Dear Rabbi Lawrence,

Can you explain where metzitzah b’peh comes from? I know that for medical reasons, like herpes, most communities do not have this practice. What about COVID?

Dear Yoni,

It is a very important topic and obviously remains a live issue to this day; according to a report in the Wall Street Journal back in early 2020, in the time span between September 2019 and February 2020, there were four reported unrelated cases of herpes simplex virus 1 in infant boys after undergoing metzitzah b’peh, the direct oral suction of the wound after circumcision. These made up four of the 22 reported cases since April 2006, when NYC began mandating the report of metzitzah-related infections. While the four babies from the report, thank God, were treated, of the greater 22, two babies tragically passed away from infection.

While some might claim that two metzitzah b’peh-related fatalities out of the thousands and thousands of brissim performed in those communities make up a statistical anomaly, we should nonetheless examine whether halacha actually demands that we take such a risk, however supposedly “minimal.” More directly put: is metzitzah b’peh an inextricable part of the mitzvah of milah, or is it something else entirely?

The Mishnah in Maseches Shabbos (133a) states that in the context of a Shabbos bris one “performs all the necessities of the circumcision”; it lists milah (removal of the foreskin), priyah (uncovering the mucosal membrane of the glans), metzitzah (drawing out blood from the wound) and the application of a bandage and cumin. Those who hold that metzitzah is a part of the mitzvah of milah point to this mishnah, because it lists metzitzah as one of the tzorchei milah, “necessities of the circumcision.” Interestingly, those who hold it is not an inherent part of the mitzvah, also point to this mishnah.

The explicit reasoning behind metzitzah is stated by Rav Papa in the related gemara: Metzitzah is done to avoid sakanah, danger; i.e., there is a health concern that, by ancient medical understanding, is evaded through drawing out blood. The Rambam in Hilchos Milah codifies this understanding as a medical requirement.

Such a notion is less surprising when examined in the ancient medical context, where bloodletting to “release the body of bad humours” was commonplace. As one might suspect, however, the consensus of modern medicine is that bloodletting is a mostly harmful and unnecessary practice.

While the adverse effects of bloodletting did not emerge as consensus until the turn of the 20th century, the risks of orogenital suction came to the halachic forefront over half a century before that in response to a situation similar to the one reported in the Wall Street Journal. In 1830s Slovakia, a number of Jewish babies, all circumcised by the same mohel, fell ill shortly after their bris; doctors determined that their illness was a result of metzitzah b’peh and suggested use of a sponge or gauze to fulfill the apparent religious requirement of “drawing out blood.” In a correspondence with Rabbi Eliezer Horowitz (the Yad Eliezer), Rabbi Moshe Sofer (the Chasam Sofer) famously endorsed the doctors’ suggestion and writes:

Nowadays we do not use the same type of bandage or cumin as described in the mishnah… Since this is done for medical reasons, one need not be particular if doctors have found other suitable medications. The same applies also to metzitzah… We could use any comparable method.

While there were certainly many poskim who disagreed and who continue to disagree, either by dismissal of the doctors’ concerns (Maharam Schick) or fear of a “slippery slope” away from tradition in deference to modern medicine (Rabbi Yaakov Ettlinger), the halachic tides had already begun to turn. By the late 1800s, numerous prominent rabbis, such as Rabbi Azriel Hildesheimer and Rabbi Shimshon Raphael Hirsch, fully endorsed alternative methods of metzitzah, namely a glass tube designed in 1887 by Rabbi Michael Cahn, the chief rabbi of Fulda, Germany. By 1955, Israeli Chief Rabbi Yitchak Herzog had unequivocally declared that “metzitzah forms no part whatsoever of the actual precept of milah, whether l’chatchila or bedieved.” While metzitzah may commonly be understood as secondary to the mitzvah itself, the strong inclination to fulfill all the “requirements” of the mishnah persists. Nowadays it is the standard in modern, centrist and many yeshivish communities to achieve metzitzah through alternative means such as metzitzah b’shforferes, use of the aforementioned glass tube.

Of course, herpes is not the only transmissible disease. In the context of this uptick in COVID cases and transmission, I think it is entirely appropriate for communities to rely on the Chasam Sofer and use a method of metzitzah that does not require the removal of one’s mask—a position published by the London Beis Din toward the beginning of the pandemic.

Rabbi Eliezer Lawrence is a doubly certified, highly rated mohel serving the NY, NJ and CT region and beyond. If you or someone you know is expecting or want to learn more about his practice, visit www.FamilyMohel.com. He can also be reached at [email protected] or at (212) 518-7334. Questions for the column can be submitted to [email protected].