For more than a decade, the charedi leaders and City Hall officials have been in a standoff over the circumcision ritual known as metzitzah b’peh.

Health officials say the practice puts newborns at unnecessary risk for catching the herpes virus, which can be fatal, while supporters say it’s a religious mandate that is no more risky than other, more common newborn-related practices.

The impasse has been followed closely by the press and the public as a significant church-state issue, but most of the focus has been on political and legal questions: Will regulating or banning the practice help the mayor at the voting booth or hurt him? If it is regulated, what is the politically safest way to do it? And from a legal standpoint, can it be regulated, or would doing so infringe on freedom of religion?

Much less focus has gone to the question of whether it should be regulated; that is, how risky is metzitzah b’peh (MBP) compared to several, more culturally accepted but risky practices, such as parent-infant bed sharing or allowing someone with a cold sore to care for a baby.

An 8-day-old baby at his bris ceremony. Getty Images

In metzitzah b’peh, the mohel sucks on the baby’s penis to draw blood away from the circumcision wound. Many believe believe it first became a part of the ritual for health reasons, under the belief that drawing blood out would cleanse the incision. Since 2000, 24 babies have contracted neonatal herpes following MBP. Two died and two were brain damaged, according to the Centers for Disease Control. Some 5,200 babies — 48 percent of all Jewish baby boys in New York City — had a bris with metzitzah b’peh in 2006, according to a study by Awi Federgruen, a professor of quantitative methodology at Columbia Business School.

After a baby died following MBP in 2005, the Bloomberg administration began trying to convince the charedi population to switch to a technique in which the mohel sucks on a sterile glass tube to draw blood from the wound, a method that is widely used and has been approved by the Rabbinical Council of America, the largest umbrella organization for Orthodox rabbis in the United States. In 2012, the Bloomberg administration began requiring parents to sign consent forms detailing the risks of MBP. There was no enforcement, however, and the forms were greatly resented but almost never used.

In 2015, Mayor Bill de Blasio instituted a new policy in which mohels who circumcised a baby who contracted HSV-1 would undergo DNA testing to determine if they were the person who passed it on, and if so, the mohel would be banned from practicing MBP. Mohels supported the plan, which the health department in Rockland County uses. However, in the two years since, approximately a half dozen babies have been infected with HSV-1 after MBP, and no DNA testing has been done.

If an infant shows symptoms of HSV-1 after MBP, the health department will ban the mohel from practicing MBP unless he tests negative for the virus … even if he provides a DNA test showing that he has a different strain of the virus than the baby.

In March, the city changed the policy so that if an infant shows symptoms of HSV-1 after the ritual, the mohel is automatically banned from practicing unless he tests negative for the virus. HSV-1, which causes cold sores, is carried by 67 percent of American adults, meaning that whether or not the mohel infected the baby, he is likely to test positive and be banned.

City health officials say DNA testing is not necessary because a positive antibody test for herpes in the mohel, plus epidemiological factors, such as the timing and location of the herpes outbreaks after MBP “provides the most solid evidence to determine the source of an HSV-1 infection,” a health department spokeswoman said. So even if a mohel who tests positive for the herpes antibody were to present the health department with a DNA test showing that he has a different strain of the virus than the baby, health officials will ban the mohel from practicing MBP. Mohels who violate such an order are subject to a $2,000 fine.While Daskalakis acknowledges that HSV-I can  be transmitted through people other than the mohel who have contact with the baby, he says that doesn’t change the fact that MBP is dangerous and should be stopped. “One really important example of a postnatal HSV exposure in our jurisdiction is direct orogenital suction [MBP],” he said. “I think that we have pretty good epidemiological evidence that thats [MBP] is one easily preventable way of postnatal acquisition of HSV.

An orthodox bris ceremony. Getty Images

“If you have someone who is walking across the street and there is a bus there that hit them, you don’t need more information about the bus if you know that it [the accident] happened,” Dr. Demetri Daskalakis, New York City’s acting deputy commissioner for disease control and mental hygiene, told The Jewish Week in a telephone interview. While DNA data, he said, “ends up being interesting, it doesn’t change the story.”

“If you have someone who is walking across the street and there is a bus there that hit them, you don’t need more information about the bus if you know that it [the accident] happened. ”

But MPB defenders say that if health officials think the practice is “easily preventable,” they don’t understand charedi culture at all.

“In life in general and in public health, we tend to accept risk if it’s an activity that we value,” said Akiva Turner, Ph.D., J.D., M.P.H. Turner, whose Ph.D. focused on the role of culture in public heath, is director of the Ph.D. in Health Science Program at the College of Health Care Sciences at Nova Southeastern University in Fort Lauderdale, Fla.

“The No. 1 injury death in South Florida is drowning in swimming pools. Are we going to get rid of swimming pools? Of course not, because we value it. If we value something we’re willing to accept risk, even the risk of death to children,” said Turner, who served as general counsel in the New York City health department from 2007-2009. “But if it’s something that we don’t value then we’re willing to accept no risk and we want the activity wiped out.” According to the Florida health department, in 2012, 57 children between the ages of 1 and 4 drowned. (In 2012 in New York City, one baby was infected with HSV-1 following MBP and was successfully treated, according to the city health department.)Health officials said their job is to raise awareness about health risks and part of that mandate is informing parents that the best way to protect babies from HSV-1 is avoid MBP. They acknowledge that “ultimately this is the parents’ decision,” but note that while HSV-1 can be treatable, “it can also cause permanent damage and can be deadly.”

“What seems to be missing [among city health officials] to me is the sensitivity, an understanding that to the Orthodox Jewish population, this is of value to them.” – Dr. Daniel Berman

Dr. Daniel Berman, an infectious disease specialist at Montefiore Medical Center and longtime defender of MBP, agreed with Turner’s point, noting the recent injury to a child at Yankee Stadium who was hit in the head after a bat broke and a piece flew into the stands. People take precautions to reduce risk — fences around pools, netting at stadiums — they don’t outlaw the activities altogether if they value them, he said.

“What seems to be missing [among city health officials] to me is the sensitivity, an understanding that to the Orthodox Jewish population, this is of value to them. Obviously it’s irresponsible if the risk were significant, but here, there is no proof that there is risk, but even if there were risk, the risk [would be] so small, and the focus should be on risk-reducing measures,” he said.

An eight-day-old baby lies in his stroller alongside photos of Jewish sages and prayers from the Psalms, after his bris circumcision ceremony. Getty Images

In 2012, city health officials published a study in a CDC publication estimating that the rate of neonatal herpes in boys that have had MBP is higher (24 per 100,000) than among the general population (8 per 100,000). Federgruen maintains that the city significantly underestimated the population of boys undergoing MBP, primarily by underestimating the number of boys born to chasidic parents and by ignoring the MBP practice among the Sephardic population altogether. Correcting for even just the first error, Federgruen argued, reduces the infection rate in the MBP population to 16 per 100,000. Because there are so few cases of babies contracting HSV-1 after MBP, the margin of error in the study is large enough to make the difference statistically insignificant. 

Even if the infection rate among boys who had MBP were higher than that in the general population, the finding shows correlation, not cause, Federgruen and Berman said.

“We tend to accept risk if it’s an activity that we value. The No. 1 injury death in South Florida is drowning in swimming pools. Are we going to get rid of swimming pools? Of course not, because we value it. If we value something we’re willing to accept risk, even the risk of death to children. But if it’s something that we don’t value then we’re willing to accept no risk.”

They argue that a difference would be due to non-MBP factors. For one thing, people in lower socioeconomic communities have a higher rate of HSV-1 infection — 90 percent compared to 67 — due to crowded conditions and homes that often have several children.

“If you look at the babies in this population, there are so many individuals that handle the baby. There are large families, friends come over, so many people handle the baby. And the fact that you have an open wound puts them even more at risk,” Berman said during a telephone interview with The Jewish Week. He also notes that it’s likely that neonatal herpes is diagnosed at a higher rate among charedi Jews because both families and caregivers are so aware of the danger. Finally, he argues out that research shows that if someone contracts herpes, by whatever means, the sores are most likely to show up at a site of trauma, not at the site of transmission, which means that the location of the resulting lesions is irrelevant. 

In addition, Federgruen notes that children tend to have lower hygienic standards than adults, adding to the contention that a household chock-full of kids has a higher likelihood of HSV-1 transmission.

“Indeed,” he said in an email, “the infection rates reported in various regional studies in North America range widely, from 5.8 to 60 per 100,000.”

Salom Hen holds his eight-day old son Ofir during a bris circumcision ceremony in a bomb shelter during the Second Lebanon War in Haifa on 26 July 2006. Getty Images

Other doctors see it differently.

“There are other routes to infections,” said Dr. Stephen Morse, a professor of epidemiology at Columbia University Medical Center. “On the other hand, parsimony would say: If there’s a lesion in a place where there could have been contact with herpes, you would assume that the most likely contact is how someone got it.”

Dr. Harold Perl, senior neonatologist at Hackensack Medical Center,  agreed. “You want to call this circumstantial evidence? It’s extremely strong circumstantial evidence,” he said.

“You now have an open wound and then you put your mouth — which is a swamp — on it?” he said. “You don’t put anything dirty on an open wound. To say, ‘Oh no, it doesn’t affect it,’ is silly.”

“You now have an open wound and then you put your mouth — which is a swamp — on it? You don’t put anything dirty on an open wound. To say, ‘Oh no, it doesn’t affect it,’ is silly.”

That said, Perl, an Orthodox Jew, knows the value the charedi community places on MBP and argues the health department needs to work from that understanding.

“You have to approach the charedi community and say, ‘We understand you are going to do metzitzah b’peh, we accept that,’” he said in a telephone interview with The Jewish Week.

Perl suggests that the focus shift to how to make the practice safer. His suggestion: Mohels would be tested for HSV-1 monthly. If the mohel tests positive, he continue to do the circumcision part of the bris but have an HSV-1 negative  trained assistant, such as a seminary student, do the MBP part of the ritual, allowing the mohel to continue in his profession.

Orthodox Jews, he said, “supervise all the meat that they eat; they can supervise the mohelim,” as well, he said.

Editor’s note: This article has been updated to include the fact that many Orthodox Jews use a sterile glass tube instead of direct oral contact during the bris.