When Circumcisions Transmit Herpes: We Need to Talk About It

A minority circumcision practice among ultra-orthodox Jews has been identified as the likely source of infants contracting herpes, but will religious sensitivities prevent the authorities taking action? It shouldn’t, and here’s why.

A new study published this month in The Journal of Pediatric Infectious Diseases Society provides evidence that the relatively uncommon but still used practice known as metzitzah b’peh (MBP) can transmit HSV-1, or the herpes simplex virus, to infants. The procedure involves the person carrying out the circumcision, known as the mohel, placing his mouth on the circumcision wound in order to suck out a small amount of blood which he then discards.

The New York Times has a description of one particular ritual:

The mohel lifted the infant’s clothing to expose his tiny penis. With a rapid flick of a sharp two-sided scalpel, the mohel sliced off the foreskin and held it between his fingers. Then he took a sip of red wine from a cup and bent his head. He placed his lips below the cut, around the base of the baby’s penis, for a split second, creating suction, then let the wine spill from his mouth out over the wound.

The health problem with this practice is that in just the American population alone, it’s estimated that more than half have HSV, and transmitting the virus to children at such a young age has been known to cause sometimes serious health complications, and even fatalities.

Cases of transmission between 1988 and 2012 were revealed in this latest study, with researchers from Penn Medicine’s Center for Evidence-based Medicine finding 30 reported cases of HSV-1 infant transmissions from New York, Canada and Israel. The systematic review, which is the first of its kind, examined six different studies, all containing descriptive accounts or case notes of infection after circumcisions that employed direct oral suction.

The researchers believe this study gives sufficient clinical evidence to say that the oral suction practice is dangerous and, while we don’t know how many are currently practicing the technique (though some figures estimate about 3,600 local circumcisions each year in New York City), it needs further investigation and follow-up.

The practice is extremely controversial, with the majority of mohels using a glass pipette or a sponge to draw blood away from the wound instead of the oral suction technique. However, there are some who stand by the ritual and fiercely defend it as safe. Furthermore, when in 2012 the New York City health department introduced a regulation requiring parents to sign a consent form before such circumcisions could go ahead, religious groups like the Agudath Israel of America and several other orthodox groups filed a lawsuit contending that the regulation violates their religious freedom.

Ultimately, a federal judge upheld the regulation based in part on the argument that it protects the religious liberty of the parents by allowing them to give informed consent, but the authorities have not been strict about enforcing the regulation, likely because of the religious sensitivities they seem to fear offending. That said, there is rising pressure for health authorities to do more on this issue.

In addition to the publication of this recent health data, the New York City Department of Health issued a health alert on July 22, saying the department had received confirmation of two new cases of HSV infection following the “orogential suction” circumcision ritual. It adds an explanation of just how damaging contracting HSV at such a young age can be:

In both of the cases reported in July, the infant boys were born to mothers with full-term pregnancies, had normal vaginal deliveries, and underwent ritual Jewish circumcision including direct orogenital suction on day of life 8. In the first case, the baby was evaluated as an outpatient on day of life 16 for pustular lesions on the penis and genital area. HSV infection was suspected, and a genital specimen collected for viral culture. The baby was admitted to the hospital and treated with acyclovir and clindamycin. Additional specimens were collected at the hospital for HSV testing, including CSF, blood, and swabs of lesions; all were negative for HSV, and the baby was discharged on day of life 19. On day of life 22, the initial viral culture taken as an outpatient was positive for HSV (non-typable). The baby was re-admitted to the hospital for intravenous acyclovir treatment. In the second case, the baby developed lesions on his penis, left thigh, and left foot beginning on day of life 17. On day of life 19, the baby’s pediatrician collected specimens for bacterial culture, which came back negative. The next day, after the appearance of new vesicular lesions, the pediatrician suspected HSV, and the baby was admitted to the hospital. Two swabs of genital lesions and one swab of a foot lesion were positive for HSV-1 by PCR. In both cases, the location of lesions, timing of signs and symptoms, and laboratory identification of HSV are consistent with transmission of HSV during direct contact between the mouth of the ritual circumciser and the newly circumcised infant penis.

There are some mohels practicing the ritual who contend that, with proper health screening under licensed (though self-regulated) circumcision practitioners, this ritual is entirely safe — that they would even go to jail rather than stop performing the ritual which, the devout believe, is the only way to confirm a newborn son as Jewish.

The problem here seems to be that we are finding it difficult to parse exactly where the line of religious liberty should end. We’ve heard the defenses for the wider practice of circumcision,  and at the very least there are some noteworthy if not compelling positive health outcomes relating to circumcision. There are also a number of arguments against circumcision, chiefly that the practice violates the autonomy of the newborn baby boy and his right to make decisions concerning his own body when he is capable. Yet, I believe those arguments aren’t needed here.

Despite what some mohels who still carry out oral suction might claim, we have strong evidence that this particular form of circumcision practice is not only just morally fraught, but is actively dangerous to the health of the child. With this in mind, enforcing a rule that demands informed parental consent, and punishing those mohels who refuse to comply or even actively flout the rule (as has been happening), is not only justified, it seems it is entirely necessary in order to safeguard the health of the child — which, of course, should always be our first concern, even above what I am sure is sincerely held religious belief.

Photo credit: Thinkstock.

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