Dr. Dustin Costescu’s name appears on a list of doctors on a Reddit forum willing to perform what many others apparently will not: “tubals” — permanent sterilization — on 20-something women convinced they do not want to have children, ever.
Costescu, a family planning specialist and assistant professor at Hamilton’s McMaster University, says any woman wishing to prevent pregnancy permanently, and who has no contraindications, or medical reasons why she shouldn’t be sterilized, should be considered appropriate for the procedure.
In fact, Canadian professional guidelines are clear: In a well-informed, mentally competent woman who understands her birth control options and the “permanency of the procedure,” sterilization should be offered regardless of age or parity, meaning whether or not she’s given birth, Costescu and his co-author Dr. Dylan Ehman write in an article published online ahead of print in the Journal of Obstetrics and Gynaecology of Canada.
However, “many women who desire sterilization at a young age experience barriers from physicians who decline to facilitate the request,” they report.
In a small case series, the authors reviewed the medical records of 29 women under 30 who had, or were on a waitlist for, sterilization at Costescu’s clinic. Most reported that when they first sought sterilization, doctors either refused to perform the procedure or refused to refer the women to a willing provider.
Some women said they were advised to seek a psychiatric evaluation, implying that it’s somehow “pathological” to want to opt out of motherhood, Costescu said.
He blames a “well intentioned paternalism” among doctors as well as inherent gender bias that women are meant to be mothers.
“Because my name happens to be on a Reddit board, and because of other articles, I’m getting more referrals from women seeking this,” Costescu said in an interview. The childfree forum contains posts like, “Article criticized UK for cutting off tax credits for 3rd child: Is that really a bad thing?,” “How can I convince my Mom that being childfree is a perfectly reasonable life decision?” and a post from New York Times reporters “looking to hear from women who regret having a child.”
There’s not a lot of longitudinal data to know whether more under-30s are seeking sterilization. “It’s unclear if this is more women choosing to be childfree,” Costescu said, “or increased comfort in advocating” for sterilization.
The surgery involves putting clips across the fallopian tubes via laparoscopic surgery, or removing a portion, or all of the tubes entirely, to prevent an egg from reaching the uterus and being fertilized.
With a traditional “tubal” the fallopian tubes can be reopened, untied or reconnected. However, a reversal doesn’t guarantee pregnancy and, in most areas, the $8,000 to $12,000 procedure is not covered. Another option is in vitro fertilization, or IVF, which can run $10,000 to $20,000 per cycle, Costescu said.
In the McMaster study, some of the women had medical conditions that could make pregnancy risky. Others already had two or more children and were certain they didn’t want another. About a third had never borne a child.
“Often these women have other role models in their life who are also childfree,” Costescu said. “They may be aunts or people in senior positions in their workplace — role models who demonstrate they can meet all of their other life goals without having children.”
Sterilization is generally safe and effective, he and Ehman write. Surgical risks include bleeding and infection, though the complication rate is less than two per cent. The 10-year failure rate ranges from less than one per cent, to five per cent among younger women. It’s a minor surgery performed under full anesthetic.
The most common risk is regret.
One U.S. review involving more than 11,000 women who underwent permanent sterilization in the 1970s and 1980s found that, after 14 years, the cumulative risk of regret was 20 per cent among those who were 30 or younger when they were sterilized, and six per cent for women over age 30 at sterilization.
However, regret was lower in women who had never had a child, compared with women with at least one, suggesting “a woman who is child-free and wishes to remain so is less likely to regret sterilization than a mother who wants no additional children,” the McMaster duo write in the JOGC. “Therefore, declining to refer or provide permanent contraception because of the risk of regret is a decision based on conscience and not evidence.”
(As an aside, they point to another study looking at major life milestones that found the fourth most common major life regret reported by Americans was becoming a parent.)
“I personally have zero worries about the risk of regret,” said a 26-year-old woman scheduled for a tubal ligation later this month at McMaster University Medical Centre. “I actually don’t remember a time when I’ve had a parental instinct (other than with animals),” she said in an email.
The woman, a small business owner in the Niagara Region who asked not to be named, said she has experienced “the typical comments about how I’ll change my mind, and that I’m ‘too young to know what I want.’ I’ve had doctors, all men, simply laugh off the situation and my concerns and tell me I’m not ready to make that decision (even though I have medical issues with my uterus and cervix).”
Her partner, she added, fully supports her desire to be child free.
Still, female sterilization has a horrid history. “In much of the 20th century, providers engaged in coercive sterilization of women from certain social locations” including Indigenous women and women with disabilities, they write. This past July, the Saskatoon Regional Health Authority released the report of an independent inquiry into Indigenous women who were coerced into being sterilized in the hours after giving birth in the city’s hospitals.
Costescu sees parallels between the forced sterilizations of Indigenous women and younger women being denied voluntary sterilizations because of paternalistic beliefs.
“In the case of Indigenous women, you are restricting women’s access to fertility. In this case you are supposing that all women must have children and women who choose childfree living are somehow making a bad decision,” he said. “They’re really two sides of the same issue.”
In the past, professional bodies advised restricting sterilization to women 30 and over, or using the “120 Rule,” in which a woman’s age, multiplied by the number of her children, had to total 120 or greater.
While new Canadian guidelines (which Costescu helped author) recommend no restrictions on the basis of age, Costescu said other doctors told many women in his practice they had to wait until they were 30. Today, the median age of first childbirth approaches 30, “which makes this number even less meaningful — half are still childless at this age.”