EXECUTIVE SUMMARY
Young women, ages 18 to 30 years, have been undergoing tubal ligation procedures for permanent contraception at a rate that is double what it was in early 2022, before the Dobbs decision.
• Using a national database, researchers studied monthly rates of sterilization, including tubal procedures and vasectomy procedures.
• Researchers found a substantial increase in procedures among women after the June 24, 2022, decision, but a level increase among men.
• The increase in permanent contraception among young people likely reflects their fears and concerns about pregnancy in the landscape of states banning abortion procedures.
New research shows a large increase in the rate of permanent contraception procedures among young women in the period from June 1, 2022, to Sept. 30, 2023 — mostly after the U.S. Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision on June 24, 2022.
Among adults ages 18 to 30 years, the rate of tubal ligation procedures doubled between early 2022 and September 2023.1
“We used a national database of medical record data and looked at monthly rates of people’s sterilization or tubal ligation and vasectomy procedures among those 18 to 30 — a younger population,” explains Jacqueline Ellison, PhD, lead study author and an assistant professor of health policy and management at the University of Pittsburgh School of Public Health. “We evaluated how they changed and found a pretty substantial increase among permanent contraception rates — much higher for females relative to males. We also found that for both tubal ligation and vasectomies, the rates were increasing among young people before Dobbs — more for females. After Dobbs, the monthly rate continued to increase for females. For males, a level increase was sustained. The rate doubled for females after Dobbs through September 2023, in the 15 months after the ruling. Removing tubes also was included in the data; we use the terms ‘tubal ligation’ and ‘permanent contraception’ because the term ‘sterilization’ is increasingly not used.”
Reflects Fear and Anxiety
The increase in tubal procedures is telling, Ellison notes. “I think it’s very possible that the Supreme Court’s decision changed people’s preferences,” she says. “It’s also possible that people had wanted to get permanent contraception before Dobbs, and then the court decision increased the urgency.”
Whatever the explanation for the increase in permanent contraception, the Dobbs decision was the catalyst for the increase in procedures. “This likely reflects people’s fear and anxiety around the possibility that they will not be able to end an unwanted pregnancy,” Ellison says.
Investigators also saw a trend of increasing numbers of men choosing vasectomies before the Dobbs decision. The authors of a different study found that from January 2019 to December 2022, most contraceptive services showed steady downward trends. These included a decrease in intrauterine device (IUD) services from 650,043 in 2019 to 591,509 in 2022, and a decrease in tubal ligation services from 103,547 in 2019 to 74,537 in 2022. But the volume of vasectomy services increased from 146,796 in 2019 to 198,212 in 2022.2
“They looked at the number of vasectomies and tubal sterilizations and looked at all ages, all people, and they found a rise in vasectomies preceding Dobbs and a decline in tubal sterilizations. This is in raw numbers,” Ellison explains. “It is not directly comparable to our study because it’s crude numbers and not the rate.”
The contraceptive trends study covered a period that included pre-COVID-19 pandemic, during the pandemic, and six months after the Dobbs decision.2
“One of the reasons we looked at this period is to include those early months of COVID,” says Julia Strasser, DrPH, lead author of the study, assistant research professor in health policy and management, and director of the Jacobs Institute of Women’s Health at George Washington University. “In the April and May 2020 period of COVID, when a lot of doctors’ offices were shut down, we do see this sharp decline in services that have to be accessed in person.”
Multiple Factors in Play
From 2019 to 2022, multiple national changes could have affected how women accessed contraception, including permanent contraception, Strasser says. For instance, it was during this period that hundreds of Title X programs closed because of the Trump administration’s rules that prohibited Title X money from going to any clinics that provided abortion care or even talked about abortion care. It also was the period when the pandemic changed how women obtained contraception, turning more frequently to telehealth options. In mid-2022, the Dobbs decision resulted in overnight abortion bans in more than a dozen states.
“There were layers of huge, external factors impacting access to contraceptive care in this time period,” Strasser says. “It’s been a very busy couple of years.”
Strasser and colleagues studied the number of permanent contraceptive procedures in the United States during the four-year period that ended on Dec. 31, 2022. These findings showed increases in vasectomies and decreases in tubal sterilization procedures, except for a spike in tubal procedures in July 2022, following the Dobbs decision.
“What we see in our study is a massive uptick in all these methods of contraception use that keeps going up in those initial months following Dobbs,” Strasser says.
But the longer-term trend of declining contraception use continues. “IUD use over time has been slowly but steadily decreasing since late 2020, early 2021, and the same is true with injectables and tubal sterilization,” Strasser explains. “If they were going down, even if just a little over time, and then were temporarily bumped up, they all seem to have kept going down afterward except for vasectomy — that is going up.”
Strasser and colleagues studied permanent contraception data very differently from Ellison and colleagues. The two sets of researchers looked at different populations, different periods, and different numbers. Ellison’s study examined rates of procedures among young adults, and Strasser’s study looked at the total number of procedures among all adults. Plus, the finding that permanent contraception use has declined among women but increased among men could be its answer to the overall decline in tubal procedures. More couples may have decided for men to seek permanent contraception instead of women, Strasser notes.
“We don’t know whether the decline we’re seeing in these [contraceptive] services [is because] they have been replaced by something else or not,” Strasser says. “We can’t tell from our data whether people will regret their decision or whether they’ll be happy about it — and we shouldn’t make any statements about whether these [findings] are good or bad,” Ellison says. “But we do know that younger people are more likely to regret sterilization down the road, relative to older women. Either way, people should not be pressured into making this permanent decision because of anxiety or fear around a policy change.”
The patient’s potential regret should not be a deciding factor in performing a permanent contraception procedure, including vasectomies. “I’m apprehensive of speculating whether people are going to come to regret this decision because probably a lot of people are happy about this decision and will stay happy and not want a reversal,” Ellison says.
Permanent contraception decisions also could be a form of protest on the part of women who are angered by Dobbs. For example, one Reddit commenter wrote, “The day the opinion leaked, I called and scheduled a consult. I was sterilized a month and a half later.”3
Another person commented, “Our reproductive rights are being stripped away at an alarming rate, and then Republicans complain that the fertility rate is dropping ... We don’t want to be forced to be pregnant if we don’t want.”3
Ensure Full Access to All Contraception
The research suggests that reproductive health providers need to ensure patients have access to a full range of contraceptive options and person-centered contraceptive care, Ellison says.
“Coercion and bias in medicine have been and continue to be a problem,” she explains. “Some people may be pressured into using a certain contraceptive method, and some were pressured against a certain contraceptive method. That’s a fear in the post-Dobbs period.”
There also are concerns that state abortion bans create a coercive policy, forcing people to continue unwanted and unsafe pregnancies. “It’s also coercive if it results in people feeling pressured to undergo this permanent procedure when they otherwise wouldn’t have done it,” Ellison adds. “We need to be clear about the fact that abortion restrictions are discriminatory against people who could get pregnant, and access to contraception alone is not a solution to this problem of abortion bans.”
Contraception access is not a guarantee. Some states are considering policies that restrict contraception access. “People have a fear of having their contraceptive options restricted, and it’s already starting to happen. It’s something we need to be aware of,” Ellison says. “We didn’t look at state-level data in our study, but I think people are concerned about their ability to access contraception in the future.”
REFERENCES
- Ellison JE, Brown-Podgorski BL, Morgan JR. Changes in permanent contraception procedures among young adults following the Dobbs decision. JAMA Health Forum 2024;5:e240424.
- Strasser J, Schenk E, Luo Q, et al. Contraception usage and workforce trends through 2022. JAMA Netw Open 2024;7:e246044.
- Reddit. Young women are getting sterilized (permanent contraception) in high numbers since the Dobbs decision, a new study finds. https://www.reddit.com/r/prochoice/comments/1c6ijk1/young_women_are_getting_sterilized_permanent/?rdt=54791
