Childfree by Choice: Stigma in Medical Consultations for Voluntary Sterilization

CHILDFREE BY CHOICE1

STUDENT

Childfree by Choice: Stigma in Medical Consultations for Voluntary Sterilization

Abstract

Voluntarily childlessness, also called being “childfree,” is a growing movement fueled by increased opportunity and access to contraception for women of child-bearing age (Richie, 2013). There is a dearth of research examining rejection in medical consultations for childfree individuals seeking voluntary sterilization. Today, although anyone over the age of 21 in the United States is eligible for voluntary sterilization, childfree women who request it are repeatedly denied. To further explore this phenomenon, we examine stigma in medical consultations for childfree individuals. Content analysis was performed to examinenarrative accounts from a popular community on the website Reddit. Results indicated that the mentioning of age and the risk of regret during the medical consultation were negatively predictive of being approved for the procedure. Women were also more likely to be asked about the risk of regret during the consultation. However, men and women reported being rejected at roughly the same rates.

Keywords: childfree, sterilization, stigma

Childfree by Choice: Stigma in Medical Consultations for Voluntary Sterilization

According to the United States Census Bureau, approximately one in five white women will never have children (2011). Of this group, half are infertile, and a sizeable portion of the other half, it is assumed, are voluntarily childless (Centers for Disease Control [CDC], 2013). The 2002 National Survey of Family Growth found that 10.3 million women used female sterilization as the primary form of contraception, but the proportion of these women who were voluntarily childless is unknown (Mosher, Martinez, Chandra, Abma, & Willson, 2004). Viewing tubal ligation as a legal, reliable, and inexpensive alternative to temporary forms of birth control, childfree women seek voluntary sterilizations from medical providers. For over 40years, anyone over the age of 21 in the United States has been eligible to be sterilized voluntarily. However, a large divide exists between the legal requirements for the procedure and the lived experiences of those seeking it. Little data exist about why individuals who fit the legal requirements for the procedure are rejected. Yet, being barred from voluntary sterilization undermines a patient’s autonomy as an active agent in the management of their health and fertility. For these reasons, the issue of voluntary childlessness is examinedthrough the use of a stigma framework. The unique and often stigmatizing nature of being childfree make online communities such as Reddit’s /r/childfree rich and detailed sources of information and records of both positive and negative medical interactions. By examining accounts of medical encounters written by childfree individuals seeking sterilization, we seek to better understand how stigma permeates these interactions and compare the experiences of childfree men and women. Then, we examine which communicative factors increase or decrease the likelihood of success in these interactions. Our approach offers a novel method for examining these narratives of interactions with medical professionals in a culture that values reproduction.

Normative Expectations of Motherhood

There is a normative expectation that married women, at a certain age, will produce children. As Gillespie (2000) suggested, there are powerful ideologies which link motherhood with womanhood. In other words, to be a woman is tandem with being a mother, and for many adult women, their social identity as a woman is linked to their status as a mother (Koropeckyj-Cox, Romano, & Moras, 2007; Park 2002). As pronatalism and associated cultural discourses create a sort of archetype of femininity that includes motherhood, making the choice to be childfree is often viewed as a perverse rebellion against nature (Gillespie, 2003). Hayden (2011) describes this idea as “intensive mothering” which is a belief that having and raising children is the most important aspect of a woman’s life.Thus, by violating normative expectations concerning motherhood, a woman who chooses to remain childfree becomes stigmatized because of her choice not to have children (Park, 2002).

This stigma manifests in the conversations that childfree women have with friends, family, and medical providers, which tend to include more personal than situational judgements. Disclosing one’s childfree status may lead either to negative personal attributions (e.g. she’s a bad person because she doesn’t like children, she must have had a bad childhood, etc.) or unwanted empathy when it is assumed that one’s childlessness is not voluntary. Durham (2009) discusses the two social factors that largely determine whether a childfree choice is likely to be accepted. The first is called “oughtness” and describes a social judgment of whether someone “should” have children. The second factor is the perceived emptiness of the lives of childfree people, and the impact that children have on the lives of their parents. Together, these two factors account for a large portion of the rejection, stigma, and social scrutiny faced by men and women who make the choice to be childfree.

Contemporary Struggles

The high satisfaction rates, reliability, and low cost of this legal form of contraception make it a viable choice for thousands of women each year (Richie, 2013). Women requesting tubal ligation surgery report a variety of reasons for their choice. Personal reasons often include freedom and a fundamental rejection of motherhood, the loss of identity associated with motherhood, and the activities commonly associated with motherhood (Gillespie, 2003). There are also a range of medical conditions for which sterilization would benefit the health of the affected woman, or for which pregnancy would be harmful. Allergies or intolerances to traditional forms of birth control, for example, may prompt a woman to request sterilization to prevent an unwanted pregnancy.

Women seeking this procedure face a multitude of challenges, including repeated denials, humiliation, procedural hoops, and the questioning of their legitimacy (Richie, 2013). Although sterilization as a form of contraceptionis most important when a woman is likely to become pregnant, age is among the most commonly cited reasons for rejection in medical consultations, often because of the risk of a woman regretting the procedure when she is older. While rates of regret are low, women under the age of 25 who come from disadvantaged socioeconomic backgrounds (below 150% of the federal poverty line) are the most likely to regret the procedure and request tubal ligation reversals (Chandra, 1998). This may be because these women lack an understanding of what the procedure entails or its permanence. However, childfree women overall do not report high rates of regret or frequently submit requests for reversals. In a longitudinal study of nearly 8,000 women who sought sterilization, 95.7% of women between the ages of 20 and 24 and 97.6% of women between the ages of 30 to 34 did not regret their decision (Wilcox, Chu, Eaker, Zeger, & Peterson, 1991). While it has been found that an association between age and the risk of regret exists, many of these studies are of low quality, and women who report regret or request reversals typically constitute a small subset of the total population (Curtis, Mollhajee, & Peterson, 2006).Age does not appear to be a factor for men who request vasectomies, even though 45% of men with two children requested a reversal, a rate of regret substantially higher than that of women (Howard, 1982).Number of children is another commonly cited reason for rejection, although there are no legal guidelines for the number of children a woman must have before tubal ligation is a viable option. Therefore, age, the risk of regret, and number of children are used as variables for determining which factors most influence the outcome of an appointment.

Stigma and the Medical Interaction

Goffman (1963) defines stigma as “an attribute that is deeply discrediting” (p. 13). Stigma permeates medical consultations for voluntary sterilization, affecting preparations made by patients, preconceptions about what to expect at the appointment, the conversation with the medical provider and the outcome of the consultation. These attributions manifest when, for example, a childfree woman is asked to undergo a psychiatric evaluation to receive tubal ligation surgery. Two types of stigma that are relevant in healthcare consultations are experienced and anticipated stigma (Earnshaw & Quinn, 2012). In this context, experienced stigma is perceived discrimination, prejudice, or stereotyping faced by childfree individuals in medical consultations that affect their ability to access healthcare services like voluntary sterilization (Scambler & Hopkins, 1986). Two commonly reported themes that this manuscript seeks to explore include age discrimination and the stereotyping of childfree individuals as doubtful or likely to regret their decision (Ritchie, 2013). Anticipated stigma is the extent to which childfree individuals expect to be stereotyped or discriminated against in medical consultations (Markowitz, 1998). We explore this idea by examining the anticipated outcomes and preparations made prior to appointments with medical professionals.

Having a concealable, stigmatized identity such as being voluntarily childfree can act as a barrier to voluntary sterilization, driving patients to look for support online (Link, Struening, Nesse-Todd, Asmussen, & Phelan, 2002). Patients may withdraw and attempt to seek communities of peers who understand what they are going through. For this reason, the presence of online support communities can act as a catalyst for encouraging those who would not otherwise seek support to ask for help (Houston, Cooper, & Ford, 2002). Among peers, online support group members label themselves as childfree in an attempt to procure information (Link, Mirotznik, & Cullen, 1991). Therefore, the use of a stigma framework to analyze content posted to digital communities is justified. To examine this idea, we explore the following research questions:

RQ1: What impact does the stigma of being childfree have on the outcome of the medical consultation?

RQ2: What differences in experienced and anticipated stigma are reported between childfree men and women?

Method

To better understand the role of stigma in medical consultations for voluntary sterilization, we analyzed posts from /r/childfree, a subreddit (or community) of the website Reddit, the front page of the internet. Defining themselves as “those who do not have and do not ever want children (whether biological, adopted, or otherwise),” men and women on /r/childfree post “rants” and “raves,” cover news, request advice, lead discussions, review social media posts, and share jokes (Reddit, n.d.).Resources on the subreddit include support groups, awards, links to childfree literature, lists of “childfree friendly” doctors, and frequently asked question lists, (Reddit, n.d.). While Reddit users in general are predominantly young, unmarried white males living in the United States (Reddit, 2016), users of /r/childfree are mostly white, college-educated, non-religious, heterosexual females under the age of 30living in North America (Reddit, 2017).

Sampling Procedures
/r/childfree has approximately 119,000 members, and posts by members frequently include narrative accounts of interactions with physicians. One trend on /r/childfree is posting narrative accounts of experiences with medical providers, both positive and negative. These medical narratives encompass a variety of appointment types, from birth control to voluntary sterilization requests.Post authors were from the United States, Canada, and the UK. Our sampling unit was a post describing a medical encounter for voluntary sterilization, our recording unit was at the post level, and our context unit was /r/childfree. We searched /r/childfree using the keywords “appointment” and “doctor,” identifying 650 total posts.Relevance sampling criteria were that the post had to be about an individual (male or female) seeking voluntary sterilization written before, during, or after the appointment. Posts merely sharing humorous photos or videos (n=20) or discussing childfree issues unrelated to the pursuit of voluntary sterilization (n=428) were excluded from our final sample (n=202). Two coders then each individually coded all posts for relevance (Krippendorf’s a = 0.91) and resolved disputes until agreement was reached on all items.

Coding Procedures

Using codes created after a review of existing literature (Gillespie, 2000; Peterson, 2014; Richie, 2013) we analyzed the content of each post. Each post was given a “1” to indicate the presence of a code or a “0” to indicate the absence of that code. Initially, 40 posts were randomly selected to constitute a reliability sample. Two coders then individually coded each post, disputes were discussed until agreement was reached on all codes. This process was repeated two additional times with 40 additional randomly selected posts until reliabilities of 0.69 or greater (Krippendorf, 2012) were reached on all codes. Remaining data were independently coded and disputes were discussed until agreement was reached on all items.

Codes

Patient Sex. This codedistinguished between posts written by women seeking tubal ligation surgery (α = 0.87) (n =163, 80.7%) and men seeking vasectomies (n=39, 19.3%). For example gender was determined from statements such as, “I made an appointment to see about getting my tubes tied.”

Rationale. This codewas an indicator for whether the rationale for requesting the appointment or not wanting children was mentioned (α = 0.71) (n=128, 63.4%). For example, “I’ve always known that I didn’t want kids.”

Preparation. This code was an indicator for whether the author of the post mentioned any preparations he or she made prior to the appointment such as Internet research, talking to friends and family, or calling doctor’s offices in advance (α = 0.77) (n=105, 52.0%). For example, “I decided to find a clinic in the city after my GP told me no one in my rural area would sterilize me.”

Anticipated Outcome. This codewas used to determine whether childfree individuals had preconceptions or expectations about the outcome of the appointment (α = 0.82)(n=135, 66.8%). For example, “I have waited until now to give it a go for the first time because I knew this shit would be dumped on me.”

Previous Rejection. This codewas used to identify cases where the individual had had their request rejected at a previous appointment (α = 0.87)(n=30, 14.9%). For example, “After many trips across Michigan, I finally found a doctor who would sterilize me.”

Outcome. This code was used to determine whether the author of the post mentioned the outcome of the appointment (n=169, 83.7%). This code was then subcoded according to document the type of appointment outcome. Possible outcomes of the appointment were acceptance (n=87, 43.1%), referral (n=24, 11.9%), or rejection (n=57, 28.2%). For example, “I received a referral to another physician.”

Appointment Variables. The codes Age (α = 0.76) (n=80, 39.6%), Number of Children (α = 0.69) (n=59, 29.2%), and Regret (α = 0.87) (n=74, 36.6%) were used to flag whether these issues were raised during the consultation with the medical provider. One example of the age code was, “People of your age tend to regret this decision when they get older.” Number of children being mentioned sounded like, “You haven’t had any children yet, and I only perform this procedure on people who have already had children or you don’t want just one more child.” One example of regret was, “He said that I might end my 10 YEAR relationship with my husband and fall in love with someone else who wants kids.”

Data Analysis

To explore research question one, we performed binary logistic regression to examine the impact of the mentioning of the patient’s age, number of children, or the risk of regret on the likelihood of acceptance, referral and rejection. These factors were selected because they appeared in existing literature as common sources of discussion during these medical interactions. Research question two was examined using chi-square tests of independence.

Results

Research Question 1

Binomial logistic regression was performed to determine the effects of age, number of children, and the provider mentioning the risk of regret on the likelihood that a request for voluntary sterilization was accepted by the provider. The logistic regression model was statistically significant, χ2(3) = 41.17, p < .0001. The model explained 21.6% (Cox and Snell r2) of the variance in the likelihood of being accepted. Of three predictor variables (age, number of children, and mentions of regret), two were significant as shown in Table 1 (Appendix A.1.).

Research Question 2

To explore gender differences in the experience of seeking voluntary sterilization, we examined rejection, previous rejection, mentioning of the patient’s age, the risk of regret, or the number of children they currently had, and whether the patient reported anticipating an appointment outcome. These factors were selected after a review of existing literature, which indicated that these were common reasons cited for rejection, or common features of these interactions. Results indicated that gender differences were not as pronounced as existing literature suggests. While frequency data indicated disparities between childfree men and women, further statistical tests did not show significant differences between groups.

The first analysis sought to examine whether childfree women (n=163, 80.7%) reported being rejected more than childfree men (n=39, 19.3%). A chi-square test of independence was conducted between patient sex and being rejected (n=68, 33.7%). There was no statistically significant association between patient sex and rejection, χ2(1) = 2.29, p = .130.

The second analysis then examined whether childfree women (n=163, 80.7%) reported being previously rejected more often than childfree men (n=39, 19.3%). A chi-square test of independence was conducted between patient sex and previous rejection. There was no statistically significant association between patient sex and previous rejection, χ2(1) = .367, p = .545.Next, reports by childfree women (n=163, 80.7%)of more rejection for mention of age in the appointment, the risk of regret, and the number of children more than childfree men (n=39, 19.3%) were examined. A chi-square test of independence was conducted between patient sex and each of the three variables in question (mention of age, the risk of regret, and the number of children). Our first chi-square test examined the patient sex and whether the medical provider mentioned age in the appointment. The test revealed there was no statistically significant association between patient sex and the medical provider mentioning the patient’s age in the appointment, χ2(1) = .795, p = .373. For the next variable (the risk of regret), a second chi-square test was performed to determine if there was a significant association between the two variables. There was a statistically significant association between patient sex and the medical provider mentioning the risk of regret, χ2(1) = 7.269 p < .007. Our frequency data show that 41% of women (n=163, 80.7%) reported regret being discussed during their consultation while only 18% of men (n=39, 19.3%) reported the same treatment.A final chi-square test for independence was conducted between the patient sex and number of children. There was no statistically signification association between patient sex and a provider asking about the number of children they had χ2(1) = .057 p < .811.