After Infant’s Death from Herpes, Scrutiny Turns to Circumcision Rite

The death of one infant boy from herpes and the infection of two others has focused attention on an ancient practice that is still used in some fervently Orthodox communities as they circumcise babies. New York City health officials are investigating whether the mohel who operated on the three boys had infected them. The city’s legal department has been granted a temporary restraining order against Rabbi Yitzchok Fischer until the investigation is complete.

Fischer practices a custom called metzitzah b’peh — loosely translated as oral suction — that is considered an integral part of the brit milah in parts of the Jewish world, though it is met with shock and distaste in others.

It’s not known if Fischer carries the herpes virus, but the restraining order forbids him from practicing metzitzah b’peh, and demands that he wear surgical gloves when he performs a circumcision.

The Talmud describes the process of removing the baby boy’s foreskin in three steps: The foreskin is cut, the mucous layer underneath is removed with a flick of the mohel’s fingernail and then the blood is removed through oral suction.

Often the first two steps are combined, and the fingernail motion is abandoned in favor of a surgical clamp.

In the third step, the mohel traditionally takes a sip of wine in his mouth, quickly sucks the blood off through the wine and spits the mixture into a bowl to be discarded. That’s metzitzah b’peh.

In some parts of the Orthodox world — mainly but not exclusively among Chasidim — metzitzah b’peh is still practiced.

Among other Orthodox Jews, however, metzitzah b’peh is considered unacceptable, and among more liberal Jews it’s unthinkable.

Fischer can do the brit either way, said his lawyer, Mark Kurzmann. He can use his mouth directly or he can suck the blood through a thin glass pipette.

“It depends on the preference of the parents, and that depends on their particular religious community,” Kurtzmann said.

He added that “tens of thousands” of circumcisions using metzitzah b’peh have been done in the last seven years, with very few adverse results.

Not true, concluded researchers writing in the August 2004 issue of the medical journal Pediatrics.

“Ritual Jewish circumcision that includes metzitzah with direct oral-genital contact carries a serious risk for transmission of HSV” — herpes simplex virus — “from mohels to neonates,” the article said. “Oral metzitzah afer ritual circumcision may be hazardous to the neonate.”

Signed by 12 medical doctors and Ph.D. researchers, the paper examined the cases of eight young babies who had developed herpes within two weeks of their circumcisions.

The only disease vector shared by all the babies was the mohelim, all of whom tested positive for the herpes virus and all of whom had performed metzitzah b’peh.

One of the researchers was Rabbi Moses Tendler, who holds a doctorate in biology and teaches biology at Yeshiva University, teaches rabbinical students at Y.U.’s seminary, specializes in Jewish medical ethics and also is a pulpit rabbi.

Tendler minced no words when discussing metzitzah b’peh.

“What people don’t understand is how widely disseminated the herpes virus is. Statistics say that 80 percent of the adult American population carries it, as you well know from how many people in their lives acquire a cold sore,” he said. “It’s an omnipresent danger, and for an infant, in the early days before his immune system kicks in, it’s not necessarily localized. It can be a systemic infection.

“I’m particularly disturbed that once this information becomes available, the mohelim don’t do what they’re told,” Tendler continued. “When the AIDS epidemic started, the gadolim” — the great rabbinic scholars of their day — “concluded that the mohelim should use a sterilized glass tube so they could avoid catching AIDS from the baby. It never occurred to them to think that the baby could catch something from them.”

Rabbi Daniel Korobkin, rabbi of Kehillat Yavneh in Los Angeles, is Orthodox and a mohel.

“I will perform a routine brit only with completely antiseptic material, making sure that I never come in direct contact with a child’s blood,” he said.

“The only exception was my own children. If a parent asks me to do it, I refuse,” he continued. “I do give the father the option of doing it himself, though. Most are too squeamish, but a few want to do it.”

Korobkin trained as a mohel in 1990 in Jerusalem; by then, he said, the dictate to avoid metzitzah b’peh had been in place for some time.

In fact, he added, the precedent for avoiding direct contact with the baby’s blood can be traced to an outbreak of disease in the early 19th century; until then the practice was widespread. Then the great sage known as Chatam Sofer decreed that such contact could expose the child to danger.

The Shulchan Aruch — the authoritative medieval compendium of Jewish law — “takes great pains to instruct every mohel to make sure that his utmost priority is the safety and welfare of the child,” said Rabbi Tzvi Hersh Weinreb, executive vice president of the Orthodox Union.

“I think it’s fair to say that there are a substantial number of Orthodox rabbis who find nothing objectionable whatsoever” in using a pipette, Weinreb said.

As an umbrella organization, the Orthodox Union doesn’t have an official policy on ritual or religious matters. If pressed for a personal recommendation on which method to use, however, Weinreb said that for safety’s sake he would suggest following Korobkin’s lead.

Rabbi David Zwiebel, executive vice president for public affairs at Agudath Israel of America, a fervently Orthodox umbrella group, said his organization is dedicated to supporting the range of religious expression found among its constituent groups.

Orthodox Jews whose traditions come from the German community never use metzitzah b’peh, he said, but it’s common in many of the Brooklyn-based Chasidic communities that trace their roots to eastern Europe.

He added that it hasn’t been proven that the babies had contracted herpes from Fischer, suggesting that other means of transmission were possible.

The question of whether metzitzah b’peh should be done depends on whether that stage of the brit is considered an integral part of the procedure or simply medical aftercare, Zwiebel said.

Communities that consider it integral often consider themselves bound to use traditional methods, such as metzitzah b’peh, he said, while those that do not consider it integral are free to use what they consider to be a safer method.

Tendler said that in his Monsey, N.Y. community the practice of metzitzah b’peh is spreading, as is cutting the foreskin and removing the mucous layer in two discreet actions. The use of the surgical clamp is coming under fire as well, he said.

“It’s seen as the frum” — or observant — “thing to do,” he said. “Being ‘frumer than thou’ is now the sign of personal piety. At certain life-cycle events, people are afraid to take a lenient approach.”

There is a religious requirement to perform a brit milah painlessly, which means as quickly and as antiseptically as possible, Tendler said.

“This is a requirement of Jewish law, not of medicine only,” he said. “Metzitzah is strictly medieval medicine, and it should have given way to modern medicine.

“We have a tradition that says that when it comes to medicine, you don’t look into the Talmud. You seek the most competent physician to tell you what to do.”