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FAQ on the Medical Aspects of a Bris

This FAQ was originally prepared for physicians in the area, to help them stay better educated about ritual circumcision. If you have any questions after reading it, please contact me () for clarification on any matter.

Q: What is the difference between standard medical circumcision and Jewish ritual circumcision (bris)?

A: From the aspect of the end results, there is virtually no difference. A bris is an excision of all the foreskin covering the glans of the penis. Jews perform circumcision because of the Biblical commandment: "And on the eighth day (of the male baby's life], his foreskin shall be circumcised."[1] Because a bris is a religious rite, signifying a covenant between G-d and the Jew, a ceremony is incorporated along with the procedure.

Additionally, the bris must take place on the eighth day of the baby's life (or later, if the baby is deemed too ill to undergo the procedure on the eighth day). A circumcision performed before the eighth day, even if done by a qualified circumcisor, is religiously invalid.

Q: My patient is Jewish. Why recommend a Mohel -- ritual circumcisor -- over a qualified M.D.?

A: Since there are various religious requirements that go along with a bris, only a person well versed in Jewish laws and customs should undertake the job of performing a bris. Although a doctor may be Jewish and experienced in doing circumcisions, this does not automatically make him or her a Mohel. Note that the Code of Jewish Law (Shulchan Aruch) devotes seven entire chapters to the intricate legalities of a bris.[2] A qualified Mohel's training not only covers the medical technique of circumcision; it also includes the religious legal training.

Q: How does the Mohel's technique differ from a doctor's?

A: Jewish law requires that the glans be entirely clear of foreskin, including the laminus mucosa membrane.[3] Sometimes doctors perform more limited procedures, and do not necessarily concern themselves with assuring that the glans is completely foreskin free (all skin and membrane resting below the corona of the penis). This is fine for a circumcision, but invalid for a bris.

Traditionally, the Mohel's technique is accomplished with just a sharp scalpel (known as an lzmel in Hebrew), and a butterfly-shaped shield to protect the glans. Although very different from some of the medical techniques, it has proven to be just as safe, and sometimes even more effective for a clean excision of the foreskin. The whole procedure usually takes a competent Mohel 1 minute or less. Medically performed circumcision, using different surgical techniques, usually takes considerably longer to perform. The quickness of the Mohel's technique is reassuring to parents.

Q. How safe is a bris?

A. The incidence of complications after both ritual and non-ritual circumcision is very low. A review of over 5000 neonatal circumcisions, published in a major American journal, noted a complication rate of well under one percent (1%).[4] According to the London Initiation Society, ritual circumcision can be carried out according to the strictest Jewish law, and yet utilize surgical techniques with satisfactory healing, and minimal or no morbidity or mortality.[5]

Q: How does a Mohel deal with jaundice and other neonatal illnesses that could delay a bris?

A: A Mohel tends to be a bit more conservative in regard to the baby's health. This is because the Mohel needs to take into consideration both the medically recognized reasons for postponing a bris, as well as the symptoms described in the Code of Jewish Law which call for postponing a bris.[6] One such example is jaundice. Most pediatricians are not too concerned with doing a bris on a jaundiced baby, unless the bilirubin count is dangerously high. However, since jaundice is one of the few symptoms that the Talmud mentions by name as a reason to postpone a bris,[7] the Mohel tends to be more conservative. A responsible Mohel will usually meet with the parents and baby before the bris to make a visual inspection of the baby, primarily to detect any jaundice and to note the shape and size of the penis. If the Mohel detects significant jaundice, he will request a bilirubin count to be performed. Generally speaking, once the Mohel knows that the bilirubin count is on its way down, he will be comfortable in going ahead with the bris on schedule. The Code of Jewish Law succinctly states the attitude that a Mohel should take regarding precarious medical conditions: "You can always postpone a bris, but you cannot return a soul once it has departed."[8]

Q: What will a Mohel do about hypospadias, chordee, webbed penis, and other penile abnormalities?

A: Part of a Mohel's extensive training is to detect penile abnormalities. Especially in cases of hypospadias and chordee, the Mohel will not do anything until he consults with the baby's pediatrician and/or urologist. In these cases, it is sometimes necessary to postpone the bris for up to a few years, until the child has reconstructive surgery using portions of the foreskin. In these cases, the Mohel can be present in the O.R. at the time of the surgery, and perform the ritual bris under the direction of the urologist.

Q: What measures does the Mohel take regarding pain management during and after the bris?

A: Because the Mohel's method is much quicker than the typical hospital circumcision, it is also far less painful. Anesthetics can relieve some of the pain of a bris, and some pediatricians therefore feel that the use of anesthetics is indicated. Most Mohels do not use injected anesthetics (known as a dorsal penile nerve block), because even though this provides the highest level of pain relief, the procedure itself is often long and uncomfortable for the child. However, there is an effective topical analgesic cream, called EMLA (available by prescription), which is applied to the surface of the penis about an hour before the bris. It has been proven to be effective in relieving much of the discomfort associated with the circumcision.[9] Other pediatricians recommend that anesthetics not be used on a neonate because of the small risk of allergic reaction. The Mohel will usually give the parents the option to use or not to use anesthetics. Parents should discuss this option with both the Mohel and their pediatrician.

Q: What is the Mohel's relationship with the baby's pediatrician?

A: Most of the time, the Mohel and pediatrician never have to confer. In those rare situations where there is a medical issue that needs clarification, the Mohel will defer to the pediatrician's better judgment.

[1] Leviticus 12:3.

[2] Shulchan Aruch Yoreh De'ah chapters 260-266.

[3] ibid., 264:3.

[4] Gee WF and Ansell JS (1976). Neonatal circumcision: a ten year overview. Pediatrics 58:824.

[5] Snowman J (1961). "The surgery of ritual circumcision." The Initiation Society, London. quoted in the Israeli Journal of Medicine 17:45-48,1981.

[6] Shulchan Aruch Yoreh De'ah, chapter 263.

[7] Babylonian Talmud, Tractate Shabbath p.134A

[8] Shulchan Aruch Yoreh De'ah, 263:1.

[9] Taddio, A., Stevens, B., Craig, K., Pratap, R., Shlomit, B., Shennan, A., Mulligan, P., & Koren, G. (1997). Efficacy and safety of lidocaine-prilocaine cream (EMLA) for pain during circumcision. New England Journal of Medicine, 336(17), 1197-1201. See also: Anna Taddio, Arne Ohlsson, Thomas R. Einarson, Bonnie Stevens, and Gideon Koren. A Systematic Review of Lidocaine-Prilocaine Cream (EMLA) in the Treatment of Acute Pain in Neonates. Pediatrics, Feb 1998; 101:1.

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