Illustrative image for Requests for Sterilization, Abortion Bans, and Reproductive Justice

Bioethics Forum Essay

Requests for Sterilization, Abortion Bans, and Reproductive Justice

In the nearly three months since the United States Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision eliminated the constitutional right to an abortion, doctors have reported increased in demand for sterilization by female patients. This interest in permanent contraception likely reflects patients’ fear of losing reproductive autonomy. It also raises several ethical issues concerning reproductive justice, including disparities in access to care and questions about autonomous decision-making.

Most of the gynecologic patients who undergo sterilization, or surgery for permanent contraception, are Black and Hispanic. This was the case even before the Dobbs decision. As communities of color are disproportionately impacted by restrictions on abortion access and have higher rates of maternal morbidity and mortality, those restrictions are not only inequitable, but also dangerous. Since gynecologic patients from marginalized backgrounds disproportionately make up patients receiving permanent contraception and are also the patients most impacted by abortion restrictions and the associated outcomes, we think it’s likely that even more Black and Hispanic patients, compared with white patients, will seek permanent contraception in response to the Dobbs decision.

Differences in preference for permanent contraception influenced by individual, familial, and cultural values and preferences should be understood, respected, and upheld. But it is unclear to what degree these differences are the result of informed consent and personal choice.  The disparity may be due to external factors and barriers. Given the history of forced sterilization in the United States, especially impacting Black women, it is important to recognize the heightened threat to reproductive justice for this community. For example, clinicians’ implicit biases influence contraceptive counseling and, some evidence suggests, may lead to greater willingness to recommend permanent contraception to Black or poor women. It is imperative that clinicians consider the history of reproductive coercion among these groups and implicit biases that may further perpetuate racial disparities in permanent contraception, while also maintaining a commitment to honoring autonomy in reproductive decision-making.

              Even as most requests for permanent contraception come from Black and Hispanic women, many of them face a clinically and ethically unjustifiable waiting period for the procedure, imposed by Medicaid, as we discussed in an article in the current Hastings Center Report. Black and Hispanic patients represent nearly half of women insured by Medicaid. The Medicaid policy mandates that a patient must wait at least 30 days, but no longer than 180 days, after signing a consent form to undergo a permanent contraception procedure. (It allows for a 72-hour waiting period instead in specific circumstances, such as premature delivery.) Although this policy was instituted to reduce the risk of coercion associated with sterilization, the implication that patients with Medicaid insurance, but not private insurance, need a mandated amount of time to consider the impact of their medical decision-making is deeply problematic. Autonomy issues aside, patients with Medicaid have unique barriers to attending outpatient postpartum visits and Medicaid insurance often expires postpartum, thus posing additional logistical hurdles to desired permanent contraception. In addition to the long waiting period, the Medicaid policy presents another obstacle to permanent contraception. For various reasons, the Medicaid consent form for sterilization is difficult to understand and access. For example,  the form is written at a ninth-grade reading level, thus some patients with may be unable to read it and provide truly informed consent for the procedure.

The reported increase in requests for permanent contraception following the Dobbs decision brings new ethical wrinkles. When a patient’s decision to seek permanent contraception is influenced by legal restrictions in accessing care—bans or limits on abortion— how can the decision be truly autonomous? How should clinicians counsel patients who request permanent contraception and perform the surgeries when a patient’s choice may reflect coercion from state laws banning abortion–and potentially increase the risk of the patient’s regret if these laws are repealed? The patient populations that the Medicaid consent form and waiting period policies were established to protect—Black and Hispanic women–are also those most affected by these barriers preventing individuals from achieving true reproductive autonomy. Regardless of the surrounding ethical and legal challenges, the role of clinicians must be to educate, empower, and trust patients to make decisions that are right for them, including the decision for permanent contraception. Thus, high-quality shared decision-making between a patient and clinician is imperative to ensuring the principles of reproductive justice and contraceptive autonomy are upheld in permanent contraception counseling conversations.

Madeline Thornton (@mjthornton26) is an MD/MPH student at the University of North Carolina at Chapel Hill. Kavita Shah Arora, MD, (@KavitaShahArorais an associate professor and the division director for general obstetrics and gynecology at the University of North Carolina at Chapel Hill and chair of the American College of Obstetrics and Gynecologists’ Committee on Ethics.

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