Less commonly practiced, and more controversial, is metzitzah b'peh, (alt. mezizah), or oral suction, where the mohel sucks blood from the circumcision wound on the baby's penis. Opponents argue that the traditional reason for mezizah in the Talmud is to minimize the potential for postoperative complications, although the practice has been demonstrated to pose a serious risk of spreading herpes to the infant. Proponents say that there is no evidence that links herpes to Metzitza, and attempts to limit this practice infringes on religious freedom.
Beginning in around the 18th century, however, it was known that this technique itself can spread infection (ironically, prevention of which was the very reason metzitzah was instituted) and harm the baby. Thus, it became quite common in the Jewish world to perform metzitzah via a different method, such as a sterilized glass tube. This helps to reduce the risk of infection and is almost the universal practice today, although in the ultra-Orthodox communities, most notably Hassidic Jews and some communities in Israel, many continue to suck on the infants freshly mutilated penis rather than use the glass tube method. However, the practice has become a controversy in both secular and Jewish medical ethics. The ritual of metzitzah is found in Mishnah Shabbat 19:2, which lists it as one of the four steps involved in the circumcision rite. Moses Sofer (1762–1839) inferred that the Talmud states that the rationale for this part of the ritual was hygienic — i.e., to protect the health of the child, though imperical and medical evidence points strongly to the contrary. The Chasam Sofer permitted metzitzah with a sponge to be used instead of oral suction in a case presented to him for a ruling. His letter was published in Kochvei Yitzchok. Moshe Shik (1807–1879), a student of Moses Sofer, states in his book of Responsa, She’eilos u’teshuvos Maharam Shik (Orach Chaim 152,) that Moses Sofer gave the ruling in that specific instance only and that it may not be applied elsewhere. He also states (Yoreh Deah 244) that the practice is possibly a Sinaitic tradition, i.e., Halacha l'Moshe m'Sinai.
Chaim Hezekiah Medini claimed the practice to be Halacha l'Moshe m'Sinai and elaborates on what prompted Moses Sofer to give the above ruling. He tells the story that a student of Moses Sofer, Lazar Horowitz, author of Yad Elazer and Chief Rabbi of Vienna at the time, needed the ruling because of a governmental attempt to ban circumcision completely if it included metztitzah b'peh. He therefore asked Sofer to give him permission to do brit milah without metzitzah b’peh. When he presented the defense in secular court, they erroneously recorded his testimony to mean that Sofer stated it as a general ruling.
The practice of metzitzah b'peh was alleged to pose a serious risk in the transfer of herpes from mohelim to eight Israeli infants, one of whom suffered brain damage. When three New York City infants contracted herpes after metzizah b'peh by one mohel and one of them died, New York authorities took out a restraining order against the mohel requiring use of a sterile glass tube, or pipette. However, the mohel's attorney argued that the New York Department of Health had not supplied conclusive medical evidence linking his client with the disease. In September 2005, the city withdrew the restraining order and turned the matter over to a rabbinical court. Dr. Thomas Frieden, the Health Commissioner of New York City, wrote, "There exists no reasonable doubt that ‘metzitzah b'peh’ can and has caused neonatal herpes infection.…The Health Department recommends that infants being circumcised not undergo metzitzah b'peh." In May 2006, the Department of Health for New York State, issued a protocol for the performance of metzitzah b'peh. Dr. Antonia C. Novello, Commissioner of Health for New York State, together with a board of rabbis and doctors, worked, she said, to "allow the practice of metzizah b'peh to continue while still meeting the Department of Health's responsibility to protect the public health."
In three medical papers done in Israel, Canada, and the USA, oral suction following circumcision was suggested as a cause in 11 cases of neonatal herpes. Researchers noted that prior to 1997, neonatal herpes reports in Israel were rare, and that the late incidences were correlated with the mothers not carrying the virus themselves. Rabbi Doctor Mordechai Halperin implicates the "better hygiene and living conditions that prevail among the younger generation", which lowered the rate of young Israeli Chareidi mothers that carry the virus, to 60%. He explains that an "absence of antibodies in the mothers’ blood means that their newborn sons received no such antibodies through the placenta, and therefore are vulnerable to infection by HSV-1."
However, in an article titled “Is Metzitza bePeh Dangerous?” written by Dr. Daniel S. Berman, MD, Chief of Infectious-Disease at New York Westchester Square Hospital, he argues that there is no proof linking Metzitza bePeh to neonatal herpes infection.
Because of the risk of infection, some rabbinical authorities have ruled that the traditional practice of direct contact should be replaced by using a glass tube between the wound and the mohel's mouth, so there is no direct oral contact. The Rabbinical Council of America, the largest group of Modern Orthodox rabbis, endorses this method. The RCA paper states: "Rabbi Schachter even reports that Rav Yosef Dov Soloveitchik reports that his father, Rav Moshe Soloveitchik, would not permit a mohel to perform metzitza be’peh with direct oral contact, and that his grandfather, Rav Chaim Soloveitchik, instructed mohelim in Brisk not to do metzitza be’peh with direct oral contact. However, although Rav Yosef Dov Soloveitchik also generally prohibited metzitza be’peh with direct oral contact, he did not ban it by those who insisted upon it,...". The sefer Mitzvas Hametzitzah by Rabbi Sinai Schiffer of Baden, Germany, states that he is in possession of letters from 36 major Russian (Lithuanian) rabbis that categorically prohibit Metzitzah with a sponge and require it to be done orally. Among them is Rabbi Chaim Halevi Soloveitchik of Brisk.
Additionally, the Talmud explicitly instructs that a boy must not be circumcised if he had two brothers who died due to complications arising from their circumcisions; this may be due to a concern about haemophilia. An Israeli study found a high rate of urinary tract infections if the bandage is left on too long.
In September 2012, the New York Department of Health unanimously ruled that the practice of metztizah b'peh should require informed consent from the parent or guardian of the child undergoing the ritual. Prior to the ruling, several hundred rabbis, including Rabbi David Neiderman, the executive diretor of the United Jewish Organization of Williamsburg, signed a declaration stating that they would not inform parents of the potential dangers that came with metzitzah b'peh, even if informed consent became law.
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