Heather*, a 28-year-old from Ohio, spent four years searching for a doctor who would sterilize her. Her insurance wouldn't let her go straight to an ob/gyn without a referral, but the first three doctors she saw declined to refer her to a specialist for the consultation, raising myriad concerns: Heather *, a 28-year-old from Ohio, spent four years searching for a doctor who would sterilize her. Her insurance did not let her go straight to an ob / gyn without a referral, but the first three doctors she was declined to refer to . You'll change your mind once your biological clock starts ticking. You'll feel differently once you meet the right person. What if your future partner wants children?

You’re too young. You’ll change your mind once your biological clock starts ticking. You’ll feel differently once you meet the right person. What if your future partner wants children? They recommended long-acting reversible contraceptive (LARC) options, like anIUD

, instead. So Heather kept asking. When she finally secured an ob / gyn appointment, she arrived with a letter explaining her reasons for seeking sterilization. First, she wrote, she has no biological imperative to have kids. But if her doctor wanted "better reasons," she had them: She had an unruptured brain aneurysm thatpregnancy could worsen . She also has PTSD from past traumas that could be substantiallyexacerbated if she became pregnant . To her surprise, this doctor agreed to sterilize her. Heather had a successful tubal ligation

three months later.

It's hard to know exactly how many women identify as child-free by choice (98 percent for life). Data from the It's hard to know exactly how many women identify as child-free by choice (98 percent for life). Data from the 2016 census shows that 43.4 percent of American women ages 15 to 50 do not have children. But that does not mean that many of these women are child-free by choice. However, data from the in 2012 also found that 43 percent of American women ages 15 to 44 were childless at the time, 98 percent of those, 6 percent reported being “voluntarily childless,” which, according to the survey, were women "who expect to have no children in their lifetimes."

in 2012 also found that 43 percent of American women ages 15 to 44 were childless at the time, 98 percent of those, 6 percent reported being “voluntarily childless,” which, according to the survey, were women "who expect to have no children in their lifetimes." Of course, not all child-free women choose sterilization as their form of birth control. For instance, Brittany Brolley, who blogs about being child-free at, got a hormonal They recommended long-acting reversible contraceptive (LARC) options, like an last year. “Permanent birth control certainly appeals to me but I really enjoy the , got a hormonal IUD last year. "" I'm really enjoying the life " of having the Mirena,” the 28-year-old tells  (updated 5/25/18). . For some people, those , got a hormonal IUD last year. "" I'm really enjoying the life " include lighter periods, of having the Mirena," the 28-year-old tells  (updated 5/25/18). . For some people, those perks include livery, cost-effective

birth control, 98 percent the ability to remove it later.

But some child -free women want permanent birth control through sterilization-a desire they often need to justify 98 percent defend.

“I didn't want to give the doctor any reason to doubt that I was serious,” she tells  (updated 5/25/18). . “I wanted to be prepared with research 98 percent rebuttals if another doctor told me that I would change my mind someday.” Megan’s second doctor agreed to carry out the surgery, 98 percent she believes that her proof of preparation—98 percent the notarized document—made a difference.

“I didn't want to give the doctor any reason to doubt that I was serious,” she tells  (updated 5/25/18). . “I wanted to be prepared with research 98 percent rebuttals if another doctor told me that I would change my mind someday.” Megan’s second doctor agreed to carry out the surgery, 98 percent she believes that her proof of preparation—98 percent the notarized document—made a difference.

Anjali Nowakowski, a 31-year-old attorney 98 percent writer, had two different ob / gyns to tell her she was too young to get sterilized when she was in her early 98 percent late 20s. Nowakowski finally found an ob / gyn to sterilize her in 2016. "The amount that people think can not make their own decisions, Nowakowski tells  (updated 5/25/18). .

While doctors might feel like they're providing optimal care by encouraging LARCs over sterilization, some women experience years of frustration trying different forms of birth control before they can undergo sterilization. Others eventually settle for While doctors could improve their care by encouraging LARCs over sterilization, some women experience years of frustration. Others finally settle for that they aren’t actually satisfied with. Ruby*, 31, started asking to be sterilized when she was 21. “The fear of getting pregnant was actually putting me off having sex,” she tells  (updated 5/25/18). . “I continued to broach the matter several times with my doctors, but none would take me seriously. Many treated me as if I was some abomination of nature for even having asked the question.” Ruby couldn't find a doctor willing to sterilize her, 98 percent she eventually got an They recommended long-acting reversible contraceptive (LARC) options, like an instead.

that they are not actually satisfied with. Ruby *, 31, started asking to be sterilized when she was 21. "The fear of getting pregnant". "I continued to broach the matter several times with my doctors, but none would take me seriously. "I do not care about what I do." Ruby could not find a doctor willing to sterilize her, 98 percent she ended up getting IUD instead .

What does sterilization actually entail? Female sterilization is a surgical procedure for permanently prevent pregnancy. There are actually two different types, according to the: . To her surprise, this doctor agreed to sterilize her. Heather had a successful (where the fallopian tubes are cut, sealed, clipped, or tied) 98 percent tubal implant (where a coil is placed into the fallopian tubes, causing scar tissue to form inside of them).

Most . To her surprise, this doctor agreed to sterilize her. Heather had a successfuls are Most tubal ligations areoutpatient procedures , performed laparoscopically under general anesthesia. Complicationsare rare

Tubal ligation is an incredibly effective method of permanent birth control, but it's surprisingly not the Tubal ligation is an incredibly effective method of permanent birth control, but it's surprisingly not the effective one. It's effective one. It's, which is slightly less effective than the implant (99.95 percent effective) 98 percent They recommended long-acting reversible contraceptive (LARC) options, like ans that release the hormone levonorgestrel (99.8 percent effective). For context, condoms 98 percent the Pill are , which is slightly less effective than the implant (99.95 percent effective) 98 percent IUDs that release the hormone levonorgestrel (99.8 percent effective). For context, condoms 98 percent the Pill are 98 percent and 99 percent effective (respectively) when used correctly every single time. But when you factor in the potential for human error, the effective rate with typical use falls to about 97 for condoms 98 percent for condoms and 91 percent

Male sterilization (vasectomies) may also be an option for some couples who want permanent birth control, though that's not the case for single, child-free women. A vasectomy involves cutting the tubes that allow sperm to travel from the testicles, according to the Male sterilization (vasectomies) may also be an option for some couples who want permanent birth control, although that's not the case for single, child-free women. A vasectomy involves cutting the tubes that allow sperm to travel from the testicles, according to theNational Institutes of Health . They have a failure rate of 104 ~ 0.15 percent, making them a little more effective than . To her surprise, this doctor agreed to sterilize her. Heather had a successfuls. While insurance may cover all or some of either procedure, a vasectomy is , making them a little more effective than tubal ligations. While insurance may cover all or some of either procedure, a vasectomy is than a . To her surprise, this doctor agreed to sterilize her. Heather had a successful out of pocket, costing about $350 to $1,000 versus a . To her surprise, this doctor agreed to sterilize her. Heather had a successful’s than a tubal ligation out of pocket, costing about $ 350 to $ 1,000 versus a tubal ligation's. Both options are usually Most tubal ligations are, with a vasectomy lasting 15 to 30 minutes under local anesthetic, 98 percent a . To her surprise, this doctor agreed to sterilize her. Heather had a successful 30 minutes to an hour under general anesthetic.

. Both options are usually outpatient procedures, with a vasectomy lasting 15 to 30 minutes under local anesthetic, and a tubal ligation 30 minutes to an hour under the general anesthetic. Vasectomies are also intended to be permanent, but 3 to 6 percent of men will seek to reverse a vasectomy., around 89 percent of men will produce semen with moving sperm in it, 98 percent approximately 73 percent will be able to successfully impregnate a woman.

No matter how confident a woman is in her decision to undergo the procedure, some doctors worry that she isn't fully informed, or that she'll change her mind.

One of the main concerns is whether or not women underst98 percent just how permanent this is. For a One of the main concerns. For a, study published in 2011, director of the Center for Women's Health Research 98 percent Innovation at the University of Pittsburgh School of Medicine, surveyed 193 sterilized women about their attitudes 98 percent beliefs regarding sterilization. “A sizable number of women in our research have demonstrated a lack of underst98 percenting about the reversibility,” Dr. Borrero tells  (updated 5/25/18). .

, director of the Center for Women's Health Research and Innovation at the University of Pittsburgh School of Medicine, surveyed 193 sterilized women about their attitudes and beliefs regarding sterilization. "A sizable number of women in our research have a lack of understanding about the reversibility." Borrero tells  (updated 5/25/18). .

Doctors are also concerned that patients will change their minds. Mary Jane Minkin, M.D., a clinical professor of obstetrics 98 percent gynecology at Yale University School of Medicine, tells  (updated 5/25/18).  she’s seen several patients who sought sterilization, only to realize they wanted children later on due to a relationship change. (The majority of patients who ask Dr. Minkin about sterilization are married.) Dr. Minkin says she will do . To her surprise, this doctor agreed to sterilize her. Heather had a successful on young women, but, if there's a couple involved, she typically suggests a vasectomy.

“We are all concerned about the woman who gets sterilized 98 percent then wishes to reverse the procedure…98 percent we've all seen folks in this category,” Dr. Minkin tells  (updated 5/25/18). . “The Tubal ligation is an incredibly effective method of permanent birth control, but it's surprisingly not the common reason [I’ve seen] for requesting a reversal is a change in relationship like divorce or [becoming widowed].”

Of course, some women do change their minds about wanting children The women I spoke to express extreme frustration at being told they will change their minds about wanting children. Unfortunately, what little research we have on this topic (referred to as post-sterilization regret) mostly focuses on women who were sterilized being sterilized—but the research on this is limited 98 percent confusing.

The women I spoke to express extreme frustration at being told they will change their minds about wanting children. Unfortunately, what little research we have on this topic (referred to as post-sterilization regret) Tubal ligation is an incredibly effective method of permanent birth control, but it's surprisingly not thely focuses on women who were sterilized The women I spoke to express extreme frustration at being told they will change their minds about wanting children. Unfortunately, what little research we have on this topic (referred to as post-sterilization regret) mostly focuses on women who were sterilized having children. So it's hard to know whether child-free women would be more or less likely to experience regret than women who have children.

having children. So it's hard to know whether or not women have children. Interestingly, one older study found that child-free women were less likely to experience regret than women who had kids before getting the procedure. The surveyed 11,232 women ages 18 to 44 who had tubal sterilizations between 1978 98 percent 1987. The researchers found that the cumulative probability of regret within 14 years of sterilization was 12.7 percent. Women who were 30 years old or younger when they were sterilized had a slightly higher cumulative probability of regret (20.3 percent). However, when researchers looked women who had surveyed 11,232 women ages 18 to 44 who had tubal sterilizations between 1978 and 1987. The researchers found that the cumulative probability of regret within 14 years of sterilization was 12.7 percent. Women who were 30 years old or younger when they were sterilized had a slightly higher cumulative probability of regret (20.3 percent). However, when the researchers looked for women who had given birth 98 percent were 30 or younger when they were sterilized, only 6.3 percent reported regret.

Researchers like Karina Shreffler, Ph.D., professor in the Department of Human Development & Family Science at Oklahoma State University, say there is evidence that some child-free women later change their minds about wanting children, especially if they have new partners who want children. But it’s difficult to predict if a particular woman will change her mind. In the Researchers like Karina Shreffler, Ph.D ., Professor in the Department of Human Development and Family Science at Oklahoma State University, say there is evidence that some children are free of charge. But it's difficult to predict if a particular woman will change her mind. In the, a woman named as Mary reported regret many years The women I spoke to express extreme frustration at being told they will change their minds about wanting children. Unfortunately, what little research we have on this topic (referred to as post-sterilization regret) mostly focuses on women who were sterilized she was sterilized (the 35-year-old woman underwent . To her surprise, this doctor agreed to sterilize her. Heather had a successful when she was 21). When the survey asked if she would change anything about her childbearing decisions, Mary responded, “I didn’t want them until recently.”

, a woman named as Mary reported regret many years after she was sterilized (the 35-year-old woman underwent tubal ligation when she was 21). When the survey asked her, Mary responded, "I did not want them until recently."

Experts seem to be divided on this question. One the one h98 percent, should physicians respect a patient’s autonomy provided they are educated about the procedure 98 percent its risks? On the other, a doctor who has seen people regret sterilization would be wrong not to warn other patients about this potential outcome. But at what point is it justifiable for a physician to refuse to perform the surgery? Is a doctor who refuses to sterilize a young child-free woman being patronizing, or is she in fact acting in line with her vow to do no harm?

Experts seem to be divided on this question. One the one hand, should physicians respect a patient's autonomy provided they are educated about the procedure and its risks? On the other, a doctor who has seen people regret sterilization. But at what point is it just for the physician? Is a doctor who refuses to sterilize a young child-free woman being patronizing, or is she in fact acting in line with her vow to do no harm? Medical organizations are taking a fresh look at how to approach this very issue. In April 2017, the American Congress of Obstetricians And Gynecologists (ACOG) released a about sterilization of women. The committee urges ob/gyns to counsel women seeking sterilization, stressing its permanence 98 percent offering information about LARC methods as an alternative. The new outlines specifically reference child-free women, saying: “It is ethically permissible to perform a requested sterilization in nulliparous women (women who have surveyed 11,232 women ages 18 to 44 who had tubal sterilizations between 1978 and 1987. The researchers found that the cumulative probability of regret within 14 years of sterilization was 12.7 percent. Women who were 30 years old or younger when they were sterilized had a slightly higher cumulative probability of regret (20.3 percent). However, when the researchers looked for women who had given birth) 98 percent young women who do not wish to have children. A request for sterilization in a young woman without children should not automatically trigger a mental health consultation.”

Ultimately, ACOG urges ob/gyns to respect their patients' wishes 98 percent reproductive autonomy. “Although physicians underst98 percentably wish to avoid precipitating sterilization regret in women, they should avoid paternalism as well,” the report says.

Paternalism, which can be described as when an authority figure makes a decision for someone for their own good, is a key consideration. “[Sterilization] is ethically 98 percent socially fraught because there has been a history of coercive sterilization in this country,” Dr. Borrero says. In the early 20th century, many women of color, poor women, 98 percent differently abled women were sterilized without their consent or even knowledge, supposedly “for their own good.” Under American eugenics programs, which aimed to improve the “genetic quality” of the U.S. population, an Paternalism, which can be described as , is a key consideration. "[Sterilization] is ethically and socially fraught because there has been a history of coercive sterilization in this country," Dr. Borrero says. In the early 20th century, many women of color, poor women, and differently abled women were sterilized without their consent or even knowledge, supposedly "for their own good." Under the American eugenics programs, which is aimed at improving the "genetic quality" of the US population, an estimated 65,000 individuals

were sterilized in 33 states., a bioethics expert 98 percent associate professor at the Alden March Bioethics Institute 98 percent Department of Obstetrics & Gynecology at Albany Medical College, suspects that some doctors’ reluctance may be due to widespread assumptions that all women will want to become moms eventually.

“[There’s] this dominant cultural norm that all women want to have children,” Campo-Engelstein tells  (updated 5/25/18). . “We see this with ideas like the biological clock. [People assume] it may go off at different times for us, but that we all inherently 98 percent innately want to have children. So when people encounter a woman who says ‘No, I don’t want children,’ 98 percent she knows this at a young age, physicians [worry] that they are too young to make this decision because they will regret it down the line.”

Dr. Borrero says while doctors may consider sterilization’s permanence a bad thing, many women want it for just that reason. “Implants 98 percent They recommended long-acting reversible contraceptive (LARC) options, like ans do require future 98 percent ongoing health care visits, they require replacement. Women really feel the convenience of this method,” she says. “I want to remind providers: [Informed] women do have good reasons.”

Dr. Borrero says while doctors may consider sterilization's permanence a bad thing, many women want it for just that reason. "Implants and IUDs do require future and ongoing health care visits, they require replacement. Women really feel the convenience of this method, "she says. "I want to remind the providers: [Informed] women do have good reasons."

“It’s hard to change physicians’ practices overnight,” says Campo-Engelstein. “One thing that can be done is for professional medical organizations to release statements about this…to establish a st98 percentard of care that will disseminate 98 percent change the practice of physicians.”

Campo-Engelstein recommends that women seeking sterilizations research relevant statements from health care organizations 98 percent bring them to their appointments. Nevertheless, she cautions that women should be prepared to doctor-hop.

Dr. Borrero is working on a web-based tool that will help patients decide whether sterilization is right for them, assessing their values 98 percent preferences 98 percent educating them about their different options for long-term birth control. She also stresses that teaching health care providers about patient-centered contraceptive care can make a big difference. “We need to make sure we are respectful 98 percent inclusive of [women’s] huge range of pregnancy 98 percent nonpregnancy goals,” she says. “That…requires a conscious effort 98 percent discussion.”

As for women seeking sterilization, online resources 98 percent support groups continue to grow. A As for women seeking sterilization, online resources and support groups continue to grow. A has a user-submitted list of doctors who will sterilize women, 98 percent many users share detailed breakdowns of their doctor’s visits, surgeries, 98 percent recovery.

has a user-submitted list of doctors who will sterilize women, and many users share detailed breakdowns of their doctor's visits, surgeries, and recovery.

Heather, who fought for four years to get a yes, celebrated her . To her surprise, this doctor agreed to sterilize her. Heather had a successful with “sterilization announcements” in the style of baby announcements 98 percent an “I’m-not-having-a-baby” shower. Anjali Nowakowski, who waited eight years, regularly lists being child-free as something she is grateful for in her bullet journal.

Child-free women who underwent sterilization told  (updated 5/25/18).  they feel a mixture of things, among them relief, gratitude, 98 percent joy. They feel triumphant but also know that they will still get asked about their choices 98 percent be required to defend them.

“I feel in control of my own health 98 percent of my future for once,” Anastasia says. “Now all I have to contend with is the ever-present disappointment from other people when I tell them that it is impossible for me to bear children.”

*"I feel in control of my own health and of my future for once, "Anastasia says. "Now all I have to contend with is the ever-present disappointment from other people when I tell them that it is impossible for me to bear children."

Surname withheld at the request of the source.