Thursday, August 21, 2014

MBP - Dispelling Some Common Misconceptions

The mere sight of the term MBP (Metzitza B'Peh - direct oral/genital suction of the circumcision wound) may set off fireworks in the minds of many of the medical halachic rationalist readers of this blog.  Some of you might have been waiting for me to say something about this subject. MBP has been in the news lately due to some high profile court rulings in New York, so it is once again a hot topic.  However, I must disappoint you by admitting that I don't have that much to add that hasn't already been said.  In fact, a close friend of mine, Shlomo Sprecher, has already written what I consider to be the most definitive rationalist medical halachic (even if he didn't use the term "RMH" to describe it!) article on this topic, and you can read it here.  I highly recommend that you read it if you haven't already done so.

However, I have come across an extreme amount of ignorance when it comes to understanding exactly what the medical concerns are regarding the transmission of HSV (Herpes simplex virus) and circumcisions.  The ignorance in the Orthodox Jewish world seems to reflect the ignorance of the general population about this virus, which I encounter on a regular basis in my medical practice. As such I feel like I need to counsel everyone regarding how this virus works, and then you can understand what the issues really are.

For starters, HSV is a virus.  That means that it cannot be treated with antibiotics.  This particular virus has the nasty habit of being incurable, which means that once you become exposed to it, it will be in your system forever.  It has figured out a way to hide deep inside your nerve roots ("ganglia") and hang out there for the rest of your life.  Every once in a while it may decide to leave its hiding place, travel up the nerves to your skin, and cause a lesion to pop out on your skin and annoy you.

When this happens, the sore is likely to shed more virus, so if someone else becomes exposed to it, he/she can catch it from you.  However, the virus is even sneakier than that.  Sometimes it travels out to your skin and sheds virus, but doesn't show any sores at all.  This is called asymptomatic shedding.  This means that you can be shedding and transmitting the virus and have no idea at all that it is going on. While an active lesion is much more likely to shed virus than when there are no symptoms, it is well known that asymptomatic shedding can and does occur.

So that's the bad news, what is the good news?  The most important good news is that HSV is generally not a very dangerous virus at all, in the overwhelming majority of cases.  The vast majority of people with this virus will go about their innocent lives and have virtually no consequences, except maybe an annoying sore every once in a while.  Most people don't even know that those annoying sores are HSV, they just think it is a pimple that came and went after a few days.  They usually don't even know that they have HSV, and they certainly don't know that they can transmit it to someone else!

But that good news can also be bad news. Why is that? Because if you don't know that you can transmit it, and it can be transmitted even if you have no symptoms at all, how are you supposed to prevent the transmission of HSV throughout the general population? Well, guess what! You now understand why close to 90% of the adult population of the US has been exposed to HSV 1 at some point in their lives.

When two moist surfaces of the body, such as the oral region, and/or the genital region come into contact, and one surface is shedding HSV, this is the most effective way to transmit the virus.  If one person has a cold sore (which is caused by HSV), or is shedding asymptomatically, and people share a cup, a kiss, share a food utensil, wipe their mouth or cough and then pass the kugel, or any other moist contact, the virus can be transmitted.  Of course the chances are very small each time this type of contact occurs, but if it happens over and over again, it only takes once ...

The vast majority of people will have been exposed to HSV in this manner.  By now you should understand that a person with HSV 1 is usually not infected because he/she is guilty of some type of sexual contact. Most of the time it was completely innocent, and most of the time the person him/herself is never even aware of having been exposed.

You probably noticed that I mentioned HSV 1, which means that there is another type called HSV 2.  This is a very closely related virus that tends to hang out more in the genital region.  This type is usually transmitted through genital or oral/genital contact.  However, there is much crossover between the two types, as HSV 1 is often found in the genitals, and HSV 2 is often found orally as well.

HSV 1 outbreaks are generally more mild than HSV 2 outbreaks, and especially with HSV 2 in the genitalia, the first outbreak can be quite severe.  But both types of the HSV virus have a very similar clinical course, and they are transmitted in basically the same way.  The reported cases of HSV transmission through MBP in New York were HSV 1 cases, not HSV 2. This is important because HSV 1 is much more common, and is still more associated with Oral infection than with genital infection.

So what's the big deal? If it is true that HSV is only a nuisance and rarely causes health problems, why is it such a concern? What is all the hoopla regarding MBP?

The big deal is that in certain very rare cases, if HSV gets into certain body fluids it can cause very serious problems.  Those two places are the blood, where it can cause viremia (a viral blood infection) or in the brain where it can cause encephalitis or meningitis.  Viral infections such as these can be extremely dangerous, and are notoriously difficult to treat, especially because antibiotics do not work against viruses.  Furthermore, as you recall, there are no cures for HSV.

When would someone be at highest risk for such a horrible infection of the blood or the brain with this virus?  For starters, if it is introduced directly into the blood. That would be really bad.  Now if you take a person who does not have a very strong and mature immune system, that would be worse.  Then if it enters the brain of someone who is still developing neurologically, that would be tragic beyond words.

Now let's make it scarier.  Let us find a well meaning person.  This person seems perfectly healthy.  He himself has no idea that he has any infections of any type. Everyone around him knows that he is "very clean" and scrubs his hands really well.  He has lived a virtuous lifestyle and has never exposed himself to any situation which would make one concerned that he may have gotten any transmittable diseases.  Maybe when he was a child in cheder he shared a cup of juice and got a little cold sore, which went away after a few days because his Mom shmeared on some Vaseline.  He was a little "tzaddik'l" and went on to become a popular Mohel.  But he has this HSV 1 virus for life.  In his mouth.

Let us go further. This mohel never sees any lesions that he thinks could represent a major health risk, except occasionally he may get a cold sore which he thinks is just chapped lips.  The mohel is such a tzaddik and so well loved and well respected that he does a Bris Milah just about every day in his community.  Asymptomatic shedding is very rare, so it only happens a few days a year, but he does a bris milah every day ....

And one fine day, a happy young couple brings their beautiful little child to shul for his bris milah.  The well meaning, wonderful Mohel performs the ceremony.  He does MBP. This young child, with an immature immune system, and a developing nervous system, now has an open wound, giving the virus direct access to his bloodstream, and to his newly forming brain.  The Mohel happens to be shedding virus that day, and has no symptoms whatsoever. And the virus gets into the baby's bloodstream, and it replicates, and may God save us, a horrible, totally preventable, unspeakable tragedy occurs.

This is the problem.  Like I said before, the cases reported in New York were HSV 1, simple Oral HSV that 90% of the adult population has.  The only way to prevent it from happening is by avoiding the exposure in the first place and protecting our children from tragedy.  May common sense prevail.


In this post, I have tried to dispel the following extremely prevalent and extremely dangerous notions (I have heard ALL of these in murmurings at shul kiddushes, Shabbos tables, during leyning - bein gavra l'gavra only of course etc...)
  1. If the Mohel is a genuine tzaddik and ben Torah there is no risk of herpes transmission
  2. the Modern Orthodox are just trying to find ways to show that the Chareidim have Herpes infested Mohelim and they are all hypocrites
  3. If the Mohel has no history of disease and has no herpes sores there can't be a risk
  4. This Mohel has done thousands of Bris Milah ceremonies and "no one" has ever had a problem (this would be extremely difficult to prove, and even if it was true, it still doesn't protect you)
If any of you have heard other such comments, I would be interested to hear them.


  1. Your statement, "The vast majority of people with this virus will go about their innocent lives and have virtually no consequences, except maybe an annoying sore every once in a while" is unfortunately not true.

    This only magnifies the gravity of introducing the virus into the bloodstream of an infant with an immature immune system.

  2. Thank you - this was a good explanation (and as a member of the "Modern Orthodox" community, I would like to agree that we are not just trying to find ways to show that Chareidim are hypocrites - for me, the first and most important concern is the infant).

    Perhaps I missed it, but I felt that no solution was offered. I understand that some communities have opted out of doing MBP and offer a different solution so as not to infect the baby. What kind of solutions do you suggest?

  3. Yoel B, Thank you so much for bringing that study to my attention. It is not surprising that the HSV virus may be linked to neurologic disorders such as Alzheimers. While much more work needs to be done before we can say with certainty what exactly the nature of the relationship is, it is certainly very intriguing and worth considering.

    Anonymous: See the article by Dr Sprecher that I referenced as far as alternative to MBP. The short version is that 1) it could be that metzitzah is not required at all, or, 2) it could be done by using a tube applied to the penis, thus creating suction and avoiding direct contact (this seems to be the most accepted way to do itand many poskim have approved this approach) or 3) it may be possible to do metzitzah by applying pressure with sterile gauze. But option 2 seems to have the most support.

  4. So then why has option 2 not been widely implemented in the Chareidi community? If it's acceptable, wouldn't people prefer that over risking the health and life of their children?

  5. I am a Charedi and I sometimes act in the capacity as Mohel. I have always done MBP. I am an open-minded person and genuinely want to know the facts in order to decide what is the right thing to do.

    First of all can you add footnotes with sources for all of the facts which you write. Also I read in several medical sources that alcohol inactivates viruses. I would therefore understood that it is safe to do MBP because the custom is for the Mohel to douse the area with strong wine during or immediately after the MBP.

    Let me also explain the reluctance to modify the technique of Metzitza so it does not include the oral contact. My belief is that Minhagei Yisroel are correct and necessary. The actual Metzitza is a requirement taught in the Gemara and saying that not to do so poses a danger. The nature of this danger is not known. It might be a Ruchnius danger, which is no less serious that a medical danger, as we know Gadol hamachti es ha'adam yoser min hahorgo, which adds up to mean that a spiritual death is worse than physical death. This metzitza has been understood in our mesorah to be done B'PEH. Hence the reluctance to change. That being said, if I would to understand that the danger is real and significant, I am open to change. Let me also say that just as I detect a tremendous distrust and even hatred from the MO community against Charedim, so I, as a Cheredi, distrust (but by no means hate chas vesholom, as you can see that there is no venom in my words here) the motives of those MO Jews who want to discredit Charedi practices, so this adds to my reluctance to just blindly believe and accept all of the anti MBP talk.

    If anyone wants to address my comment, please do so in a dignified way.

    1. Katche-Lab, while alcohol does destroy viruses, a mohel's swishing wine in his mouth and/or putting it on the wound won't work. Strong wine is 12-13% alcohol, but for disinfection the optimal concentration is 60-90% alcohol, and its effectiveness as a disinfectant drops sharply at concentrations below 50%. See . In comparison, standard "80 proof" brandy or vodka contains only 40% ethyl alcohol. A 70% alcohol/water solution is fine for sterilizing instruments or swabbing unbroken skin before an injection, but would never be used on an open wound.

    2. Please see here

      In times of HaZaL the wine was diluted, but the undiluted was also drinkable. It seems to have had a much higher alcohol concentration.

      Given the performance of MBP is not DRINKING, perhaps HaZaL INTENDED the undiluted wine to be used for the mitzva?

    3. TGbR: Your suggestion is interesting, however, yeast cannot make alcohol stronger than a 12-14% concentration. Until distillation was invented, wine could never be stronger than that. In order to be effectively sterilize a surface and kill viruses, a concentration at least 67% is required. Even our strongest whiskeys do not reach that concentration.

  6. Anonymous: Your question regarding Option # 2, (the use of a tube instead of direct oral suction), was actually originally proposed by R Samson Raphael Hirsch and Ravb Azriel Hildesheimer. Option # 3 (using a sponge or gauze) seems to have been proposed in a letter by the Chatam Sofer. Since then many poskim have upheld these opinions. However, many poskim have rejected that approach as well. I chose not to delve into that discussion in depth, only because others have done so before me. Most Chareidim today follow the poskim who have ruled that metzitza needs to be done with direct oral suctioning. Those that have been following my blog know well that I usually treat topics like this one at length and with a thorough halachic analysis. I apologize for not doing that this time, for the reasons I gave already See this link
    for more about this issue

  7. Katche-Lab: Thank you so much for your comments, and especially for the tone of your questions. By no means do I ever mean to God forbid express any hatred or mistrust for a fellow Jew that is doing what he/she believes to be the Ratzon Hashem. The fundamental issue here is in general, the MO community believes that MBP was instituted as a health precautionary measure, based on what was believed at the time to be a health benefit. As such, since it has been shown to be dangerous, it should not be done any longer,or at least it should be done in a way that does not expose the baby to unnecessary risk. You clearly espoused a very different viewpoint, which has led you and the Chareidi world to a very different conclusion. Your viewpoint is that MBP is being done to avoid a spiritual danger, and thus of course that would not have changed at all due to current medical advances. This very clearly delineates the divide between the two camps, and if we can at least accord each other the respect of understanding the two different perspectives, we can move forward without any hate or anger. Now that we have established that, we can go on to discuss your other questions.

    It is important to note, that the reason this partyicular debate is often so heated, is because it involves what the MO community believes is an issue of sakanat nefashot. If it was simply a matter of philosophical disagreement, it wouldn't bring out so much vitriol. People can get heated when discussing matters of life and death. I promise to do my best to stay calm ;-)

    1) alcohol: I plan on dealing with this issue in a coming post. so forgive me for not answering that question in this comment.
    2) references and footnoes: Everything I said in my post is well known basic medical information about the HSV virus. I did not quote anything controversial. However, since you requested ma'areh mekomot, I will give sources in the medical literature in an upcoming post to back up everything I said. Many readers of the blog never make it to the comments section, and I want it to be more public.

  8. The Medical Halachic Rationalist
    I reciprocate in appreciation of your respectful tone in responding to me.

    Let's assume that I am wrong, from a medical standpoint, in my suggesting that the alcohol used in the metzitza would effectively deal with the danger. Let me take my other argument about the spiritual consideration a bit further. Al pi halacha one does not do the circumcision at all when there is a real danger. We see this in the case of Maisu echov machmas milah, or yarok or adom etc. Now no one will deny that occasionally we hear the tragic story of a botched milah. That means that there is a chance of that happening. The halacha does not consider this a significant risk. The secular world who have no appreciation of the mitzvos say that that we are endangering a child for nothing, while a religious Jew says that to violate the mitzva of bris milah, would be most destructive and it's importance is absolute and worth the risk. But when a risk, which by halacha guidelines is considered significant, is present, we don't do the milah. In the issue at hand, we are discussing an aspect of milah which is not Me'akev, but is considered to be important. Even in the letter from the Chasam Sofer (if authentic) which is cited to support those who oppose MBP, he attributes kabbalistic meaning to MBP. The fact that he ruled there not to do MBP, dorsn't really prove anything to me, because I think anyone would have ruled so in that instance in which there was evidence of a real danger. But what would he have ruled without the presence of the epidemic described in that letter. I would not advocate MBP in the presence of a danger which is considerably significant. The question only exists in the situation as it is, that there seems to be evidence of a remote chance of some danger. I don't know how to measure the risk factor and at what level it becomes a halachicly recognized danger.

    Furthermore, according to the mesorah of MBP, this is the way the mitzva was intended by Chaza'l, because of the hidden spiritual kabbalistic aspects of it, so to say that the dangers involved justify the position against this practice would be an argument against Chaza'l. The Chasam Sofer doesn't completely undo the practice of MBP. He only says that in that particular case we shouldn't do MBP, but the practice remains intact in other cases where we don't see the presence of that danger. If the question presented to him was to decide in a general sense that MBP is universally dangerous and therefore never called for, and our mesorah and the Kabbalists were wrong because of the lack of medical knowledge in their times, it could reasonably be argued that he would have ruled in support of MBP.

  9. I've heard the following rationalizations for MBP, the first two of these claimed to be having a basis in medical science:

    • If the mohel drinks and/or rinses his mouth with wine (or shnaps) immediately before doing MBP, it prevents transmission of the virus, because of the alcohol in the wine which "kills the germ". And mohels who do MBP all know this and do it, so there's no problem with MBP.

    • The mother is the one who almost always changes the baby's diaper, coming into contact with and/or cleaning the bris wound and the baby could "just as easily" have contracted the virus on it's genitals from the baby's mother (or anyone who changed their diaper). This statement inevitably goes with an accusation that blaming the mohel for the baby having contracted the HSV virus is anti-Semitic or anti-Chassidic or some other paranoid delusion.

    • Chazal say that harm does not come to "shluchei mitzvah." Certainly in the case of Bris Milah, such an important mitzvah, harm will not come to the baby.

    • Along the same lines of the above, the zechus of the essential mitzvah which brings boys into Klal Yisrael, it will protect the baby from any harm, even if there is some herpes transmission.

    • Hundreds of thousands of babies have gotten MBP in the past x years and how many of them actually get sick? It never really happens, it's just a fluke thing that the Anti-Semites use to persecute us.

    • It never happened to anyone I know or anyone any of my friends know, and that covers many thousands of babies. It's just hype.

    • Eisav soneh es Yaakov - it's a halachah in the Torah. The goyim and Reformim and Conservativim will always be jealous of us and hate us and looking for ways to hurt us. They are just trying to make a beautiful part of our mesorah, Toras Moshe MiSinai, look bad, because Western culture now sees this beautiful mitzvah as gross and unsanitary. They are just being goyim. They are also trying to make shechita illegal all over Europe. They just hate us and want to destroy our Torah and our Mesorah. Eisav soneh l'Yaakov - they are doing what Hashem meant for them to do - hate us.

    I was at a bris where the father of the infant did MBP, as the mohel didn't want to and the father was from a "Heimish" (Chassidish Light) family and believed strongly in the importance of direct oral MBP. Of course the father rinsed his mouth out well with wine or shnaps immediately before doing MBP. His family was all relieved that he did it, being that there was one child in the family for whom it wasn't done, and for whom they are all still very fearful that the child's neshama will be marred for life having failed to obtain all the important kabalistic spiritual impacts that oral MBP supposedly has on the child's neshama for it's entire life, which will affect his spiritual life in so many ways, which will in turn affect his material life and of course it will limit the spiritual heights which he can obtain, etc.

    I personally find it ironic that the fear of NOT doing MBP (orally and directly) is about having this child losing a once-in-a-lifetime essential spiritual mechanism, the lack of which negatively and dangerously impacts the child's neshama and ability for spiritual fulfillment in every aspect of his life, and for the rest of his life. While the HSV virus in reality and in provable fact does stay with a person for his whole life, but is only dangerous when transmitted into the blood stream of an infant.

  10. Katche-Lab: Regarding your comparison with the danger of a botched Milah. I do not believe the two situations can be compared. A botched Milah is generally due to error on the part of the one doing the circumcision. It may be true that since thousands of circumcisions are done every year, it may be inevitable that someone somewhere will at some point make an error. However it is inherently obvious that we should take every precaution to make sure such things don't happen (such as making sure every mohel is properly trained, and so on). Since we are commanded by the Torah to do a brit Milah, it is obvious that we should do it in the safest manner possible. This is not much different then the occasional horrible tragedy we hear about a family suffering a loss due to a sukkah burning as a result of the Shabbat candles. No one would suggest that we should stop lighting candles, though we would all agree that taking every possible precaution to do it safely is important. However, MBP, is not necessary for the mitzvah, and no matter how many precautions we take, direct oral contact with the wound is still risky.
    Your other points regarding the spiritual benefits of MBP, is well stated, but is still reiterating the different approaches that we have to this issue. We would simply be going around in circles if we continued to debate that question.

  11. The Medical Halachic Rationalist
    I have no intention to debate this or to go in circles. My intention is to present this point of view as one of merit. There is a real issue here, and a decision needs to made. Each side needs to empathize and respect the other and be willing to collaborate to come up with an approach that is workable for all. Otherwise all that we will have is members of each camp deriding the other. If one says that such a mutually acceptable approach can not exist, because the practices are mutually exclusive, I say that can't be asserted yet because a collaborative attempt to find a mutually acceptable approach has not yet been made, to the best of my knowledge. In most instances, when people put their heads together solutions can be found. But again, mutual respect it the first prerequisite.

  12. Katche-Lab: I thought that the New York law requiring informed consent by parents seemed to me like a very reasonable approach. it gives everyone the right to decide, and educates the parents regarding the risks. this is what is done by every medical procedure. just as by every medical procedure people have the right to give or withhold informed consent, including discussing the issue with religious advisors if that is what they choose to do. Milah could work the same way, and everyone would be happy. the Chareidim could choose to do it based on their religious advisors, and the MO could choose not to. Please note that I am not intimately familiar with the entire law as proposed, but this aspect of it seemed like a reasonable compromise to me. I am not sure why there was objection to it. this is not about deriding anyone, it is about safety. Also please note that this compromise is still a huge compromise, as ideally I wouldn't want anyone to expose their baby to an unnecessary risk. However, I concede that there are those who (mistakenly in my opinion) believe that this a religious obligation, and they therefore should retain this right. This brings up a lot of questions, but it certainly seemed like a reasonable way to find a solution to me.

  13. This was an excellent post. As an experienced Mohel, I can attest to the much energized feelings on both sides of the argument. Those who are pro MBP will not be persuaded to change their view, and those against it will stick to their opinion, as well.
    What I myself can add is that there is no doubt in my mind that Metzitzah was performed by direct oral suction throughout the generations. All alternatives were introduced (in the 19th century) because of concerns of the transmission of disease as a result of MBP. Many of those opposed to changing the practice would compare it to using a flashlight for bedikas chametz or something similar. Some will have no issue with it, and some will be Moser Nefesh to use a candle. It is a sensitivity that is (hopefully) rooted in well-meaning yiras shamayim. However, one does not need to look far and realize that Gedolim, such as the Chasam Sofer (yes, the letter is authentic), ruled that any method of Metzitzah is valid, as long as it draws the blood in the same manner. And that’s the same Chasam Sofer who was wont to use the borrowed term “Chadash Assur min HaTorah”. Another reason that MBP is so strongly defended in certain circles (I do not like to use labels) is because it brings up the history of anti-Semitic and reform hostility of the past.
    Once again, I appreciate your writing on this issue.

  14. The Medical Halachic Rationalist

    According to you, in the times of the Gemara wine could not have been stronger than 14% alcohol. I can't argue with you logic, because I'n not a scientist to know about how strong wines could be without distillation, nor am I a historian to know whether distillation was used in wine production in those days. (Although distillation was certainly used then for the production off Zefes and Itran) But I think your conclusion is disproved from the Mishna Shabbos 133b 'אם לא טרף יין ושמן מערב שבת כו . If you try to blend wine and oil, they will soon separate and the oil will rise to the top. So this would not be possible to prepare before Shabbois for a Shabbos morning Bris. But if you use whisky or even a strong liqueur, you can blend it and they will remain blended. You need a much stronger concentration of alcohol than 14%, so obviously the wine that they used in the time of the Mishna was stronger than that.

    1. Katche-Lab, I'm not sure what you are trying to say, but the יין ושמן mentioned in the Mishnah was not for use in the Mohel's mouth as an antiseptic before Metzitzah. It was used to treat the wound post-Bris.
      Please forgive me if I misunderstood your intent.

    2. It seems my comment was put in the wrong place so my intent isn't clear. I was responding to the following comment.

      The Medical Halachic RationalistSeptember 10, 2014 at 8:46 PM
      TGbR: Your suggestion is interesting, however, yeast cannot make alcohol stronger than a 12-14% concentration. Until distillation was invented, wine could never be stronger than that. In order to be effectively sterilize a surface and kill viruses, a concentration at least 67% is required. Even our strongest whiskeys do not reach that concentration.

      I was proving that in the times of Chaza'l the wines were much stronger than 14% alcohol. This is contrary to his assertion.