Earlier this month, a Michigan state lawmaker announced that she had undergone a sterilization procedure because she didn’t want to risk getting pregnant with Donald Trump as president. Laurie Pohutsky, who is 36, said she had already decided with her husband that they didn’t want more children. Pohutsky announced her decision at a political rally, attracting international attention and, she has since said, death threats.
The backlash is largely stemming from Pohutsky’s politicization of an intimate decision between a husband and wife, but the headlines have also brought to the fore an issue that has gotten little attention: a spike in the number of young women making this decision at the time of a global fertility crisis — some, much younger than Pohutsky.
According to research published last month in the journal Health Affairs, the incidence of both tubal ligation and vasectomy increased after May 2022 among men and women ages 19–26, doubling among young women. The Dobbs v. Jackson Women’s Health Organization case that returned the question of abortion to states was decided by the U.S. Supreme Court in June of that year.
“Our study shows that the Dobbs decision has had a profound effect on young adults’ reproductive choices, leading many to opt for permanent contraception in the months following the decision,” Julia Strasser, director of the Jacobs Institute of Women’s Health and assistant research professor of health policy and management at The George Washington University Milken Institute School of Public Health, said about the research.
While elective sterilization is a personal decision, it is not without societal costs, particularly in a time when declining birth rates pose demographic challenges worldwide. Those costs are both financial (a procedure can cost up to $6,000, although this is not paid by those on Medicaid or with private insurance) and emotional — counseling before sterilization aims to prevent a patient’s regret. Moreover, healthcare providers wrestle with myriad issues including how to ensure fair access without overly encouraging or restricting the procedure, amid a history stained with abuses.
The American College of Obstetricians and Gynecologists (ACOG) said in a 2024 statement on “ethical issues and considerations” surrounding permanent contraception that sterilization should not be considered elective, but a “medically indicated, time-sensitive procedure” as a means of “ensuring health equity.” According to ACOG, “Permanent contraception is the most used method of contraception among females aged 15–49 years (18.1%) and is more common than male permanent contraception (5.6%).”
Since the Affordable Care Act, commonly known as “Obamacare,” took effect in 2012, insurers have been required to offer contraception at no cost to the patient. Surgical sterilization is riskier than other types of contraception and is considered permanent. “Do it once, lasts forever,” Planned Parenthood says on its website. While tubal ligation can be reversed, unlike bilateral salpingectomy (removal of the fallopian tubes), there are still risks, not just with the surgery, but to a future pregnancy.
As such, even proponents of reproductive rights say it’s not a decision that should be made impulsively by any woman, let alone one in her early 20s. And there is research that shows that a woman’s desire for children can change throughout her childbearing years.
The risk of regret
Historically, insurers have denied claims to any procedure not deemed “medically necessary” although that changed after the Affordable Care Act became law, said Robin Fretwell Wilson, the Mildred Van Voorhis Jones Chair in Law at the University of Illinois College of Law.
As younger women seek sterilization, another question that is raised is “informed consent,” which is also a factor in discussions about medical body modification for minors. With regard to sterilization, Wilson said, the question is, “Can a person really know what their future self would want and are they in a position of being able to predict that and avoid regret?”
As described in The Wall Street Journal, the latest research on the brain shows that people in their late 20s make better decision than those in the early 20s, causing some people to propose that the period of time between age 18 and 29 be classified as “emerging adulthood.” The ACOG statement acknowledges this, saying that “full cognitive maturation — including the ability to incorporate long-term goals into complex decision making — is not reached until the mid-20s.”
And even a person who is convinced at 28 that they don’t want children could change their mind 10 years later after falling in love with someone who does.
One study found that more than a quarter of women who had elective tubal ligation later had regret, and an ACOG statement said that one analysis found that 10% of women who had a tubal ligation had surgery to reverse it. “In this study, young age at the time of sterilization was significantly associated with regret,” the statement said.
Dr. Kavita Arora, the lead author of the 2024 ACOG statement and a professor of obstetrics and gynecology at the University of North Carolina School of Medicine, noted that regret is reported after all types of surgery. Clinicians, she said, must respect the autonomy of the patient, understanding that “the patient is the expert in their own lives, their values, their experiences, their goals” and that the goal is for the physician and patient to work together to come up with best plan of treatment.
Still, the issue of regret is “a big part of what clinicians struggle with on the ground, especially post-Dobbs, where we feel like patients are being coerced into a permanent contraceptive method that they may not have initially wanted because of the health care policy environment around them,” Arora said.
She added that it’s important that patients are “well-counseled” and understand the alternatives available and both the physical risks and the risks of regret, which she said are greater for those under 30 and those with fewer than two children at home.
Catherine Pakaluk, a social scientist and associate professor at The Catholic University of America, said that it’s important that women know that the desire to have children — or not — is likely to change over time. She pointed to the findings of researchers at the University of California, Berkeley, who surveyed women of childbearing age in Kenya over time, asking about the total number of children they would like to have. The numbers varied so much among each individual that the researchers’ paper was called “The Illusion of Stable Fertility Preferences.”
“We find that although desired fertility is quite unstable, most women perceive their desires to be stable. Under hypothetical future scenarios, few expect their desired fertility to increase over time, but in fact increases in fertility desires are common,” the researchers wrote, later adding that “across horizons of 3 to 9 years, more than 60% of respondents change their stated desired number of children, and 20% change by 2 or more children.”
What physicians consider
The American College of Obstetricians and Gynecologists said in its 2024 statement, “Obstetrician–gynecologists should strive to avoid bringing into the clinical encounter biases around gender, race, age, and class that affect thoughts on who should or should not become a parent.”
While saying “Respect for an individual patient’s reproductive autonomy should be the primary concern guiding permanent contraception provision and policy,” the paper also laid out guidance for physicians treating women who seek sterilization. The recommendations include: suggesting options for long-lasting, reversible forms of contraception, discussion of risks in surgery to reverse a tubal ligation and suggesting the consideration of a partner’s vasectomy as “an option with fewer risks and greater efficacy.”
It also warns physicians against “medical paternalism,” saying that while health care providers may have a “protective impulse to help a patient avoid regret” this undermines the patient’s autonomy.
Physicians who do not want to perform sterilization because of “religious beliefs or other moral values” should offer alternate forms of contraception or refer the patient elsewhere, the paper says.
Another concern of the physicians’ group is that not everyone has equal access to medical care. The urgency of making a decision on sterilization may be influenced by someone who only has health insurance for a short time, or is already in the hospital to give birth, Arora said. (About half of tubal ligations are performed within 48 hours after a birth, and Pakaluk points out that might not be the best time to be making this decision, particularly if the birth was difficult.)
Others may have coverage for sterilization now, but may not later have the means for reversal later if they want it.
And hovering over the conversation about sterilization, beyond horrific abuses of the past, is the fact that there are differences in rates among ethnic groups: African American, Native American and Latina women are up to 2 times more likely to have been surgically sterilized than White women, and women without insurance or on Medicaid are 1.4 more times likely than their counterparts with private insurance, according to the ACOG statement.
“Although these data may reflect patient preferences, the reasons for these differences are not clear and raise concerns that all patients do not have equal access to the full range of reversible contraceptive methods. Patients who historically have been disenfranchised may have concerns about future inadequate insurance coverage. Additionally, it is possible that patients with low incomes and patients of color may be counseled differently about contraception than White patients or those with private insurance,” the statement said.
Why are more women getting sterilized?
Tubal ligation as a means of contraception has been available in the United States since the 1960s, with the rates growing every decade since. But after the Dobbs decision, researchers have been tracking increased numbers of men and women seeking sterilization in the states with the strongest abortion restrictions.
Writing about the increases last year in JAMA Health Forum, researchers Jacqueline Ellison, Brittany Brown-Podgorski and Jake Morgan noted an “abrupt” increase in permanent contraception rates since 2022 that suggested a “policy-induced change in contraceptive preferences.”
“Dobbs may have also increased a sense of urgency among individuals who were interested in permanent contraception before the decision,” the researchers wrote.
Danielle Pacia, a bioethicist and research associate at The Hastings Center, a bioethics research institute in New York state, said that while surgical sterilization must be considered carefully, it’s important that it be available to all women equally and that’s not the case now, since women on Medicaid must wait 30 days for approval unlike women with private health insurance. Moreover, believing that an individual should have control over their reproductive choices, Pacia said she is troubled by states that require a partner’s permission.
“Of course, anytime you have a medical procedure that has a higher-than-average risk of any kind of complication, you need to be really careful about how you educate your patient so they’re making an informed decision. However, these barriers that feel very gendered, they need to be dismantled,” Pacia said.
Of course, there are some people that think there should be more barriers to sterilization, not fewer, especially among a generation of older Americans who are struggling with their adult children’s decision not to have children. The New York Times addressed this late last year with an article headlined “The Unspoken Grief of Never Becoming a Grandparent.”
Then there’s the global fertility crisis, but about this, Arora said, “Population level questions, about population size and fertility, are probably not well imposed on the individual,” citing China’s former one-child policy as an example. “It just doesn’t go well.” People who want couples to have more children are better off advocating for policies like subsidized childcare than for more restrictions on permanent contraception, she said.
Pakaluk, a mother of 8 and the author of “Hannah’s Children: The Women Quietly Defying the Birth Dearth,” said that even for women in the mid-30s with multiple children, the chance of changing your mind is strong enough to warrant choosing a different form of contraception, even though there are doctors who have had success reversing tubal ligations. And she noted that the number of women choosing surgical sterilization for political reasons or out of fear is still quite small compared to those who are choosing it for other reasons.
Still, she said, “It’s not that I think everybody should have babies or everybody should have lots of babies, but I want to protect women’s opportunities to make decisions with full information, and the concern is that the information isn’t there. How many women know it’s very common to want more babies later? How many women know in their 30s they will not be as fertile as they were in their 20s? The humane approach, in a climate where there is a widespread lack of knowledge, is to get knowledge to people.”
She added: “Because you feel one way at 23, you might not feel that way at 33,” and women should know this when considering a “potentially irreversible procedure at a young age.” According to the Cleveland Clinic, the success rate for pregnancy after a tubal ligation reversal is. between 50-80%, dependent on the woman’s age and the surgeon’s skill, among other factors.
At least for now, there are still more babies being born in the U.S. (about 3.6 million in 2023) than women being sterilized (estimates are 700,000 a year). But there’s no question that, like the “shout your abortion” phase, “shout your sterilization” is gaining ground among certain young Americans. On Pinterest, people are sharing ideas for “sterilization parties” that celebrate the procedure publicly, much like Pohutsky did in her announcement.