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Tuesday, January 5, 2016

'The way we always do it' (oral suction at circumcision)

“This is the way it was done, the way we always do it, the way it should be done,” says Hadassah, a soft-spoken 28 year old Chassidic woman from Borough Park. Why does she do it? “I try not to think about what we do,” she admits. “That's the beginning and end to it.”

Really? I say. “It doesn't make sense to do things and not think about it,” she agrees. But “you grow up like it, that's what you are used to.”

We are talking about the ritual of metzitzah b’peh (“oral suction”), direct mouth contact to draw blood from a newly circumcised penis. The mohel sips wine, extracts a small amount of blood with his mouth, spits it out, and continues with the ceremony.

First based on a Talmudic injunction to draw out blood for the sake of avoiding danger, presumably on the basis of ancient Greek medicine, such direct oral suction was the way circumcision was practiced in Jewish communities for hundreds of years. Only later, beginning in the 19th century under the pressure of modern scientific theories of disease, did MBP give way to substitutes (involving a sterile pipette). While the use of such techniques is now universal in non-Orthodox communities, as well as widespread in modern Orthodoxy, MBP is still widely practiced.

The mere description of direct suction makes many readers instinctively recoil. Beyond repugnance, 30 cases of herpes and 3 deaths have been connected to the practice in a review of the scientific literature between 1988 and 2012. And the opinions of medical experts are clear. Miriam Laufer, professor of pediatric infectious diseases at the University of Maryland, says, “Given the fact that the majority of adults have acquired HSV [herpes virus] infection and can occasionally shed HSV in their saliva and the devastating consequences of HSV infection in newborns, I would think that we should consider metzitzh b’peh an important health risk and it should not be practiced.” Even many Orthodox rabbis find reason to forbid the practice. Rabbi Yosef Blau, of Yeshiva University, agrees with Laufer: “As a community that relies on current medical knowledge to determine matters relating to health risks, modern Orthodox mohalim will not do metzitza b’peh.”

Yet the New York City Department of Health and Mental Hygiene, finding little success in its attempt to require consent from parents before MBP, has chosen to work with community leaders and rabbis to reduce rates of infection among mohalim; evidently, therefore, the practice is not in immediate jeopardy. Rabbi Avi Shafran, Director of Public Affairs for Agudath Israel, opines that “evidence for an inordinate danger posed by MBP is lacking,” and that, lacking such evidence, the ancient Jewish reverence for custom should be respected.

It might be easier to understand why some rabbis would see nothing wrong with MBP. But why would anyone take part in the ritual, let alone advocate it for their children?

Hadassah (not her real name) allows as how there might be some reason to be leery of direct oral suction. “I get why someone might think about it, it makes people uncomfortable, there are risks.” But her three boys, ages 4, 6, and 8, all went through direct oral contact. “There was never a question of not doing it,” she said.

What does she and other adherents of MBP see in the ritual? Against the judgment of the scientific and medical establishment, who sees it as unnecessary risk taking; and the raised eyebrows of some of their Orthodox brethren at what they see as an unnecessary danger (“The mere chance of endangering our newborns ought to overrule a ritual custom,” says Avital Chizhik-Goldschmidt, an Orthodox journalist in New York), what do they find in it worth preserving?

As a physician myself, halachically observant (though not Orthodox), and the father of a son who underwent conventional circumcision without oral suction, I thought I would find passionate defenders of MBP, ultra-Orthodox Jews for whom the spiritual meaning of the practice outweighed its obvious risks, imbuing the most intimate of rituals with a sacred adventurousness.

But what I found was a surprising conventionality, a willingness to go with the flow because it's what is done. Hadassah, for example, hasn't thought about it much, because it's the tradition. She grants that “in every circle there are people who [might] have questions about MBP,” just like in every other area in life, but in her circles, “it's mesorah [received tradition], taken for granted.”

If it's taken for granted, why is it such an important part of the tradition? Katle Kanye, the pseudonym of a widely read Chassidic blogger, writes that seeing MBP as a ritual under attack is part and parcel of many ultra-Orthodox Jews' self image as an embattled group. “True or not, it appears to us [Chasidim] that those who oppose MBP would like it better if they could ban circumcision altogether.” Shafran concurs: “There is an automatic, reflexive negativity among Orthodox Jews toward being told by secular writers or authorities to discontinue a Jewish practice.”

But what about positive reasons for the ritual? Yes, Katle Kanye says, there is a Kabbalistic text which maintains the importance of direct oral contact, but “that reference is for community bosses and sermon writers. The ordinary people don't ask where it comes from. It's just what the Jewish community does and should keep doing. And no one wants anyone to think their kids are the equivalent of uncircumcised [for not getting MBP].”

A Chasidic father, known as “The King of America” on the popular Chasidic chat site Kave Shtiebel, agreed that government efforts to restrict MBP made his observance more meaningful. “The mohel did MBP for all my kids,” he messaged me in Yiddish. “My wife and I were very happy that God gave us the merit of doing the mitzvah properly. Usually in America you don't need much self-sacrifice to do mitzves. But when [Mayor Michael] Bloomberg interfered, I asked the mohel to let me do the MBP myself, so as to be even more punctilious in the mitzvah and make it as beautiful as possible. Of course, it doesn't compare to the self-sacrifice which our parents had, but even so…”

Psachyo Friedmahn, a Chabad-affiliated man in his 20s, plans to train as a mohel, partially so that he can perform MBP on his future sons (that is, with direct oral contact). He seemed exceptional among those I talked to for his insight into why he, personally, supports the ritual: “I am part of a community which practices it,” he told me, “ and I also recognize a broader religious value of the practice” — based on Kabbalistic texts mandating direct oral contact. He sees it as a custom, but a valuable and binding one.

Not all those who support MBP are Chasidic. Chaim Neustadt (not his real name) is 30 years old, wears the “Charedi uniform minus the hat,” and has had difficulty finding an ideological camp he can entirely call home. Nevertheless, he affiliates, broadly speaking, with the frum (religious) Baltimore Orthodox world. Before he had his son a year and a half ago, he asked advice of a rabbi he respected regarding direct oral contact during the circumcision. This rabbi cited the ruling, well-known in Orthodox circles, that an uncircumcised Jew cannot eat from the Paschal sacrifice.

Neustadt remembers that rabbi's advice.”According to the hard-core understanding, a baby whose circumcision lacked direct oral suction remains [as if uncircumcised], with no remedy. … So if [in the days of the Messiah] the bringing of the Paschal sacrifice is renewed, don't you want your son to [be able to fulfill the commandment] then too? While he characterizes himself as “ambivalent” about the whole thing, he says “he just let it happen” for his son; “it was a given.”

Positive reasons aside, those who allow MBP to be done for their children do acknowledge the risks. Many mention that friends or family members are not suspected to carry herpes, and thus they feel comfortable using them as mohels. “It helps to have a mohel in the family,” acknowledges Hadassah. “I trusted [ours] explicitly; I know he is overcautious.” “I've never heard of a herpes complication here,” said Neustadt. “The mohel was the head of my kollel [yeshivah for married men].”

Friedmahn, of Chabad, wouldn't have much to say to someone who had objections to the practice. “If a person finds it off-putting solely for medical reasons, and therefore believes it should be strictly regulated, I would find such an attitude very understandable, and I wouldn't really have much to say.” Neither would he be sure how to respond to those “who seek to vilify religious observant Jews who engage in the practice.”

Hadassah seemed — on prompting — to have already devoted some thought to those who might be opposed to the practice. “In every circle there are people who have questions, who have awareness [about the problems]. People who have questions in life. I've heard of such a thing.” If someone had questions, she concluded, “I would help them deal with it.”

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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