Method
Participants. Members of the Israeli Association of Obstetrics and Gynecology were engaged as participants for this study.
Procedure. Participants were approached via an email that contained a link to a Google Forms questionnaire. Participation was voluntary, and anonymity was maintained to ensure the authenticity of responses.
Measures. The questionnaire was designed to examine a range of issues related to the prescription of contraceptive pills to minors without parental involvement. It included questions about the participant’s professional experience, the number of minor patients treated in the past year, and specific cases of prescribing contraceptives to minors without parental knowledge.
The questionnaire further explored the participant’s practices around documentation and communication with minors. It also investigated whom physicians typically consulted in these situations, and their understanding of the legal obligations and potential consequences associated with such prescriptions, including the extent of parental access to minors’ medical records through Health Maintenance Organization (HMO) applications.
Participants were also asked to express their opinions on various ethical and professional dilemmas concerning the prescription of contraceptives to minors, parental involvement, and the potential impacts on the minors’ sexual behavior and welfare.
Demographics and Clinical Data. Detailed demographic and clinical data were collected, including age, sex, country of birth, nature of employment, the socio-economic status of the clinic locality, the patient population served, and the year of medical graduation. Information on additional training received post-medical school was also gathered.
Statistical Analyses. The collected data were analyzed using t-tests or ANOVA for comparison of responses across groups, with a significance threshold set at p<0.05. Fisher’s exact test was employed to examine the association between categorical variables.
Data cleaning
Incorrect year of MD qualification
- Some respondents entered their tenure years or a short form of the year completed, I fix this manually.
- When provided short form of year, I just add “19–”.
- When provided with tenure, I calculate by subtracting from 2022 (the year of the questionnaire).
| 57 |
96 |
| 62 |
24 |
| 57 |
93 |
| 55 |
95 |
| 38 |
202 |
| 70 |
34 |
Other/Undisclosed place of MD studies
- Unified the undisclosed (missing) place of MD with “other”.
Results
Participant Characteristics
Out of the 179 voluntary survey respondents, two identified as non-gynecologists, and out of the remaining n = 177 (henceforth referred to as the full sample), there were n = 132 (74.58% of the full sample) who treated minors in the previous year (referred to as the exposure sample). The full participant data appears in Table 1.
Table 1: Demographics table
| Characteristic |
exposure, N = 132 |
full, N = 177 |
| Age |
52 (11) |
51 (11) |
| Female |
85 (65%) |
114 (65%) |
| Place of birth |
|
|
| Israel |
93 (71%) |
131 (74%) |
| Countries of the former USSR |
17 (13%) |
21 (12%) |
| Eastern Europe |
8 (6.1%) |
8 (4.5%) |
| USA / Canada |
6 (4.6%) |
8 (4.5%) |
| Western Europe |
5 (3.8%) |
5 (2.8%) |
| South America |
1 (0.8%) |
2 (1.1%) |
| other |
1 (0.8%) |
1 (0.6%) |
| Youngest child's age |
|
|
| 0-11 years |
50 (38%) |
75 (43%) |
| 12-14 years |
9 (6.9%) |
14 (8.0%) |
| 15-17 years |
14 (11%) |
16 (9.1%) |
| 18 and up |
53 (40%) |
63 (36%) |
| I don't have children |
5 (3.8%) |
7 (4.0%) |
| Employment status |
|
|
| self employed |
52 (40%) |
62 (36%) |
| both salaried and self employed |
48 (37%) |
58 (34%) |
| salaried |
30 (23%) |
52 (30%) |
| Sector treated in your primary clinic |
|
|
| Mostly Jewish |
87 (67%) |
110 (64%) |
| Mixed |
43 (33%) |
60 (35%) |
| Mostly Arab |
0 (0%) |
3 (1.7%) |
| Patients' socio-economic status |
|
|
| low |
3 (2.3%) |
5 (2.9%) |
| medium-low |
42 (33%) |
67 (39%) |
| medium-high |
68 (53%) |
81 (47%) |
| high |
16 (12%) |
20 (12%) |
| Place of MD graduation |
|
|
| Israel |
106 (80%) |
142 (80%) |
| Eastern Europe |
13 (9.8%) |
16 (9.0%) |
| Western Europe, USA, Canada |
7 (5.3%) |
9 (5.1%) |
| Other |
5 (3.8%) |
8 (4.5%) |
| Middle East |
1 (0.8%) |
2 (1.1%) |
| OB/GYN specialty status (board certification) |
|
|
| Resident |
2 (1.6%) |
14 (8.0%) |
| Senior, up to 5 years |
32 (25%) |
37 (21%) |
| Senior, 5-10 years |
11 (8.5%) |
19 (11%) |
| Senior, 10-20 years |
34 (26%) |
43 (25%) |
| Senior, more than 20 years+ |
50 (39%) |
61 (35%) |
| Years since MD graduation |
24 (11) |
23 (12) |
| Participation in formal training about caring for minors |
|
|
| no training |
95 (73%) |
137 (78%) |
| conference |
30 (23%) |
32 (18%) |
| written procedure |
5 (3.8%) |
6 (3.4%) |
Clinical Reality
Table 2: Clinical reality of the surveyed gynocologists
| Characteristic |
N = 132 |
| How many contraception consultations for minors did you perform during the past year? |
|
| 1-5 |
24 (18%) |
| 5-10 |
25 (19%) |
| 10-20 |
30 (23%) |
| 20-50 |
31 (24%) |
| 50+ |
21 (16%) |
| Unknown |
1 |
| In how many cases did the minor refuse parental involvement? |
|
| always/almost always |
12 (9.2%) |
| sometimes |
83 (63%) |
| never |
36 (27%) |
| Unknown |
1 |
| When a minor refused parental involvement, did you actually prescribe contraception without parental consent? |
|
| always/almost always |
87 (74%) |
| sometimes |
7 (5.9%) |
| never |
24 (20%) |
| Unknown |
14 |
| In cases in which you prescribed contraceptives without parental consent, did you document the prescription in the minor’s health file |
|
| always/almost always |
104 (93%) |
| sometimes |
2 (1.8%) |
| never |
6 (5.4%) |
| Unknown |
20 |
| In cases in which you prescribed contraceptives, did you document the reasons for prescribing without parental consent in the minor’s health file? |
|
| always/almost always |
41 (37%) |
| sometimes |
26 (23%) |
| never |
44 (40%) |
| Unknown |
21 |
| In cases in which you prescribed contraceptives without parental involvement, did you explain to the minor that the prescription is documented in her health file? |
|
| always/almost always |
83 (75%) |
| sometimes |
11 (10%) |
| never |
16 (15%) |
| Unknown |
22 |
Perception of Laws and Regulations
Parental involvement
Table 3: Perception of the law regarding parental involvement and frequency of prescribing to minors
|
Prescribes to minors
|
Total |
p-value |
| almost always |
sometimes |
never |
| Perception of the law regarding parental involvement |
|
|
|
|
0.9 |
| age dependent |
33 (38%) |
2 (29%) |
8 (33%) |
43 (36%) |
|
| does not know/not required |
48 (55%) |
4 (57%) |
14 (58%) |
66 (56%) |
|
| parental involvement required |
6 (6.9%) |
1 (14%) |
2 (8.3%) |
9 (7.6%) |
|
| Total |
87 (100%) |
7 (100%) |
24 (100%) |
118 (100%) |
|
Table 4: Perception of the law (dichotomized) regarding parental involvement and frequency of prescribing to minors
|
Prescribes to minors
|
Total |
p-value |
| almost always |
sometimes |
never |
| Perception of the law regarding parental involvement |
|
|
|
|
0.4 |
| does not know/age dependent/not required |
81 (93%) |
6 (86%) |
22 (92%) |
109 (92%) |
|
| parental involvement required |
6 (6.9%) |
1 (14%) |
2 (8.3%) |
9 (7.6%) |
|
| Total |
87 (100%) |
7 (100%) |
24 (100%) |
118 (100%) |
|
Perception of data-access and clinical practice
- Assuming that parents have viewing permissions on the HMO app, we test the association with prescribing to minors without parental knowledge.
Table 5: Perception of the law and parental data access knowledge (purchase history)
|
Parents can view purchase history
|
Total |
p-value |
| correct |
incorrect/doesn’t know |
| Prescribes to minors |
|
|
|
0.13 |
| yes |
48 |
44 |
92 |
|
| no |
16 |
7 |
23 |
|
| Total |
64 |
51 |
115 |
|
Table 6: Perception of the law and parental data access knowledge (visit summary)
|
Parents can view visit summary
|
Total |
p-value |
| correct |
incorrect/doesn’t know |
| Prescribes to minors |
|
|
|
0.8 |
| yes |
34 |
58 |
92 |
|
| no |
9 |
14 |
23 |
|
| Total |
43 |
72 |
115 |
|
Table 7: Perception of the law and parental data access knowledge (contraceptive prescription)
|
Parents can view contraceptive prescriptions
|
Total |
p-value |
| correct |
incorrect/doesn’t know |
| Prescribes to minors |
|
|
|
0.5 |
| yes |
43 |
49 |
92 |
|
| no |
9 |
14 |
23 |
|
| Total |
52 |
63 |
115 |
|
Clinical practice and stances
Table 8: Stances by practice (2 levels - yes/sometimes vs never)
| Stance item |
GTM's who prescribe w/o parental inv. |
GTM's who never prescribe w/o parental inv. |
p-value |
| There are cases when it is right to give pills to a minor without the knowledge of her parents |
4.81 (0.56) |
4.38 (1.06) |
0.064 |
| It is better for the minor to receive pills without the knowledge of her parents, than for her to become pregnant |
4.83 (0.52) |
4.46 (1.02) |
0.10 |
| Giving pills to a sexually active minor is in her best interest, even if it is without her parents' knowledge |
4.77 (0.49) |
4.29 (1.08) |
0.043 |
| Minors should be allowed to choose whether to allow their parents to see the part of their medical file that deals with sexual and sexual issues |
4.35 (0.92) |
3.79 (1.18) |
0.040 |
| The fact that the minor's record is exposed to the parents prevents me from giving the minor good treatment of sexual and sexual issues |
3.04 (1.47) |
2.74 (1.51) |
0.4 |
| It can't be that parents didn't know that their underage daughter was taking pills |
1.97 (0.98) |
2.38 (1.17) |
0.13 |
| Giving a minor pills encourages her to have sex |
1.69 (0.81) |
1.79 (1.14) |
0.7 |
| Teenage/extramarital sex is inappropriate |
1.70 (0.96) |
1.50 (0.66) |
0.2 |
| I am not willing to risk legal action, so I will not give pills to a minor without the knowledge and consent of a parent |
1.65 (0.76) |
2.22 (1.38) |
0.066 |
| In cases where it is in the best interest of the minor patient, I will give her a prescription for pills even without her parents knowing about it |
4.40 (1.07) |
3.58 (1.38) |
0.012 |
Table 9: Stances by practice
| Stance item |
GTM's who always prescribe w/o parental inv. |
GTM's who occasionally prescribe w/o parental inv. |
GTM's who never prescribe w/o parental inv. |
p-value |
| There are cases when it is right to give pills to a minor without the knowledge of her parents |
4.85 (0.39) |
4.29 (1.50) |
4.38 (1.06) |
0.003 |
| It is better for the minor to receive pills without the knowledge of her parents, than for her to become pregnant |
4.86 (0.44) |
4.43 (1.13) |
4.46 (1.02) |
0.013 |
| Giving pills to a sexually active minor is in her best interest, even if it is without her parents' knowledge |
4.78 (0.49) |
4.71 (0.49) |
4.29 (1.08) |
0.007 |
| Minors should be allowed to choose whether to allow their parents to see the part of their medical file that deals with sexual and sexual issues |
4.35 (0.91) |
4.29 (1.11) |
3.79 (1.18) |
0.050 |
| The fact that the minor's record is exposed to the parents prevents me from giving the minor good treatment of sexual and sexual issues |
3.01 (1.48) |
3.43 (1.40) |
2.74 (1.51) |
0.5 |
| It can't be that parents didn't know that their underage daughter was taking pills |
1.93 (0.99) |
2.43 (0.79) |
2.38 (1.17) |
0.10 |
| Giving a minor pills encourages her to have sex |
1.70 (0.83) |
1.57 (0.53) |
1.79 (1.14) |
0.8 |
| Teenage/extramarital sex is inappropriate |
1.68 (0.95) |
2.00 (1.15) |
1.50 (0.66) |
0.4 |
| I am not willing to risk legal action, so I will not give pills to a minor without the knowledge and consent of a parent |
1.60 (0.72) |
2.14 (1.07) |
2.22 (1.38) |
0.010 |
| In cases where it is in the best interest of the minor patient, I will give her a prescription for pills even without her parents knowing about it |
4.45 (1.01) |
3.71 (1.60) |
3.58 (1.38) |
0.003 |
Consideration
Table 10: Considerations by practice (2 levels - yes/sometimes vs never)
| Consideration |
GTM’s who prescribe w/o parental inv., N = 94 |
GTM’s who never prescribe w/o parental inv., N = 24 |
p-value |
| Parents right to know |
2.34 (1.07) |
2.61 (1.37) |
0.4 |
| Fear of damaging my relationship with the minor's parents |
2.19 (1.06) |
2.26 (1.21) |
0.8 |
| Fear of a violent/harsh reaction by parents towards me |
2.58 (1.41) |
2.35 (1.37) |
0.5 |
| Fear of legal action |
2.07 (1.06) |
2.57 (1.50) |
0.14 |
| Age of the minor |
3.59 (1.29) |
3.65 (1.11) |
0.8 |
| The minor ability to understand the significance of the decision, the implications and risks |
4.35 (1.05) |
3.95 (1.00) |
0.11 |
| Does the minor have a rational reason for refusal (as opposed to just not wanting the parents to know) |
3.10 (1.41) |
3.45 (1.30) |
0.3 |
| Rights and dignity of the minor |
4.46 (0.79) |
4.14 (0.89) |
0.12 |
| My ability to verify her medical background and contraindications to pills without parental involvement |
4.22 (1.09) |
4.05 (1.09) |
0.5 |
| The risk to the health of the minor that may be caused by taking the pills |
4.12 (1.26) |
3.87 (1.25) |
0.4 |
| The risk to the health of the minor as a result of having sex without pills |
4.72 (0.80) |
4.22 (0.85) |
0.016 |
| Fear of a violent/harsh reaction by the parents towards the minor if they knew that she is taking pills |
3.62 (1.30) |
3.09 (1.62) |
0.2 |
| The desire to preserve the minor in a therapeutic relationship with me |
3.32 (1.31) |
2.57 (1.44) |
0.029 |
| How supportive the parents really are, and how valuable it is for them to know that the minor is having sex and taking pills |
3.39 (1.15) |
3.43 (1.24) |
0.9 |
| Existence/absence of other adult support resourcefor the minor (aunt, older sister, etc.) instead of her parents |
3.52 (1.24) |
3.83 (0.98) |
0.2 |
Table 11: Considerations by practice
| Consideration |
almost always, N = 87 |
sometimes, N = 7 |
never, N = 24 |
p-value |
| Parents right to know |
2.29 (1.04) |
3.00 (1.29) |
2.61 (1.37) |
0.2 |
| Fear of damaging my relationship with the minor's parents |
2.15 (1.05) |
2.57 (1.27) |
2.26 (1.21) |
0.6 |
| Fear of a violent/harsh reaction by parents towards me |
2.61 (1.44) |
2.14 (0.90) |
2.35 (1.37) |
0.5 |
| Fear of legal action |
2.06 (1.07) |
2.17 (0.98) |
2.57 (1.50) |
0.2 |
| Age of the minor |
3.56 (1.31) |
4.00 (1.10) |
3.65 (1.11) |
0.7 |
| The minor ability to understand the significance of the decision, the implications and risks |
4.38 (1.05) |
4.00 (1.15) |
3.95 (1.00) |
0.2 |
| Does the minor have a rational reason for refusal (as opposed to just not wanting the parents to know) |
3.05 (1.41) |
3.71 (1.38) |
3.45 (1.30) |
0.3 |
| Rights and dignity of the minor |
4.48 (0.78) |
4.29 (0.95) |
4.14 (0.89) |
0.2 |
| My ability to verify her medical background and contraindications to pills without parental involvement |
4.24 (1.08) |
4.00 (1.29) |
4.05 (1.09) |
0.7 |
| The risk to the health of the minor that may be caused by taking the pills |
4.16 (1.21) |
3.57 (1.81) |
3.87 (1.25) |
0.3 |
| The risk to the health of the minor as a result of having sex without pills |
4.72 (0.81) |
4.71 (0.76) |
4.22 (0.85) |
0.035 |
| Fear of a violent/harsh reaction by the parents towards the minor if they knew that she is taking pills |
3.65 (1.30) |
3.14 (1.21) |
3.09 (1.62) |
0.2 |
| The desire to preserve the minor in a therapeutic relationship with me |
3.27 (1.31) |
4.00 (1.26) |
2.57 (1.44) |
0.026 |
| How supportive the parents really are, and how valuable it is for them to know that the minor is having sex and taking pills |
3.41 (1.15) |
3.14 (1.21) |
3.43 (1.24) |
0.8 |
| Existence/absence of other adult support resourcefor the minor (aunt, older sister, etc.) instead of her parents |
3.55 (1.24) |
3.14 (1.21) |
3.83 (0.98) |
0.4 |