With Regard to the Metzitza b’Peh Controversy (Editor's Summary)
Shimon M. Glick, MD
Arthur I. Eidelman, MD, FAAP, FABM
The possible relationship between metzitza b'peh and neonatal genital herpes has recently been discussed by a variety of medical and halachic authorities. Summaries of their opinions are as follows: In August 2004 (in English), and subsequently in February 2005 (in Hebrew), articles authored jointly by medical academicians and Talmudic scholars on the results of a study regarding the possible relationship of metzitza b'peh and neonatal genital simplex infection (HSV-1) were published. Prof. Avraham Steinberg, an advocate of the ritual tradition, had published opposing arguments. The following is a summary of both approaches.
Position A: Metzitza b’Peh is Dangerous
The objective of the first study, published in Pediatrics, was to describe neonate genital HSV-1 infection after ritual circumcision in order to initiate antiviral treatment. Eight neonates with genital HSV-1 infection after ritual circumcision were identified between the years 1994-2002. The study found that in all of these cases, the mohel had performed the ancient custom of metzitza b’peh, which is currently practiced by only a minority of mohalim. Six infants received intravenous acyclovir therapy. Four infants had recurrent episodes of genital HSV infection, and 1 developed HSV encephalitis with neurologic sequelae. All four mohalim tested for HSV antibodies were sero-positive. The authors conclude that pediatricians should be aware of a potential transmission of HSV-1 by metzitza b’peh in order to start appropriate antiviral treatment promptly and to avoid severe neurological impairment.
After contacting the Chief Rabbinate of Israel and other halachic authorities, the same authors published a comprehensive rabbinic-historic review on this issue, published for Israeli and Jewish physicians, rabbis and the Hebrew-speaking readership in order to avoid Chilul Hashem. They argue that while the practice of metzitza b’peh might have been appropriate in previous generations to protect the newborns from disease, there is no Talmudic source halachically requiring oral metzitza and therefore, based on the potential of oral contamination of HSV-1 to newborns as documented in their earlier publication, strictly sterile conditions are required for the procedure. The authors concluded: “Ritual Jewish circumcision that includes metzitza with direct oral-genital contact carries a serious risk for transmission of HSV from mohalim to neonates, which can be complicated by protracted or severe infection. Oral metzitza after ritual circumcision may be hazardous to the neonate” (p. 259). Although the cases occurred only in an extreme minority of circumcisions, the halachic rule “in cases of pikuach nefesh one does not follow the majority” stands. Thus they wrote, “the same consideration that led the Talmudic sages once to establish the custom of the metzitza for the sake of the infant could now be applied to persuade the mohel to use instrumental suction” (p. 262). The Talmud carefully protected the neonate from potential risks associated with brit milah and is the oldest source in the history of medicine to describe e.g. hemophilia in the context of circumcision; for these children at risk of fatal bleeding, the Talmud requires delaying of circumcision in order to secure medical safety, as articulated clearly by Maimonides: “We should not circumcise a child who is afflicted with any sickness at all, since the danger to life takes precedence over everything. Circumcision can be performed at a later date, while it is impossible to bring a single Jewish soul back to life”. Following Maimonides’ Talmudic approach, Rabbi Moshe Sofer (1762–1839), a.k.a the “Chatam Sofer”, published his halachic decision regarding cases of newborns contaminated by oral metzitza: He advised to abolish oral metzitza due to potential danger for the neonate and to replace it by alternative sterile approaches.
Supported by these Talmudic and rabbinic sources, that sparked the famous controversies regarding the status of Metzitza b’Peh during the 19th and 20th centuries, the authors call for the requirement of strictly sterile conditions and replacing oral metzitza by instrumental metzitza in order to protect the newborn; it is the authors' clear goal to encourage brit milah in the Jewish population and therefore, metzitza should be performed – according to the Talmudic and rabbinic sources – in a sterile way to protect the newborn.
Position B: Proof is far from Conclusive
According to Prof. Avraham Steinberg, the aforementioned cases and conclusion are extremely problematic: 7 of these cases occurred in Israel and another has occurred in Canada over the course of eight years (1994-2002). It should be noted that in four of the eight cases the mohalim were not tested for HSV antibodies and in one other case a positive level was found both in the mohel’s blood and in the mother’s blood. This all adds up to offer a very low level of probability, even in cases where metzitza b’peh is performed, and the association has not been firmly proven. During the mentioned duration of time, in Israel at least 40,000 brit milah ceremonies with traditional metzitza b’peh had taken place, of which, 7 may have resulted in contagion of HSV, although in half of these cases, there is no proof whatsoever that the mohel had positive levels of HSV antibodies, and in one of these cases it may have been the mother that caused infection. Moreover, in the articles by Gesundheit et al there is no explanation how these few cases were accumulated, whether or not there were other cases of HSV infection during that time and by the same mohalim, and whether or not other family members of these babies suffered from HSV. Finally, no test of DNA between Mohel and infant had been taken, a test which is the only scientifically reliable way to prove contagion. Such serious limitations of the study, which at most creates a chashash rachok (a very far concern), cannot serve as a contra-indication to any medical procedure, and since metzitza b'peh is considered by many halachic authorities to be essential for the mitzvah of brit mila this study is scientifically insufficient to consider the annulment of metzitza b'peh.
Hence, the most authoritative Rabbis – Rabbi Y.S. Elyashiv and Rabbi S. Wosner – issued a clear and firm objection to the annulment of metzitza b'peh.
Either way, Steinberg concludes, the mohel should take cautious measures in order to relieve us even of this far concern of infecting an infant with HSV.
C. Editor's Note
Review of the data of the published articles and above noted comments does not support, at this time, a categorical ban on metzitza b'peh nor a need for routine screening of mohalim for potential herpes infectivity. However, if the clinical experience of an individual mohel or the results of his serologic tests suggest a possibility of him being infective, then instrumental suction should be strongly considered.
It is relevant to point out that, to the best of our knowledge, no public health authorities in the US or in Israel have forbidden metzitza b’peh at the present time.
 Benjamin Gesundheit, M.D., Galia Grisaru-Soen, M.D., David Greenberg, M.D., Osnat Levtzion-Korach, M.D., David Malkin, M.D., Martin Petric, Ph.D., Gideon Koren, M.D., Moshe D. Tendler, Ph.D., Bruria Ben-Zeev, M.D., Amir Vardi, MD, Ron Dagan, M.D., Dan Engelhard, M.D., “Neonatal Genital Herpes Simplex Virus Type 1 Infection After Jewish Ritual Circumcision: Modern Medicine and Religious Tradition”, Pediatrics, Vol. 114 No. 2 (August 2004), pp. 259-263 [hereinafter cited by page number]. May be found at the author’s site:
http://www.jewishmedicalethics.org/?page_id=30 – Quotes are given with the author’s consent.
 Benjamin Gesundheit, M.D., David Greenberg, M.D., Shlomo Walfish M.D., Ron Dagan, M.D., Gideon Koren, M.D., David Malkin, M.D., Moshe D. Tendler, Ph.D., “Infectious complications with herpes virus after ritual Jewish circumcision: a historical and cultural analysis” (Hebrew), Harefuah, Vol. 144 No. 2 (February 2005), pp. 126-32; 148-9 [hereinafter cited as “Gesundheit: Harefuah”]. May be found at the author’s site:
 See note 2.
 b.Yoma, 84b; b.Ketubot, 15b – and Gesundheit: Harefuah, p. 131.
 Tosefta Shabbat 15:8 and parallels.
 Maimonides, Mishneh Torah, Hilchot Milah 1:18; see also Shulchan Aruch, Yoreh Deah 263;2.
 This Responsa of the “Chatam Sofer” was published in 1845 in Kochavei Yitzchak, Vienna, p. 40. The original full text and its discussion is also available on B. Gesundheit’s website: www.jewishmedicalethics.org.
Editor’s Note: M. Halperin addressed this specific issue in his article “The Tradition of Metzitza” and suggested a different approach: see pp. 23-35 supra.
 A. Steinberg, entry 'Milah' (Hebrew), in: Encyclopedia of Halacha and Medicine2, Jerusalem 2006, pp. 492-494.
 i.e. If he has sores in his mouth he should refrain from doing metzitza b’peh; he should either use a tube or let another perform the metzitza b'peh; he should thoroughly wash his mouth with 70% alcohol and salve the area of circumcision with a proper anti-herpes ointment (zovirax etc.).
 See also Sprecher S., "Mezizah be-Peh – Therapeutic Touch or Hippocratic Vestige", Hakirah – The Flatbush Journal of Jewish Law and Thought 3;15-66:2006 and the letters in the subsequent issue Hakirah – The Flatbush Journal of Jewish Law and Thought 4;9-19:2007.