Author: daniellecampisi

This is an archaic tradition of some Orthodox mohels that involves oral removal of blood from the head of the baby’s penis as part of the brit milah ritual.  This is potentially dangerous because it can spread infection from the mohel’s mouth to the newborn.  Metzitzah is never practiced by progressive mohels or physician mohels and should be abandoned by all who do circumcisions. As a substitute, Orthodox mohels can now remove this blood by use of a glass pipette and gauze.

A baby will cry vociferously if circumcised without any anesthesia.  In fact, most babies will cry just from undressing them and placing them on the Circumstraint board with their legs restrained by Velcro.  However, if the baby is properly anesthetized and is comforted during the procedure by a pacifier dipped in sweet wine, the baby will usually be extremely comfortable and not cry at all during his circumcision. Although in years past circumcisions were performed by doctors in hospitals without the use of analgesia, both the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists now specify that analgesia/anesthesia should be provided for all babies undergoing circumcision.

The anesthetic technique most commonly used is called a ring block. All digits—a finger, a toe, the penis—have two nerves on their top—dorsal—surface and one nerve on the bottom—ventral—surface. If these nerves are numbed with a small amount of 1% to 2% lidocaine, then roughly 90% of babies will not cry during their circumcision. Unfortunately, anesthetic creams such as EMLA (Eutectic Mixture of Local Anesthetics) are not effective in preventing the pain of circumcision. If applied to the base of the penis roughly an hour before the lidocaine is injected, EMLA might make the administration of lidocaine for the ring block less uncomfortable for the baby.  But the cream is relatively expensive and the FDA does not approve its use in babies less than 30 days of age.

Babies are also extremely comforted during their circumcision by the sweet wine traditionally given to them on a pacifier or on a wine-soaked piece of gauze. Pediatricians who have studied this use of wine say that it is not the alcohol that calms the baby but rather the “sugar high” that the baby gets. It is therefore problematic when a couple, instead of providing the mohel with a traditional sweet kosher wine such as Manischewitz for the bris, gets a high quality Israeli dry wine.  The baby will have no interest in this whatsoever. 

Complications from circumcision—whether performed as part of the brit milah ceremony or in a hospital—are extremely rare. When they do occur, they fall into 3 categories:  Infection, bleeding, or the appearance of inadequate skin having been removed.    

1. Infections are an almost unheard-of consequence of circumcision.  Signs of infection are swelling and redness of the head or shaft of the penis, pus, and odor.  If any of these are seen in the days following a circumcision, the baby must be brought to see his pediatrician immediately.  
2. Bleeding.  There are usually a few small spots of blood seen on the baby’s diaper in the first couple of changes following a circumcision.  There should never be a pool of blood and the penis should never be covered in blood.  In either of these cases—or if there continues to be blood on the diaper eight or more hours after the procedure—the mohel or the child’s pediatrician should be notified so that the baby can be evaluated.  
3. Excessive or inadequate skin removed.  While bleeding and infection post circumcision are rare, one not infrequently sees the skin of the shaft of the penis trying to ride up over the head of the penis in the first few days following the procedure.   This does not indicate that the mohel has taken off too little skin. The amount of skin that the mohel removes is largely determined by the anatomy of the penis. Rather, this appearance of excessive residual skin is caused by either redundancy of the skin of the penile shaft or by a fat pad in the baby’s lower abdomen which pushes the skin of the shaft further up the penis than is usually the case.  If the parents gently uncover the head of the penis by pushing the skin of the shaft back towards the baby’s abdomen each time they change the diaper for the first few days following the circumcision, the mobile skin on the shaft  will eventually stick to the underlying penis in the correct position.  Long term appropriate healing will then ensue.

Circumcision is one of the most frequently performed surgical operations in the United States. It is a very safe procedure and it is extremely rare for complications or infection to occur.  

The operation involves removing the fold of skin that surrounds the head of the penis along with the mucous membrane underlining this skin.  This leaves the skin covering the penile shaft intact but exposes the head—the “glans”—of the penis.  

There are 3 main instruments used for performing circumcisions in the U.S.

1. The Mogen clamp—the traditional instrument used at a brit milah ceremony
2. The Gomco clamp—very commonly used in hospitals
3. The Plastibell—This is a plastic bell-shaped cap that covers the head of the penis and is secured with a string

The initial steps of the circumcision procedure are similar regardless of which instrument is selected.

The first step is for the mohel to grasp the already anesthetized skin (see following chapter on “Anesthesia”) surrounding the head of the penis/glans using the tip of a small clamp.  The mohel then separates this skin from its adhesions to the underlying glans. The now loosened foreskin is then pulled up over the head of the penis, clamped at the point where it is to be excised, and cut off above the clamp with a scalpel.  

The clamp is then released, allowing the skin covering the shaft of the penis to return to its normal position.  There is usually scant or no bleeding because the skin just below where the incision is made has had its blood vessels sealed by the pressure of the instrument used. The only after-care needed is an application of an ointment to the part of the diaper that will touch the penis every time the diaper is changed for the five days following the circumcision. This will be soothing for the baby and will keep the diaper from sticking.

The Mogen clamp consists of two strips of silver-plated metal connected at one end by a screw and at the other by a hinge.  There is an indentation on the baby’s side of the clamp to protect the head of the penis.  It is a safe, easy-to-use instrument that allows for a quick and almost bloodless circumcision.

The instrument employed for the actual cutting of the skin is almost always a sterile scalpel blade.  Traditionally mohels used “izmails” or special razor-sharp two-sided knives which were handed down from generation to generation of mohels.  In Biblical times sharpened stones were used to perform ritual circumcision.  Exodus 4:25 relates how Moses’s wife Zipporah uses a stone to circumcise Moses’ son; in Joshua 5:2 God tells Joshua to “make sharp knives out of flint for yourselves and circumcise the children of Israel”. 

Whereas traditionally the sandek held the baby on his lap with the baby’s legs apart while the mohel performed the circumcision, most mohels today—especially physician mohels—are more comfortable having the baby placed on a “Circumstraint”—a specially molded piece of plastic with indentations corresponding to a baby’s body shape. The baby’s legs are restrained with Velcro straps, thus largely immobilizing the baby’s genital area. 

Once secured in the Circumstraint, the mohel cleans off the genital area with an antiseptic solution, and performs the circumcision while saying:

The mohel then dresses the circumcised penis with an ointment-impregnated wrap, puts the baby in a diaper, and hands the baby to his mother.

1. The baby must be healthy enough to be circumcised:

—The baby’s doctor must give the baby medical clearance for the procedure

—The anatomy of baby’s penis must be normal. If, as rarely occurs, the urinary opening—the urethra—emerges at the bottom of the penile shaft instead of at its end—a condition called “hypospadias”—then the foreskin of the penis may be needed for subsequent repair by a pediatric urologist and a circumcision should not be performed.

—The child must not have a bleeding disorder

2. The baby should not be hungry. 

For the baby to be most comfortable during his circumcision he should not be extremely hungry yet should not have too full a stomach.  If the baby is last fed too long a time prior to his circumcision, there is a good chance he will be begin crying from hunger and be already annoyed and uncomfortable before the circumcision begins. On the other hand, if the baby is fed just before the circumcision, there is an increased chance of the baby regurgitating and, besides creating a mess, possibly choking.  It is best, therefore, to feed the baby about one hour before the brit milah ceremony is to begin.

3. If at all possible, the baby’s diaper should be clean at the start of the ceremony.

4. While the mohel will have all the equipment necessary for the performance of the circumcision, it is the parents’ responsibility to have clean diapers and some form of ointment (such as Vaseline, A&D, or Aquaphor) available for post circumcision care.

How much does a mohel charge?

Costs for a mohel’s services vary around the country. Currently in the Boston area mohel fees range from $500 to $700. In New York City that figure is $650-$850. Parents should know the fee their mohel is charging before engaging him or her so as to avoid any misunderstanding or embarrassment on the day of the bris.

When you hire a mohel, you are paying him/her for several things:

1. Their skill and experience in performing a safe circumcision
2. Their knowledge of the Jewish ritual and prayers involved in the brit milah ceremony
3. If the mohel is a physician, the time taken out of their practice to do your bris
4. The travel time back and forth to the site of the bris. 

Most mohels will give you a receipt that can be submitted to your health insurance company.  If he/she does not, ask for one.  Although health care insurers usually will not pay for a bris ceremony, they will almost always reimburse individuals the amount they would have paid a physician for doing a circumcision postpartum in the hospital. 

How do you pay the mohel?

Most mohels like to be paid at the time of the brit milah ceremony but not until the ceremony is over and they are about to leave. The best way to make this payment is to put the agreed-upon fee (in either cash or check) into an envelope and hand it to the mohel as he or she departs. As the mohel is usually coming from his or her car to your house or synagogue, they will generally not have the facilities to accept credit card payments.

If you haven’t chosen a mohel yet, learn more about choosing a mohel here.

As with choosing a doctor or lawyer, choosing a mohel is best done by personal recommendation. If you do not know anybody who could provide such a recommendation, consider calling a local synagogue and asking for the names of mohels in your area with whom they have had good experiences.  Often your obstetrician’s office or the hospital maternity service where you deliver can provide recommendations for you. 

The most important thing to find out when you speak with a potential mohel is whether or not you are comfortable with his or her style. If there are specific features of a bris that you want, make sure that you mention this to your potential mohel. Find out if he/she uses an anesthetic. Find out what sort of instrument they use to perform the circumcision. Inquire if their service is mainly in Hebrew or in English.  Ask what their fee is.  Most mohels will charge within the same dollar range for their area. Learn how much a mohel charges for a bris here. See how flexible they are in terms of scheduling the bris at a time on the eighth day most convenient for you and your family.  You may also wish to ask your potential mohel about his or her level of experience.  References are usually not asked for, but you can do so if you wish. 

It is best to make initial contact with the mohel before the delivery of your child. This is the case even if you do not yet know the sex of your child. The mohel will understand your calling, answer any questions you might have, and thus give you the opportunity ahead of time to see if you feel comfortable with this individual.  

The mohel is an individual who is trained in both the religious aspects of the brit milah ceremony and the medical aspects of performing a circumcision.  Formerly rabbis did not want physicians to become mohels, because it was felt it would detract from the religious nature of the event. However, over the last several decades this attitude has changed and now both the Reform and Conservative movements have special programs to teach Jewish physicians the ritual involved in performance of the brit milah service so that they can serve as mohels.

Being a mohel is a great honor. It allows one to participate in a significant, joyous family event by helping parents fulfill one of the essential mitzvahs of Judaism:  bringing their newborn son into the Covenant between God and the Jewish people.  The mohel is supposed to be not only knowledgeable about Jewish law and skillful in performing a circumcision, but should also be a respected individual, one who is looked up to by the community.  Historically, mohels have always been held in high regard, even by non-Jews.  In fact, Queen Elizabeth II had the Chief Rabbi of Great Britain perform Prince Charles’s circumcision.  

The mohel has several specific tasks:

1. He/she is the service leader at the brit milah ceremony. 
2. He/she is a teacher explaining the brit milah ceremony and other Jewish traditions to parents, other family members, and guests who may not be familiar with Jewish law and ritual. The mohel also may awaken in the family the desire to pursue Jewish tradition more fully.
3. The mohel fulfills the medical role of performing the circumcision safely and as painlessly as possible.  By doing so in the context of the brit milah ceremony, he/she is thus the one who “puts the seal” on the child’s entrance into the Covenant between the child, the Jewish people, and God.

Because of the religious nature of the brit milah ceremony, only a Jew can function as a mohel in a kosher bris. Only in circumstances where it is impossible to find a mohel who can be available on the eighth day—perhaps in remote communities with small Jewish populations—can a non-Jewish physician perform the circumcision while a Jewish man or women recites the ritual prayers.

The brit milah service is remarkably straightforward and simple. It consists of a series of prayers that both explain the Biblical origins of the ceremony and ask God’s blessing on the new baby and his family.

Even before the ceremony begins, however, the mohel will set up all the equipment he or she needs for the circumcision. This consists of the instruments for the circumcision itself, an infant restraint board if one is to be used, gauze, ointment, and alcohol wipes.  Wine is poured into both the kiddush cup and into a little dish containing a pacifier that will be used to comfort the baby during the circumcision procedure.   

At some point prior to the beginning of the ceremony most mohels will go with the parents to a private area and give the baby a local anesthetic, lidocaine, via injection at the base of the penis.  This very brief procedure usually results in the baby having a pain-free circumcision.  Babies who get this “ring block’ anesthesia are usually relaxed and do not cry during the circumcision part of the brit milah ceremony.  The exact same treatment is given to babies who have their circumcisions done in the hospital.   

Just before the ceremony begins the sandek is seated in a chair at the side of the table next to the Chair of Elijah and next to where the mohel will work.  The kvetter and/or kvetterin are waiting just across the room holding the newborn baby the mother has given to them.

The mohel—or if present, a clergy member—calls the guests to order.  The mohel may remind the audience that the ambience of a brit milah ceremony, while joyous, should still be dignified and that guests should act with the same comportment and degree of attentiveness as they do in synagogue. In today’s era of high-technology, guests are asked to turn off their cell phones and all other noisemaking devices. If parents have prepared their own brit milah booklet, it is distributed at this time. Sometimes musical prayers are sung to set the mood for the service.

The service now begins. The mohel motions the kvatter/kvatterin to approach to where the mohel and sandek are positioned.  The mohel then encourages the assembled guests to say in unison and enthusiastically “baruch habah—”blessed is the one arriving!”

The prayer service then begins.  This includes:

— The discussion of the Chair of Elijah and Elijah’s role in the coming of eternal peace

— The passage from Genesis 17: “you shall keep my Covenant….” followed by a resuscitation of the events that followed:  God’s directing Abraham to enter into a special Covenant with Him that will be applicable to all future generations in exchange for having Abraham and all of his household circumcised and agreeing to fulfill the role of being a sacred people unto God. The removal of the foreskin of all Jewish males—circumcision—is described as an everlasting physical sign of this connection between God and the Jewish people.

Depending on how the mohel designs his or her service, at this point there might be:

1. An explanation of the significance of the brit milah laws and ceremony
2. A discussion of the significance of the eighth day for performing a bris
3. Remarks about the medical nature of circumcision or the analgesia used

As with many Jewish occasions, such a teaching—a drosh—is always appropriate at a bris.  

The circumcision is the next part of the ceremony.  The mohel explains that it is actually the father’s obligation to perform his son’s circumcision—but that since most fathers are not surgically trained, the father will have a mohel—his representative—fulfill the mitzvah of removing the foreskin.   Once it is confirmed that the mohel will be acting as a substitute for the father, the father recites the blessing—in English or in Hebrew—acknowledging that he is fulfilling the obligation to have his son circumcised:

I am ready to fulfill the mitzvah of having our son circumcised as the Blessed Creator commanded us in the Torah:  “Throughout your generations every male among you shall be circumcised when he is eight days old.”

The circumcision is now performed.  The mohel places the baby on the infant restraint board or, in some cases, on the lap of the sandek.  The sandek will place in the baby’s mouth the pacifier dipped in wine from the bowl that had previously been placed on the mohel’s worktable.  Both the sucking on the pacifier and the sugar from the wine have a tremendous calming influence on the child.  

Often the mohel will talk or tell a story to the assembled guests while he or she does the circumcision.  Sometimes, if clergy are present, the rabbi or cantor will lead a song while the mohel is working. 

Just prior to the actual cutting off of the foreskin, the mohel says the circumcision blessing:  

Blessed are You, Lord our God, Ruler of the universe, who has sanctified us with  commandments and has given us the commandment concerning circumcision.

The father then says:  

Blessed are You, Lord our God, Ruler of the universe, who has sanctified us with  commandments and has commanded us to make our sons enter the Covenant of Abraham and Sarah.

The mohel concludes this part of the ceremony with a prayer expressing a wish for the baby’s speedy recovery from his circumcision and for the good health of the mother and baby.  The last segment of this blessing looks ahead to the baby’s growth and future life: 

May his parents raise him to the study of Torah, the building of loving relationships, and the practice of good deeds.

The site of the circumcision is dressed by the mohel and the baby is removed from the restraint board.  He is now handed to the mother who at this point is often giddy with relief that the circumcision itself is over. 

Now begins the naming ceremony where, for the first time, the child’s Hebrew name is announced to the community. If clergy is present, they will often do this part of the ceremony.

The ceremony starts with the prayer leader—mohel or clergy— reciting what is basically a prayer of thanksgiving:

May the father rejoice in his offspring, and his mother be glad with the fruit of her womb

The parents then read the Parents’ Prayer:  

We pray for the well-being of our son.  As we have brought him before you this day, so may he always be in Your presence.  Guard him, protect him, love him as deeply as we do.  Grant him a life of blessing filled with length of days, good health, loving relationships, and a legacy of good deeds.

As noted above, there are three wishes for the newborn boy that are prayed for repeatedly in the brit milah service:  

1. That the child become an avid student of Torah (and all knowledge)
2. That the child enter into a worthy marriage/partnership
3. That the child will grow into an individual who will lead a life committed to the practice of good deeds

These are, in fact, the traits most valued in Judaism: study of the laws that promote life and community as expressed in words of the Torah, leading a righteous and charitable life, and participating in the life of the world by marrying, having children, and raising future generations who will also share these cherished values.

At this point in the service the floor is turned over to the parents who can discuss why they chose the names for the baby they did and to thank their guests for coming.  This is the time for family members to talk about the significance of the birth of this child for them, to tell family stories, and to celebrate in whatever way they see fit the marvelous arrival of this new child.    

The specific closing prayers of the brit milah ceremony are up to each mohel and/or clergy member. Often there will be three closing blessings:

—The shehecheyanu, a blessing thanking God for allowing friends and family to gather together for this simcha, this happy celebration.

—The blessing over wine.

—The priestly benediction invoking God’s blessing on this growing family.

More traditional Jews will at this point acknowledge the mohel’s role with a handshake and the Yiddish words “yashur koach”, which means roughly “may you go from strength to strength”.

Now comes that very important and explicitly commanded part of the brit milah ceremony: the serving of the festive meal!  The biblical origin of this is described in Genesis 21:8:

Abraham made a great feast on the day Isaac was weaned. 

This is interpreted to mean “when Isaac was circumcised”.  It is the only meal explicitly described in the Torah that follows the performance of a mitzvah. 

The food served can be anything from bagels and cream cheese served buffet style to a fully catered meal. Often traditional Jewish food is served such as lox and bagels, cold cuts, hot kugel, and fruits and salads.

A chair for Elijah the Prophet is set up at every bris next to where the sandek sits.  According to the text of the brit milah service, this chair is set up in honor of Elijah the Prophet who represents the coming of eternal peace. Traditionally the baby, carried by the kvatter or the kvatterin, is “dipped” into the Chair of Elijah before being handed to the sandek.

Why is this chair set up? 

The rationale for this comes from the Book of Kings where it is seen that Elijah, after preaching to his Jewish neighbors, becomes frustrated at their lack of obedience to God’s laws as stipulated in the Torah. At one point Elijah retreats to a cave and calls out to God (Kings 19:14): 

The Israelites have rejected your Covenant, torn down your altars, and put your prophets to death with the sword. I am the only one left, and now they’re trying to kill me too.  

But God scolds Elijah, telling him to return and serve the people whose prophet he is (Kings 19:15):

Go back the way you came.

The dual customs of setting aside a chair for Elijah the prophet at every bris and of putting out a cup of wine for Elijah at every Passover Seder are supposedly a rebuke to Elijah, showing his eternal spirit that although the people to whom he preached disobeyed God’s laws then, Jews throughout the centuries have in fact continued to follow God’s precepts by celebrating traditions and holidays such as the brit milah ceremony and the Passover Seder. 

The Chair of Elijah is set up to the right of the sandek’s chair according to the Talmudic dictum that” a student walks to the left of his teacher”, Elijah in this case being considered the teacher. Formerly in many European synagogues the congregation had a purpose-built double chair, combining seats for Elijah and for the sandek. Examples of these can often be seen at Jewish museums.

There are several roles in the brit milah ceremony where family members and friends can participate. It is considered an honor and a privilege to be asked to fulfill these roles.

Sandek

Being named the sandek is the highest honor and most prestigious role that a family member or friend can be given in the brit milah ceremony. In traditional ceremonies, the Sandek also holds the baby while the mohel does the actual circumcision.  But not liking moving targets while doing surgery, most contemporary mohels will place the baby on a plastic restraint board of the kind used in hospitals for the performance of the circumcision.

The honor of being a sandek can be given to any family member or friend the parents so choose. Most commonly the honor is given to one or both of the grandfathers (there can be more than one sandek and they could be grandmothers as well). If there are two sandeks, they sit side-by-side and either alternate in holding the baby or one holds the baby during the ceremony and the other comforts the baby with wine on a pacifier during the circumcision. 

There is a tradition that the sandek should be a person worthy of respect, one the parents would have their child look up to.  While it is no means required for the Sandek to wear a tallit and yarmulke during the ceremony, both are encouraged and lend elegance and spirituality to the occasion. The sandek, as he is holding the baby, is the only one who sits during the brit milah ceremony. Everybody else stands (if they are able) in honor of the newborn.

The Kvatter and Kvatterin.

The role of the kvatter or kvatterin (female kvatter) is to bring the baby from the mother to the sandek by way of the Chair of Elijah (see section on “Chair of Elijah“).  These can be any one or more people of the couple’s choosing. Traditionally, a young couple seeking to begin a family themselves is chosen for this role.  But in contemporary brit milah ceremonies anyone—relative or friend–can share in this honored task. Often multiple family members will form a human chain of kvetters to pass the baby from the mother to the sandek. Formerly, being a kvatterin was the only role a woman could play at a bris ceremony; now, of course, women can share any of the honors of the brit milah service.  Also, while the sandek does have to be Jewish, the kvetter/kvetterin do not.

While the above are the two official honors at a brit milah ceremony, there are other means of allowing relatives and friends the privilege of participating in the event:

Lighting of the candles.  As mentioned previously, while this is not a mandatory part of the brit milah ceremony, it does lend beauty and dignity to the event. Any guest present can light the candles and say the blessing over them. However, lighting of the candles cannot be performed on Shabbat.

Blessing over the challah.  Saying the blessing over bread before starting the festive meal is a time-honored custom and brings a sense of increased religiosity to the brit milah ceremony.