The first time Bri Seeley told her doctor she wanted to be sterilized, she was 24 years old.
In some ways, she had always known she did not want to have children, but the idea really started to take root in high school. By the end of college, it had blossomed. While friends and boyfriends debated baby names and imagined their futures as parents, she dreamed of her own future as an entrepreneur -- a writer, fashion designer and aspiring women's empowerment activist. Motherhood, she knew deep in her bones, was not for her.
But the naturopath whom Seeley saw for her annual exam told her that because of her age, she was not a good candidate for permanent sterilization. The following year, Seeley asked again -- and was rebuffed again. Next year, the same thing.
"Every single year she would say to me, 'You will never find a doctor to do that for you,'" said Seeley, who is now 31 and lives in Los Angeles, and who has blogged for The Huffington Post about her experience. Though her desire for the procedure only grew, she said, the anger she felt after her initial rejection gradually gave way to a kind of numbed resignation.
"[The naturopath] would say, 'You can go get a consultation, but you're going to pay for this consultation, and they're going to tell you no,'" Seeley said. "You're too young."
Among women of reproductive age in the United States, more than 60 percent currently use some form of contraception. Within that group, 64 percent turn to reversible or one-time options, but the rest rely on permanent methods: male sterilization (i.e. vasectomy), or, more frequently, female sterilization, according to the Guttmacher Institute.
Women who seek sterilization tend to cluster in certain demographic groups. Those who are over 35, have been married or have had at least two children are more likely to undergo the procedure, which is done either by cutting or clamping a woman's fallopian tubes or by placing tiny inserts that prevent the joining of a sperm and egg.
For young women to whom the above characteristics don't apply -- women who are at their peak fertility, yet certain they do not want babies of their own -- finding a doctor to perform sterilization can be challenging, even impossible, as J. Bryan Lowder explored in a 2012 piece for Slate. Elsewhere online, anecdotes of frustration abound. "So far I've asked three doctors about a tubal ligation and they've all flat out told me no even after I discuss my reasons with them," a user on The Childfree Life forums wrote in a thread about tubal ligation for women under 30.
But how much responsibility do health care providers bear when it comes to guiding young women through contraceptive decisions with lasting effects that aren't, in many cases, medical at all?
The American College of Obstetricians and Gynecologists weighed in on the topic last year with an updated policy statement on the benefits and risks of sterilization. The statement concludes that it's both a safe and effective means of permanent birth control. "Women who have completed their childbearing are candidates for sterilization," it says -- without elaborating on what, precisely, that means. Does it refer to women who have already had a child, or several, and have now decided they're done? Or could that category also include an 18-year-old woman who has determined she's "completed" before ever getting started?
A major area of focus for ACOG, and the OB-GYNs it seeks to counsel, is the question of regret. A comprehensive 2008 review looking at sterilization in the United States found that patient regret is the most common lasting complication of sterilization, and one that disproportionately affects women: Up to 26 percent of female patients say later that they regret the procedure, according to statistics cited in the study, compared to less than 5 percent of men who have a vasectomy. And age, the researchers concluded, is the top predictor of regret. Women who were under 30 when they were sterilized were twice as likely as their older counterparts to say they had later misgivings.
"Thirty is not a totally arbitrary [cutoff]," said Dr. Deborah Bartz, an assistant professor of obstetrics and gynecology at Harvard Medical School and a researcher involved with the 2008 review. "There is some biologic plausibility and social plausibility [to that finding] that makes sense to some extent."
For Seeley, 30 -- or nearing it -- seemed to be the magic number. When she turned 29, she went off the birth control pill, which she'd been on since she was 18, because she'd begun to experience physical and emotional side effects.
That same year, after yet another frustrating visit with her doctor, she read an article about young women undergoing sterilization that prompted her to go online and find a physician willing to perform the Essure procedure -- a form of permanent contraception in which small inserts are placed in a woman's fallopian tubes to form a natural barrier. She found an OB-GYN, scheduled an appointment and began to prepare. Seeley arrived at the consultation armed with the article and her journal chronicling her many reasons for wanting to live child-free.
"[The doctor] went through the standard list of questions, like, 'Well, you know it's permanent -- what about a temporary option?'" Seeley said. "I said, 'I don't want a temporary option. I've had one for the past 11 years, and I've been asking for a permanent one for the past six. This is who I am. This is what I want.'"
By the time the 15-minute consultation was over, Seeley had made an appointment to undergo the procedure. She'd also gotten her doctor's assurance that she seemed like a woman who knew what she wanted and who was, in fact, a very good candidate for sterilization.
Ultimately, ACOG's official stance is that if a woman is well-informed and seeks sterilization, it doesn't matter how old she is or whether she's already had a child. Patients should be informed of the factors that have been shown to increase the risk of subsequent regret, but in the end, the decision is their own. (Women seeking Medicaid coverage for the procedure face additional barriers in that they must be at least 21 years old and go through a 30-day waiting period between initial consent and the procedure, based on a controversial Medicaid rule enacted in the late 1970s.)
But there are countless ways that conversation can actually take place, depending on the provider. And doctors and nurses often bring their own beliefs and assumptions to the table.
"I personally, whether I'm seeing a 22-year-old or a 30-year-old, would counsel her very vigorously, and I would certainly take more time with someone who has never had a child, or who is very young," said Dr. Eve Espey, chair of the department of obstetrics and gynecology at the University of New Mexico.
Espey called the whole topic "difficult," noting that it surfaces issues of paternalism and autonomy.
"In some ways, it's very difficult to see a 22-year old make a decision for the 35-year-old she will be someday and not have major concerns that she might regret that decision," she told HuffPost. "On the other hand, at what point do you say, 'Of course the woman is autonomous and can make her own decisions about her reproductive health'?"
Increasingly, there has been a move within the reproductive health field to shepherd women of all ages and life stages toward long-acting reversible contraceptive options, or LARC. These are the most effective forms of reversible contraception available, and safe for nearly all women of reproductive age -- even those who have not yet had children, but who may want to someday. Earlier this fall, for example, the American Academy recommended that long-acting contraceptive methods be considered the first choice for teens who have decided to be sexually active.
"We'd like to see improved provision of long-acting reversible contraceptives," Bartz said. "They're equally effective [as sterilization], they're equally easy for most women to receive. But then we can remove the idea of permanency and potential for regret."
Yet for some young women who don't want to have children, irreversibility is exactly what they are looking for.
"The fact that it was permanent really appealed to me," said Heather Gentry, 28, a married, child-free woman in Georgia who got her tubes tied last fall. She has never wanted to be a mother (though her husband does have kids from a previous relationship), and has always struggled to explain her stance to those who question it.
"It's almost indefensible -- not in the sense that it's bad, but it's a yes or no question," she said. "Do you want to have children or not? If you don't, then you don't. Period."
Gentry went to her nurse practitioner, thinking about having the Essure procedure or even just a copper IUD inserted. "I needed something that didn't have hormones," said Gentry, who has tried four different brands of birth control pills at various stages of her life. "I have depression problems, and every time I added hormones on top of that, it seemed to aggravate the problem."
In Gentry's case, however, it was her health care provider who encouraged her to pursue a more lasting option. She described the encounter in a blog post for Offbeat Home: "'If I were you, I would just get my tubes tied,'" Gentry quotes her doctor as saying. "Floored, I asked why. 'Well, they'll put you to sleep, then you'll wake up and it'll be over. There's minimal pain with recovery because it's a laparoscopic procedure.'"
Psychologically, getting sterilized has affected Gentry in ways she didn't plan for. She finds she is far more tolerant of children than she once was, and enjoys their company more. She no longer worries that if she coos over a baby, or spends time playing with a child, it will signal to herself, or others, that she holds some private, untapped longing for motherhood.
"Something about making that decision, and being clear and true to myself, means that if I'm at the grocery store and I see a cute toddler, I can say 'Look at him!'" she said.
But in other ways, Gentry's emotional response to the procedure has been exactly what she predicted it would be.
"I have had no moments of regret," she said. "It's one of the best things I have ever done."