Rare circumcision ritual generates controversy in New York

NEW YORK -- For thousands of years, rabbis performed a simple procedure to cleanse the wound during a ritual circumcision: Like outdoorsmen treating a snake bite, they sucked blood from the cut and spit it out.

That age-old procedure is now the subject of a clash between religion and science in modern-day New York.

Prompted by a child's death from an infection, the state Health Department is drawing up its first set of safety guidelines governing the practice, which was abandoned by most Jews long ago but has survived among the ultra-Orthodox in a few Hasidic communities.

Doctors have long been concerned that the procedure -- called "metzitzah b'peh" in Hebrew -- could spread disease. But their argument became urgent last year when New York City health officials said the practice had given a baby a fatal infection.

The illness was caused by herpes simplex type 1, the common virus in saliva that causes cold sores. Usually harmless to adults, it can be deadly to newborns.

The death was believed to be the first in the United States to be associated with metzitzah b'peh, but the city said it had linked four other herpes infections since 1988 to two mohels, as those who perform ritual circumcisions are called. Two more cases were reported in 2005, including one in which a child suffered brain damage.

Efforts to curtail the practice have met with resistance from some Hasidic leaders, who say the act is commanded by Jewish law. They threatened protests after the city's health commissioner recommended that infants not undergo the procedure.

The state guidelines will stop short of a ban but will include voluntary precautions that could reduce the chances of infection during a bris, as a ritual circumcision is called, said state Health Department spokesman Robert Kenny.

Rabbis will probably be asked to inform their congregations about the risks, and parents will be advised to seek prompt care from a pediatrician if their baby develops a fever or rash. Steps will also be taken to "ensure that mohels have full knowledge of their health status" before performing the ritual, Kenny said.

He declined to discuss details, saying the guidelines were still being developed. But several religious leaders have suggested that mohels be asked to rinse their mouths with alcohol, undergo regular testing for disease and refrain from doing circumcisions if they have a cold sore.

The guidelines are likely to displease some doctors.

Dr. Jonathan M. Zenilman, a professor at the Johns Hopkins School of Medicine in Baltimore, said that while infections have been rare, the potential for harm is substantial enough to justify a ban.

"This is something that is pretty much counter to all of the infection-control measures that we have," Zenilman said.

Asking mohels (the word is usually pronounced MOY-il) to police themselves could be ineffective, he warned. As many as 70 percent of all adults have herpes simplex 1, and it is difficult to detect periods when the virus is contagious.

It is unclear how the Hasidic community will react to the guidelines.

Rabbi David Niederman of the United Jewish Organizations of Williamsburg, a Brooklyn neighborhood with a large number of ultra-Orthodox Jews, has argued for no government action, saying there is too little medical evidence to justify a public warning about a ritual performed safely thousands of times a year.

"Parents have been alarmed unnecessarily," he said, adding that he has received calls from worried mothers.

"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."

Rabbi J. David Bleich, a professor of both Jewish and secular law at Yeshiva University, said the debate over metzitzah b'peh began in Europe during the mid-19th century, when suspicion arose that it was spreading tuberculosis. Ever since, there has been disagreement over whether the practice was required under Jewish law or simply recommended for medical reasons.

A majority of Reform and modern Orthodox mohels decided it was recommended, and now clean a circumcision wound with sterile gauze, a sponge or a glass tube.

But a century and a half of debate has not resolved the argument, and Bleich suggested that actions by health authorities would not settle the issue either.

"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."