Ultra-Orthodox Jews Have Lower Autism Rates–Is It Because They Circumcise Their Boys Differently?

Ultra-Orthodox Jews Have Lower Autism Rates–Is It Because They Circumcise Their Boys Differently?
Mohel Manachem Fleischmann (L) concludes the circumcision ceremony of baby infant Mendl Teichtal at the Chabad Lubawitsch Orthodox Jewish synagogue on March 3, 2013 in Berlin, Germany. (Sean Gallup/Getty Images)
Jennifer Margulis
According to a 2015 article published in the peer-reviewed Journal of Autism and Developmental Disorders, children of modern Jews are more frequently diagnosed with autism spectrum disorder than those of ultra-Orthodox Jews and Arabs.

The study, which was led by Dr. Raanan Raz, who was at the Harvard School of Public Health at the time, analyzed data collected on more than 2,400,000 children from the Israeli National Insurance Institute.

Raz and an international team of scientists suggested that a lack of awareness in the ultra-Orthodox Jewish community could account for the discrepancy.

Since ultra-Orthodox Jews in Israel “refrain from modern life,” as they put it, they would be less likely to seek out a modern doctor to make an autism diagnosis.

Raz and his colleagues also proposed that ultra-Orthodox Jews (UOJ) simply don’t want people to know they have children with autism.

“Traditionally, mental disorders in these populations may be stigmatized and, especially in the UOJ population, might also negatively affect other family members’ arranged marriage processes,” the scientists wrote.

Underreporting Doesn’t Explain It

Dr. Mitchel Shertz is a pediatric neurologist and director of Child Development & Pediatric Neurology at Meuhedet in North Israel. He has looked closely at the autism rates in Israel.

According to his research, the average rate of autism among the ultra-Orthodox is 1.5 cases per 1,000 children; among Arab children, it's 3 cases per 1,000; among secular and modern Jews in Israel, it's 5.5 to 9 cases per 1,000. This means that modern Jews may have nearly six times the number of children with autism as very religious Jews.

But, according to Shertz and other experts, the gap isn't due entirely to either underreporting or underdiagnosis.

“Now we understand that the rarity of autism among the ultra-Orthodox and Arabs is a key factor in lowering autism frequency in Israel,” Shertz told a reporter at the Israeli newspaper Haaretz in 2014.
How can something be causing autism in the modern Jewish community without affecting ultra-Orthodox Jewish and Arab communities?

Environmental Exposure as the Cause

Raz’s team pointed out that an environmental factor that could be causing autism among modern Jews “would have to relate to exposures experienced separately, and with distinct temporal patterns, by the different groups.”
William Parker, a scientist who spent almost 30 years doing research at Duke University, has combed the scientific literature to try to understand why secular Jews have higher rates of autism.

Parker said that he believes that it's related to differences in circumcisions in each community.

It isn't the circumcision itself, Parker said, but the way it's done that may be causing brain damage among modern, more secular Jews. Why? Because modern Jews almost always give their newborns acetaminophen, which is the main ingredient in Tylenol.

In Israel, Tylenol is called Acamol or Dexemol. The active ingredient is paracetamol, which is the word used for acetaminophen throughout Europe as well.

Acetaminophen is likely a causative factor in the rise in autism among children, especially boys. During traditional circumcisions, ultra-Orthodox Jews usually don't use Tylenol.

Instead, they often use wine or other alcohol. For example, in some cases, the baby is given a rag soaked in vodka to suck on during the circumcision.

“You only need to know two facts to understand the observations,” Parker said. “First, our published research has shown that exposure to acetaminophen very early in life can cause autism in susceptible children. Second, modern Jews but not ultra-Orthodox, tend to use acetaminophen during circumcision.
“Many Jews, both modern and ultra-Orthodox, usually use a bit of alcohol to help babies get past the pain of circumcision during traditional circumcision ceremonies. Unfortunately, alcohol is also one of the factors known to make people more sensitive to adverse reactions to acetaminophen.”
What about Arabs living in Israel and elsewhere? The age of circumcision among Muslim families varies, depending on the culture, region, and family. For many, the ceremony involves an elaborate rite of passage into manhood, for which pain medication isn't appropriate. And many, if not most, Arabic families living in Israel don’t circumcise newborns. Instead, they wait until the boy is about 13 years old. At this age, a child’s brain is much more developed and much less vulnerable to environmental assaults.
Finally, alcohol, which amplifies the negative effects of acetaminophen, is also forbidden in Islamic cultures and not given to children as medicine.

Circumcision Raises Autism Rates

In 2015, Danish scientists found that circumcision was associated with a two-fold increase in the prevalence of an infantile autism diagnosis.
2013 research published in the journal Environmental Health also found an association between autism and circumcision.

But Parker said that the reasons for the connection aren't widely appreciated.

“We have been looking at this issue since 2016, and evidence is overwhelming that use of acetaminophen for anything early in life, whether it be vaccination or circumcision, is going to lead to autism in a subset of babies and small children,” Parker insisted.

How Could Baby Tylenol Cause Autism?

Parker explains that the baby’s liver is part of the problem.

The liver is the organ that normally detoxifies drugs.

“The best available evidence tells us that the most vulnerable time for acetaminophen-induced brain injury is immediately after birth, when the baby’s liver suddenly becomes independent from the mother’s liver,” he said. “The baby’s liver is only meant to process breastmilk, not drugs such as acetaminophen.”

Parker pointed to a 2008 case-controlled study that showed that adverse reactions to vaccines were associated with autism, but only if acetaminophen was used, not ibuprofen.
“There is such a large volume of circumstantial evidence that we can be certain, without any reasonable doubt, about acetaminophen causing many if not most cases of autism,” Parker said. “Each bit of evidence by itself is concerning but not conclusive. However, up to 20 different lines of evidence have tipped the scales for us.”

Acetaminophen Plus Oxidative Stress Causes Autism

But if acetaminophen really causes autism, given the popularity of the drug for babies and children, why don’t more people have autism?
“Most babies, even newborns, can handle some level of drug exposure,” Parker said. “The problem comes when too much oxidative stress builds up, which occurs in some, but not all, babies. Oxidative stress plus acetaminophen are key ingredients in the development of many, if not most, cases of autism. They must both be present, or autism will not result.”
Oxidative stress is a metabolic condition that hinders drug metabolism. It can be caused by a wide range of factors, including genetics (babies who are homozygous for MTHFR mutations, for example, are at higher risk), exposure to a variety of environmental toxins (such as alcohol used during circumcision), and other medical conditions.

It's difficult to predict which babies and children are going to have enough oxidative stress to put them at real risk from acetaminophen, Parker said.

For Parker, who has published three peer-reviewed papers showing the connection between autism and early exposure to acetaminophen, and his research team, the observation that modern Jews have more children with autism than Orthodox Jews isn't surprising. It’s expected.

“Dr. Raanan Raz at Harvard got it exactly correct,” Parker said. “It is an environmental factor that is individually experienced but depends on religion. He nailed it, although he didn’t mention acetaminophen by name.”

Never Give a Baby Tylenol

According to a 1994 study published in the journal Pediatrics, acetaminophen doesn't work well for pain associated with circumcision. So the solution for modern Jews, according to Parker, is simple: Don’t use it.
Some Jewish parents are choosing to forgo the procedure. “While I’m not qualified to offer an opinion with regard to analgesia in neonates following circumcision, I can say that some Jewish people are rethinking the necessity of circumcision altogether," said Rebecca Wald, executive director of Bruchim, a nonprofit that advocates for the open inclusion of Jews who choose not to practice infant circumcision.

“It just makes sense to avoid injuring and traumatizing a newborn,” Wald continued. “We don’t fully understand how this impacts the developing brain, but it can’t be good. Efforts to ameliorate the pain are well-intended but also have potential downsides.”

Other Jews, like the ultra-Orthodox, forgo all conventional pain medication and use comfort measures such as breastfeeding instead of analgesics. And still others choose to use a different pain medication, such as baby aspirin, instead.

But the bigger picture is perhaps a little more complex.

“The people of this planet have almost universally embraced acetaminophen as a safe drug,” Parker said. “They’re wrong. But changing that perception appears to be an uphill battle. We’re hoping to reach a tipping point soon. But when? Our research has shown that the drug was never shown to be safe for brain development, and we have nearly 20 lines of evidence which have absolutely convinced us that the drug causes many—if not most—cases of autism. But the practice hasn’t changed yet.”
Jennifer Margulis, Ph.D., is an award-winning journalist and author of “Your Baby, Your Way: Taking Charge of Your Pregnancy, Childbirth, and Parenting Decisions for a Happier, Healthier Family.” A Fulbright awardee and mother of four, she has worked on a child survival campaign in West Africa, advocated for an end to child slavery in Pakistan on prime-time TV in France, and taught post-colonial literature to nontraditional students in inner-city Atlanta. Learn more about her at JenniferMargulis.net