Thursday, September 11, 2014

MBP Again! A Scientific Perspective?

Well, just as I was preparing my next topic for discussion, MBP has resurfaced as the big subject of conversation in the rationalist blogosphere.  So I just HAD to say something, so here it is.  First, please read this article here.  A well known group of MBP defenders authored this article, and it is important to read before you continue with this post.  Second, please read R Natan Slifkin's response to this article here.  Now you are prepared for what I have to say.

The article is full of very tricky language and misleading use of medical literature, so one has to be careful not to fall into the trap being laid out by the authors.

They begin with a statement designed to make one think that New York City is outlawing a religious practice:
"In  September 2012, New York City passed a regulation declaring metzitza be peh (MBP), a part of many ritual circumcisions, illegal, unless the circumciser or mohel obtains a signed form from the parents, including: “I understand that direct oral suction will be performed... and that [the New York City Department of Health and Mental Hygiene] advises parents that direct oral suction should not be performed because it exposes an infant to the risk of... herpes (HSV)... infection, which may result in brain damage or death.”
The language chosen by the authors, that MBP is "illegal", is a deliberate misrepresentation of the actual regulation.  The NYC government website here describes the regulation in a very clear manner.  It is clear that the city deliberately avoided making the practice illegal, and simply required a consent form prior to its performance.  While one can argue that this is simply an argument over semantics, sometimes a choice of language can be highly misleading even if it is technically true.  Especially when the pattern repeats itself throughout the article as I am about to demonstrate.

Why would they choose to misrepresent the true nature of the city regulation?  Of course they do so in order to frame the city health department as the enemy of religion, instead of simply as acting in their proper capacity in their mandate to protect the health of the citizens of New York City.

I will take a pass on the legal comments that follow in the next two paragraphs of the article, simply because I am not a legal scholar and don't know enough to comment on the nuances of the court decisions.  However, they then continue as follows:
"In response to the ruling, Sam Sokol wrote, on these pages, an article entitled: “Analysis: New York circumcision controversy emblematic of longtime Orthodox ideological split,” advancing two positions: (a) “Contemporary medical knowledge” supports the assertion of a causal link between MBP and HSV infections, as stated by the Centers for Disease Control and Prevention and “several prominent contemporary decisors of Jewish law (poskim)” – specifically Rabbi Tendler, described as a son-in-law of Rabbi Feinstein, and Rabbi Slifkin, otherwise known as the Zoo Rabbi; (b) MBP is practiced by a fringe segment of the ultra-Orthodox."
In item "a", the authors claim that Rabbi's Tendler and Slifkin are the rabbinic advocates of the idea that there is a causal link between MBP and HSV infections.  This is both highly confusing and grossly inaccurate, as neither of these Rabbis ever claimed to be the source of the assertion that there is a causal link between MBP and HSV.  The causal link was reported in the medical literature, and each Rabbi reacted to the information appropriately: Rabbi Tendler, in his role as a posek, by proposing that other forms of metzitzah are halachically acceptable; and Rabbi Slifkin, in his role as a popular proponent of the Rationalistic approach to Jewish tradition, by explaining how different streams of Judaism would react to this scientific information.  Neither Rabbi ever "advanced" the "position" that MBP causes HSV, as the authors claimed.

The authors also identify these two rabbis (WADR to these two individuals), as if they are the only rabbis who have supported halakhic alternatives to MBP! When Sokol wrote about "several prominent decisors of Jewish law" he was referring to none other than the Chasam Sofer, Rav SR Hirsch, Rav Azriel Hildesheimer, and numerous other poskim throughout the generations!

But then in item "b" they fall right back into their pattern of using misleading and deliberately incendiary language.  They claim that Sokol "advanced the position" that "MBP is practiced by a fringe segment of the ultra-Orthodox".  Once again they choose language that portrays their detractors as the enemy, as if Sokol was demeaning the practitioners of MBP by calling them a "fringe segment."  In fact, Sokol uses no such demeaning language, as he tried in his article to be balanced and open to the fact that there are different streams and approaches to this issue.  They are trying to pick a fight, while Sokol was simply being open and honest.

However, the real problems begin when they start quoting the medical evidence. 

Allow me to explain some basic facts that most people who are not familiar with reading medical articles are not necessarily aware of.

First fact. To prove a true causal link between two variables "a" and "b" is extremely rare and extremely difficult in modern medicine.  Even when data strongly suggest an association between the two variables, one can often claim that a hasn't actually been proven to cause b.  See this article in Wikipedia which explains this concept.  Therefore, the authors are actually correct when they claim that no causal link has ever been proven.

However, if a correlation between MBP and HSV infections in the newborn has been identified (which has been identified), and there is a clear mechanism by which MBP can cause HSV (which there is), and this implied causation fits with everything else we know about both variables (which it does) then assuming a causation between a and b is extremely reasonable even if technically one can claim that it hasn't been "proven".  Especially when the danger and risk of assuming that no causation exists is so significant. So the authors are playing the semantics game again by claiming that there is no "causal link".  While it is a true statement, it is also a very dangerous statement.

Another fact.  Every single study published in scholarly medical journals ends with a section describing the limitations and flaws of the study.  This is important for any honest researcher to recognize openly the particular shortcomings of their work.  Even the most widely accepted and influential studies have flaws, and it is  always important for physicians who use these studies to care for their patients to understand the limitations of the evidence presented. However, recognizing the limitations does not invalidate the findings of the study, it simply helps us understand the limits of the practical application of its findings.

So now let's look at the following paragraphs:
"A 2013 University of Pennsylvania study, moreover, analyzed the relevant evidence and all the prevailing literature and concluded that: “This evidence base is significantly limited by a very small number of reported infections, most of which were not identified or documented systematically. Other important limitations include incomplete data about relevant elements of the cases, the presence of confounding factors, and indirect data sources.”
"As to the single study claiming statistical evidence for an elevated risk among babies who underwent MBP, the Penn report noted that the study lacked scientific foundation: “this finding is limited by methodological challenges in determining the total population at risk, limited information about some of the cases, and the small number of infected infants.”
These paragraphs are so grossly misleading that it is obscene. The actual conclusion of this Pennsylvania study reads as follows:
"...Standard principles of infectious disease suggest that exposing a neonatal circumcision wound to human saliva, even briefly, creates a risk of HSV transmission... Neonatal HSV infection can cause severe morbidity and death, so mitigating potential risks for infection is critical. Current evidence suggests that direct orogenital suction during ritual circumcision was the likely source of infection in recent cases that resulted in significant illness and death (emphasis added)..."
The authors simply ignored the findings and conclusions of the entire University of Pennsylvania article, and they blatantly contradict the opinions and assertions of the researchers.  Instead they chose to quote those few sentences in which the researchers honestly discuss the understandable limitations of their study.  In fact, the Pennsylvania researchers recommended that the only way to prove causality would be to design a randomized trial with two groups of ultra orthodox Jews, in two cohorts, and to perform a proper prospective trial.  We all know that this would be completely impossible to do, as the ultra-Orthodox would never cooperate with a trial that asks half of them to randomly decline MBP.

We therefore have to rely upon the best science available, and on common sense.

Although this concludes my analysis of what was written in the article,  I cannot leave the topic without mentioning what was not written in the article. No mention of the following scientific articles that support the relationship between MBP and HSV infection:

Gesundheit B - Neonatal genital herpes simplex virus type 1 infection after Jewish ritual circumcision: modern medicine and religious tradition. Pediatrics - 01-AUG-2004; 114(2): e259-63

Centers for Disease Control and Prevention (CDC) - Neonatal herpes simplex virus infection following Jewish ritual circumcisions that included direct orogenital suction - New York City, 2000-2011 MMWR Morb Mortal Wkly Rep - 8-JUN-2012; 61(22): 405-9

Distel R, Hofer V, Bogger-Goren S, Shalit I, Garty BZ. Primary genital herpes simplex infection associated with Jewish ritual circumcision. Isr Med Assoc J 2003;5:893–4

Rubin L, Lanzkowsky P. Cutaneous neonatal herpes simplex infection associated with ritual circumcision. Pediatr Infect Dis 2000;19:266–8

Koren A - Neonatal herpes simplex virus infections in Israel Pediatr Infect Dis J - 01-FEB-2013; 32(2): 120-3

Yossepowitch O1, Gottesman T, Schwartz O, Stein M, Serour F, Dan M. Penile herpes simplex virus type 1 infection presenting two and a half years after Jewish ritual circumcision of an infant.  Sex Transm Dis. 2013 Jun;40(6):516-7

These are just some of the articles that have been published and have been ignored by the authors.

In summary, the authors of this article chose to:
  1. .... mischaracterize the New York City government as if they were somehow trying to outlaw a religious practice, while in fact the City was only trying to protect the health of its' citizens, while preserving their religious rights
  2. .... misrepresent Rabbis Slifkin and Tendler as if they were the ones who asserted that there was a causal link between MBP and HSV, while they simply were using the available medical information to discuss areas that they are fully competent and qualified to discuss.
  3. .... identify the above two rabbis as if they are the only Orthodox Rabbis who support alternatives to MBP, while numerous rabbis including the Chassam Sofer are the actual sources for the halakhic alternatives!
  4. .... misquote Sam Sokol by claiming that he referred to "fringe segments" in order to make him sound like he was demeaning to the practitioners of MBP
  5. .... state that no "causal link" has been identified between MBP and HSV, which although in the strictest sense it may be true, it completely misrepresents what contemporary medical science believes to be true based on the overwhelming available evidence
  6. .... completely and utterly ignore the findings and conclusions of the most important and most complete study of the relationship between MBP and HSV, and instead to quote the researchers discussion of the limitations of their study
  7. .... completely and utterly ignore the scientific studies that contradict their contention that MBP does not cause HSV



  1. At least two times, you have the word **it's** in your article when you really meant **its**. Its without an apostrophe is possessive, while it's with an apostrophe is a contraction of the two words **it is**.

    Kol tuv! (After making the fixes, feel free to delete this comment)

  2. The taktics used by the authors of the article "kasherising" MBP are looking very much like the Muslim Takije.

  3. DR, I apologize for the error and thanks! I have no editor except for myself, and I never excelled in grammar (hence my choice to go into medicine, where I can write all sorts of gibberish ;-). Please feel free to correct any other errors you may find.

  4. I have been battling against MBP in the UK for years- unsuccessfully.
    The Initiation Society rules themselves state that it should not be done yet the majority of Mohelim in the UK do it.
    At a meeting a couple of years ago, I asked whether there was any "Gadol" those who practice MBP would be willing to go to, together with me to ask the Shaalah.
    One Chosid stood up and said if Moshe rabbeinu himself was here and told me not to do it, I wouldn't listen!
    Such is the entrenchment of opinion.
    My argument against it, in addition to the safek sakanah argument, is that in an age when Millah is under threat and paedophilia is the greatest crime in the eyes of society, it would only take one photograph (taken from an I phone of a guest at a Brit), of a hairy Mohel sucking an infant penis in full view of 20-30 men, to be published in the Daily Mail, and Millah would be finished in the UK, as we know it.

    I gave a lecture on the threat to Brit millah recently in the UK, but as with all of these things, I was preaching to the converted.
    Those who needed to listen weren't there.

    i fear it is only a matter of time before Millah is a medical-only procedure, only allowed in designated clinics.
    millah- as we know it in the UK will soon be confined to the annals of history- and we will only have ourselves to blame.

  5. Keep up the good work!
    A Mohel