Gender norms, regret and frustration

No ICB in the UK requires that male patients seeking vasectomy undergo a 1-year trial of another form of contraceptive. But of course, this is explained rather straightforwardly by the lack of long-lasting reversible contraceptives available to men. It is also important to note that while vasectomy and tubal ligation both bring about sterilisation, the two are different procedures with different kinds of associated risks. In particular, vasectomy is performed under local anaesthetic, while tubal ligation is performed under general anaesthetic. When procedures are not themselves directly comparable, we cannot assume that it is necessarily a matter of discrimination to offer them on different conditions. Whether the IUD requirement is justified depends on the reasons for some ICBs having this specific policy. Why an IUD, and why the requirement of a 1-year trial, rather than merely offering the patient this or other alternatives (as is the case in other ICBs)?

It may be that the reason for approving sterilisation only on condition of a 1-year trial of an IUD is in order to enforce a ‘cooling off period’—while still providing adequate birth control—to ensure that the patient gives the matter sufficient thought. Buturovic, for example, argues for such a time period: ‘We should not want sterilisation to be available at the press of a button. To the contrary, obstacles to sterilisation for young women are precisely the process needed to weed out the confused and uncommitted’.6 However, this reasoning would only justify the imposition of a waiting period, and not insistence on a specific method of contraception. Further, counselling regarding alternatives and explaining the ramifications of sterilisation is considered sufficient for male patients, for whom no set time period for ‘cooling off’ is mandated.

Alternatively, the IUD requirement may be based on the premise that (1) women are more likely to regret their choice to be sterilised, and (2) that healthcare policy may justifiably constrain access to choices that individuals may regret. But discrepancies in the ease with which male and female patients can access elective sterilisation have been widely criticised in recent years; and in large part, these discrepancies seem to reflect gendered differences in normative expectations when assessing a patient’s request.7 The presupposition that a patient will change her mind about motherhood (or feel the call of a maternal instinct) and regret the procedure later in life seems to play a significant role in healthcare provider denials of female sterilisation requests. As has been noted elsewhere, denial of a competent patient’s request on this basis constitutes unjustified paternalism; it is also not supported by empirical evidence.8 A 1999 US study of women sterilised between the ages of 18–30 found that only 6.3% of those with no children regretted their decision to be sterilised; in a 2015 Slovenian study, only 1.3% of women regretted this decision.9 10

There are many things that we may elect in life which, despite making our decisions fully autonomously, we later come to regret: a tattoo reminding one of a former lover, a marriage to someone who later cheats and indeed becoming a parent. Expressing regret about parenthood is widely considered far more taboo than the converse.11 Nonetheless, as Mertes notes, ‘there is a discrepancy between the level of scrutiny to which a request for sterilisation is subjected as opposed to a request for fertility treatment’. This aside, we do not generally consider it to be the role of healthcare providers to protect us from regret, but rather to promote and respect patient autonomy and best interests. The greater risks associated with female sterilisation (eg, the health risks that come with general anaesthetic) might warrant particularly thorough counselling with regard to benefits and disadvantages of different forms of birth control in order to promote informed consent, but the possibility of regret pertains to outcome, which is near-identical for male and female sterilisation. I say near-identical because motherhood, as has been argued elsewhere, is often taken as more strongly intrinsic to womanhood/femininity than fatherhood is to masculinity.12 Gestation in itself, independent of genetic parenthood, also carries a particular value to many women, and sterilisation might thus be considered the loss of this particular value in addition to the loss of reproductive opportunity more generally. However, sterilisation does not represent a complete loss of this opportunity, as it will not necessarily prevent a donated embryo being carried to term. It is also worth noting that gestation carries significant risks to health and well-being, which present a counter-argument to appeals to the special value of gestation as justifying extra conditions on female sterilisation.

Persuasion

As noted above, the requirement to trial of any specific form of contraceptive is not justified if the aim is only to enforce a period of reflection to ensure genuinely informed consent to sterilisation. So why an IUD? Here, we may compare the IUD requirement with a different genre of healthcare policy. A number of US states (including Alabama, Texas, Virginia, Illinois and North Carolina) have introduced legislation in recent years that mandates an ultrasound prior to abortion. On a similar note, 15 US states have a two-trip mandate, which requires a patient to receive counselling in person before they receive an abortion, and to have a waiting period beginning after the counselling has taken place, thus necessitating two trips to the relevant facility.13 The mandatory waiting period itself, as in the case of sterilisation, would be enough to ensure appropriate reflection. Insistence on an IUD, like the insistence on an ultrasound (and in some states, insistence on transvaginal ultrasound) is not necessary for ‘cooling off’, but rather, seems intended to put the patient off their elected procedure. It might be hoped that the mandated intervention will change the patient’s mind, or that the prospect is sufficiently unpleasant or cumbersome to put the patient off pursuing sterilisation, even if her mind remains unchanged. One 2022 article reports waiting periods of up to a year for IUD removal appointments in England and Northern Ireland.14 The pain associated with IUD insertion and removal can thus be combined with the expected difficulty of scheduling and attending the relevant appointments (as well as the later appointment for sterilisation) as ‘putting off’ rather than ‘cooling off’ factors. Alternatively (to take a more charitable view) the insistence on an IUD may be an attempt to change the patient’s mind by demonstrating the superiority of the IUD vis-à-vis the patient’s values, health and goals. Either way, the answer to ‘why an IUD?’ (as opposed to ‘why a 1 year wait?’) would therefore be, ‘to curb female sterilisation’.

If female sterilisation represents a significantly greater strain on health service resources, it might be argued that it is justifiable for ICBs with fewer resources to try and redirect women towards cheaper alternative forms of birth control. In a healthcare system with limited resources, such as the NHS, justice-based considerations may justify constraints on the types of healthcare offered to different patients. The cost of a procedure needed to achieve an end in one patient may be far greater than the cost of a procedure needed to achieve the same (or similar) end in a different patient. Due to the differences in male and female reproductive anatomy, sterilisation procedures for male and female patients carry different financial costs (as well as different recovery times and so on). For example, according to the costings published by the East and North Hertfordshire CCG in April 2017, the estimated cost per patient over 15 years for the IUD, vasectomy, combined contraceptive pill and female sterilisation were £31, £260, £303 and £1161, respectively. These figures taken in isolation suggest that female sterilisation was roughly 4.5 times more expensive to the NHS as vasectomy during this year.

However, it must be noted that the costs for providing a specific form of birth control over a given period is not the only relevant NHS cost to consider. Users of hormonal contraceptives, including the hormonal IUD, can expect to experience any of a number of common side effects, including nausea, headaches, breast soreness, depression, weight gain and acne; the copper IUD commonly causes heavier periods and more cramping (particularly during the first 3–6 months after insertion). At best, an incorrectly inserted IUD will cause pain and will have to be re-fitted, and in worse cases may cause uterine perforation. Finally, we may also compare the contraception costs above to Public Health England’s 2018 estimate of the cost of maternity care: £5505 per live birth, and £1982 per pregnancy (including those ending in abortion or miscarriage).15 If the IUD requirement is motivated by the aim to reduce patient sterilisation numbers in order to save budget, it is far from clear that this is a financially efficient strategy.

However, more importantly, it is not a morally legitimate exercise of an ICB’s decision-making power. Appealing to budgetary considerations to justify the IUD requirement strongly implies that this policy is expected to change the minds of a significant number of patients, so that they will no longer pursue sterilisation. If the IUD requirement is only a proxy for a ‘cooling off’ period, it makes no sense as a money-saving mechanism: the cost of the IUD insertion and removal is simply added to the cost of the sterilisation procedure. Thus, if designed to conserve resources, the IUD requirement must be expected to work in (at least) one of three ways:

1. By persuading enough patients that the IUD is equal or superior to sterilisation (with regards to their motivations for seeking sterilisation) that they do not continue to pursue sterilisation;

2. By presenting an obstacle to sterilisation sufficient to persuade enough patients change their minds about sterilisation entirely; and/or

3. By presenting an obstacle to sterilisation sufficient to persuade enough patients to seek sterilisation privately, rather than using NHS resources.

Both (b) and (c) straightforwardly undermine equity in male and female patient treatment, and verge toward punitive treatment of female patients who seek sterilisation. This is further underpinned by the pain associated with IUD insertion for many, particularly nulliparous, women (as noted in section 1). It might be argued, however, that (a) does not undermine equity in the health service: women who have sought a reliable method of birth control are still provided with this, and they still retain the option to pursue sterilisation later if they are not satisfied with the IUD. Nonetheless, I would argue that women seeking sterilisation are not merely seeking reliable birth control; they are pursuing something more specific, and it would be disingenuous to claim that their request would therefore be genuinely fulfilled by the provision of the IUD. As McQueen notes, for example, ‘Sterilisation can provide these women with a sense of control, satisfaction, independence, relief and/or finality, allowing them to commit fully to their preferred lifestyle and freeing them from worries of pregnancy’.8