Why is it so hard for some women to get their tubes tied?

If you’re under 35, childless and want to be sterilized, you could spend years navigating a labyrinth of refusals, obstruction and shame. Are doctors protecting women from regret or depriving them of a legitimate choice?

Why is it so hard for some women to get their tubes tied?

Illustration, Mikey Burton.

Sheri Peterson* was 25 when she first asked her hometown doctor in southern Ontario about having her tubes tied. Deep down, she knew children were not for her and, as she had discovered, neither were most methods of birth control. The pill gave her perpetual PMS and the patch made her moody ;  after that, she tried condoms and, occasionally, the “pull and pray” method. But she says her doctor “was really blasé — she just didn’t take me seriously.” It marked the beginning of a long pattern: “I’d ask, and I was always brushed off.”

Then, when she was 31 and at the doctor’s to be fitted for an IUD, Peterson learned she was pregnant. “Right away, I thought, ‘I can’t have a baby.’ ” Her doctor didn’t hesitate in telling her who to call to have the pregnancy terminated.

After the abortion, Peterson had the IUD inserted, but it caused her severe cramping. So last summer she sat down with a Toronto gynecologist and asked, straight up, to be sterilized. Once again, the doctor dismissed the idea, saying that young women often regret it. “I told her, ‘So what if I regret it? That’s on me,’ ” Peterson says. “But she just shut me down. At that point, after everything, I felt worn out by the whole situation.”

Related: I don’t want kids and it’s not because I’m selfish

It’s an experience surprisingly common in Canada. The internet is rife with personal stories that describe the quest to find a physician willing to perform a tubal ligation on a woman under 35, and how it can stretch into a years-long odyssey of pleas and doctor shopping. Given studies that show up to 30 percent of young women eventually regret their decision, doctors are reluctant to do it. When the woman is young and childless, many refuse altogether.

For most, “it’s not an ethical or moral opposition,” says Dr. Dustin Costescu, an obstetrician and gynecologist at McMaster University in Hamilton, Ont. “It’s more of a misplaced or well-intended paternalism, not wanting to do harm… as in, ‘When I was your age, I didn’t want kids either.’ ” Yet for the young women asking, a refusal can feel a lot like being robbed of a legitimate choice to remain child free.

Reproductive medicine is notorious for its battles. In the last century alone, women fought for the right to birth control education, the pill and legal abortion. Now, in the not-so-new millennium, after these hard-won victories have helped to recast first-time motherhood as a mid-life chapter and when governments are rolling out funding for IVF, a small but growing cohort of young women are finding they have to fight for the right to never procreate.

Hannah Greene,* a 30-year-old Toronto publishing executive, says it’s a battle made worse by an infuriating double standard on permanent birth control: While she has been trying to convince doctors to tie her tubes for the last nine years, her brother was given a vasectomy at 26. At a recent doctor’s appointment, Greene, whose long-term partner doesn’t want children either, was told, “Have your partner get a vasectomy.” She left fuming. “Why are men’s decisions on not having children respected, but women’s are not?”

In Canada, about 20,000 tubal ligations are performed each year, the vast majority are done in women who want no more children, rather than childless women. The 136-year-old surgical procedure is not always reversible. It prevents conception by blocking or removing a woman’s Fallopian tubes, the two slender tunnels that connect the ovaries to the uterus and where the egg and sperm make their fateful rendezvous. Until 1969, the American College of Obstetricians and Gynecologists endorsed a policy that said doctors should consider sterilizing a woman only if her age multiplied by the number of children she had equalled 120 or greater. Canadian doctors once relied on a similar formula and often required a woman to have her husband’s consent.

We might like to think we’ve come a long way since then. But as recently as 2007, a Catholic hospital in Humboldt, Sask., was forced to compensate a 39-year-old woman who had been refused the procedure after giving birth to her second child. In 2009, a 21-year-old married Toronto woman, pregnant with her second child, made headlines after going public when her obstetrician said she was too young to be sterilized (she had requested the procedure be done after the birth). And it was only last November that the clinical guidelines in the Canadian Contraception Consensus were changed to stipulate that if a woman is well informed and gives her consent, then neither her age nor whether she has children “should be a barrier to permanent contraception.”

Still, Costescu, who co-authored the new policy on behalf of the Society of Obstetricians and Gynaecologists of Canada, knows that not all doctors will follow it — nor do they have to. “A surgeon doesn’t have to perform a procedure he or she doesn’t want to do,” he says. Many doctors send him notes saying they “don’t perform ‘tubals’ on women under 30,” especially if they’re childless. One physician said she didn’t know any doctor who would.

Most patients are not waffling, they’re committed. They’ve thought about this for a long time

Costescu doubts patient safety is the sticking point: Serious problems occur in fewer than one in 1,000 women who have their tubes tied. Rather, the chance that a woman will one day wish she wasn’t sterilized seems to be the top reason doctors refuse to provide it. Recent studies suggest about 4 percent of women overall will regret the decision, Costescu says, but that number jumps to 20 or 30 percent among younger women. This makes tubal ligation a unique case in the medical world — regret is rarely considered a risk factor for a surgical procedure.

History also plays a role in the controversy. Forced sterilizations were part of the ugly eugenics movement in the early 20th century and legal in Alberta until 1972. There are still concerns over the prevalence of tubal ligation among minorities and poor women. At the Saskatoon Health Region, officials are investigating allegations, made last fall, that medical staff pressured indigenous women to have their tubes tied against their will.

All this compounds the sensitivities around who should be sterilized, says Costescu. “It contributes to a defensive stance by clinicians worried about performing an inappropriate tubal.” Which is why he hopes the revised policy will reassure doctors that they can proceed with a tubal ligation on any young and childless woman who chooses it, provided there is informed consent.

At his practice, Costescu performs about 50 female sterilizations a year, and half of those are on women under age 30 — a proportion that he finds is growing. “Most patients are not waffling, they’re committed. They’ve thought about this for a long time.”

As an obstetrician and gynecologist at Women’s College Hospital and St. Joseph’s Health Centre in Toronto, Dr. Yolanda Kirkham understands why some doctors say no; she’s said it herself to some younger women who ask her for a tubal ligation. She doesn’t see it as being paternalistic; it’s just protective of a young patient’s future self.

“So much can happen in life that could make a woman regret her decision,” she says. “They could meet someone with whom they want to have children or meet a new partner. Or something could happen to one of their children — a child could become terminally ill or die in an accident. These things happen and it’s sad.”

Related: Childless by choice

Meanwhile, tubal ligation is an elective procedure and “there are so many excellent options” for long-acting reversible contraception that many women are not aware of, Kirkham says, which is why it can take several visits to make sure a patient is well informed, is not being coerced and fully understands the potential for regret. “For a woman in her early 20s, she still has 20 or 25 years left of reproductive potential. That’s longer than she’s been alive. We all know we’ve changed since our 20s, and that’s where the hesitancy comes from.”

But Christine Overall, a philosophy professor at Queen’s University in Kingston, Ont., and author of Why Have Children? The Ethical Debate, says a lot of the tension here is rooted in the tendency to continue to define womanhood in terms of reproduction, child-bearing and motherhood. Women who want children are rarely asked to explain their decision, she says, but women who don’t face an “unfair burden of justification.”

Yet the right not to procreate is an integral right of autonomy, says Overall. The possibility a woman will regret her choice should not be grounds for denying it: “It’s not part of a doctor’s responsibility to protect women from making an error. It’s the doctor’s job to make sure they have all the information they need to make an informed choice.” Ageism, she says, is at work. “It’s a bias against young women. The doctor is purporting to know what’s better for the woman than the woman herself.”

Still, Overall believes unwilling doctors should not be compelled to provide the procedure. “But I can’t see how they could refuse to refer a patient to someone who would — that’s unethical. It’s like saying I will ensure you are not fully informed.”

Back when abortions were a notoriously hard-to-get procedure, women relied on a savvy underground network to find backstreet doctors. Today, young women post their pleas and rely on the web to learn the names of “non-judgmental doctors” willing to tie their tubes. They appear to be in such short supply around the world that lists their identities by country.

Which is why Alyna Poremba knew what to expect. The court reporter from Brantford, Ont., was 20 when she started researching tubal ligations online and quickly realized how hard it might be to convince a doctor that she was committed to a child-free life. But she had a strategy: “I decided I would start asking right away to be sterilized and for it to be put in writing in my medical records,” says Poremba. That way, in the future, she could say, “Look, I’ve been asking for years and I haven’t changed my mind.”

Then, last March, the first gynecologist she saw made “personal attacks on my ability to reason” and told Poremba she needed “psychological counselling.” She also said she wasn’t ethically obligated to provide Poremba with a tubal ligation or refer her to someone who would.

Poremba, now 22, left “embarrassed, insulted and upset,” but determined. Later that day, she hit the web, compiled a list of Hamilton-area gynecologists and started cold-calling. After two rejections, someone told her about a family planning doctor at McMaster University who might help: Dustin Costescu.

At 33, and only three years into his private practice, Costescu knows he is gaining a reputation as a doctor of last resort for young women turned down elsewhere. Often the referrals are sent for “a second opinion, which is essentially a euphemism for referring a patient for a tubal that the first doctor doesn’t want to perform,” he says. But he says his counselling is no less rigorous than any other doctor’s.

In July 2015, Poremba had her first appointment with Costescu. There were invasive questions and a thorough discussion of birth control options, but she explained she did not feel these were options for her. And this time, Costescu surprised her: “You are allowed to make choices that I wouldn’t make,” he said.

“I felt really empowered,” Poremba says. Last November, the same month Canada’s new guidelines on tubal ligations were released, Poremba got her wish. Now the proud bearer of two tiny incisions, one in her navel and the other along her bikini line, she says happily, “I never have to worry about birth control ever again.”

She is thinking about posting her happy news online, along with the name of her willing doctor — knowing too well there’s a small army of young women out there hungry to hear it. “It’s an invisible fight,” says Sheri Peterson, who is shoring up her energies for another round. “No one wants to rally or march over this. I just want to quietly live my life—and not have babies while doing it.”

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