Courtney, age 33, has known she does not want kids since high school. But how, exactly, she would prevent pregnancy in the long term remained an open question. If something went wrong with her birth control in the interim, she could get an abortion. Perhaps, one day, her husband would get a vasectomy. Then Roe came crashing down. “When it was leaked, it was a moment of, I would say, fear and a lot of sadness for women—also a little bit of panic,” Courtney, who lives in Pennsylvania, where abortion is still legal, told me. “Seeing how quickly the laws change is scary,“ she explained. She reached out to her doctor’s office about sterilization.
For people who ovulate, there are two primary forms of permanent birth control: Tubal ligation stops eggs in the ovaries from traveling to the uterus by “tying” the fallopian tubes, and bilateral salpingectomy (or “bisalp”) cuts the tubes out altogether. While long-term birth control like IUDs prevent fertilization by altering the environment of the uterus, tube surgery ensures there’s nothing for sperm to fertilize in the first place. The procedures are more than 99 percent effective in perpetuity. Courtney, for her part, elected for a bisalp; her outpatient laparoscopic procedure, which takes just 30 minutes to perform, is scheduled for Aug. 4. “I’m a little nervous about any complications about essentially removing a part of my body,” Courtney says. “But I’m excited and hopeful and praying that everything goes well.”
In a moment defined by the rollback of many rights in the U.S., more and more Americans are thinking like Courtney. Abortion is no longer protected, following a Supreme Court decision finalized in June. “Having that option,” said Sara Nunn, 33, from California, who had abortions in 2017 and in the pandemic, “it gave me this silent confidence.” (Nunn got a bisalp on May 31.) Now, justices are hinting that access to contraceptives is next. And pregnancy loss, including unintended miscarriages, will continue to be criminalized. To many, sterilization appears to offer a one-way ticket out of this mess. While the decision to get a tubal ligation or bisalp is a deeply personal one—and most people who pursue it have identified as “childfree” for years—the procedure has always intersected with the political, whether it’s been forced on people of color and incarcerated people or freely chosen by others. “This is the little power that I can take back,” Kaitlin, 30, from Pennsylvania told me.
Vanessa, a 36-year-old Minnesotan, has known she didn’t want kids for decades. But she didn’t begin to think seriously about permanent sterilization until the pandemic. Until that point, she had felt that health care had always been accessible to her; suddenly, “elective procedures,” primary care visits, and more were on hold. Vanessa made an appointment with her gynecologist and took a list of 16 reasons why she wanted to be sterilized with her. The items included bad side effects from previous birth control methods, the cost of child rearing, gun violence, and, item No. 10, fascism: There is “an ever-growing religious theocracy, and white supremacy,” Vanessa wrote. “The U.S. ticks off more than a few boxes to be considered a failed state. Again, why would I want to bring a child and especially a Black child into this? There was an attempted coup in January.”
Vanessa’s gynecologist approved the procedure without hesitation and Vanessa underwent surgery on April 28. Four days later, in the middle of her recovery, Politico leaked the draft decision indicating the Supreme Court would indeed overturn Roe v. Wade. “The timing of this surgery couldn’t have been better,” Vanessa said. But she has not been immune to the anger and sadness of the moment. “I’ve had people be like, why do you care? You got sterilized, that’s not a problem,” she told me. “I don’t know how to tell you to care about other people.”
Not everyone who pursues sterilization gets their doctor’s stamp of approval so easily. In some cases, women still have to get their husband’s approval before a surgeon will even consider doing the procedure. Ingrained misogyny and medical paternalism make it notoriously difficult for people to get assigned female at birth, or AFAB, sterilization in the United States. Many doctors reflexively distrust women (or people they perceive to be women) to make permanent decisions about their health. Often, childfree people find themselves being “bingoed” by their surgeons—a term used in online communities to describe being asked invasive or demeaning hypotheticals like, “what if you met a man and he wanted to have children?” Even when they can claw their way to a sterilization procedure, many find their friends, family, and the culture at large continue to reinforce the idea that it is an obligation for women to become mothers—or at the very least, to be open to the possibility of it.
Sara W., 31, from Utah, has experienced his resistance firsthand. “As soon as that document leaked,” she says of the Roe reversal, “I made a doctor appointment that day.” While her husband has had a vasectomy (a form of birth control with a failure rate of less than 1 percent), she wanted an extra layer of protection. But the surgeon she was referred to dismissed her concerns. “I think the most offensive thing he said in this whole interaction was, he was asking me to come up with a scenario in which I would possibly need my tubes removed if my husband had a vasectomy,” she told me. “I told him I am a victim of sexual assault and I don’t believe that being married to a good man is enough to keep me safe.”
Sterilization is not only used to prevent conception, either. Suzanne Zuppello, a 34-year-old freelance writer based in New York, has the BRCA1 genetic mutation. That means she has a 67 percent lifetime chance of getting ovarian cancer, as well as an elevated risk of breast cancer and more. In April, after learning that many ovarian cancers begin in the fallopian tubes, she decided to have the tubes removed. “I don’t think you’re ever going to be 100 percent certain that you made the right decision,” Zuppello told me about her various procedures, which include a 2015 double mastectomy. But the Supreme Court’s decision to overturn Roe reaffirmed her choice to get a bisalp.
Even as sterilization has offered Zuppello some reassurances about her future health—including a near-surefire way to prevent an unwanted pregnancy—her case is a little more complicated. Namely, Zuppello thinks she may want children some day. In 2016, Zuppello began freezing her eggs; already right-wing politicians across the country are challenging the legality of embryo creation and storage. And if she were one day to get pregnant through IVF, she could still be in the position of needing an abortion if something goes awry with the pregnancy. “There is the other part of me that’s like, oh great, this is the first domino,” she says of the Roe decision.
What united everyone I spoke to, whether they were already sterilized or hoping to be, whether their procedure made sense to their doctor or not, was the sense of relief that sterilization can offer. “Having a child would be extremely dysphoric for me,” said Ladner Stroud, 31, in Washington state. While the primary care doctors they’ve asked about sterilization “looked at me like I have three heads,” they plan to undergo sterilization as part of their bariatric weight loss surgery this fall. For Alex Blackstone, 33, also from Washington state, the rationale can be characterized in a long and detailed list of their own—they don’t have the money, they are neurodivergent and living with mental illness, they have roommates and no family support—or in one little fact: “I don’t like kids and never have.”
Sterilization can pretty much ensure that they never do. But the procedure is hardly for everyone, as it’s more or less permanent. A bisalp can never be reversed; while a tubal ligation can be, somewhere between 20 and 50 percent of patients are still unable to get pregnant after a reversal procedure. “I’m lucky enough I know I don’t want kids,” Courtney says, adding: “There are some people who are kind of on the fence about having kids—they might not know. This ruling is going to impact those people.” Do they get sterilized, or live with the possibility of ever-more-serious repercussions for reproduction, both accidental and intended? For some, sterilization might not be the solution, but a new source of pain.
As Americans respond to the overturn of Roe and ever-accumulating limitations on their reproductive agency, sterilization is likely to become more common (unless and until right-wing politicians decide to come for sterilization, too). But the childfree people I spoke to believe it’s important to continue fighting to keep other options on the table, too. Reproductive rights have brought families out of poverty, helped women to leave abusive relationships, and advanced equality among all genders. “When I think of full body autonomy, I think of full body autonomy,” Vanessa says. In the past, many women, especially women of color, “didn’t have the ability to practice that,” she adds. For now, at least, she does. “And so I am.”