off to a time agreed upon by the family and mohel. When the bilirubin numbers are higher than what is considered normal, the bris may also have to be pushed off.
6. What is the format of the ceremony and how long does it take?
A. The Bris ceremony takes approximately 15 minutes (the surgery is a very small part of that time). It begins with the welcoming of the baby who is carried in by a couple who are selected for that honor. The baby is then placed on the "Chair of Elijah, the Prophet" who's spiritual attendance is acknowledged at every bris. Afterward, a close family member or Rabbi is given the honor of "sandek" - to hold the baby during the circumcision. The Mohel will then begin to do his work, concluding with the reciting of blessing over wine.
7. Q. How long will it take to heal and what is the aftercare?
A. After the ceremony the mohel will examine the baby to determine that the bleeding has stopped. At that point the mohel will apply a special bandage which will remain on for 24 hours. After the bandage is removed, the mohel will give specific instructions to the parents to give frequent baths, clean the area with soap, and apply bacitracin for 3 days after the bris to prevent infection. During the healing process the remaining mucous membrane under the head of the penis will swell and turn pinkish. There will also be a yellowish crust that forms over the affected area as the skin begins to heal.
8. Q. Will the baby be able to urinate after the bris?
A. The baby will be able to urinate before, during and after the bris, and hopefully will not begin until the diaper is back in place. The Bris will not interfere with nursing or urination.
9. Q. Should the baby be given any painkillers such as tylenol and advil?
A. Advil and aspirin is not recommended to be used after the Bris.They inhibit the activity of an enzyme called cyclo-oxygenase which results in the blocking of pain, and act as an anti-inflamitory, but also affect the platelets affecting the ability to clot and close the wound. If the baby has discomfort, one may give 0.4ml of infant tylenol.
10. Q. Is it normal for the top of the babies penis to be deep red?
A. Yes. The redness on the top of the penis is the normal color of the infants penis and will change with time. The bris procedure exposes the top of the penis, but does not create any injury at the top. The affected area is only on the skin which drops down toward the bottom of the penis.
11. Q. Why should I cause injury to my child's genitals? If he wants a circumcision, he can always choose one later in life?
A. Jewish law requires a male child to be circumcised on the eighth day from birth. Aside from this being a mandate recorded in the Bible, it allows for the procedure to be accomplished with minimal bleeding, little pain and quick healing. When a bris is performed later in life, it is a far more invasive procedure that must take place in a hospital setting, sealed through stitching and often leads to excessive bleeding. A parents choice to do a bris by a competent mohel at the very early stages of life has medical benefits according to many physicians, complies with the Torah law, and avoids a far more complicated surgery which is necessary when done later on in life.
12.Q. Do you use a Mogen Clamp (known as the Bronstein Clamp)?
A. The technique I use in circumcision is to use a guard known to mohalim as a Mogen, which protects the penis during the cutting to ensure that nothing aside from the foreskin is removed. There are some Mohalim who use a clamp known as the Bronstein clamp which resembles the standard Mogen (many people are unable to tell the difference - see pictures below), but has an additional clamping element to it. The advantage to the clamp is that there will be little or no bleeding at the time of the cut since the clamp serves as a hemostat to block all blood vessels. I DO NOT use the Mogen clamp. The Mogen clamp is considered by many medical professionals to be more of a risk since if not placed carefully because it can accidentally clamp down on the penis amputating part of the glans. It is true that most mohalim who use this clamp are proficient with it and the risk is low, but my preference is to eliminate the risk entirely. I prefer to be less concerned with the bris being "bloodless", and more concerned about the child's safety. People often consider the bleeding to be the dangerous part of the bris, when in actuality even when there is bleeding, the actual blood loss is very minimal. I use the latest forms of expensive hemostatic powders and special bandages such as surgicel to ensure that the bleeding stops immediately after the Bris. For further discussion about the clamp, click here.
A. The American Academy of Pediatrics recently (August 27, 2012) modified their stance on circumcision for all babies born in the United States. Based on new research they found that the health benefits outweigh the risks. See here for an article in the New York Times on the issue. Most of the parents I encounter decide to circumcise for religious reasons. However, the fact that it is supported by the medical community is reassuring. See below for a recent article by Dr. Edgar Schoen (former chief of pediatrics at kaiser permanente in oakland) recommending in
2. Q. How is circumcision performed and is it dangerous?
A. Circumcision is a relatively minor procedure that is medically acceptable starting from within the first 24 hours of birth. It is performed with sterile equipment just as it would in a surgery room. Measures are taken to make sure that only what needs to be cut will come into range of the knife, protecting the baby from any harm. The use of special hemostatic medicines control the bleeding so that within minutes of the procedure the bleeding has essentially stopped. The baby will feel some pain at the moment of the incision but within seconds will be comforted with a topical anesthetic and the pain will subside.
3. Q. Do you inject anesthesia?
A. Injections of anesthesia are unnecessary and tend to increase the level of discomfort of the baby. A traditional bris is completed within the same minute that it begins. The greatest anesthetic is the time factor which allows the baby to be comfortably back in his mother's arms immediately after the bris. Injections of anesthesia to comfort the baby tend to have an opposite effect by prolonging the procedure and are at times ineffective at blocking the nerves. Furthermore, I apply a topical anesthetic immediately after the incision to numb the area. In the past I have offered to bring a pediatrician who can administer injections. However, after years of performing bris' in the presence of pediatricians, who have all agreed that anesthesia is not necessary due to the speed of the bris, I no longer offer this as an option.
3. Q. Isn't it better to have a trained physician perform the bris?
A. No, for many reasons. The method of performing the bris in hospitals is to use a device called the gomco clamp (see below) causing 10 minutes or more of pain to the baby as the device is placed tightened on the foreskin. When used in conjunction with injections, the pain will be less acute but the procedure will take even longer. Another method that has become commonly used in hospitals is the Plastibell. This procedure also has many steps causing it to take more time and seems to have an increased risk of infection. In contrast, a bris performed by a proficient mohel who is trained in the use of a Mogen is quicker and thereby less painful to the baby. Furthermore, a bris performed by a physician would often not be acceptable according to Jewish law, demanding further blood to be drawn in the future. Religiously observant urologists, pediatricians and gynecologists refer to a competent mohel, recognizing that the technique of the mohel far surpasses the procedure performed in hospitals.
See here for an article by Rabbi Ari Cartun as to the advantage of a mohel - http://www.jweekly.com/article/full/15332/which-one-is-better-doctor-or-mohel/
The lengthy procedure performed by physicians with the use of an anesthetic can be viewed here: Gomco, Plastibell. In contrast, the procedure performed by a trained mohel using the mogen takes less time from start to finish than just the injection of the anesthetic alone.
4. Q. Where can the Bris be performed?
A. A bris can be performed either in a synagogue or in one's private home. Some are more comfortable with a more private family setting, whereas others prefer to celebrate this special event together with friends.
5. Q. When should the Bris be scheduled for?
A. According to Jewish Law, a bris should be scheduled for the 8th day from the day of birth (including the day of birth). For example if a baby was born on Tuesday, the bris will take place the following Tuesday. Being that in Jewish Law the eve is part of the following day, if the the baby was born on a Thursday night the bris would take place Friday one week later. Under special circumstances where the baby isn't yet healthy enough to undergo a bris, the bris will be pushed off to a time agreed upon by the family and mohel. When the bilirubin numbers are higher than what is considered normal, the bris may also have to be pushed off.
6. What is the format of the ceremony and how long does it take?
A. The Bris ceremony takes approximately 15 minutes (the surgery is a very small part of that time). It begins with the welcoming of the baby who is carried in by a couple who are selected for that honor. The baby is then placed on the "Chair of Elijah, the Prophet" who's spiritual attendance is acknowledged at every bris. Afterward, a close family member or Rabbi is given the honor of "sandek" - to hold the baby during the circumcision. The Mohel will then begin to do his work, concluding with the reciting of blessing over wine.
7. Q. How long will it take to heal and what is the aftercare?
A. After the ceremony the mohel will examine the baby to determine that the bleeding has stopped. At that point the mohel will apply a special bandage which will remain on for 24 hours. After the bandage is removed, the mohel will give specific instructions to the parents to give frequent baths, clean the area with soap, and apply bacitracin for 3 days after the bris to prevent infection. During the healing process the remaining mucous membrane under the head of the penis will swell and turn pinkish. There will also be a yellowish crust that forms over the affected area as the skin begins to heal.
8. Q. Will the baby be able to urinate after the bris?
A. The baby will be able to urinate before, during and after the bris, and hopefully will not begin until the diaper is back in place. The Bris will not interfere with nursing or urination.
9. Q. Should the baby be given any painkillers such as tylenol and advil?
A. Advil and aspirin is not recommended to be used after the Bris.They inhibit the activity of an enzyme called cyclo-oxygenase which results in the blocking of pain, and act as an anti-inflamitory, but also affect the platelets affecting the ability to clot and close the wound. If the baby has discomfort, one may give 0.4ml of infant tylenol.
10. Q. Is it normal for the top of the babies penis to be deep red?
A. Yes. The redness on the top of the penis is the normal color of the infants penis and will change with time. The bris procedure exposes the top of the penis, but does not create any injury at the top. The affected area is only on the skin which drops down toward the bottom of the penis.
11. Q. Why should I cause injury to my child's genitals? If he wants a circumcision, he can always choose one later in life?
A. Jewish law requires a male child to be circumcised on the eighth day from birth. Aside from this being a mandate recorded in the Bible, it allows for the procedure to be accomplished with minimal bleeding, little pain and quick healing. When a bris is performed later in life, it is a far more invasive procedure that must take place in a hospital setting, sealed through stitching and often leads to excessive bleeding. A parents choice to do a bris by a competent mohel at the very early stages of life has medical benefits according to many physicians, complies with the Torah law, and avoids a far more complicated surgery which is necessary when done later on in life.
12.Q. Do you use a Mogen Clamp (known as the Bronstein Clamp)?
A. The technique I use in circumcision is to use a guard known to mohalim as a Mogen, which protects the penis during the cutting to ensure that nothing aside from the foreskin is removed. There are some Mohalim who use a clamp known as the Bronstein clamp which resembles the standard Mogen (many people are unable to tell the difference - see pictures below), but has an additional clamping element to it. The advantage to the clamp is that there will be little or no bleeding at the time of the cut since the clamp serves as a hemostat to block all blood vessels. I DO NOT use the Mogen clamp. The Mogen clamp is considered by many medical professionals to be more of a risk since if not placed carefully because it can accidentally clamp down on the penis amputating part of the glans. It is true that most mohalim who use this clamp are proficient with it and the risk is low, but my preference is to eliminate the risk entirely. I prefer to be less concerned with the bris being "bloodless", and more concerned about the child's safety. People often consider the bleeding to be the dangerous part of the bris, when in actuality even when there is bleeding, the actual blood loss is very minimal. I use the latest forms of expensive hemostatic powders and special bandages such as surgicel to ensure that the bleeding stops immediately after the Bris. For further discussion about the clamp, click here.
Mogen Clamp (Bronstein Clamp)
Standard Mogen
Gomco Clamp (used in hospitals to perform circumcision)
j. weekly
Thursday, January 3, 2013
Circumcision is not only Jewish, it’s good for you
By Dr. Egar J. Schoen
In this country, circumcision is the norm. According to the Center for Disease Control and Prevention, 89 percent of non-Hispanic white males in the United States are circumcised. If an American boy is uncircumcised, it generally means his parents are immigrants, usually Hispanic, or low-income.
The exception is a small number of middle-class boys whose parents have been convinced by activist anti-circumcision groups to leave their baby boys “intact,” as they call it. Parents targeted by lay anti-circumcision groups are usually well educated, secular and liberal, live in coastal “blue” states and are attracted to alternative/holistic medical practice.
Many Jews fall into this profile, so that now, thousands of years after the covenant between Abraham and God mandating circumcision on the eighth day (Genesis 17), we see Jewish boys with foreskins. The Bay Area is ground zero for activist organizations gunning against circumcision, such as NOCIRC, NOHARMM and Intact. The arguments of these cultlike groups are based on anecdotes, testimonials, false theories and bogus claims with no scientific support.
Recently, as compelling medical evidence demonstrates the significant health advantages of circumcision on newborns, there has been a flurry of desperate activity by anti-circumcision groups, as they see their cause being decimated. They picketed the local office of the American Academy of Pediatrics, and the executive director had to call the police. At an AAP meeting in San Francisco in July, I was harassed by anti-circumcision protesters, leading the hotel to assign me a security guard. This all followed last year’s unsuccessful attempt to criminalize infant male circumcision in San Francisco.
The documented evidence of the lifetime preventive health advantages of circumcision is overwhelming. This year, the AAP stated that the significant benefits of newborn circumcision outweigh the minor risks. Severe infant kidney infections, which can lead to kidney damage, are 10 times more common in uncircumcised males in the first year of life. The presence of a foreskin leaves a young boy susceptible to painful local infections (balanoposthitis) and inability of retraction (phimosis).
In sexually active years, circumcision provides 60 percent greater protection against HIV/AIDS, which has killed over 20 million people in Africa and tens of thousands in this country. The United Nations, the World Health Organization and the National Institutes of Health have all endorsed circumcision to help prevent HIV/AIDS. Other sexually transmitted infections that circumcision helps protect against are genital herpes, human papilloma virus (the cause of penile and cervical cancer), trichomonas and bacterial vaginosis. The advantages in old men include avoidance of penile cancer and urinary infections, which are prevalent in the elderly, as well as easier genital hygiene in the incapacitated.
The newborn period is the ideal time for circumcision. Not only does early circumcision lead to a lifetime of health advantages, but it is the easiest and safest time to perform the procedure. After the trauma of birth, a newborn is programmed to deal with distress. Stress hormones, such as hydrocortisone and adrenaline, are extremely high, as is the pain-relieving compound endorphin. The male hormone, testosterone, is often in the adult range. All these hormone levels fall within the first few weeks of life. The newborn foreskin is thin, making the procedure quick and safe and virtually painless when using local anesthesia. Healing is rapid, and complications, usually minor, are less than 0.5 percent.
At older ages the procedure is more difficult, with a longer recovery time and a tenfold higher complication rate. The need for general anesthesia makes the procedure riskier. Almost all circumcision deaths have been due to complications from general anesthesia.
As noted, uncircumcised males, compared with those who are circumcised, are prone to many health dangers from birth through old age, and also may have social problems in the United States, where circumcision is the standard. In addition, the easier genital hygiene leads to improved and more varied sexual relations. Above all, Jewish men with foreskins are abandoning an ancient family tradition and culture.
My advice for anti-circumcision Jewish parents is, “enough already.”
Dr. Edgar J. Schoen is the former chief of pediatrics at Kaiser Permanente in Oakland and clinical professor of pediatrics, emeritus, at UCSF. He lives in Richmond.
Thursday, January 3, 2013
Circumcision is not only Jewish, it’s good for you
By Dr. Egar J. Schoen
In this country, circumcision is the norm. According to the Center for Disease Control and Prevention, 89 percent of non-Hispanic white males in the United States are circumcised. If an American boy is uncircumcised, it generally means his parents are immigrants, usually Hispanic, or low-income.
The exception is a small number of middle-class boys whose parents have been convinced by activist anti-circumcision groups to leave their baby boys “intact,” as they call it. Parents targeted by lay anti-circumcision groups are usually well educated, secular and liberal, live in coastal “blue” states and are attracted to alternative/holistic medical practice.
Many Jews fall into this profile, so that now, thousands of years after the covenant between Abraham and God mandating circumcision on the eighth day (Genesis 17), we see Jewish boys with foreskins. The Bay Area is ground zero for activist organizations gunning against circumcision, such as NOCIRC, NOHARMM and Intact. The arguments of these cultlike groups are based on anecdotes, testimonials, false theories and bogus claims with no scientific support.
Recently, as compelling medical evidence demonstrates the significant health advantages of circumcision on newborns, there has been a flurry of desperate activity by anti-circumcision groups, as they see their cause being decimated. They picketed the local office of the American Academy of Pediatrics, and the executive director had to call the police. At an AAP meeting in San Francisco in July, I was harassed by anti-circumcision protesters, leading the hotel to assign me a security guard. This all followed last year’s unsuccessful attempt to criminalize infant male circumcision in San Francisco.
The documented evidence of the lifetime preventive health advantages of circumcision is overwhelming. This year, the AAP stated that the significant benefits of newborn circumcision outweigh the minor risks. Severe infant kidney infections, which can lead to kidney damage, are 10 times more common in uncircumcised males in the first year of life. The presence of a foreskin leaves a young boy susceptible to painful local infections (balanoposthitis) and inability of retraction (phimosis).
In sexually active years, circumcision provides 60 percent greater protection against HIV/AIDS, which has killed over 20 million people in Africa and tens of thousands in this country. The United Nations, the World Health Organization and the National Institutes of Health have all endorsed circumcision to help prevent HIV/AIDS. Other sexually transmitted infections that circumcision helps protect against are genital herpes, human papilloma virus (the cause of penile and cervical cancer), trichomonas and bacterial vaginosis. The advantages in old men include avoidance of penile cancer and urinary infections, which are prevalent in the elderly, as well as easier genital hygiene in the incapacitated.
The newborn period is the ideal time for circumcision. Not only does early circumcision lead to a lifetime of health advantages, but it is the easiest and safest time to perform the procedure. After the trauma of birth, a newborn is programmed to deal with distress. Stress hormones, such as hydrocortisone and adrenaline, are extremely high, as is the pain-relieving compound endorphin. The male hormone, testosterone, is often in the adult range. All these hormone levels fall within the first few weeks of life. The newborn foreskin is thin, making the procedure quick and safe and virtually painless when using local anesthesia. Healing is rapid, and complications, usually minor, are less than 0.5 percent.
At older ages the procedure is more difficult, with a longer recovery time and a tenfold higher complication rate. The need for general anesthesia makes the procedure riskier. Almost all circumcision deaths have been due to complications from general anesthesia.
As noted, uncircumcised males, compared with those who are circumcised, are prone to many health dangers from birth through old age, and also may have social problems in the United States, where circumcision is the standard. In addition, the easier genital hygiene leads to improved and more varied sexual relations. Above all, Jewish men with foreskins are abandoning an ancient family tradition and culture.
My advice for anti-circumcision Jewish parents is, “enough already.”
Dr. Edgar J. Schoen is the former chief of pediatrics at Kaiser Permanente in Oakland and clinical professor of pediatrics, emeritus, at UCSF. He lives in Richmond.
