By Teresa Baron.
Getting your tubes tied is no easy feat. Plenty has been said in recent years about barriers to elective sterilisation, and persuading a doctor to do the deed is a particularly difficult for young, child-free women. If a woman has a long-term partner, her practitioner will often encourage her to see if she can get him to have a vasectomy instead; if she’s single, she will often be told to consider the preferences of a hypothetical future partner; and if she’s young and child-free, her practitioner might suggest that she wait a few years, ‘just in case’ she changes her mind about motherhood. (It is worth noting that couples seeking to have children are usually not treated with the same kind of scepticism about their motivations or commitment).
However, in certain parts of the UK, it’s not enough to persuade your practitioner that you’ve thought carefully enough about sterilisation, understand the relevant risks, and are competent to give informed consent. Some integrated care boards have more demanding policies, and require that a patient trials an intrauterine device (IUD) for at least a year before she’ll be allowed to have her tubes tied. (There are a few exceptions – for example, for women who have their tubes tied during caesarean section.)
The IUD is a small device inserted into the uterus, which prevents fertilisation or implantation of a fertilised egg. This is widely considered a safe and effective contraceptive option, and the copper IUD is one of very few non-hormonal contraceptives currently available to female patients. However, many women report that the insertion process is painful, and some also experience pain for many months following insertion. When IUD removal appointments are not readily available, this can have debilitating consequences. Lucy Colleer, an NHS Transformation Manager, was recommended the copper IUD as an alternative to hormonal contraceptives that had impacted her mental health for several years. However, not only was the IUD insertion procedure painful, she ‘was nearly bed bound with pain and nausea’ for days afterwards. After this pain impacted her day to day life and intimacy for about six months, Colleer decided to have it removed.
Another young professional, Anna* says that after her IUD was fitted, her doctor thought that her pain was being caused by an incorrect insertion: ‘They scheduled an ultrasound, for which I had to wait for many weeks while the pain became increasingly bad. After one month I was barely able to get up off the sofa and I decided to have the IUD removed.’ For Stephanie O’Donohue, a content and engagement manager for Patient Safety Learning, the pain of IUD insertion ‘was like nothing I had ever experienced before, it felt like a knitting needle was piercing my womb. I screamed uncontrollably and cried throughout. I was left shaken for days and traumatised for many years, extremely fearful to return for it to be removed.’ Although such experiences are not universal, pain during IUD insertion is widely reported (particularly for women who haven’t had children) and the NHS does not routinely provide pain relief during this procedure.
Let’s face it: if the NHS just wants to ensure that a patient has certainly, definitely, absolutely made up her mind about tying her tubes, a mandatory waiting period would suffice. The IUD requirement takes things a step further. This offers us a lens to think about the ethical limits of ‘nudging’ patients away from elective procedures seen as too costly (economically or socially) to offer readily. Tubal ligation is 4-5 more expensive than vasectomy, and must be performed under general anaesthetic (unlike vasectomy, which is a far less invasive procedure and is performed under local anaesthetic). At the same time, the IUD is not ‘sterilisation-lite’. The data available suggest that sterilisation has specific psychological and emotional benefits for many patients who seek it – not only offering greater security against the risk of unwanted pregnancy, but also acting as the embodiment of an important life decision. (And despite the fears cited by reluctant doctors, sterilisation regret among child-free women is vanishingly rare).
If sterilisation does represent a nonfungible good, the basic principle of equal treatment suggests that this is a good that the NHS should provide to male and female patients equally. Moreover, patients should have equal access to treatment with patients in the next county over. It seems far from reasonable to make women in a few areas of the UK prove their determination by submitting to an unnecessary and invasive intervention as a condition of their requested treatment.
*This name has been changed
Author: Teresa Baron
Affiliations: University of Nottingham
Competing interests: None declared
Social media accounts of post author: https://www.teresabaron.co.uk/