Metzitzah b'peh

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Metzitzah b'peh is a very dangerous Jewish practice that puts the health of the infant boy at risk from infection. Holt (2013) reported tubercular mohelim were infecting infant boys with tuberculosis.[1] In more recent times, boys have been infected with herpes and some have died.

(The following quoted text is from the free Wikipedia article Metzitzah b'peh (oral suction):)

The ancient method of performing metzitzah b'peh (Hebrew: מְצִיצָה בְּפֶה), or oral suction[2][3]—has become controversial. The process has the mohel place his mouth directly on the circumcision wound to draw blood away from the cut. The majority of Jewish circumcision ceremonies do not use metzitzah b'peh,[4] but some Haredi Jews use it.[5][6][7] It has been documented that the practice poses a serious risk of spreading herpes to the infant.[8][9][10][11] Proponents maintain that there is no conclusive evidence that links herpes to Metzitza,[12] and that attempts to limit this practice infringe on religious freedom.[13][14][15]

The practice has become a controversy in both secular and Jewish medical ethics. The ritual of metzitzah is found in Mishnah Shabbat 19:2, which lists it as one of the four steps involved in the circumcision rite. Rabbi Moses Sofer (1762–1839) observed that the Talmud states that the rationale for this part of the ritual was hygienic — i.e., to protect the health of the child. The Chasam Sofer issued a leniency (Heter) that some consider to have been conditional to perform metzitzah with a sponge to be used instead of oral suction in a letter to his student, Rabbi Lazar Horowitz of Vienna. This letter was never published among Rabbi Sofer's responsa but rather in the secular journal Kochvei Yitzchok.[16] along with letters from Dr. Wertheimer, the chief doctor of the Viennese General Hospital. It relates the story that a mohel (who was suspected of transmitting herpes via metzizah to infants) was checked several times and never found to have signs of the disease and that a ban was requested because of the "possibility of future infections".[17] Moshe Schick (1807–1879), a student of Moses Sofer, states in his book of Responsa, She’eilos u’teshuvos Maharam Schick (Orach Chaim 152,) that Moses Sofer gave the ruling in that specific instance only because the mohel refused to step down and had secular Government connections that prevented his removal in favor of another mohel and the Heter may not be applied elsewhere. He also states (Yoreh Deah 244) that the practice is possibly a Sinaitic tradition, i.e., Halacha l'Moshe m'Sinai. Other sources contradict this claim, with copies of Moses Sofer's responsa making no mention of the legal case or of his ruling applying in only one situation. Rather, that responsa makes quite clear that "metzizah" was a health measure and should never be employed where there is a health risk to the infant.[18]

Chaim Hezekiah Medini, after corresponding with the greatest Jewish sages of the generation, concluded the practice to be Halacha l'Moshe m'Sinai and elaborates on what prompted Moses Sofer to give the above ruling.[19] He tells the story that a student of Moses Sofer, Lazar Horowitz, Chief Rabbi of Vienna at the time and author of the responsa Yad Elazer, needed the ruling because of a governmental attempt to ban circumcision completely if it included metztitzah b'peh. He therefore asked Sofer to give him permission to do brit milah without metzitzah b’peh. When he presented the defense in secular court, his testimony was erroneously recorded to mean that Sofer stated it as a general ruling.[20] The Rabbinical Council of America, (RCA) which claims to be the largest American organization of Orthodox rabbis, published an article by mohel Dr Yehudi Pesach Shields in its summer 1972 issue of Tradition magazine, calling for the abandonment of Metzitzah b'peh.[21] Since then the RCA has issued an opinion that advocates methods that do not involve contact between the mohel's mouth and the open wound, such as the use of a sterile syringe, thereby eliminating the risk of infection.[5] According to the Chief Rabbinate of Israel[22] and the Edah HaChareidis[23] metzitzah b'peh should still be performed.

The practice of metzitzah b'peh was alleged to pose a serious risk in the transfer of herpes from mohelim to eight Israeli infants, one of whom suffered brain damage.[8][24] When three New York City infants contracted herpes after metzizah b'peh by one mohel and one of them died, New York authorities took out a restraining order against the mohel requiring use of a sterile glass tube, or pipette.[7][25] The mohel's attorney argued that the New York Department of Health had not supplied conclusive medical evidence linking his client with the disease.[25][26] In September 2005, the city withdrew the restraining order and turned the matter over to a rabbinical court.[27] Dr. Thomas Frieden, the Health Commissioner of New York City, wrote, "There exists no reasonable doubt that ‘metzitzah b'peh’ can and has caused neonatal herpes infection....The Health Department recommends that infants being circumcised not undergo metzitzah b'peh."[28] In May 2006, the Department of Health for New York State issued a protocol for the performance of metzitzah b'peh.[29] Dr. Antonia C. Novello, Commissioner of Health for New York State, together with a board of rabbis and doctors, worked, she said, to "allow the practice of metzizah b'pe to continue while still meeting the Department of Health's responsibility to protect the public health."[30] Later in New York City in 2012 a 2-week-old baby died of herpes because of metzitzah b'peh.[31]

In three medical papers done in Israel, Canada, and the US, oral suction following circumcision was suggested as a cause in 11 cases of neonatal herpes.[8][32][33] Researchers noted that prior to 1997, neonatal herpes reports in Israel were rare, and that the late incidences were correlated with the mothers carrying the virus themselves.[8] Rabbi Doctor Mordechai Halperin implicates the "better hygiene and living conditions that prevail among the younger generation", which lowered to 60% the rate of young Israeli Chareidi mothers who carry the virus. He explains that an "absence of antibodies in the mothers’ blood means that their newborn sons received no such antibodies through the placenta, and therefore are vulnerable to infection by HSV-1."[34]

Recent events

  • 2020: Four New York baby boys have contracted herpes from the mohel in six months.[35]

See also

References

  1. REFjournal Holt, L. Emmett (2013): Tuberculosis acquired through ritual circumcision, in: JAMA. 61 (2): 99-102. Retrieved 29 February 2020.
  2. REFweb Nussbaum Cohen, Debra (14 October 2005). City Risking Babies' Lives With Brit Policy: Health Experts, The Jewish Week.
  3. REFweb Nussbaum Cohen, Debra (23 December 2005). City Challenged On Ritual Practice, The Jewish Week. Retrieved 19 April 2007.
  4. REFnews (2 February 2014)."N.Y. newborn contracts herpes from controversial circumcision rite", Jewish Telegraphic Agency.
  5. a b REFnews Fink, Eliyahu / Eliyahu Federman (29 September 2013)."Controversial circumcisions".
  6. REFweb (7 June 2005). Metzitza Be'Peh – Halachic Clarification, Rabbinical Council of America. Retrieved 6 April 2007. The poskim consulted by the RCA agree that the normative halacha permits using a glass tube, and that it is proper for mohalim to do so given the health issues involved.
  7. a b REFnews Hartog, Kelly (18 February 2005)."Death Spotlights Old Circumcision Rite". Retrieved 22 November 2006. "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."
  8. a b c d REFjournal Gesundheit, B., et al. (August 2004): Neonatal Genital Herpes Simplex Virus Type 1 Infection After Jewish Ritual Circumcision: Modern Medicine and Religious Tradition, in: Pediatrics. 114 (2): e259–63, PMID, DOI. Retrieved 28 June 2006.
  9. REFnews (8 June 2020)."Another Jewish baby has contracted herpes through bris", NY Daily News.
  10. REFnews (5 March 2016)."Should extreme Orthodox Jewish circumcision be illegal?", The Week. Retrieved 30 June 2020.
  11. REFweb NYC, Orthodox Jews in talks over ritual after herpes cases.
  12. REFweb Berman, Daniel S.. Is Metzitza bePeh Dangerous? Icons-mini-file acrobat.gif. Retrieved 9 July 2012.
  13. REFweb (24 October 2020). Lawsuit Unites Jewish Groups, collive.com. Retrieved 1 January 2013.
  14. REFnews (12 June 2020)."City Urges Requiring Consent for Jewish Rite", nytimes.com. Retrieved 1 February 2013.
  15. REFnews (25 October 2012)."Assault on Bris Milah Unites Jewish Communities", CrownHeights.info.
  16. REFweb Editorial & Opinion, The Jewish Week. Retrieved 25 April 2012.
  17. REFbook Katz, Jacob: Divine Law in Human Hands. ISBN 978-9652239808.
  18. REFweb (16 April 2020). The Chasam Sofer's ruling on Metzitzah Be-peh, onthemainline.blogspot.com.
  19. Sdei Chemed vol. 8 p. 238
  20. REFweb Kuntres Hamiliuim, Dhengah.org. Retrieved 25 April 2012.
  21. REFweb The Making of Metzitzah, Tradition. Retrieved 2 May 2014.
  22. REFweb Chief Rabbinate of Israel. Retrieved 26 April 2013.
  23. REFweb Edah HaChareidis. Retrieved 26 April 2013.
  24. REFweb Rare Circumcision Ritual Carries Herpes Risk, My.webmd.com. Retrieved 25 April 2012.
  25. a b REFnews Newman, Andy (26 August 2005)."City Questions Circumcision Ritual After Baby Dies". Retrieved 23 November 2006.
  26. REFweb Clarke, Suzan (21 June 2006). State offers new guidelines on oral-suction circumcision, The Journal News. Retrieved 28 June 2006.
  27. REFweb Nussbaum Cohen, Debra (23 September 2005). City: Brit Case To Bet Din, The Jewish Week. Retrieved 23 November 2006.
  28. REFnews Nussbaum Cohen, Debra (23 February 2006)."Controversy rages in New York over circumcision practice", The Jewish Ledger. Retrieved 23 November 2006.
  29. REFweb (November 2006). Circumcision Protocol Regarding the Prevention of Neonatal Herpes Transmission, Department of Health, New York State. Retrieved 23 November 2006. The person performing metzizah b'peh must do the following: Wipe around the outside of the mouth thoroughly, including the labial folds at the corners, with a sterile alcohol wipe, and then discard in a safe place. Wash hands with soap and hot water for 2-6 minutes. Within 5 minutes before metzizah b'peh, rinse mouth thoroughly with a mouthwash containing greater than 25% alcohol (for example, Listerine) and hold the rinse in mouth for 30 seconds or more before discarding it.
  30. REFweb Novello, Antonia C. (8 May 2006). Dear Rabbi Letter, Department of Health, New York State. Retrieved 23 November 2006. The meetings have been extremely helpful to me in understanding the importance of metzizah b'peh to the continuity of Jewish ritual practice, how the procedure is performed, and how we might allow the practice of metzizah b'peh to continue while still meeting the Department of Health's responsibility to protect the public health. I want to reiterate that the welfare of the children of your community is our common goal and that it is not our intent to prohibit metzizah b'peh after circumcision, rather our intent is to suggest measures that would reduce the risk of harm, if there is any, for future circumcisions where metzizah b'peh is the customary procedure and the possibility of an infected mohel may not be ruled out. I know that successful solutions can and will be based on our mutual trust and cooperation.
  31. REFweb (12 March 2012). Baby Dies of Herpes in Ritual Circumcision By Orthodox Jews, abcnews.go.com.
  32. REFjournal Rubin, L.G. / P. Lanzkowsky (2000): Cutaneous neonatal herpes simplex infection associated with ritual circumcision, in: Pediatric Infectious Diseases Journal. 19 (3): 266–67.
  33. REFjournal Distel, R. / V. Hofer / S. Bogger-Goren / I. Shalit / B.Z. Garty (December 2003): Primary genital herpes simplex infection associated with Jewish ritual circumcision, in: Israel Medical Association Journal. 5 (12): 893-894.
  34. REFjournal Halperin, Mordechai (December 2006): Metzitzah B'peh Controversy: The View from Israel, in: Jewish Action. 67 (2): 25, 33–39. Retrieved 15 February 2007. Quote: The mohel brings the baby’s organ into his mouth immediately after the excision of the foreskin and sucks blood from it vigorously. This action lowers the internal pressure in the tissues of the organ, in the blood vessels of the head of the organ and in the exposed ends of the arterioles that have just been cut. Thus, the difference between the pressure in the blood vessels in the base of the organ and the pressure in the blood vessels at its tip is increased. This requirement has deep religious significance as well as medical benefits....Immediately after incising or injuring an artery, the arterial walls contract and obstruct, or at least reduce, the flow of blood. Since the arterioles of the orlah, or the foreskin, branch off from the dorsal arteries (the arteries of the upper side of the organ), cutting away the foreskin can result in a temporary obstruction in these dorsal arteries. This temporary obstruction, caused by arterial muscle contraction, continues to develop into a more enduring blockage as the stationary blood begins to clot. The tragic result can be severe hypoxia (deprivation of the supply of blood and oxygen) of the glans penis.28 If the arterial obstruction becomes more permanent, gangrene follows; the baby may lose his glans, and it may even become a life-threatening situation. Such cases have been known to occur. Only by immediately clearing the blockage can one prevent such clotting from happening. Performing metzitzah immediately after circumcision lowers the internal pressure within the tissues and blood vessels of the glans, thus raising the pressure gradient between the blood vessels at the base of the organ and the blood vessels at its distal end—the glans as well as the excised arterioles of the foreskin, which branch off of the dorsal arteries. This increase in pressure gradient (by a factor of four to six!) can resolve an acute temporary blockage and restore blood flow to the glans, thus significantly reducing both the danger of immediate, acute hypoxia and the danger of developing a permanent obstruction by means of coagulation. How do we know when a temporary blockage has successfully been averted? When the “blood in the further reaches [i.e., the proximal dorsal artery] is extracted,” as Rambam has stated.
  35. REFnews Oster, Marcy (20 February 2020)."4 NY babies get herpes from Jewish circumcision rite in past 6 months", The Times of Israel. Retrieved 12 April 2020.