BS”D
Brit Milah
Medical & Jewish Perspectives
Dr. Padra Gad Nourparvar
Board Certified Family Medicine
Trained Mohel
British Milah, or circumcision, is performed over a Jewish male eight days after they are born.
The procedure is performed with a mohel – a person who may have mastered the set of Jewish laws regarding circumcision and been given extensive practical training.
At any Brit Milah, the mohel removes the baby’s foreskin and draws blood from the reproductive organ, after which the baby is given a Jewish title.
Medical Data
It is a principle of Jewish life that our decision to perform mitzvot is not in line with the “practical benefit. ” At the same time, the mitzvot frequently have positive observable effects in your everyday life.
CIRCUMCISION OVERVIEW — Circumcision in the male is removing the foreskin of the penis. The practice of circumcision dates to ancient times. In early Egypt, prior to biblical instances, circumcision was performed to increase male hygiene. Later, routine circumcision of male infants was perhaps the Abrahamic covenants, giving rise to religious circumcisions that continue to this day in the Jewish and Muslim faiths.
Circumcision rates in the united states vary according to geographic place, socioeconomic status, religious affiliation, insurance policy, hospital type, and racial and ethnic group. The incidence in 2008 was about 55 to 57 percent according to hospital coding data, but this really is probably an underestimate of the actual incidence of circumcised males, that is likely closer to 80 per cent, due to miscoding and due to the fact some circumcisions are performed immediately after hospital discharge or later within life for religious, medical, as well as personal reasons [1]. Based in coding data, circumcision rates are highest from the Midwestern states (74 percent), and then the Northeastern states (67 percent) and Southern states (61 percent), and therefore are lowest in the Western states (30 percent).
There are no studies that give reliable data about how many males who are circumcised immediately after birth for elective or surgery indications. An Australian survey found in which approximately 18 percent of males who had been not circumcised as infants reported that they can were circumcised subsequently [2, 3].
NORMAL PENILE DEVELOPMENT AND HYGIENE — From birth, the foreskin, sometimes referred to as the prepuce, is attached towards the end of the penis, a place known as the glans. With time, the foreskin separates from the particular glans, forming a space involving the skin and the glans. Separation is completed in 50 per cent of boys by age 3 years, 95 percent by age 5 a long time, and 99 percent by age of puberty. In a small number regarding uncircumcised males, partial adhesions bringing about accumulation of smegma may remain throughout childhood, and even into adolescence.
BENEFITS OF CIRCUMCISION — There are various medical benefits to male circumcision. However, factors other than circumcision (eg, volume of sexual partners, use of condoms, people papillomavirus (HPV) immunization, penile hygiene) are probably much more important risk components for penile medical disorders than not being circumcised.
Reduction within urinary tract infection — Urinary region infections (UTIs) are uncommon within males; the greatest risk is male infants less than 12 months old. Studies consistently report that uncircumcised male infants are at higher risk of UTI weighed against circumcised male infants. UTIs in infants can lead to kidney infection requiring hospitalization and, rarely, severe infection and demise. If the urinary tract can be normal, long-term sequelae from UTI tend to be unlikely.
Cancer — Cancer of the penis is rare, but uncircumcised men are at increased risk for developing the ailment. Good hygiene and HPV immunization may possibly reduce or negate this chance.
Cervical cancer is more common in women whose male sexual partners usually are not circumcised. HPV immunization may lessen or negate this risk.
Penile problems — Uncircumcised males are at increased risk for inflammation of the glans; this problem rarely arises in circumcised men, as effectively. Uncircumcised boys who practice good penile hygiene are less likely to experience penile inflammation.
Infection — Studies suggest that circumcision helps decrease the chance of acquisition of human immunodeficiency disease (HIV), HPV, and probably herpes simplex virus type 2 (HSV-2), and also some evidence that it may protect against trichomonas and chancroid infection. Circumcision does not protect against infection from gonorrhea, chlamydia trachomatis, as well as syphilis. It is important to see, however, that many circumcised adult males acquire these diseases. Circumcision may lower the chance of acquiring the infection, but no eliminate it.
Hygiene — Inside the uncircumcised male, the space involving the foreskin and the glans has to be cleaned regularly. Proponents of circumcision argue that it’s difficult for uncircumcised boys and men to keep up proper hygiene.
ADVERSE EFFECTS CONNECTED WITH CIRCUMCISION
Procedural risks — An correct complication rate is difficult to ascertain because the largest studies use coding diagnoses and inconsistent definitions. In addition, data have generally not been stratified to account for timing of the procedure, process, provider type, setting, length regarding follow-up, timing of complications, and severity of complications.
In two studies that included a complete of over 200, 000 circumcisions performed in U . s . hospitals, the rate of complications during and from the first month after the process was approximately 0. 2 per cent [4, 5].
A systematic review identified of sixteen prospective studies of complications next neonatal and infant circumcision by various providers from 12 countries and primarily while using the Plastibell [6]. The median volume of any adverse event was 1. 5 percent (range 0 to 16 percent) plus the median frequency of any considerable adverse event was 0 per cent (range 0 to 2 percent); seven studies reported no serious undesirable events, but three studies reported that one to two percent of boys had a significant complication. Complication rates were slightly reduced 10 retrospective studies.
Complications/sequelae regarding circumcision include:
Inadequate skin eradication, which may result in a great unsatisfactory cosmetic appearance and revision of the procedure. This is a common complaint, although the frequency is poorly documented from the literature.
Bleeding, which is normally mild and controlled with nearby pressure, but surgical intervention and transfusion can be required on rare occasions.
Disease, which is usually mild and treated by local antibiotics, but sepsis may appear and death has been reported.
Urethral complications, including urethrocutaneous fistula and meatal stenosis. Meatal stenosis may appear when urine from a moist diaper irritates the exposed ventral urethral meatus of the circumcised penis.
Glans injury, such as penile amputation
Removal of excessive skin, which may result inside a denuded penile shaft
Epidermal add-on cyst
Adhesions, which range from mild to dense (also referred to as skin bridges)
Cicatrix (a circumferential scar that always develops at the incision line and is often associated with a hidden penis)
Complications from anesthesia
Other considerations — The prepuce contains specialized sensory tissue that is certainly removed during circumcision. Some men assume that the end of the penis becomes less sensitive when the foreskin is removed and that sexual sensation can be decreased. However, most circumcised males do not necessarily describe psychological trauma or reduced sexual function or desire due to the procedure.
Parents should know that some health plans do not cover the cost of circumcision. Parents should call their health plan directly to determine if the procedure is protected.
PAIN CONTROL DURING CIRCUMCISION— Studies in newborns show that signs of stress/pain occur in the circumcision procedure. These include crying, increased heart rate, and improved blood pressure.
Parents should discuss what pain control measures are going to be used before their child can be circumcised. The American Academy of Pediatrics (AAP) recommends that every infants undergoing circumcision have adequate pain control during and following procedure [7]. The American College of Obstetricians and Gynecologists (ACOG) supports the conclusions of the AAP and also states that pain control should be provided. Swaddling, oral sugar answers, or acetaminophen may be given as well, but should not be used since the primary method of pain alleviation.
Mohels use significantly faster techniques than as used by general doctors which may need less pain control.
CIRCUMCISION PREPARATION AND PROCEDURE
There are several situations that may cause a circumcision to become delayed. For example, in babies who are born prematurely, circumcision is usually delayed until they you will need to be discharged from the infirmary. Babies who are born using a defect of the penis should be evaluated by a urologist, exactly who may recommend delaying circumcision. If there is a family history of a bleeding disorder or the baby has bleeding problems, circumcision is delayed until it is often determined that the baby isn’t at increased risk of bleeding in the procedure.
Technique — The infant is positioned in a restraint or held by family inside a bris. The penis and a place of skin around the base of the penis are thoroughly cleaned.
There are various techniques for performing circumcision; the option of which technique is used depends on the physician’s preference and practical knowledge. The three major methods of circumcision include the Gomco clamp, the Plastibell product, and the Mogen clamp. The procedure takes about 15 to a half-hour.
Post-procedure care — After the particular circumcision is completed, a gauze dressing is generally applied. Use of a lubricant beneath gauze helps to prevent it from adhering to the glans. The gauze should be taken off and replaced with every diaper change for 24 hours. The circumcision site is cleaned with tepid to warm water and a cotton ball once or twice a day. Normally the infant urinates within 12 hours of the procedure.
After the first 1 day, the gauze is omitted plus the lubricant is applied directly to the penis for 3 to 5 days. This helps keep the spot clean and keeps the wound site from staying with the diaper. At first, the penis look red. In a few days and nights, a soft yellow scab will develop. This is normal and will go away in a few days. During this process, parents should watch out for worsening redness, swelling, bleeding (larger than a quarter-size about the diaper) or drainage that will not go away. Any of these signs should prompt a call towards the infant’s healthcare provider.
Usually the penis needs no further care once it’s healed.
PUBLIC AND PROFESSIONAL OPINIONS ABOUT CIRCUMCISION — Professional societies and lay groups have expressed a wide range of views concerning the advantages and disadvantages of routine circumcision.
Throughout 2012, the American Academy of Pediatrics (AAP) task force on circumcision of the male infant concluded that “the health improvements of newborn male circumcision outweigh the particular risks; furthermore, the benefits of newborn male circumcision justify having access to this procedure for families exactly who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition regarding HIV, transmission of some sexually sent infections, and penile cancer. Male circumcision will not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction” [7]. In comparison to their previous statement, this statement is often a stronger affirmation of the health improvements of circumcision. However, the AAP did not recommend routine circumcision. They stated, “Parents should weigh the health improvements and risks in light with their own religious, cultural, and personal preferences, as the medical benefits alone might not outweigh these other considerations pertaining to individual families” [7].
The procedure can be performed at the hospital before the mother and baby are discharged (if not a bris), or can be performed just as one outpatient procedure with local anesthesia as late as ninety days after birth. After three several weeks, the procedure usually requires common anesthesia. Ideal time is 1-2 weeks old.
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Exactly why Brit Milah?
Brit Milah practically means “covenant of circumcision. ” Abraham, Judaism’s founding father, was the first person in history undertake a Brit Milah. In fact, he circumcised himself.
Abraham vowed which he would teach his descendents to be able to serve God with perfect love. In return, God promised to make sure the survival of Abraham’s progeny – the household of Hebrews that became the country of Israel that have since been referred to as the Jews.
As long as there would be human beings on earth, God assured Abraham, there would be Jews. This covenant or pact concerning God and Abraham was sealed from the act of circumcision.
Today, by simply performing the act circumcision, Jews perpetuate the covenant and make their children part of that eternal promise.
The Much deeper Meaning
The fact that the Brit Milah is conducted on the eighth day after having a boy is born hints to the idea of eternal Jewish continuity.
Inside the Torah, all references to the particular numbers have great significance. By way of example, the number six represent the physical world that has four directions (north, south, east and west) plus along. The six days of development, the six days of the particular work-week, also allude to the particular physical world.
Seven adds a spiritual element towards the physical. The seventh day, Shabbat, adds spirituality to our lives though it is still inside realm of the physical earth. Eight, on the other side, transcends the physical altogether. By way of example, the eight-day miracle of Chanukah can be beyond nature, surpassing the physical constraints of natural laws and standards. Eight represents a increased dimension of reality.
God’s guarantee that Abraham’s children would survive forever like a nation defies the laws regarding nature. History has proven continuously that even the most powerful nations we know are bound eventually to go away into extinction – e. h., the Egyptians, Greeks and Romans. Yet the Jews, a numerically unimportant people, are still here, alive and well.
The Brit Milah, performed about the eighth day, reminds us that Jewish survival isn’t a natural phenomenon, but any supernatural one. Jewish survival defies the particular laws of nature. This explains why the mark of circumcision is made on the reproductive organ – it symbolizes the concept that the Jewish People’s seed can never be destroyed.
In addition, Brit Milah is done specifically on the website that is identified with each of our greatest physical desires, thus empowering us to rise above the demands of the body’s.
Jewish Reasons
The truth can be, there is no “logical” argument for cutting a sheet of flesh off a helpless baby.
Yet circumcision has been practiced on Jewish males for all around 4, 000 years, ever considering that Abraham was so commanded by simply God. Why does the foreskin must be removed?
In Kabbalistic terms, the particular foreskin symbolizes a barrier that prevents growth. For example, when the Torah speaks about approaching God, it calls upon us to “remove the Orlah, the foreskin of the heart” (Deut. 10: 16).
While Abraham circumcised himself at age 99, God added the mail “heh” to his name. “Heh” is section of God’s own name, signifying in which through Bris Milah, the individual adds a dimension of spirituality towards the physical body.
The Objective of the Ritual Circumcision
Translating Brit Milah as simply “circumcision” rather than “covenant circumcision, ” erroneously implies that removing the foreskin is the most significant element of the mitzvah.
In truth, however, the circumcision must be along with the intention to forge any blood pact between God plus the Jewish people.
For this reason an individual who underwent a medical circumcision, without intent to fulfill this commandment, should undergo a subsequent process performed with specific intent to fulfill this mitzvah. This subsequent process is relatively painless, involving only the drawing of blood from the reproductive organ, but done from the name ofBrit Milah.
Personal Commitment
The secret to Jewish continuity lies in the Brit Milah, which beefs up one’spersonal commitment to God. Once this really is achieved, the communal commitment will emerge on its own.
In his covenant of circumcision, Abraham vowed to train his descendants to serve The almighty with perfect devotion. This may be the essence of Brit Milah – it represents the individual’s personal commitment to God. One’s communal identification with Judaism is definitely a positive thing. But the mitzvah of British Milah teaches us that unless gleam personal commitment, it will not necessarily endure.
May we all merit to bring our children into the Covenant of Abraham and see their Jewish identity flourish and grow.
Extending Honors to Family and friends
It is deemed a great honor to be a part of the Bris. Here are the various “tasks” given out as honors to a few of the guests:
1) “Kvatter” – normally a married couple. Preferably, this couple hasn’t yet had children of his or her, as the honor is considered a good omen to have children. The baby’s mother hands the little one over to the female kvatter, who passes the baby to her husband. He then brings the baby into the room where the Bris is to happen.
2) “To Elijah’s Chair: ” The honoree’s task is usually to place the newborn on the particular elevated, ornate “Throne of Elijah, ” pertaining to tradition says that Elijah attends every Bris.
3) “From Elijah’s Couch: ” the honor of taking the baby from the “throne. ”
4) “Sandak: ” This is the highest honor, usually given towards the grandfather, an elder, or a terrific scholar. The honoree holds the newborn across his knees as the Bris is performed, an honor considered add up to offering incense in the Holy Brow.
5) Mohel: The one who performs removing the foreskin should be God-fearing and professionally competent. [A Jewish Bris differs from the “secular circumcision” in that it involves special added steps referred to as Priyah and Metzitzah. A child that is circumcised by a doctor from the hospital often does not obtain a proper Bris. ]
6) Delights: The honoree recites the delights and announces the baby’s title.
7) “Beside the Blessings: ” The honoree holds the baby while the blessings are recited plus the baby is named.
Naming children
A name defines a person’s fact. Choose carefully.
The naming of an Jewish child is a most profound spiritual moment. The Sages say that naming children is a statement of the woman’s character, her specialness, and the woman’s path in life. For from the outset of life we give any name, and at the end regarding life a “good name” is all we take with us. (see Talmud – Brachot 7b; Arizal – Sha’ar HaGilgulim 24b)
Jewish Customs
Naming a Jewish baby isn’t just a statement of what develop he will be, but also where he originates from.
Ashkenazi Jews have the custom of naming a kid after a relative who has perished. This keeps the name and memory alive, and in a metaphysical way forms a bond involving the soul of the baby plus the deceased relative. This is a terrific honor to the deceased, because its soul can achieve an elevation in line with the good deeds of the namesake. The little one, meanwhile, can be inspired by the good qualities of the deceased – and produce a deep connection to the previous. (Noam Elimelech – Bamidbar)
What if you wish to use the name of an relative who passed away, but another living relative has got the same name? In that situation, if the living relative is closely associated with the baby – parent, grandparent, or sibling – then you shouldn’t use the name. Otherwise, it’s okay.
Sephardi Jews also name children after relatives who are still alive. This source is from the Talmud, which records a baby named after Rabbi Natan whilst he was still alive (Shabbat 134a).
Some customarily choose a name in line with the Jewish holiday coinciding with the particular birth. For example, a baby born at Purim-time could be named Esther or Mordechai. A lady born on Shavuot might become named Ruth, and a baby born on Tisha B’Av, the particular Jewish day of mourning, could be named Menachem or Nechamah.
Likewise, names are sometimes chosen from the Torah portion corresponding to the week of the birth. Many names and occasions are mentioned in each Torah piece, offering a spiritual connection involving the baby and that particular biblical physique.
Inner Meaning
In Hebrew, a name isn’t merely a convenient conglomeration regarding letters. Rather the name uncovers its essential characteristic. The Midrash (Genesis Raba 17: 4) tells us that the 1st man, Adam, looked into the essence of the creature and named it appropriately. The donkey, for example, is characterized by carrying heavy, physical burdens. So in Hebrew, the donkey is namedchamor – from the same root as chomer, meaning materialism. (Contrast this with British, where the word “donkey” doesn’t reveal much in regards to the essence of a donkey! )
Identical idea applies to names of people. For example, Leah named the woman’s fourth son Judah (in Hebrew, Yehudah). This originates from the same root as the saying “thanks. ” The letters may also be rearranged to spell out the particular holy Name of God. The significance is that Leah wanted to be able to particularly express her “thanks to be able to God. ” (Genesis 29: 35)
It is important to choose a name that may have a positive effect, since when it is used the man or women is reminded of its this means (Midrash Tanchuma – Ha’Azinu 7). The one who is called Judah is constantly reminded of the amount of gratitude we should have to God!
Esther, the hero of the Purim story, is a name which originates from the word “hidden. ” Esther was considered a very beautiful woman (she was chosen to become queen), but whatever her external appearances, her hidden internal qualities were much more beautiful.
Another example is the favorite name “Ari, ” Hebrew pertaining to lion. In Jewish literature, the lion is often a symbol of a go-getter, someone who sees an opportunity to do a mitzvah, and pounces about it. (see Code of Jewish Legislations O. C. 1)
Of training course, there are bad names, as well. You won’t want to opt for the name “Nimrod, ” since the name means “rebellion. ” Along with in biblical times, the ruler Nimrod threw Abraham in to a fiery
furnace as an work of rebellion against God.
In order to name a male after ladies, you should try to keep as a lot of the letters of the name as possible. For example, Dina could become interchangeable with Dan, or Bracha and Baruch.
More Guidelines
It’s a good idea to give a child a Hebrew name to use in English also – electronic. g. Miriam, David, Sarah, Noah, Rachel. Using this method, your child not only carries a Hebrew name, but he’ll put it to use, too! This can be a vital hedge against assimilation; the Midrash (Bamidbar Raba 20: 21) says that the Jewish people were redeemed from Egypt partly from the merit of having kept the Jewish names. As a baby, I had one uncle exactly who always called me by my personal Jewish name (“Shraga” means candle), a constant reminder to maintain my Jewish identity.
There is hesitancy to make use of the name of a individual that died at a young age, or suffered an unnatural demise. The reluctance stems from the fear that the misfortune may, inside a spiritual manner, be carried over to the new bearer of the particular name.
Contrary to popular perception, it is not forbidden to announce the name of an baby before his Bris. Inside a metaphysical sense, however, the child will not actually “receive” his name until the Bris. This is based on the truth that God changed Abraham’s name jointly with his Bris – at age 99 (Genesis 17: 15). Furthermore, the boy only receives the complete measure of his soul for the Bris, and a person cannot truly be “named” until obtaining that completion. (see Zohar – Lech Lecha 93a, Ta’amei Minhagim 929).
REFERENCES
Aish
Blank S, Brady M, Buerk E, et al. Male circumcision. Pediatrics 2012; 130:e756.
Badger, J. Circumcision. What you think. Australian Forum 1989; 2:10.
Badger, J. The great circumcision report part 2. Australian Forum 1989; 2:4.
Wiswell TE, Geschke DW. Risks from circumcision during the first month of life compared with those for uncircumcised boys. Pediatrics 1989; 83:1011.
Christakis DA, Harvey E, Zerr DM, et al. A trade-off analysis of routine newborn circumcision. Pediatrics 2000; 105:246.
Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: a systematic review. BMC Urol 2010; 10:2.
American Academy of Pediatrics Task Force on Circumcision. Circumcision policy statement. Pediatrics 2012; 130:585.
Taddio A, Stevens B, Craig K, et al. Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision. N Engl J Med 1997; 336:1197.
Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision. Pediatrics 1999; 103:686.
Lander J, Brady-Fryer B, Metcalfe JB, et al. Comparison of ring block, dorsal penile nerve block, and topical anesthesia for neonatal circumcision: a randomized controlled trial. JAMA 1997; 278:2157.
Schoen EJ. Ignoring evidence of circumcision benefits. Pediatrics 2006; 118:385.
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