The debate about ritual circumcision with metzitzah b’peh (direct mouth-to-wound oral suctioning by the mohel) is complex, as it involves halachic, historical, social, medical, technical and potential regulatory components.
My personal interest and experience in ritual circumcision is long standing. I studied to be a mohel in Israel and was certified as a mohel by the Israeli Rabbinate in 1983. I have performed many circumcisions, mostly on babies of family members, and occasionally on children and adults from the former Soviet Union. Furthermore, as a vascular surgeon for the past 22 years, I have frequent interaction with infection and wound healing issues.
My first interaction with probable disease transmission from metzitzah b’peh (MBP) was in 1998, when an infant in my wife’s pediatric practice was treated for herpes infection of his genital area soon after a bris that included MBP. The latest case of an infant death in New York attributed to herpes associated with MBP is deeply disturbing to any parent, mohel, rabbi or public health official. Clearly we need to discuss MBP and at least entertain potential changes in ritual practice.
For those in a position to influence the debate, I present the following medically related points.
Transmission of herpes via MBP does occur in some cases. This has been amply established by multiple case studies reported in the medical literature and many unreported cases. These cases showed herpes in the genital area soon after a bris that included MBP; with little probability of a source for the infection other than the mohel’s mouth. While the frequency of such infection is difficult to quantify, it must be noted that medical case literature most often under-reports the frequency of unusual disease presentations prior to a widespread awareness of the disease having emerged amongst medical practitioners.
Even if we did not have these case reports, the potential for infection is totally consistent with what we know about herpes virus transmission, via oral contact. Would any sensible adult knowingly kiss a person infected with herpes, especially with an open wound? In our modern society, we accept this line of reasoning without question, yet somehow in the MBP discussion, arguments are presented which inexplicably imply that this logic somehow does not apply to a newborn. To the contrary; newborns may be at even greater risk since they are known to be relatively immune compromised.
In the 19th century, even before the widespread acceptance of Pasteur’s Germ Theory of Disease, there were many reports of children with genital syphilis and tuberculosis attributed to MBP. At the time, this generated significant halachic debate and led many rabbis to restrict MBP, most notably Rabbi Moshe Schreiber (the Chasam Sofer), who ruled that MBP could be accomplished by instrumental suction or a gauze/sponge. Ample evidence exists that in many European cities, the custom of many Orthodox communities was changed as a result.
Over time and with the essential elimination of syphilis and tuberculosis as a risk factor, MBP has had resurgence amongst some elements of the Orthodox community. We seem to have forgotten what was obvious to many over a century ago — that communicable diseases can be spread via MBP.
The herpes virus is a relative newcomer to the known pantheon of communicable diseases, most frequently associated in adults with oral and genital lesions. Is there any reason, however, to postulate that it behaves in some special way during a bris? Do we really need additional case studies to reconfirm the medical paradigm of infection transmission?
Herpes infection in a newborn may lead to lifelong infection, chronic neurological impairment and, at times, death.
The Talmud recommends MBP as beneficial to the health of the baby, consistent with ancient Greek and Roman medical theory. However, based on the current mainstream medical understanding of wound healing and infection prevention, there is no known medical benefit to MBP; certainly none that would outweigh its currently observed potential for harm.
A person may not be aware that he is infected with herpes, and virus shedding from the mouth surfaces may at times, occur without obvious oral sores. This is why we cannot expect caring and well-meaning mohels to be able to solve this problem by not performing MBP when they know themselves to be ill. To lessen the incidence of transmission we may construct an elaborate public health system to track and ensure that our mohels are “disease free” via frequent, perhaps monthly physical exams, blood and salivary immunoglobulin tests and perhaps viral cultures. Even if effective, are our mohels willing to accept this burden or are we willing or able to impose this on them?
From a technical standpoint, the goal of MBP is to apply suction and draw out blood from the wound. It can be easily demonstrated that suction may be equally accomplished via a sterile tube or to an even greater extent with a mechanical apparatus that does not involve any oral contact.
In order to have a sound and effective dialogue, we need to first accept the obvious — that MBP does entail a certain, yet at present, unquantified, risk of herpes transmission, and when transmission does occur, the results can be catastrophic. If this truism is accepted, rabbis and communal leaders can then productively discuss the other issues that may be pertinent and come to a conclusion.
Some of these questions are: Is the practice based on strict halacha or is it a less restrictive “minhag” (custom)? Are the origins of this practice and the historically attributed medical benefits relevant today, considering current medical knowledge that disavows the benefit of MBP and instead documents potential harm? Does the perceived threat to the “mesorah” (Jewish tradition) that any change in ritual practice would potentially cause, justify the risk of significant harm to the occasional newborn? What role, if any, should governmental regulation have?
I hope that medical misinformation will not cloud the discussion.
Gary A. Gelbfish is a practicing surgeon and certified mohel.