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.
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.
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.