On July 22, the New York City Department of Health and Mental Hygiene revealed that two new cases of neonatal herpes had been diagnosed during July. One baby was found at 16 days old to have “pustular lesions on the penis and genital area,” and a 17-day-old was found to have “lesions on his penis, left foot, and left thigh.”

Based on the timing and the locations of the lesions, the male infants had contracted the herpes simplex virus during their Jewish circumcision custom, a bris, which occurs on the eighth day of life. Circumcisions are a standard—even beneficial—health practice. But each of these boys underwent a bris that followed an ancient ritual not widely practiced outside the ultra-Orthodox community.

Metzitzah b’peh (MBP), the orogential (mouth to genitals) suctioning of blood from the penis of an infant male following circumcision, poses one of the most unique and upsetting public health issues. While infants who do not undergo MBP can contract neonatal herpes, infants who do are 3.4 times more likely to do so, according to the New York City Department of Health. Since 2000, 16 cases of neonatal herpes have resulted from MBP in New York City alone, with three proving fatal and others causing long-term health effects, including brain damage. A practice that sounds immediately abhorrent and baffling to nearly anyone outside New York’s ultra-Orthodox community has forced a controversial clash of local politics, culture, and power.

MBP has been practiced for millennia with varying regularity among different sects of the Jewish community. However, in 1837, Chasam Sofer, a revered sage in the central and eastern European Jewish world, said oral suctioning could be stopped when it appeared to cause a public health crisis in Vienna. He stated that Jewish law did not state MBP as necessary for fulfilling the Jewish commandment of circumcision, and “even if oral suction had been mentioned in the Mishnah, we would be able to change it to another method which accomplishes the same thing, so long as we heed qualified physicians.” Other rabbis followed with similar rulings, and in many circles, MBP eventually fell out of practice for most Jews.

Multiple religious authorities definitively stressed during the reporting of this article that MBP is not at all necessary to complete a bris. “The most fundamental precept of Jewish law is preservation of health, and life comes first. There’s no close second,” says Ben Hirsch, who was raised in Brooklyn’s ultra-Orthodox community and is now an advocate against abuse within the community. “The rabbis are obligated under Jewish law to defer to medical professionals, but they are refusing to do so, and infants are being maimed and killed.”

Most succinctly, Dr. Moshe Tendler, a microbiologist and professor of Talmud at Yeshiva University, wrote in a 2004 Pediatrics article: “The rule that’s above all rules in the Torah is that you cannot expose or accept a risk to health unless there is true justification for it.”

But Agudath Israel of America, the most powerful Haredi (a more extreme and traditional form of Orthodox Judaism) organization in the United States, has endorsed the safety of the practice. When asked if he thought MBP was safe, Director of Public Affairs Avi Shafran said in an email, “We do indeed, certainly safer than skiing. Or driving. Or crossing a street in Manhattan, for that matter.” Both the New York City Health Department (PDF) and the CDC have outlined the practice’s significant risks to the safety and health of an infant.

As of 2012, the city estimates 3,600 circumcisions involving MBP are performed each year, but mohels (religious figures who perform the circumcision) and others connected with the Brooklyn ultra-Orthodox community estimate the numbers closer to 5,000 to 10,000 annually.

Based on these high numbers, those who support MBP argue that if it were a risky procedure, there would be more than 16 incidences reported in the New York City area since 2000. “If it were a real danger, you’d see a lot more cases,” said Rabbi Adam Epstein, who was trained and certified as a mohel in New York. “A person who grows up in a pornographic country is going to have trouble understanding these purity customs. Of course it sounds archaic and disgusting to a pornographic mind. I can’t defend my view to the general public that has been exposed to different ideas.”

Yerachmiel Simins, a lawyer who has represented the community in negotiations with the city and the state over MBP, said it has “been practiced for millennia, and you have an incredible safety record over time. Under their [the Health Department’s] theory, you’d expect to see hundreds or thousands of cases, and you don’t see them even when it’s a reportable disease. The numbers haven’t gone up at all.”

But that assumes parents are reporting all of the cases or that hospitals are consistently tracking them. “Most families in the Hasidic community go to a doctor that the community had made a deal with to get their child looked at. Depending on what the doctor sees, they really avoid going to the hospital,” says Shmarya Rosenberg, a former member of the Chabad-Lubavitch community of ultra-Orthodox Jews. Rosenberg is the blogger and journalist behind FailedMessiah, a site devoted to exposing abuse and corruption within the ultra-Orthodox world.

“My suspicion is that there are many more cases of milder herpes infections,” he says. And many parents will refuse to report the mohel who performed MBP, he adds: “I think some parents try to bring their kids to hospitals outside of the state, where reporting is different. I truly believe there are cases that are never reported.”

Rosenberg specifically alleges that Maimonides hospital in Borough Park, Brooklyn, which is home to a large ultra-Orthodox community, does not adequately report cases. “I’m sure that people who bring their kids to Maimonides find the case is never probed. Maimonides is very dependent on the Haredi community,” he says. Maimonides has denied that claim. In a statement to The Daily Beast, the hospital said: “Maimonides Medical Center adheres to all federal, state and city regulations, as well as our own explicit policies which require staff to inform the NYC DOH of cases of neonatal herpes.”

Hirsch believes MBP stems from the competition among Hasidic rabbis to “demonstrate one segment is holier than another.” In an arms races to prove they are holier than thou, rabbis add more and more prohibitions and prerequisites. “When it comes to something mundane, like kosher laws, their pronouncements may be absurd, but so be it,” says Hirsch. But MBP is “an issue where there is no doubt that children are dying and being harmed for life.”

Few parents within the community hesitate to submit their sons to this form of circumcision, despite the health risk noted by the New York City Department of Health and CDC. Part of that, though, is a result of many parents not even realizing they are exposing infants to a life-threatening disease. “They don’t understand science. They have no secular education for the most part. They go to schools where they are taught only in Yiddish and only about Jewish subjects. They know nothing,” says Rosenberg.

It’s not just that many parents are not aware of the health risks. There is immense communal pressure to have MBP performed. Frimet Goldberger wrote in the Jewish Daily Forward about her son undergoing MBP. At the time of his bris, she was recovering from a C-section and unable to attend. She did not know MBP would be performed, but she says she doesn’t think it would have made a difference to the ultimate outcome. “It probably wouldn’t matter to me anyway had I been aware that the mohel is performing MBP, because everyone did it,” she said in an email. “Standing up to ‘everyone’ and to the community’s traditions and norms, or what they consider the absolute, indisputable halakhah [Jewish law], would’ve been unthinkable.” Her son is now 9 years old and never contracted neonatal herpes, but Goldberger says she wishes he hadn’t gone through with MBP. “I can’t go back in time and undo it, but I am upset—not at my family and the community, who truly believe in this—but at my own naiveté. Yes, I regret that I allowed my son to undergo this risky and potentially life-threatening procedure.”

Hirsch also believes even when parents do understand the potential risks associated with MBP, they will still submit their infants to the tradition. “They believe they are obligated to engage in it,” he says. They treat MBP not only as a divine commandment, but one that bears incredible social weight in the community. To defy a rabbi’s order on a bris, a highly public event that is meant to be a celebration, can seal one’s fate as an outsider for life. “They’re believers and, in most cases, captive. They can’t just defy their leaders and pack up and move to Montana,” Hirsch says.

What is so difficult for anyone outside the community to understand is the pressure of social stigma. It not only motivates parents to concede to the practice, but also not to report incidences when medical issues arise. “When parents go to the hospital with a baby boy infected by a mohel, there is pressure to identify the mohel. Yet they know that if they expose a mohel, their life is over,” says Hirsch. “They’d become a pariah and their children would be unable to get married or get into schools. Would some of these parents choose not to treat an infant infected by a mohel and instead sacrifice a child knowing they’ll face this intense pressure? Maybe.”

More despicably, mothers often bear the brunt of the communal stigma. “If parents are seen as cooperating with authorities, the mohels and rabbis turn on the mother and accuse her of being promiscuous,” says Hirsch. “In several cases, they have accused mothers of having herpes and giving it to her child.”

Ironically, if an ultra-Orthodox mohel is asked to perform a bris for a less religious couple outside the community, he will not perform MBP for his own safety. “If he [the mohel] doesn’t know the family and thinks there’s a possibility that the father or mother has had multiple sexual partners, the mohel becomes worried that he will pick up an STD the baby boy may have gotten from his mother,” says Hirsch. “The mohel will not perform MBP because he is worried about his own health—yet the bris is deemed perfectly valid. The hypocrisy is astounding.”

For these reasons, it is incredibly thorny for the government at any level to try to interfere with the practice. Civil measures may be no competition for intense social pressures in a community built on tradition over law.

However, many people outside the Hasidic community argue that the government and secular authorities have not done nearly enough to combat the MBP and save the lives of infants. MBP didn’t begin facing major government scrutiny in the United States until the 21st century. In 2003 and 2004, three cases of neonatal herpes, one of which was fatal, alerted New York City’s Health Department to the practice and its dangers.

At the time, Michael Bloomberg was mayor, and he and his then-health commissioner, Thomas R. Frieden, now the director of the Centers for Disease Control and Prevention, handled MBP with kid gloves. The Hasidic community is a notorious voting bloc in New York City politics. They have their own customs and even their own law enforcement and courts, so effecting change through civil government is challenging at best. It was a massive understatement when Frieden said, “This is a very delicate area, so to speak.”

Thus, rather than denounce, ban, or regulate the practice, Bloomberg merely announced, “We’re going to do a study, and make sure that everybody is safe,” adding, “It is not the government’s business to tell people how to practice their religion.” But during his final term in office, Bloomberg led the strongest formal government action against MBP to date. In 2012, he pushed the Board of Health to pass a parental consent form requiring mohels to detail the health risks of MBP and obtain written permission before the ritual circumcision could be completed.

It was a step toward better regulating MBP, but those familiar with the workings of the tight-knit ultra-Orthodox community say it is largely ineffective—and that it is not carefully enforced.

It’s a “meaningless, toothless consent form,” says Hirsch, who believes the practice should not be permitted at all. Still, the form deeply upset many proponents of MBP. Agudath Israel of America, the International Bris Association, the Central Rabbinical Congress of the United States and Canada, and a group of individual rabbis tried to block the consent form from taking effect by filing a preliminary injunction. A district judge ruled against them in January 2013, and they have appealed to the 2nd Circuit of the U.S. Court of Appeals.

Viewing the parental consent forms as a violation of their religious freedom, some mohels do not provide them or obtain written permission from parents. “You’re assuming they [the parents] are being asked,” Rosenberg says when asked how parents are willing to submit their infants to this risk. “It’s not like these mohels are going up to them, even when they’re supposed to. They do a bris the way it’s been done for years.”

Paul Berger reported for the Jewish Daily Forward this year how Rabbi Avrohom Cohen, the head chairman of the American Board of Ritual Circumcision, flouted the parental consent law and never received written permission from parents. Cohen reportedly disregarded parents’ desires in certain cases. Rosenberg’s interview with Cohen also confirmed that mohels will not perform MBP if they fear the parents have been “promiscuous” and they can contract something from the baby.

Although religious figures in the ultra-Orthodox community may ignore the parental consent law, some argue the government has been remiss and lax in its handling of MBP. For one, government officials do not always understand the significance of MBP or how it is performed. “Prosecutors don’t have a clue about this issue. I’ve been called by ADAs asking for help understanding this issue,” says Hirsch.

He and Rosenberg believe things have only gotten worse under Mayor Bill de Blasio’s leadership. On his site Failed Messiah, Rosenberg posted last September a video of de Blasio campaigning for the votes of the Satmars, a sect of Hasidic Judaism, and appearing to nod and agree to the proclamation to remove the parental consent form. De Blasio later said at a January press conference that the parental consent form would stay in place “while searching for a solution that we think is more effective.”

De Blasio’s back-and-forth has confirmed Hirsch’s and Rosenberg’s fears that the city will not be taking a strong stance against the practice anytime soon. “The city has not been doing enough to stop the practice for a decade,” says Rosenberg. “Certainly, de Blasio has no intention of enforcing the consent forms.” Rosenberg says that not only are mohels not getting written consent, but the city and hospitals aren’t monitoring them to make sure that they are distributing the form.

When presented with allegations that the city is not properly enforcing the parental consent form, the Department of Health responded in an email: Since 2013, when the [parental consent] law has been in effect, there have been five cases. In all of the cases, we have asked whether there were forms and, in the two cases where we were able to identify the mohel, we have requested them from him. One of the mohels had a form which he provided. The other one did not. The Department issued orders banning both mohelim from practicing direct oral suction.

That less than half the mohels in these cases could be identified shows the serious difficulties in regulating MBP and, subsequently, holding the mohels accountable.

“The fact that secular authorities are just stepping aside makes them akin to being an accessory to murder,” says Hirsch. “Mayor de Blasio has made it clear that he is not willing to risk the political backlash from the ultra-Orthodox bloc vote. That Mayor de Blasio has stepped back from Bloomberg’s position is outrageous—he is in essence saying, ‘Go kill your infants as long as you vote for me.’”