Lack of access to permanent birth control

There’s a shift happening where – thanks to family planning awareness, access to contraception and cultural changes – having children is finally being perceived more as a choice rather than a default narrative. As a result many more people deliberately choose not to have children.

There are various reasons for deciding one way or another, it’s a complex choice and arguably the biggest you can make in your life. I knew from an early age that I wouldn’t have children, and wanted to safeguard myself to the maximum extent possible.

Even though I decided without doubt, having put a lot of consideration into my decision, I felt that it wasn’t trusted and that it was put to question if I can even make such a choice once I started looking into options for permanent birth control.

Contraceptive sterilisation seems to be a contentious issue. In my native country Croatia it is only possible to get sterilised once you are over 35 even though the age of majority is 18. Many countries where sterilisation is legal have similar age restrictive laws, some even with additional requirements such as already having a certain number of children or needing spousal consent.

Before 1969, the American College of Obstetrics and Gynecology had suggested that sterilization be performed according to an arbitrary formula involving age and number of children. It was called the rule of 120. A woman’s age multiplied by the number of her children had to total 120, or she could not be sterilized: Thus a woman of 25 with four children could not be sterilized. And one of 40 with two children could not either.”


Even where sterilisation is legal and a patient meets all criteria it can be difficult to find a doctor willing to perform it. While accessibility varies per country, this is generally more often the case for female sterilisation in comparison to male. Claims that a patient is too young, might change their mind and will come to regret their decision are common.

Refusals are so common that online childfree communities have taken it upon themselves to put together a list of those rare doctors that do perform the procedure.

The issue with rejecting a patient on this basis is not only that it gives them no way to appeal, as it’s impossible for anyone to prove that they will not change their mind – it’s also that as adults we should be entitled to our own regret. Having freedom and responsibility to make regrettable decisions is an essential part of life. Coming to terms with our choices is how we can come to understand ourselves more profoundly, become aware of faults in our reasoning and be able to carve out a better path for ourselves going forward. And so even if it was determined a patient will regret their choice (or they are assessed to be at high risk for regret), in taking away their choice they are not heroically saved from their regret, they are deprived of the opportunity to experience it.

In case of sterilisation the unfortunate consequence is that it takes away arguably the only option to be rid of the burden of fertility. While other methods of contraception are more readily available they are not as foolproof, may cause adverse side effects and/or are not fully within patient’s control (e.g. ‘stealthing’ with condom use).

As long as it’s clear a patient is well informed in their decision and making it on their own accord it’s wrong to deny their choice for the possibility of regret. We do not accept this sort of regret prevention being enacted in other areas of life. If a person is capable of deciding to take on debt, enlist in the army, have a child, then they should also be able to opt to get sterilised without having arbitrary restrictions imposed on them. After all, family planning is the responsible path to take.

Sadly the common experience for those seeking sterilisation, especially women, seems to be inappropriate comments, endless doctor shopping and baseless refusals. During my search I had the pleasure of having a doctor claim he can’t perform the surgery in his country due to ethical reasons during paid preliminary consultation for said surgery. More shockingly he then proceeded to imply that if I complain of abdominal pain he can perform exploratory operation and take out my fallopian tubes under the guise of them being infected. His suggestion would of course leave me completely vulnerable had he neglected our covert agreement and not taken out my tubes during surgery.

The lack of access, seemingly for no other reason than not being trusted to make the choice, is disappointing. Those persistent and with means to engage in medical tourism are likely to eventually get their way regardless, but others will simply be denied the option. There is a slow change happening however – earlier this year American College of Obstetrics and Gynecology put out a committee statement arguing for a different approach regarding patient regret:

“When patients consider an irreversible decision such as permanent contraception, it is possible that a physician may feel a protective impulse to help a patient avoid regret. However, this beneficent desire to “protect” a patient from the consequences of a permanent decision is a form of medical paternalism and should be avoided because it overrides or undermines patient autonomy.”

“Patients—not their physicians—are the ultimate experts on what is important and meaningful to them. Further, being a fully autonomous person with decisional capacity carries the risk of decisional regret, and eliminating all risk of regret is not possible. Denying permanent contraception to those who request it comes at the cost of limiting the ability of patients to fully express their reproductive autonomy regarding when and whether to become pregnant and to parent. This phenomenon has been coined the “dignity of risk”. When a physician or an institution restricts decisional capacity, the risk of regret may be reduced; however, eliminating decisional authority is ethically more problematic than decisional regret. Furthermore, any steps to verify sustained intent, such as requiring a mental health consultative visit before permanent contraception, no matter how well-meaning, serve as an additional barrier to care and should be discouraged as routine practice.”