When Hands Are Tied Instead of Tubes: The Barriers Women Face in Accessing Tubal Ligations Caroline Conway '24

BY CAROLINE CONWAY ’24

Cover Image: A baby lying in its crib. The decision to have a child carries significant emotional, financial, and professional implications, yet current medical policies can deny women access to one of the most effective forms of birth control, leaving them without the resources necessary to act on the decision to not have children.

Source: Wikimedia Commons Motivations for Childlessness and a Brief Introduction to Tubal Ligations

According to the U.S. Census Bureau, roughly twenty percent of American women will remain childless for the entirety of their lives (Dye, 2010). Only about half of these childless women are infertile (Richie, 2013). These statistics counter the social perception that childbearing is an inevitable part of female adulthood. For the purposes of this article, “women” refers to femaleidentifying individuals with the biological means to bear children, and “childlessness” describes the absence of biological children without accounting for surrogacy. Women decide against having children for myriad reasons. One motivation is to avoid the substantial economic burden of children — the United States Department of Agriculture (2013) found that the average middle-class family pays over 300,000 dollars to raise just one child to adulthood. Furthermore, this figure fails to account for the cost of college and potential medical emergencies. Thus, the apprehension women may feel due to this cost, particularly single women and/or women with a lower or unstable income, is understandable. Other women choose childlessness to avoid passing on hereditary diseases. Additionally, some women see childlessness as an altruistic choice that reduces their carbon footprint and prevents them from contributing to the adverse effects of population growth. Other women choose not to have children to avoid dangerous pregnancy complications or to evade the general disruption pregnancy/child-rearing might pose to their professional and/or personal lives (Richie, 2013). This is a non-exhaustive list of common reasons women cite for choosing childlessness, but it is essential to note that no one “reason” is necessary to justify such a choice. Some women simply do not want children, and that is reason enough not to have them. It follows that sexually active, voluntarily childless adults should have access to effective, long-term contraception.

Some voluntarily childless women turn to tubal ligations. A tubal ligation is a permanent sterilization procedure for women intended to prevent future fertilization by blocking the fallopian tubes. Generally, this surgery involves tying each fallopian tube with suture material and severing it. One primary tubal ligation method is the Pomeroy technique, in which a 2-cm loop of the tube’s midsection is tied off and the portion of the tube above the ties is then removed. Another common method is the Parkland technique, which involves tying the tube in two places and cutting away the portion in between these ties (EngenderHealth, 2002). This surgery is common; from 2006 to 2008, sterilization was second only to the pill as a form of contraception in American women ages fifteen through forty-four (Mosher & Jones, 2010). Globally, sterilization (including vasectomies as well as tubal ligations) is the most common method of contraception (EngenderHealth, 2002). The popularity of tubal ligations is unsurprising given the difficulty of accessing abortions in parts of the country and around the globe. Not all women are comfortable with the ethical implications of terminating a pregnancy or have the means to terminate a pregnancy, since state laws within the United States can make such terminations next to impossible. Therefore, some women who wish to remain childless identify preventing all future pregnancies as their best choice. This is easier said than done, however, as tubal ligation access remains a controversial topic in the medical field. Due to the prevalence of medical paternalism in tubal ligation consultations, the choice to undergo this operation may not be a choice at all.

Medical Paternalism and Tubal Ligations

The issue of tubal ligation access for voluntarily childless women has a historical basis in the U.S. — the American College of Obstetricians and Gynecologists codified pronatalist bias in the 1960s with the “120 rule.” According to this guideline, a woman qualified for sterilization if the product of her age and current number of children was at least 120, meaning that a childless woman could undergo the procedure at the age of 120. This standard was repealed in 1969 but was promptly replaced with requirements of a minimum age of twenty-one and the need for a doctor’s approval to undergo a tubal ligation (Lalonde, 2018). Today, despite the widespread use of sterilization as a safe and effective form of birth control, the path to tubal ligation procedures is often a challenging one for women to navigate, since doctors can choose to bar a patient access to a tubal ligation on the grounds of medical paternalism (Mertes, 2017).

Medical paternalism is the phenomenon in which a medical professional decides which treatments "some women who wish to remain childless identify preventing all future pregnancies as their best choice. This is easier said than done, however, as tubal ligation access remains a controversial topic in the medical field."

Figure 1: An illustration of various surgical procedures on the Fallopian tubes. Though invasive, tubal ligations are considered a safe and highly effective form of birth control.

Image Source: Wikimedia Commons

to offer a patient based on the doctor’s opinion of what is in the patient’s best interests. Generally, this is intended to utilize doctors' extensive training to maximize patient well-being (Mertes, 2017). For example, if a medical professional was approached by a patient who wanted an amputation, but the doctor knew they could instead save the limb in question, that doctor would likely refuse to perform the amputation and would offer the treatment they considered more appropriate instead. Essentially, medical paternalism is a gray area in medicine in which physicians might have the option to disregard patients’ desires. When a doctor disagrees with a female patient about whether a tubal ligation is justified, conflict results. In the absence of specific guidelines determining who can and cannot get a tubal ligation, individual doctors are relatively free to act on their personal judgments, essentially turning the consultation process for tubal ligations into a battle of wills. Because medical paternalism grants a doctor the last word on the matter, childless women often lose this battle. This is evident from the fundamental gap between the population of women who wish to be childless and the population of women who would be granted a tubal ligation upon request (Mertes, 2017). Even women with children demonstrate this access gap, as one study found that 31 percent of women who requested a postpartum tubal ligation were denied the procedure and that 46.7 percent of these women became pregnant within the next year (Thurman & Janecek, 2010). The practice of medical paternalism can often mean that childless women are unable to undergo tubal ligation procedures even in the absence of substantial health risks related to the operation. The need to obtain a doctor’s approval effectively bars many childless women from having tubal ligations, as their doctors can deny them access to the procedure based solely on the doctors’ belief that the women will eventually want children.

Before rejecting the application of medical paternalism to tubal ligation requests, one must understand why doctors feel that such paternalism is necessary. One of the primary justifications doctors cite for medical paternalism in tubal ligation procedures is the concern that patients may come to regret the procedure and be powerless to do anything about it, as it is meant to be permanent. Evidence suggests that this concern is not entirely unfounded. One study found that 20.3 percent of voluntarily sterilized women ages thirty and younger regretted their sterilizations, and 5.9 percent of women older than thirty reported regret (Hillis et al., 1999). Physicians can use such statistics to argue that denying a woman access to a tubal ligation is in her best interests, since she might regret the procedure later. However, the reality of the nature and frequency of regret related to tubal ligations renders such arguments hollow. The women regretting their sterilization procedures represent relatively low proportions of the patient population. Hillis et al. (1999) found that over 79 percent of women thirty and under who had a tubal ligation expressed no regret regarding their decisions, and over 94 percent of women expressed no regret in the age group over thirty. Additionally, some permanent procedures with considerably higher regret rates are far less regulated. For example, one study found that 37 percent of patients regretted getting a tattoo, yet 24 percent of patients were able to access a tattoo procedure while under the legal age limit (Aslam & Owen, 2013). This suggests that doctors’ concerns about regret are not well supported, as regret is a problem with relatively few women who have had a tubal ligation performed and does not seem to factor as heavily into policy enforcement for other permanent procedures.

In contrast, the denial of tubal ligation access carries a substantial risk of regret. One study found that 47 percent of women denied sterilization regretted not being sterilized — a percentage more than twice as high as the 20.3 percent regret rate in women thirty and younger who were granted the procedure (Lalonde, 2018). This suggests that doctors not only place excessive emphasis on regret in women who undergo tubal ligations, but also that doctors fail to consider the regret women suffer from as a result of being denied the procedure. If doctors truly seek to minimize patient regret, they should arguably find a 47 percent regret rate more compelling than a mere 20.3 percent, especially considering that biological parenthood remains possible via in vitro fertilization after a tubal ligation.

Researcher Cristina Richie (2013) found that one of the most common reasons doctors provide for denying women tubal ligations is that the women are too young. Consequently, many doctors opt to impose a minimum age limit of twentythree on the procedure (Richie, 2013). This is a judgment on the doctors’ part; United States law allows women to get tubal ligations at and above the age of twenty-one. This restriction rests on the assumption that women requesting tubal ligations will come to regret their decision with age.

Another reason doctors choose to deny women tubal ligations is a lack of spousal consent.

Richie (2013) found that fifty percent of doctors performing female sterilizations required spousal consent before agreeing to perform the procedure. This restriction, like the one on age, is meant to protect the patient from the possibility of future regret, assuming that a disagreeing spouse would expect children in the future and that the patient should plan accordingly. The effects of this policy are that unmarried childless women face extensive difficulty in accessing tubal ligations because doctors might assume that their future spouses will want children, and married women lack full bodily autonomy when their spouses are unsupportive of their decisions regarding sterilization.

Finally, the application of medical paternalism to matters of tubal ligations today reflects the “120 rule” from the 1960s –many doctors require the woman trying to receive a tubal ligation to have at least one child before the operation is performed (Richie, 2013). This restriction is based on the assumption that women will regret having a low number of children less than they will regret having no children at all.

Many of the requirements to get a tubal ligation reflect the assumption that all women want to be and should be mothers. Take, for instance, the argument of regret. Fertility treatment, like a tubal ligation, will significantly impact a woman’s ability to bring a child into the world and requires careful consideration. However, researcher Heidi Mertes (2017) notes that regret is not emphasized comparably for fertility treatments: “If regrets are talked about at all in the fertility clinic, it is mainly in the sense that infertile couples should do everything they can to conceive a child in order to prevent future regrets” (p. 315). Some individuals might argue that this discrepancy is partially due to the permanence of tubal ligations, but the process of parenting a child is arguably as long-lasting as tubal ligation effects. Additionally, tubal ligations can be reversed in some cases, and parenthood remains possible through means such as surrogacy or adoption. The stark contrast in concern over regret between tubal ligations and fertility treatments reflects a societal pressure on women to have children. Medical paternalism can allow this pressure to be incorporated into medical care.

The Consequences of Tubal Ligation Denial

Philosophy professor Martha Nussbaum (2008) created a list of “central human capabilities” necessary to achieve a state of well-being: life, bodily health, bodily integrity, senses/ imagination/thought, emotions, practical reason, affiliation, other species, play, and control over one’s environment. Nussbaum (2008) describes bodily integrity in part as “having opportunities…for choice in matters of reproduction” (p. S110). It is easy to see how a tubal ligation would aid a woman in the pursuit of such autonomy. Undergoing a tubal ligation not only grants women the reproductive choice Nussbaum describes, but also removes the economic, physiological, and psychological factors of parenthood that might prevent them from achieving a state of personal flourishing. Denying women tubal ligation access alters their ability to achieve happiness on the most fundamental level by limiting their capacities for long and healthy lives. In addition to bodily integrity, Nussbaum (2008) includes both life and physical health in her list of central human capabilities that are key to well-being. Pregnancy complications can negatively impact a woman’s health. For example, pregnancy has been linked to high blood pressure and increased risk of cardiovascular diseases in some women,

Figure 2: Anti-abortion protestors outside a Planned Parenthood facility in Portland, Maine. Legal and social opposition to abortion can leave women unable to choose childlessness in the case of an unwanted pregnancy resulting from tubal ligation denial. Image Source: Wikimedia Commons

especially in those who are younger when they give birth to their first child (Parikh et al., 2017). In other cases, pregnancies can be mortal. According to Dr. Adrian Brown, pregnancy/ childbirth mortality is the leading cause of death for fertile women in developing countries (Eaton, 2003). The risk for complications and death due to pregnancy varies from woman to woman but can be evaded with the avoidance of pregnancy itself. Tubal ligations are tied to patient health in relation to cancer risk as well. One study reported that tubal ligations were associated with a twenty percent reduction in ovarian cancer risk and in peritoneal cancer risk, and the study also found that tubal ligations were associated with a general decrease in the risk of cancers of the fallopian tubes (Gaitskell et al., 2016). Granting women tubal ligations upon request with informed consent, therefore, could save and/or prolong those women’s lives. Most other areas of life allow individuals to assess the risk of injury or death and reach their own conclusion about whether the relevant activity is worth that risk, and people are given the freedom to opt out of activities that they consider too high-risk. Take donating an organ, for instance. One does so at their own risk, accepting personal responsibility for the outcome. Societal standards allow such responsibility to fall on the individual alone. However, medical paternalism can allow pregnancy to be treated as an exception to this rule.

Medical paternalism is based on the Hippocratic Oath’s mandate that physicians “do no harm.” However, physicians using paternalism to deny their patients tubal ligations may inadvertently harm those patients. Take, for instance, the testimony of one voluntarily childless woman researcher Kristin Park (2002) interviewed: “It’s like you’ve done something wrong, or somehow you’re not matching up, or you’re a failure in some way” (p. 30). This description of being a voluntarily childless woman reflects the toll pronatalist societal expectations have taken on the woman’s well-being. She feels judged and out of place as a result of her decision to not have children. When doctors perpetuate childbearing expectations by refusing to perform tubal ligations on childless women, they can contribute to harmful stigmas that depict voluntary childlessness as a moral wrong. Kristin Park (2002) found that many voluntarily childless interviewees felt that they were viewed as more materialistic, cold, and self-centered than their peers with children. These perceptions are evidence that voluntary childlessness is a stigmatized identity like any other, requiring individuals to find coping mechanisms in the face of negative stereotypes The tubal ligation is considered one of the most effective forms of birth control, with a failure rate below one percent (Mosher & Jones, 2010). In denying childless women access to such an effective birth control measure, doctors risk exposing women to unwanted pregnancies and unwanted abortions — both experiences associated with emotional and physical pain. Such pain might result from pregnancy complications, as previously discussed, or could stem from postpartum psychiatric disorders. For instance, one in seven women who recently gave birth experience significantly disruptive depressive episodes. New mothers are also prone to postpartum recurrence of prior psychiatric illnesses. For example, 21.4% of new mothers with a previous diagnosis of bipolar disorder and 13.3% with a previous depressive illness require postpartum admission for these conditions (Wisner et al., 2006). Considering these dangers of pregnancy, medical paternalism as a basis for denying tubal ligation access does not seem consistent with the Hippocratic Oath’s requirement that doctors “do no harm” to their patients.

Conclusion

The issue of how medical paternalism impacts tubal ligation access is more than a question of mere birth control convenience; the decision to deny someone the procedure can rob them of their bodily autonomy and have lasting impacts on their well-being. This suggests that a policy change is necessary — patients, rather than their doctors, need to be responsible for weighing the risks of potential regret and making informed decisions. One of the voluntarily childless women Park (2002) interviewed demonstrated the conviction that could drive tubal ligation consultations going forward: “It’s my life. It’s what I want to do. I think I’ve learned not to apologize for it anymore” (p. 36).

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