REALM33

Directorate of Information Preservation and Archival

Subject Profile – File Extract

Designation: Metzitzah B’Peh (מְצִיצָה בְּפֶה) — Oral Suction in Circumcision

Also Known As: “MBP”  ·  “Direct Oral Suctioning”  ·  “Direct Orogenital Suction”  ·  ███████

Talmudic Source: Babylonian Talmud, Tractate Shabbat 133b — “Any mohel who does not perform metzitzah endangers the child and should be dismissed”

Community: Haredi (ultra-Orthodox) Jewish communities  ·  Not universal in Orthodox Judaism  ·  Rejected by Reform, Conservative, and most Modern Orthodox communities

Public Health Classification: HSV-1 transmission risk to neonates  ·  NYC: 24+ documented linked cases since 2000, including deaths and permanent disability

Current Status: ACTIVE — REGULATED IN NEW YORK — UNDER INVESTIGATION IN BELGIUM — December 2025

DECLASSIFIED – September 25, 2025

Fig. 1 – Historical depiction of brit milah, the Jewish ritual of circumcision performed on the eighth day after a boy’s birth. Metzitzah b’peh is a specific sub-element of this ceremony practiced by a subset of haredi communities. / Public Domain

The Practice — What It Is and What It Involves

Metzitzah b’peh (מְצִיצָה בְּפֶה) is Hebrew for “suction by mouth.” It is a specific step within the Jewish ritual of circumcision — brit milah — in which the mohel (the trained practitioner who performs the circumcision) places his mouth directly on the freshly circumcised wound and draws blood from it by oral suction. This is performed immediately after the excision of the foreskin, before the wound is dressed. The mohel typically sips wine first, then applies his mouth to the infant’s wound, draws blood mixed with wine, and expels it from his mouth.

The practice is not universal in Judaism and never has been. The overwhelming majority of Jewish communities worldwide — Reform, Conservative, Liberal, and most Modern Orthodox — do not practise metzitzah b’peh. Alternatives to direct oral suction have been accepted and used for well over a century: sterile glass tubes, pipettes, sponges, and cloths accomplish the same mechanical function — drawing blood from the wound — without placing the mohel’s saliva in contact with the infant’s open tissue. The Rabbinical Council of America, one of the largest Orthodox rabbinic organisations, officially endorses these alternatives as halakhically valid. The practice in its direct oral form persists primarily within haredi (ultra-Orthodox) communities, where it is framed as an essential element of authentic Talmudic tradition.

The public health significance of metzitzah b’peh is specific and documented: adult human saliva commonly carries herpes simplex virus type 1 (HSV-1), the virus responsible for oral cold sores. HSV-1 is extraordinarily common in adults — estimates place carrier rates between 50% and 80% of the adult population — and in adults it typically causes mild or no symptoms. In neonates, who have no established immune defences against the virus, HSV-1 infection can cause encephalitis (brain inflammation), permanent neurological damage, and death. An adult mohel who carries HSV-1 asymptomatically — with no active cold sore, no visible symptom, no awareness that he is infectious — can transmit the virus to an infant through oral suction. The infant has no defence against it.

The Talmudic Source and Its Original Medical Rationale

The Talmudic basis for metzitzah b’peh is found in the Babylonian Talmud, Tractate Shabbat 133b, where the Amora Rav Papa states that a mohel who does not perform metzitzah (suction) endangers the child and should be removed from practice. The Hebrew word metzitzah means suction without specifying the method — the Talmudic text does not specify that this suction must be performed orally. The identification of metzitzah specifically with direct oral suction emerged through later rabbinic practice and interpretation rather than from the original Talmudic language.

The Talmudic rationale was medical: the sages of the Talmudic period understood suction of a wound to prevent health complications. Within the framework of ancient medicine — long before germ theory, before any understanding of microbiology, and before any knowledge of viral transmission — the application of suction to a wound represented a reasonable protective measure against what we would now describe as blood pooling, swelling, and infection. The problem is not that the ancient sages were irrational; the problem is that the medical understanding on which the practice rested was subsequently overturned by 19th-century science, and the question of how Jewish law should respond to that overturning is the central theological dispute that has surrounded metzitzah b’peh ever since.

Fig. 2 – Rabbi Moshe Sofer (1762–1839), known as the Chatam Sofer, the most influential Orthodox voice in favour of maintaining metzitzah b’peh in its original oral form as germ theory emerged. His ruling that changes to Talmudic practice constitute a forbidden deviation — chadash assur min haTorah (“the new is forbidden by the Torah”) — shaped the haredi position that has persisted into the 21st century. / Public Domain

The 19th Century — Germ Theory and the First Crisis

The collision between metzitzah b’peh and modern medicine first became acute in the 19th century, as germ theory — the understanding that specific microorganisms cause specific diseases — emerged in European science and as epidemics of infectious disease swept through European Jewish communities with documented links to the circumcision ceremony. Cases of syphilis, tuberculosis, and other diseases transmitted through the circumcision wound accumulated in the medical literature of Western European communities, particularly in Germany, France, and the Austro-Hungarian Empire.

These cases forced a confrontation within rabbinic authority that has not been resolved to this day. The reformist position — taken by Haskalah-influenced rabbis and later by what would become Reform Judaism — held that if the original Talmudic rationale for metzitzah was medical (protecting the infant from harm), and if that medical understanding was now demonstrably wrong, then the practice should be modified in light of better medical knowledge. Alternatives such as glass tubes achieved the same purpose — suction — without the disease transmission risk that had caused the original harm.

The traditionalist position was defined most influentially by Rabbi Moshe Sofer — the Chatam Sofer — the leading rabbinic authority of Central European Orthodox Jewry in the early 19th century. The Chatam Sofer ruled that metzitzah b’peh was a binding Talmudic requirement and that deviation from it was prohibited regardless of external circumstances. His broader principle — often summarised as chadash assur min haTorah (“the new is forbidden by the Torah”) — established the theological framework that traditionalist communities still invoke: the practice must be maintained because it is ancient, and any accommodation to external pressure constitutes a dangerous precedent toward assimilation and departure from authentic Jewish law. This position was adopted and entrenched by the haredi rabbinic authorities of Eastern Europe and, through them, by the haredi communities of 20th and 21st century New York, Israel, and Antwerp.

The fact that the medical cases in 19th-century Europe involved diseases other than herpes — and that the mechanism of transmission involved different pathogens — meant that the crisis was partially resolved in those communities without definitively settling the underlying halakhic question. Enough traditional mohels adopted glass tubes to reduce disease incidence; enough haredi communities maintained oral suction to keep the controversy alive. By the time the specific HSV-1 mechanism was understood in the late 20th century, the halakhic positions had already calcified along lines drawn more than a century earlier.

The Documented Case Record — New York City, 2000–Present

The modern public health crisis surrounding metzitzah b’peh is primarily documented through the New York City Department of Health and Mental Hygiene, which has tracked cases of neonatal herpes linked to the practice since 2000. New York City has the largest haredi Jewish population outside Israel, concentrated primarily in Brooklyn neighbourhoods including Borough Park, Crown Heights, and Williamsburg, and in Rockland County. The concentration of haredi families, mohels practising metzitzah b’peh, and neonatal HSV-1 cases in the same geographic area created the conditions for the most systematically documented epidemiological record of this practice’s public health consequences.

The Medical Mechanism — Why Neonates Are Specifically Vulnerable

The specific danger of metzitzah b’peh to infants is not that adults who perform it are more likely to carry HSV-1 than the general population — the carrier rate in adults is similar across all demographics — but that neonates are uniquely vulnerable to HSV-1 in a way that adults are not. In a healthy adult, HSV-1 typically establishes a dormant infection in nerve ganglia and reactivates intermittently, producing cold sores or remaining entirely asymptomatic. The adult immune system has developed the adaptive responses to contain it. A neonate has none of these defences. The infant’s immune system is functionally immature, with no prior exposure to HSV-1 and no established antibodies. When HSV-1 is introduced directly to an open wound on an eight-day-old infant, it can cause neonatal herpes — a systemic infection that spreads to the brain, causing encephalitis, and to multiple organ systems simultaneously.

The further complication, documented in the New York cases, is that a mohel carrying HSV-1 may have no visible symptoms — no cold sore, no tingling, no external sign — at the time he performs metzitzah b’peh, and yet still be actively shedding the virus in his saliva. This is known as asymptomatic viral shedding, and it is a well-established property of HSV-1 infection. It means that a mohel who genuinely believes himself to be uninfected and acts in complete good faith can still transmit the virus to an infant he is trying to protect. The NYC Department of Health’s guidance is explicit: “Even if the mohel has no symptoms or obvious signs of HSV-1, such as cold sores near their mouth, they could still have the virus and not know it.” Mouthwash, handwashing, and sterile instruments can reduce but cannot eliminate this risk as long as direct oral contact with the wound is made.

Fig. 3 – Herpes simplex virus (HSV) under transmission electron microscopy. HSV-1, which causes oral cold sores in adults, is carried asymptomatically by an estimated 50–80% of adults. In neonates, whose immune systems cannot mount the defences that contain it in adults, HSV-1 infection can progress to encephalitis, permanent neurological disability, and death. / Public Domain / CDC

The Internal Jewish Debate — Halakhic Positions and Community Fractures

The debate about metzitzah b’peh is not simply between the Jewish community and secular public health authorities. It is also, significantly, a debate within Jewish tradition itself — a disagreement about what halakha (Jewish law) requires, what it permits, and how Jewish law relates to modern medical knowledge.

The traditionalist position, maintained by haredi rabbinic authorities including the Central Rabbinical Congress of the USA and Canada, holds that direct oral metzitzah is an essential Talmudic requirement whose abandonment would constitute an unacceptable concession to secular pressure. Some authorities in this camp go further: the Chatam Sofer’s ruling that non-oral suction invalidates the circumcision is still cited by some poskim (halakhic decisors), meaning that in their view the ritual itself is invalidated if a glass tube is used instead of the mohel’s mouth. This positions any accommodation as not merely a religious compromise but a fundamental failure to perform the circumcision at all.

The mainstream Orthodox position, represented by the Rabbinical Council of America among other bodies, holds that the Talmudic requirement is for metzitzah — suction — and that the method of suction is not halakhically specified as oral. On this reading, using a sterile glass tube or pipette fully satisfies the Talmudic mandate while eliminating the public health risk. Many individual poskim across the Orthodox spectrum have ruled in favour of alternatives, citing the Talmudic principle of pikuach nefesh — the preservation of human life — which overrides nearly all other religious obligations. If a practice endangers life, Jewish law generally requires that it be modified or abandoned.

The 2025 Belgium case added a specifically internal Jewish dimension to the controversy that the New York situation had not previously included at the same intensity: it was a complaint from within the Jewish community — filed by a rabbi against other rabbis — that triggered the police investigation. Rabbi Moshe Aryeh Friedman of Antwerp, an anti-Zionist rabbi known for his public criticisms of haredi customs, filed his police complaint in November 2023 specifically citing child endangerment as the legal basis. That a Jewish religious figure initiated the regulatory action against other Jewish religious figures transformed the framing of the Antwerp situation from a simple external intrusion on religious freedom into a more complex internal community dispute — with external legal consequences.

The 2025 Belgium Raids — A New Front

At approximately 5:00 am on May 14, 2025, Belgian police executed search operations at three locations in Antwerp — two in the Jewish Quarter, one in the nearby Green Quarter — confiscating circumcision instruments from the homes of several mohels. Among those searched was Rabbi Aharon Eckstein, described as one of the most experienced mohels in Belgium. “They arrived around 5 a.m., didn’t say much, just searched the house and took my toolkit,” Eckstein told reporters. He stated his intention to continue performing circumcisions since he had not received a formal order to stop. No arrests were made in the raids.

The raids were the culmination of a complaint filed in November 2023 by Rabbi Moshe Aryeh Friedman against six named mohels, followed by a September 2024 notification to police that circumcisions were being conducted without legally required approvals. In Belgium, the law requires all circumcisions to be performed by licensed medical professionals — meaning that traditional religious circumcision by non-medically-licensed mohels is technically illegal under Belgian law, irrespective of the metzitzah question. The investigation therefore combined two distinct legal questions: the general question of unlicensed medical practice and the specific question of metzitzah b’peh.

The raids sparked immediate and fierce reaction within both the Antwerp Jewish community and the broader European Jewish leadership. Rabbi Menachem Margolin of the European Jewish Association characterised the raids as “yet another red line crossed in the intimidation of Jewish religious figures in Belgium” and drew an explicit connection to Belgium’s earlier ban on shechita (ritual slaughter for kosher meat). The European Jewish Association’s diplomatic envoy for antisemitism noted that Belgium has no clear legal framework for certified mohels and called for a European Union-level certification process. Several community members compared the early morning searches — with armed officers, body cameras, and police assigned to each family member — to historical police actions against Jews. The Belgian Health Minister responded that Belgian law permits ritual circumcision when performed by a qualified physician under health and safety standards, and rejected any suggestion of antisemitic intent.

The Antwerp situation is significant beyond its local dimensions because it represents the emergence of a new regulatory model in Europe: legal action against unlicensed circumcision practice, initiated in this case not by secular health authorities acting independently but by a complaint from within the Jewish community itself. By early 2026, Belgium was reported to be considering broader circumcision regulatory legislation. Similar legal questions are active in Ireland, Germany, and other European countries where the intersection of religious practice and medical licensing law has not been legislatively resolved.

The Religious Freedom vs. Child Welfare Framework

The most durable tension in the metzitzah b’peh debate is the one that cannot be resolved by more data: the conflict between religious freedom and the state’s interest in protecting children who cannot consent to procedures performed upon them. This tension has produced distinctly different regulatory outcomes across jurisdictions and reflects deep disagreements about where the limits of religious freedom lie when those limits involve the physical welfare of non-consenting minors.

The religious freedom argument is that the state has no legitimate authority to regulate an ancient religious practice conducted within a community on willing participants (the parents, on behalf of their sons), that the risks — while real — are low in absolute terms, and that state interference constitutes exactly the kind of religious persecution that constitutional and human rights frameworks were designed to prevent. As Rabbi David Niederman of the United Jewish Organizations of Williamsburg told the New York Times during the 2005 controversy: “We chose America because of religious freedom.”

The child welfare argument is that the infant is not a willing participant in any meaningful sense — he is eight days old and cannot consent — and that the state has both the authority and the responsibility to protect the physical welfare of non-consenting persons regardless of the religious beliefs of those performing the procedure. The American Academy of Pediatrics, in its technical report on circumcision, advises explicitly against metzitzah b’peh on the grounds that it creates a preventable infection risk that the infant has no means of avoiding. The NYC Department of Health’s guidance states that this risk cannot be eliminated as long as direct oral contact is made. There is no legal or regulatory framework anywhere that permits a practitioner to impose a preventable communicable disease risk on a non-consenting minor in the name of religious tradition — but the enforcement of this principle against a practice embedded in a specific religious community’s self-understanding as a requirement of divine law raises questions about state power and religious minority rights that have not been uniformly resolved.

What makes the debate particularly difficult is that the documented case numbers — while serious in their individual consequences — are numerically small relative to the number of metzitzah b’peh circumcisions performed annually. The CDC estimated approximately 3,564 metzitzah b’peh circumcisions per year in New York City alone; the documented case rate of 24.4 per 100,000 means that the probability of any specific infant being infected is less than 0.025%. This does not change the nature of the risk — an eight-day-old infant with neonatal herpes encephalitis faces a catastrophe regardless of the statistical rarity — but it shapes the community’s perception of that risk as negligible in practice, and fuels the argument that the regulatory response is disproportionate to the actual harm.

Archival Status

Metzitzah b’peh is assessed by this Directorate as a case study in the collision between religious tradition, medical science, community autonomy, and state authority that cannot be resolved by appealing to any single principle. The practice has a documented Talmudic origin and a documented medical rationale in ancient medicine. That rationale was overturned by germ theory, and the question of how Jewish law should respond to that overturning has produced a legal dispute within Judaism that predates the modern state and has not been settled. The public health consequences — neonatal herpes, brain damage, infant deaths — are documented in peer-reviewed literature and CDC reports. The internal Jewish debate is genuine, with substantial halakhic authority on both sides. The comparison to blood libel accusations — which historically attributed murderous intent to Jewish practices around children — is explicitly raised by some community members in response to regulatory action, and this historical context shapes how any external intervention is received by communities for whom the memory of persecution is not abstract.

The Antwerp raids of 2025 marked a significant escalation: direct police action, confiscation of equipment, and a formal criminal investigation initiated by a complaint from within the Jewish community itself. Whether this signals a broader European regulatory trend or remains a local controversy shaped by the specific dynamics of Belgian law, the Friedman complaint, and Antwerp’s particular community tensions remains to be determined. What is determined is that the underlying conflict — between a practice considered by its adherents to be a divine commandment and a public health risk that health authorities consider preventable — is not approaching resolution.

Recommended classification: ACTIVE CONTROVERSY — BETA TIER. Practice status: ongoing in haredi communities. NYC regulatory status: consent requirement in force, cases monitored. Belgium: criminal investigation open (2025), no arrests. HSV-1 case record: 24+ linked cases in NYC since 2000, including fatalities. Internal Jewish halakhic debate: unresolved. Religious freedom litigation: ongoing. Monitoring: active.

Fig. 4 – The Chatam Sofer (1762–1839). He ruled in the early 19th century that metzitzah b’peh was binding and unchangeable. By 2025, his ruling was still being cited in Antwerp courts and New York hospitals. Somewhere between his desk in Pressburg and a 5:00 am police raid on a mohel’s home in Belgium’s Jewish Quarter, a question about the relationship between divine commandment and medical knowledge remains unanswered. / Public Domain