N.Y. health board proposes consent waiver on circumcision rite

New York City health officials have proposed requiring that Jewish parents sign a consent waiver in order to use a controversial circumcision-related rite.

At a city Board of Health meeting on Tuesday, the department’s deputy commissioner for disease control, Dr. Jay Varma, proposed the waiver for the use of direct oral-genital suction, known as metzitzah b’peh. The form would indicate that parents are aware of the risk of infection.

The controversy over metzitzah b’peh was reignited in March after it came to light that an unidentified infant died Sept. 28 at Brooklyn’s Maimonides Medical Center from “disseminated herpes simplex virus Type 1, complicating ritual circumcision with oral suction,” according to the death certificate.

Health Department investigations of newborns with the herpes virus from 2000 to 2011 have shown that 11 infants contracted the herpes virus when mohels, or ritual circumcisers, placed their mouths directly on the child’s circumcision wound to draw blood away from the circumcision cut, according to a statement from the department. Ten of the infants were hospitalized, at least two developed brain damage and two babies died.

Varma said during the meeting, according to The New York Times, that two of the families whose babies contracted herpes after metzitzah b’peh was performed did not know it would be used. He added that since March, other families have called the department with concerns that their mohel would perform the rite.

A public hearing on the consent waiver proposal is scheduled for next month, with a vote by the board slated for September.

Last week, city Health Commissioner Dr. Thomas Farley called for an end to metzitzah b’peh and said that several hospitals, including those serving the haredi Orthodox Jewish community, have agreed to distribute a brochure that describes the risk of contracting the herpes virus from the practice.

The rite is not used in most Jewish circumcision ceremonies, but many in the haredi Orthodox community still adhere to it. Haredi leaders have resisted calls to replace direct oral suction with alternative approaches used by some mohels, such as the use of a sterile tube or gauze to take the blood from the circumcision wound.

Death Spotlights Old 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 ultra-Orthodox communities as they circumcise babies.

As New York City health officials continue to investigate whether Rabbi Yitzchok Fischer had infected the three boys, here in Los Angeles, while people have expressed shock at the story, they are even more surprised that the custom is still in practice at all.

Metzizah b’peh — loosely translated as oral suction — is the part of the circumcision ceremony where the mohel removes the blood from the baby’s member; these days the removal of the blood is usually done using a sterilized glass tube, instead of with the mouth, as the Talmud suggests.

While it’s not known whether Fischer carries the herpes virus, the city ordered him to stop performing metzizah b’peh by mouth and to use a sterile tube and wear surgical gloves when performing a circumcision.

But is anyone else practicing it?

Los Angeles rabbis and mohels say that the practice is not prevalent, confined primarily to Chasidic groups.

“Even within the Chasidic community the procedure is restricted to only parts of that community,” said Rabbi Yitzchok Adlerstein, director of Project Next Step at the Simon Wiesenthal Center. “And in the non-Chasidic community, some of the most [Orthodox] conservative thinkers have gone on record as being opposed to the procedure.”

The demographic is so small, that there are no statistics available on exact numbers that still perform metzizah b’peh or even which Chasidic groups still practice it.

And it’s not a custom that’s about to gain popularity.

“I certainly don’t see it as becoming more prominent,” said Rabbi Daniel Korobkin of Kehillat Yavneh, who has been a licensed mohel for 15 years. Korobkin stressed that at this stage of the investigation, fears should be tempered.

While all those interviewed acknowledged the death of the baby as a terrible tragedy, none believed there should be any reason for people to panic.

“Most Jews aren’t Orthodox here,” said Samuel Kunin, a board-certified urologist who has been a mohel for 15 years catering to the non-Orthodox Los Angeles community. “I don’t think, in general, it’s going to affect many people. So far, nobody’s even questioned me about the issue.”

One of the most popular mohels in the community said he only had one person question him recently because of the case. “I’ve been doing this for over 25 years,” Rabbi Yehuda Lebovics said. He said that people trust him. “They know I’ve never had an infection of any kind, and that I clean my instruments, wear gloves and wash my hands.”

Korobkin added that while people are definitely aware of the current incident, he has not received any anxious phone calls from parents who have brit milah ceremonies approaching. That may have something to do with the fact that Korobkin has only performed metzizah b’peh on his own sons. “Because their immune systems are closer to mine, and both my wife and I knew we had no communicable diseases,” he explained. “But I would not take the risk for myself personally, because I wouldn’t want to contract or transmit a disease from or to a child.”

Korobkin also refuses to perform metzizah b’peh without the tube — even if parents ask.

“No matter how long a guy’s beard is or how pious a person is, you can still contract herpes or even HIV through a blood transfusion,” he said.

While he acknowledged the Talmud’s reasoning of metzizah b’peh at the time it was written was to prevent any unhealthy coagulation of the blood, today, he argued, using a device that ensures the mohel’s mouth doesn’t come into direct contact with the child is just as effective and acceptable.

“We know the practice is not based on anything in Jewish law, it’s something that is meta-halachic,” Korobkin said. “So the question is, can you really justify endangering a child’s health for something that only provides a nonhalachic benefit? And the logical conclusion is no. It doesn’t make any sense.”

Lebovics, who also only practices metzizah b’peh with a tube, agreed. “Since the spread of AIDS and herpes has also become more prevalent, it’s not good for either me or my patients. I stopped doing [metzizah b’peh] many many years ago.”

Korobkin also cited an article in the August 2004 edition of the journal Pediatrics, in which scientific medical studies proved that eight babies in Israel contracted the herpes simplex virus following ritual circumcision using metzizah b’peh.

“And the most important overriding principle for any mohel, the first directive we receive in our training, is that the child’s safety is paramount,” he said. “It comes before anything. If there’s even a question that there might be a problem, we always delay the brit.”

So why would anyone take the risk, however small, of performing metzizah b’peh?

“The Talmud also speaks of a mystical concept that is supposedly beneficial for the child when metzizah b’peh is performed,” Korobkin said.

That is apparently something that those who continue to practice metzizah b’peh are not willing to relinquish.

Both Korobkin and Adlerstein confessed to not knowing what the exact benefits were. However, according to Adlerstein, “some people see these nonhalachic sources as an integral part of the brit milah.”

He also pointed out that in particular branches of Chasidism “there is a tradition that believes every mitzvah operates on both the surface plane and the mystical plane. It all ties in to the greater rules about how God ordered the cosmos.”

Whatever the reasoning, people affiliated with the anti-circumcision movement used Internet blogs and chat rooms to spread the story when it initially broke in New York, and spread accusations that equated rabbis with pedophiles. However, none of those interviewed feared a major backlash against the community.

“Mohels view themselves as physicians,” Korobkin said.

As to the accusations of pedophilia, he said, “There’s nothing glamorous or sensual about a bloody infant phallus. Metzizah b’peh is both unprovocative and unsensual. It’s not a desirable thing to do by any stretch of the imagination. Anyone who wants to take a stab at Orthodox practices doesn’t need to take this particular issue to do that.”

Kunin agreed, saying, “I think this is going to have a small effect, if any at all. And then only in the Orthodox community [where metzizah b’peh is practiced]. Anti-circumcision people have an amazing way of manipulating the media.”

Lebovics also felt the issue was being blown out of proportion, but conceded that “anything negative about something Jewish is not good for the Jewish people.”

If, however, the New York City Health Board discovers that the three babies did in fact contract herpes from Fischer, then, and only then, Korobkin said, “a stance should be taken by the rabbinical bodies; some kind of cautionary release, that every mohel should be regularly tested for communicable diseases, and that he should not be practicing metzizah b’peh. However, to say across the board it should not be performed, I don’t think that’s something that should be regulated, as long as the proper precautions are taken.”

Adlerstein added: “Most of those regulations are currently in practice, with mohels who do regularly check themselves. I believe that this issue will be and is already being addressed by groups that will protect the health of the babies.”

So far, he continued, there has been no causal link established in Fischer’s case. “There’s no smoking gun here.”

The real issue here, he said, “is the risks of the state intruding on important matters of personal choice, such as religious beliefs. Society has sort of gone on record as being reluctant to intrude on personal choice. And there are far greater health risks these days, including risks in pregnancy, or unprotected gay sex, that far outweigh metzizah b’peh that has been practiced for decades and decades.”

The Great Mohel Question

Choosing the person who will perform a surgical procedure on your 8-day-old son is not a decision that should be taken lightly.

While it may sound obvious, most mohels say, “Pick someone with whom you feel comfortable.”

And that tends to be the case, with many in the area finding their work via word of mouth. Usually they are approached by someone saying, “You did my friend’s, cousin’s, brother’s son’s brit, and we want you to do our son’s.”

Parents should feel comfortable enough around the mohel to ask any questions, no matter how silly they may seem.

Beyond that, there are several other considerations to take into account. First you must make the decision whether you want to use an Orthodox, Conservative or Reform mohel. If you want anesthesia to be used on your baby, you’ll need to find a mohel who is also a licensed medical practitioner. Mohelim who are not medical practitioners are not allowed to administer anesthesia, although many use creams that contain mild anesthetic properties.

Other issues that parents should take into consideration include the type of ceremony the mohel intends to perform, how many years’ experience he or she has and yes, how much they charge for their services.

Parents should also try to ask more technical questions regarding the actual procedure itself, including the sterilization of the mohel’s instruments and whether or not he or she uses surgical gloves.

Most importantly though, the brit milah is a major Jewish life-cycle event. It’s important that both you and the mohel are in sync with how the religious part of the ceremony and naming of the baby will be conducted. — KH