Snip, Snip

Another week, another post; this one on Jewish ritual circumcision…wait, what? How is this an infectious disease issue, you may ask? I’m not spoiling the ending…you’ll have to read to find out.

First, a meta-post: my apologies for the delay between my last post and this one. I have been struggling with how to best write this particular post, and when you read it, you’ll understand why. While I make no apologies for the views expressed on this blog, and I certainly do not shy away from controversial topics, even I had to acknowledge that this particular one is a bit dicey and had to be handled carefully; and it took me some time to figure out how best to do just that.

Those of you who know me In Real Life, know that I am Jewish. For those who are meeting me on this blog, well, shalom! However my views run toward the reform—the nonobservant—end of the spectrum. The particular subject of this blog is, in general, absolutely central to the Jewish experience. Circumcision (warning, some images NSFW) is, according to the Torah / the Old Testament, the primary covenant between God and the Jewish people. It is, arguably (and according to a more traditional viewpoint), the single most important practice that marks a male as Jewish. Separate from this, circumcision and one’s status as circumcised or not is also a highly personal and intimate thing, simply due to the details of the act itself [1]. So: a blog post about an extremely personal, intimate issue that is one of the central tenets of a major religion–where do I sign up? Here, apparently…

But as you’ll see, I am not writing about circumcision in general, nor do I wish to address any of the broader controversies surrounding it. No, here I am writing about one very specific practice, limited to a relatively smaller group of ultra-observant Jews, that has profound and personal (to my professional experience) infectious disease implications.

Now, where to begin…

The New York City Department of Health and Mental Hygiene (DOHMH for short) recently made headlines when they passed a regulation that will require consent from parents before an infant can have a particular form of Jewish ritual circumcision. The practice, known as metzitzah b’peh, is prevalent in parts of the ultra-Orthodox community and is distinguished by the circumciser (a mohel) using his mouth to remove blood from the incision. Its origins lie in a series of rabbinic injunctions regarding the practice of ritual circumcision and the need to let a small amount of blood out to, ironically, prevent infection. As its origins are hundreds of years old, the true medical necessity of this practice is doubtful to put it mildly. And while it should be obvious to any observer, it had apparently not occurred to the rabbinate that advocated for this practice that this itself could be a HUGE infectious risk.

Sure enough, over the years that this practice has been performed, a number of infants in Israel and scattered around the rest of the world have contracted disseminated Herpes Simplex Virus (HSV) infections from mohels who had an oral HSV infection at the time of the circumcision. In general, infants who are exposed to HSV through skin or mucous membrane contact are much less able to limit it to a simple skin infection. The virus invades and causes a disseminated infection, with organ damage, meningitis/encephalitis, or both. And the brain infection can lead to deafness, blindness, or permanent brain damage. Ultimately a severe disseminated HSV infection in an infant can be fatal; it frequently is, without treatment. And infants exposed to HSV via metzitzah b’peh are no different from infants exposed through other means.

This became an issue for the City of New York, and then in particular for me, when infants born in ultra-orthodox communities in Brooklyn began to contract HSV from mohels who practiced metitzah b’peh, starting in 2003–2005. To date, 11 infants have been identified who contracted an HSV infection in this way. I have taken care of one of them.

As a 4th-year medical student I took care of an infant who was in the throes of an acute HSV infection secondary to this practice. He had already suffered severe brain damage and was blind and possibly deaf. He was in the Intensive Care Unit. He was very, very sick. At the time, I was furious at his parents, who blocked investigation into the case at every turn. The family was hasidic, typical of these cases, and while the mother’s claims to be ignorant of the identity of the mohel and absent at the circumcision were believable given the gender separation present at orthodox religious ceremonies, the father’s professed ignorance was an obvious lie. In traditional circumcisions, the father holds the infant on a pillow on his lab while the mohel performs the act. That the father would not have seen the act itself, or met the mohel, was an impossibility. But they did not want the secular medical community invading their sacred world. They did not want the secular law enforcement community invading it either. And despite our pleas, and those from the city, that stopping this practice at that time would prevent needless future suffering and save lives, the hasidic community put up road blocks, insisting they would handle this internally through a Beit Din, or rabbinic court. Eventually, one of the mohels (who was responsible for 3 cases and 1 death) was identified and barred from practicing circumcision. However, since many of these religious procedures are performed without any civic oversight, it is unclear whether even this ban is being upheld.

It is in the context of this experience that I am ecstatic to see the city government finally taking some more substantive action through overall regulation. The DOHMH regulation requires informed consent from the parents before this practice of metzitzah b’peh can be done. That means being told of the risks of HSV infection–including blindness, brain damage, hospitalization for weeks, and death. I wholeheartedly agree with the idea of informed consent and regulation of this practice, but actually feel this does not go far enough. The regulation, despite how it might appear from the vigorous negative response from the orthodox community, lacks teeth. A mohel who performs this practice will only be investigated when a case of HSV is brought to the attention of the health department. And the punishment? A sternly-worded letter, a warning. No revoking of licenses, and certainly no arrests.

Not all physicians agree with the DOHMH decision, and feel it does too little:

Indeed, some panel members said they believed that requiring consent did not go far enough. “It’s crazy that we allow this to go on,” said Dr. Joel A. Forman, a professor of pediatrics at Mount Sinai School of Medicine.

I agree with Dr. Forman[2] and the many other physicians who recognize this procedure is exceedingly hazardous to an infant’s life. It should not be allowed to continue. Moreover, some orthodox rabbis also agree and go farther still:

“There is no requirement to make metzitzah b’peh. The Talmud says plainly it is not part of the ritual but belongs to the medical, post-surgical component,” said Rabbi Moshe Tendler, a medical ethicist and a dean of Yeshiva University’s rabbinical school, where he teaches fourth-year students about circumcision. Tendler, who has a doctorate in microbiology, said, “There is no doubt that insistence on metzitzah b’peh is wrong. I firmly believe that making metzitzah b’peh is a criminal act.”

With this last statement, I wholeheartedly agree. Based on my experience with my patient—seeing the devastating end result of this infection, seeing the way that the city was barred from investigating the cases, seeing the way the parents didn’t even seem to care that their obstruction was possibly affecting other infants—I believe that this practice needs to be outlawed. More specifically, as a clear and present danger to the children of the Jewish community, it should be illegal. Should an infant contract an infection due to a mohel’s performing this practice, that should be considered assault. An infant’s death from infection secondary to this practice should be considered manslaughter. The guilty party would be the mohel. And should the parents block investigation, as with any criminal investigation they could be considered liable—for charges of obstruction of justice, accomplice charges, I’m not sure of the correct legal terminology. But if this practice is handled as a criminal act, there could be legal consequences for them.

I am aware this is possibly trampling on religious freedom. I am aware this is a slippery slope, where if we can claim this practice is dangerous, what else can we claim? What other practices can we outlaw? But a practice that has devastated the lives of 11 infants and killed 2 just in New York City, let alone others around the world, cannot be allowed to continue. And an injunction or ban without legal consequences is useless. And along with punishing the mohels, legal consequences should have the potential to impact the families. Any law that does not do this, that does not cut off demand as well as supply, will likely not be effective.

Let me be clear—I am not in favor of a ban on circumcision. I am not even in favor of a ban on the practice of bloodletting during circumcision—this can be done using a sterile glass pipette in a way that is not a risk to the infant. It is only the specific practice of metzitzah b’peh, where the mohel puts his mouth on the infant’s genitals and in so doing exposes defenseless, innocent infants to the risk of death, that I feel should be outlawed.

As physicians, our obligation is to ‘first do no harm’. Not ‘first do no harm only when it is easy, convenient, and in keeping with religious and social norms’. The DOHMH regulation is a start, but only a start. The practice of metzitzah b’peh needs to be complete cut out… pun intended.

  1. Do I need to…ummm…spell it out…? The pictures in this link should be clear enough.  ↩

  2. A disclaimer: Dr. Forman was my program director during my pediatric residency at Mount Sinai, so I am a bit biased.  ↩