Zevachim 22b ~ On the Physical and Mental Dangers of Circumcision

Milah knife..jpg

An uncircumcised Cohen may not, we are told in a Mishnah, offer sacrifices at the Temple in Jerusalem.  Just how did the Mishnah know this? In tomorrow's daf, we learn the answer:

זבחים כב,ב

 אמר רב חסדא דבר זה מתורת משה רבינו לא למדנו מדברי יחזקאל בן בוזי למדנו: כל בן נכר ערל לב וערל בשר לא יבא אל מקדשי לשרתני

Rav Chisdah says: We did not learn this matter from the Torah of Moses, our teacher; rather, we learned it from the words of the prophet Ezekiel, son of Buzi: “No stranger, uncircumcised in heart or uncircumcised in flesh, shall enter into My Sanctuary to serve Me” 

From the words "uncircumcised in flesh" the Talmud learns that a Cohen for whom circumcision would be life-threatening is forbidden to take part in sacrificial rites.  Earlier, (on page 15b) Rashi explains how circumcision might be dangerous:

 ערל. כהן שמתו אחיו מחמת מילה

Not circumcised: This means a Cohen whose brothers have died due to circumcision.

To understand the today's daf, we need to remind ourselves of the genetics of hemophilia. So let's go.


The classic teaching about bleeding deaths and circumcision is found in Yevamot 64a.

יבמות סד, א 

תניא מלה הראשון ומת שני ומת שלישי לא תמול דברי רבי רבן שמעון בן גמליאל אומר שלישי תמול רביעי לא תמול... א"ר יוחנן מעשה בארבע אחיות בצפורי שמלה ראשונה ומת שניה ומת שלישית ומת רביעית באת לפני רבן שמעון בן גמליאל אמר לה אל תמולי

It was taught: If she circumcised her first son and he died, and her second son and he too died, she should not circumcise her third son, so taught Rebbi.  Rabbi Shimon ben Gamliel stated that she should indeed circumcise her third child, but [if he died] she must not circumcise her forth...Rabbi Yochanan said that there was once a case in Zippori in which four sisters had sons:  The first sister circumcised her son and he died, the second sister circumcised her son and he died, the third sister circumcised her son and he died, and the forth sister came to Rabbi Shimon ben Gamliel and he told her "you must not circumcise your son" (Yevamot 64:)

The Talmud here is describing a disease that is affected through the maternal line (hence the four sisters - all of whom seem to pass this disease on to their male children). The disease is X-linked Hemophilia A; the term X-linked indicates that the faulty gene is carried on the X chromosome, which is men is always inherited from the mother. Hemophilia A is an X-linked recessive genetic disease, first described by the American physician John Conrad Otto, who in 1803 described a bleeding disorder that ran in families and mostly affected the men. John Hay from Massachusetts published an account of a "remarkable hemorrhagic disposition" in the New England Journal of Medicine in 1813.

NEJM report of hemophilia 1813.png

If the mother is a carrier  - as were each of the four sisters in Zippori - then she has a one in four chance of passing on the disease to a child, and that affected child will always be a son:

In Yevamot, the rabbis argued over a technical point - that is, how many cases of bleeding are needed to establish a pattern. According to Rebbi (that is  Rebbi Yehuda Ha-Nasi, c. 135-217 CE.) two cases were sufficient, while Rabbi Shimon ben Gamliel insisted on three cases before ruling that there was a life threatening pattern.  Indeed the disease in boys must have been very perplexing, because (as you can see in the diagram above) not every boy would be affected. In fact, if the mother is a carrier and the father is not, there is only a 50% chance of a boy having hemophilia.  It is this fact that perhaps explains the dispute between Rebbi and Rabbi Shimon ben Gamliel regarding how many children need to exhibit the disease before we can assume that any future male child will also have it.  If every boy born in the family would have been a hemophiliac, Rabbi Shimon's ruling would have seemed unnecessarily cruel.  But since by chance, half of the boys born might not have hemophilia, the need to demonstrate the prevalence of the disease (in a society in which its genetic foundations were not known) seems eminently sensible.

In  Hemophilia A there are various genetic mutations that result in low levels of clotting factors. These levels may be only mildly decreased, or so low that severe life threatening hemophilia results. It is treated with transfusions of clotting factors which restore the levels to normal. Although these transfusions must be given several times a week in those with severe disease, there is hope that recombinant clotting factors can lengthen the time between the needed transfusions.

A Different explanation FROM Rabbenu Tam

In tomorrow's daf in Zevachim, we learn that there were indeed examples where what we call hemophilia A had been diagnosed, and as a result there were Cohanim who remained uncircumcised as adults. At least according to Rashi. But his grandson, Rabbenu Tam, has a different explanation. The Cohen did not have a clotting disorder. Rather, he was afraid of the pain of the procedure:

ערל. מפרש רבינו שלמה  בכל מקום שמתו אחיו מחמת מילה ור"ת מפרש דמומר לערלות וקרי ליה לבו לשמים לפי שאינו עושה אלא מדאגת צער המילה

According to Rabbenu Tam, this Cohen does not refuse circumcision as an act of religious rebellion. Rather, he refuses because of the pain involved in the procedure. Rabbenu Tam does not explain why the parents of the Cohen in question had not has him circumcised as a newborn - when he was in no position to object. But he makes a larger point: that a Jewish man who, out of fear, refuses to be circumcised - or to circumcise his newborn son - is not considered to be a religious rebel. Instead, he is called "one whose intentions are for the sake of heaven" - קרי ליה לבו לשמים.

Perhaps this expansive thinking of Rabbenu Tam might include today those who choose not to give their Jewish children a Brit Milah, because of concerns about informed consent.  Iceland recently introduced legislation to ban circumcision until a child reached the age of consent and could make an informed decision about his own genital future.  Rabbenu Tam would of course have wanted all Jewish newborn boys to have a Brit Milah and be welcomed into the Covenant of Abraham, but might he also understand those who felt differently?

[Partial repost from Repost from Yevamot 64a.]

Tagged: Hemophilia ACircumcision


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