Contraception I: Introduction and Permissibility for Health

When is contraception permissible? What role do health considerations play in permissibility?

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By Laurie Novick

Rav Ezra Bick, Ilana Elzufon, and Shayna Goldberg, eds.
 

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A Complex Decision

Previously, we learned about the mitzva of procreation (pirya ve-rivya)—a foundation of life from the moment of Creation, the first beracha in the Torah, and a Divine mandate to all humanity. "

Yeshayahu 45:18

Not for void did He create it, for settlement [shevet] did He form it...

As we discussed there, a man is obligated on a Torah level to have a boy and a girl (pirya ve-rivya) and enjoined to continue having children (la-erev), both of which are contribute toward settling the world (shevet). A woman may be obligated in having one child as a matter of shevet, and, upon marriage, takes on a halachic responsibility to facilitate her husband’s procreation. In so doing, she fulfills a mitzva as well.

Bringing children into the world is thus a core value in Judaism, often reflected in our communal structures. Having a large family remains the aspiration for many men and women in Orthodox communities. Yet members of these communities increasingly wonder how to balance the imperative and the desire to raise families with the physical, emotional, and financial demands that endeavor entails. 

For most of human history, options for avoiding conception have been limited. Halachic questions about pursuing contraception arose primarily in cases of great need. In recent decades, however, this has changed, especially as more contraceptive options have emerged that raise fewer halachic concerns, and as women have pursued higher education and entered the workforce in growing numbers. On the whole, contraceptives have become more widely available, and their use has become more prevalent in halachically observant communities.

Both in public and in private,[1] questions about whether or how contraception and family planning can be compatible with Halacha arise more often. In particular, many young people preparing to marry, while deeply committed to building a family, wonder if they could delay having children until they feel more emotionally or financially prepared—or get farther along on their career tracks. Couples who have already been blessed with children may wish to space out births, often to preserve physical or emotional or marital health, and may not be sure how many children they can ultimately handle.

Sara Morozow and Rivka Slonim articulate some of these tensions:

Sara Morozow and Rivka Slonim, Holy Intimacy (Shikey Press, 2022), 178–179

Many of us still approach this area of life with trepidation, often with sparring voices in our head. We recognize the great zechut and privilege of bringing another neshama [soul] into this world. We cherish the possibility of making a singular contribution to Klal Yisrael, both in present and future. We seek that sense of unique fulfillment that comes from mothering. But, depending on variables in our life, we might also struggle with physical or psychological challenges, a less than able spouse and partner, or something as pedestrian as our need to breathe...

Though these questions are common, the answers are highly individual, and halachic approaches to these issues vary widely. We address health concerns in this piece, and a range of other factors in our next piece. Before exploring these considerations, let’s look at a few additional underlying considerations that make decisions about pursuing contraception especially delicate.

What are hashkafic factors that inform halachic decisions about contraception?

Humility before God  Contraception is often referred to as “birth control,” which highlights the question of how much control we can, or should, exert over reproduction, and when we should leave matters in God’s hands.

Traditional sources frame conception and contraception as matters beyond full human grasp. In this vein, a Talmudic passage categorizes the biblical King Chizkiyahu’s desisting from procreation as an overstepping of boundaries, an attempt to exert human control over a matter beyond the human domain:

Berachot 10a

For it is said: “In those days, Chizkiyahu became deathly ill and Yeshayahu ben Amotz the prophet came to him and said to him, “So said the Lord of Hosts, give orders to your household, for you are dying and will not live” [Melachim II 20:1, Yeshaya 38:1]… [Yeshaya] said to [Chizkiyahu]: Because you did not occupy yourself with pirya ve-rivya [procreation]. [Chizkiyahu] said to [Yeshaya]: Because I saw with ruach ha-kodesh [a sacred spirit] that children will issue from me who are not worthy. [Yeshaya] said to [Chizkiyahu]: Why should you be involved in God’s secrets? You are required to do what is commanded of you, and God will act as He sees fit.

When pregnancy and childbirth entail no clear medical risk, the question, “Why should you be involved in God’s secrets?” can foster a general attitude of caution with respect to contraception.[2]

Even when we view medical developments as a tool given by God, medicine has yet to enable all couples to become pregnant at will, and contraceptives aren’t foolproof. The extremely high level of efficacy of some contraceptives does, however, impart a sense of control that can seem to be at odds with humility before God. Care should be taken so that pursuit of contraception does not erode respect for God’s ultimate control over matters of birth and life.

Limitations on Bodily Autonomy Contemporary discourse on contraception often emphasizes a woman’s right to make choices about her own body. In Jewish thought, though, the body is understood as a vessel whose purpose is to enable us to serve God. Each person bears responsibility for making life choices, including choices about their own body, within the broader framework of seeking to do God’s will.

Sefer Ha-chinuch 73: She-lo le’echol tereifa

Among the roots of this mitzva: Because the body is a vessel for the soul through which [the soul] performs its actions, and without which it would never be able to complete its work, therefore [the soul] comes under [the body’s] protection for [the soul’s] good and not for its harm, for truly God does not do harm but benefits all; therefore, the body within [the soul’s] hands is like tongs in the hands of the smith who brings out with it [the tongs/body] an instrument for the sake of his deeds.

Since physical autonomy is not an absolute Jewish value, a person’s mere wish to use contraception, as a matter of autonomy, does not simply override a mitzva to pursue procreation.

This means that a woman needs to clarify her reasoning and take Halacha into account before pursuing contraception—even if she would otherwise have prevented pregnancy without hesitation.

A Woman’s Role  We closed our piece on procreation with a look at Rav Yitzchak Arama’s description of a duality of a woman’s life purpose: being a thoughtful and righteous woman of valor coupled with childbearing and childrearing, which he calls her “minor purpose.” When childbearing is religiously conceived of as not just a central aspect of a woman’s life, but as a life purpose, then it can be more challenging to push that aside in the service of other life purposes. ‘Miriam’, a religious woman quoted in a recent paper about Orthodox women’s reproductive choices, gets to the heart of the conflict:[3]

Miriam, quoted in Lea Taragin-Zeller, “Towards an anthropology of doubt: the case of religious reproduction in Orthodox Judaism,” Journal of Modern Jewish Studies 1, vol. 18 (2019): 13, https://doi.org/10.1080/14725886.2018.1521182

I keep on asking myself: Who is first? My husband? My children? The house? Work? My body? Who is first?

Halachic Considerations

Tension with Positive Mitzvot  As illustrated by the above passage about Chizkiyahu, preventing conception is often in tension with halachic imperatives to procreate. Again, these include the mitzva of pirya ve-rivya (to attempt to have at least one boy and one girl), shevet (the Divine directive to settle the world), and the rabbinic la-erev, which requires or at least encourages continued engagement in procreation, even after pirya ve-rivya has been satisfied. (Learn more here.)

These halachot themselves represent a fundamental Jewish value of embracing life and the opportunity to perpetuate our people’s covenant with God through having children. It can be tricky to know what personal considerations might be recognized as bearing halachic weight in the face of this tension.

Asymmetry  Though a married woman bears responsibility for helping her husband to fulfill his obligations to procreate, her halachic obligations are not equivalent to his. Women are exempt from pirya ve-rivya, and likely from la-erev as well, taking on at marriage an indirect commitment to facilitate a husband’s mitzva fulfillment. Whether shevet obligates a woman to bear at least one child is debated. (See more here.)

On the other hand, most contraceptive methods act on a woman’s body without male intervention—and pregnancy and childbirth take place in the woman’s body.

This asymmetry can add another level of complexity to the tension with positive mitzvot. A couple typically need to come to a joint halachic decision about contraception, even though their individual halachic obligations and their physical stakes in the process are not the same.

Tension with Prohibitions  As we will explore in more detail later on, some contraceptive methods may be in violation of the halachic prohibitions of hashchatat zera (wasting seed) or of sirus (sterilization). Even when contraception can be halachically pursued, not every contraceptive method will be available to a halachically observant couple. Contraceptive choices are imperfect and relatively limited to start with, so that Halacha’s further limitation of choices can pose a real challenge.

Methodological Challenge

In this piece and the next, we explore when contraceptive use is halachically permitted, moving in the following pieces to halachic discussion of specific methods. There is a major methodological challenge in applying early sources on contraception to our present-day conversation. We can trace this challenge back to the Torah.

The opening chapters of Bereishit promote procreation as both a blessing and an imperative (see here). A brief narrative description of contraception follows fairly close behind. Onan, Yehuda’s second son, chooses to avoid procreating with Tamar, the widow of his older brother, Er.

Bereishit 38:7-10

And Er the firstborn of Yehuda was bad in the eyes of God, and God caused him to die. And Yehuda said to Onan, come to your brother’s wife and have yibum [a levirate marriage] with her and establish zera [seed] for your brother. And Onan knew that the zera would not be his, so that when he had relations with his brother’s wife he would waste [shichet] to the ground so as not to give zera to his brother. And what he did was bad in the eyes of God, and He caused him to die as well.

Both Er and Onan are understood to have attempted the ‘withdrawal method’ of contraception.[4]

Rashi Bereishit 38:9

And he would waste to the ground – thresh inside and scatter outside.

Given the severe consequences, the brothers’ behavior is clearly viewed very negatively. The challenge lies in what the verses leave unclear: whether their sin was in using a particular contraceptive method or in the practice of contraception itself.

This methodological challenge carries through to the Talmud and early halachic responsa. These texts often focus on the permissibility of specific early contraceptive methods—which were typically less reliable, and in more direct tension with the prohibitions of hashchatat zera and sirus, than many modern methods are.

Forerunners to the modern cervical cap and diaphragm first become available in the 1830s; nonoxynol-9 as a common active ingredient for spermicides in the 1950s; the contraceptive pill and copper intrauterine device (IUD) only in the 1960s. Earlier halachic texts could not address these methods directly, since they had not yet been developed. This is especially unfortunate because some modern methods of contraception are not in tension with the prohibitions of hashchatat zera or sirus, making them the ideal test case for questions about the permissibility of contraception per se.

While halachic luminaries of the mid to late twentieth century, such as Rav Shlomo Zalman Auerbach, Rav Moshe Feinstein, and Rav Eliezer Waldenberg, addressed early iterations of current methods, their views seem to have evolved as knowledge of the methods did, and methods and halachic attitudes toward them have continued to evolve in the past few decades.

When a halachic ruling relating to an older method is permissive, we can generalize to a modern method that raises fewer halachic concerns to begin with. But when a ruling relating to an older method is prohibitive, we often cannot be sure as to how the specific method inquired about affected the ruling, and therefore cannot know whether that ruling would still apply to more modern methods.

Keeping this methodological constraint in mind, we begin our halachic discussion of contraception and when it can be used with a focus on health considerations, which often provide a halachic basis for contraceptive use.

In our next piece, we explore the halachic permissibility of pursuing contraception when there are other factors, unrelated to health, that might motivate a couple to want to prevent pregnancy.

Contraception and Danger

The Talmud discusses two main forms of contraception. The kos shel ikkarin (cup of roots) or sama de-akarta (root potion), had sterilizing effects, raising questions of sirus, the prohibition of sterilization. The moch, wadding inserted vaginally before or after intercourse to absorb semen and prevent conception, raises questions of hashchatat zera, the prohibition of ‘wasting seed,’ or semen. We look more closely at these prohibitions and their tensions with these early contraceptive methods in the third and fourth pieces of this series.

At this opening stage of discussion, we introduce the key Talmudic texts pertaining to each of these methods and turn directly to their relationship to a woman’s health in situations of potential danger to it.

Kos Shel Ikkarin

In a Talmudic passage, Yehudit, wife of Rabbi Chiyya and mother of two sets of twins—two boys and two girls—makes the decision to drink a sterilizing potion to avoid the pain she has experienced with childbirth:

Yevamot 65b-66a

Yehuda and Chizkiya were twins, one finished developing at the end of nine [months] and one finished developing at the beginning of the seventh [month]. Yehudit, Rabbi Chiyya’s wife, had [particularly severe] pain with childbirth. She changed her clothes [to disguise herself] and came before Rabbi Chiyya. She said: Is a woman commanded in pirya ve-rivya? He said to her: No. She went and drank a root potion. In the end, the matter was revealed. He [Rabbi Chiyya] said to her: Would that you had given birth to one more wombful for me. For the master [esteemed Rabbi] said: Yehuda and Chizkiya were brothers, Pazi and Tavvi were [their twin] sisters.

According to this account, Yehudit took her exemption as a woman from the mitzva of procreation as halachic grounds for drinking the potion, without her husband’s knowledge. His response does not halachically criticize her, and thus implicitly sanctions her actions.

The precise definition of “tza’ar leida,” pain with childbirth, is not clear from this passage. In his commentary, Ritva argues that sterilization through altering reproductive anatomy is clearly permissible when conception would put a parent’s life at risk. He adds that sterilization with a potion (as opposed to directly damaging her reproductive organs) would be permissible for a woman who had difficulty at labor, even if it would not put her life at risk:

Ritva Yevamot 65b

She had pain with childbirth. This means pain without danger, for otherwise, even if she were obligated in pirya ve-rivya, there is nothing that stands before pikuach nefesh. The practical halachic significance regards a man who is prohibited from sterilizing himself since he is obligated in pirya ve-rivya, for on account of pain with intercourse he may not sterilize himself with a potion, but in a case of danger it would be permissible.

Shulchan Aruch rules that a woman may drink a kos shel ikarin in order to prevent pregnancy, without detailing on what specific grounds she may do so:

Shulchan Aruch EH 5:12

A woman is permitted to drink a root potion to sterilize herself so that she cannot bear children.

Commentators disagree as to when this would be permissible. On the one hand, Beit Shmuel argues that this is a blanket permission:[5]

Beit Shemuel EH 5, s.k.14

It implies that, even without any particular pain, it is permissible

On the other extreme, Bach claims that a woman is only permitted to drink a sterilizing potion either when sterilization is medically necessary or when her childbearing difficulties exceed those of most women:

Bach EH 5:9

A woman is permitted to drink it in order that she not bear children. That is to say, it is a given that for the purpose of healing it is permissible, but even if it is not for healing but in order that she not bear children it is also permissible…And it also implies that it is not permissible even from the outset except when she has pain with childbirth like Rabbi Chiyya’s wife in Yevamot, for Rabbi Chiyya permitted it from the outset, but if she doesn’t have pain with childbirth more than other women in general, it is prohibited…For Rambam only said that one who sterilizes a woman is exempt on a Torah level but prohibited rabbinically in a case where he sterilizes her without the need to save her from the danger of difficult childbirth, but for the need that she not bear children with difficulty like Rabbi Chiyya’s wife, it is permissible

There is broad consensus that a woman is permitted to drink a potion that would fully sterilize her in a case of danger to her life, or where she has had especially difficult childbirths, or where this step is needed for medical reasons.

The Moch and Danger

In its discussion of the moch, the Talmud presents three categories of women for whom pregnancy would present unique danger: an eleven-year old (in an era when minor marriages sometimes took place), a pregnant woman (believed to be at risk of miscarriage if carrying twins),[6] and a breastfeeding mother:

Yevamot 12b

Rav Bibai repeated a tannaitic teaching before Rav Nachman: Three women have sexual relations with a moch: a minor [between 11-12], a pregnant woman, and a nursing woman. A minor lest she become pregnant and lest she die, a pregnant woman lest her fetus miscarry, a nursing woman lest she wean her child [on account of a new pregnancy] and lest he die…the words of Rabbi Meir. But the sages say: Each of them continues to have relations as normal and may they have mercy from the Heavens, as it is said, “God protects the foolhardy” (Tehillim 116:6).

As we’ll see in our next piece, halachic interpretations of this passage vary widely. For our purposes, what is most significant are the implications for using contraception in cases of danger to health. In a landmark responsum, the third Lubavitcher Rebbe (the Tzemach Tzedek) reads this passage as providing a basis for permitting use of a moch during intercourse when pregnancy or childbirth poses a special danger.

Responsa Tzemach Tzedek EH 89

…God made it a part of the nature of creation that in a majority of cases these three women do not become pregnant, and what is written, “may they have mercy from the Heavens, as it is said, ‘God protects the foolhardy,’” means that it will not happen even a minority of times…Even though the sages say “each of them continues to have relations as normal and may they have mercy from the Heavens,” this is only regarding these three women. But regarding another woman…since most women [are likely to] conceive and give birth, if there is a concern for danger in pregnancy or childbirth, even if the concern is not enormous and merely resembles the concern lest she wean her son, for even if she weans him, the concern of danger is still not great, even so, she is permitted to have intercourse with a moch, meaning that a moch be there at the time of relations to absorb the zera (seed).

Though there are notable dissenters,[7] when other methods of contraception were scarce, authorities widely agreed to permit use of a moch during intercourse in cases where there is a known risk to life (sakana) or where they may be a risk to life (safek sakana) or even just a plausible concern for risk (chashash sakana), rather than forcing a couple into long-term abstinence or divorce.

In a comprehensive responsum, Rav Ovadya Yosef reviews the full history of halachic rulings regarding the moch. He confirms that the overwhelming halachic consensus is to permit use of a moch as contraception in cases of chashash sakana.

Responsa Yabia Omer EH 10:24

You have come to know that many and great [authorities] permitted inserting a moch prior to intercourse in a situation of concern for danger…For nothing stands in the way of saving a life [pikuach nefesh]… And even in a situation of “concern” for danger one should be lenient. However, since nowadays the ointment like a soft soap [spermicide] is widespread, which, when placed in the woman’s anatomy prior to intercourse, causes the seed to perish, it is more fitting to use that, since it is halachically preferable to a regular moch. And it is correct that permission be granted for a set time, like a year or a year and a half, and afterwards the woman return to be checked by physicians, for it is possible that she has fully healed and there is no further concern for danger, and she can get pregnant.

Rav Yosef’s ruling includes a couple of caveats:

He notes that a less halachically problematic contraceptive should be used when one is available. He thereby makes it clear that permission to use a moch in cases of chashash sakana extends to other methods.

He also suggests that where Halacha permits contraception for the sake of protecting a woman’s health, permission should be limited, and her medical condition should be reevaluated by physicians every twelve to eighteen months. We might infer that in some cases, where a condition is irreversible or long-term, this requirement might be waived.

Mental Health and Danger

In a responsum written in 1959, Rav Moshe Feinstein explicitly permits a moch even in cases where concerns for danger are based on mental health, such as suicide risk.

Responsa Iggerot Moshe EH 4 74:3

Regarding the matter of a woman who has a nervous sickness (nerves), and is very frightened of becoming pregnant, one should permit her not to become pregnant, since she is ill with nerves in a major way, for it has come out of her mouth once that she does not wish to live and even would cause this for herself, therefore it is certainly a concern of danger, and one should permit her even with an actual moch for some time until they see that she has improved, and a “the heart knows its own bitterness,”  but since the medications that one places vaginally that are called foam [spermicide] are effective for her, and there is no need for a moch, one should permit her to use foam for two years.

Like Rav Yosef, Rav Feinstein limits the duration of the permission to use contraception and expresses a preference for methods other than the moch. Rav Feinstein also indicates that consulting a mental health professional may not always be necessary in assessing whether there is concern for danger, when that is clear to a woman herself.

Halachic permission to use contraception would also apply in cases where becoming a parent presents severe mental health dangers for the father.[8]

Requiring Contraception

The responsa we have seen until now address contraception in terms of whether or not it is permitted. Rav Eliezer Waldenberg notes that, in certain cases, contraception is required. When pregnancy or childbirth present a real danger, a couple is not permitted to attempt to conceive.

Responsa Tzitz Eliezer 9:51 Treatise on Medicine in the Family 2

(5) One should not build a foundation for stringency and not obeying the physicians’ instructions based on unique cases that occurred where people did not listen to the physicians’ instructions and the woman conceived and gave birth and was unharmed. And a husband is not permitted to impede [contraception] on this basis.

That is to say, Rav Waldenberg is opposed to deliberately applying in these cases the idea that “God protects the foolhardy.” However, when effective treatments that remove the danger of pregnancy or childbirth without undue risk or burden are available, decisions about conception and contraception are left up to the couple in consultation with their healthcare team.[9]

Self-Assessment

We’ve seen that a physician’s statement that pregnancy would present danger to a woman is taken seriously by Halacha, and serves as a basis for permitting or even requiring a couple to use contraception. This opens up the question of the extent to which a woman can assess her own medical or health needs.

The classic case is that of a sick person breaking their fast on Yom Kippur, which is clearly permissible in situations of chashash sakana. The Talmud states that a medical opinion that there is no concern is overridden if the sick person themself is convinced they are in this halachic category and must eat, because a person can sense their own condition:

Yoma 83a

Rabbi Yannai said: If a sick person says he needs [to eat on Yom Kippur] and a physician says he does not need to, we listen to the sick person. What is the reason? “The heart knows its own bitterness” [Mishlei 14:10]. That is obvious, what might you have said? That a physician is more halachically reliable. This teaches us [otherwise].

Shulchan Aruch rules accordingly:

Shulchan Aruch OC 618:1

A sick person who needs to eat, if there is an expert physician there, even if he is an idolator, who says: If they don’t feed him it is possible that his sickness will get worse and he will be in danger, we feed him based on his statement. And it goes without saying [if he said] “lest he will die.” Even if the sick person says that he doesn’t need it, we listen to the physician. And if the sick person says “I need it,” even if a hundred doctors say he doesn’t need it, we listen to the sick person.

Writing about measures taken for a sick person on Shabbat, Mishna Berura rules that this principle has broad application:

Beiur Halacha 328:10

For “the heart knows its own bitterness” applies in all matters, and even if a doctor says [the sick person] doesn’t need any medicine, we don’t listen to him [the doctor]. But if the illness is known, and the sick person says that the medicine works for this illness and the doctor says that it doesn’t, there is no rationale to listen to the sick person and violate Shabbat for no reason [but in any case, it is possible to say that where the sick person says that he knows that the nature of his body is to heal from this illness if he takes this healing treatment, it is possible that we listen to him, for even in this it is slightly applicable to say a person is more expert in his body than a hundred doctors]…

Mishna Berura raises the possibility that a person’s sense of what their body needs might sometimes even override established medical protocol. More recently, in the era of modern medicine, Rav Eliezer Waldenberg affirmed the wide applicability of this principle to other cases where preserving health may require adjustments to how Halacha is observed.

Responsa Tzitz Eliezer 15 32 2:8

We must believe him, that he is telling the truth about how he feels, because we don’t presume that people are evildoers…and the matter of “the heart knows its own bitterness” is not based on the force of reason, but rather on the force of deep feelings that a person has been granted in order to preserve his body…

We saw above that Rav Feinstein invokes the principle “the heart knows its own bitterness” to give credence to expressions of suicidal ideation in assessing the permissibility of contraception. It is not clear to what extent this approach could extend to physical health as well. While it remains proper, as Rav Yosef writes, to consult medical professionals on questions of health and halacha, their opinion might not always be the last word on someone’s condition, especially when we trust that a woman assessing the severity of her own condition is not an “evildoer,” but rather committed to observing Halacha.

Health Considerations

We have seen that even a moch, which raises concerns of hashchatat zera, could be permitted in cases of concern about potential danger (chashash sakana) and that even a kos shel ikarin, which raises concerns of sirus, could be permitted in cases of danger or when there is another medical need for healing. Therefore, modern methods that do not raise the same level of halachic concern could be permitted in these cases, and potentially in others.

Rav Eliezer Waldenberg presents a multi-tiered categorization of health concerns, including: sakana, chashash sakana, sickness or difficult childbirths, general weakness and chronic health conditions. Rav Waldenberg rules that more serious health concerns allow for a wider choice of permissible methods, but is open to contraception using preferred methods in a wide range of cases:

Responsa Tzitz Eliezer 9:51 Treatise on Medicine in the Family 2

1. A woman for whom pregnancy and childbirth are a sakana [danger], and contraceptives should be used so that the woman not become pregnant…but taking these actions must be done in the manner of first [permitting] the most lenient [method], as long as there is no medical impediment to the efficacy of the action…2. Even in a situation where the sakana of pregnancy is not clear and there is only a chashash sakana in it, even though the concern is not great, in any case, many halachic authorities also maintain that on account of this one should permit the use of methods mentioned in the prior cases. 3. In a situation where there is no danger and the woman is merely sickly, and pregnancy causes her particular pain and great suffering, then one cannot permit to her use of all [types of methods] mentioned regarding the prior cases…5. Establishing the need to use contraceptives for a woman must be done in with clarity and not merely with supposition…in a case where it is difficult for a woman on account of sickness and general poor health to raise more children, and a physician has established this, there is room to permit the woman, in accordance with the view of the halachic authority, to temporarily take a pill orally…

Rav Moshe Feinstein relates to the asymmetry in the woman’s and man’s mitzva obligations as a halachic factor in making decisions about contraception when considerations of a woman’s health are at play.

Responsa Iggerot Moshe EH 3:24

…If she is a sick woman, even though she will not be endangered by this [pregnancy and childbirth], but rather will become extremely sick, it makes sense that if he [her husband] has fulfilled pirya ve-rivya, she can avoid [conception] in this way [with the pill] even permanently. Since for the sake of the mitzva of shevet [or la-erev, ed.] a woman is not subject to her husband to become sick from this more than women do in general, for even for the sake of pirya ve-rivya, perhaps she is not subject to become sick on account of this, but he would be obligated to divorce her even before ten years pass, since she does not want to become pregnant on account of the illness….

Rav Moshe establishes that for serious health considerations that fall short of chashash sakana, a woman is permitted to use at least the contraceptive pill, because she is not directly obligated in procreation. She can do this indefinitely if her husband has fulfilled pirya ve-rivya. If he hasn’t yet had a boy and girl, Rav Moshe suggests that it might still be permissible for a woman to use the pill indefinitely, even if though this would mean that her husband would not be able to fulfill pirya ve-rivya unless he were to divorce her.

Rav Moshe goes on to suggest that divorce would be mandatory for the husband in a case of a wife planning never to conceive again on account of health reasons, if he has not fulfilled pirya ve-rivya. However, Halachic practice is not to compel men to divorce their wives for reasons of pirya ve-rivya. Using contraception at this point would also presumably be less of a halachic concern if the health condition or contraceptive use on account of it is temporary.

Rema EH 1:3

…Even if he married a woman and dwelled with her for ten years, we have not been accustomed to force him to divorce her, even though he has not fulfilled pirya ve-rivya.

Perhaps because of the asymmetry in men’s and women’s obligations in procreation, Rav Moshe permits use of the contraceptive pill in cases where a woman has genuine health concerns, even where the mitzva of procreation has not yet been fulfilled.

Responsa Iggerot Moshe EH 4 74:2

….Even if they have not yet fulfilled pirya ve-rivya, only that the woman is weak, she can take the contraceptive pills since there is no issue of wasting zera in vain. And know that in these matters it is necessary each time to consult an expert rabbi and not to rely only on the physician, even if he is God-fearing.

To summarize our discussion of contraception and a woman’s health, contraceptive use is permissible at any stage of life when pregnancy or childbirth may present a danger or risk of danger to the prospective mother’s physical or mental health (beyond that inherent in any childbearing).

According to some halachic authorities, more general physical weakness or mental health considerations provide grounds for contraceptive use as well, at least with more halachically preferred methods. (We discuss different methods in our next piece.) Halachic and medical or psychological counsel contribute to making this type of assessment, and a woman's self-assessment can also play an important role

Health of the Fetus

Now that we’ve discussed how Halacha takes a woman’s health into account in questions about the permissibility of contraception, let’s turn to situations where there are concerns about the health of the potential offspring. When there is a real concern that a couple’s children would inherit a deadly or debilitating genetically transmitted disease, Rav Shlomo Zalman Auerbach permitted use of contraception.[10]

Minchat Shlomo 3 103:1

I am in doubt regarding someone who has a hereditary disease, so that his children will be in pain for their entire life, or someone who suffers from a deficiency in blood clotting, which passes on to males (hemophilia), if it is permissible on this account [parental illness or carrier status] not to fulfill pirya ve-rivya…If the fear is of having intellectually or physically disabled children, and the distress of divorce is very great for both of them in a way that they are prepared to spend a great amount of money to be saved from this, it seems that they are permitted to use a diaphragm and the husband is not obligated to divorce if the distress is, as was said, very great for both of them.

Rav Auerbach’s specific mention of the diaphragm follows from his personal ranking at the time of contraceptive methods. We discuss various preferences among methods in a later piece, and return later to the way in which this argument compares suffering to great financial loss.

Since Rav Auerbach’s death, the choices available to couples in this type of situation have expanded. Originally, the only options were to risk the birth of an affected child, to use contraception indefinitely, or to divorce. In recent decades, developments in assisted reproductive technologies have opened up new options. Through preimplantation genetic testing (PGT), couples can now screen ova or embryos for specific genetic mutations, implanting only embryos that do not seem to carry the genetic markers for a given disease. Such testing is possible only if they conceive through in vitro fertilization (IVF).

In a responsum to Puah Institute, Rav Asher Weiss rules that couples are not obligated to pursue such treatments, but that they are encouraged to do so, and can fulfill the mitzva of peru u-rvu in this fashion.

Rav Asher Weiss, Puah Responsa, Fertility, Ancestry, and Genetics, p. 479

Regarding the question whether one is required to attempt to have children through IVF (PGD [=preimplantation genetic diagnosis]) …Truly there is no obligation of the mitzva of pirya ve-rivya in this, for the obligation in the mitzva is only the natural act that a person has the ability to do…certainly one should encourage them…to occupy themselves with all strength in order to bring fine, living offspring into the world. And in my humble opinion it is clear, that even if there is no obligation in this, there is a mitzva, and also in this way a person fulfills pirya ve-rivya, for in any case he has brought living offspring into the world.

In some cases, some halachic authorities go even farther, Rav Shlomo Dichovsky, for example, rules that in some severe cases of genetic disease, a couple planning to marry is obligated to agree to pursue PGT.

Rav Shlomo Dichovsky, Puah Responsa, Fertility, Ancestry, and Genetics, p. 478

Carriers of a genetic disease who wish to marry each other, despite knowing of the risk it entails, can do this, as long as childbearing is done through assisted reproduction, and it will be possible to choose the healthy embryos....If they wish to marry and to have normal relations, and they are not prepared to pursue IVF, one should prevent this from them, as one can prevent a person from endangering themselves. Although this involves a creature who has not yet been born, there is a mitzva here to love one’s neighbor as oneself and an obligation to prevent suffering...

For PGT to be a successful reproductive strategy, a couple typically must use contraceptives to avoid conceiving naturally. Therefore, permission to use contraception long-term is implicit in any permission or obligation to pursue PGT.

Older Mothers

The discussion above regarding health applies to women at any age, and advanced maternal age, defined as pregnancy at age 35 or older, is typically considered safe. Nevertheless, as a woman ages, health risks to both mother and fetus increase. The likelihood of congenital abnormalities also increases with maternal age. In particular, the risk of many chromosomal abnormalities, including Down Syndrome, rises significantly between ages 35 and 40.[11]

Halachic authorities disagree as to whether concern for this risk can provide a basis for permitting contraceptive use. In 2003, Rav Shemuel Ha-Levi Wosner ruled that concern for chromosomal abnormality above age forty does not provide a basis for actively using contraception, even for a couple with many children. However, he would permit a woman in this situation to delay her immersion to avoid relations during her fertile window:

Responsa Shevet Ha-Levi 11 278

Regarding a woman who is already forty-two, and she is afraid of becoming pregnant because of what the doctors say nowadays, that from age forty and up there is a high percentage of children with defects, and she has up to this point nine healthy and blessed children. I have been asked about this many times and my response is the same, that according to Halacha one should not be concerned, to practice abstinence completely on account of this or to practice contraception, for it is known that even though there is some bit of correctness in their words, that the percentage of children with defects is higher than before forty, in any case it is known that this is not most children, for the clear majority of children are healthy and we follow the majority on a Torah level, and if so it is not possible to rest contraception at this time on halachic pillars, and if in any case the woman is very frightened, my faithful advice is that she delay the time of her immersion by a few days in a way that she will likely not conceive then, and if she nevertheless becomes pregnant, it is from Heaven for the good with a healthy child…

In a responsum from 2003, Rav Yaakov Ariel took a different approach, granting some halachic weight to a woman’s concerns about the effects of advanced maternal age on fetal health when she has reason to consider herself done with childbearing.

Rav Yaakov Ariel, Puah Responsa, Contraception, p. 31-32

4. The physicians do not recommend having children as a woman approaches the age of forty, at which the percentage of children with defects rises significantly. And indeed, a woman who has given birth to a large number of children before this, can include this consideration among other considerations and cease childbearing. However, women who married later and did not manage to fulfill the mitzva of pirya ve-rivya, are not prevented from bearing children even over age forty in order to merit having children, and so too, one with the desire and ability to have additional children.

Though the beginning of this ruling seems to condition permissibility on a having had an unspecified “large number of children,” the end implies that the deciding factor is whether pirya ve-rivya—which could be as few as two children, a boy and a girl— has yet been fulfilled. Rav Ariel is also careful to make clear that Halacha does not prevent a woman over forty from choosing to bear children despite these risks.

Rav Yehuda H. Henkin permits contraception for well-founded concerns of advanced maternal age even in cases in which pirya ve-rivya has not yet been fulfilled. He bases himself on a ruling of Maharshal (which we’ll look at more closely in our next piece) permitting contraception to a couple whose prior children were not upstanding individuals, and who are afraid of a repeat:

Responsa Benei Banim 2:38

If children with defects like Down Syndrome will be born…it [Maharshal’s ruling] is not the same matter as what his honor [the questioner] wrote, that he is afraid lest his children be born with defects, because Maharshal deals with a case where a woman already has children who do not go in the proper path and therefore there is a basis to think other children will follow them, which is not the case for mere concern or fear. Only if affected children were already born, or even if they were not yet born but the doctors say that because of the parents’ genetics or age or another reason it is likely that such children will be born, then one should permit contraception even if they have not fulfilled pirya ve-rivya.

What is the relative authority of healthcare professionals, rabbis, and women in making assessments about contraception and women’s health?

In a piece on the process of medical halachic decision-making, Rav Yitzchok Breitowitz cites a Dr. Keilson as dividing rabbis deciding medical-halachic issues into four categories, aligned with the four sons of the hagadda:[12] Wise, Evil (or incompetent), Simple (not understanding the issues at hand), or One Who Doesn’t Even Ask, ruling without consulting regarding the medical facts.

Although medical definitions of potential danger and halachic categories of chashash sakana are not necessarily identical, it is praiseworthy for rabbis to seek medical knowledge from professionals before making a halachic ruling that depends on a medical condition. A halachic ruling based on a misunderstanding of medical facts would be erroneous—and potentially dangerous.

Unfortunately, misunderstandings regarding a woman’s health condition still sometimes lead to imprecise rulings, in part because a woman and her husband may not communicate their situation effectively,[13] and in part because halachic authorities are not always well versed in medicine.

Several of the responsa cited in this piece specifically mention medical knowledge and physical examinations as factors in rendering rulings about contraception. This reflects an admirable rabbinic understanding that medical input can prevent misunderstandings and increase halachic accuracy.

As long as patient-doctor confidentiality is not compromised, there can be real advantages to physicians and halachic authorities being in open dialogue, each representing their own realms of knowledge and authority. This can be an important corrective for the potential of a rabbi making a ruling that underplays a woman’s medical needs.

At the same time, there is a risk that in building this dialogue between medical and halachic authorities, a woman’s voice might be shut out. Jewish Studies Professor Michal Raucher makes this point in her study of Charedi women in Israel:

Michal Raucher, Conceiving Agency: Reproductive Authority Among Haredi Women (Indiana University Press, 2020), 43

At least in the field of reproductive medicine…the lines of authority between doctor and rabbi are blurred because of how the two figures have come to work together. Haredi women struggle to enter the conversation about their reproductive health care because doctors and rabbis do not prioritize women’s own reproductive experiences and authority.

As we have seen, Halacha recognizes that “the heart knows its own bitterness,” also with respect to medical or psychological conditions on Yom Kippur and Shabbat. A rabbi and doctor presumably have special knowledge of their fields of expertise. Do they necessarily have more knowledge than a woman does about her own body and mind?

This concern is compounded by a known systemic bias in medicine, in which women’s unique medical needs have been understudied,[14] women’s descriptions of pain or medical concerns have historically been taken less seriously than men’s or ascribed to emotional distress,[15] and female patients are more frequently interrupted than male patients, even by female physicians.[16]

Dr Elizabeth Comen traces this bias to physicians historically prioritizing women’s childbearing capacity over women’s health:[17]

Elizabeth Comen, “How Gender Bias has Shaped Women's Health,” Harvard Medicine: The Magazine of Harvard Medical School, October 2024

"If you look throughout history, what was valued and focused on in the health of women was predominantly the idea that we are vessels, that we are valued for our childbearing capacity, whether it was being excluded from NIH trials because you couldn’t have women of childbearing age, or you couldn’t run a marathon because your uterus would fall out, or whatever it may be as it related to your primary god-given function on earth to reproduce.... The problem is that so many things women face are unique to their biology — we are not small men."

Thankfully, physicians are working on correcting these biases, and many are sensitive, professional, and thorough. Sometimes, rabbinic involvement in these decisions can help increase sensitivity to a woman’s self-assessment. This can work in two directions, to help permit a woman to become pregnant when she so desires and danger is not clearly medically established, and to help permit a couple to practice contraception when a woman’s concerns about her health go beyond what her doctor recognizes.

In a responsum on having children after pirya ve-rivya has been fulfilled, Rav Yaakov Ariel, highlights the halachic significance of a woman’s perceptions of her own condition and needs.

Rav Yaakov Ariel, Puah Responsa, Contraception, p. 31

2. The man is the one obligated in the mitzva. The woman is exempt…And therefore it is impossible to command the woman to endanger herself and to suffer more than she has the capacity for. However, the woman, by virtue of being a partner to her husband in fulfilling the mitzva, needs to help him to fulfill the mitzva in accordance to what is possible for her. 3. It is difficult to determine for a woman what she can do and what is possible for her. Indeed, the matter is given over to her hands and “the heart knows its own bitterness.”…

Rav Ariel goes on to discuss the ways in which a Rabbi nevertheless provides important counsel, and notes that sometimes a woman might be mistaken in how she assesses herself, but that should neither override nor overshadow the significance of self-knowledge.

Like Halacha, medicine evolves. In the past few decades, especially in light of increased recognition of medical uncertainty, a person-centered-care model that emphasizes the patient’s more active participation in medical decisions has begun to replace a paternalistic model based on doctors’ authority:[18]

Lichtstein, Daniel M., "Strategies to Deal with Uncertainty in Medicine." The American Journal of Medicine 136, no. 4 (2023): 339–340

Medicine is a highly complex profession. We are responsible to strive to do the best we can for our patients at all times, yet diagnostic dilemmas are not uncommon and the preferred evaluation and treatment are not always clear. In addition, we have all made errors in our careers, and some of these can be traced to not acknowledging uncertainty and not having the humility or willingness to admit when we do not know something. Our patients deserve to know when we are uncertain and we should not only not hesitate to discuss our uncertainty with them, but we should embrace it....Acknowledging my response to uncertainty led me to embrace shared decision-making or patient-centered decision-making in medicine, and I actively engage my learners in the value of this approach. Being humble enough to say, “I don't know,” and to recognize when consultation with colleagues or consultants is indicated is critically important, and something our patients deserve.

As halachic authorities become more aware of medical uncertainty and bias and of the benefits of person-centered medical care, the dynamics of halachic decision-making on these issues may likewise shift to a model in which a woman’s account of her own medical needs takes on greater weight.[19]

Health considerations are given very serious weight in halachic decision-making about the permissibility of contraceptive use. Contraception is permitted in cases of concern for potential danger, and more general physical or mental health considerations may also allow for pursuing contraception. Decisions about contraception must begin with a careful look at a woman’s physical and mental health and potential concerns for the fetus.

In our next piece, we look at other significant factors relevant to the halachic permissibility of contraception at different stages of life.

Further Reading

• הרב אליקים ג' אלינסון, "תכנון המשפחה ומניעת הריון" הוצאת מורשת תל אביב תשל"ז

• הרב ד"ר אברהם שטיינברג, "מניעת הריון", אנציקלופדיה רפואית הלכתית. ניתן למצוא כאן.

• שו"ת פוע"ה, מניעת הריון, מכון פוע"ה ירושלים תשע"ה

• הרב גבריאל גולדמן והרב מנחם בורשטיין, ספר פוע"ה ג: הריון ולידה, מכון פוע"ה ירושלים, תשפ"א

[1] Conversations about contraception have also evolved. Contraception is closely linked to marital relations and—depending on the method—can also affect the experience of sexual intimacy, for which Halacha mandates sensitive and tzanua discussion.

For example, as we learned here, our sages prohibit public teaching regarding sexual prohibitions, a ruling that could arguably affect discussion of contraception as well:

Mishna Chagiga 2:1

We do not expound on prohibited sexual relations before [groups of] three [or more people].

As contraceptive use increased over the course of the 20^th century, some authorities initially suggested that halachic constraints around discussions of prohibited sexual relations should also apply to discussions of contraception.

For example, in a responsum written in the United States a few years before combined hormonal contraceptive pills were approved for use there, Rav Moshe Feinstein writes:

Responsa Iggerot Moshe EH 1:64

In the matter of a woman for whom it is dangerous to become pregnant, 11 Nissan 5718 (1958)…That this law should be similar to [the law of] forbidden sexual relationships that we don’t expound in groups of three [or more], as is brought in Chagiga 11, [yet] it was discussed in a periodical, which is like expounding before thousands, and also before lay people…

Since that time, traditional restraint around public discussion of sexuality has been substantially diminished in general society, leading to changing norms even among Orthodox Jews. Rav Eliezer Melamed lays out some of the considerations (available at https://ph.yhb.org.il/14-00-00/).

Rav Eliezer Melamed, Peninei Halacha, Introduction to Simchat ha-bayit U-virchato

I freely admit that some of my teachers and friends advised me to forgo writing and publishing this material, or at least make it less explicit. Most of them were worried about the fallout for me, and a few felt that it is inappropriate to elaborate in writing about intimate topics. But there is much misunderstanding and misinformation circulating among the general public, which casts our holy Torah in a negative light, as if its goal is to minimize the joy of ona. Therefore, I felt it necessary to present the position of our holy Torah clearly, in accordance with the Sages and poskim. Doing so will protect our holy Torah from this slander, and will also protect our dear couples, men and women, from the pain and inadequacy caused by the misinformation.

Today, it has likewise become more accepted to discuss contraception in written works accessible to the general public, and halachic rulings on contraception that were previously transmitted only orally have increasingly found their way into print.

[2] In the early 1970’s, Rav Moshe Feinstein expressed this concern:

Responsa Iggerot Moshe, EH 4:72

Regarding the matter of a woman taking contraceptive pills…without a great need, she should not take even this…it is like trying to outsmart the will of God.

At the same time, another Talmudic passage suggests that there might be some scenarios where it would be correct to respond to unusually difficult circumstances by limiting procreation:

Bava Batra 60b

It was taught [in a baraita]: Rabbi Yishmael ben Elisha said…From the day when the evil kingdom [Rome] spread, that decrees evil and harsh decrees upon us, and nullifies Torah and mitzvot from us, and doesn’t allow us to gather for a berit mila, and there are those who say a pidyon ha-ben, it is logical that we decree upon ourselves not to marry a woman and have children…

[3] Available here: https://www.academia.edu/37522133/Towards_an_anthropology_of_doubt_the_case_of_religious_reproduction_in_Orthodox_Judaism_Journal_of_Modern_Jewish_Studies

[4]There are alternate explanations of the brothers’ sin. For example:

Yevamot 34b

…Not like the act of Er and Onan, for there [with Er and Onan] it was not in the normal way [anal intercourse].

Yevamot 34b

Rav Nachman bar Yitzchak said: For it is written, “And He [God] caused him [Onan] to die as well.” He [Onan], too, died the same way [as Er]. It makes sense for Onan, because the zera would not be his. But Er, what is the reason that he acted thus? In order that she not become pregnant and her beauty diminish.

[5] Derisha argues that it would be fully permissible to drink a kos shel ikarin if a woman has trouble giving birth, without detailing the extent of the difficulty she experienced.

Derisha EH 5

This implies that even a married woman is permitted to drink in order that she not bear children, and so writes Beit Yosef, for it sounds from the end of the chapter Ha-ba al Yevimto that a woman is permitted to drink a root potion, and so I saw that they ruled halacha in practice with a woman who had difficulty giving birth, that they permitted her to drink a root potion. And one should not raise the difficulty that perhaps even when the woman is permitted to drink it, in any case the man has a mitzva to divorce her or to marry another woman in addition to her, for Tur wrote above in siman 1, that if he has fulfilled pirya ve-rivya and married a woman who is not fertile he does not need to divorce her.

[6] Tosafot Yevamot 12b s.v. shema tei’aseh ubarah sandal

Rabbeinu Tam explained that a sandal [a type of miscarriage] is when a woman is pregnant with twins, if she has intercourse without a moch, and the semen comes between the two fetuses and presses them and makes one a sandal [a type of miscarriage].

[7] Rabbi Akiva Eiger seems to take this approach, though it seems that he was not aware of a more lenient ruling by Maharshal that we will see in a later installment of this series:

Responsa Rabbi Akiva Eiger (first edition), 71

Regarding the matter that his honor discusses regarding a woman who is bitter in spirit, who with each childbirth has difficulty giving birth and is in great distress, and she is always in danger, to permit her to have intercourse with a moch, to place a moch in her vagina prior to intercourse. In my humble opinion it does not seem correct to permit, since we have not found someone who explicitly permits it.

[8] Rav Yonatan Rosenzweig, Nafshi Be-she’elati 11:2

There are [cases] where doctors state that he will develop depression or anxiety as a result of the birth of children, to the point where he would be defined as (at least) a choleh she-ein bo sakana, he is exempt from pirya ve-rivya.

[9] Shulchan Shlomo Medicine 3 pp. 74-75, note 3

He wrote in Nishmat Avraham EH 5 that he heard from a director of a psychiatric department that today it is possible to treat a woman with a history of depression and mental illness to the degree that she attempted suicide postpartum in the past, and it is possible in the great majority of cases to prevent a return attack of postpartum depression, and he sees no reason from his perspective to forbid a woman like this from becoming pregnant. (Up to here is what he wrote.) Based on this, it would seem that there is no prohibition for a woman like this to get pregnant if she wants to, and she is not considered to be putting herself in danger, because in a great majority of cases it is possible to prevent the danger. On the other hand, if she does not want to get pregnant because she is afraid of an attack of depression, etc., despite the treatment, it stands to reason that it is permissible for her to use one of the contraceptive methods – according to the instructions of a halachic authority – and her husband cannot force her to [help him fulfill] the mitzva, and our master [Rav Shlomo Zalman Auerbach] agreed with the above.

[10] https://hebrewbooks.org/pdfpager.aspx?req=47990&st=&pgnum=30

[11]Alexander P. Frick, “Advanced maternal age and adverse pregnancy outcomes,” Best Practice & Research Clinical Obstetrics & Gynaecology 70 (2021): 92-100

At 12 weeks of gestation, the risk for Trisomy 21 for a 20-year-old woman is 1/1068 as compared to 1/68 at 40 years of age, reflecting an exponential rise from the age of 35 [25]. Trisomy 18 and 13 are both less common than Trisomy 21 across all ages but demonstrate a similar increase in risk with the increasing maternal age, rising from 1/2484 at age 20 to 1/157 at age 40 for T18 and 1/7826 at age 20 to 1/495 at age 40 for T13, again at 12 weeks gestation [26]. Sex chromosomal abnormalities (XXX, XXY, XYY) show a more modest increase in the rate with the advancing maternal age as compared to T21.

Available here: https://www.sciencedirect.com/science/article/pii/S1521693420301127

Elmerdahl Frederiksen L, Ølgaard SM, Roos L, et al., “Maternal age and the risk of fetal aneuploidy: A nationwide cohort study of more than 500 000 singleton pregnancies in Denmark from 2008 to 2017,” Acta Obstet Gynecol Scand. 103 (2024): 351-359

Using pregnant women between 20 and 29 years of age as reference, pregnant women between 30 and 34 years had less than a two-fold increased risk (OR 1.69, 95% CI: 1.50–1.90), pregnant women between 35 and 39 years had a fourfold increased risk (OR 4.67, 95% CI: 4.18–5.23), 40–44 years had a 16-fold increased risk (OR 16.27, 95% CI: 14.29–18.53), and pregnant women ≥45 years had a 36-fold increased risk (OR 36.16, 95% CI: 23.47–55.70) of any aneuploidy.

Available here: 10.1111/aogs.14713

Thank you to Yoetzet Halacha Hannah Spellman, MD, for supplying this research.

[12] How A Rabbi Decides A Medical Halacha Issue – by Rabbi Yitzchok A. Breitowitz Synopsis of Presentation Conference on Jewish Medical Ethics San Francisco, CA February 18-20, 1996

Available here: https://olami.org/jhealth_post/how-a-rabbi-decides-a-medical-halacha-issue-by-rabbi-yitzchok-a-breitowitz/

[13] Available here: https://www.mekomit.co.il/%d7%9e%d7%90%d7%97%d7%95%d7%a8%d7%99-%d7%94%d7%a1%d7%98%d7%98%d7%99%d7%a1%d7%98%d7%99%d7%a7%d7%95%d7%aa-%d7%a2%d7%9c-%d7%94%d7%99%d7%9c%d7%95%d7%93%d7%94-%d7%94%d7%97%d7%a8%d7%93%d7%99%d7%aa/

[14] https://pmc.ncbi.nlm.nih.gov/articles/PMC8095335/

[15] https://www.ynetnews.com/health_science/article/r1ljgw11c0

https://www.theatlantic.com/health/archive/2015/10/emergency-room-wait-times-sexism/410515/

[16] https://pubmed.ncbi.nlm.nih.gov/11456245/

[17] Available here: http://magazine.hms.harvard.edu/articles/how-gender-bias-medicine-has-shaped-womens-health

[18]  Available here: https://www.amjmed.com/article/S0002-9343(22)00933-0/fulltext

See also here for more on person centered care: Santana MJ, Manalili K, Jolley RJ, Zelinsky S, Quan H, Lu M. How to practice person-centred care: A conceptual framework. Health Expect. 2018 Apr;21(2):429-440. doi: 10.1111/hex.12640. Epub 2017 Nov 19. PMID: 29151269; PMCID: PMC5867327.

Available here: https://pmc.ncbi.nlm.nih.gov/articles/PMC5867327/

[19] See here for a discussion of this paradigm in the laws of nidda: Shayna Goldberg and Judah Goldberg, “Ba’al Ha-Bayit-Centered Halachic Consultation,” in The Next Generation of Modern Orthodoxy, ed. Shmuel Hain, (Ktav, The Orthodox Forum, 2012), 53-73.

Available here: https://www.yutorah.org/lectures/777840/Ba%E2%80%99al-Ha-Bayit-Centered-Halakhic-Consultation