New York – Metzitzah B’Peh – Where We Are And Where We Need To Go

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    Gary A. Gelbfish MD, FACS, is a vascular surgeon in private practice. He is a mohel certified by the Rabbinate of the State of Israel.New York – As a vascular surgeon for over 20 years I care for wounds daily. As an occasional mohel for 30 years I am familiar with all aspects of milah. I thus feel obligated to share my perspective on this most important topic. If I don’t, who will? In order to decide halachic matters, rabbis need accurate and representative medical input. This is my only goal.

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    From a medical perspective, the controversy over metzitzah b’peh (MBP) has focused on whether indeed there is any serious risk of transmission of the herpes type-1 virus from the mohel to an infant. Why is this a concern? It is well established that over 50 percent of adults show serological evidence of previous infection with oral herpes and some of these people will shed herpes from their mouth even without open sores. A 1999 study found that 70 percent of adults shed virus at least once a month even without oral lesions. This data suggests a theoretical risk of herpes infection transmission when a mohel has direct oral contact with the bris wound. An infant is immunocompromised, and an infection that is relatively mild in an adult can be deadly in an infant.

    Is this just a concern, or does such infection transmission actually happen? There are a number of cases with a high index of suspicion that link MBP to herpes infection of an infant’s genital area. There were three such cases in the 1990′s (one of whose care I was involved in); eight cases reviewed in a paper in the medical journal Pediatrics in 2004; three cases between 2004 and 2006 in New York City, including an infant death and another who survived but with significant neurological damage; an additional four recently published cases in New York City from 2006-2010, and a death in 2011 in New York City attributed to MBP. These total 19 cases. It is almost certain that there are others, since not all cases are reported. Mandatory reporting was instituted in New York State in 2006. In New Jersey, no such requirement exists today.

    It is the opinion of many infectious disease specialists and public health authorities that the association between MBP and herpes is adequately established by these cases, considering the location of the herpes in the infant’s genital area, the timing of infection soon after the bris, the clusters of association with a given mohel and other epidemiological parameters.

    Furthermore, basic medical theory eschews oral contact with a wound, especially since our current medical knowledge does not attribute any benefit to MBP. The risk/benefit ratio is thus infinite. As such, these specialists recommend modifying MBP by either using a gauze or glass tube instead of direct oral contact. This was the solution approved by the Chasam Sofer and other rabbanim, and adopted by many Jewish communities, when faced with the same issue more than 150 years ago.

    A dissenting, minority opinion is presented by Dr. Daniel S. Berman, an adult infectious diseases specialist who has published in the lay press on this topic. He has reviewed the above data, critiqued the authors of previous medical articles, and has questioned the validity and motivations of their medical opinions. He suggests anti-religious bias as a significant factor in their conclusions and in the actions of the New York City department of health. He doubts that MBP is the cause of infection and posits that herpes is more likely contracted from other sources, such as caretakers of the infant. He also argues that no absolute confirmation of a causal relationship in any of these cases has ever been proven. To prove causality would require DNA evidence linking the specific herpes strains and this has never been done. It must be noted, however, that to perform DNA analysis, community and mohel cooperation would, of course, be necessary and this has not been forthcoming.

    I am unaware of other physicians who share the essence of Dr. Berman’s point of view. Nevertheless, my observation is that Dr. Berman’s opinion has been accepted by the overwhelming majority of the chassidish and yeshivish communities. “Nothing has been proven and MBP is absolutely safe” has become the mantra in this discussion. Furthermore, there has been no halachic call to modify MBP at this point except from the Rabbinical Council of America.

    I have described the status quo, but now come the real issues. Is it appropriate to accept a minority view in matters of fact and pikuach nefesh? How should halachic authorities decide in a case where medical facts and their interpretations are of such prime importance and where those facts are the subject of debate?

    Furthermore, I shudder to think of the almost unrecoverable stain and loss of confidence on the integrity of the halachic process that would result, should MBP be ultimately proven (via DNA or other means) to be a source of herpes transmission. Many will appropriately ask, “How could we have permitted such significant halachic decisions to be made based on the unconventional and minority opinion of Dr. Berman, when most other specialists felt that an association between MBP and herpes had been amply established? What type of system permits this to happen? Why didn’t we seek a wider consensus?”

    Some have said that the Chasam Sofer’s p’sak has no relevance today, since they claim that it was only a hora’at sha’ah; a ruling under unusual circumstances that is applicable only for a given time and place. Even if so, perhaps we qualify for a hora’at sha’ah p’sak today, considering that infection with herpes type-1 virus today is at epidemic levels in adults and the consequences to an infant who contracts it is so great. Let those who claim that MBP is absolutely safe prove its safety and we can then reverse this temporary modification.

    What do I recommend? I believe that the time has come to establish a formal medical committee that will consider the input and opinions of multiple national experts on pediatric infectious disease, virology and public health. There are plenty of such experts who can weigh in on this debate. This committee will issue a report and make a best-determination of probable fact, considering what is known today. It will also highlight legitimate differences of opinion where they exist. This report can be updated as further data emerges. Poskim can then use these finding of fact to make a determination of halacha.

    I know there are many halachic issues. Amongst them: Is MBP a minhag or part of the actual bris? Is it only a medical recommendation by the Talmud that can be modified or discarded as medical knowledge changes? Does metzitzah need to be b’peh or is any other suction source or method of drawing away blood equivalent? Since I am not a rabbi, I am not qualified to rule. I merely seek a way to have fair representation of medical facts and judgment for those ruling on halachic matters.

    I believe an organized approach will increase medical factual accuracy, and also result in increased confidence in the halachic process. Our children deserve nothing less than both of these outcomes.

    Gary A. Gelbfish MD, FACS, is a vascular surgeon in private practice. He is a mohel certified by the Rabbinate of the State of Israel.


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    72 Comments
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    Rabbi Yair Hoffman
    Admin
    11 years ago

    Bravo! Finally.

    11 years ago

    I don’t understand why DNA testing is not insisted upon. Would it not either exonerate the Mohelim or provide very convincing proof of a medical problem? What justification is used for allowing Mohelim who may be killing babies to continue doing so without even the simplest of medical assurances?

    11 years ago

    What is the opinion of those orthodox Mohalim who are certified Pediatricians over the world and “Not certified under the State of Israel”.

    I use a Mohel residing in New York.Who is certified by the N.Y. State b.o.h. and tested via DNA every 90 days.
    He travels all over the world if needed.

    Truth
    Truth
    11 years ago

    As a medical prof. with experience in infectious disease I don’t accept your defining outcome. I think you’re coming more from a Mohel aspect than a medical.
    I also don’t accept Dr. Berman’s opinion right now.

    What is needed is a panel of 5 people to look into this subject. 2 should be Poskim, 2 should be Mohelim and one should be an infectious disease expert with knowlege in virology (Doesn’t have to be a MD) (Should Not be someone from or has to to do with the Frum community).

    Actually Dr. Gelbfish you would make a good candidate to sit on this panel as one of the Mohelim. You could explain it to the ID expert and ask pertinent questions.

    What I’m shocked about is that this hasn’t been done yet. We are talking about Pikuach Nefesh. Are we putting PC before our kid’s lives? I’m also upset at the other side for so easily jumping on the Gov. band wagon to stop MBP. We need expert opinions, not quasi – medical opinion.
    The panel’s recommendations should be accepted by e/o in the Frum community, no exceptions.

    11 years ago

    With all due respect, who are you to modify MBP that has been performed for 1000’s of years? And as you agree, in all 19 cases it was NOT proven that the Mohel is the cause of infection since it can only be proven by DNA testing.

    And what a poor statement, because only a minority are still practicing MBP therefore it should be banned. Yes, it is the minority (unfortunately) that are “Medakduk” on every halacha as our generations before, not like the majority of Jews that are Americanized and prioritize comfortably before yiddishkiet.

    Weeee
    Weeee
    11 years ago

    A formal Medical Commity wont work because you will have the zealots screaming its anti-torah and anti judaism. and if their rebbi says we should do MBP so be it

    Nebech
    Nebech
    11 years ago

    I actually started to take this Doctor seriously
    Untill I read the end

    Gary A. Gelbfish MD, FACS, is a vascular surgeon in private practice. He is a mohel certified by the Rabbinate of the State of Israel.

    I don’t consider rabbinate of Israel a certification
    I would not eat their food
    And I would not touch their mohels

    abeytt03
    abeytt03
    11 years ago

    Dr. Gelbfish, presents some of the facts very nicely and with a simplistic understanding. While the facts here are mostly accurate, and I agree with his overall premises, for a true understanding of the issues and a in depth discussion, people should seek out previously published articles on the subject which have a very solid grasp on the academic and halachic details involved in this complex discussion. A good start is Dr. Solomon Shprecher article, from which much of the details in Gelbfish article are gleaned from.

    Bruria
    Bruria
    11 years ago

    Take a bow, Dr. Gelbfish. This was excellent and timely. This needs to be read by our rabbis, pediatricians, mohelim, parents, and anyone who cares about the health of our children. Thank you for being the voice of reason!

    11 years ago

    Thank you DR. Gelbfish. Wonderful article. I feel that Jews used to actually be logical and nowadays so many people have turned our religion into anything other than logical. Yes, there are things we do because Hashem says so, but there are things that the Rabbis said we should do that only made sense for certain reasons and when you remove those reasons, the practice of the rabbis should not be followed, such as metzitza b’peh. We were once the religion that seemed the smartest because of the way our halacha is practiced and works with the way the world changes, but all of that is changing now…

    11 years ago

    After reading Dr. Berman’s article in Dialogue, I was totally unconvinced and horrified that such illogic was being unopposedly written. All Dr. Berman succeeded in doing was maybe maybe maybe showing that MBP could not be 100% proven to be the cause of the HSV the infants contracted. That in no way proved that it wasn’t far and away the most likely cause. I am extremely gratified and and grateful for Dr. Gelbfish’s article.

    Michel
    Michel
    11 years ago

    Ditto to #1 . A rational approach and one that must be undertaken if we are to maintain the ability of the Torah to be an Etz Chaim and relevant in every generation. One can only question the motivation of the Mohelim who do not provide DNA, and the parents of the child if they are a stumbling block too. Lets get to the bottom of it and soon. Meanwhile, my children and grandchildren will have a mohel who uses a pipette.

    lakewooder
    lakewooder
    11 years ago

    Dr. Berman suspects the motivations of the scientists disagreeing with him. If his suspicions are correct, his opinion stops being a minority one and is the only credible opinion. We must find a way to judge, objectively, the motivations of those experts.

    Member
    11 years ago

    Finally we have physicians who are involved in the press and showing that this is indeed a major concern we must address. I am a physician and I fully support that this is a medical issue more than it is a spiritual issue at this time.

    pinny
    pinny
    11 years ago

    people who know dr gelbfish know that he is a man of impeccable character and extremely learned!.He makes alot of sense.

    bigwheeel
    bigwheeel
    11 years ago

    Dr. Gelbfish. I agree 100% with your conclusions and recommendation. My concern and (possible) opinion on this issue is not from a professional perspective. Because I am neither a Rav, Mohel or MD. Only as a Yid who is interested to hear opinions and receive guidance on a fundamental Halachic issue. There are Two Rabbonim whose opinion and guidance I accept unequivocally. R. #1 is an elder person (Not a Mohel) who rules on medical and technological issues. Before he issues an opinion, he always consults with the relevant experts.; R. #2 , a 40 year old Rabbi who is also a world class Mohel who is also well-versed in technology. People of such caliber and integrity should attend (or lead) a conference like the one you suggested, in addition to experts in the medical field. (MDs.)

    11 years ago

    From 1990’s to the present 2012, appx. 20 years you claim of un-substantiated cases (no DNA test’s) that their was just “10 cases” you also say that 70 percent of adults have the virus any way! That means that statically 7 of the 10 cases would get the virus anyway! That leaves us with 3 questionably cases from 10,000’s mBp’s!
    I would also note that it is a fact that 100,000’s get infected from hospitals, clinics, doctors offices yearly from necessary and necessary procedures! Where is the outcry!!!

    בכל הדורות נהגו המוהלים לבצע את המציצה בפה, היינו המוהל מוצץ בפיו דם ממקום פצע המילה. אמנם מציצה בפה דווקא הוא דבר שאינו מפורש בתלמוד, אך כי יש מהפוסקים שדייקו בלשון הגמרא, שהכוונה בפה אכן מציצה בפה מוזכרת בפירוש במקורות הקבלה, וכן כתבו כמה ראשונים
    —————————
    שבלי הלקט הל’ מילה סי’ ח; ספר העיטור שער ג, הל’ מילה ח”ד; מחזור ויטרי הל’ מילה סי’ תקה; אבודרהם הל’ ברכות ריש שער ט; רמ”א יו”ד רסה א;. וראה באריכות בשד”ח מערכת מילה, קונט’ המציצה. וראה בשו”ת באר משה ח”ב סי’ פ, שהביא דברי הגאונים ר’ יצחק אלחנן ספקטור, ר’ חיים עוזר גרודזנסקי, ור’ אליעזר סילבר, שבמקומותיהם נהגו כל החרדים למצוץ בפה דווקא

    poyt63
    poyt63
    11 years ago

    B19 cases in over 20 years. I wonder what else he would stop doing. I am sure you don’t drive in cars or walk in the street or eat food, many more people have died in the last month from these “dangerous” acts and they are all proven beyond a doubt.

    11 years ago

    The article states: “I know there are many halachic issues. Amongst them: Is MBP a minhag or part of the actual bris? Is it only a medical recommendation by the Talmud that can be modified or discarded as medical knowledge changes? Does metzitzah need to be b’peh or is any other suction source or method of drawing away blood equivalent? Since I am not a rabbi, I am not qualified to rule. I merely seek a way to have fair representation of medical facts and judgment for those ruling on halachic matters.”

    Isn’t anyone else bothered by the fact that this mohel hasn’t investigated the halachos involved here?

    11 years ago

    גיטין נ״ז:
    ״כי עליך הורגנו כל היום״ ריב״ל אמר
    זו מילה שניתנה בשמיני. וא״כּ נראה
    למצוח מילה כדבּעי הוא בכלל סכנה
    וצריכים למסור נפשו ע”ז

    !אבל התורה דהיינו הקבּ”ה מגינה ומצלת

    mmmmm
    mmmmm
    11 years ago

    CIrcumscision is a medical procedure. When it comes to yom kippur if a doctor who is a mumcha (expert) paskens that a patient must eat, which is an issur Kares we listen to him over a rav and over the patient. If the doctors have ample proof that there is a safek pekuach nefoshos here, that has to be taken into consideration. How many times on any given shabbos are hatzoloh members doing “melochos Dorayysa” because a doctor says take the patient to the hospital on a safek pikuach nefesh.
    Of course all evidence from the Doctors must be presented to Qualified Rabonim who can diffrentiate if this is politically driven or it is straight medical facts. We must not compromise on our mesorah nor can we compromise on the health of our children.

    bored
    bored
    11 years ago

    binyan ztion 23-24 forbade use of sponge quoting chassam sopher as making no sense. both he and his most famous student rabbi samson raphael hirsch in shemesh marpeh insisted on metzitza bipeh and both allowed pipes if needed. rabbi hirsch said a bris without metzitzah is a covenent into irreligious modernity. binyan ztion suggests a commitee to oversee health of mohalim. we cannot abandon our traditions dr.

    11 years ago

    May I ask you a very simple medical question:
    If you compare the numbers of side effects that happened in the last 20 years from Government required Immunization shots given to babies, atleast 1 out 5,000 had problems that had to be taken to a Dr. or to Hospital.
    So in comparison. 19 cases between 75,000 new born boys is a smaller number.
    Dear Dr. can you answer?

    bubii
    bubii
    11 years ago

    With all this controversy about mbp i think we are being paralyzed with fear as the saying goes paralysis by anylasis

    11 years ago

    Excellent article.

    I would also like to read about the permanent brain damage that MBP can cause, which can initially be undetected for years. Dr. Jonathan Zenilman from Johns Hopkins is on record about this risk.

    In any event, I believe MBP should be banned immediately, in any way possible, by the government, or by the community.

    Anon Ibid Opcit
    Anon Ibid Opcit
    11 years ago

    The practice is disgusting and dangerous. Little children die from it. That would be enough reason to ban it on the grounds of protecting lives. On top of that there is no halachic requirement, and it makes Jews look like animals to the Gentiles. End it already.

    11 years ago

    Its either dangerous or it isn’t. Some people claim that the previous studies or opinions are biased. Lets have an unbiased study and follow the outcome. That is all the article says and it makes perfect sense.

    Normal
    Normal
    11 years ago

    Ironic that many people are presenting silly arguments while babies are dying.

    Member
    11 years ago

    I tried to tell my mother who is of a reform background about the MBP procedure and I tell you that she was so abrasively outly disturbed that she had to cover her ears and she would not listen.

    Nobody
    Nobody
    11 years ago

    This is the lede:

    “Furthermore, basic medical theory eschews oral contact with a wound, especially since our current medical knowledge does not attribute any benefit to MBP. The risk/benefit ratio is thus infinite”

    Given the number of brissim that happen every year with MBP, the risk here is very low, but *doctors* attribute no value to MBP. Why should we agree with that assessment? What if they considered there to be no value to the Bris itself?

    And then consider that at least *some* of these cases are wrongly attributed (just look at the recent very public case which was just a big “never mind” in the end) so the risk is even lower.

    It would seem that statistically the baby is more likely to die in the car ride to the place of the bris.

    Matzoslocal101
    Matzoslocal101
    11 years ago

    I would insist on DNA testing of the Mohel AFTER DNA testing of both parents and after follow up serological testing of the mother revealed that she remained seronegative 12-16 weeks post partum. i.e., that NYC DoH followed the standard epidemiological guidelines, (that it has never applied to a suspected MBP infection) as used in every other serious HSV-1 investigation since the technique was first used in 1976. To demand the mohel be checked before the mother, the undisputed source in 90% of NHSV infections, is absurd,