“For Bris – anesthesia or not? I believe only a licensed medical doctor can use anesthesia… But is this just when injected? I don’t know what’s more painful, injecting the anesthesia (a needle in such a sensitive area) or just snipping without the anesthesia.  How do the doctors do it at the hospital? Do any non-MD mohels use any kind of topical anesthesia? Any feedback is appreciated! Thanks”

This is a good but complicated question that doesn’t have an easy answer.

But to explain it in a short way it depends and most of the time there is no wrong or right way to do it.

I preform circumcision for older babies that most doctors are not able to and I also have training in anesthesia and Pain management. I preform pain injections for different ages and procedures and I’ll familiar with the different options. I always give different options to my patients for pain control in circumcision and you should be able to discuss that with whoever is doing the circumcision for you.

Basically using anesthesia or not depends on few things.

It depends on 1. the instrument used, 2. the skill and speed of the doctor or Mohel doing the circumcision and 3. the age of the baby.  4. How sensitive the parents are! 

1. The mogen shield (not clamp) is the least painful and the fastest method.  So if this option is used you may be able to do it with topical creams and some other non injection options. It doesn’t control bleeding so other ways of blood control are used. However that’s the reason it’s less painful; it doesn’t press the skin together to control the bleeding. I prefer this method and use it also and I have different ways of stopping bleeding quickly and safely. Traditional mohels use this unless they are using the mogen clamp.

The other instruments used are the Mogen Clamp, Gomco and Plastibell. These techniques are more painful so injection would be recommended, especially for the last two which can take 15 times more time and involve more steps, cutting and instrumentation.  They all press the skin to give bloodless results which can cause more pain.

American Pediatric Association recommends that some form of anesthesia be used and they don’t accept topical anesthesia as adequate anesthesia. However, they are referring to the last three tools which are more painful and not the first one mentioned above which is used by traditional Mohels.

2. If the Mohel or Doctor is fast and skilled he can do the procedure very fast using the Mogen technique which would minimize the baby’s pain. A good Mohel can do a circumcision under a minute using the Mogen Shield.

3. Older babies experience more pain so injection would be recommended for them. Circumcision for 1-2 week old babies are least painful and would be the ideal age for many other reasons.

4.  Until recently it was not recognized that babies experience pain. However, recently there has been more talk and attention to this topic.  Babies can cry for different reasons not related to pain like for being wet, hungry or laying on their back at the same time they are getting circumcised.  They also feel the pulling of skin even when they are numb and have no pain. It’s also difficult to say how severe the pain is since they may cry for small amount of pain.

In terms of the pain of the injections, the injections can be done without pain and burning if done with other “tricks” that are used. I use two to three of these “tricks” and the injections are 99% painless.

The bottom line is that if you are using a fast and good Mohel or Doctor, using the Mogen Shield and not the clamp, topical cream and Tylenol along with other things that can be done to make the baby comfortable could be adequate. Although it may not be completely pain free but you can argue that the risk doesn’t outweigh the benefit. The same way anesthesia is not usually used for short and minimally painful procedures like blood draw.

If the other methods are used, especially Gomco or Plastibell, then injection would be recommended and it can be done in a pain free manner if the doctor knows what to do. Not all doctors know or may not care to do that.  Another option is to bring a doctor to do the injection and the Mohel does the circumcision.

For Brit Milah it’s very important to use someone who is qualified as a Mohel otherwise the bris may not be kosher and the baby may have to go through avoidable painful procedures for revision (see these related articles http://www.drmohel.com/aap-need-to-re-do-circumcision-rises-reasons-unclear-los-angeles-doctor-mohel/ and also http://www.drmohel.com/bris-los-angeles-doctor-mohel-circumcision-israeli-iranian-repeats-bris-milah-age-92-los-angeles-doctor-mohel-news/ ) . 

Most of the doctors in Los Angeles would not be accepted by the Rabanut of Israel as a qualified Mohel even if they are accepted or called a Mohel in America.  Please consult a competent Rabbi like Rabbi Zargari or Rabbi Shofet for recommendations.  I would say that is the biggest service the parents could do for their loved ones and the most important step in avoiding unnecessary pain.