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Wrestling with the covenant

2000; BMJ; Volume: 172; Issue: 1 Linguagem: Inglês

10.1136/ewjm.172.1.64

1476-2978

Ross DeHovitz,

Child and Adolescent Health

This week, I am our practice's designated pediatrician to see all of the hospitalized patients. My job is to see all the newborns for our group until I hand over this responsibility the following week. Most of the parents I meet I won't see again unless they choose me as their pediatrician. Walking into the nursery, I check the assignment board to see what my duties will be today. I ask the nurse in charge, “How many circs today?” She answers, “Just one. Baby Boy Kessel.” I'm glad there is only one. I do not enjoy performing circumcisions. I don't love procedures, anyway, and I've always been hesitant about doing this to nonconsenting newborns. Most of the world's males do fine with intact foreskins. In the back of the nursery, “Jim Kessel” (not his real name) waits with his infant boy. I introduce myself and congratulate him on the birth of his son. Jim asks, “Do you use anesthetic for the circumcision?” Parents always ask this question. The truth is that many kids cry anyway, even when we know we hit the right spot with the lidocaine. I try to finesse. “Absolutely,” I say. “I put a little lidocaine locally just under the skin right here at the base of the penis. But I also like someone, such as yourself, to put your finger in his mouth. I think the sucking is just as important.” We start setting up for the circumcision. He signs the consent form, and I place the infant in the leg restraints on the circumcision board. This board is a piece of white plastic with a smooth depression in the shape of an infant. The child fits entirely in this groove, and the legs are kept still with white adhesive straps. “Baby Sam” starts to cry with the placement of the restraints but settles down quickly as he endeavors to bring a meal into his mouth from dad's finger. I start to administer the anesthetic. “I hope you don't mind if I look away,” Mr Kessel says. “I've seen one or two of these, but I don't want to see my own son's.” I ask, “Was it a home circumcision? A bris?”* “Yes,” he answers. “I've seen a few, but I never was comfortable with it.” Jim's remark makes me recall all the doubts I've been struggling with. Why do we have to remove a perfectly normal piece of skin in these kinds? True, I occasionally see infected foreskins in older children, which cannot happen if the foreskin is removed at birth. But, I wonder, when we remove a foreskin, do we remove something else? What are we taking away from a boy by doing this? As I inject the anesthetic over a period of 10 seconds, Baby Sam cries out intermittently. He clearly feels the medication, but this sting should quickly dull. I am reminded of the new studies that are showing some benefits of EMLA (Lidocaine-prilocaine) cream and of the use of a ring block of lidocaine. I still use the dorsal nerve block, mostly because that is how I was trained. The lidocaine is now in. I ask, “Are you Jewish?” “Yes,” he answers, “but my wife is Catholic, and if I weren't Jewish, I wouldn't even be thinking of doing this. It's really more the grandparents who are pushing it.” “I know what you mean,” I say. “I'm Jewish, and I have some discomfort with the procedure. But I've done a lot of bris's, and it's amazing how powerful the tradition is to the family.” Yet, as powerful as it is in Judaism, I have non-Jewish families who definitely want circumcision for all sorts of “legitimate” reasons. They say things like, “We want him to look like his dad” or “It's easier to take care of when it's circumcised” or “The grandparents want it.” “You know, Jim,” I say. “We don't have to do this. I want you—not your parents—to want to circumcise your child.” “No, I have to,” Jim responds. “I can't be the one who breaks the tradition.” “Which tradition?” I ask. “The tradition to circumcise, or the tradition to have a bris?” He answers, “To circumcise. But I suppose there is a religious part of this as well.” “Well,” I reply, “if you would like me to, I can say the blessing when we come to the right time.” Jim looks in Baby Sam's eyes and says, “If you want.” I”m not sure whether he truly understands me, but I let the moment pass and drape the infant's penis with a sterile cloth. I touch the foreskin with a forceps. There is no cry or grimace. The anesthetic has taken effect. Baby Sam continues to suck on Jim's finger as I take a thin hemostat and start to separate the foreskin from the underlying glans penis. I ask Jim, “How does your wife feel about it?” Jim was looking away as he spoke. “She really has left it up to me. You see, ordinarily, I feel that we shouldn't mess with nature. Maybe it has a purpose?” I swallow hard as I expose the glans completely. I'm already halfway through this. Should I continue? He's asking all the right questions. I say, “I agree with you that there is at most a marginal medical benefit, if any, to circumcision, so a reason to do it would be cultural or religious and not medical. But to Jews, this is the mark of the covenant that God made with Abraham, and it hasn't changed in 3,000 years.” I describe to him how, with the rise of reform Judaism in the 1800s, there was a movement to abolish circumcision. But while keeping kosher and wearing skullcaps were deemphasized, abolishing circumcision was felt to cut off the connection between God and the Jewish people. This radical movement died out, and the tradition to circumcise was maintained. I continue, “How powerful is it in today's Jewish community? One of my Jewish female colleagues has said that it would be very difficult for a Jewish girl to date a Jewish boy who was uncircumcised.” Jim answers, “Well, that's why I feel I have to do this. I want to give him the choice to go in whichever direction he wants.” I think to myself how ironic it is that an irrevocable procedure can be perceived as creating choice. I place the clamp on the penis and separate the glans from the foreskin. Baby Sam cries out briefly as he feels the sting of the circular clamp compress the foreskin and its nerves at its base. He sucks more vigorously as he loses all feeling in his foreskin. The clamp is tightened. “All right,” I say to Jim. “The clamp is on, and I'm ready to remove the foreskin. This is where I would ordinarily say the blessing.” Jim is silent. With scalpel in hand, I start to cut. I feel that I have to make the offer again. “Would you like me to say the blessing?” Jim is still looking at Baby Sam as he caresses the fine hair on the baby's scalp. “Yes. Please,” he answers. “Boruch atah Adonai elohaynu melech haolam asher kidshanu b'mitzvotav vitzyvanu al ha milah. [We praise You, Adonai our God, Sovereign of the Universe, who sanctifies us with commandments, and commands us regarding circumcision.]” And then Jim says, “Amen!” As I finish removing the foreskin, all is quiet. Jim continues to look away while his finger offers comfort in the baby's mouth and his other hand wipes the tears from his own eyes. I show Jim how to dress the newly exposed glans penis and then take the baby out of the restraints to wrap him up for his bassinet. As I hand him to Jim, he holds his infant son securely and with tenderness. Jim thanks me, takes him back to Mom, and I leave to see the next child. I suppose it is possible that the power of this ritual is not just in the procedure. It might be the higher plane reached by the juxtaposition of a new father offering his newborn, in the tradition of his ancestors, a permanent mark on a life-giving organ and a blessing over the entire process. Or it might just be a procedure that separates a newborn from his foreskin forever. A week later, I receive a letter from Jim's wife: We had struggled with the decision to do the circumcision, but since I'm not Jewish and Jim is, I thought it would be important to make sure that Sam could have as strong a tie as possible to his father's family and heritage. For these reasons, I thought it was very special that you said the prayer. It makes me feel wonderful to know that he received a blessing and not just a surgery. Thank you so very much. I now accept that medical science may never be able to prove whether the foreskin is a piece of prehistoric human culture that now exists only as a reservoir of infection, or whether it is a magical piece of erectile tissue that aids in sexual performance and protects the underlying glans penis. I also know that in the Jewish tradition, none of this matters. Here, the foreskin is a kind of barter. We remove foreskin by this procedure. We also take away whatever magical powers a foreskin possesses, but that skin is traded for a connection with a culture infinitely more powerful in its achievements and a heritage infinitely more durable in its longevity.