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Tuesday, August 30, 2005

Metzitzah B'Peh

The Metzitzah B'Peh controversy has been roiling for months. For some background, go here, here, here, here, and here.

Now that you're caught up, read Krum's posting on Christopher Hitchen's breathless, hysterical, completely wrong take on the controversy.

Though I am personally not a proponent of the practice of Metzitzah, and it was not performed by the mohel at my sons' brisim, I am troubled by the call for government regulation of the practice. I cannot imagine that there are people who feel that an inconclusive study such as the one quoted by the opponents of the practice is enough to create a situation where the government should get involved in regulating a religious ritual. There are many problems with the study from Pediatrics that supposedly proves that Metzitzah bears a risk for the fatal transmission of the Herpes virus.

The study is based on the deaths from Herpes of eight children, who had been circumcised with Metzitzah within a short period before their deaths. Though these deaths are of course distressing, the article does not offer any conclusive evidence that the practice was the source of these infants' infection. In one case, the mother of the infant tested positive for the virus. In none of the cases were any of the other caregivers (fathers, nurses, doctors, babysitters) tested for the virus, even though the study clearly states that most cases of the virus are transmitted by caregivers, through non-genital contact.

In addition, the article has not tried to explain the fact that the practice of Metzitzah is performed tens of thousands of times a year, by mohels who must have a rate of infection close to that of the general population (up to 90%, by many estimates) and there has yet to be a show of sick or dead babies along the numbers which one would expect from such a "dangerous" practice.

The bottom line is, before we think about banning a religious practice that seems to have been performed safely for centuries, there needs to be more evidence than a poorly sourced, inconclusive, anecdotal study.
As Krum rightly points out:
But since when does our society ban anything based on a single study? Should we ban TV, burgers, sugared sodas, and trampolines because there is some evidence that it harms kids?
I think this needs more study before we call for the end of a practice. After all, there are many opponents of the rite of circumcision, who feel it to be a barbaric practice in itself. Should the government cave to their calls to "protect the innocent eight-day-old Jewish children being mutilated"? Which brings up another interesting point. The journal which published the study "proving" that Metzitzah is potentially fatal? It is put out by the American Academy of Pediatrics, which has been staunchly against circumcision altogether for decades.

No bias there.

28 Comments:

Anonymous uncle moishy said...

1) Just because Hitchens is odious generally and particularly obnoxious in this article (deliberately, I suspect) doesn't mean everything he says in it is wrong.

2) You really can't blame Bloomberg for appeasing a large voting bloc. It's what politicians must do to survive. Look how many times the Orange County politicians have tried to find a way to secure public funds for a Satmar-only Special-Ed school in Kiryas Yoel. Given NYC's term limits law, Bloomberg will have plenty of time to take a principled pro-health stand on this issue (like the ones he's taken on smoking in bars and trans fats in restaurants) after he's elected, if that's what he wants to do.

3) My real complaint is with the Jews. What does it take to realize that applying one's mouth to an open wound on an 8-day-old child is an invitation to disaster? Mouths are not sterile. They harbor communicable germs and disease. For the pro-metziza-b'peh crowd, the best that can be hoped for from more study is a finding that, compared to the use of sterile instruments, metziza b'peh entails a "relatively small" increase in risk. But what comfort is it to a parent to know that the chance of this happening was "only" 1 in 10,000 if your son turned out to be the lucky "one?"

Those with time on their hands are advised to read up on the story of Dr. Semelweis (sp?).

3:23 PM  
Blogger Leapa said...

Ortho, though I don't have a strong opinion on MBP, I do admire your honesty in taking a counterintuitive (relative to your other non-conservative postions) stand.

3:54 PM  
Anonymous cosmo said...

Nice post OM.

From chakira: "Tendler has had his name horribly dragged through the mud in the Haredi world."
Much in the same way he did to the Mohel, who if I am not mistaken was found not to be the cause of the babys death. Has there been a retraction by R' Tendler or an apology?

Uncle Moishy,
Point #3 you made: HOW DARE YOU!!! There are obviously views that allow metzizah to be done other than b'peh, but for you to call out "the Jews" is absolutely deplorable. Who the hell do you think you are? There are those who feel very strongly about their minhagan and don't deserve to be chastised by the likes of you. Take a look at Krums post again and read OM postagain (that is if you even read it the first time): "In addition, the article has not tried to explain the fact that the practice of Metzitzah is performed tens of thousands of times a year, by mohels who must have a rate of infection close to that of the general population (up to 90%, by many estimates) and there has yet to be a show of sick or dead babies along the numbers which one would expect from such a "dangerous" practice."
If you dont want to practice it DONT. BUT DON'T YOU DARE BERATE OTHERS FOR FOLLOWING THEIR MINHAGIM. We don't just open the yellow pages and pick the first name on the list. a mohel is chosen based on reccomendation and experiance.

4:06 PM  
Blogger rebba shlita said...

uncle moishy is a jerk this blog o.m deserves a hat tip. and i agree with cosmo but one step further even though there are rabonim today that say it does not have to be done or with a straw, cosmo you refer to it as a minhag it is not this was how a bris was done, not a mihag. so uncle moishy watch what you say b/c obviously you dont care much for the as you call us jews. some respect please.

4:45 PM  
Anonymous uncle moishy said...

I apologize for my use of haughty and imprecise language.

My real complaint is with those Jews who insist on slavish adherence to a minhag -- one that originated at a time when no one understood the biological sources of disease -- in the face of knowledge that it is dangerous to their children. If you don't believe that such a practice increases risks to you son's health, then you are ignorant and/or in denial (and may be the real jerk in this conversation).

Orthodoxy has splintered to a point where there simply is no one out there to make definitive halachic rulings that are accepted by all (or even a majority). Consequently, we are stuck with rulings that reflect the best available knowledge from hundreds of years ago but no way to modify them in light of more recent information.

5:13 PM  
Anonymous cosmo said...

Yes rebba, OM does deserve a hat tip.(forget the rules, sorry krum)


Uncle Moishe,

You are missing the point. You obviously did not read the post. So go back and read it again. To call us "ignorant" or "jerks" for following halacha is in itself krum. As OM and Krum have posted the correlation between Metzizah and diseased babies is suspect at best. Personaaly I have yet to see a baby get sick from metzizah, and the only case that I have heard about is the one called out by R' Tendler and in that case the Mohel was found to be "disease" free.

As far as the bacteria in the mouth go; the mohelim I've seen rinse with alcohol first, which is enough to sanitize the mouth. In addition not all oral bacteria are bad.

So again, mohelim are chosen carefully, if you choose not to do metzizah that is your perogative. But DON'T YOU DARE call any of us who carefully choose whom to be our shliach, "jerks" or "ignorant"!

5:33 PM  
Anonymous kelli said...

cosmo said:
Personaaly I have yet to see a baby get sick from metzizah
...

Hey, I've never met a kid with cancer, so it doesn't happen?

The issue needs to be investigated more thoroughly. But to say "I've never seen it happen, so it doesn't" is just plain ignorant.

Perhaps it is not an issue. But if there seems to be a problem, it needs to be INVESTIGATED. Just saying "This is our practice - end of story" is a horrible solution.

6:51 PM  
Blogger shleppy said...

The argument is kind of bankrupt. Any credible medical person will tell you that M is a dangerous practice. If you want to bury your head in the sand or wait for some study that will never happen, that's your problem. But don't pretend you aren't putting a baby needlessly at risk for the sake of "keeping up with the Schwartzes."

8:27 PM  
Anonymous bishul akum said...

ortho good post you are starting down a slipery slope here

11:58 PM  
Anonymous bishul akum said...

Tendler has had his name horribly dragged through the mud in the Haredi world."
Much in the same way he did to the Mohel, who if I am not mistaken was found not to be the cause of the babys death. Has there been a retraction by R' Tendler or an apology


It works both ways,He is too arogant to admit a mistake

12:01 AM  
Anonymous J said...

So, OM what would it take you to be convinced? 2 studies? 3? 4? If a study has relatively good evidence, than I think something empirically based, although seemingly somewhat anecdotal, such as the study can be taken at face value. Is it completely conclusive? No. But it certainly presents some strong evidence.

Regarding the banning on things based on a study or two, this is hardly comparable to French fries and the like. In those cases, it is possible that long term repeated exposure may endanger some children. But in this case any mohel that has herpes could almost every time seemingly give the child a dangerous disease.

Also, regarding what you said, "it's been practiced safely for thousands of years". How do you know this? Are you sure that no children have died from herpes after getting MBP? It's quite possible that it may have been extremely prevalent, but just not recognized.

Also, one can raise poignant questions on the questions that you raise on the study. You mention that "what about the thousands of children that get MBP each year and are not injured". Again, where is your evidence? Do you know that children are not dying from "SIDS" or something, is not really herpes? Do you know children are not being infected?

Lastly, regarding the policy of the AAP, they favored circumcision until 1999 http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/3/686 . Than, since they could not find any significant evidence of it's benefits that maintained a position of "when the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child".

What else do you expect them to do after they found no conclusive evidence? Say they still favored it? They’re not Jewish.

To say that they are against it is quite misleading.

Also, they are not against it per say, just not for it. This is hardly the same way you portray it.

Also, even if they were "against" it, does that mean they could never again publish a study in support of themselves? That's hardly a fair thing to say. Just because they found some good evidence it does not mean it should be discounted.

To conclude, I think this study is significant in that it raises significant doubts about MBP. That within itself should encourage the academic field, if not the religious field, to pursue the hard facts regarding this issue?

Is it enough to ban it? I don't know. Some people obviously think yes. I think they are entitled to that opinion, based on this study. Things are banned after a study or two. If a previously approved drug is shown to be harmful in a study, it's usually yanked off the shelf right away by the FDA.

This obviously also gets into the issue of the government getting involved in religious practices. Obviously something that’s very tricky. On the one hand you have to be against the Islamic terrorists that claim they are obligated to do what they do by religion. But than you’re going to give a free pass to the Jewish potentially harmful practice.

Thin Lines…

12:40 AM  
Anonymous uncle moishy said...

Some edifying spare-time reading on a somewhat-related subject:

http://en.wikipedia.org/wiki/Semmelweiss

It's astonishing to think how little was understood medically just 150 years ago.

1:12 AM  
Blogger rebba shlita said...

j said,

i think its a typo i thought you just compared mbp to terrorists. this is the most outrageous thing i have ever heard for saying this and please excuse me O.M but this is called for, j for writing that you should rot in he-l and i really mean that. they say the worst anti- semites are the jews that is if you are even jewish. this response of mine is not for your whole article (which i dont agree with) it was for that stupid incensitve remark calling frum jews islamic terrorists.you should be banned from this blogg. and you should apologize.

9:55 AM  
Blogger Rebeljew said...

"Perhaps it is not an issue. But if there seems to be a problem, it needs to be INVESTIGATED. Just saying "This is our practice - end of story" is a horrible solution."

Not much to add to that. Good posture in any health - halacha related forum.

11:28 AM  
Blogger Rebeljew said...

RS

I think J was just warning of a legal precedent. If we hide MBP behind "religious practice" legally, then ad absurdum, our enemies would hide islamic terror behind the same screen. I do not think (s)he meant a comparison beyond that. All in all, by this logic, it is better to attack the study as OM does rather than to shield it from legal scrutiny.

4:01 PM  
Blogger GoldaLeah said...

An honest question. Should the rate if infection among mohels match the rate of infection of the general population or of the frum population? Herpes is an STD. Surely the rate of infection among the Orthodox is lower than 90%

6:31 PM  
Blogger jewishwhistleblower said...

This is an area that needs regulation as our community simply doesn't anymore.

See my posts at:
http://jewishwhistleblower.blogspot.com/2004_12_01_jewishwhistleblower_archive.html

By the way Orthomom made the Forward:

Orthodox Union Riles Working Moms
By FORWARD STAFF
September 2, 2005

The country's largest Orthodox organization posted an essay on its Web site last week that sharply criticized working mothers.

"Let's shatter the myth [of] a mother who works outside of the home," Sara Malka Poupko Reichman wrote in an essay titled "Diary of a Professional Mother," which was posted on the homepage of the Orthodox Union's Web site.
...
The essay, which first appeared several years ago in the O.U.'s Jewish Action magazine, drew criticism from Orthodox bloggers on the Internet and from some Orthodox women who work.

"Um, is someone a bit defensive?" asked popular blogger Orthomom, a mother of four. "Laud yourself all you want. But when it comes to my life's choices... please shut up."
...

9:33 PM  
Blogger orthomom said...

Golda Leah:
An honest question. Should the rate if infection among mohels match the rate of infection of the general population or of the frum population? Herpes is an STD. Surely the rate of infection among the Orthodox is lower than 90%

Actually, this type of Herpes, HSV-1, is not an STD. It is the virus that causes cold sores. So if you know anyone that has ever had a cold sore, (or fever blister, as it is sometimes called), then they are infected with the HSV-1 virus, and can transmit it by kissing, touching, or other casual contact. And the rate in the frum community would be expected to be similar to that of the population at large.

9:41 PM  
Anonymous J said...

Right on rj.

10:06 PM  
Anonymous uncle moishy said...

In last week's Forward (which I first read today), it said that 90% is the percent of the general population that tests positive for herpes antibodies. If I understand correctly (I am not a medical professional -- much to the distress of my parents, z"l), this does not mean that 90% of us are actively harboring herpes, but that 90% of us have been exposed to it and are carrying antibodies for it as a result. But herpes is also incurable (despite the antibodies), and anyone who has had it may have it "flare up" again.

Of course, my opinion is that it ain't just herpes we ought to fear here, but any and all manner of viruses, bacteria and who knows what else that may be found in a person's saliva but not in a sterile tube.

2:00 AM  
Blogger orthomom said...

this does not mean that 90% of us are actively harboring herpes, but that 90% of us have been exposed to it and are carrying antibodies for it as a result.
No. Once you are exposed, you can have a flare-up and actively shed the virus at any time for the rest of your life. And not every flare-up is visible to the eye, one can shed the virus and not know it.

3:05 AM  
Anonymous cosmo said...

Kelli<

I did NOT say it dosen't happen. I am reiterating what krum and OM have stated that the incidence if the journal article os correct should be a hell of alot higher, and should have come out long, long, long ago, not just after R' Tendler called out said Mohel.

rebba shlita,
you are much too kind. There is alot worse that should be said about j. But out of respect to OM i will not post them here.

12:05 PM  
Anonymous Anonymous said...

Come to the Jewish families board on babycenter.com and debate this issue (I need some more excitement!)

8:58 PM  
Blogger seaslipper said...

Maybe you should consider the facts presented in the Health Commisioners letter to the community:

In November 2004, the Health Department was notified of 3 male infants with herpes simplex type 1 (HSV-1). All were circumcised by one mohel (Mohel B), who performed metzitzah b’peh. The infants developed herpes infection in the genital area 8-10 days after circumcision and were hospitalized for several weeks. One baby died from the infection. Two additional cases were reported by physicians in 2005 and both were also consistent with infection from metzitzah b’peh. Every case occurred in the time frame consistent with transmission from metzitzah b’peh.

Our investigation found Mohel B to be the source of the cases reported in 2004, and metzitzah b’peh to be the means of infection for these and other cases, for the following reasons:
• All infants tested culture-positive for HSV-1, which is found in the mouths of most adults.
• The location of herpes sores (on infant genitals and buttocks) is very unusual and strongly suggests that infection was introduced at the genitals.
• Infection is consistent with acquisition of herpes at circumcision. For example, two infants who were circumcised several weeks after birth showed signs of infection in the time frame that would be expected from infection acquired during circumcision.
• The medical circumstances are inconsistent with infection acquired at delivery, in the newborn nursery, or from caretakers.
• Several mothers tested negative for HSV-1, making it impossible for them to have been the source of infection.
With an estimated average of fewer than 30 cases of all forms of infant herpes infections occurring per year in New York City, the odds of one mohel being associated with 3 cases of neonatal herpes are infinitesimally small (about 6.9 million to 1). In the interest of allowing religious communities to address these health concerns first, the Health Department agreed to let rabbinical authorities ensure that the Mohel B stopped performing the practice at least until the authorities conclude an investigation.

In addition, the connection between metzitzah b’peh and neonatal herpes has been documented in the medical literature. Three investigations published within the past 5 years (from New York City,1 Israel,2 and Canada3) describe 11 males with HSV-1 infections on their genitals following metzitzah b’peh. There appear to be some individuals who are more likely to spread infection. Among the 11 published cases, there are 4 pairs of cases (including the 1988/1998 cases from New York City).
Health Department

12:02 PM  
Anonymous Anonymous said...

Anyone that would permit a fervent religious man to cut their baby's penis and then suck blood out of the wound he just inflicted to the penis with his mouth or by any other means is not only an aberration, but is no different from any child molestor and should be prosecuted, and be considered a danger to society.

There are probably some religions that practice canibalism, bestiality and any other number of horrors but should they be allowed as "carte blanche" religious freedom? Most definitely not.

A man sucking blood from a baby's penis is WRONG!!!!!!!!!!!!!!!! ANYONE WHO DISAGREES WILL HAVE A VERY HOT TIME IN THE AFTERLIFE.

1:31 AM  
Anonymous dr. dave said...

Metzitzah update

You are errorneous in your comment about 8 babies dying. They got sick. You did not read the paper. All information points to typical maternally transmitted neonatal herpes. (This is a review of 30 years of papers on neonatal HSV research)

Two years of my research have yielded the following:
1) Neonatal herpes is typically the result of a primary infection. The definition of Primary infection is: "virus positive seronegative" i.e., no antibodies to indicate a previous infection.
2) "Asymptomatic primary infection is the rule rather than the exception".

- Whitley RJ, Kimberlin DW, Roizman B. Herpes simplex viruses. Clin Infect Dis. 1998 Mar; 26(3):541-53

3)An 18 year study of 58,000 women indicates primary infection carries more than double the risk of neonatal infection, than non- primary or recurrent HSV.
) Brown ZA, Wald A, Morrow RA, Selke S, Zeh J, Corey L, Effect of Serologic Status and Cesarean Delivery on Transmission Rates of Herpes Simplex Virus From Mother to Infant JAMA 2003 Jan 8;289(2):203-209

4) Timing of 1-28 days is typical of maternally transmitted herpes.(Some other sources say as late as 8 weeks)
AAP Pediatric Redbook, & Kimberlin DW. Neonatal herpes simplex infection. Clin Microbiol Rev. 2004 Jan;17(1):1-13. These 2 sources BTW are mentioned in NYC Doh Health 2005 Alert #46. The author of the Alert cites these sources regarding Acyclovir antiviral treatment but ignores the rest of the paper which describes their cases as typical maternally transmitted NHSV.

4) Tendler's paper used 23 year old American HSV-1 statistics to blame the Mohel for orally infecting newborns in 7 Israeli and 1 Canadian cases. Current information indicates:

62.5% of known neonatal herpes types were HSV-1

Kropp RY., et al. Neonatal Herpes Simplex Virus Infections in Canada: Results of a 3-Year National Prospective Study, Pediatrics 2006 117:1955-1962

75% of genutal herpes in Tel Aviv is HSV-1.
Samra Z, Scherf E, Dan M. Herpes simplex virus type 1 is the prevailing cause of genital herpes in the Tel Aviv area, Israel. Sex Transm Dis. 2003 Oct;30(10):794-6.
Every test that could have proven or disproven the source was avoided by Temndler and the NYC DoH. Follow up serology, serologic testing for discordant partners, DNA comparison where one Mohel was accused in two cases, etc. All were meticulously avoided.

Additionally none of the authors have ever done a paper on neonatal herpes, but many have been critical of traditional circumcision.

This does not include many of the lies concerning history in the paper, i.e., the Chasam Sofer who died in 1839, was influenced by Ignacz Semmelweis' May 1847 discovery of disease transmission (in an obstetrics ward, not because a baby got tuberculosis from a mohel) and therefore permitted instrumental suction, even thouh the instrument was not invented until 1887.

11:29 AM  
Anonymous Anonymous said...

And you really have to ask the "metzitzah b'peh" advocates: When Avraham Avinu performed the first bris (on himself), did he also do metzitzah b'peh? ... if he performed metzitzah b'peh on himself, how exactly did he do this? (Can the "metzitzah b'peh" people demonstrate the proper procedure for performing self-"metzitzah b'peh"?)

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