New York Debates State Guidelines for Circumcision Procedures

By Linda Orlando

For thousands of years, rabbis called "mohels" have performed ritual circumcisions on male infants. The circumcision, called a bris, was performed in a home and not in a hospital, and would usually end with the mohel cleansing the wound using a simple procedure called "metzitzah b'peh" in Hebrew—he would suck the blood from the cut and spit it out.

Most Jews abandoned that part of the ritual long ago, but there are some ultra-Orthodox sects in a few Hasidic communities that still practice it as part of ritual circumcisions. But a heated debate has been brewing between religion and science in New York City, where the state Health Department is drawing up its first set of safety guidelines to govern circumcision. The debate was sparked last year by the death of a child who had undergone the metzitzah b'peh circumcision ritual by a mohel who used the centuries-old method.

Doctors have been concerned for years that the metzitzah b’peh procedure could spread disease, but until now the government has not gotten involved in the debate. But last year New York City health officials said the practice had given a baby an infection that caused it to die. The infection was caused by herpes simplex type 1, a common virus in saliva that causes cold sores. Up to 70% of all adults carry the herpes simplex 1 virus, and it is difficult to detect when the virus is contagious. Usually the virus is harmless to adults, but it can be deadly to newborns.

New York City officials say they have linked four other herpes infections since 1988 to two mohels, and two more were reported in 2005, including one in which a child suffered brain damage. Although there have been suggestions by government officials and the medical community that the practice should be stopped, such suggestions have been staunchly opposed by some Hasidic leaders who say that Jewish law commands the act. When the city’s health commissioner recommended that infants not be circumcised, Jewish leaders threatened protests.

Dr. Jonathan M. Zenilman, a Johns Hopkins School of Medicine professor, said that although documented infections from the metzitzah b’peh procedure have been rare, there is enough potential risk involved to justify a ban on the ritual. "This is something that is pretty much counter to all of the infection-control measures that we have," Zenilman said. He added that asking mohels to police themselves to prevent risks would be ineffective, particularly since it is unusual for someone to know if they even have the herpes simplex 1 virus since its effects are relatively benign in adults, and it is difficult to tell when it is contagious.

The state guidelines being considered will stop short of a ban, but will include voluntary precautions that may reduce the chances of infection. State Health Department spokesman Robert Kenny did not discuss details, saying that the guidelines are still being developed. But he said that rabbis will probably be asked to inform their congregations about the risks, and steps will be taken to "ensure that mohels have full knowledge of their health status" before they perform the ritual. The guidelines will advise parents to seek medical care immediately if their baby develops a fever or rash following a bris. Several religious leaders have also suggested that mohels be required to undergo regular testing for disease, refrain from doing circumcisions if they have a cold sore, and be required to rinse their mouths with alcohol prior to performing the ritual.

There is mixed reaction among the Hasidic community to the idea of guidelines. Rabbi David Niederman of the United Jewish Organizations of Williamsburg has said that there is too little definitive medical evidence to justify the government warning the public about a ritual that has been performed safely, thousands of times a year, for thousands of years. Niederman said that he has received calls from worried mothers and he believes that they have been alarmed unnecessarily. "We are not fanatics," Niederman said. "If there is evidence that this practice is not safe, we will not do it. We will be the first ones to act. That is embodied in the same Torah that tells us to make a bris for a child."

The debate over the metzitzah b’peh ritual began in Europe during the mid-19th century when doctors began to suspect that the procedure might be spreading tuberculosis. Since then there has been ongoing disagreement over whether the practice had been recommended years ago for medical reasons, or whether it is actually required under Jewish law. Most Reform and modern Orthodox mohels decided that it was simply recommended for medical reasons, and now they clean a circumcision wound with a sponge or sterile gauze.

Rabbi J. David Bleich, a professor at Yeshiva University, said that guidelines proposed by health authorities will not settle the disagreement over the validity and safety of the procedure. "Whatever changes are going to come are not going to come because of government pressure," he said. "If you want to change the way rabbis are doing things, the way to do it isn't to threaten them."