In defense of Jewish circumcision


This past week, I was in Miami for the bris (or brit), the Jewish ritual circumcision, of my grandson. It’s a good time to offer a defense of the Jews’ most ancient ritual.

According to various reports, there are Jews — and not only Jews who have forsaken their Jewish identity — who oppose circumcising their sons. They are still a minority, but they are vocal and, I suspect, growing.

Their primary arguments are that circumcisions, whether for religious or medical reasons, are unnecessary; that they are a form of mutilation; and that the act inflicts serious pain on the 8-day-old for no good reason.

Let’s begin with the first objection. In fact, circumcision is both medically and religiously necessary. People are free to object to circumcision, whether performed by a mohel (Jewish ritual circumciser) or a physician. But they need to be honest with the facts.

“The scientific evidence is clear that the benefits outweigh the risks,” Dr. Jonathan Mermin of the Centers for Disease Control and Prevention announced in 2014. 

“The benefits of male circumcision have become more and more clear over the last 10 years,” added Dr. Aaron Tobian, a Johns Hopkins University researcher.

Circumcision is so medically beneficial that many African countries demand that their male citizens get circumcised. The reason is that, other than sexual abstention, circumcision is the best way to reduce the risk of contracting AIDS. And there are multiple other health benefits.

Personally, I would endorse the bris even if there were no medical benefits. I only cite these benefits to refute those who argue that circumcision is not beneficial, or is even harmful.

What matters to me are the religious benefits of giving one’s son a bris — or brit milah, “covenant of circumcision,” to give it its full name. They are, of course, not as objectively measurable as medical benefits, but they are even greater.

I found the circumcisions of my two sons and two grandsons more emotionally and spiritually moving than any other religious activity in my life. Here I was, in as dramatic a way as one could imagine, bringing my sons and grandsons into the Jewish people and into the Jewish covenant with God. I thought about how my father had done this to me, and his father to him, going back to Abraham, more than 3,000 years ago. I thought about all the Jews who, at the risk of their lives, brought their sons into the covenant during the many anti-Semitic periods in Jewish history.

As for “mutilation,” that is a complete misuse of the term. The term properly describes what is done in many Muslim societies to the genitalia of young girls. That is why it is called “female genital mutilation.” Its vile purpose is to deprive women of the ability to enjoy sexual intercourse. And its effects are prolonged excruciating pain and permanent physical disfigurement. To compare that to the removal of the foreskin is not only absurd, it trivializes the horror of female genital mutilation.

With regard to pain, of course the baby experiences pain. The question is how much and whether there is any lasting trauma.
The amount of pain is essentially impossible to judge for a number of reasons, however. One reason is that we can’t ask the baby: “What is your level of pain from 1 to 10?” Another is that many babies barely whimper during the brit. Virtually all cry far more loudly and for far more time when they have gas or are hungry — and neither condition is regarded as abnormally painful, let alone traumatic.

Nevertheless, the request of any parent who wants to have lidocaine injected into their baby’s foreskin to numb the pain should be honored. There is no halachic issue here; after all, adult men who undergo a brit can be fully anesthetized.

To assess whether one wants one’s son to undergo a brit milah, one has to recognize one of the most important laws of life: Everything has a price. There is a price paid for having a brit, and there is a price paid for not having one.

The price for having one is momentary pain in an infant. That’s it. The idea that a man pays some lasting price for not having his foreskin is refuted by the experience of virtually every circumcised male who has ever lived. I have only met one man in my life who was troubled about not having his foreskin. On my radio show, I once interviewed a spokesman for an anti-circumcision group based in — you’ll be shocked to learn — San Francisco. And I told him I thought he must be very bored to devote so much of his time to lamenting his lost foreskin.

As opposed to the minuscule price paid for having a brit, there is an enormous price paid for a Jew not having a brit. The advantages wildly outweigh the momentary pain. The brit uniquely strengthens a Jew’s religious identification, and the ceremony instills in the family and in the community present at the ceremony a profound identification with the nearly four millennia of the Jews’ world-changing history. 

Dennis Prager’s nationally syndicated radio talk show is heard in Los Angeles from 9 a.m. to noon on KRLA (AM 870). His latest project is the Internet-based Prager University (prageru.com).

Health benefits of circumcision reinforced


In the circumcision wars, circumcision has been winning some big battles.

A new survey of medical data going back more than two decades has found that the health benefits of circumcision far outweigh the risks. The publication of the article on April 4 by the medical journal Mayo Clinic Proceedings is the latest development to tip the scales in favor of circumcision in the long-running scientific, cultural and political struggles over the practice.

Some say this series of arguments has damaged the efforts of American anti-circumcision activists.

“They’re in disarray. They used to be very organized, raising money and so forth,” said Edgar Schoen, a clinical professor emeritus of pediatrics at the University of California, San Francisco, and a longtime champion of the medical benefits of circumcision. “People don’t listen to them that much anymore.”

The authors of the new survey reviewed some 3,000 studies on male circumcision published since 1988 and found evidence indicating that circumcision significantly reduced the chances of contracting a number of diseases, including urinary tract infections, human papillomavirus and HIV.

“When considered together with ethical and human rights arguments, neonatal circumcision should logically be strongly supported and encouraged as an important evidence-based intervention akin to childhood vaccination,” wrote authors Brian Morris, Stefan Bailis and Thomas Wiswell.

Morris, the study’s lead author and a professor emeritus of medical sciences at the University of Sydney, has long been an advocate for the health benefits of male circumcision, authoring the 1999 book “In Favour of Circumcision.”

Circumcision opponents — known in some circles as “intactivists” — generally dismissed the new study.

“It’s very easy for researchers to design their studies and the analysis of their studies to come out with conclusions that they want,” said Ronald Goldman, author of “Circumcision: The Hidden Trauma.” “So they’re finding what they’re seeking, in other words. There’s no objectivity here.”

The so-called “circumcision wars,” as they have been dubbed by the media, spilled into the American political sphere in 2011 when anti-circumcision activists submitted more than 12,000 signatures to place a San Francisco city ballot measure to ban the practice. The measure spurred heated debate as pro- and anti-circumcision advocates traded accusations of anti-Semitism and child abuse.

However, before the measure could go before voters, a state judge ordered it struck from the ballot as a violation of state law. The California State Legislature subsequently outlawed any local bans on circumcision.

The medical landscape tilted against anti-circumcision activists in 2012 when the American Academy of Pediatrics issued revised guidelines on the practice, stating for the first time that “the health benefits of newborn male circumcision outweigh the risks.” This marked a reversal of the academy’s neutral stance and undercut a key talking point of anti-circumcision activists, who had argued that the practice had no support from any major medical organization.

Anti-circumcision advocates disputed the notion that their efforts have run aground, but some acknowledged that the legal and political terrain has become more challenging.

“There was an enormous and immediate clampdown on any type of legislation gaining a foothold to protect male children in the United States,” said Lloyd Schofield, an anti-circumcision activist who served as a spokesman for the San Francisco ballot measure.

However, Schofield and other anti-circumcision activists point to Europe as more receptive territory.

Attempts to limit or ban non-medical circumcision of boys under 18 have intensified in Europe in recent years. The efforts gained steam after a German court ruled in 2012 that circumcision amounted to causing bodily harm — a ruling that triggered brief bans in various locales in three German-speaking countries.

Last October, the Parliamentary Assembly of the Council of Europe issued a non-binding resolution condemning the practice of circumcision for boys as a “violation of the physical integrity of children.” Several Scandinavian political parties and medical associations are seeking a ban, as are the children’s welfare ombudsmen of Denmark, Finland, Greenland, Iceland, Norway and Sweden.

Jewish groups have pushed back strongly against efforts to ban the practice.

Part of the trans-Atlantic difference in attitudes may be rooted in cultural practices. The study in Mayo Clinic Proceedings cited an estimate that only 10 percent of European males are circumcised. In the United States, the authors calculated that neonatal circumcision rates had dropped from 83.2 percent in the 1960s to 77.1 percent in 2010 as a result of demographic and policy changes.

One of the primary reasons cited by the authors for declining circumcision rates is the country’s rapidly growing proportion of Hispanics, who tend to circumcise their children at far lower rates than non-Hispanic blacks and whites. The report cited figures from the Centers for Disease Control and Prevention indicating that only 44 percent of Mexican-American male infants were circumcised, compared with 76 percent of black males and 91 percent of white males. However, the report also noted that circumcision rates among all three groups appear to be increasing.

Another major factor cited by the report for lower circumcision rates was the reduced number of states that provide Medicaid coverage for circumcision. Currently, 18 states do not cover the procedure through Medicaid, up from just six in 1999. Anti-circumcision groups have urged additional states to cease covering circumcisions.

The new study calculates that hospital circumcision rates are 24 percent higher in states that cover the procedure through Medicaid compared to those that do not, after controlling for other factors.

The American Academy of Pediatrics’ 2012 policy statement explicitly urged insurance providers, including Medicaid, to cover neonatal circumcisions. Although there have been reported efforts in several states to restore Medicaid coverage, to date none has made the switch.

Douglas Diekema, a professor of pediatrics at the University of Washington and a member of the pediatrics academy’s task force on circumcision, urged caution in interpreting the study’s findings, saying that circumcision rates are notoriously difficult to calculate because of the number that are performed outside of hospitals. However, he said the impact on decisions by parents would be driven not so much by the data as by media attention.

“It’s not so much that this paper is so radically important as that it seems to be getting a great deal of press,” Diekema said. “Press coverage gets the attention of parents.”

Health issue or anti-Semitism: Switzerland joins German circumcision ban


Today come reports that hospitals in Zurich and St. Gallen have suspended the practice on Jewish and Muslim boys in the wake of a similar ban in Germany ordered by a judge in Cologne.

Judges in Cologne concluded that circumcision, even when performed by a doctor, is considered “bodily harm,” since a boy under age 14 years cannot legally give consent. And now Berlin’s Jewish Hospital banned this procedure out of fear that its Doctors could face prosecution and even incarceration.  The Netherlands had banned circumcision stating that ‘it was ritual slaughter’, but recently reversed this ruling.

Great Britain’s Orthodox Chief Rabbi said that a ban on circumcision was mandated by two of the Jewish peoples’s worst enemies – the Seleucid ruler Antiochus IV and the Roman Emperor Hadrian.

Believe it or not, an American city, San Francisco, was set to vote to proscribe one of the central rituals of an entire religious community, the Jewish people, who have been circumcising male infants since the time of Abraham.  Fortunately, the vote was postponed.  Many Muslims, of course, also practice circumcision, while millions of other American parents have eagerly supported this procedure for their infants for hygienic or health reasons.  To add fuel to the fire, anyone who performs a circumcision may be fined $1000 or be committed to a year in jail if this vote was affirmative.  Mark Stern, a lawyer for the American Jewish Committee, said, “This is the most direct assault on Jewish religious practice in the United States.  It is unprecedented in Jewish life.”  The proponents of the bill insist that circumcision is “mutilation and barbaric.  Under pressure, the vote did not materialize.

Russell Crowe (the actor) said: “Circumcision is barbaric and stupid.  Who are you to correct nature?”  Is the “You” the Jew?  ” But do not be concerned,” Russell Crowe continues.  “I have many Jewish friends.  I love my Jewish friends.  I love the apples and the honey and the funny little hats, but stop cutting your babies,” he declared.  Who gave him a moral authority that he knows what is best for Jews, Muslims, and others who prefer the benefits of circumcision for their male children.

Anti-circumcision activists have been speaking out against circumcision for decades, but in the last several years the San Diego-based advocacy group has prepared anti-circumcision legislation for 46 states.  The head of the group says that “his circumcision as an infant resulted in diminished sexual sensitivity as an adult.”  Is this double-speak?  How would he know the difference?  Does he know for a fact that his limitations or an inability to have sexual gratification is a result of his circumcision?  Does he conclude that for thousands of years, no Jews or Muslims or billions of other people have had no or limited sexual satisfaction?  There are some data to suggest the opposite – that removal of the foreskin allows greater gratification.   

MEDICAL CONCERNS:

The warm, moist mucosal environment under the foreskin favors growth of microorganisms creating an environment that could lead to infection both to the man himself and his sexual partner(s)

Paraphimosis is a condition in which the skin that normally folds over the penis, the foreskin, tightens and retracts and cannot return to its normal position over the head of the penis.  If not corrected, the penis will swell and the blood flow to the head may be cut off, damaging the tissue.  It is usually caused by inflammation or infection of the foreskin and may be associated with poor personal hygiene.  Paraphimosis can only occur in uncircumcised men.  Treatment includes circumcision on an emergency basis.

Phimosis occurs when the distal foreskin cannot be retracted over the glans penis.  In the infant, the foreskin normally cannot be retracted over the glans and should not be forced.  With normal growth and stretching of the foreskin, it will become retractable in 90% of children by the age of 6 years.  However, local irritation or infection (balanoposthitis) can cause an abnormal constriction of the foreskin, preventing it from retracting normally.  Often there is pain and swelling, which may be associated with infection of the glans.  Occasionally, a urinary tract infection is present.  A circumcision is indicated particularly when there is superimposed balanitis, balanoposthitis, urinary tract infection, or obstruction.

Balanitis and balanoposthitis are infections of the glans and foreskin.  It is most commonly found in uncircumcised males and frequently presents during the preschool years.  Balanitis may be caused by entrapment of organisms under a poorly retractable foreskin—gram-negative or gram-positive bacterial organisms may be causative, and recently, group A beta hemolytic strep has been implicated.  Monilia infections (yeast) are also associated with balanoposthitis in infants.  Syphilis should also be considered. 

Signs and symptoms include swelling, erythema, penile discharge, pain on urination, bleeding, and occasionally ulceration of the glans.  Additionally, a careful examination of the base of the penis should be performed to look for a strand of hair, which may cause strangulation and edema.

Various types of injuries and trauma can involve the foreskin.  One extremely painful example is when the foreskin “gets caught” in the zipper of the boy’s pants, resulting in an extremely painful emergency situation requiring immediate circumcision.

BENEFITS OF CIRCUMCISION

The benefits of circumcision include: (1) decrease in many types of infections (2) decrease in “strangulation” of the penis; (3) lower incidence of inflammation of the head of the penis, (4) reduced urinary tract infections, (5) fewer problems with erections, (6) a decrease in certain sexually transmitted infections, such as HIV, HPV, genital herpes, syphilis, and other microorganisms in men and their partners, (7) almost complete elimination of invasive penile cancer,  (8) a decrease in urological problems generally, and (9) prevention of the foreskin getting “stuck in the zipper.”

An article was published in Lancet on January 6, 2011, written by Maria Wawer, et al. from Johns Hopkins University and Rakai, Uganda.  Male circumcision has been linked to a reduction of HPV infection in men and a reduced risk for cervical neoplasia in women with circumcised partners.  The results showed a significant reduction of 28% in the prevalence of high-risk HPV infection in female partners of circumcised males.  Male circumcision also reduced the incidence of high-risk HPV in women.  The authors suggest the reduced penile HPV carriage may explain the way in which circumcision helps prevent HPV infection in women.  The authors conclude that their findings indicate that male circumcision should now be accepted as an efficacious intervention for reducing the prevalence and incidence of HPV infections in female partners.

Problems involving the penis are not rare in pediatric practice.  A study by Wiswell (1980-1985) looked at 136,000 boys born in U.S. Army hospitals, where 100,000 were circumcised, and there was less than 0.01% complications, which were mostly minor with no deaths.  But of the 36,000 who were not circumcised, the problems were more than ten times higher and there were two deaths (Wiswell and Hachey, 1993).

THE WORLD HEALTH ORGANIZATION

The WHO and several Centers for Disease Control support circumcision as a preventative measure against HIV transmission.

SOCIETAL AND POLITICAL PRESSURE

There are recent alarming reports of harassment by medical professionals of new mothers (especially Jews) in an attempt to stop them from having this procedure carried out.  There has been a trend by pediatric organizations to skirt the truth in favor of what could be viewed as “New Age political correctness,” spurious “human rights” rhetoric, or perhaps fear of litigation stemming from a very, very unlikely surgical mishap.

Is it remotely possible that we are beginning to experience the events of the 1920s and 1930s in Germany – where governmental rules were “codified and classified and recorded to ensure the proper conduct of current and future generations.”?


Dr. Norman Lavin is a clinical professor at UCLA Medical School.

Discourage male circumcision, Dutch doctors urge


A Dutch medical association has called on politicians and human rights groups to discourage male circumcision.

The Royal Dutch Medical Association last week appealed to politicians to speak out about the procedure, called a brit milah in Hebrew, in an attempt to encourage religious groups to find an alternative rite of passage, Reuters reported.

The association represents surgeons, pediatricians, general practitioners and urologists. One year ago, the association released a report against male circumcision for non-medical reasons.

Female circumcision, also called female genital mutation, has been banned in the Netherlands since 1993.

Rabbi Binyomin Jacobs, president of the Dutch Association of Rabbis, told Reuters that about 50 male Jewish babies are circumcised in the Netherlands each year.
Jewish boys traditionally are circumcised at eight days of age and Muslims at some time during boyhood.

There are about 40,000 Jews and 1 million Muslims living in the Netherlands.

First Person – Snips and Snapshots


To snip or not to snip … that wasn’t the question. When my obstetrician asked me during my pregnancy what I planned to do about my son’s circumcision, he wasn’t referring to the health controversy that now seems as dated as whether to go Atkins or South Beach. Instead, he wanted to know whom I planned to entrust with this delicate task. I assumed it would be a mohel, but my doctor informed me that today’s parents have a wide array of options. I could also pick an obstetrician, a pediatrician, a pediatric urologist or the latest in full-service circumcision, the pediatric-urologist-turned-mohel.

I didn’t know what to do — and as a single mom, I didn’t have a husband around to offer some male input. It was almost like asking a father to have an informed opinion about his daughter’s bikini wax. Except that while a bad bikini wax might only ruin a spring break, my decision could affect my son’s sexuality for the rest of his life.

My obstetrician lobbied for the job, telling me that in more than 20 years, he only had to re-do one. The first time, he explained, he was so nervous, he barely took anything off and had to repeat the entire procedure from scratch. As frightening as this sounded, I felt reassured that he erred on the side of caution. I also liked that he had two decades of experience, but then I wondered: Has the technology changed? Maybe there was a new painless procedure, like the circumcision equivalent of LASIK? The more research I did, the more confused I got. There seemed to be heated debate about which type of anesthesia, antibiotic, and scalpel to use. Should I go with a guy who uses Elamax or kosher wine? Lidocaine or homeopathic ointments? The Mogen Shield or the Gomco clamp?

What I really wanted to see were before and after shots, the way surgeons whip out photos of boob jobs and Botox procedures. My friend Kim suggested that mohels compile photos of their work in a book titled, “Head Shots.” The closest I could come were testimonials on a Web site called eBris.com, home of pediatrician-turned-mohel Dr. Fred Kogen. There I found rave reviews from parents. A Mrs. Cohen, whose son is now in preschool, wrote: “I have had many, many occasions where I have had to change the diapers of other boys. I must tell you, our son has a perfect penis. Many of the other moms have commented to me how pretty Seth’s penis is compared to their sons.'” (Incidentally, for the rest of Seth Cohen’s life, everyone from future girlfriends to future employers can learn with a quick Google search that his mom thinks he has a “perfect penis.”)

Another parent wrote simply: “You have a great touch.” (The mohel with the great touch … hmm. It sounded a little Catholic church to me.)

Another parent wrote: “….Even our pediatrician said that you ‘did a fantastic job!’ We are attaching one of his photos, so you can see how much he has grown in just a few short weeks.”

I eagerly clicked on the photo. Incidentally, it was an actual head shot.

Aside from Kogen’s cheesy mass-market vibe (did I really want somebody with an 800 number cutting my son’s private parts?), I worried about the fact that Kogen claims to perform six to seven circumcisions each week. Would all of his work have the same cookie-cutter look, the way that girls who got nose jobs at my mostly Jewish high school and all went to the same brand name Beverly Hills surgeon now have exactly the same nose? Would my son’s girlfriends one day recognize a Kogen penis the way boys in my high school could identify a Glassman nose from across the cafeteria?

In the end, I decided to let my obstetrician do it. The fact that he forgot to circumcise Zach in the hospital and then went on vacation for a few days, gave me pause, but when his partner, who looks like he’s about 16 years old, offered to do it, I declined. If something went wrong, I didn’t want to have to explain to Zach that I let the junior guy in the practice slice and dice. Instead, my parents and I trekked over to my OB’s office for what I like to call an office bris.

For the next week, friends, family, and even colleagues called asking after my son’s genital region.

“I think it’s fine,” I’d say, and I’d report on the color of the scar tissue, the decreased use of gauze pads and the progression to a tub bath again.

Most important, Zach seemed pleased with the result. When I’d change his diaper and he’d pee against the wall, he’d laugh hysterically. Apparently, the pain was gone, and his equipment still worked right.

“Maybe that’s his testimonial,” my doctor chuckled at our next appointment.

“Yeah,” I replied, “Or maybe the joke is on us.”

Lori Gottlieb, a commentator for NPR, is the co-author of the forthcoming “I Love You, Nice to Meet You” (St. Martin’s Press). Her website is www.lorigottlieb.com.