Tuesday, December 4, 2012

Bris Prep: What Happens During a Bris That You Might Not See

By REBECCA WALD

I have a friend, an educated man, who insists that circumcision during a bris involves nothing more than pulling the foreskin forward over the glans and snipping off the “excess” skin with a single cut. He is a grandfather who served as a sandak and held his grandsons during their ritual circumcision procedures. How could it possibly involve anything more, since he watched it take place before his own eyes?
I explained to my friend that the foreskin must be separated from the glans first because in infants the foreskin tightly adheres to the glans, like a fingernail to the nail bed. I told him there is a frenulum that is severed before the foreskin is fully pulled over the glans and excised.

A frenulum is an elastic band of tissue that secures mobile organs in the body. The intact penis has a frenulum connecting the foreskin at the base of the glans. The human mouth has three frenula: one under the tongue and another two connecting the upper lip and lower lips to the gums. In girls with intact sex organs, there are frenula that connect the clitoris to the prepuce (the female equivalent of the foreskin).  

I told my friend that mohels typically insert a metal instrument (probe) between the glans and the foreskin and circumnavigate the glans, breaking the frenulum and any adhesions. He still said this was impossible. After all, this is not what he saw when he was holding his grandsons. Our conversation left me confused. I believed my friend to be accurately reporting what he saw during his grandsons’ brisim, but I also felt certain of the anatomy and standard procedure.

Fast forward to a few weeks ago. Someone who follows Beyond the Bris sent me an email. She had reluctantly attended her first bris a few days before. She said the baby was brought out asleep and slept through the whole procedure. Everyone remarked what an easy bris it was for the infant and how well the mohel did his job. At some point during the meal that followed, our reader learned the baby had been “prepped” beforehand. Could this prep have somehow explained the child sleeping through his bris?

Both situations I have described, the apparent single-snip bris and the situation of a baby seeming to peacefully sleep through his bris might seem unrelated. In fact, I believe they could both be the consequence of bris prep: what happens during a bris behind closed doors (sometimes) before the child is presented for the public ceremony.


Circumcision Surgery Techniques

There are several different methods for circumcising an infant. This is true for hospital circumcisions as well as ritual brisim. Bris techniques include the traditional technique, the Gomco clamp technique, and the Mogen clamp technique. With all of these, the mohel typically uses a probe or small hemostat to dissect the adhesions, including the frenulum preputii penis, before the foreskin is removed.

Sometimes the mohel separates the foreskin from the glans in in the presence of those assembled, seconds before the foreskin is sliced off. This is the most traditional technique and possibly the one that causes the least pain to the infant when done by a skilled and experienced mohel. Sometimes the destruction of the frenulum and the removal of adhesions takes place in a separate room before the baby is presented, as part of the bris preparation. In this case the procedure is prolonged and one can assume the baby’s pain is also prolonged. 


It should be noted that bris prep can also include application of anesthetic cream or, if the mohel is also a doctor, the administration of a dorsal penile nerve block. The latter is an injection (in itself painful) that does not fully anesthetize the penis but can provide some relief. Many doctors find the dorsal penile nerve block problematic and/or unnecessary and do not use it.   

According to Fred R. Kogen, M.D., an experienced California mohel: “The ‘prep’ usually entails strapping the baby on a restraining board, cutting and clamping using the Gomco clamp, then bringing the baby out for the ceremony, strapped and clamped, covered by a blanket so that the device is not visible to the guests. A final cut, necessary with the use of the Gomco Clamp, occurs later during the ceremony.” On his web site Dr. Kogen goes on to say that he doesn’t use the Gomco clamp (he uses the Mogen clamp) and that he does not prep the baby in any way other than applying a numbing cream before the procedure.


It should be pointed out that babies who have been prepped in private need not be presented on a circumcision board. They might be strapped to a circumstraint during the bris prep and then removed, placed on a pillow, and brought into public view once they have stopped crying. 

Nor is it only mohels that use the Gomco Clamp who may conduct a private bris prep that includes the breaking of adhesions. According to his online guide guide for parents, certified mohel David A. Bolnick says that before the bris, in a private room, he will examine the child, cleanse the genital area, and "release any adhesions between the glans and the foreskin."

Not Just a Little Snip

The myth that circumcision is just a little snip is perpetuated by the observation of bris attendees that the baby slept right through it or, in my friend’s case, the observation that ritual circumcision only involves a single snip. Parents and others should be aware that before a bris babies are sometimes painfully “prepped” outside of public view.

They should also know that the quietly
sleeping baby they see may actually be in shock. Darcia Narvaez, Ph.D., writing for Psychology Today, says babies sleeping through the procedure isn’t possible without total anesthesia, which isn’t given. “Babies go into shock, which though it looks like a quiet state, is actually the body’s reaction to profound pain and distress.”   

Whether rendered unconscious from shock, or having finally retreated to sleep as a way of coping with severe pain, these babies who are temporarily free from self awareness are the lucky ones. A 2010 study estimated that 117 neo-natal deaths occur each year in the United States as the result of circumcision. This is on par with the number of infants that die each year from SIDS. Other children may sustain events during or shortly after their circumcisions that can include heart attack and stroke. In such cases it is often ruled that the timing of the death was mere coincidence due to an underlying defect in the child.


Bris prep can make Jewish circumcision appear easier on the infant than it is, which can in turn make parents and invited guests feel more comfortable with what is taking place. It may also make a mohel look like an expert at performing a virtually painless procedure when this is not the case. (A mohels skill is typically judged by guest perception of the babys experience, as well as the cosmetic outcome.) However, even when some of the pain of circumcision is removed from public view, it is nevertheless a full reality for the infant. 

I hope that parents planning a bris will consider brit shalom, an alternative religious ceremony that does not include circumcision. Apart from the pain and possible complications of brit milah, there are other excellent reasons not to alter the natural anatomy. Of course, some parents feel a strong obligation to circumcise and will do so no matter what. At the very least, they should be fully informed of the different circumcision protocols and consider the degree of trauma each may involve.

12 comments:

  1. thank you for this personal look at infant circumcision within the Bris.....I hope more parents will look into the peaceful ceremony of Brit Shalom. It sounds just wonderful!!!!

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  2. Thank you for this, Rebecca. In Victor Schonfeld's film, "It's a Boy," I believe he shows the mohel doing the most painful and prolonged part of the circumcision out of the parents' view - but I had the impression that it followed the formal ceremony. Either way, circumcision's promotion as only briefly painful, benign, or (worst of all) even "spiritual" is an elaborate hoax.

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  3. Rebecca, this piece left me gasping for air. What deception! I also recall this secretive torture from "It's a Boy", but thought maybe it was an anomolous practice not widely done elsewhere. The idea that infants are in shock also needs to be more widely appreciated. Thank you for bringing these things to light.

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  4. Thank you Rebecca for focussing on the facts that may make a bris appear to be less invasive than it is.

    Like Georganne I was reminded of Victor Schonfeld's film, "It's a Boy" though the part that I think Georganne is referring to came after the cutting when the men rushed the baby into another room to try and stop the bleeding. I got the impression that the mohel was trying to apply enough pressure to stop the bleeding, perhaps applying his mouth out of the range of the camera?

    Circumcisions that have been filmed, both ceremonially and in medical settings as instructional videos for parents, often appear as a "slight of hand". Hoax is a good word for it.

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  5. Thanks for an illuminating insight. If it has not already been, this information should be made known to the German Bundestag before they vote on legislation to overturn the recent Cologne court judgement.

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    1. Most representatives won't care for it. Most of them don't care about what is done to an infant during circumcision at all. They don't care about the anatomical damage done, they don't care about the risk of trauma, they don't care about the boy's right to decide about his own body later in his life.

      The only thing that matters to most of them is "that Jews must be allowed to perform all of their rituals". Everything else just doesn't matter to the German government, and to most of the representatives.

      It is a real pity that this court judgment occurred in Germany—Of all places, the *one* country that simply *cannot* outlaw forced/infant circumcision due to historical reasons.

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  6. Excellent reporting, Rebecca! Thank you.

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  7. I too have had the impression that, in the case of ritual circumcision, "separation of the synnechia" took place after the circumcision cut, and that a mohel's elongated fingernail was often used to do this. One reason some of us have such varying ideas of what "usually" happens could be due to the recent phenomenon of Jewish physicians becoming members of the Mohelim. That imports elements of US medical practice into cuts done by such a doctor-mohel. Medical cuts always involve the blunt probe being used before the circumcision cut, and that could easily have found its way into ritual procedures. And of course, despite the implied tension of competition, there is nothing to prevent mohelim and doctors from exchanging ideas at any time.

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  8. I'm disguste that this is called "excellent" reporting. I've attended many Brit Milah ceremonies AND as an RN working in a nursery I also assisted with infant medical circumcisions.
    In NO Instance, including with my own son, was there any more than a BRIEF period of discomfort and in none of the instances was there any "prep" that would have made the child unable to respond to pain if he was experiencing pain. Some screamed out, some whimpered, others just gave a slight jerk..and all had the exact same procedures. My own son, cried out much more for his shots than for his circumcision and I was with him every single moment. He was not strapped on a board either, but held. And no one sucked on his penis.
    I'm ashamed at some of the people here that I'm having a hard time even believing are actually Jews to make such absurd lies. This reads like yellow journalism with fallacious allegation to try to make people think that something is done to their babies when their babies are out of sight to drug them

    when you don't have the evidence you fabricate it.

    oh it's slight of hand because you don't see them do the horrible things you accuse
    oh they do it quickly out of sight of others

    Bullshit.mortality risk is estimated at 1 in every 500,000 neonatal procedures conducted within the United States according the American academy of Family Physicians
    there is a greater risk of death from certain vaccines
    In the five year period from 2006 through 2010, 17,595 people in the U.S. reported adverse reactions to pneumococcal and Hib vaccines; 464 of these people died after receiving their shots.

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    1. Having read the above from an RN I just want to weep.I would have thought as a nurse this person would have known that the penis is an internal organ due to its foreskin covering. Without it, the head of the penis becomes dry and keratinised with a loss of sensitivity. The fact that this person allowed their own Son to be mutilated in this way goes beyond all belief. Regardless of what the mortality rate is, this is still unacceptable.

      The writer states, and I quote "In NO Instance, including with my own son, was there any more than a BRIEF period of discomfort".......so presumably this makes it ok....? I would suggest if the anonymous writer is a woman, who therefore doesn't know what it is like to live with a circumcision, then she should stand by her conviction and get one too. If however the writer is a man, then this is even more worrying that a man would allow his Son to have this unecessary mutilation.

      One can only hope that in the years to come, victims of circumcision will have the right to sue for sexual genital mutilation damages in court. Only then will the cutting stop.

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  9. I'm pretty okay with the circumcision thing. Done as a baby - I'm not Jewish - I gather with a Gomco and I've no ill effects but all the benefits. I attended with my kiddos when they were done and not a sound with good local anaesthetic. The suggestion that there are loads of unhappy maimed guys out there is trash. I've two kids and at 37 excellent sex life for near 20y. My two cents.

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  10. Thank you. People deserve to know the truth about how risky, painful, and invasive infant circumcision is. They need to learn how complex the human anatomy is. No two circumcisions are alike as there is no dotted line on a penis telling a circumciser where to cut. I was neonatally circumcised at birth by a U.S. "doctor". I endured traumatic corrective meatotomy surgery at age 5 for meatal stenosis, and other complications. I have an intact son, so I can see just how much tissue was removed from my body without my consent. As an adult, I feel violated and mutilated. I have seen several circumcision videos and I am horrified this was done to me when a helpless, healthy infant.

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