Following the death of two babies from herpes – one in 2004 and the other last fall – New York City’s Board of Health has issued a proposal that parents sign an informed consent release before a mohel performs a controversial oral suction procedure called metzitzah b’peh.

An estimated two-thirds of baby boys in the haredi community are circumcised in a manner that includes metzitzah b’peh, Rabbi David Zwiebel of Agudath Israel of America told the New York Times last March, when the latest herpes-related death came to light.

The procedure involves a mohel using his mouth to directly clear the wound of blood in the final stage of a ritual circumcision.

But beyond the haredi world, parents may not even know about the issue, says Dr. Aaron Jesin, a Toronto family physician and Orthodox mohel who believes informed consent is a good idea when it comes to metzitzah b’peh. “At least it gets them thinking about what’s going on.”

One mother whose son was circumcised in Toronto recently told The CJN that her mohel never mentioned it.

“We just thought, ‘No one does that anymore,’ and didn’t realize until too late.”

Another Toronto father who was aware of the issue said he “sought an Orthodox mohel who understood our concerns.” But he said friends have been “surprised when they learned [it] was used at their bris after the fact.”

More than 200 haredi rabbis in the United States have signed a statement opposing the New York City Board of Health proposal and defending the tradition. They say they intend to continue practising it, citing government interference in a religious matter.

 “The legislature is going to tell us how to make brissim?” asked one signatory, Rabbi Yisroel Belsky, head of the Yeshiva Torah Vodaas in Brooklyn, N.Y., in a recent cover story of the glossy Orthodox weekly Ami Magazine. “Let’s say I’m the head of a New York State legislative body… and one day I walk into the Waldorf Astoria and tell the head chef, ‘Listen, there’s a new rule about how you have to cook.’ He’d say, ‘Are you crazy? You’re telling me how to cook?’”

Between 2004 and 2011, New York had 11 reported cases of herpes simplex infection following brit milahs. Two boys were left with lasting brain damage. And with at least one past case in Toronto (in 1994) and others in Israel, this is clearly a global problem.

Jesin explained that metzitzah (suction) is the last of three essential brit milah steps, as described in the Mishnah. Metzitzah was included for health reasons, and Jesin said drawing out the blood can clean the wound and introduce white blood cells for healing.

Yet the Mishnah doesn’t specify oral suction. In the 19th century, the Chatam Sofer, a leading authority, ruled that oral suction wasn’t necessary if a mohel was sick. He also permitted alternative suction methods, and some mohels at the time – who were also newly aware of modern theories of disease transmission – began using a glass tube, the prevailing practice today.

In June, the U.S. Centers for Disease Control issued a statement that “before circumcision, mohelim [sic] should inform both parents whether they perform direct orogenital suction and explain the risk of herpes transmission, so that parents can choose not to have their newborn exposed.”

Despite the popular belief that the two strains of herpes (Type 1 and Type 2) correspond, respectively, to oral and genital herpes, either strain can infect either region (or other areas, such as the eyes).

In an adult, herpes can be annoying or painful, but in a vulnerable newborn, herpes causes devastating skin and eye blisters, brain infection and even death. Most cases in babies are transmitted by the mother.

Jesin said he used metzitzah b’peh when he started 33 years ago, “but then I went to a lecture by Rabbi [Moshe] Tendler,” the rosh yeshiva of the Rabbi Isaac Elchanan Theological Seminary at Yeshiva University, who holds a PhD in microbiology and has angered many with his stance against metzitzah b’peh.

The Ami Magazine cover article, titled “Taking Action! The fight for metzitzah b’peh,” strongly condemns New York City officials and the Centers for Disease Control.

“Mathematically, the number of kids getting infected from metzitzah is so low that it doesn’t even weigh in as a percentage,” Rabbi Belsky says in the article.

In another article in the same issue, a prominent mohel asserts that all mohels are tested to prove they’re herpes-free.

Yet it’s estimated that between 20 and 50 per cent of the adult population carry the virus (mostly as cold sores). And a study published in the journal Pediatrics concluded that it’s possible for an asymptomatic mohel to pass on the disease.

Jesin said that “if you believe metzitzah b’peh is… Halachah from Moshe on [Mount] Sinai, then you will feel very strongly that it’s the only way.”

Such parents may be willing to accept the risks, but for others who are simply unaware of the practice, Jesin believes they should be informed.

Despite the precarious situation surrounding brit milah in Germany – where a court ruled in June that circumcision violates children’s rights, leaving its legality in question – and a growing number of young Jewish parents who are rejecting the rite, Jesin said discussing the issue of metzitzah b’peh can only be a good thing.

“Hiding is not going to help,” he said. “You’re saying we shouldn’t talk about it, shouldn’t fix the problem, because [some haredim] are worried?”

By dealing with the issue head-on, “basically you’re saying, ‘Let’s do it safely.’”