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July 23, 2004/Av 5 5764, Vol. 56, No. 44
Couples have many birth control optionsDR. STEVEN WININGERHelping patients select the method of contraception that best meets their needs is an integral part of providing care for women. Most women prefer reversible options such as birth control pills, patches, vaginal rings, injections or implants that administer hormones to prevent contraception; barrier methods such as a diaphragm, condoms, cervical caps or contraceptive sponges; or IUDs (intrauterine devices).However, some women prefer a permanent method of contraception such as a minimally invasive tubal occlusion that closes the fallopian tubes. There is also a new, completely incision-free hysteroscopic procedure (a scope is inserted through the vagina rather than through an incision) that closes the fallopian tubes. Called Essure, this noninvasive procedure was recently approved by the Food and Drug Administration (FDA). Some couples opt for a vasectomy, a permanent form of male sterilization. For my observant Jewish patients, using birth control raises many issues since Judaism believes that a home without children is a home without blessing. The first mitzvah in the Torah states: "And God blessed them and said to them, 'Be fruitful and multiply; fill the earth and subdue it'" (Genesis 1:28). There has been much debate among rabbis and scholars throughout the years about the interpretation of this verse. The Talmud (Mishnah Yevamot 6:6) reports that the school of Shammai interpreted this to mean that a married couple should have a minimum of two sons, while the Hillel school's interpretation is to have at least a son and a daughter. The view of Hillel and his school prevailed and this is the current halachic interpretation, although there is disagreement about whether this means that couples can stop trying to have children after having a boy and a girl. Additionally, the Mishnah of Yevamot states that women are not obligated to be fruitful and multiply. It is the prevailing opinion in traditional Jewish law that it is a man's duty to marry and have children, whereas a woman is free to remain childless. However, this interpretation is not without controversy. Other relevant Torah verses state: "And you, be fruitful and multiply; bring forth abundantly in the earth and multiply on it" (Genesis 9:7). Also, "He who fashioned and made the earth ... He did not create it to be empty, but formed it to be inhabited" (Isaiah 45:18). Halachically, it is also forbidden for men to waste or destroy their seed. However, Jewish law does allow contraception under certain circumstances, such as when a woman's health (physical, mental or emotional) would be imperiled by a pregnancy. The Talmud also states in the Beraita of the Three Women that young girls, pregnant women and nursing mothers can use a "moch," an absorbent, to prevent pregnancy. Most rabbis and scholars would agree that birth control is an option when there is the likelihood that a baby will suffer from a genetic disease. Because there are many different circumstances that can prompt a desire to use contraception, observant Jews who want to practice birth control should discuss their situation with their rabbi and their physician. If an observant couple decides to use birth control, there is general, but not unanimous agreement, that the hormonal form of birth control (pills, patches, injections and implants) is the most acceptable since it does not interfere with the passage of sperm. "The pill" may be the method of choice since it is administered orally and the Talmud contains several discussions of a "cup of roots" that a woman could drink to avoid conception. Breast-feeding provides a natural, but not foolproof, form of contraception, and should never be relied upon for long-term protection. Since the commandment to procreate rests primarily on men, according to most traditional rabbinic authorities, any contraceptive method, such as coitus interruptus, condoms or a vasectomy is prohibited. However, since the commandments to protect health and life supersede the duty of the male to propagate, the use of condoms may be sanctioned to protect against the spread of an incurable sexually transmitted disease if the wife or husband is infected. My patients seek advice about birth control for many reasons. Some want to delay having children, some want to space the arrival of their children, some have already been blessed with all the children they want and others do not want to have children. We work together to identify the best option to meet their needs. For observant Jews who follow halachic teachings, however, a decision about contraception requires more than medical expertise - the advice and counsel of a rabbi is an essential part of the process. Steven J. Wininger, M.D., a board-certified OB/GYN, practices at the Arizona Wellness Center for Women in Phoenix. |
