The Center for Investigative Research has found that, during a five-year period ending in 2010, female inmates in the California prison system were sterilized without the required state approval. Because it is an irreversible procedure, the consequences are lifelong. Naturally, this raises all sorts of questions about appropriate consent and proper procedure when it comes to sterilization as a possible option for incarcerated women as well as for female patients in general.


Tubal ligation — also known as 'having your tubes tied' — is a type of permanent birth control or female sterilization technique that was first performed in 1930 and is now one of the most commonly used family planning methods worldwide. The procedure involves cutting or blocking the fallopian tubes to permanently prevent pregnancy, and can be done anytime, including after childbirth. A tubal ligation, then, disrupts the movement of the egg to the uterus for fertilization and blocks sperm from traveling up the fallopian tubes to the egg. Although, reversal is possible in some cases, tubal ligation should be considered permanent.

Less than one in 100 women who have had their tubes tied get pregnant after one year, according to the World Health Organization. Significantly, tubal ligation does not affect the production or flow of female hormones in the body and does not change sexual desire or satisfaction. The procedure, which is frequently performed immediately after childbirth, also does not interfere with a mother's milk production or adversely affect the health of the child. In fact, benefits are conferred by the procedure: women who undergo tubal ligation have a decreased risk of developing ovarian cancer, according to the National Institutes of Health, as well as a reduced risk of the development of pelvic inflammatory disease.

But despite the positives, there is one inherent risk: lifelong regret.


Many countries require women to wait for a specified period of time between making the decision to undergo sterilization and the procedure. Most healthcare providers recommend pre-sterlization counseling, as other long-term contraceptive options, such as an intrauterine device (IUD), exist and may be suggested. In the U.S., women must be 21 years old to be eligible for a sterilization procedure covered by federal Medicaid funds, the Indian Health Service, or U.S. military health insurance. With rare exceptions, Medicaid-funded sterilizations require a 30-day waiting period between consent and the procedure.

In all 50 states, any woman undergoing a publicly funded procedure must sign a special consent form. A few states have special consent forms for every woman who seeks sterilization. Interestingly, there are no such restrictions regarding vasectomy, a male sterilization technique, though it has a higher success rate of reversibility.

Immediate postpartum sterilization may have advantages, but the chance that a woman will regret her decision is higher with women who undergo the procedure at this time. Research suggests that regret after postpartum sterilization may be more common among younger women (less than 30 to 35 years old), those having caesarean sections, women with few children, women whose marital status changes, and in cases where a child subsequently dies or becomes ill.

According to the Collaborative Review of Sterilization study, the cumulative probability of expressing regret following tubal sterilization is 12.7 percent. The American Congress of Obstetricians and Gynecologists (ACOG) finds a slightly larger percentage of regret, roughly 20 percent; it reports that the overwhelming majority of women younger than 30 years — a full 80 percent — do not regret their sterilization decision. That said, long-term regret is more common among underserved women.

The other side is only rarely addressed: the potential regret of those who fail to get the procedure.

Another Type of Remorse

Only half of the women who request postpartum sterilization during prenatal contraception counseling actually undergo the procedure. "In one study, nearly one half of women with unfulfilled postpartum sterilization requests became pregnant within one year, twice the rate of women who did not request sterilization," reports ACOG. With the added responsibility of caring for a newborn and the changes as to what insurance covers after giving birth, many women may not be able to return to their doctor for an alternative method of contraception in the postpartum period.

The direct annual cost of unintended pregnancy to the health care system can be measured in dollars and cents, but it is unknown what psychological and financial price is paid by an individual woman. This is not to say that an unintended birth might ultimately provide great happiness; unfortunately, in cases of extreme poverty or where an older child becomes sick, an unintended pregnancy might overwhelm a mother.

As these judgments are so intensely personal, and a woman's state of mind is of paramount importance, the decision to perform a tubal ligation, a life-altering procedure, is an extremely delicate decision, especially right before or during a procedure. "There are specific situations where you cannot say it's informed consent, and one of them is during childbirth or labor," said Dorothy Roberts, University of Pennsylvania law professor and expert on sterilization. "No woman should give consent on the operating table."

A Brief History of Eugenics in the U.S.

Sterilization is commonly considered coerced when misinformation, intimidation tactics, and in some cases financial or other incentives are used to compel an individual to undergo the procedure. Obviously, forced sterilization occurs when a woman is sterilized without her knowledge or consent. Such cases have occurred in the U.S. as recently as the 70s.

Indiana enacted the country's first eugenics legislation in 1907. Eugenics commonly advocates practices that might improve the genetic composition of population, and became popular worldwide following the death of Charles Darwin. Eventually, 32 states followed with some 13 states enacting laws specifically permitting sterilization of criminals. By 1924, approximately 3,000 people had been involuntarily sterilized in America, the vast majority (2,500) in California.

The practice was largely abandoned after World War II, when the Supreme Court in 1942 struck down a case testing an Oklahoma law that prescribed involuntary sexual sterilization for repeat criminals.

It is estimated that during the entire time of legal eugenics programs in the U.S., more than 60,000 Americans endured involuntary sterilization. The Buck v. Bell ruling in 1927, which allows compulsory sterilization of the so-called "feeble-minded," has never been overruled.

Souces: Committee Opinion of the American College of Obstetricians and Gynecologists. Access to Postpartum Sterilization. 2012.

Bartz D, Greenberg JA. Sterilization in the United States. Reviews in Obstetrics and Gynecology. 2008.

Boardman LA, Desimone M, Allen RH. Barriers to completion of desired postpartum sterilization. Rhode Island Medical Journal. 2013.