Frequently Asked Questions

Welcome to the newest section of this website. Most of the information one might need to select a circumciser is within the body of the original website. However, certain questions are frequently asked that periodically require revisiting. Also, topical items arise that may be of interest or require further explanation. That is why this section was formed and will be used to answer frequently asked questions (FAQ'S) and act as an editorial section. If new articles or subjects arise, I will present them for the purpose of updating the website.

Sam Kunin, M.D., Diplomat of the American Board of Urology,
Fellow of the American College of Surgeons and Certified Mohel

How does one choose the right person to circumcise their child?

While many people contact me for both ritual and non-ritual circumcision because I am a urologist, just as many do because I am a mohel (ritual circumciser). Some think a urologist is best trained to perform circumcisions while others feel a mohel has a wealth of experience and may be more "gentle" or "humane" while circumcising their son. There are potential faults with both schools of thought.

During my training to become a board certified urologist, I was fortunate to be part of a program that actively taught and performed both infant and adult circumcision. However, while presenting a new and improved form of circumcision anesthesia at the Western Section American Urologic Association meeting in November of 2007, many urologists, including department chiefs, said they had never performed an infant circumcision and that it was not part of their training program.

Urologists may be trained to care for infant circumcision complications, but are not necessarily trained or adept at performing infant circumcisions. All too often, if a child does not have a hospital circumcision due to some health problem, he is later referred to a urologist. Many urologists will say an infant circumcision cannot be done then and that the child must wait until one year old and then have it done under general anesthesia.

Any experienced infant circumciser can perform circumcisions under local anesthesia as late as 3 to 4 months old. Some may be done at an older age under local anesthesia but may require sutures to assure no bleeding. However, many circumcisers are not trained to handle problems that may occur immediately or later.

It is advisable to ask your circumciser if he or she is equipped to handle serious bleeding or complications. Obstetricians, pediatricians or family physicians will only treat minor problems. Most orthodox mohels, who are not physicians, also only know temporary measures that any circumciser may use to handle mild bleeding. However, anything more will require the services of a urologist or emergency room physician.

Furthermore, a non-medical mohel is obligated to use equipment for the circumcision that most doctors prefer not to use. Some mohels use a Mogen Shield, a non-clamping devise, which dates back a few hundred years and offers little clamping action. Most mohels use the Mogen Clamp, based on the design of the Mogen Shield, which provides a clamping action to prevent bleeding.

The Mogen clamp is not my personal choice for a circumcision. I can fully understand and appreciate the orthodox obligation to use a Mogen devise and know that many physicians use the same instrument. Extremely religious families must obviously use such a circumciser. However, all children are not born alike and there are anatomical situations where the Mogen clamp is not the clamp of choice. This is particularly so with babies who have large fat pads, a small penis, scrotal swellings, congenital rotation of the head of the penis and/or findings that mimic hypospadius (a condition where the urethral opening is not at the tip of the penis).

Unfortunately, although circumcision has been performed for thousands of years there are no clear-cut stated standards as to what constitutes a good circumcision. All agree that there must be no bleeding. Jewish standards demand that if a penis is hidden in fat the head must be visible when it is erect or one pushes the skin down on either side of the penis. Otherwise, there is little agreement as to how much skin must be removed or what constitutes a good cosmetic result.

There are techniques available to determine exactly how much skin to remove. An optimal cosmetic result allows for easier care and less potential for post-circumcision problems.

Therefore, being a urologist or a mohel does not guarantee that your needs will be met. Decisions are best met by considering the circumciser's experience, an interview and personal recommendations. Even though you are reading my website, that may be the last source one should use. No one will purposely create a website that does not put themselves in the best light.

These two questions are best answered together. The short answer is, "Yes, I do perform infant, child, adolescent and adult circumcisions for both Jews and non-Jews.

A mohel who is a physician may perform a non-religious circumcision. Under the protection of separation of church and state, orthodox mohels may perform a ritual circumcision. However, non-medical mohelsx do not have any license or malpractice insurance that would allow them to perform non-ritual medical circumcisions. Furthermore, although they can remove a foreskin, they may not inject an anesthetic agent without a license.

Physician-mohels must make sure that families understand that a medical circumcision has no religious status. Furthermore, a mohel must not circumcise a Jewish infant before the eighth day.

Although retired from my full-time urology practice I still maintain hospital privileges for newborn circumcisions in the NICU and newborn nursery and am available for non-ritual circumcision. Such privileges require a valid license, malpractice insurance and proof of continuing education.

Older children, adolescents and adults are circumcised at an adjacent surgery center or office. Most adolescents and adults are best circumcised in an office setting under local anesthesia. It is less expensive and avoids all of the potential risks of general anesthesia

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The American Academy of Pediatrics (AAP) highly recommends local anesthesia for infant circumcision. It is difficult to believe they would if there was potential danger in doing so. Still, there are some circumcisers, particularly those who will not or cannot administer local anesthesia, who continue to bring up this issue.

Parents have told me that some circumcisers try to influence them by suggesting that injection anesthesia may cause nerve damage. To the best of my knowledge this never has been reported in the formal medical literature. Would the AAP recommend injection anesthesia for circumcision if such a complication occurred? Furthermore, even if true, nerve damage would never come into question with DFLA (see below) because it is administered in the foreskin that is removed. The tissue to be removed is clamped prior to removal so there is no absorption of the anesthetic agent.

Local anesthesia may be delivered via topical creams or injection.

Topical creams, particularly EMLA are expensive and must be applied by parents an hour or more before the circumcision. This means that proper dosing is not supervised. Potential complications include methemaglobinemia (a blood problem), local swelling with tissue distortion, and an efficacy rate reported as lower than injections.

Studies suggest that an infant sucking on an oral sucrose solution may provide as much comfort as topical creams. That is why hospitals routinely have the infant suck on a pacifier or gauze sponges soaked with sugar solution. At a brit (ritual circumcision) most people think the baby becomes drunk sucking wine. However, kosher wine has low alcohol content and a high sugar content. It is best to dilute the alcohol.

Injections are delivered as:

1. a nerve block at top of the base of the penis (Dorsal Penile Nerve Block, DPNB),
   
   
2. a block encompassing the entire circumferential base of the penis (Ring Block)
   
   
3. or a combined local block of the outer foreskin and a ring block to the inner layer (Dorsal Foreskin Local Anesthesia, DLFA).

All blocks are less expensive and generally more affective than any topical application. With the DPNB or ring block there is potential for black and blue marks which potentially, but rarely, may act as a focal point for a local infection. Also, these injections may be absorbed or can act as an irritable focus causing prolonged crying until it wears off.

Since the DPNB is injected into the foreskin to be removed there is no absorption, irritable focus, nerve damage or hematoma. In my experience, ninety percent of children having a DPNB never cry with the injection.

During my experience with DPNB, a method I developed and presented to the Western Section of the American Urologic Association, I have also found that DPNB aids in performing a better cosmetic circumcision. The injection, which is between the inner and outer layers of the foreskin, separates the two layers, allows me to selectively pull up and remove an optimal amount of the inner layer. This is particularly advantageous with difficult cases.

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Do you use a restraint?

In her excellent book, The New Jewish Baby Book, Anita Diamant provides a list of questions for the mohel. A question about restraints is one of them.

The question, itself, almost always suggests a negative connotation, one website suggesting that it is, "Inherently abhorent," or that it scares those assembled. However, can you imagine a circumcision being performed without the child being restrained in some manner? I doubt it.

I have seen one orthodox mohel keep the board out of sight by having the person holding the infant sit with his back to the guests. On the holder's lap is a pillow with a towel over the pillow. Under the towel is a flat board with straps to secure both the arms and legs.

Prior to 1959, when the Olympic Circumstraint board was developed, even in hospitals, nurses had to physically restrain the infant, usually placing their forearms over the infant's shoulders while spreading the legs apart and holding them down. In the same manner, at a ritual circumcision a relative or friend must do the same while the infant is on a pillow. While the hospital nurse is trained, there can be no guarantee of similar expertise in a home setting where the infant may be held either too tight or loose.

Once the Olympic Circumstraint was introduced it became universally accepted. Stang introduced his Circumcision Chair that is well conceived and is gaining use in hospital nurseries. However, it may be somewhat bulky and imposing at a ritual circumcision.

As with any medical device, optimal results are obtained when it is used correctly. One website suggests that the infant is placed on a, "Cold, hard board." Common sense suggests that a thoughtful circumciser would pad the board with a surgical towel and diaper. Most do.


The Circumstraint board has slots available to restrain both the arms and legs with Velcro straps. A child is more likely to cry if his arms are restrained. However, it is not necessary to strap the arms at all. In my experience with over 9000 infant circumcisions no infant has ever reached down to the area where I am working.

In order to make the guests comfortable my Circumstraint board has been cut down and trimmed to make it less bulky. The board is padded with a sterile surgical towel and diaper. The infant is also covered with similar towels and a receiving blanket.

A padded restraint board, with the legs properly secured and the arms not secured, is safe, comfortable, reliable and consistently effective when circumcising infants.


Every attempt must be made to make the infant as comfortable as possible and perform the safest and best circumcision possible. To that extent, over the past 25 years I have always prepared the baby in a separate area before bringing him in for the ceremony and circumcision. However, one mohel writes, "I do not begin the procedure in the bedroom and complete the surgery in front of the guests. This method causes much distress to the baby and should be avoided."

My experience with close to 10,000 circumcisions does not support this claim. Parents are thankful that I perform a brit in this manner, saying that is more humane and relieves a lot of anxiety for them and their guests.

Furthermore, often there are accompanying medical findings such as scrotal swelling, abundant fat pad or congenital bending and or twisting of the penis that require special attention which is better attended to in the quiet of a separate area. Circumcision must never be considered to be a "one-size fits all" procedure. Every infant is unique and therefore demands individual care.

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