'Why is it such a scandalous thing?': the women who have to fight for their right to be child-free

Queensland dance instructor Sue knew she wanted to be child free from the age of 15. It’s a decision she has never regretted. At 24, she saw a gynaecologist and requested tubal ligation for the first time, having had unwelcome side-effects from hormonal contraception. Her experience made her reluctant to ever see a medical professional again.

“He refused to even entertain the idea, treated me very condescendingly, and then insisted on administering an internal examination I didn’t need,” says Sue, not her real name. “I now recognise that the combination of his disrespect for me with violation for which I wasn’t prepared has caused me lasting trauma.”

An article published in April in the Journal of Medical Law by lawyer Joshua Taylor described how Australian women may desire access to procedures such as tubal ligation and hysterectomy “for family planning purposes; medical concerns, such as alleviating pain; or for comfort reasons, such as no longer wanting to menstruate”.

“Women are routinely denied access to these procedures on the basis of their age, especially when they have yet to bear children,” he wrote. “This decision is largely defended on the grounds that women will come to regret such decisions.” But he argued that “such decisions are generally unethical and may constitute discrimination under Australian laws”.

Concern that people may regret permanent procedures like vasectomy or tubal ligation and change their mind about having children is a reason some medical professionals are reluctant to perform them, especially on younger people. But a study published in the journal Obstetrics and Gynecology found “most couples who choose sterilisation … are satisfied with their decision and do not experience regret”.

At age 25, Sue fell pregnant, and had a termination. It took more than a decade of trying different forms of contraception, including the IUD which caused her side-effects, before she was finally granted a tubal ligation at the age of 37.

“It wasn’t until they were about to anaesthetise me that one of the medical team said, ‘How many children do you have Sue?’ and when I said ‘none,’ there was this complete pause in the whole room.

“It never occurred to me that people would see this as problematic for a 37-year-old woman who’d never wanted children. An otherwise very progressive friend expressed at length how appalled she was with my decision. I learned right away not to share it with people.”

Sue says her life is full enough without children. “All my career I’ve been a teacher and a mentor,” she says. “I’ve lectured in university, I now run a ballroom dance studio and it’s all about developing people’s confidence. I looked at parenthood and I thought, ‘Well I can have that. Or I can have everything else’.”

She says people still struggle to speak openly about choosing to be child-free and their reasons for it. But she believes as more people have been forced to put their lives on pause during the pandemic, they will have time to think about the future, what they want, and whether children are a part of that. She hopes for those that choose not to, the process of choosing their contraception of choice, whether vasectomy, long-acting reversible contraceptives (Larc), or tubal ligation, will be easier than it was for her.

“If you’re old enough to make the decision to have children, then surely you’re old enough to be permitted to make the decision not to,” she says.

“I don’t understand why it’s such a scandalous thing. People have to think much more about being sterilised than they think about having children, I mean people can fall pregnant by accident for God’s sake. But you can’t have a medical procedure by accident, there’s a lot of hoop jumping you have to go through, and I find it absurd that a more permanent choice can still be so frowned upon.”

Sue is just one of many women who have been refused access to permanent sterilisation procedures such as hysterectomy, or tubal ligation, where the fallopian tubes are cut, tied or blocked to permanently prevent pregnancy. Larcs, which include intrauterine devices and Implanon, and can provide protection against pregnancy for years, are giving women more options, especially those denied permanent procedures. But it is only in recent years that information about Larcs has become more widespread in Australia.

In 2017, the Royal Australasian College of Obstetricians and Gynaecologists said low uptake of Larcs “may be related to Australia’s prevailing cultural norm of oral contraception, and practitioner and patient misperceptions of the safety and efficacy of Larc, which have been dispelled in recent years”. The World Health Organization now recommends Larcs as a first-line contraception method for young women.

The business manager for clinical services and operations for Queensland family planning provider True Relationships & Reproductive Health, Sharon Stokell, says Larc use is on the rise.

“Especially for young people, and if a 23-year-old is adamant that they don’t want children and they’ve never wanted children, it is very, very difficult to access tubal ligation services,” Stokell says. “So certainly I think there’s a particular population who are using Larc instead of having that tubal ligation, for example because they just can’t get it. There’s no one that will provide it.”

Attitudes towards having children and reproductive health are also changing because of the Covid-19 pandemic and recession, she adds. And it’s not just women; inquiries into vasectomies have also increased, especially in 2020.

“Covid in particular has seen an increase in the amount of people that have been ringing about vasectomy,” Stokell says.

“The interest has been particularly strong this year.”

Stokell says there are a few reasons for that, one of them being that the pandemic and other pressing issues such as climate change have made people reluctant to have more children, or to have any children at all, so they are seeking out a more permanent contraceptive option. It has also given people time to think about their health and their future, she says.

“For some people it’s a fear, the pandemic has brought about a lot of fear for people around life.”.

Dr Philip Goldstone, the medical director of national family planning organisation Marie Stopes Australia, agreed that “the increasing awareness and availability of highly effective Long Acting Reversible Contraceptive methods has contributed to the steady decline in demand for tubal ligation”.

“Provision of Larc methods is simple, with some methods lasting 10 years, with effectiveness equal to that of tubal ligation,” Goldstone says.

A spokeswoman for Marie Stopes says decision making around planning for pregnancy seems to be changing, alongside broader life plans, “due to the pandemic and recession”.

“Some people with planned pregnancies have decided to access abortion due to unforeseen financial insecurity and other emerging stressors. Some people want to change to more efficient methods of contraception, knowing that abortion access could be difficult.”

She says in counselling sessions, staff were increasingly hearing from people choosing not to parent, “and particularly young women who choose to be child-free”.

“Their reasons are diverse and deeply personal,” she says. “The hashtag #ChildFree is increasingly used in online conversations among some communities as a political term to decide not to parent.”

Marie Stopes Australia managing director, Jamal Hakim, says: “Every person has the right to bodily autonomy.

“Access to tubal ligation and vasectomy services as permanent forms of contraception form part of the options available,” he says. “This however does not always translate in practice with system barriers, particularly for people who are choosing to be child free.”

Anecdotally, there are still barriers when it comes to choice, she says. In the public system, there can be inflexible restrictions, such as age or number of children. In many health and hospital regions, it can take a great deal of referrals and time to seek a tubal ligation consultation, after which some patients are denied their choice.

In May 2019, Marie Stopes Australia ran a social media campaign requesting that those who had faced difficulty accessing tubal ligation send a private message to discuss their experiences. Women reported having tried alternative contraceptive methods which caused side-effects. Some had numerous unplanned and unwanted pregnancies as a result of method failure, or the inability to find a suitable contraceptive method.

“Those who choose to continue with an unplanned pregnancy have an increased risk of delayed initiation of prenatal care, low birth weight, reduced rates of breastfeeding, developmental delays and increased rates of infant mortality,” a Marie Stopes spokeswoman said. “Therefore, it is important that all people have access to the contraceptive methods that suit their needs.”

Anna is another woman who doesn’t want children and has chosen permanent sterilisation. She says she and her husband have still not told some members of her husband’s family that they are child free by choice, or that she underwent the medical procedure.

Despite she and her husband using contraception, Anna fell pregnant twice before undergoing tubal ligation, and got an abortion each time.

“We had had our contraception fail twice,” she says. “I didn’t feel confident that anything other than something permanent would offer me safety. I think I’m quite aware of the impact a child has on your lifestyle, on your body and on your sleep habits. And both my husband and I had periods in our life where we’ve suffered depression, and I’m prone to anxiety and I just would imagine that adding a small child and sleep deprivation to the mix would make that so much worse.”

Anna says she hopes there comes a time where she and her husband can speak more openly about their child free choice with members of her husband’s family.

“I think we should talk about it as a society more,” she says.