Interview with Dr. Elizabeth Hintz (Issue 5.3)

Dr. Hintz’s article, “Childfree Sterilization: A Normative Rhetorical Theory Analysis of Paradoxical Dilemmas Encountered by Childfree Patients and Providers,” will  be published in an upcoming issue of RHM. In this interview, assistant editor, Amy Reed, asked Dr. Hintz about the origins of this scholarship, its relevance to current conversations around abortion, and more!

AR: Your article, “Childfree Sterilization: A Normative Rhetorical Theory Analysis of Paradoxical Dilemmas Encountered by Childfree Patients and Providers,” explores the ways in which physicians and patients conceptualize childfree sterilization. Can you tell me a little bit about how you came to this research topic? In particular, what makes the topic of childfree sterilization ripe for rhetorical study?

EH: Daena Goldsmith (2019), the author of normative rhetorical theory (NRT), once wrote that scholars should “Look for interesting questions at points of friction: the place where situations from your life rub up against the theory” (p. 226). I became interested in voluntary childlessness because I have known since I was a young child that I never wanted to have children. Further, my husband and I are a childfree couple, and voluntary childlessness is on the rise in the United States. As a graduate student, I seriously considered requesting voluntary sterilization, but became discouraged after reading about the struggles of other young women on the /r/Childfree subreddit. Further, living in a politically Conservative state at the time, I was sure that I would face strong resistance. My then-boyfriend (now husband) and I decided that he should pursue a vasectomy instead because we presumed that he would face far less resistance. We were right.

Language is the vehicle by which we enforce and resist culturally legitimated assertions about what is right, real, and valuable. The patient-provider interaction, in this context, is often the battleground where patients seeking voluntary sterilization must fight to prove the legitimacy of their request against a backdrop of pronatalism and in an arena of paternalism where their wishes often come second to the attitude of their provider. Hence, examining what sterilization represents to patients and providers, what dilemmas they face in communicating about sterilization, and what they do to overcome such dilemmas, is necessary for illustrating the harms caused by procedural denials, and the reasons why such denials potentially occur.

AR: Your article suggests that physicians and patients value reproductive autonomy differently in the space of childfree sterilization, with patients viewing sterilization as an acceptable extension of autonomy and (some) physicians viewing sterilization as an unacceptable medical risk, liability, or condition for regret. Reproductive autonomy has gained national attention in recent weeks with the leaked Supreme Court opinion. I’m wondering how you see this research connecting to these larger national discussions about abortion?

EH: Reproductive policy has long limited reproductive autonomy by creating rules and enforcing attitudes regarding who “ought” to reproduce. Today, disparities in access to voluntary sterilization exist due to a patchwork of inconsistent state-to-state legal oversight left in the wake of anti-eugenics legislation. Childfree women, in particular, seeking sterilization are often denied access to the procedure, physicians citing their age (“too young”), marital status (unmarried), parity status (not having children or not having “enough” children), and likelihood of regret. Patients may request sterilization voluntarily both to forgo having children altogether or to limit family size. The myth of sterilization regret as being common among childfree women persists despite the largest study examining post-sterilization regret ever conducted, which followed 11,232 women over 14 years, finding that women without prior births were least likely among all groups to express regret following sterilization; 6.3%, 95% CI 3.1, 9.4).

In my view, the issue of access to voluntary sterilization for people looking to forgo having children is as important to the discussion of reproductive autonomy as the issue of access to contraception is for people looking to limit family size. The common rejoinder that female patients should “just take long-acting reversible contraception (LARC)” (e.g., an IUD) is inane. Even if female patients can access and afford it (as not all health insurance plans are required to cover birth control), many patients (including the author of this article) are unable to take birth control for a variety of reasons (contraindications) and many more experience intolerable adverse effects. The leaked Supreme Court opinion and looming overturn of Roe v. Wade suggests the possibility that childfree women may be both barred from taking permanent, value-concordant measures to prevent unwanted pregnancy(ies), and unable to act should one result.

AR: Your article suggests that the impact of physician refusal to perform childfree sterilization procedures is distributed unequally, with female identifying people and LGBTQIA+ people facing greater resistance from physicians and/or experiencing greater harm when such procedures are refused. This made me think about how medical racism and ableism might affect physician decisions with respect to childfree sterilization. Did any of your data shed light on the experiences of people of color or disabled people in these contexts?

EH: Although the anonymous nature of the data in this study (from Reddit) made it impossible to determine specific users’ race/ethnicity or ability status, these findings do suggest that problematic systems of meaning are being called upon to determine who “ought” to be granted access to sterilization. Those systems of meaning are inherently sexist, racist, cisheteronormative, and ableist (among others, e.g., classist) because they are paternalistic holdovers of eugenicist sterilization policies. These policies historically enabled the involuntary sterilization of Black, Indigenous and people of color (BIPOC) patients, patients from low socioeconomic status (SES) backgrounds, and patients with disabilities, among others, while white, able-bodied, affluent patients desiring sterilization voluntarily have been denied. Put differently, patient-provider interactions in which a patient’s request for sterilization is adjudicated have always functioned to punish and control female patients and reinscribe culturally legitimated attitudes about who should and should not reproduce. Despite 2020 guidance from the American College of Obstetricians and Gynecologists (ACOG) recommending that physicians uphold patient autonomy as paramount, provider discretion makes room for such bias to affect decision-making regarding the provision of sterilization. It also merits mention that no comparable guidance concerning the provision of male sterilization, to the author’s knowledge, has ever been issued by the American Urological Association (AUA). The closest contemporary AUA guidance, the 2015 “Vasectomy Guideline” is a guide on how to perform a vasectomy, the word stem “ethic” not appearing anywhere in the document, again reinforcing the apparently unproblematic nature of male sterilization.

AR: What is one thing you’d like medical professionals to learn or appreciate from your research on childfree sterilization?

EH: The bottom line is that patients, especially young female patients, seeking voluntary sterilization are trapped in communication paradoxes. They must convey the urgency of sterilization while they are young and fertile without emphasizing their youth. They must argue for the urgency of sterilization to avoid an unwanted pregnancy now without emphasizing their nulliparity (i.e., that they have never had children). These reasons (i.e., being young, not having had children) are often used by medical professionals to deny their requests. These patients may soon find themselves in a situation in which they may not be able to afford or take/tolerate birth control, may have their requests to be sterilized voluntarily to prevent unwanted pregnancy(ies) repeatedly denied, and may be unable to receive an abortion.

As my research confirms, denying sterilization is more than denying a patient’s reproductive autonomy (significant enough), but also patients’ self-knowledge, rationale for the sterilization request, and childfree and LGBTQ+ identities, which perpetuates paternalism (contradicting ACOG guidelines) and cisheteronormativity (despite the increasing diversity of gender identification and sexual orientation).

Adhering to the ACOG guidelines concerning the provision of voluntary sterilization (especially for young, nulliparous women) is one way to correct biased appraisals of sterilization requests, affirm patients’ own self-knowledge as valuable, and prevent harms (e.g., unwanted pregnancy) far more immediate and tangible than the future possibility of sterilization regret.

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