Wednesday, April 10, 2013

Two more cases of babies' herpes linked to metzizah

CNN   Editor's note: The content of this story may disturb some readers.
update 4/9/13 JPost is reporting that the initial report was incorrect and that only one additional baby - not two - has herpes.
update 4/10/13 I am not poskening. I am providing a forum for people to discuss issues. There seems to be two approaches here. There are those who are saying "you are a moron for endangering your child for a practice which has absolutely no religious significance." These people's major goals are showing 1) MP has not religious significance 2) It is dangerous 3) no intelligent person would do it.
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update 4/16/13 U of Penn issues disclaimer and says study was misquoted
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update 4/11/13  U of Penn study finds no increased danger for MP
Jewish leaders this week pointed to a recent independent study by Penn Medicine at the University of Pennsylvania that found little evidence to support the claim that a circumcision practice known as Metzitzah B'Peh (MBP) leads to an increased likelihood of herpes in infants.
 In a study published in December last year, University of Pennsylvania's Center for Evidence-based Practice reviewed several studies linking circumcision with oral suction, a common ritual for many Orthodox Jews, and herpes simplex virus (HSV) type 1. Though four published studies since 2000 suggested that such a link does exist, Penn doctors found the evidence to be "small and significantly limited."
The study was cited in an appeal filed Monday in the U.S. Second Circuit Court of Appeals challenging a New York City Department of Health (DOH) regulation that seeks to place limits on the practice.
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My approach is to try to provide cognitive empathy. I want everyone to understand the basis of thought underlying the two sides. So while Doc-J has provided an excellent example of those who are convinced that only delusional nut cases would do MP - I wanted to explain that it is possible not to be stupid or irresponsible and do MP. I am not advocating or rejecting it.

Historically MP was disavowed to the degree to which it was shown to the poskim that it is dangerous. See Sheilas Dovid cited in the Sdei Chemed's kuntres on MP. Very little is accomplished by telling frum people who have a clear mesora for many generations in their family and communities that they are ignorant savages and are violating halacha. Once this need for defeating the opponent fades it is easier to have a discussion and find a solution..[see comments  for the rest]


New York (CNN) -- Two more infants have contracted the herpes virus after undergoing an ultra-Orthodox Jewish type of circumcision, which has been linked to the spread of the potentially deadly virus to newborn boys, according to the New York City Health Department.

In the ritual, known as metzitzah b'peh, after removing the foreskin of the penis the person performing the procedure places his mouth briefly over the wound, sucking a small amount of blood out, which is discarded. Antibacterial ointment is applied and the wound is bandaged. The health department says the procedure is dangerous because the contact with the mouth could transmit diseases such as herpes.

Most adults are infected with the herpes simplex virus type 1, and while they may have no symptoms, the virus may be present in their saliva, according to the health department. (It is different from herpes simplex virus type 2, which is usually transmitted sexually.)

"While HSV-1 in adults can cause the common cold sore, HSV-1 infection in newborns is very serious," a department statement says.[...]

131 comments :

  1. there is one thing i don't understand,after all everyone agrees that metzitza could be performed with an instrument,and the only rational reason on insisting to do it with the mouth, is because our parents and grandparents did it that way,and we would not like to change the way how the bris was performed for thousands of years,o.k i can understand it,but if our health officials tell us there is a slight chance of the baby contacting a fatal disease,why on earth would we insist on putting the lives of our precious children at risk? is a nice MINHAG yeherag v'al yaavor? or am i missing something.
    CH.S

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    1. after all everyone agrees that metzitza could be performed with an instrument

      Who exactly is everyone? Rav Machpoud does not agree, and neither do numerous other poskim. That it can be done, and under certain circumstances as a b'diavad, hardly means that everyone agrees that it can be done l'chatchila.

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    2. NOT everyone agree that it can be done with an instrument. It would have to be glass and even that some dont hold of. As long as the mohel rinses his mouth with alchohol nothing will happen. Its the idiots that dont do it that cause issues.

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    3. "As long as the mohel rinses his mouth with alchohol nothing will happen."

      That's not what the expert doctors say, and I've spoken to them.

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    4. > As long as the mohel rinses his mouth with alchohol nothing will happen

      That's actually completely incorrect.

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    5. That's not what the expert doctors say, and I've spoken to them.

      Expert doctors where? Would you mind trying to confirm that with the Israeli ministry of health. They seem to be under the impression that so long as the mohel uses the proper disinfectant mouth wash, and has a moth full of wine when doing the procedure there is no danger to the baby.

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  2. Good summary by CNN, but overlooked by most media is that MBP is post-surgical wound care, and not a component of the bris milah commandment. It is, therefore, at best, the pious fool, the shoteh chosid, who does it, or at worst, the rasha. Metzitzah can be done with a tube, as occurred when Rav Moshe Feinstein was sandek, which happened frequently. Alternatively, ordinary modern wound care can be performed, i.e., a sterile gauze to clean the wound. Now, because of media reports like the above, people will think the wrong thing about Jews and bris milah. Some Jews may forego bris milah for their infant sons. Non-Jews may forego circumcision, despite the health benefits. Ultra-orthodox infants will be subject to more MBP, and suffer brain damage or die. This is what the fanaticism of Agudath Israel and their allies has brought us. And what about MBP on Shabbos - does that bring chayiv kareis?

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    1. and not a component of the bris milah commandment. It is, therefore, at best, the pious fool, the shoteh chosid, who does it, or at worst, the rasha.

      Please learn the halakha and then speak.

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    2. What you really mean is, obey Daas Torah and don't speak. Not gonna happen.

      Correct me if I'm wrong, but after looking at your blog, where you describe yourself as a good Jewish boy from New Jersey who went onto semicha and learning kabbala in the holy yeshivot of Yerushalayim, I have to ask whether you're a baal teshuva. Some poskim require hatafas dam bris for baalei teshuva. Did you do that? And if so, how did you handle the MBP issue? MBP was not likely done for your bris milah. If as you say its halacha, and neither a minhag nor simple wound care, should MBP be done for adult baalei teshuva?

      But let's say you're not a baal teshuva. Do all adult men need to check whether MBP was done for them, since you're saying its halacha? And if, upon checking, it wasn't done, do the men need to have hatafas dam bris and MBP? Have you done this?

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    3. Correct me if I'm wrong,
      Gladly. For the fact that it is halakhalease see the Tur/B"Y and Shulhan Arukh Yoreh Deah 264:4(the latter writes)
      וא"כ מוצצין המילה עד שיצא הדם

      Further for the necessity of MBP and not by means of Kli please see:
      Arukh HaShulhan Y"D 264:15
      Divrei Melaciel 4:87
      The Sdei Chemed in his kuntres on MBP
      Nishmat Avraham 264:10
      Har Tzvi Y"D 214
      Minchat Yitzhak 3:101, 9:97 and 9:98
      Tzitz Eliezer
      Divrei Yatziv Y"D 155
      Chelkat Yaakov Y"D 142 and 144
      Shevat HaLevi 2:131, 4:134
      Rav Eliashiv Kovetz Teshuvot 102
      Rav Auerbach Lev Avraham 29:15
      Rav Kanievski Biur Halakha 331.
      Rav Mordechai Eliyahu Ozer Eliyahu 264:4

      For those that say it is halakha Moshe M'Sinai see:
      Talmud Yershalmi Peah chapter 2
      Binya Tzion 24
      Maharam Shik O"H 152
      Mahari Aasd Y"D 258
      Or HaChaim Yayikra 13:3
      Ot HaBrit 32
      Matzor Dvash Y"D 18

      Some poskim require hatafas dam bris for baalei teshuva.
      Some, not all, and only Ashkenazi authorities(I'm Sephardi in case you missed that). There is a big difference between some(Hatfat Dam Brit) and all(MBP).

      And if so, how did you handle the MBP issue? Well I had a Brit when I was 8days old, and with MBP according to halakha. HOWEVER, if you are talking Hatafat Dam Brit. The Shulhan Arukh also says that Pria is necessary, and without pria a person is not considered circumcised. How is that handled in Baalei Teshuvim??? Like I said earlier, learn the halakhot and then speak about them.

      If as you say its halacha, and neither a minhag nor simple wound care, should MBP be done for adult baalei teshuva?
      Again demonstrating your ignorance of the halakhot. However the poskim DO say that for adult Gerim who need an actual milah(not a HDB) that MBP is absolutely necessary. I'll let you hunt up sources for that one.

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    4. I think the original point that was lost is that according to the Gemara metzitzah is a post-surgical measure to prevent infection and complications. It's the Kabbalah where it takes on an importance of its own as part of the procedure.

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    5. You didn't read the list of sources then, because what you are saying is not true. The last I checked the Yerushalmi was Gemarra, and part of the halakhic process.

      It's all great to regurgitate the various bits of propaganda you have heard against MBP, however, I challenge to try to prove your point from the sources themselves.

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    6. "Some poskim require hatafas dam bris for baalei teshuva"

      Is that in case the original Bris was not done by a mohel, or is it part of a giur l'chumra?

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    7. Is that in case the original Bris was not done by a mohel, or is it part of a giur l'chumra?
      It is in the case where the original Brit wasn't done by a mohel. If you would like I can provide sources... however it is completely off topic of this discussion.

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  3. "No, it couldn't have been the mohel."

    OK, then by implication, the mother and father weren't actually innocent virgins who are are faithful to one another andconduct themselves modestly so she got a disease that she gave to her child? This is how you defend a mitzvah, let alone a minhag?

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    1. This is how you defend a mitzvah, let alone a minhag?
      Do you have a habit of classifying things the Shulhan Arukh states as halakha as simply minhagim? Do you realize that there are poskim that view MBP as halakha Moshe M'Sinai?

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    2. You're misunderstanding me. Genital HSV type 1 OR 2 is generally a sexually transmitted disease. ) So, I'm saying that if you say "the baby got it from the mother" that are you are necessarily implying something about the mother and/or the father; for a couple to enter into a marriage having been shomrei negia and then conducting themselves modestly within the marriage is pretty good insurance against STDs. I am assuming that for couples in the communities where MBP is the norm, there is a chazaka that they in fact were shomrei negia etc. As to any invidious implications about an adult (e.g. a mohel) having oral HSV1? There really aren't any; it's THAT common.

      So what I'm saying I'm saying is: IF I'm right about the chazaka, (you know these communities better than I, so please, if I'm wrong, say so) THEN we MUST assume that the baby's herpes WASN'T acquired from the mother during the birth process. Wouldn't that make "the baby got it from the mother" hoza'at shem ra?

      Please notice that up to this point, I haven't said a word one way or the other about the halachic status of MBP. But yes, I realize that there are poskim holding that MBP is halakha Moshe M'Sinai. Do they also hold that hoza'at shem ra – in a way that blames an innocent couple for their baby's dangerous illness – is a fitting way to defend it?

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    3. Since when is the Yerushalmi not the Gemarra?

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    4. Since when do we follow the Yerushalmi when it differs from the Bavli?

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    5. I realize that there are poskim holding that MBP is halakha Moshe M'Sinai. Do they also hold that hoza'at shem ra – in a way that blames an innocent couple for their baby's dangerous illness – is a fitting way to defend it?

      If the mohel had done his job(well if the mohel had done his job this would not be an issue at all) he would have checked the medical records of the new-born and known if there were any medical complications.

      A sick baby at the end of a Brit, with the odd exception, is most usually the fault of a mohel that did not do due diligence and best practices.

      Not that parents haven't lied to their mohelim and even paid doctors to fake medical records, but it is a rarity, and not the rule.

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    6. Look, I realize this is an emotional issue but when it comes to new onset herpes lesions on the tip of the penis of a baby who just had a milah and mouth-to-mouth contact with the mohel you last two paragraphs simply do not apply.
      A mohel who is asymptomatically shedding herpes virus can do all the due diligence he wants. And saying that parents and paid doctors faking medical records is a factor here is like blaming the victim of a rape instead of the rapist. I'm sorry, I don't mean to be inflammatory and I have a tremendous amount of respect for you but in this instance I have to strongly disagree.

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    7. Since when do we follow the Yerushalmi when it differs from the Bavli?

      How do you see it as differing? Is it presenting a different halakha? No. It is simply saying(which a good number of Rishonim and Acharonim argee with) that the source of the halakha is Moshe M'Sinai.

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    8. And saying that parents and paid doctors faking medical records is a factor here is like blaming the victim of a rape instead of the rapist.

      Did I say that was the case here? No. I didn't. I said a sick child at the end of a Brit(whatever sickness not just herpes) is 99.9% of the time the fault of the Mohel who didn't do due diligence.

      On the rare occasion one will go wrong because parents misinformed the mohel. I know a case where the parents paid the doc to keep the child's hemophilia off the medical records...

      However, I'm not saying what you are accusing me of, you need to calm down.

      Further, considering the death rate for milah done under the Israeli Health ministries guidelines is one quarter of that done in US and Canadian hospitals by medical professionals. I'm going to go with the Israeli Ministry of Health and their understanding of the issue.

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    9. Death rate isn't the only relevant statistic. If the virus goes to the baby's brain, even if he survives there's a 70% chance of brain damage.

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    10. Yoel B

      You are correct. Which is why best practices are supposed to be observed. If they are not, the mohel needlessly endangers the baby. If they are, there is little to no concern.

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    11. Rabbi Tzadok - what is this Yerushalmi you keep on bringing up? I checked the source, and all I found was a general discussion about all future laws having been given on Har Sinai. Nothing at all about Metzitzah, let alone Metzitzah B'Peh. Could you be a little more specific, since you are making a very big deal about this Yerushalmi? Thanks.

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    12. "Did I say that was the case here? No. I didn't. I said a sick child at the end of a Brit(whatever sickness not just herpes) is 99.9% of the time the fault of the Mohel who didn't do due diligence. "

      What? Explain what role 'due diligence' plays in any of this.

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  4. Rabbi Tzadok,your post's just confirmed what i always suspected,that anyone dabbling in Kaballah is either a fraud or is delusional and needs psychiatric help,how in Gods name could you justify doing METITZEH BPEH and endangering the life of a newborn,when the vast majority of poskim agree that METZITZE could be done with an instrument,anyone insisting in this day and age when diseases are so rampant to use the mouth for metzitzeh,is either criminally insane are is a ROTZEACH

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    1. Please name these poskim. I have posted an extensive list of poskim who clearly say contrary. Likewise if you pick up the sefer Milah Shleimah(the necessary text for those wishing to gain certification with the Ministry of Health in Israel), you will find that exactly the opposite is the case.

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  5. It is my understanding that even those that practice and defend MBP do not do it with an adult bris for geirus. Now, bris is accepted as a requirement for male geirus. So, we have clear indications that MBP is not an absolute halachic requirement for fulfillment of milah. If so, and if there is a known health risk, why should minhag and kaballah override sakonos nefashos?

    I understand the kabbalistic influence on halachah even though I reject it and stand on solid ground, including my ancestor, the Chasam Sofer. What I do not understand is 1. the confusion of minhag with halachah, and 2. the denial of the scientific evidence of the risks of MBP.

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    1. It is my understanding that even those that practice and defend MBP do not do it with an adult bris for geirus. Now, bris is accepted as a requirement for male geirus.
      Proof please?

      I will gladly provide you with a list of sources, including the official sefer of the Israeli Rabbinut that says it is necessary if you can provide your sources that say that it is not done with an adult Brit for Gerut.

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  6. Here's my question: we have a whole bunch of halachos that were instituted on the basic of anecdotes and incidental happening. One guy stabbed himself with the bread knife so we all remove it during bentching. One guy killed himself and his family so guests are not allowed to give food to their host's kids.
    Yet here we have repeated cases of infants getting seriously ill from MBP, we have a gemara which defines metzitzah as a sanitary procedure, we have multiple poskim who allow indirect MBP and we have a fine tradition of Litvish gedolim who either banned MBP or only allowed indirect for centuries and suddenly we are told Kabbalah says you have to do it so you have to, no questions?

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    1. we have multiple poskim who allow indirect MBP and we have a fine tradition of Litvish gedolim who either banned MBP or only allowed indirect for centuries
      Who? Name them!!!

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    2. suddenly we are told Kabbalah says you have to do it so you have to, no questions?

      This is great right here. So typical of the other side of this debate. The sources go against you, you can't make a good argument with any real support for your position. However, since you don't like MBP simply blame it on those wacky mystics, everyone knows they're all crackers, and that should suffice.

      What utter rubbish.

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    3. A complete list as well as a historical record of the way MBP has been done on and off for the last few centuries:

      http://www.hakirah.org/Vol%203%20Sprecher.pdf

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    4. Wow... It ignores the Yerushalmi... Ok I can get past that, then quotes one Rabbi(the Hatam Sofer) who he notes is extraordinarily lenient, and three others who say that metzitzah with a kli is techincially permissable, but one should not change the custom. All of these Rabbanim lived in the last 150yrs. This is your centuries of Litvitsh Gedolim?
      One actual Gadol, and three Rabbanim(who while I am sure they were somebody) are relatively unknown...
      I suggest you check the Chazon Ish and the Chafetz Chaim as well.

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    5. > However, since you don't like MBP simply blame it on those wacky mystics,

      I could make the opposite argument. Mystics don't like the way the halacha is going from a straight reading of the Gemara so why not come up with something about realigning the sefiros as the secret but really true reason something is done?

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    6. Michael - the Aruch Hashulchan says no such thing. Your understanding of the issue is so warped it would be funny were it not so serious. Take a look at what Rav Herzmg said too. Not so far away from Garnel.

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    7. Ah, but according to the way the Rambam says that we derive halakha, Mikra, Mishnah and two Talmuds... I can show that MBP is not only a halakha, but it is halakha Moshe M'Sinai.

      Likewise the many(all really) Gedolim who support MBP make no claims to it's authenticity from Kabbalah, they do so from the actual sources in the Gemarra and Rishonim. That is the halakhic process.

      However,
      Mystics don't like the way the halacha is going from a straight reading of the Gemara so why not come up with something about realigning the sefiros as the secret but really true reason something is done?
      That is the same baseless argument that you already made. Prove the Gedolim wrong! Show that you know more Torah than them!
      Do you know the rarity of the Ttitz Eliezer, Rav Elishiv, Rav Auerbach, Rav Kanievsky, Rav Ovadia Yosef, Rav Mordechai Eliyahu and Rav Ben Tzion Abba Shaul all agreeing on something? Yet on this issue they speak with one voice, and claim it is Torah. So prove them wrong if you have the chops. If not show some humility.

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    8. Michael - the Aruch Hashulchan says no such thing. Your understanding of the issue is so warped it would be funny were it not so serious. Take a look at what Rav Herzmg said too. Not so far away from Garnel.

      Try again. Though I miss sourced above it is 19 not fifteen. Feel free to take a look:
      http://www.hebrewbooks.org/pdfpager.aspx?req=14244&st=&pgnum=281

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  7. I cannot understand why the deontology of Mohalim does not make herpes tests (on the mouth of the mohel) compulsory if they perform metzizah bepeh.

    I would suppose that this serious negligence.

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    1. Here's from webmd:

      "Herpes tests are done to find the herpes simplex virus (HSV). Results for a rapid viral culture may take 2 to 3 days, while results for a standard culture can take up to 14 days. Antigen detection test results are ready in a day. Polymerase chain reaction (PCR) test results are ready in 1 to 3 days. Results from an antibody blood test are ready in 2 days. The results from an antibody test called an enzyme-linked immunosorbent assay (ELISA, EIA) may be ready in about 2 hours."

      So let's use the antibody test, right?

      "Antibody tests cannot tell the difference between a current active herpes infection and a herpes infection that occurred in the past."

      http://www.webmd.com/genital-herpes/herpes-tests?page=3

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    2. your question is a sound one, Url. Real stats (like Yoel's info?)must be considered. tsarich iyun

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  8. Michael - please take a look here:
    http://www.hakirah.org/Vol14Zuriel.pdf

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  9. Yes of course I have seen the Aruch Hashulchan Michael. He is referring to people who suggest using a sponge, not those who use a tube next to the mouth.

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    1. Oh so you understand the Arukh HaShulchan better than Rav Eliashiv or Rav Shlomo Shochet(who wrote Milah Shleimah, the fundamental text for Rabbinut and Ministry of health certification). Ok... Who are you exactly that you understand the intent Arukh HaShulchan better than these Rabbis?

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  10. See also here for further evidence that your understanding of the Aruch Hashulchan is mistaken, as well as other sources about metzitzah using a pipette:
    http://www.haemtza.blogspot.com/2012/09/the-proper-performance-of-bris-milah.html

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    1. Sorry J. your source doesn't prove his/your point. There is a stira between what the Aruch HaShulchan writes and that which is attributed to him in a sefer. The Aruch Hashulchan takes precedence unless you can prove that he changed his mind. Rabbi Tzuriel conjectures that is what happened but brings absolutely no proof. His son's view carries no weight - he was not a posek and his scholarship is problematic.

      this is the footnote


      הבעל ערוך השולחן עונה בשנת תרנ"ט למוהל ר' אלכסנדר טערטיס שהמציא את המכונה למציצה, ודבריו הובאו בספר "קובץ דם ברית" (שנת תרס"א) וכן שוב ב"ספר הברית" של הרב משה בונם פירוטינסקי (סוף עמ' רכג) ואלו הם דבריו: "בדבר המכונה מהמציצה, למותר להאריך, ודבר שפתים אך למחסור. ותבוא ברכה על הממציאים המכונה הלזו, ואותם פשוקי השפתים השוכבים בין שפתים, דבריהם בלי טעם ובלי ריח. ולאשר הדברים פשוטים, לא ראיתי להאריך בזה מגודל הטרדה, ואו"ש וברכה, ידידו הדוש"ת באהבה. יחיאל מיכל הלוי עפשטיין החופ"ק נווהארדק.
      ואמנם צריכים ליישב סתירה בדברי הגאון. בספר ההלכות "ערוך השולחן" (יורה דעה סי' רסד ס"ק יט) כותב: "ודע שיש בזמנינו שאומרים שיותר טוב לעשות המציצה לא בפה אלא באיזה ספוג שמספג את הדם. ולא נאבה להם ולא נשמע להם. ורבותינו חכמי הש"ס היו בקיאים ומחוכמים יותר מהם. אך זהו בודאי שהמוצץ יהיה לו פה נקי בלא שום מחלה, ושיניים נקיים" עכ"ל לעניננו. אבל ליישב הסתירה הוא קל. כי בספר ההלכות התנגד הרב לשימוש הספוג שאינו מושך את הדם ממקומות הרחוקים. וספר זה כתב קודם, ולפי "בית עקד ספרים" חלק יורה דעה נדפס הספר בורשה שנות תרנ"ד-תרנ"ח. אבל המכתב הנ"ל למוהל טרטיס בענין מכשיר המושך הדם, נכתב בשנת תרנ"ט. ולדעתו הוא שיפור על השיטה הקודמת. וכן למכתב שכתב עלינו לשמוע כי הוא בתרא מול מה שכתב בספרו על ההלכה, שהיה מוקדם וגם על השיטה הקודמת.
      וכן בנו של מחבר "ערוך השולחן", הרב ברוך עפשטין הוא תומך נלהב במציצה ע"י שפופרת ואחרי שמביא דברי הרופאים המומחים שהתריעו מפני סכנה או לכל הפחות נזק, כותב "ובזמן הזה רוב המוהלים בארצות המערב משתמשים בכלי מציצה שהוא מכונה של שפופרת" (מקור ברוך, ח"ג עמ' תרנב).

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    2. BTW Rabbi Tzuriel is not a posek and while he is familiar with many sources and I own a number of source books which are useful for interesting citations - he is not one to rely on in interpreting halacha.

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  11. R Marc D Angel

    http://www.jewishideas.org/articles/metzitzah-bpeh-oral-law

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    1. That wasn't written by R' Angel, it wasn't written by a Rabbi at all. It was wirtten by a Cantor and it is simply a regurgitation of the Hakira article noted above. It doesn't prove the point, especially against the numerous poskim that say contrary.

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    2. Thanks for the clarification Ramatz. I mistakenly thought it was RaMDA. However, I am not trying to prove any points here - other than, ask what is your take on preventing transmission of HSV virus during Milah?

      Delete
    3. However, I am not trying to prove any points here - other than, ask what is your take on preventing transmission of HSV virus during Milah?

      My take is that a mohel needs to take all reasonable precautions to protect the child's life and health while remaining within the bounds of halakha.

      Doctors and dentists are regularly checked for infectious diseases and mohelim should be no different. Best practices should always be followed despite inconvenience to the mohel.

      If things are done properly there is very little risk to the infant. It is when they are not that things can go wrong very quickly.

      Delete
    4. and since you are a Mohel, do u use disposable blades, or if you don't , how do u sterilise them?

      Delete
    5. I always have a disposable knife or two on hand which are perfectly acceptable to use.

      However, I also have a specially made knife that prefer to use as it hold a better edge. For that I follow(of course) the Ministry of Health protocols. Clean the knife after the brit and sterilize in a ministry approved autoclave. Before the next brit restrilize the knife(well all the tools actually).

      How is sterilization done? They pare cleaned. Placed unwrapped, in a ministry approved autoclave, and run for a full cycle. They then are placed in ministry approved sterilize packaging, and run through another sterilization cycle in a ministry approved autoclave.
      Process is repeated before a Brit.

      Some people in order to save on sterile packaging store the kelim in alcohol between britot. That wasn't the way I was taught, but it would work just as well for all intents and purposes.

      Delete
  12. The rabbanut advises using a tube:
    http://www.bhol.co.il/article.aspx?id=53009

    It is absolutely clear from the way Michael is conducting this discussion that he does not understand the inyan at all, nor the historical contexts of the polemics. Read what Rav Herzog said again and find out what Rav Soloveitchik's opinion was. Reb Moshe wrote that anyone who thought metzitza was part of the mitzva was in utter error and he understood the sources better than you. Go read up and try to understand the arguments instead of reeling off marei mekomos.

    ReplyDelete
    Replies
    1. The rabbanut advises using a tube:
      I wouldn't suggest putting that on your test when you go to get certified by Rabbinut.

      It is absolutely clear from the way Michael is conducting this discussion that he does not understand the inyan at all, nor the historical contexts of the polemics.

      As typical, when you cannot prove your point with sources, resort to Ad hom...
      I learned Mohelut under Rav Mahpoud and his Talmid Rav Shimon Dror. I was tested by Rav Mahpoud, was well as Rav Eliashiv's primary mohel Rav Shlomo Shochet. As well as being certified by the Rabbinut and Ministry of Health.

      What are your qualifications to talk about this matter oh anonymous blogger?

      Delete
    2. J you are playing a game. You cited the Aruch Hashulchan - except he doesn't say what you claim he is. You are relying on Rabbi Tzuriels interpretation - which doesn't carry much weight. You cited Rav Herzog - I'll accept that you correctly stated his views and you have Rav Solveitchik. Rabbi Tzadok has cited a number of sources that disagree - and you have not refuted a single one of those sources.

      Further for the necessity of MBP and not by means of Kli please see:
      Arukh HaShulhan Y"D 264:15
      Divrei Melaciel 4:87
      The Sdei Chemed in his kuntres on MBP
      Nishmat Avraham 264:10
      Har Tzvi Y"D 214
      Minchat Yitzhak 3:101, 9:97 and 9:98
      Tzitz Eliezer
      Divrei Yatziv Y"D 155
      Chelkat Yaakov Y"D 142 and 144
      Shevat HaLevi 2:131, 4:134
      Rav Eliashiv Kovetz Teshuvot 102
      Rav Auerbach Lev Avraham 29:15
      Rav Kanievski Biur Halakha 331.
      Rav Mordechai Eliyahu Ozer Eliyahu 264:4

      For those that say it is halakha Moshe M'Sinai see:
      Talmud Yershalmi Peah chapter 2
      Binya Tzion 24
      Maharam Shik O"H 152
      Mahari Aasd Y"D 258
      Or HaChaim Yayikra 13:3
      Ot HaBrit 32
      Matzor Dvash Y"D 18

      You haven't shown that Rav Moshe would prohibit MP nor have you demonstrated that the majority of contemporary poskim prohibit it. So even if they don't hold MP is essential for milah - that doesn't mean that they prohibit it. If they do prohibit it - please bring citations.

      Thus all you have shown is that there are some poskim who definitely require using a tube. However the predominate weight of poskim do not and it is that hurdle you have to jump - and you haven't done it.

      You are the one who show a lack of understanding of the issue.

      Delete
    3. Just a quick question. From what I see in the list of sources that you just quoted, they were written before the current information that has been documented now regarding the sakana of HSV and heaven knows whatever other transmittable diseases in regards to MBP. The same question applies to Rav Tzadok who quotes the Chazan Ish and the Chofetz Chaim. I admittedly do noy know what they say about the issue but don't they have to be reevaluated in light of new information that we do have. Over the past 20 years the potential dangers of this procedure. Regardless of whatever they wrote in their responsa. At what point does sakana nefashot override all other considerations? From what I understand of the halacha, sakana nefashot would override the mitzva of Mila itself. Here we are just talking about the metzitza aspect of it.

      Delete
    4. Barty,

      Yes the older poskim would have to be re-evaluated in light of modern evidence.
      Which is what the later poskim(Rav Eliashiv, the Tzitz Eliezer, Rav Mahpoud ect) have done in conjunction with the Israeli Ministry of Health.

      Delete
  13. Of course I realise that a majority of Israeli charedi poskim pasken that way. You have misunderstood the Yerushalmi. There is nothing to argue about. Dr Sprecher's article is a widely acknowledged masterpiece which you fail to grasp. Until the fight started with reform the Chasam Sofer's position was near unanimous. The reason his talmidim changed is clearly because of that fight and this is the same reason they sought to supress his teshuva. Metzitza clearly fits in with the medicine of Chazal's era, the Gemara itself says it is to prevent sakana and an intellectually honest and historically aware reading of the rishonim clearly shows this. For you to cite Rav Machpoud against the Chasam Sofer demonstrates how little you understand. Having kabala from Rav Elyashiv himself would mean nothing if you don't understand the history of this issue. Soon you'll bring me the Tzitz Eliezer who mixes in the issue of kelayos yoatzos to organ donation. I am perfectly entitled to regard that as lunacy and in the same way I am entitled to adopt Rav Herzog's position on this issue. The predominant weight of current charedi poskim have an approach to Chazal and science that is very different from mine. One cannot examine this issue without taking those assumptions into account.

    ReplyDelete
    Replies
    1. J. I appreciate you finally admitting that you are not following the same concept of halachic authority as Rabbi Tzadok and I are. So instead of accusing us of not understanding elementary texts - you should have just said you are not paying attention to the majority of contemporary authorities - that you have different authorites. Our argument all along was that of the normative position of poskim who as you have pointed out are chareidi.

      Delete
    2. You have misunderstood the Yerushalmi.

      You made that same unsupported claim regarding the Arukh HaShulchan. If I was just relying on my understanding of the Yerushalmi I would be concerned. However, I am not. I am also relying on the understanding of the various Rishonim and Acharonim who point to it as the basis for saying that MBP is halakha Moshe M'Sinai.

      Delete
  14. Tens of thousands of physicians and scientists, represented by these medical groups, strongly discourage MBP: American Academy of Pediatrics, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Sexually Transmitted Diseases Association. They filed an amicus letter in November 2012, in, Central Rabbinical Congress v. NYC Department of Health, 12 CV 7590, which can be read on the federal PACER web site, together with all of the other litigation documents on file. Here's just one excerpt: "The clinical and epidemiological data evidencing the health risks ofdirect oral suction are
    incontrovertible. Numerous infectious diseases, including HSV, have been transmitted
    through direct oral suction, and direct oral suction increases the risk of infectious disease
    transmission." The federal District Court denied the motion to enjoin enforcement of the NYC informed consent rule. A second motion to stay the District Court order pending appeal was denied.

    All of this just happened. Did the rabbis cited know about this latest medicine and science? No.

    ReplyDelete
    Replies
    1. Did the rabbis cited know about this latest medicine and science? No.
      Actually it depends on which Rabbis you are referring to. The Arukh HaShulchan(as well as the Chazon Ish and the Chafetz Chaim) make mention of possible health risks.

      By the time we get to the more recent poskim, the Ttitz Eliezer, Rav Elishiv, Rav Auerbach, Rav Kanievsky, Rav Ovadia Yosef, Rav Mordechai Eliyahu, Rav Ben Tzion Abba Shaul and Rav Mahpoud they most certainly do know.

      This isn't exactly new science. Rather this is almost uniquely an American problem, because the Constitution of the United States deprives the courts of the ability to punish Mohelim who willfully and knowingly endanger babies. While I cannot speak directly to these two cases, the previous one's that have come out of New York all share a few things in common:
      1) They were the same two mohelim, who know that they have a communicable disease(one of them has even done this while symptomatic).
      2) They use a "Borsenshtein" clamp. Which has long been forbidden(see Tzitz Eliezer 8:29) because it causes tissue damage resulting in increased infection, and even death.
      3) They did not do the necessary follow-up care to make sure the baby was healing properly.

      In Israel(which despite being almost exclusively MBP) we don't have these problems. The reason being that if the mohel did any of the things above, he would lose his license, face fines and even possible jail time.

      In the US you can't even advertise that a mohel is a danger, on account of religious freedom, and libel laws. However, before we chase off after the New York Times' latest liberal crusade(they are against circumcision in general) which unfortunately is being picked up by CNN now, let's at least check some facts first.

      Delete
    2. In Israel(which despite being almost exclusively MBP) we don't have these problems.

      this point seems to be a matter of dispute. from professor wikipedia:

      הרב שאול פרבר ממכון עתים, המספק ייעוץ בטקסי מעגל החיים היהודי, מעריך כי רוב טקסי ברית המילה בישראל, נעשים על ידי מוהלים חרדים, בדרך של מציצה בפה.[47] מאידך, הרב הלפרין טוען,‏[45] שקרוב "ל 90% מהבריתות בישראל מתבצעות כיום על ידי תחליף מציצה – שאיבה באמצעות שפופרת", ומצביע על כך ששבעה מקרי ההדבקות בהרפס שהוצגו בפני הוועדה הבינמשרדית לפיקוח על המוהלים, לאחר שקרו בשלוש השנים שקדמו לדיון, התרחשו במגזר החרדי.

      bit.ly/YHQHWQ

      Delete
    3. Interesting. If you follow the source link to the article by Rav Halperin, he actually quotes various sources with widely diverging numbers.

      Though I'm not sure that Haaretz is a better source, though I would typically trust ITIM(despite their activism).

      Delete
  15. I am perfectly happy to admit that I am not following the same conception of halachic authority as you. Rather I am following that of Rav Herzog (who described the position adopted by contemporary charedi poskim on this issue as 'toeh u'mateh bedavar sheyesh bo chashash sakono' - Rav Elyashiv was his talmid btw), that of R. Moshe Feinstein (I am not saying that he regarded it as a chiyuv to use a kli, but described the position that mbp is a hlmm as a 'plitas hakolmus') and Rav Soloveitchik, who would not allow mbp in his presence. Note that all of them lived after the Hungarian polemicists and the Sdei Chemed and nevertheless were no less forceful in their opinions.

    ReplyDelete
  16. Rabbi Tzadok,i'll try again,even according to you that Metzitzah is halacha lemoishe misinai,but you will agree that a bris done with metzitzah with an instrument is halachakli a valid bris,yes or no ?
    if the answer is yes,then my question to you is,where the hell do you get the chutzpah the audacity to put a young baby's life in danger by insisting in using a potentially diseased mouth on an open wound,when all the health authorities are telling us that scores of jewish baby's die or get brain damaged every year caused by metzitza
    anyone doing metzitza with his mouth in this day and age when the herpes disease is rampant,is either criminally insane and belongs in an insane asylum,or he is ROTZEACH a murderer and belongs behind bars

    ReplyDelete
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    1. anyone doing metzitza with his mouth in this day and age when the herpes disease is rampant,is either criminally insane and belongs in an insane asylum,or he is ROTZEACH a murderer and belongs behind bars,

      That statement is simply hysterical. First it denotes a major ignorance of the relevant halakhic literature. When the poskim say NOT to change the practice, they mean not to change the practice.

      Herpes is not rampant. Check the facts, all of the infections in NY were done by two(just two) mohelim who knowing that they were infected, did it anyway.

      my question to you is,where the hell do you get the chutzpah the audacity
      That is a question better directed to the majority of the poskim today, who require MBP.

      when all the health authorities are telling us that scores of jewish baby's die or get brain damaged every year caused by metzitza,
      Patently not true. First the Israeli Ministry of Health recomends the procedure, as anyone who has been certified by them knows. Second a score is numerically 20. The article under discussion says 13 since 2000. That in itself is less than a score, in over a decade. That primarily because of what in Israel, would be called criminal negligence on the part of the mohel, not because of MBP.

      May I suggest you attempt to calm down and look at the situation rationally. So far your comments have been rather emotionally charged, while ignorant of the issues and verging on outright hysteria.

      Delete
  17. Okay, so now that I have my seforim in front of me:
    We start with the Chasam Sofer. He shows quite convincingly that the purpose of MBP was to prevent illness and that therefore the final step of cicumcision is to prvent illness and that MBP was considered by the Chazal as a great way to do it.
    The Maharam Shik, his student, came up with the idea that the CS's permission to do MBP indirectly was temporary. He has no evidence for this and, WADR to his greatness in Torah, the "it was only temporary" excuse comes up way too often whenever a great posek decides something in a manner that goes against "the grain". Did the CS pasken something controversial? Must've been temporary despite no evidence that it was. (Some Chareidim apparently are now doing this to "cleanse" Rav SR Hirsch, zt"l, by attributing all his non-Chareidi positions on science, the infallibility of Chazal, etc. to forgeries)
    The Tiferes Yisrael(Shabbos 19 in Boaz), Shoel U'Meishiv 4:7, Ktzos HaShulchan 382:2 and Chochmas Adam 382:2 all hold that MBP isn't part of the circumcision process. Perhaps they're all heretics?
    Then we have the Maharatz Chayot and the Mishnah Berurah in the Biur Halacha (ch 331)in the name of the Yad Eliezer where he again justifies using a sponge since the main point isn't to use your mouth but to get blood out of the wound and a sponge is superior therefore it's even permitted on Shabbos.
    Word on the street is that Rav Yitzchak Elchanan permitted indirect MBP and the Briskers starting from Rav Chaim, zt"l, all forbid direct MBP. The Kores Bris (ch 264) also permits indirect MBP where direct MBP is not possible.
    The Mateh Levi, acting on the advice of Rav Yaakov Posner, zt"l, also permitted indirect MBP.
    The Har Zvi (YD ch 214) says you can do indirect MBP to prevent disease.
    Even the Binyan Tzion, who opposed indirect MBP, apparently started that a mohel who is potentially contagious should not do MBP until he can guarantee he's not anymore. And since HSV sheds asymptomatically no mohel can guarantee a lack of a contagious state.
    Shevet HaLevi 6:148:2 suggests indirect MBP can be done if there is a risk of infection. The Aruch HaShulchan rules permissively. Rav SR Hirsch and Rav E Hildeheimer permit it.
    The Nishmas Avraham says his colleagues can't recall any baby getting Hepatitis or HIV from direct MBP. He does NOT mention HSV.
    Finally, Daat Kohen brings the reason for defending MBP from charges that it spreads disease from the concept that since science is always changing, what doctors say today they change their mind about tomorrow. We are not going to do that with HSV. The virus and its mode of transmission are well understood. Oh, and he also permits indirect MBP (Daat Kohen 140)
    During WW2 parents circumized their children under threat of death from the Nazis, y"sh. But nowadays we need no external threat. We want to endanger our children all by ourselves!
    So what's more important? The life of the child or doing the procedure "the right way"? Is it worth exposing a child to a potentially deadly virus when a halachic compromise position exists?

    ReplyDelete
  18. i am asking something from a different angle entirely.

    why not require any mohel who is herpes positive to report that fact? or go one step further - require mohelim to test for herpes (and HIV)?

    if a mohel is positive for either, would halacha require revealing this fact?

    ReplyDelete
    Replies
    1. if a mohel is positive for either, would halacha require revealing this fact?

      To my understanding, yes absolutely.

      Delete
  19. Further for the necessity of MBP and not by means of Kli please see:
    Arukh HaShulhan Y"D 264:15
    Divrei Melaciel 4:87
    The Sdei Chemed in his kuntres on MBP
    Nishmat Avraham 264:10
    Har Tzvi Y"D 214
    Minchat Yitzhak 3:101, 9:97 and 9:98
    Tzitz Eliezer
    Divrei Yatziv Y"D 155
    Chelkat Yaakov Y"D 142 and 144
    Shevat HaLevi 2:131, 4:134
    Rav Eliashiv Kovetz Teshuvot 102
    Rav Auerbach Lev Avraham 29:15
    Rav Kanievski Biur Halakha 331.
    Rav Mordechai Eliyahu Ozer Eliyahu 264:4

    None of these sources are Rishonim. Neither the Gemara, Rambam, nor Shulchan Aruch require MBP.

    ReplyDelete
    Replies
    1. Evidently, neither the Rambam, other Rishonim, or Shulchan Aruch thought the Yerushlami was operative.

      Delete
    2. Rabbi Tzadok, I ask again -- please specify where Yerushalmi states that MBP is a requirement!

      Delete
  20. Michael - The fact is that the Aruch Hashulchan only condemns those who do metzitzah with a sponge, not those who do it with a tube. The fact that you quote Reb Chaim Kanievsky, while not noting that the Biur Halacha he is going on brings using a kli as a legitimate option illustrates the dishonesty of your approach. Your lack of understand of the scientific background to this issue is also painfully obvious. And the rishonim did not think that mbp was a hlmm. There's a reason that the term hlmm first came to be associated with mbp in the contexts of nineteenth century Hungarian polemics, but you demonstrate no understanding of this whatsoever.

    ReplyDelete
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    1. You demonstrate a sad need to resort to ad hominem attacks instead of substantial arguments of any kind.

      Oh and the Aruch HaShulchan condemns the use of a kli, and then gives a few examples. However, the condemnation of a kli, whether or not it falls in his examples, still stands.

      Delete
  21. Okay, let's try this. Like with the who brain death convtroversy, terms tend to get muddled.
    Let me be clear on my position: I am not calling for the abolishing or forbidding of metzitzah b'peh like those great kofrim, the Briskers. (I'm being sarcastic in case that wasn't obvious)
    By all means, do it. Use suction generated by the mohel's mouth to remove blood from the incision. You satisfy the Gemaras (both of 'em) and all the understood intents. But don't put your lips directly on the penis when there's a chance of passing on a contagious virus that will irreparably harm the infant. Use a tube.
    Alternatively make it mandatory that a mohel has to go on a regular basis (say, monthly) and have his herpes antibody status checked. The minute he turns positive he is removed from his post. Would that be better?

    ReplyDelete
    Replies
    1. Alternatively make it mandatory that a mohel has to go on a regular basis (say, monthly) and have his herpes antibody status checked.
      Rav Mahpoud says every three months. It's not like this hasn't been thought of. The problem in the US is there is no way to enforce standards or procedures.

      Delete
  22. Where is this Yerushalmi? I looked at the reference you cited and could not see what you meant.

    ReplyDelete
  23. From Critic:

    We are all missing the big point and arguing about very little.

    The issue is plain and simple. In America, any time one of OURS does something wrong we jump through hoops to defend him. It happens with child molesters and is happening with MBP. If the Agudah and others would have created an organization that implements the rules that R Tzadok says they already have an Israel, all would be well. R Tzadok is acknolwedging the potential for danger and says that with proper testing, all is fine.

    Instead, our leaders proclaim loudly that "It can not possibly be true" and claim that the certain mohel is one of the great tzadekai hador, etc. They balk at voluntarily implemting a system...and then after a few more years and some more reported cases, the city gets more involved and wants to regulate...then our leaders dig in even deeper and go to court over it all the while proclaiming how it can not be true with the usual shouts of anti-semitism.

    The entire issue is self created here in America. If our leaders would remove EGO and be able to accept from others, they would have implemented these procedures a few years ago, saved some babies and the city would have been fine.

    Instead, this huge chillul Hashem has erupted, one that should have been avoided. The lesson still has not been learned and, by their own stubborness and stupidity, our own leaders may in fact be putting bris mila itself at risk.

    It is really quite shameful and disturbing.

    ReplyDelete
  24. I am an Orthodox Jewish surgeon. To all who defend metzitzah be'peh, I would like to make the following offer/challenge: I will - at no cost to you - perform any surgical procedure you need, on ONE condition:

    Instead of using a standard antiseptic skin prep to clean your skin, I will rinse my mouth out with alcohol and spit on your skin prior to making the incision. No other skin cleanser will be used. At the conclusion of the procedure, prior to closing the skin, I will again rinse my mouth out with alcohol and then spit into your open wound. I will then sew the skin shut.

    Any takers? If you are not prepared to subject yourself or loved ones to a surgical procedure done under these conditions, I respectfully suggest you get off you halachic high horses.

    ReplyDelete
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    1. Excellent answer!

      Delete
    2. Excellent answer!

      If you are a reformnik, and have no problem throwing out halakha the consensus of poskim.

      Otherwise it is another absurd and histerical answer. The Mohel's mouth(if done correctly) does not make direct contact with the wound. Rather it surrounds the base, while the wound itself is then surrounded by the wine(or whiskey depending on minhag) that is in the mohel's mouth.

      Otherwise this answer is simply more fear mongering propaganda.

      Delete
    3. No, Michael, you are not being rational.

      Obviously, there is contact, and this is how the virus is transferred. If there is no physical contact, as you claim, then there is no MBP, so what is wrong with using the tube?
      It seems your decision making process has gone haywire. Whilst you "claim" to uphold Torah from Sinai, you are denying the central halachic principle of sakkanot nefashot.
      You have elevated the concept of MBP to be the supreme halachic ideal, which is above even risk to life. You claim that if it is done "correctly" there is no danger to life, which is self contradictory, and disproven by empirical evidence.

      Delete
    4. Doc-J you have made an interesting offer. Why don't we play with your answer and see what happens. What if we increase the possible gains - a person might be cured from cancer if he undergoes your procedure or perhaps be cured of paralysis or dementia. Would it be worth while? On the other hand what if the dangers were reduced a bit - such as the fact that despite thousands of bris milas - the infection rate is rare?

      Would you allow someone to have his wisdom teeth extracted - despite a finite chance of death? Would you allow your son to play baseball or football - despite the clearly documented dangers? What about getting in a car to by a loaf of bread - despite the finite dangers?

      What I am getting at is that this like most decisions in life requires a cost benefit analysis. If the MP had absolutely no significance then why take any chance. As its significance rises a person is increasingly willing to take greater chances.

      Whether MP has any actually significance is what this discussion is all about. Not whether people who do it are rational or nuts.

      Delete
    5. DT, you are plying games, which may ultimately cost the lives of people. I believe it was R Yisrael Salanter who publicly made a kiddush on Yom Kippur and then ate food, because there as a finite risk to life due to an outbreak of some disease.
      For your argument, you are essentially saying that it is acceptable to lose a few babies each year due to direct transmission of HSV, rather than take the precaution of using tube - which is halachically valid anyway.
      You argument is also false, since you are making comparison between chalk and cheese.
      There is no documented transmission of HSV when using a tube. However, there are cases of HSV when using MBP.
      So whether there is a risk of being hit by a meteorite when going to the supermarket or not, there is not the risk of catching HSV and dying.
      It seems that both you and Ramatz are not taking into consideration sakanot nefashot, and are not being honest about the severity of the halacha in such a case.
      RMF would always ask a doctor in case of sakana, and then make a halachic decision. here you are rejecting the doctor's opinion outright, because it might mean you have to take a different approach to halacha, and perhaps face being kicked out of your shul.

      Delete
    6. No Eddie you are misunderstanding me - again! I am not poskening. I am providing a forum for people to discuss issues. There seems to be two approaches here. There are those who are saying "you are a moron for endangering your child for a practice which has absolutely no religious significance." These people's major goals are showing 1) MP has not religious significance 2) It is dangerous 3) no intelligent person would do it.

      My approach is to try to provide cognitive empathy. I want everyone to understand the basis of thought underlying the two sides. So while Doc-J has provided an excellent example of those who are convinced that only delusional nut cases would do MP - I wanted to explain that it is possible not to be stupid or irresponsible and do MP. I am not advocating or or rejecting it.

      Historically MP was disavowed to the degree to which it was shown to the poskim that it is dangerous. See Sheilas Dovid cited in the Sdei Chemed's kuntres on MP. Very little is accomplished by telling frum people who have a clear mesora for many generations in their family and communities that they are ignorant savages and are violating halacha. Once this need for defeating the opponent fades it is easier to have a discussion and find a solution.

      this was also seen in dealing with child abuse - to the degree to which it is shown to the poskim that abuse is very harmful and prevalent - then the readiness to drop the screams of "but is is mesira" increases.

      So again Eddie - I am not poskening or even advocating - I am trying to create and atmosphere of understanding where changes - if needed - can be brought about. No one is threatening me with kicking me out of shul or really cares about what my approach to halacha is - except perhaps a couple people who who read this blog. 99% of people in my shul don't use internet and have no idea that I have a blog or even know what a blog is.

      Delete
    7. And my approach in this particular debate is not to reject MBP or to prove it immoral or unhalachic. My concern is purely that danger in transmission of viruses. this is why I gave the example of R' Salanter. Of course fasting is D'Oraita for Yom Kippur, and so it can be argued that MBP might also be. But there is a clear situation where lethal virus is quite common, and we must protect the child.

      I once asked Dayan Berkowitz ztl in London about smoking - and he said that the custom of separating fish and meat was due to saving lives and not a kashrut issue. Yet today, there are no cases of people dying from eating fish and meat on the same plate, while there are many cases of people dying from smoking. So if people are still strict about fish and meat, then certainly they should be strict about real dangers such as HSV.

      Delete
    8. Obviously, there is contact, and this is how the virus is transferred. If there is no physical contact, as you claim, then there is no MBP, so what is wrong with using the tube?
      It seems your decision making process has gone haywire. Whilst you "claim" to uphold Torah from Sinai, you are denying the central halachic principle of sakkanot nefashot.


      1) Not every mohel follows best practices. Not every mohel does MBP according to all of it's halakhic parameters. I have seen that with my own eyes during my training.

      2) What is wrong with the tube is that many many poskim have said that using a kli is ossur.

      3) Let's be realistic about the danger. Every case of HSV that is related to MBP in NYC is traced back to two Mohelim(one of whom even did it when he had open sores). Despite that there have only been twelve cases of infection in 13yrs. I'm not a very well established mohel(my first brit was my own son 2.5yrs ago), and I have done more than 12britot.

      So we have two mohelim who are infected, who during the course of this time have probably done hundreds(if not thousands) of britot each, and only 12 children have been infected.

      Now if a Mohel knows that he has a communicable disease(or if he know's the child has one, which should be determined from the pre-check) it is obviously forbidden for the mohel himself to do the MBP.

      There are currently 1.6 Million Jews in NY(http://www.jewishdatabank.org/Reports/Jewish_Population_in_the_United_States_2011.pdf). The number of britot done each year easily must fall within the tens of thousands with the majority of those involving MBP... So 13 in as many years cannot be considered a serious Skana Nefashot. If it is, then so is driving with a child in a car, or feeding a baby baby formula.

      Further even the NYC Department of Health has issued protocols by which MBP can be done safely without danger to the child. http://protectmilah.org/wp-content/uploads/2012/11/MBP-NYS-Protocol.pdf

      So really what we are seeing here is little more than fear mongering by an intactivist leaning media.

      Delete
    9. Dear Michael,

      if we were debating fish and meat having been on the same plate, and whether it needs a second tevilah or not, then i would accept your utilitarian calculus.

      Firstly, there may be the figure you give , but they are not all haredi Jews, so the section of the Jewish population is much smaller than the figure you give.

      Nevertheless, 13 babies (how many deaths?) is not a trivial matter. Again, I have to question your judgement and ability to make sound halachic decisions if you are willing to sacrifice a few babies so you can keep your prestige in the Haredi world and your perceived place in Olam Haba.

      I would rely on R Shachter, who forbids MBP, and i don't care if he hits someone with a baseball bat.

      Delete
  25. There are larger concerns that need to be considered. In particular, there are many loosely affiliated Jews who hire traditional mohelim for their children's bris. I suspect the insistence on MBP will drive many people away from choosing a frum mohel.

    ReplyDelete
    Replies
    1. There are two answers to that:
      1) We can abandon Torah and our sages and thus abandon MBP.
      2) We can educate the parents regarding both Torah and the safety(despite the fear mongering in the media that would just as soon do away with milah all together) of MBP.

      To me only one of these seems to be a valid choice for a Torah observant Jew.

      Delete
    2. Oh c'mon, we are not arguing that Torah be abandoned. Dont play the "Reform card".

      You will never educate people that placing the mouth on an open wound is a good idea, especially when the vast consensus of public health officials (including many frum Jews) recommend that it not be done.

      Now, if the Shulchan Aruch, Rambam, and major Rishonim required that the metzitza be done with the mouth OR if metzitzah itself were meakev perhaps there would be something to discuss. Absent either of those conditions, I think you face an uphill battle defending MBP.

      Further, I do not know how the use of a tube can be considered metzitzah b'keli. A sponge absorbs blood. The tube itself will not remove the blood without the mouth of the mohel. It is still the peh of the mohel doing the metzitzah.

      Lastly, the fight against MBP is not part of the larger battle against milah. Bloomberg has been a big proponent of milah worldwide and with the recent evidence showing that milah reduces the risk of HIV, the battle against milah has, for the most part, died down.

      Delete
    3. You will never educate people that placing the mouth on an open wound is a good idea, especially when the vast consensus of public health officials (including many frum Jews) recommend that it not be done.

      Apparently not. Unlike the guess work that went into the New York Department of Health's statistics, the UPenn and their University hospital says no real danger.
      http://www.news-medical.net/news/20130410/Study-Circumcision-does-not-increase-risk-of-herpes-in-infants.aspx

      So can we please move on past the "oh no, it's dangerous" charade. The Israeli Ministry of Health has ruled that it is safe, and now that has been independently confirmed by a leading research hospital in the US.

      If you want to make other arguments about why it should be done away with, I would be glad to hear them, but it should be clear by now that the "dangerous" card is nothing more than a scarecrow, propaganda piece.

      Delete
    4. that UPenn report is dubious, look at the end of it: ""This is a procedure the Jewish community has been performing for thousands of years without an issue, and that has not suddenly changed in the last ten years." "

      Yes, it has changed in the last few years, since in USA 70% of the population have HSV1 virus. This might not have been the case in Ashkenaz or Sepharad of 1000 years ago.

      Delete
    5. Yes, it has changed in the last few years, since in USA 70% of the population have HSV1 virus. This might not have been the case in Ashkenaz or Sepharad of 1000 years ago.
      Do you have proof of that other than the NYDOH propaganda?

      Delete
    6. If NYDOH is propaganda, then I don't know what to say.
      It is a very common virus, people get cold sores all the time.

      Delete
  26. Let's be honest. This:
    http://foreskinman.com/monstermohel.htm

    is the image of Mohelim(and Jewish circumcision) that the liberal media want to project. It is MBP today, and milah altogether tomorrow. The rest is just scare tactics and fear mongering.

    ReplyDelete
  27. Instead of using the hard statistics from the Israeli Ministry of Health regarding risk of infection, this is the guesswork that the New York City Health Department used to come up with their "statistics."
    To estimate the number of males potentially exposed to direct orogenital suction each year, first the number of males entering full-day or half-day kindergarten in Jewish day schools in New York City in 2010 was obtained (6,197) (1). Next, the proportion of those children attending schools that could be considered ultra-Orthodox (Hassidic, 2,665 [43%] and Yeshiva, 1,797 [29%]) was derived from New York City data included in a national census of Jewish day schools (2). Next, an assumption was made that 100% of males entering Hassidic schools (2,665), and 50% of those entering Yeshiva schools (899) would have had direct orogenital suction, yielding an estimated annual population at risk of 3,564. This estimate was multiplied by 5.75 (years) to estimate the number of male infants (20,493) likely exposed to direct orogenital suction during the April 2006–December 2011 surveillance period (Table 2).

    The number of male infants unlikely to have been exposed to direct oral suction (352,411) was estimated using vital statistics data for the number of live male births (372,904) in New York City during the 5.75-year surveillance period, after subtracting the number of males estimated to have been exposed to direct oral suction (20,493).* The risk for neonatal HSV-1 or untyped HSV infection following Jewish ritual circumcision with confirmed or probable direct orogenital suction during April 2006–December 2011 in New York City was estimated to be 24.4 per 100,000, a risk 3.4 (95% confidence interval = 1.3–9.0) times greater than the risk for HSV-1 or untyped HSV infection among male infants unlikely to have had direct orogenital suction (Table 2).

    http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6122a2.htm

    ReplyDelete
  28. The incidence of problems with MBP is so low that for any other condition it would be called very minor incidence event. It's like smallpox and tuberculosis which are not considered active diseases to be concerned about.

    The whole furor about this is political and anti Torah. There is debate of whether it is a chiyuv or not but in medical terms the incidence is so minor that it is really not an issue.

    It's worse than Bloomberg's diseased big gulp ban. It's more of his fevered anti Orthodox actions.

    ReplyDelete
    Replies
    1. There is good reason to believe that many incidents go unreported. Public Health officals regularly concern themselves with preventable disease regardless of how many deaths occur. Besides, I dont see how a preventable disease can be considered "minor". It is not minor to the one who gets it.

      This is not anti-Orthodox. Plenty of Orthodox shomer torah umitzvos are against MBP. The mayor is not anti-Orthodox and it doesnt help to cry anti-Semitism or anti-Orthodox anytime you disagree with a government policy. This mayor has bent over backwards to please the Orthodox and signing a waiver is a far cry from outlawing the practice which is what public health officials want him to do.

      Delete
    2. There is good reason to believe that many incidents go unreported.

      How is that? Such an illness in a neonate would require medical treatment. Thus it would be reported.

      Delete
  29. Rav Tzakok:

    Earlier you accused your detractors of resorting to ad hominem attacks. Yet, knowing absolutely nothing about me, you first response to my post was just that - an ad hominem attack, essentially accusing me of being an anti-halachic reform Jew. Shame on you.

    For the record, I am shomer mitzvot. Also, for the record, years ago, in preparation for the britot of my own sons, I studied with a mohel who basically "looked over my shoulder" while I circumcised my sons. I did not need him for the technical aspects, but for the halachic ones. I did not just want to be a technician. I wanted to know the pertinent halachot of what I was doing. However, as this was many years ago, I am not prepared to go toe to toe with anyone here quoting sources, as those were the only halachic circs I performed, and I cannot claim to be able to recall all the sources we learned at the time.

    And for the record, my teacher was an old time, European rav (who would best be described as charedi - although I am not.) I simply saw him as the best person to learn from.

    So, clearly, "yesh al mi li'smoch" in that MBP is not the ONLY way to perform halachic milah.

    And just as I am not going to argue source by source with you, I would respectfully recommend you not venture into the realm of science, surgical technique, infectious disease and the like. I've forgotten more on the subject than you will ever know. To say that if you put your mouth over the infant's penis in the "proper" way then there will be no contact with the wound is simply laughable in the world of infectious diseases or just plain science. And a swig of alcohol in your mouth - even the most pricey single malt - will do little or nothing to prevent disease transmission.

    But, if you disagree, my offer stands.

    And, DT: NO, the FDA or any governing medical authorities would not allow me to do this if it MIGHT cure cancer. It would only be authorized under very strict and tightly controlled studies with very strict oversight, and very detailed informed consent beforehand. The same informed consent the New York rabbis are fighting to stop.

    ReplyDelete
  30. > We can abandon Torah and our sages and thus abandon MBP.

    I'm not sure but I think this statement might be inflammatory. What it implies is that those of us who insist on indirect MBP - not abandoning the mitzvah but doing it in a fashion that will protect lives - are abandoning Torah. As I noted above there is a whole slew of poskim who either allow indirect MBP or insist on it. Are they also abandoning Torah?

    ReplyDelete
  31. It is really incorrect to refer to the vaunted New York protocol as "best practice." To virtually all physicians and medical scientists, "best practice" and "placing a person's mouth on a fresh surgical wound, which is really OK if you use wine, spirits or Listerine as mouthwash" do not exist in the same universe.

    At best, the 2006 protocol might better be called not "least bad practice" but "the best that those who hold MBP is miSinai will accept." In any event, not only was it was a compromise, it was rescinded* due to pressure from an outraged medical community.

    Speaking of best practices, they change as knowledge changes. Practices that once were considered mandatory might become virtually prohibited and vice versa. In contrast, one of the characteristics of Halacha l'Moshe miSinai is that it is immutable, except (perhaps, sometimes) minor details of how to perform the mitzvah ("we used to use wine, now we use....")

    That said, one of the few studies of of how prevalent neuropsychiatric disorders are in the hareidi community** did find that hareidi kids in the UK, given that they could mostly be classified as urban and low income, fared well in terms of prevalence of learning disorders in comparison with non-Jewish kids in similar socioeconomic circumstances; the authors attributed this to the broad and deep community support networks in the hareidi world.

    *http://www.thejewishweek.com/news/new_york/exclusive_protocol_controversial_bris_practice_was_rescinded_2007

    **http://digirep.rhul.ac.uk/file/1308cf70-6300-9a3c-7e42-e37964a8cda9/3/article_submitted_March_04.pdf

    ReplyDelete
    Replies
    1. I got ahead of myself. The connection I was trying to make: There have been suggestions that neonatal herpes infections due to MBP may be underdiagnosed. It is certainly true that not all such infections reveal themselves with a skin eruption. However, neonatal herpes tends to produce a lot of brain damage. If there were an elevated prevalence of undiagnosed herpes infections in a population there would almost certainly be more brain damage and so more learning disabilities. That UK study did not have such a finding.

      Delete
  32. http://www.news-medical.net/news/20130410/Study-Circumcision-does-not-increase-risk-of-herpes-in-infants.aspx

    Jewish leaders this week pointed to a recent independent study by Penn Medicine at the University of Pennsylvania that found little evidence to support the claim that a circumcision practice known as Metzitzah B'Peh (MBP) leads to an increased likelihood of herpes in infants.

    ReplyDelete
    Replies
    1. Ben,

      They won't listen to the Israeli Ministry of Health, what makes you think they will listen to one of the most prestigious research hospitals in the US?

      {begin sarcasm}Clearly MBP is extremely dangerous putting killing hundreds and endangering thousands of infants each year, and must be stopped at all cost. Since the practice appears strange and even abhorrent to our modern sensibilities the science must agree with our predilictions, and if it doesn't it should be ignored for obvious common sense.{end sarcasm}

      Really though, this debate isn't about the health of children, since there is no actual evidence that it endangers children's health at all. It is about appearance, and what "appears" normative and accepted in Western society. An adult male putting his mouth anywhere near the genitalia of a child sets of alarms for people(in many cases rightly so), and thus this practice is condemned. Not because a child is endangered, but because it resembles another abhorrent act.

      Delete
    2. Rav Tzadok, I wouldn't dream of arguing with you in kabbala. Try to show the same respect for medicine and its practitioners.
      One study, not even freely available but references on a website, does not a "psak" make.
      We often mock the Open Orthodox folks because of their "pick and choose" method of paskening - did a posek say a woman can have an aliyah nowadays? Well who cares if every other posek says they can't, we hold like him!
      Yet, with respect, your comment is the exact same thing. One study, of possibly questionable quality, agrees with your point of view and you latch onto it to prove your point. Never mind the multiple studies out there from equally prestigious institutions that contradict it, you have that one study.
      You wouldn't give an aliyah to a woman based on such logic. Don't endanger the lives of infants based on that same logic please.

      Delete
    3. Garnel,

      I do have the utmost respect for Medicines practitioners. I also realize what makes a scientific study, and what was done by the NYDOH was not one. The Israeli Ministry of health has found no problem with MBP in their own studies. Only forbidding it if the mohel is actually symptomatic.
      The UPenn study simply verifies what the Israeli Ministry of Health has been saying for a very long time.

      Now if you can provide a scientific study that says otherwise, I would be happy to listen. However, so far I have lots of opinions, but nothing solid. Lot's of fear mongering with little fact.

      Delete
    4. Rabbi Tzadok, in case you missed it, some of us have been wondering about that Yerushalmi you've been quoting. Thus far nobody has been able to figure out what you're referring to, though you seem to be taking it very seriously. So please do us all a favor and provide the exact wording of the passage you have in mind, or at least a more specific reference. Or, if you realize that you've misquoted, please be honest enough to correct your mistake. Thanks.

      Delete
  33. Rav Tzadok, have you seen the Penn Study? Probably not. In fact, no one outside Penn seems to have seen it. It wasn't reviewed by an external authority, it wasn't published in any available journal. As a professor of medicine I have access to Medline and most health journals and I can't find a copy of it. All that should make you suspicious. If I told you I heard of a teshuva from Rav Moshe, not published anywhere but someone told me he'd read it some place, in which he permitted mixed dancing at social functions as long as it was Tuesday and cloudy, would you believe me? Would you be okay with me telling folks Rav Moshe permits mixed dancing?

    But if it's references you want:
    http://pediatrics.aappublications.org/content/114/2/e259.full
    http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6122a2.htm

    ReplyDelete
    Replies
    1. Important point - who discovered this study?

      Delete
    2. Would you be okay with me telling folks Rav Moshe permits mixed dancing?

      Garnel you raise a good point. Will have to check into the study a bit. I know folks at Penn.

      But if it's references you want:
      Didn't say references, I said scientific studies that show a direct correlation. Honestly if you drink from a glass from someone who has an active HSV outbreak you may contract HSV. However at what rate?

      The first reference you provide says that it is not a study, and that it doesn't have statistics on instance.

      The CDC is just a reiteration of the NYDOH guesswork. Where they have taken their 13 cases from the last four years, guessed at how many britot there were with MBP and then made up a statistic. Nevermind that other details of how those 13 occurred ect.

      Before you can say that there is a legitimate danger, you need a scientific study documenting instance. For example, the US documents a 1:100,000 death rate for hospital performed circumcision. US protocol requires a local anesthetic. Israel documents a 1:250:000 death rate in circumcisions(in general) and both in Hospital and by mohelim they do not allow local anesthetic. Would you therefor say that local anesthetic poses significant risk that it's use should be discontinued?

      Let me give you a few scientific studies to look at an compare. Take the one the US Army did on health risks of Cirucmcion(Wiswell & Geschke, 1989) that had an overall medical complication rate of 0.19%(the lowest of any US study done) and an infection rate of 0.06%, or a Washington State study (Christakis Et. Al. 2000) in which children circumcised in hospital an an infection rate of 0.008%. Compare that to Ben Haim et al 2005 in which 17% of the circumcisions were done in hospital 83% done by Mohelim(using mbp) total complication rate was 0.34%(slightly higher than US numbers) BUT infection rate was 0.01%.

      The hard math simply isn't in your favor.

      Delete
  34. Michael: I just reviewed the entire Ben Haim paper. There is no mention of MBP being done or not in the circumcisions they reviewed, despite your claim to the contrary. So, that study cannot be used to prove anything as relates to this debate.

    I will say, that having observed both physicians and non-physician mohelim many times over many years I have always said that the mohelim were "slicker" at the procedure than the docs. Practice does, after all, make perfect. So my complaint is not about technique - well trained mohelim are superb at what they do in my expert opinion.

    But, technical proficiency still will not prevent disease transmission via an open wound.

    ReplyDelete
    Replies
    1. There is no mention of MBP being done or not in the circumcisions they reviewed, despite your claim to the contrary.
      It said 83% of the Britot were done according to ritual. Feel free to check with Rabbinut if you like, but failure by a certified mohel to do MBP results in loss of license. There may had been a few done via tube or gauze if the Mohel thought, and could justify real danger(either his own infection or that of the baby), but otherwise one should assume that they were done MBP.

      Delete
    2. Ramatz, are you saying that all Rabbis in Israel with a license do MBP?

      Delete
    3. Eddie,

      They are supposed to. When you do your test circumcision you had better if you want to pass.

      Delete
  35. I would have to disagree. I live in Israel, too, and have watched lots of circumcisions. NEVER seen MBP - and that's over ten years. (And I usually get close, since I enjoy watching the technique of good mohelim.) I am sure that is a function of the type of communities we both live in. But, I know that most of the mohelim I have observed are Rabbanut certified.

    Please don't take offense at this, but that is a major problem with reading scientific studies. And it's something that many (maybe even most) physicians do. Unless you have rigorous academic training and are involved in an academic environment, it takes a fair amount of expertise to read a study and a)evaluate its results b)assess whether the study was done properly enough such that the stated results really mean anything. There's an incredible amount of sloppy science out there. Often even in the most prestigious of journals. People often read a study superficially to validate their own beliefs and practice. It takes a lot of training to parse the results and data presented to see if they really prove anything.

    You simply cannot make that assumption about MBP being performed in the Ben Haim study unless it is specifically stated. Were I to make such a statement at a scientific meeting I'd be laughed off the podium.

    ReplyDelete
    Replies
    1. I would have to disagree. I live in Israel, too, and have watched lots of circumcisions. NEVER seen MBP - and that's over ten years.

      Well if you live in Israel, it should be easy enough to check with Rabbinut as to what is required. I suggest you ask them, because you seem to be quite in the dark about it.

      While there are mohelim that "work under the table" and do not have certification, I can't speak to what they do. Further it is clear from page three of the study that such Mohelim were not considered in the study. They clearly state the Mohelim considered followed all of the regulations and protocols set by the Rabbinut and Ministry of health, which includes MBP. Like I said, if you don't believe me ask the Rabbinut.

      Delete
  36. Michael:

    I have no problem in engaging in a civilized discussion with you on this subject. But, there's no reason to be snarky or insulting. My interests - as I assume are yours - are the facilitation of halachic, yet safe milah. You seem altogether too willing to adopt an atagonistic tone to everything I write. There's really no need for that.

    Unfortunately, I am out of the country for a week at a conference, so my access to mohelim and rabbanut officials to question is limited - as is my internet access and time. But, I certainly will pursue more accurate info next week.

    The limited info I've seen from Rabbanut sources online from here is that they leave metzitzah be'peh vs b'kli up to a discussion between the mohel and the parents. If I'm wrong, please direct me to information to the contrary.

    ReplyDelete
    Replies
    1. Regarding the Ben Haim Study, taken from the Journal itself:
      חשוב לזכור כי למרות ביצוע מציצה מסורתית בפה, במהלך המאה האחרונה לא נצפתה עד העשור האחרון פגיעה בנימולים. כמו כן מחקרים שנעשו בארץ הראו רמת בטיחות שווה בין בריתות שבוצעו בידי מוהל מסורתי המבצע גם מציצה בפה לבין בריתות שנעשו על ידי רופא
      Ben Chaim J. et al. IMAJ 7:368. 2005 , הובא באברהם שטינברג שם, בעמ' 388

      Now you had said, I just reviewed the entire Ben Haim paper. There is no mention of MBP being done or not in the circumcisions they reviewed, despite your claim to the contrary. So, that study cannot be used to prove anything as relates to this debate.
      So did you miss that paragraph? Just curious. I'm not sure how you could have read the paper, and found no mention of MBP when it is very clear in that paragraph.

      For information on what the procudures of Rabbinut are, you can either contact Rabbinut directly or you can contact ITIM http://www.itim.org.il/eng/

      Delete
  37. "Very little is accomplished by telling frum people who have a clear mesora for many generations in their family and communities that they are ignorant savages and are violating halacha"

    But if they are violating halacha and they think they are following halacha, there is no way to dissuade them unless you cite the halacha showing they are going against it. Playing with "kid-gloves" only reinforces their belief that they are adhering to the age-old halacha while no one else is.

    ReplyDelete
    Replies
    1. As Rav Pam once said - it doesn't pay to yell at the masses that they are doing something wrong. You have to convince rabbis they respect of their community.

      Delete
  38. Michael:

    I was at a computer that didn't "do" Hebrew (as I noted, I'm out of the country.) I accessed an English translation that for whatever reason, didn't have that paragraph. Puzzling. I'll look into it further.

    ReplyDelete
  39. Michael:

    Again, I'm doing this "on the fly" while out of town, but...

    I just read the article in English on the IMAJ website. Same reference as yours. That line is no where to be seen. It does make you (or, at least me) wonder why a comment about MBP is posted in Hebrew, but not in the English journal that is likely to be read by a non-Israeli readership.

    But, either way, that's why I saw no reference to MBP.

    Of note, their study was of only 66 circs, if memory serves. I do not know what reporting requirements exist legally in Israel regarding reporting neonatal infections. Also, the article does not publish data about what percentage of milah in Israel is done by rabbanut certified mohelim. And we also have no hard data on whether mohelim - even if they got certification - actually do MBP. So, without a denominator, we cannot draw effective conclusions.

    In addition, NY State only mandated reporting around 2005 or 2006. NJ and Maryland - just two examples of large Orthodox populations (i.e., Lakewood and Baltimore) don't have reporting requirments, I believe.

    All I'm trying to say here, is that scientific data is VERY tricky and really hard to parse and interpret correctly. And as I pointed out earlier, most physicians I know can't spot a poorly done study.

    And for the record, I have contacted a mohel acquaintance of mine - frum rabbi, rabbanut certified - to find out his training instructions. I'll report as more info comes in.

    ReplyDelete
    Replies
    1. Their study was of 19,478 males of which there were 66 complications. The reason it would be in Hebrew was because it was done in Israel and published in an Israeli journal of medicince where it is likely to be read, well, in Hebrew.

      Delete

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