An increasing number of bioethicists are raising concerns that young childless women requesting sterilisation as means of birth control are facing unfair obstacles. It is argued that these obstacles are inconsistent, paternalistic, that they reflect pronatalist bias and that men seem to face fewer obstacles. It is commonly recommended that physicians should change their approach to this type of patient. In contrast, I argue that physicians’ reluctance to eagerly follow an unusual request is understandable and that whatever obstacles result from this reluctance serve as a useful filter for women who are not seriously committed to their expressed requests for sterilisation. As women already disproportionally bear the birth control burden, less resistance that men might be getting in terms of voluntary sterilisation works to women’s advantage, providing a much needed balance. Societal attitudes towards women and motherhood should not be confused with individual physicians’ reasonable reluctance to jump at a serious elective procedure at fairly mild expression of interest.
- clinical ethics
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An increasing number of bioethicists are raising concerns that young childless women (YCW) requesting permanent sterilisation as means of birth control are facing unfair obstacles. This represents a significant change of perspective. Where early discussions saw an ethical dilemma1 the most recent ones see inconsistency, paternalism, pronatalist bias and discrimination. Thus, Mertes2 observes that physicians treat differently women who request in vitro fertilisation (IVF) versus women, especially YCW, who insist that they be voluntarily sterilised—while the choice of the former group is taken as self-evident, the choice of the latter is questioned. She stipulates that this is due to physicians’ understanding of possible decision regret that the two groups are facing, and provides some evidence suggesting that there is no much difference in regret between women who have children and those who are voluntarily childless. McQueen3 is concerned that refusal to immediately schedule the procedure encroaches on the patient’s autonomy which entails possibility of making a mistake. Like Mertes, McQueen laments purported (anecdotally based) difference of the ease by which men and women sterilisation requests are met and likewise suggests that physicians are guided by anticipated regret. Others, such as Lalonde4 and Richie,5 have recently raised very similar concerns.
In the cases reported—all of them in the West and primarily, though with some exceptions, in the USA and UK—YCW seeking sterilisation face no legal obstacles. This has been the case for a while—the relevant landmark cases in the USA were passed in the 1970s. This is a case of physicians seemingly resisting a procedure that is legally permitted. However, I will argue that there are multiple reasons why they could be justified in doing so.
Regret is a wrong metric to analyse sterilisation requests
Regret is a faulty metric for assessing decision-making. Human decision-making processes are highly heterogeneous6 and anticipated regret is just one out of many. Regret should not be confused with changing of one’s mind—while change of mind is common, regret is much less common than we think. Gilbert7 8 has shown that decision-makers are likely to underestimate the extent to which they will adapt to whatever situation they find themselves in as well as rationalise or misremember the role that their own decisions played in it. Sevdalis and Harvey9 similarly conclude, based on experimental evidence, that ‘people making decisions should discount the regret and rejoicing that they anticipate will be associated with potential outcomes arising from those decisions.’ Nor are these rationalisations to be dismissed as irrational—to the contrary, the process of rationalisation can be understood as a rational one that, on balance, leads to improved decision-making.10
Regardless of any value of regret-based decision-making, it is not at all clear that this is what physicians’ reluctance to perform elective sterilisation in YCW is based on. For example, an experiment that provided doctors with a vignette describing a woman seeking voluntary sterilisation showed that it was frequency of physicians’ church attendance that was the most distinguishing factor among those who said they would try to dissuade the patient from tubal ligation.11
We should always keep in mind that reasons stated in support of a decision might or might not be actual causes of that decision.12 Our introspective insight into our own motivations is limited and faulty, and the same is true of physicians. Therefore, proponents of immediate access to sterilisation are right to wonder whether physicians’ reluctance to perform the procedure is based on their assessment of the likelihood of regret or whether there are some other beliefs that are factoring into it. However, in addition to traditional beliefs about motherhood and women’s role in society there exist multiple reasons why a young well-informed person would earnestly request sterilisation while being ambivalent or even opposed to it, and physicians taking these possibilities into account are not necessarily making a mistake.
Extraordinary requests require extraordinary evidence
One possibility is that women are bullied into sterilisation by their male partners. Women already disproportionately bear the burden of contraception. While some experimental evidence suggests11 that doctors’ reluctance is greater when male partners disagree with the woman’s request rather than when they agree with it, it is not out of question that whatever reluctance remains when the (male) partner agrees could be partly explained by the suspicion that the woman is doing it to please her male partner, or even that he uses it to control her ability to bear children to other men, a possibility that evolutionary psychologists constantly warn us about. After all, one might reasonably wonder, why does not the male partner get a vasectomy instead?
In addition: self-injury is a major public health concern13 especially among adolescents and young women: a study has shown that, in the UK, 20% of females aged 16–24 have self-harmed.14 Therefore, the likelihood that any YCW self-harms is an order of magnitude higher than the likelihood that she would benefit from sterilisation.
Furthermore, self-harm among young adults seems to be increasing at the same time as requests for voluntary sterilisation among YCW. The two could be unrelated, or caused by the same factor: we just do not know yet what the relationship is between the two, if any. However, this uncertainty coupled with a high prevalence of self-harm makes a wide range of attitudes on the part of obstetrician-gynaecologists (ObGyn) justifiable: it is reasonable for them to ignore the possibility that sterilisation in YCW could sometimes be a form of self-harm, but also, to consider it.
Yet another possibility is that sterilisation requests by young women are a misguided expression of youthful rebellion. Being sterilised at young age provides a shock value that can enhance one’s status in certain communities. Many young people flirt with the idea of childlessness and, rather than being upset by opposition of the mainstream to it, they revel in it. A woman demanding to, say, be sterilised at 20, can easily find herself as a front page story with thousands of (mostly hateful) comments. While reading some of these stories, one does detect a bit of pride these women take in defying the choice of the masses. It is also perhaps notable that all reports of uncooperative physicians come from Western countries where multiple alternatives to natural conception, should sterilised women change their mind later, are available, therefore lowering the cost of sterilisation pursuit for reasons unrelated to reproduction.
Voluntary sterilisation is sometimes compared with cosmetic surgery. Like sterilisation, cosmetic surgery is an elective procedure that is supposed to enhance quality of life but where change of mind is a real possibility. Yet, women seeking cosmetic surgery seemingly face no obstacles comparable to young women seeking voluntary sterilisation. To the contrary, it is common even among the very young—in 2017 alone over 200 000 surgeries were performed on patients aged 13–19 in the USA.15 A part of the explanation for this discrepancy probably lies in the fact that cosmetic surgeons are dedicated providers of cosmetic surgery in a way ObGyns are not dedicated providers of tubal ligation. It is quite possible that if women consulted other physicians whether they should undergo cosmetic surgery, they would be discouraged from it. Furthermore, it should also be noted that, according to some, ‘it is now widely recognized that psychological assessment and referral is an important element of the care of patients undergoing cosmetic surgery.’16 Thus, cosmetic surgery requests are not always taken at face value, either.
In any case, in contrast to desire to be child free, desire to both procreate and enhance one’s appearance is widespread. An overwhelming majority of US adults, for example, express a desire to have a child over the course of their life—in 2013, only 5% said they did not want children.17 In fact, the ideal and intended number of children is, on average, greater than the actual number women end up having in a vast majority of countries18; in the USA women on average have almost a whole child fewer than they wished.19 Since cosmetic surgery is simply much more common than voluntary sterilisation, requests for cosmetic surgery do not face the same evidentiary challenges that requests for sterilisation do.
The widespread desire for children could be plausibly explained by evolution (organisms with no interest in having offspring would be selected against) or cultural expectations (women are socialised into motherhood since early age) or conformity (a vast majority of adults around us have at least one child) or any combination of the three. But regardless of the cause, the fact remains that desire for children is widespread while demands for sterilisation by YCW are extremely rare. While seemingly unjust, this enormous gap should factor into physicians’ assessment of whether to proceed with the procedure immediately on request.
Historically, sterilisation was often used as a punishment. And when a patient demands what most others would consider a punishment, a physician is justified in noting, internally, that the patient’s request is extraordinary. He might also reasonably conclude that extraordinary requests require extraordinary evidence. A mere apparent conviction should not always be taken at the face value.
Many women will obviously strenuously object to the idea that they are egged on towards sterilisation by their partners or that they are using it to self-harm or to impress their Instagram followers. They are right to do so and their feeling of being patronised is understandable. Yet, at the same time, so is any doctors’ reluctance to perform the procedure. A doctor cannot immediately rule out all too common existence of controlling boyfriends and self-harming young women. Any doctor who takes any of these possibilities into account is in fact behaving according to normative standards that doctors are frequently lectured on: of not committing a base rate fallacy.
Physicians’ reluctance decreases the chance of base rate neglect
Physicians are sometimes criticised20 for committing base rate fallacy. The essence of that argument is that, when forming a belief, one needs to take into account new evidence presented (such as symptoms of a disease or a request for permanent sterilisation by a YCW) and a base rate probability of such requests (ie, prevalence of the disease or proportion of YCW who do not want children). When physicians (and others) rely too much on new evidence and ignore base rates this is considered a ‘base rate neglect’. Just because symptoms look like those of a plague, it does not necessarily mean or it might not even be very likely that plague is, in fact, present.
The case that doctors face when YCW demand sterilisation is one where a base rate is extremely low, thus numerically analogous to a very rare disease. How low? Richie5 points to the fact that close to 20% of American women remain childless. However, more than a half of that number is due to medical infertility. Single heterosexual and homosexual women who desire children (sometimes described as ‘social infertility’) but do not pursue assisted reproductive technology and a large number of women who would want children if they had partners also belong to this group. After their numbers are subtracted, we need to take into account those requesting sterilisation for medical reasons (not wanting to pass on a genetic condition or having a condition that is incompatible with pregnancy). In all likelihood the proportion of women who are child free by choice for a reason that is not medically indicated is less than 5%. But even that number significantly overestimates the number of women in this group who demand(ed) permanent sterilisation when they were under 30. This number is likely under 1%. Some and perhaps many ObGyns will never face a single patient of this kind.
Thus, the case of sterilisation poses a greater burden of proof than, say, IVF, because its base rate (the percentage of women who do not want to have children) is much smaller. If physicians were to ignore this very low base rate in question they would be victims of a well-documented but widely understood to be erroneous tendency to overweight new evidence at the expense of statistical regularities.
Are childbearing decisions supposed to be narrowly rational?
A typical physician is unlikely to deeply reflect on subjective probabilities and utilities of a patient expressing desire for sterilisation, or their odds of regret. However, even if they are not demonstrably performing Bayesian analyses, they are justified in intuitively taking into account alternatives that could lead a young woman to demand sterilisation despite not truly wanting or even intending to go through it.
One could reasonably ask whether narrowly probabilistic framework is a correct way to approach childbearing decisions or even a good normative model of decision-making.21 After all, decision to have children is not ‘largely based on the false belief that parenthood will make people happier’, as Mertes claims. Most often, there is no much decision at all, but rather a continuation of a series of life stages that at least as frequently merely happen as they are deliberately chosen.
However, we should also note that it is precisely proponents of an immediate access to sterilisation that are advocating for this kind of misguided notion of rationality: ‘…those who want to become parents… (need to be)… more actively challenged to weigh the pros and cons of this important life decision, in the context of reproductive medicine and (especially) also in the general population,’ Mertes writes,2 suggesting that decisions based on cost-benefit analyses are somehow superior to less reflective ones. That this is a dubious proposition has been discussed at length in many places22–25 and there are good reasons to think that, more often than not, this kind of calculated rationality leads to increased paternalism.26
Persistence is a key proof of sterilisation intent
How hard is it for a YCW in the USA or UK to obtain sterilisation? Or, as it has recently been asked: ‘Why do women seeking voluntary sterilization face such extraordinary difficulties?’4
It turns out, on closer reading of the accounts of those publicising their struggles, not all that hard. Bri Seeley, one of the women who wrote about their struggles to get sterilised, thus reports27:
At the age of 24 I began to ask my doctors if I could be sterilized. Year after year at my annual exam I would state my case—each year unchanged from the previous year. At each visit my physician told me that I was too young, what if I changed my mind?….
… I side-stepped my physician and researched my options online. It was time to go straight to the source. I scheduled a consultation appointment with a gynecologist who could perform the procedure… The consultation was brief… I was able to communicate my passionate stance well enough that I was granted my wish. The appointment was set for six weeks later.
In other words, as soon as Seeley seriously looked for a physician who would perform the procedure (rather than merely mentioning it during her annual exams) she was sterilised.
Christina Richie28 similarly made curiously little effort to find a doctor who would provide much desired sterilisation. Instead, she, too, relied entirely on her own doctor without ever making an effort to find another doctor or even look up the laws relevant for her desires:
During my annual check-up, I told my female doctor that I had researched and considered the various methods of permanent contraception and I wanted to be sterilized via tubal ligation. At the time I was in graduate school in the Boston area, working on what would be my first master’s degree. Without asking why I did not want children, the doctor dismissed me as ‘too young’ to get sterilized and told me to ‘come back in a few years when I had a kid’. Although I protested that I would not be ‘having any kids ever’, I did not push for sterilization because I thought there must be a law preventing me from getting sterilized.
At the end, Richie was not sterilised at all—instead, her husband was; the same happened to Lori Witt. Other reports provide fewer details but typically have desired endings—Holly Brockwell and Julie Pam were both sterilised, the latter at age 22. So was Erin Iwamoto-Galusha at age 25. Lalonde’s claim that ‘women seeking sterilization in 2017… are… treated as objects of population policy’4 overstates the magnitude of the problem. Voluntary sterilisation of women in the USA has been legal for more than 40 years. Whatever few obstacles to being immediately sterilised do exist, at worst serve as a nudge that helps rather than hurts women, including those seeking sterilisation.
As Mertes observes, patients undergoing IVF are overcoming obstacles to parenthood which likely leads to greater satisfaction as well as self-selection. But the same is true of obstacles, such as they are, to voluntary sterilisation. 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 confused and uncommitted. If there existed a pill that could cause instant and permanent sterilisation without negative side effects, should it be available over the counter? At the supermarket checkout?
Sterilisation is sometimes analogised to euthanasia,29 especially in respect to weight that is given to patients’ autonomy compared with other considerations. However, euthanasia requests, in countries where euthanasia is legal at all, face a number of significant obstacles before the procedure is completed. While voluntary sterilisation is obviously not the same thing as euthanasia, neither are the obstacles that young women desiring it face or the urgency of their requests. For start, there are no legal obstacles, and having the procedure does not require psychiatric evaluation, a formal approval by a committee, and so on. Although there is an ongoing debate regarding immediacy of access to hormone replacement therapy and replacement of medical assessment with informed consent,16 30 gender reassignment protocols, with which sterilisation is sometimes also analogised,31 likewise currently require a significant period of evaluation.
IVF procedure is chosen out of necessity and is at the very least unpleasant and often painful and frustrating. Therefore, by its very nature, IVF selects for only the most persistent (future) parents. Similarly, a bit of sterilisation resistance selects for the best future non-parents.
Immediate sterilisation is not necessarily men’s gain, women’s loss
Evidence that young childless men have easier access to sterilisation appears to be largely anecdotal. However, even if it is so, several of the arguments raised above remain relevant.
First, while men and women typically desire the same number of children on average, some evidence suggests that men are almost twice more likely to be voluntarily childless than women.32 Also, when birth control fails, men, unlike women in the West, have no control over their procreative outcomes. Consequently, physicians have fewer reasons to question their desire for sterilisation than those of young women.
But even if we assume that the optimal level of sterilisation resistance is the exact same for men and women, it does not follow that this is necessarily the level facing men—it could be the one facing women, it could be somewhere in the middle, or lower, or greater than either. Just because men are easily getting it does not make it a thing of value.
Finally, it is unclear how women benefit from being sterilised instead of having their partners undergo vasectomies. It is often observed33 that women currently bear most of the financial and health-related burdens of contraception. While there is plethora of hormone-based contraceptives for women, men still only have two options—a condom and a vasectomy. If men were favoured for sterilisation among couples seeking it, a much needed balance rather than a favour to men would be obtained. A physician somewhat reluctant to perform tubal ligation or another form of sterilisation is, however, indirectly and inadvertently providing that balance, just like what happened with Richie28 and Witt. They chose to see this as unfair, but it could also be seen as an outcome that, to a partnered woman, confers all benefits of sterilisation with none of the costs.
Accounts of denied sterilisation requests reveal that many women in this situation feel pressured by societal expectations and pronatalist societal bias; they understandably oppose the idea that they should be judged primarily on whether they have become mothers. While these complaints contain important truths they fail to take into account the upsides of these societal attitudes for those women (certainly a large number and by all appearances a majority in many places) which relish the role of motherhood.34 Regardless of whether one focuses on the upsides or downsides of motherhood and the status it confers on women in society, however, these should not be confused with individual physicians’ reasonable reluctance to jump at a serious elective procedure at fairly mild expression of interest.
Contributors The article is entirely based on the work of ZB.
Funding This study was funded by Ministarstvo Prosvete, Nauke i Tehnološkog Razvoja (Grant: 47010).
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
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