Brian McBeth and Circumcision

“As for you, you shall keep my covenant, you and your offspring after you throughout their generations. This is my covenant, which you shall keep, between me and you and your offspring after you: Every male among you shall be circumcised…He who is eight days old among you shall be circumcised…So shall my covenant be in your flesh an everlasting covenant.” – Genesis (Bereshit 17:9)

As a new parent, we are faced with a multitude of decisions regarding the care of our little ones. As a new Jewish parent, we approach parenthood with the benefit of our tradition and teaching. The wisdom of Jewish learning through the ages provides a prism through which to view our parenthood, and we look forward to sharing with our new little ones the beauty of our tradition, Jewish holidays and family life. Many of us appreciate the modern perspective and want our children to benefit from current science and medical knowledge. We  take advantage of different resources to guide our decisions about the healthiest foods, approaches to childcare, and health care for our children.

Parents of baby boys also face the decision whether to have a circumcision for their newborn son, and Jewish parents additionally consider whether to follow the mitzvah (tradition, commandment) of Brit Milah. These are two separate but related considerations. As a physician and a mohel, when I am approached by Jewish parents, I try to tease apart the two aspects of these conversations to address questions regarding the medical aspects of circumcision as well as the spiritual and religious components of Brit Milah.

Circumcision is a widely practiced medical procedure that is performed by physicians and other practitioners in different settings all over the world. It can safely be performed in a hospital, clinic or home, and has a very low rate of complications. There are different techniques and instruments used, the details of which are beyond the scope of this writing, but the most frequently reported complications of the procedure are minor bleeding or infection (estimated at approximately 1% of all circumcisions nationally). Rates of circumcision vary widely from country to country, and even regionally in the United States, and depends largely on the ethnic background of the parents, familiarity with the procedure, and regional medical practice.

There are a number of well documented medical benefits from infant circumcision. Over the last forty years, medical research has demonstrated a lifetime of benefit, starting from infancy and extending through adulthood. Circumcised boys show a significantly lower rate of infant urinary tract infections (UTIs) and lower rates of hospitalization and complications from these infections which can be significant in the first few years of life. Typically, UTIs are easily treated with antibiotics, but occasionally will be complicated by pyelonephritis (kidney infections), sepsis, renal scarring and renal insufficiency/failure. These complications are not common, but occur more often in uncircumcised boys. Other more minor infections in infancy and early childhood include balanitis and balanoposthitis which typically occur only in uncircumcised boys. These conditions stem from bacterial and fungal causes and are often related to the challenges of cleaning under an adherent foreskin at a young age.

Circumcision is well documented to reduce rates of certain cancers – penile cancer is almost nonexistent in circumcised men though it is also rare in uncircumcised men. The more significant protective effect is noted in female partners of circumcised men, who have significantly lower rates of cervical cancer. It is felt that this is related to lower transmission rates of human papillomavirus virus (HPV), now known to be a closely tied pathogen to cervical cancer development. The presence of foreskin – for a number of physiological reasons – allows greater persistence of a number of sexually transmitted pathogens, increasing transmission. Higher transmission rates of HPV, syphilis, herpes virus (HSV), and possibly gonorrhea are noted in uncircumcised men. However, most importantly, there are now extensive data that show that circumcision reduces human immunodeficiency virus (HIV) transmission by approximately 60%. Multiple large research studies in different African countries have documented circumcision to be an efficacious public health intervention to reduce significantly transmission of HIV, and this is why the World Health Organization (WHO) advocates for its wide use to reduce disease transmission.

Lastly, there are foreskin complications that occur uncommonly but can be physically and emotionally traumatic for boys and men. As an emergency physician, I have treated boys and men with traumatic foreskin entrapment in zippers, which is a very painful and distressing condition, though typically does not lead to permanent morbidity. Paraphimosis is another condition whether the foreskin becomes right and constricting, trapping the glans and shaft. This is an emergent medical condition that requires a surgical intervention to prevent ischemia (cutoff of blood flow) and necrosis (tissue death) of the end of the penis. These are not common conditions, but I have treated men and boys with all of these foreskin complications, and when parents decide to circumcision their son, they know with confidence that he will never deal with any of these preventable issues. For these medical reasons and based on decades of research data, the American Academy of Pediatrics updated its position statement in August 2012 to acknowledge that “the health benefits of newborn male circumcision outweigh the risks”, but allow that “the final decision should still be left to parents to make in the context of their religious, ethical and cultural beliefs”.

Which brings us to Jewish parents’ consideration of whether to do a Brit Milah or a hospital circumcision. Both will result in the same physical endpoint, and the same medical benefits, as outlined above. A Brit Milah performed by a certified, experienced mohel is as safe as a hospital circumcision, whether it is performed by a rabbi or physician mohel because mohelim do a greater volume of circumcisions since this represents a large part of their work (as opposed to a hospital pediatrician for whom it’s a small component of his/her practice). There are no data to suggest any higher rate of infection, bleeding or other complications when the procedure is done in a home or synagogue setting vs. hospital. Effective anesthesia can be used in a home or private setting to make sure your little one is as comfortable as possible during the procedure. This is a point that you should discuss with your mohel or physician if it will be done in the hospital. Generally the discomfort a baby boy feels is minimal and temporary. The baby may start crying before the procedure when the diaper comes off because of the discomfort of being exposed, and the crying is usually over by the time the diaper is back in place.

The real consideration is whether as parents, you would like to welcome your son on the eighth day into the Covenant of Avraham. This mitzvah dates back thousands of years and represents a direct connection to our ancestors, a connection to Jewish history. There have been periods of tremendous oppression and suffering, with prohibition of Brit Milah, among other aspects of Jewish religious practice. During the Holocaust, for example, Jewish parents went to extraordinary lengths and literally risked their lives to ensure that their sons had Britot. They were ensuring that their sons had a permanent mark that would forever identify them as Jews, for which they realized they would likely suffer as well.

But it is clearly more than just a connection to history and the people of Israel. A Brit Milah is a physical representation of a spiritual covenant. Brit (or bris) means “Covenant”, and the physical act of removal of foreskin represents a willingness and commitment to lead a life of Torah, to embrace spirituality above materialism and to acknowledge a connection both to G-d and to the Jewish people. The three blessings that we give an eight day baby at the time of his Brit are “Torah, Chuppah and Ma’asim Tovim”. Chuppah is the wedding canopy, and represents the connection to the longevity and endurance of the Jewish people, as well as the joy and love and celebration of the family – at the time of a wedding or welcoming a new baby. Ma’asim tovim are “good deeds”, and here we see the emphasis on actions outside of self-interest: giving to the family, giving to the community – we wish for the newborn baby’s life to shine to the whole world and be a blessing and source of pride from that day forward.

At a Brit Milah, we are celebrating the arrival of a beautiful, special new life, and we are also anticipating with excitement and joy all the days of his life to come. It is an overwhelmingly emotional moment, full of simcha for the entire family. Whether a family decides to keep it small and intimate in the home or arranges for a larger ceremony in a community center or synagogue, it is a moment in time that will never be forgotten. The joy will resonate and will be felt for years and years to come.

As a Jewish parent, the decision is whether you will also embrace the tradition of Brit Milah that we’ve enjoyed throughout our long history, and I would suggest speaking to a rabbi or mohel who would be able to answer any questions or provide additional details on this beautiful mitzvah.

A warm mazel tov to you in this exciting time.

Brian D. McBeth, MD
Certified Mohel
Board Certified Physician