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Why Do We Doubt And Police Those Seeking Permanent Contraception?


As with any major decision, regret is a possibility, but we should still accept the fact that adults are capable of making their own decisions about their bodies and living with the consequences.

I recently had a laparoscopic salpingectomy to remove my fallopian tubes. Ever since, I’ve felt as though a load has been lifted from my shoulders. I’ll be 30 years old in a few weeks, and I’m happy to know that I am sterile; that I have power over my own body.

I wish I could say it was a smooth road — that my doctor listened when I told them I didn’t want biological children, respected my decision, and scheduled the surgery straight away. In fact, my OB/GYN asked me to discuss my decision to have the procedure with a psychiatrist — which made little sense to me, since my general practitioner (GP) referred me for it after confirming that I was sure. After this experience, I began hearing stories from other women who had far worse experiences than I did. As it turns out, it’s not easy to walk into an OB/GYN’s office and walk out with an order for permanent contraception.

In Canada, where I live, around 10% of those with uteruses rely on a tubal ligation (which is the surgery to “tie” the fallopian tubes) for contraception. In the U.S., about 27% of people with uteruses rely on sterilization as the main form of contraception. About 750,000 people (in Canada and the U.S. combined) have opted for the less invasive alternative to ligation, Essure, a form of permanent contraception that involves the insertion of coils into the fallopian tubes. Before making a decision about their own bodies, many must first clear any number of hurdles.

“With cis-women . . . bearing children is theoretically ‘part of being female’ (or at least part of being born with a uterus), so we may think that they ‘need more time’ or ‘will change their mind’ as a woman,” says Dr. Sarah Warden, a physician at the Bay Centre for Birth Control in Toronto. While many doctors, including Dr. Warden herself, find this view both sexist and outdated, it should come as no surprise: any woman who says she doesn’t want children has probably been told she will change her mind. It’s disturbing but not especially shocking that this belief extends to some in the medical profession.

Alison Gorbould is in her forties. She tells me she had been talking to doctors about permanent contraception since she was in her twenties. “I’m an aunt and a godparent and tons of my friends have kids I am close to. So I love kids, but I’ve just never wanted my own,” she explains. Gorbould spent 14 years on the pill before deciding, in her early thirties, that she wanted to stop taking it. “I talked to my doctor and she said that tubal ligation was not an option,” she says. “I pressed her and she said ‘too many people your age change their minds’ — which I understand is true, but it still felt really patronizing. It wasn’t a spur-of-the-moment decision. I had never wanted kids.” Gorbould went from doctor to doctor until she was finally allowed to receive permanent contraception in the form of Essure.

It’s not easy to walk into an OB/GYN’s office and walk out with an order for permanent contraception. Click To Tweet

Alex Adler, 31, lives with a number of conditions, including fibromyalgia, chronic fatigue syndrome, multiple chemical sensitivities, chronic depression, anxiety disorder, and PTSD. She has no desire to have children and doesn’t feel she has the support system she would need to raise a child even if she wanted to. Her GP — like mine — was compassionate regarding her desire to receive permanent contraception, but the OB/GYNs Adler saw were a different story. They all refused to perform a tubal ligation on her, instead recommending the IUD as a temporary but longer-term form of contraception.

When Adler attempted to have an IUD inserted, the pain was so severe she ended up walking away without one. One OB/GYN refused to believe Adler when she explained this, insisting the attempted insertion had been painful because it had been done by a resident; she told Adler that she would insert one, and if it hurt too much she would put Adler under general anesthesia. “It didn’t feel like a choice at all,” Adler says. “I was terrified, I didn’t trust her, and I felt really vulnerable. Her boast that she’d get the IUD in me ‘before [I was] done screaming’ didn’t inspire confidence.”

I ask Dr. Warden why there’s such insistence on the IUD. “I think the emphasis on long-acting, reversible contraceptives is there because: a) many patients still don’t know about them and that [they are] an option, b) it is less invasive/risky, c) in the case of the progesterone IUD (Mirena/Jaydess), it has other benefits for people with uteruses as well,” she says. “[When I say] ‘non-invasive,’ I’m basically referring to risk. There are no incisions required into any tissues, so the risk of infection and scarring is lower. We do not need general anesthesia, which adds risk to a procedure.”

But at what point does the practitioner’s own feelings or opinions about permanent contraception get in the way of the patient’s overall well-being?Alex Adler feels her physician crossed a line. “I went into the appointment [to get an IUD] with severe anxiety . . . I really didn’t want to go through it, but I felt that I had no other choice,” she says. “After [the doctor] prepped me, she sounded my cervix to make way for the IUD. The pain was unbelievable. I screamed and went into panic. I told her to stop the procedure . . . She ignored me and insisted she needed to finish the procedure. I saw that she probably wasn’t going to listen to me, and had no way to get away from her, so I agreed just to get it over with.” This violation of her consent and her trust triggered Adler’s PTSD. Adler still has an IUD that continues to make her physically uncomfortable, and feels she has no other options.

Considering these experiences (as well as my own), I was curious about the impact of mental health for people seeking these procedures. Are those with mental health issues more or less likely to be listened to and believed when seeking permanent contraception? As someone who lives with moderate depression, I wondered if I was forced to see a psychiatrist before having my procedure precisely because of my mental health history. Was my decision not taken seriously because my mind wasn’t considered “normal”? I lucked out and ended up talking with a great psychiatrist, who agreed that the move was sexist — but it easily could have gone another way.

“If a patient is competent to make the decision, but is having mental health issues, we’d want to ensure this is a position they’ve held consistently for some time,” says Dr. Warden. “But that’s no different [from how we’d treat] anyone asking for permanent contraception. In my experience, mental health issues that do not affect competency [are] not a factor in later regret.”

Unfortunately, not all medical professionals see things that way. Sometimes, the stigma of mental health is a factor when it comes to a woman’s bodily autonomy. For example, Alicia Sarah Raimundo, 27, lives with anxiety and depression, has survived a suicide attempt, and was recently diagnosed with Asperger’s Syndrome. A psychiatrist introduced her to the idea of permanent contraception when she was only 13 years old; Raimundo says the doctor was “worried I’d pass my brain onto another kid — like it was the worst thing in the world.” This suggestion traumatized her and made her feel unworthy of being a parent.

As an adult, however, after years of contemplation, Raimundo decided that bearing children was not something she wanted to do. Whenever she mentions the possibility of permanent contraception to an OB/GYN, she is told that she is too young to make such a decision, then offered non-permanent options — until the doctor reads her full medical history, including her mental health history, and then “they want to schedule the process the same day and completely forget everything they just said to me.” Raimundo hasn’t opted for permanent contraception yet, even though many doctors have agreed to perform the procedure. “When I find a doctor who wants to do it because I am a human with rights and not because they think mental illness is a plague on society, I’ll do it,” she tells me.

In addition to mental illness, gender and the traditional binary also complicate this issue. Dr. Warden raises the point that some medical professionals may be more likely to believe trans masculine people than cis women when they say they don’t want children. The reason some trans masculine people with uteruses opt for permanent contraception, Dr. Warden says, is often nuanced, going beyond the desire not to bear children. There can be a strong disassociation between their identities and their biology that causes extreme stress; for this reason, some physicians might be more likely to agree to permanent contraception in the form of a hysterectomy so they can feel more comfortable with themselves.

Studies show that young women experience a higher rate of regret after undergoing permanent contraception; according to one study, 20% of women under 30 regret the decision, while only 6% over 30 regret it. (Dr. Warden says the studies have not differentiated between cis and trans women, and adds that since the reasons trans people have for seeking permanent contraception often differ from those of cis people, their rates of regret are not easily comparable.) As with any major decision, regret is a possibility, but we should still accept the fact that adults are capable of making their own decisions about their bodies and living with the consequences. “Perhaps we need to view it from a more gender-fluid continuum,” Dr. Warden says; “i.e., ‘Regardless of my gender assigned at birth, bearing children does not fit within my identity as a human.’”

Some progress seems to have been made — after all, I’m a single, childless woman under 30 who managed to get sterilized with minimal trouble — and Dr. Warden notes that it has gotten somewhat easier for many women seeking permanent contraception. Many people are beginning to challenge and change some outdated views regarding biology as it relates to gender. However, the bodies of people with uteruses have always been policed, from our weight to how much or how little sex we have to what we do with our bodies in general. It is long past time for us to view all people as deserving of dignity, bodily autonomy, and control over their own reproductive health decisions. Clearly, there is still a long way to go.