Denials of permanent contraception high on list
Subtle and more overt acts of reproductive counseling coercion still occur in the United States, affecting more than two in five women in their lifetime, research shows.1
Coercion can be subtle, such as when a provider strongly recommends a particular method without first asking patients what they want. Or it can be overt and even abusive — such as denying someone a method they asked for because of the provider’s biases and beliefs.
Investigators measured coercion using a Coercion in Contraceptive Care Checklist that was given to more than 1,000 survey participants. Among people who had talked to a healthcare provider, 18.46% said they had experienced coercion during their last contraceptive counseling. Also, 42.27% said they had experienced coercion at some point in their lifetime.1 (See the checklist.)
Contraceptive Care Checklist
The Contraceptive Care Checklist is a short, simple tool with five boxes to check. The first two are related to what investigators call downward contraceptive coercion, which is the pressure to not use contraception. The last three are examples of upward contraceptive coercion, which is the pressure to use contraception.1 The checklist items are:
- “The healthcare provider would not give me the birth control method I wanted.”1
- “The healthcare provider made me feel that I should not use birth control.”1
- “The healthcare provider made me keep using a birth control method that I wanted to stop using.”1
- “The healthcare provider made me feel like I had to use birth control.”1
- “The healthcare provider made me use a specific birth control method.”1
Reference
- Swan LET, Cannon LM. Healthcare provider-based contraceptive coercion: Understanding U.S. patient experiences and describing implications for measurement. Int J Env Res Pub Health 2024;21:750.
“Any pressure from a provider for a patient to use or not use contraception is contraception coercion,” says Laura E.T. Swan, PhD, LCSW, a research scientist with the department of population health sciences at the University of Wisconsin-Madison in Madison, WI.
Providers who do not carry a full range of contraception options are not necessarily engaging in coercion, but this definitely is an access barrier, she notes.
“There’s an important difference between access barriers and contraceptive coercion,” Swan says. “Both have structural roots and are influenced by sexism, racism, and capitalism, but coercion is manifested interpersonally with the healthcare provider.”
When patients have difficulty accessing the method of their choice at a particular provider’s office or when they have to make multiple trips to the clinic to get the contraceptive of their choice, their access to contraception is obstructed. But coercion involves direct intervention by the provider to force or prevent someone from using a particular method.
“For example, pressuring a patient to not use contraception would be coercion,” Swan adds. “Discouraging or refusing a patient from receiving a permanent contraception procedure like a tubal ligation is coercion.”
Anecdotal examples of this type of coercion abound on social media. For example, a Reddit site, r/childfree, had these personal stories:
- 34-year-old woman with pulmonary hypertension: “Doctors refuse to perform tubal ligation without ‘signed agreement of spouse.’”2
- Woman in her 20s: “She told me she won’t do them for people under 30 and because of my BMI surgery is risky and since it’s an elective surgery she doesn’t want to do it. I’m bipolar and on a ton of medication. Me getting pregnant is life or death. I take every precaution I can, but I can’t get on hormonal birth control due to my mental health. I don’t want kids. I’ve never wanted kids. I feel so broken hearted and scared.”3
- 30-year-old married woman: “I talked to the Dr. for two minutes before she told me she wouldn’t do the [permanent contraception] procedure because I didn’t give a good enough reason.”4
- 18-year-old patient: “The doctor said ‘Oh, I will change my mind in the future, and I will want kids.’ The doctor was not understanding at all despite the review on the subreddit saying they ‘were.’”5
- 43-year-old woman: “Was denied: Reason: TOO OLD! ... I’m disappointed and angry. I was told at 23yo I was too young, what if my boyfriend wanted children, I need to wait until I’m 40yo. Guess Freaking What. 43yo and I AM TOO FREAKING OLD!!”6
Refusing to provide patients a permanent contraception option because of the physician’s personal beliefs regarding the patient’s demographics, reasoning, and needs is contraceptive coercion.
“We’ve seen evidence in the literature of people — especially those on Medicaid — being unable to access permanent contraception,” says Jenny Higgins, PhD, MPH, director of the UW Collaborative for Reproductive Equity and Bissell professor of reproductive health, rights, and justice in the department of obstetrics and gynecology at the University of Wisconsin-Madison.
Another example of contraceptive coercion is pushing a patient to use a long-acting reversible contraceptive (LARC) method, such as an intrauterine device (IUD) or implant, Swan says.
“Coercion can be overt when they refuse to give a patient a method or refuse to remove an implant or IUD,” Swan says. “It can be more subtle when the provider indicates in their contraception counseling that one method is more preferred or suitable than another method.”
Research evidence shows that some physicians refuse to remove LARC methods, Higgins notes.
“Contraceptive coercion does not happen randomly or uniformly,” Higgins explains. “Structurally oppressed individuals are significantly more likely than privileged counterparts to experience contraceptive coercion at the healthcare level.”
This phenomenon is true for Black, Indigenous, people of color (BIPOC) patients and also for low-income, Medicaid patients and LGBTQ+ patients, she adds.
Reproductive coercion has a long and sordid history in which the primary victims were people in vulnerable communities, including BIPOC individuals.
For instance, soon after Norplant became available commercially in the United States in February 1991, judges gave women convicted of child abuse or drug use during pregnancy the choice of using Norplant or serving time in jail. Also, legislators in more than 12 states introduced measures that would have coerced women to use Norplant, some of which would have offered financial incentives to women on welfare if they used Norplant. Some even forced women to use Norplant or lose their benefits, according to the American Civil Liberties Union (ACLU).7
Going further back in history, there were forced sterilizations and experiments on BIPOC people and people with disabilities.
For example, in the 1950s, more than 7,000 people were sterilized — often against their will — in North Carolina because of a welfare program’s connection to the eugenics movement. The state had already been sterilizing people in mental hospitals and troubled youth, but shifted to women on welfare out of a concern that they would overwhelm the welfare system.8
According to a report by NPR, “One girl sterilized by the board is described in her file as ‘often away from home’ and ‘constantly talks about boyfriends.’ She was 12.”8
Reproductive contraceptive coercion has evolved from decades of attempts to limit the childbearing of BIPOC communities, Higgins notes.
“There have been all sorts of efforts where policies and healthcare stem from a place of [believing that] low-income people of color need to have fewer kids,” she says.
Remnants of this entrenched, racist, societal belief can be found in biases held by healthcare providers in the 21st century.
“Researchers showed providers vignettes of different patients and had the provider say what method they thought the patient should use, and they found that people of color were more likely to receive a LARC recommendation from a provider, as were people from lower socioeconomic classes,” Higgins says.
The study from 2010 found that healthcare providers were more likely to recommend IUDs to patients who were of low socioeconomic status or who were Black or Latina. This study had 524 healthcare providers look at 18 videos of patients to see if they would recommend levonorgestrel intrauterine contraception to the patient in the video.9
“So, when a master’s level, high-income white person comes into a doctor’s office, just by nature of living in a white supremacist culture, that person’s fertility will be treated differently than a 19-year-old Black person receiving Medicaid,” Higgins says.
The most common contraceptive coercion — 15% — involved use of the birth control pill, the new study shows. Tubal ligation or other permanent contraception was the second most commonly cited method for which participants experienced coercion, and the third most common one was the IUD.1
One Black participant described her experience with a provider who dismissed her contraceptive concerns: “I confided in my doctor that I don’t handle birth control hormones very well and the side effects were [too] day-altering. As expected, she dismissed my concerns and wanted to try a different formula of progesterone and estrogen or the copper IUD. I dismissed those options due to reasonable concerns and she told me that she expected to see me pregnant sooner than later if I didn’t pick a better method.”1
Providers sometimes are unaware that their words are being perceived as contraceptive counseling coercion by patients.
“My sense is that providers are working under enormous pressure within flawed systems,” Swan explains. “One problem is how much time providers have to spend with patients. It’s a high expectation for us to say, ‘You should be delivering patient-centered care,’ which they absolutely should be doing, but it’s a high expectation when they have so little time with patients.”
Another issue is related to providers’ perspective on contraception. When doctors or scientists look at research involving contraceptive effectiveness and risks and benefits, their understanding of data is different from how patients perceive the same information.
“It’s this idea that maybe there is a mismatch between what patients are viewing as acceptable and what providers are thinking of as acceptable,” Swan says. “Providers tend to be in this population health perspective [mindset], and patients are thinking about their own bodies.”
REFERENCES
- Swan LET, Cannon LM. Healthcare provider-based contraceptive coercion: Understanding U.S. patient experiences and describing implications for measurement. Int J Env Res Pub Health 2024;21:750.
- Refused tubal ligation. Reddit. r/childfree. https://www.reddit.com/r/childfree/comments/jaw3yv/refused_tubal_ligation/
- Denied a tubal ligation. Reddit. r/childfree. https://www.reddit.com/r/childfree/comments/v8mupo/denied_a_tubal_ligation/
- Denied sterilization because my “reasons weren’t good enough.” Reddit. r/childfree. https://www.reddit.com/r/childfree/comments/v8mupo/denied_a_tubal_ligation/sterilization_because_my_reasons_werent/
- Got denied from doctor on the list on here …, should I keep next appointment or not for different doctor? Reddit. r/childfree. https://www.reddit.com/r/childfree/comments/1dkecj2/got_denied_from_doctor_on_the_list_on_here_should/
- Just left my appt to request sterilization at age 43 yo. Was denied. Reason: TOO OLD! Reddit. r/childfree. https://www.reddit.com/r/childfree/comments/d2fw18/just_left_my_appt_to_request_sterilization_at_age/
- Norplant: A New Contraceptive with the Potential for Abuse. ACLU. Jan. 31, 1994. https://www.aclu.org/documents/norplant-new-contraceptive-potential-abuse
- Rose J. A Brutal Chapter In North Carolina’s Eugenics Past. NPR. All Things Considered. Dec. 28, 2011. https://www.npr.org/2011/12/28/144375339/a-brutal-chapter-in-north-carolinas-eugenics-past
- Dehlendorf C, Ruskin R, Grumbach, et al. Recommendations for intrauterine contraception: A randomized trial of the effects of patient’s race/ethnicity and socioeconomic status. Am J Obstet Gynecol 2010;203:319.e1-8.
Subtle and more overt acts of reproductive counseling coercion still occur in the United States, affecting more than two in five women in their lifetime, research shows.
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