The quest to stay childfree

[liv]

So I saw a sexual health nurse this week. She was ever so friendly and communicative, and didn't patronize me, and took my opinions seriously. But on the down side, she wasn't very competent at performing the actual exam, she poked me about until I bled before she managed to take any samples. I think good bedside manner is more important to me, though.

After some discussion she reckoned my best long-term contraceptive option is the plain copper coil, without hormones. Apparently that will give me ten years of protection with a failure rate that's too small to measure accurately. She echoed what I've been told before, that the NHS regard the coil as a better option than sterilization, cos it's more effective but still reversible, and doesn't require surgery.

Well, more effective is a big plus, and I can totally see the point of avoiding unnecessary operations. But reversibility seems like a big downside to me. I have this strange paranoia about finding myself in a society which is either regressively sexist, or has low standards of medical care, such that I can't get a replacement coil when this one reaches the end of its lifetime. This is probably quite unlikely, but I may have 15 or even 20 years of fertility ahead of me and I can't bank on my situation being the same as it is now for that whole period. The other reason why I want to do something irreversible is that I've had a lot of relationships with people who thought that if I loved them enough I'd change my mind about not wanting kids. I want to be able to say to potential partners up front, not just that I'm childfree, which sounds like an opinion, but that I can't have children, which would be a physiological fact.

jack expressed some of my mindset in terms of, I am afraid I might betray myself one day. I might get an attack of hormones or biological clock or something, and go through a brief period of unreason and thinking I want children after all. At least removing a coil requires making a medical appointment, so it would give me a few days to think over a hasty decision. But I'm more afraid of pressure from a partner. It's easy to tell myself that if someone tried to nag me (or worse) into having kids, I would totally dump them rather than give in, but realistically I know how hard it can be to end a relationship. Obviously I hope I wouldn't get involved with anyone abusive, but I'm no more immune to being bullied into following unreasonable demands than anyone else.

On the medical side, my feeling is that the risk of surgery, while higher, is a one-off. If I don't get a bad reaction to the anaesthetic or pick up a iatrogenic infection, well, I can stop worrying about it forever after. Whereas the very unlikely risks associated with using a coil are ever-present. Now I know that hormone-free is an option, I'm less worried by that possibility, but still.

So the question is, should I insist on sterilization even though I know it will mean a fight (and possibly paying for it to be done privately)? And even though I do take seriously the relative medical disadvantages of that option? It's the greater effectiveness of the coil that makes me lean towards accepting that option even though I would rather have something more permanent. I suppose a compromise is to agree to have a coil fitted, and if it goes wrong in some way, then ask for sterilization as a back-up plan. Or, well, revisit the issue in a few years' time and see if the medical consensus has changed, as well as me being older so less likely to be regarded as flighty and expected to change my mind about having kids any time.

Comments

[kass]

I'm glad there's a hormone-free coil option. I had what some doctors regarded as adverse effects to hormonal birth control (the pill) -- email me if for any reason you want to hear more about that. Anyway, the hormone-free coil seems like a good solution for that reason.

It seems unlikely to me that in ten years' time you'll be living in a place where you won't have access to the sort of birth control you want. But I can see why it frustrates you to not simply opt for surgery, which would give you want you want without the need to worry about it in future. (It strikes me also that should you, later in life, decide that you want to parent a small person -- however unlikely that may be! -- you could always adopt one. Nothing says you have to gestate one yourself.)

[liv]

Oh, thank you for this. I did have quite a major concern about long-term exposure to exogenous hormones, so a hormone-free coil seems like a much better option to me. Personally I was fine with the combined pill, but I was told that I can't have that any more since I am over 30 as well as fat. I suppose I could fight to get that instead of the progesterone-only pill, which gives me mild, though bearable, side-effects. Now I am registered with a specific GP instead of just dealing with the drop-in family planning clinic, I think she is fairly sympathetic to the view that fat people should have the full range of contraceptive choices. But basically I don't want to have to take oral hormones every day until menopause. It's true that the progesterone-based coil represents only about 10% of the dose of contraceptive pills, but I'm still reluctant to use that as a long term option.

Regarding ongoing access to birth control, I know I'm being paranoid but my worries aren't completely unfounded. There are plenty of places in the world now where women can't easily get safe, reliable contraception. What if a great opportunity comes up in one of those places, whether for career, romance or even the chance to make a difference where it's needed? I don't want to be thinking, well, can I risk moving to somewhere where contraception may be a problem. As it is, healthcare is a major factor putting me off looking for jobs in the US, and I would be rather more prepared to take a risk if I knew I was sterile.

I'm also afraid of the political rise of ultra-conservative movements. The twin attitudes of treating women as a force of scary chaos that must be controlled, and abhorrence towards spending any money at all on public projects (except possibly wars) are spreading even to civilized countries. The other concern is ecological disaster; right now, I consider myself lucky to have about a 75% chance of avoiding rape, but a few more incidents like Hurricane Katrina could strip away what little protection women have. I don't lie awake at night worrying that these things will happen tomorrow, but I don't want to bet my life that society in 2030 will be similar to my current situation.

You are absolutely right about adoption. There are many reasons why that seems a better option if I ever do make a dramatic u-turn in my position about having children. But thank you for reminding me of that.

[naath]

Being >30 means you can't get the pill now? Sometimes I think these people are CRAZY MAD.

I've had zero luck so far with getting fixed on the NHS, but then I am younger than you. The private cost is in the region of 1000 pounds from Marie Stopes who will almost certainly do it with no more than a cursory "you sure?" although I've heard bad stories about their after care and ymmv and that is a lot of money). I went with drugs (Implanon) because I was more worried about the potential side effects of a coil (and, oh yes, scared of the "getting it in" procedure); of course that's a huge ymmv area.

I share your worries about the future of health care provision, unfortunately it seems to be hard to convince the NHS that this is a legitimate worry. I'm also concerned about the long-term side effects of the drugs (although I'm unsure how I weigh this verses the beneficial (to me) side effects of the drugs).

[blue-mai.livejournal.com]

i would have thought that the effectiveness during the next ten years would be more important than the small risk of not being able to access decent healthcare or a replacement coil in ten years time. the worry about being pressured into something later on is a separate thing, and it is a worry... but i still think 'most effective now' would be your main concern

[liv]

I am very much leaning towards this view, yeah. Rationally, effectiveness is a bigger factor than permanence, it's just that emotionally I really want to do something irreversible. I think what I should do is get over that prejudice and make the decision on sensible grounds.

[hatam_soferet]

*hugs*

I do think that your voiced concern about changes in healthcare/contraception is worth taking seriously inasmuch as it sounds like one o'dem psychological things saying "hai maybe we don't want permanent contraception akshuly." It might, for instance, be the ALL WOMEN MUST WANT BABIES part of your social education feebly fighting the decisions the rest of you has made, if you see what I mean. It might be interesting to try exploring that in your mind a bit, but as a practical concern I think you're right to label it as a weird paranoia - realistically it's not going to happen the world over in ten years, I don't think.

Regardless, I'd say push the NHS on properly permanent options. It happens that we're saturated in a culture that seems to think popping sprogs out of the snatch is a basic human desire, need, and right, so the NHS and its minions naturally want to prioritise that idea in everything they do. But you've been absolutely adamant that you don't want to have babies for pretty much your entire life, and anyway you're smarter than most of the NHS.

Because really, why the buggering fuck should you be denied what is clearly the most sensible birth-control method just because you've decided you don't want children and the NHS has decided you do, you're not a fucking brood mare. You're entitled to contraception under the NHS, this is the method you want, they can bloody well give it to you.

Er, shavua tov.

You are wonderful when you get angry on my behalf!

[liv]

Dear badger, thank you for this, it's really cheering and supportive. I think you're being a little unfair, though you do have a point about the underlying misogyny which is complicating my decisions.

It may be that worrying about future blocks to contraception or generally having less control over my life and sexuality is a symptom that I'm not really sure about the permanent thing. But I think it's the other way round: I really really want to do something permanent, so my brain is coming up with all kinds of rationalizations about why I must have the permanent option even though it's objectively less good.

And it is less good. It's not just sexism which is leading people to advise me against sterilization. Having surgery when you don't need it for immediate medical reasons has obvious downsides. And the rate of spontaneous reversals of tubal ligations is genuinely, objectively higher than the rate of either unwanted pregnancy or complications for women using the coil. So it's not at all obvious that sterilization is clearly the most sensible birth-control method.

At the same time, I do see the point of kicking up a fuss, because I do have a good chance of being listened to and that might make things easier for women in the future. I am rather aware that if I were poor or black or both, I would probably find the medical establishment much more enthusiastic about sterilizing me. (Though in that situation I doubt I would have doctors and nurses who had plenty of time for me and took my views seriously, and could easily be identified as People Like Us.) The problem is that I'm not sure I should put effort into fighting the system over an irrational whim. I know it's a purely emotional preference, not an actual rational medical decision. I might be smarter than many people, but I'm not being very intelligent about this, I'm acting on bizarre and unrealistic terrors!

Re: You are wonderful when you get angry on my behalf!

[hatam_soferet]

It may be that worrying about future blocks to contraception or generally having less control over my life and sexuality is a symptom that I'm not really sure about the permanent thing. But I think it's the other way round: I really really want to do something permanent, so my brain is coming up with all kinds of rationalizations about why I must have the permanent option even though it's objectively less good.

I was picturing a bit of brain, hidden like the racist bit everyone has and mostly picked up from culture, that says something like "But All Women Must Want Babies, so I must want babies. But I have also decided that I don't want babies. This is a problem. So I need to be envisaging a future where contraception isn't available, and where ipso facto I will have to get pregnant and have Babies, and everything will be okay, I will have Babies and not betray my other decisions. So let's invent a future in which we can't have contraception and must have babies because then we can be Proper Women even though we do have Principles." Anyway, not important.

Surgery is a tad more risky than the other options, etc, but hell, people have cosmetic surgery all the time, and people go through the most extraordinary procedures to try and get pregnant, I don't suppose those are entirely safe either. Not the point, I know.

...spontaneous reversals of tubal ligations...

Oh OK I was sort of assuming something a bit more drastic, like they do for puppies. They don't do tubal ligations on puppies.

I spose mostly it's just I get tired of seeing people prioritise Being Nice and Not Making A Fuss over their own wants, because no-one ever says thank you for being so nice and not making a fuss, so it's a big con. I can't tell if you're doing that or not here, but I tend to assume a lot of that in everyone, cos there's a lot of it about, and react accordingly. Which, you're right, is a bit unfair.

[karen2205]

I reckon the coil is a reasonable temporary option. Practically/financially/logistically unless you can persuade the NHS to sterilize you while you're unemployed, you're going to be going into a new job soon and probably won't want the immediate outlay of money on a private operation/complicated discussions with your boss/HR dept over why you need time off when you've only just started a job. I think that stuff is best delayed till you're secure in a new job, when you'll be able to take time off more easily and more able to afford to have it done privately, if the NHS won't cooperate.

I don't know how this factors into your thoughts re bullying by a partner who wants kids, but it is possible to reverse most sterilizations - with quite a lot more hassle than simply removing a coil, but unless they do a hysterectomy it's still potentially reversible.

[liv]

Thank you, those are both really good points. The actual practical process of going through an operation is something that I need to take into account. And yes, it might well be better to wait (like everything else in my life at the moment!) until I'm settled in a job and know what my financial situation and lifestyle are.

I do also realize that sterilization isn't truly irreversible or permanent. So that means its advantage over the coil is not as great in real life as it looms in my mind. It does somehow seem like something that people in general will take more seriously. Perhaps people will decide not to go out with me at all, if they know that I'm sterilized, instead of not listening when I say I'm childfree.

[hatam_soferet]

Perhaps people will decide not to go out with me at all, if they know that I'm sterilized, instead of not listening when I say I'm childfree.

You know, if that's really the issue here, you could just say that you're sterilized. They're not exactly going to be able to tell the difference. Yes, lying to a partner isn't great in that it implies a certain level of distrust, but this whole emotional thing is built on inherent distrust anyway, so it's not that dissimilar.

Back to the Being Pressured To Be Nice thing.

[verazea]

You know, if that's really the issue here, you could just say that you're sterilized.

That does strike me as wrong and the kind of thing that could get make someone very upset if/when they found out. It might be better to say "I have a coil, permanently". If someone completely disregards their partners wish to remain child free and pushes them to have children anyway then that's a stress on the relationship itself, as well simply disregarding liv's wishes. It's not as if liv isn't upfront about wanting to be childfree!

[hatam_soferet]

Precisely.

That is, it seems like the kind of dynamic that's so deeply screwed up you can't possibly start trying to accommodate it in any form, which is kind of scary, and makes me wonder - Liv, dearest - what the heck is with that. Especially given that you do appear to be in a relationship with a partner who respects you being childfree.

[shreena]

Indeed. There's a sense in which it might be helpful to be on a non-permanent form of contraception - because it helps you weed out the people who don't respect you and not continue dating them. (I am not implying that your current partner is in this category, I barely know him!)

[forestofglory]

Argh! This whole thing makes me very angry. (especially if I start to think about how reproductive rights intersect with race issues)

Good luck figuring out what you want and getting it.

[nanaya]

Personally I was fine with the combined pill, but I was told that I can't have that any more since I am over 30 as well as fat.

WTF!? I'm over 30 and fat, my doctors have never batted an eyelid about it. In fact, I once went to a sexual health clinic and made an appointment with a doctor to discuss my contraceptive options, and he was frankly rather short with me. The pill was the best option around, he told me, and I really shouldn't change at all, since he could see no medical reason behind my considering it. While I didn't think much of his manner, I did at least appreciate his straight-talking.

My view, FWIW, is that using the coil for a few years and seeing how it goes is probably a good idea. Like it or not, surgery is a big risk, and if you can avoid it, that's probably a good thing. I'm not suggesting your fears could never manifest, but they're probably not useful things to be formulating your decisions around. By all means do what you can to protect yourself, but the future is uncertain at best, and probably not a great guide for helping you work through decisions you are making right now.

If, after a little while on the coil, you still feel it isn't enough or that you definitely do want to go ahead with sterilisation, you may also be in a better position to push for it, because you can say you've tried the coil and it's not good enough for your needs.

[mongoose]

Um, I realise I'm setting the cat among the pigeons here, but I think you're making an assumption here that is so basic you may not even have realised it is an assumption.

The assumption is that you are going to have sex, no matter what.

Now, obviously, it is your choice whether or not you do that. My personal choice is that if I am not prepared to take responsibility at a given point in time for the chance that it may result in a child, I will not have sex. I realise that's an unusual attitude these days, and I would not attempt to inflict it on you or anyone else, but if you will allow me I will explain it so that you understand where I'm coming from on this.

I'm not being anti-feminist here. I strongly believe that if two people have consensual sex, they are jointly responsible for any consequences (and by "consequences" I don't just mean pregnancy; they could include, for instance, anything from mild regret at having rushed into it too soon to the betrayal of an existing partner). I won't discuss shades of less-than-consensuality here because you've already done it brilliantly in a previous post, except to say that it seems to be reasonable common sense that the more one partner pushes the other, the greater their share of the responsibility should be considered to be. But my main point is that there is an element of responsibility, and I think that has been somewhat obscured in recent years by the development of contraceptives. If effective contraceptives exist, then people no longer have to make hard decisions about what happens if a pregnancy occurs. Now I'm not saying that's in any way a bad thing in itself; but I am saying that separating the idea of responsibility from sex is, in my opinion, an unwanted side effect that ought to be minimised.

I think there's a great deal of pressure in today's culture to regard sex as a need, or at the very least as the norm. In fact, though obviously the species as a whole needs sex, no individual does. What is more, we are constantly bombarded in the media with the message that sexual urges can't (or possibly shouldn't?) be resisted. That doesn't seem too bad on the face of it, but what it is actually saying is, "We must have sex! We don't have any choice in the matter!" Heaven knows I am not in any way asexual, but I absolutely rebel when people try to persuade me that I have no self-control, or that it is wrong that I should have self-control.

Once again, I'm not attempting to counter-persuade here or to sell the merits of celibacy; it has stood me in very good stead for many years now, but it's the sort of thing you really have to be very sure about choosing for yourself, rather than being swayed by someone else's argument. All I really want to say is... there is a whole different angle on this entire set of issues, and I hope at least I've articulated it well enough to set a few people thinking.

[leora]

One thing I haven't seen addressed (although it may have been and I missed it), how does the risk of surgery compare to the risks of getting the coil 3 times? It seems like 3 should be the most you'd need it, but you might need it up to 3 times (menopause runs late in my family, so I'm used to the idea of making sure contraception is in place in the later years if you don't want a kid). I think that's an important thing to compare, since the surgery is one time and the coil is not.

Second, I think you could honestly tell a partner, "I can't have kids" even if you have a coil and not a sterilization. You can't have kids when you have a coil, and you can't have kids when you have deep psychological reasons not to. You are not able to have kids with someone. I think that's a reasonably true statement and I think it's okay to save the details of why you can't have kids til later in a relationship. I think: I can't have kids, which is good because I never, ever want to have children. And then saying you don't want to discuss it further at this point should be enough for the beginning of something with someone and might encourage those who want kids to not pursue you further.

I do wish people would take other people seriously about such things, and I do think many people do. But it's true that some people don't, and a bit of prevention is sensible as you don't know who will and who won't until it's annoying or problematic.

[(Anonymous)]

Obviously, anecdotes aren't data, but one of my biggest fears about getting a coil fitted was the number of friends that I've had who have expelled the thing afterwards.

Oh, and they do hurt quite a lot to get put in. Not unbearably so just at the "two glasses of wine and a large bar of chocolate" level. But I imagine that sterilization probably would hurt as well.

Becky