By Auriane Vez and Sander Dekker
Getting a sterilisation may seem like a very personal decision to make, yet one might be surprised how many people will get to have a say in it, ranging from real-life doctors and psychologists to hypothetical partners and speculative future versions of oneself. The choice not to have children is still met with scepticism. We found that getting a sterilisation in the Netherlands still comes with a lot of pushback from medical professionals, who made various assumptions about whether we would regret our decision based on our gender, age, and relationship status. Our experiences overlap in some ways but are different in others. For example, Auriane’s experiences as a cisgender woman were different from Sander’s, who, despite being non-binary, was still treated as male by the medical institutions. We will explore how heteronormativity, pronatalism, and power dynamics influence the trajectory of getting a sterilisation, and finally, how getting a sterilisation can be seen as a political act. Our hope is that if you are in this process of getting a voluntary sterilisation or consider doing so, you will find comfort, strength, and arguments to assert your agency and positionality during your interaction with the medical professionals.
In order to understand why obtaining a voluntary sterilisation is still a challenge today, it is essential to look into the societal imperative of motherhood. This imperative can be understood through the lens of heteronormativity and pronatalism. Heteronormativity is not only the social expectation that one should be heterosexual, but it is also a way of life. In a heteronormative society, people are expected to get married, have children, and conform to gender roles. These expectations are institutionalised as the society is structured, organised, and regulated around heterosexual norms. As social norms about gender become institutionalised, the personal becomes political.
One way that heteronormativity is institutionalised is through pronatalist policies. Pronatalism actively promotes and views childbirth as an essential obligation. Women are expected to have children, and motherhood becomes inherent to womanhood. The philosopher Paddy McQueen (2019), who wrote in defence of voluntary sterilisation, explains that the idea that a woman “will eventually grow out of her infant state, will reach maturity and will then wish to have children” is conveyed repeatedly throughout literature, movies, and advertisement, but also throughout medical practice and government policies.
While societal expectations heavily emphasise motherhood as intrinsic to womanhood, the social identities of men are less narrowly defined by fatherhood. Men are generally expected to want children, and their decision not to have children will be subject to scrutiny, too. However, this scrutiny is substantially less intense compared to the societal pressure and stigma faced by women, whose identities are often closely tied to motherhood. This reflects deeply ingrained gender norms that position motherhood as a central aspect of womanhood while allowing men more flexibility in defining their social identities beyond fatherhood.
These discourses end up being internalised by medical professionals, which directly impacts access to voluntary sterilisation. Indeed, Paddy McQueen (2019) asserts that doctors control access to sterilisation. This is evident from our personal experiences:
Auriane: Initially, I had to persuade my GP, who subsequently referred me to a gynaecologist. Then, I had to convince the hospital’s GP, who allowed me to meet with the gynaecologist, whom I also had to convince. Finally, I had to convince a psychologist that I was certain and knowledgeable about MY body and what I wanted. Despite all these efforts, all the medical professionals I interacted with collectively decided FOR ME whether I would be granted sterilisation or not. What is really interesting (and frustrating) is that despite having the power to make the final decision, the medical professionals consistently presented this choice as mine.
The contradictory discourse from the medical professionals that Auriane encountered illustrates the internalisation of pronatalist and heteronormative norms. This directly impacts access to sterilisation. Sterilisation is not a medical necessity, as the patient’s health does not depend on it. Therefore, doctors are not obliged to aid in the procedure if they are not convinced it will benefit the patient. This inevitably makes access to sterilisation dependent on the arbitrary opinions of medical professionals, which can be heteronormative and pronatalist. The opinions of medical professionals regarding the appropriateness of sterilisation vary depending on age, sex, mental health, and relationship status. This can have a significant influence on how much pushback someone gets, or in some cases, even whether one can get a sterilisation at all.
Heteronormativity is also prevalent in the medical guidelines regarding sterilisation. The paradigm of these guidelines and information brochures presumes a gender binary. Indeed, the language presumes all people with testicles to be men and all people with ovaries to be women. Non-binary, transgender, and intersex people are not taken into consideration. Furthermore, while the operation itself is different for a person with ovaries than it is for a person with testicles, there are also unnecessary differences in the way people are treated leading up to the operation. People who are perceived as women will generally face more scrutiny than people who are perceived as men. People treated as men will usually only see a general practitioner and a urologist. However, when someone with a uterus seeks to get a sterilisation, it is not uncommon that there will also be a medical psychologist involved, besides the general practitioner and the gynaecologist. This psychologist needs to evaluate whether the desire not to have children is influenced by any mental health issues or caused by a traumatic experience, such as miscarriage or abuse. This attitude reflects the idea that women naturally desire to be mothers, and that there is probably something wrong with them if they lack this desire.
Auriane: I was lucky to have an understanding and curious psychologist for the psychological evaluation. Despite being understanding, the entire conversation was around regret and having to prove that I would not regret my decision. The only thing this conversation allowed me to realise was that if there were complications during my surgery, I would still feel no regrets about my decision. Nevertheless, having to see a psychologist about a decision I had already thoroughly considered and made for myself was quite challenging. Once again, my agency and autonomy over my own body were taken away. When I expressed how patronising this was to the gynaecologist, they replied they feared being responsible for regrets I might feel later, as I never know what life could bring me.
This illustrates what medical professionals are most concerned about: that the patient comes to regret having a sterilisation, especially when they are young and single. Some clinics and hospitals will not even treat anyone below 30 or 35 years old. Both of us decided to get a sterilisation before our thirties, Auriane at 28 and Sander at 29. We were both told we were still very young to make such a final decision.
Auriane: The question of my age was always brought up. So I kindly reminded them that if a woman of my age or even younger were considered capable and mature enough of making the decision to have children, I should be equally considered capable of making the decision to not have any.
Having one’s decision questioned because one is told that one is not old enough to know for sure whether one will not change one’s mind can feel extremely infantilizing. Even more so when considering that people our age are considered mature enough to make the equally final decision to have a child and take care of it.
The politics of regret is extremely selective. According to the political scientist Dianne Lalonde, regret is based on norms defining what should be regretted. She asserts that the notion of regret is rooted in pronatalism and the biological imperative to have children as women. The sociologist Orna Donath builds upon the idea that regret excludes the fact that women can regret being mothers. Indeed, in her study, she demonstrates that some women regret having children and “wish to return to being nobody’s mom” (Donath 2017, p.xiii). This again highlights the social construction of regret, the influence of pronatalism, and the social imperative to become a mother.
Another way that the politics of regret and heteronormativity are intertwined in the process of getting a sterilisation is how medical professionals look at the patient’s relationship status. The decision to have a sterilisation is presumed to be made while being in a long-term monogamous relationship. When someone single applies for a sterilisation, they will be told that they are likely going to regret it once in a relationship. In our society, others often dismiss people’s desire not to have children with the argument that they simply have not found the right partner yet. However, when someone finds their true love, they will inevitably want to have babies with them, or so it is believed. This idea also exists among medical professionals.
However, the interest of the medical professional in one’s relationship status goes beyond concern for the permanency of the patient’s desire not to have children. The patient may also regret the decision due to the impact it will have on their love life. Even if someone has a relationship and does not necessarily want to have children personally, they are still expected to take the wish of their partner into consideration. Both of us were asked, “What if your partner wants to have children?” This implies that we should still consider having children for our partner’s sake.
Sander: Being single, I was told by the urologist that I would be severely limiting my dating options with a sterilisation, because, as she said, “most women do want to have children.” The urologist also told me about long-term relationships ending due to one partner wanting children while the other partner did not. This would be another way in which I may come to regret my decision to have a sterilisation.
This focus on the desires of partners omits the fact that someone can select a partner who is on the same page as they are. Neither of us would choose a partner who would want to have children. These matters can easily be discussed early on in a relationship, without destroying any long-term bond.
Auriane: My partner at the time did not want children either. My gynaecologist asked me why he was not the one who was getting sterilised. To which I asked, “why would it be ok for him to get sterilised and not for me? And what if I am not with him anymore?” I wanted autonomy over my own body regardless of my relationship. I think this demonstrates how medical professionals will use any argument to attempt to withhold sterilisation from the person asking for it, especially the people perceived as women.
Indeed, medical professionals can give many reasons to dissuade people from getting a sterilisation.
Sander: For my urologist, the risk of regret was not the only reason why she objected to me getting a sterilisation while being single. She also felt that the decision should be made together with a partner. I was accused of denying my future partner a say in this decision. Obviously, this moral judgement has nothing to do with risk assessment or medical expertise. Fortunately for me, my urologist eventually agreed to perform the operation, despite her own opinion on the matter. However, I know some doctors will not set aside their moral judgement in favour of bodily autonomy. At a meeting for childfree people, I spoke with a man whose general practitioner refused to give him a referral for a sterilisation, precisely for this reason—because he would be denying his future partner the choice.
This shows that the hypothetical desire for children of a hypothetical partner can matter more to a doctor than their patient’s actual desire not to have children. It also illustrates the arbitrary influence of the personal opinions of medical professionals when it comes to getting a sterilisation.
Of course, it is understandable that a doctor does not want to perform a procedure that the patient will regret later. We do believe that medical professionals are genuinely concerned about the well-being of their patients. It is also reasonable to assess whether the patient understands all the risks involved. But if a doctor refuses to perform a desired procedure that would give a patient more control over their own body, unless the patient can thoroughly convince the doctor that they will not come to regret it later, it takes away the patient’s agency and bodily autonomy.
Sander: My counsel meeting with the urologist was basically a 25-minute debate where the urologist tried to talk me out of getting a sterilisation. The urologist was convinced from the start that I would come to regret it. This resulted in rather futile conversation. No matter how certain you are about your decision, any argument you present can always be countered with the argument that you could change your mind about it. That is not something that can be proven or disproven.
Arguing that someone will one day change their mind is not only pointless, but also disrespectful. In order to have a discussion as equals, one should at least acknowledge the other as the authority regarding their own desires. The philosopher Talia Mae Bettcher has made an argument for the ethical importance of first-person authority. First-person authority applies to statements about personal attitudes, which include opinions, beliefs, and emotional responses toward various aspects of life and experiences. Our attitudes are in the first place a private matter. Bettcher asserts that by stating our attitudes, we choose what we reveal about our inner lives and take responsibility for them. Once we share our attitudes, we create space to talk about them, but it is not up to others to contradict them. Doing so would infringe on the person’s autonomy. So even if there is a chance that someone would change their mind about something, it is still wrong for another person to claim the authority to know better what that person is going to think, as it undermines the person’s autonomy in the present.
Considering how the power of medical professionals undermines our bodily autonomy and reproductive rights, it is important to talk about how getting a voluntary sterilisation can be an embodied political act. As previously mentioned, the personal is political, as gendered bodies are governed by policies. In times when reproductive rights are being revoked and questioned, it is rather apparent how bodies are policed and how, in this context, the very personal choice of having children or not is political. During the process of getting a voluntary sterilisation, our bodies are also at the mercy of medical professionals and institutions, which, as we have discussed throughout this article, perpetuate and materialise the internalised heteronormative and pronatalist norms.
Auriane: As I knew that the process of getting a voluntary sterilisation would be an emotional endeavour, I decided to approach it as an embodied political act. In that way, I could transform the frustration of seeing my agency being taken away into power for change.
This activism work took on various forms, including efforts to educate the medical professionals and institutions I encountered during the process. Recognizing the inherent power dynamics, I used my positionality of being a student in gender and sexuality to assert the power of the knowledge I was using to construct my argument. I provided academic articles to highlight the ethical issues surrounding sterilisation denial and discussions on regret. I leveraged my privileged position not only to advocate for myself but also to advocate for systemic change. I wanted to participate in what bell hooks calls “political solidarity,” where women and other gender minorities gather and share their commitment to face and fight patriarchal oppression. I had myself benefited from the political solidarity in connecting with other women to find out which hospital seemed to be more favourable towards granting a voluntary sterilisation to younger women.
I used the rhetoric of medical professionals and turned it around to show them how their perspective was not only oppressive but rooted in pronatalism. For example, I highlighted their bias by mentioning to them that they would not ask a woman why she does want kids the way they were questioning why I did not want any. I am pleased to share that during the mandatory psychological evaluation, I learnt that the gynaecologist had written in their report: “we do not ask women who are going to have children if they will regret it.”
When I woke up from the surgery, I immediately felt the relief of knowing the social expectation of having children was not an option anymore. Knowing that when people would tell me, “oh, but you will change your mind, you will see,” I would have my body backing me up when answering that this would not happen. I reclaimed power over my own body and embodied the resistance against the heteronormative and pronatalist norms while knowing that I had planted the seeds of reflection in the minds of the medical professionals I had connected with throughout this process.
Sander did not approach her sterilisation as a political act in the same way as Auriane did. Afraid to antagonise the medical professionals who would decide whether or not she could get a sterilisation, she did not want to argue with them more than necessary. This still meant that Sander had to defend her decision against her urologist’s arguments, but she did so in terms of personal disagreement and how she felt about having her autonomy being undermined, rather than pointing out the pronatalist rhetoric. For Sander, the political aspect of her decision was primarily about taking responsibility for birth control.
Sander: For me, getting a sterilisation was about taking control over my body. By becoming infertile, I would no longer have to worry about getting someone pregnant. The idea of accidentally becoming a parent has always been terrifying to me. But even if an unintended pregnancy could be ended with an abortion, that is still not something I want my partner to have to go through. While I made the decision primarily for myself, it was at least partially a political decision as well. With my sterilisation, I have taken responsibility regarding anticonception for both myself and my partners. I think that it is too often expected that the partner who can get pregnant has to take the burden of contraceptives and deal with the consequences of pregnancy. By having a sterilisation and talking about it, I also want to challenge this unequal division of responsibility. I think more men should consider having a sterilisation if they are sure that they do not want to have children and not just expect their partners to take care of that.
Shifting the responsibility of contraception away from individuals with a uterus is another political approach to a voluntary sterilisation. The sociologist Krystale Littlejohn discusses in her book Just Get on the Pill: The Uneven Burden of Reproductive Politics that contraceptives, like housework, can be considered a form of domestic labour. This labour is primarily undertaken by women and individuals with a uterus due to social expectations linked to gender, despite there being multiple forms of contraception available for people with testicles. Such assumptions go unchallenged and influence behaviour, reinforcing the division of responsibility. This unequal division is also upheld by some clinics that provide sterilisation. For example, on their website, Snipmeister tells men younger than 30 to reconsider getting a sterilisation if their partner has no objections to getting an abortion. While normalising sterilisation as a form of anticonception could help share the responsibility more equally, pronatalist sentiments continue to uphold the unequal division by discouraging permanent forms of birth control in favour of temporary ones and even abortion, regardless of whether people even want to have children at all.
Navigating the landscape of voluntary sterilisation unveils the intricate interplay between personal agency and societal expectations. By engaging with medical professionals and institutions, we confronted deeply ingrained gender norms that perpetuate unequal burdens in reproductive health. By leveraging personal experiences or advocating for systemic change, we not only reclaimed power over our bodies but also challenged and attempted to reshape prevailing narratives. Getting a voluntary sterilisation is about personal choice, but it can also be about dismantling oppressive structures and paving the way for more inclusive and equitable reproductive health practices and gender norms.
Sources
- Bettcher, T. M. (2009) Trans identities and first-person authority. In L. Shrage (ed.), You’ve changed: Sex reassignment and personal identity (pp. 98-120). Oxford: Oxford University Press.
- Donath, O. (2017). Regretting Motherhood: A study. North Atlantic Books: Berkeley, California.
- Lalonde, D. (2018). Regret, shame, and denials of women’s voluntary sterilization. Bioethics, 32(5), 281-288.
- Littlejohn, K. E. (2021). Just Get on the Pill: The Uneven Burden of Reproductive Politics. University of California Press.
- McQueen, P. (2019). A defence of voluntary sterilization. Res Publica, 26(2), 237-255.