MALE CIRCUMCISION a Jewish perspective

Dr Sifman discusses why male circumcision is part of the Jewish religion and outlines the procedures involved in the surgery and function of the Mohel

For Jews male circumcision is the fulfilment of a Divine command (Gen.17.11 et seq). It is designated 13 times as a Brith (covenant), between the almighty and the jewish people. Unless there is a medical contraindication it should take place on the baby's eighth day even on the Sabbath or a holy day.

Key points
* Jews have practiced circumcision as a religious commandment for over three thousand years
* The technique is different from other methods and should be judged on its own
* Doctors are urged to acquaint themselves with the procedure and with the immediate post circumcision appearance and the natural healing process

Seventy years of atheist communism left scores of 1000's of uncircumcised jews in the former Soviet Union. Since glasnot huge numbers of jews of all ages from infancy to over 70 years have come forward to affirm their commitment to their rediscovered legacy and duty.

The operation is performed by a Mohel. He is required to be an observant orthodox jew. He has to study the religious laws and surgical skills required for the operation. In the United Kingdom the training and examination of students is under the Initiation Society of Great Britain (founded in 1745) and the London Beth Din (Jewish Ecclesiastical Court). A mohel's duties demand the highest standards of ethics, religious practice and surgical skills including strict hygiene.

One or two days prior to the ceremony the qualified mohel visits the baby to ascertain that he is fit for circumcision. He will base his decision on his observation as well as enquiry about possible medical contraindication. A penile abnormality such as hypospadias requires an urologist's opinion. The religious ceremonial and prayers are an essential element of the ceremony but will not be detailed here except to say that this is when the boy receives his name.

In the presence of relatives and friends the baby is placed by his father on a pillow on the lap of the Sandek in a supine position. The Sandek is usually a grandfather, a rabbi or other respected personage. The Sandek is shown how to hold him with thighs abducted and his feet and knees held firmly. This is where the baby protests and why I encourage the mother to be in the room so that she can realize that the greater part of the crying is not due to the operation itself. The baby is given sugar water to drink and suck for a calming effect (1).

The mohel prepares the skin with a suitable solution. He assesses the amount of foreskin to be removed in order that the entire glans and corona will be completed exposed. He may decide to use a probe with which to separate the underlying membrane from the glans. He steadies the penis between index and middle finger and pulls forward the required amount of foreskin with the tips of the fingers of the other hand. The proximal section of the designated skin is then intoduced into the slit of a flat metal shield which is applied in order to protect the glans and shaft lying below the shield.

The skin is held taut and using a special very sharp knife or scalpel the skin is cut flush with the shield with one sweep of the blade. Usually part of the underlying membrane remains round the glans. It is very gently grasped between the two thumb nails and retracted in order to permanently expose the whole glans and corona. All this takes less than a minute. A firm dressing is now applied to obtain haemostasis. There is no suturing. Care is taken not to make the dressing tight enough to cause urinary retention. In our experience this is a very rare complication indeed. It is worth mentioning that many fathers and others have remarked that the baby's cry does not change at the moment of incision. The baby is then returned to his mother to be fed, hugged and loved. Within half an hour the mohel will check the baby in the presence of the parents/carers. He will particularly check that there is no bleeding and that the dressing is on satsfactorily. He will give clear instructions regarding the post-operative care and leave printed instructions with contact numbers for further guidance and to reinforce what he has already said.

Special attention must be paid that there is no bleeding, undue swelling of the glans and he must pass urine within four hours. I always emphasise that he must also be looked at during the night. The next day the mohel will remove the baby's dressing, once more checking that all is well and leave further instructions. The penis will look red and raw. Healing takes place by epithelialisation and is complete within seven to twelve days. A creamy coloured oozing from the raw area is not pus. Quite often there is a swelling which may take a few weeks to resolve. Complications are fortunately rare, bleeding being the most common. Frequently what parents describe as bleeding turns out to be a normal slifght ooze. The mohel must always be available when concern is expressed. When parents apologise that they have called me for nothing I sincerely assure then that I prefer to be called for nothing than for a serious problem!

After any circumcision complications can occur. The most common are bleeding - very rarely serious - infection and bad surgery. Meatal stenosis is a later complication against which we advise parents to use a little Vasaline over the meatus as long as the baby is in nappies to prevent ammoniacal irritation and inflammation. All of the above are rare in our experience.

Jewish religious circumcision should be recognised as being standardised and very different from the Plastibell or hospital surgical methods. Also bear in mind that there is no general anaesthesia with its own dangers. A plea must be made for GPs and hospital doctors to acquaint themselves with the appearance of a recently circumcised child before rushing to make a diagnosis of infection or mutilation! Sometimes the unnecessary surgical intervention is what causes the 'mutilation'. Please when worried parents bring you their baby, or you yourself happen to see what you consider to be a bad result, contact the mohel and let him see the child too before drastic action is taken. He may be able to reassure you. The competence and good results of moheilm is confirmed by the number of non-jewish parents who use their services. The relatively very low complications rate has been confirmed even by opponents of circumcision in general. Despite this it has to be said that, locally at least, we see very few problems following jewish circumcision done within 8 days of birth (2). If the surgeon really wants to know how skillfully the operation can be done he should solicit the privilege of being present at one of the ceremonies. He will witness a technique that bears comparison with that of any master surgeon (3).

Morris Sifman is Medical Officer of the Initiation Society

1 N.Hauari et al. Br Med J Vol 310: 1498
2 L.Rangecroft Univ. Of Newcastle, Department of Child Health Newsletter. Nov.1995
3. J.P.Blandy, J of Hosp.Med February 1968: 552

Other articles on male circumcision on Family Medicine's website

Male circumcision: a paediatric surgeon's perspective

Male circumcision: the case against

Male circumcision: a Muslim's perspective