When Rachamim “Rocky” Cohen was planning his oldest son’s brit milah, the ancient Jewish ritual of circumcision, the mohel, or ritual circumciser, asked if he wanted should use direct oral suction, known as metzitzah b’peh. Cohen, a Lubavitch Chasid who lives with his wife, two sons and a daughter in Miami, told him to do whatever he wished. The mohel didn’t use the controversial technique during that bris two years ago, but without asking again, performed metzitzah b’peh on Cohen’s younger son, now 6 months old.
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“If he had asked me I would have been a little more hesitant,” said Cohen, an attorney, who also said he trusts the mohel “99.99 percent” but that there’s a slight concern it could pose a risk to the baby.
The New York City Department of Health and the United States Centers for Disease Control say there is risk to a baby’s health and life any time direct oral suction is used as part of a brit milah, since the mohel can unwittingly transmit a potentially lethal virus by putting his mouth on the open wound. A baby circumcised using metzitzah b’peh has a 3.4 times greater chance of contracting Herpes Simplex Virus-1, or HSV-1, than one is circumcised without it, the CDC says.
The city is now moving to regulate the practice by requiring that mohels obtain informed parental consent before using direct oral suction. The 11 members of the New York Board of Health will vote on the proposed change to health regulations on September 13.
Backlash from the Haredi community, the only one that uses direct oral suction, has been vociferous, equating the regulation with the worst persecutions in Jewish history.
At a meeting in late June at the Central Rabbinical Congress in Williamsburg, Brooklyn, Rabbi Aharon Teitlebaum, head of the faction of the Satmar Hasidic community centered in the upstate New York village of Kiryas Joel, said, “We will fight until the end. We will not compromise. We held out in the Spanish Inquisition and in German concentration camps, so too will we hold out against the metzitzah b’peh decree.”
Members of the Haredi community say public health authorities have not incontrovertibly proven the link between metzitzah b’peh and the babies’ HSV-1 infections. Articles in the Haredi press have attacked the health department’s assertions and portrayed the community as a victim of government “intimidation tactics.” A July article in Yated Neeman, a weekly Haredi newspaper, said the Health Department’s assertion that babies have been infected with herpes from the ritual is “a myth” that authorities are “bent on propagating.” They accuse the department of instigating a type of mohel witch hunt, badgering parents with ill babies to give up mohel names.
In the Yated article, the father of an infected boy faulted his wife for infecting their son by chewing on her finger when she had visible cold sores and then changing the post-circumcision dressing. The mother of another of the neonatal herpes victims said an older sibling was to blame for licking the baby’s pacifier.
But infectious disease experts say that these theories are not likely, particularly when the herpes sores appeared in the diaper area.
“[It] just makes no sense,” said Dr. Jonathan Zenilman, president of the American STD Association and chief of the Infectious Diseases Division at the Johns Hopkins Bayview Medical Center. “Where are the girl cases if it can be transmitted that way? If that happened with the number of people who have herpes we would see tons of babies all the time.” Zenilman spoke from Israel, where he taught a summer course on advanced epidemiology at Tel Aviv University.
Others warn what will happen if the health department maintains its approach.
“The result will clearly be litigation and more confrontation,” wrote Rabbi David Zweibel, executive vice president of Agudath Israel of America, in a letter to the New York City Health Department. “[It] is fostering the perception in the community that the Department is heavy-handed, set on direct confrontation, and potentially interested in perhaps banning metzitzah b’peh and regulating other aspects of bris milah as well.”
New York City Health Department spokeswoman Alexandra Iselin Waldhorn said the proposal is legal and that the department is confident it would hold up against a lawsuit.
At a July press conference, New York City Mayor Michael Bloomberg said, “We have an obligation to keep people alive and safe and the courts have held that up repeatedly.”
While mohels in other segments of the Jewish community use a glass pipette to suction the blood or wipe it away with gauze, for the ultra-Orthodox, metiztzah b’peh is an inviolable tradition.
“The authorities are trying to infringe on that freedom by taking away a certain religious process, which is unconstitutional,” said Rabbi Avrohom “Romi” Cohn, chairman of the American Board of Ritual Circumcision, a Brooklyn-based organization with 75 to 80 members that all practice direct oral suctioning.
Monitoring the situation in New York, Israel’s pediatrics society has requested that Israel's Ministry of Health require informed parental consent for metzitzah b’peh or that the suction be done without direct oral contact.
The CDC’s June report, which is based on a New York City Health Department study, cites just 11 reports of neonatal herpes traced to direct oral suction between 2000 and 2011. Two of the babies died and at least one was left with brain damage. In 2006 the department began requiring health care providers to report HSV-1 in babies under two months old.
There have been additional cases this year and others not included in New York City Health Department reports because they involve residents of other areas.
In June, a two week-old baby from Kiryas Joel was admitted to New York Presbyterian/Columbia University Medical Center for treatment after being infected with HSV-1 through direct oral suction during his brit milah. After a two- to-three-week hospitalization he appeared to have recovered, said Dr. Lawrence Stanberry, chairman of the pediatrics department at Columbia University Medical Center and Pediatrician-in-Chief of the Children’s Hospital of New York Presbyterian. There have been three cases at the hospital in the past five years, he said. “Most often those babies have to be on anti-virals for life.”
At Monmouth Medical Center near the large Haredi community of Lakewood, New Jersey, a baby was admitted in early 2012 with HSV-1 caused by oral suctioning during his circumcision. Another baby was treated there a year or two earlier for the same reason, said a source. Both survived.
There have been no other cases related to metzitzah b’peh reported to the New York City Health department this year, said Waldhorn.
“The risk is small, but the risk is not zero, and the consequence is really substantial,” said Stanberry, who edited a medical textbook on neonatal herpes.
“It’s one of those diseases which is not common but it is deadly. Neonates’ immune system is not mature, and that’s why we try to protect them in that first month of life in particular,” he said.
A brochure informing parents of the risk of the ritual and advising that they consult with their mohel and pediatrician is now being distributed at all city-run hospitals as well as eight other hospitals in New York City and on Long Island. It is also being distributed, in English and Yiddish, in communities outside the city by the New York State Department of Health.