‘Is Your Family Complete?’ How Bias Affects Child-Free Couples Seeking Birth Control

When Payal Das (name changed) and her husband got married in 2006, they were certain they didn't want to have children. The couple soon started looking at long-term contraceptive options to ensure they could remain childfree.Payal was not keen on oral contraceptives because of the possibility of long-term side effects. She was not comfortable with opting for an intrauterine device either. The couple instead wanted a permanent solution like vasectomy for him or tubal ligation for her. These methods involve a minor surgical procedure to cut the tubes that carry the sperm and the egg, respectively, thereby preventing pregnancy.Both are considered safe and effective methods of contraception, particularly vasectomy, as it’s a less complex surgery than the one for women, and the recovery period is shorter.“My husband was ready to do it so we approached a urologist. They looked at us as if we were from Mars, as if we were insane. Their first question was, ‘Is your family complete?’,” Payal recalled.'I Won't Have Children': The Trials of Choosing a Childfree LifeThe doctor ridiculed Payal and her husband and denied them the vasectomy, telling them they would want children in the future. For about seven years after, Payal and her husband continued to look for doctors in Mumbai who would do the procedure for them, only to be repeatedly denied, before ultimately giving up on the idea and opting for other contraceptive methods.In India, more and more couples are choosing not to have children. Their reasons are diverse. Some don’t want the financial burden of raising a child. Others simply have no desire for children and prefer the freedom to pursue their passions. For still others, it’s anxiety about climate change and the uncertain future it suggests.Yet, even as more people see childbearing as a choice to make—and not a predetermined path—they are faced with a healthcare system in India that is incompatible with exercising this reproductive choice.Childfree couples encounter judgmental doctors who interpret the government guidelines in bad faith, ridicule their choices and try to impose their own views about children and family on their patients.Once they decided they didn’t want to be parents, Rupsha, a freelance content writer based in Kolkata, and her husband were keen on sterilisation because of “the prospect of safe sex without the fear of pregnancy,” as Rupsha put it."For about five years or so, we had been looking for a vasectomy or a bisalp (a sterilisation method in which the fallopian tubes are removed), only to be refused every time."RupshaAll the doctors they consulted told them that they couldn’t get sterilisation because government guidelines did not allow them to get it unless they already had children.Climate Anxiety: If You Plan to Not Have Kids, You're Not AloneThe guidelines on permanent sterilisation by the Government of India’s National Health Mission (NHM) state that to be eligible for the procedure, an individual must be under 60 years old, if a man, or between 22 and 49, if a woman, must have been married at some point in their life, and must have at least one child above the age of one.However, when consulting a surgeon for a different issue, Rupsha and her husband casually enquired about getting a vasectomy and, to their surprise, the doctor agreed to do the procedure. “Honestly, we were prepared for a no, but he agreed. He even said that it was our choice, and he wouldn't question us on that,” Rupsha said. Within two weeks, her husband underwent the surgery with no hitches.Speaking to The Quint, Sarita Barpanda, a reproductive rights activist and lawyer, said that denying sterilisation to childfree couples did not have any legal grounds—and this was a result of how doctors were interpreting the guidelines.“There is no ceiling in the law. It does not say you can only provide it (sterilisation) to one section of people—and not to the other. It only gives a yardstick that these are some people who could be eligible for the service."Sarita BarpandaDr Shaibya Saldanha, a consultant obstetrician and gynaecologist based in Bengaluru, also said that the guidelines do not restrict childfree couples in India from getting permanent sterilisation.She added that she has referred at least two childfree couples, on their request, to a urologist for vasectomy.Have More Kids? Why Elon Musk’s Latest Hot Take May Not Be His BestExplaining the context in which the NHM guidelines were framed, Dr Saldanha said, “In India, family planning programmes have been quite coercive. It was common for private and government doctors to coerce women, especially women from poor families, to undergo sterilisation immediately after they had a child.""With the infant mortality rate in India still being quite high, sometimes the child would die, and the women would then have to undergo a complicated procedure to reverse the sterilisation.”Dr Shaibya SaldanhaIt was to prevent such issues that the guidelines were framed, she said.Dr Saldanha believes that the reason many doctors deny sterilisation to childfree couples may be because they are concerned about them regretting the choice in the future. “It’s not that every couple is always going to be together. Say they break up, they are with a new partner, and they want to have children with them. The procedure cannot be easily reversed,” she said. Moreover, some doctors may be reluctant, as per medical ethics, to perform a surgery that is not strictly necessary.Dr Saldanha acknowledged that very often doctors refuse because they are judgmental about their patients’ choices. She reckons that one in 10 of her clients are couples who are childfree by choice. Many of them have come to her after having faced rude behaviour from other doctors. “They go to the gynaecologist for some other issue and when the couple says they do not want to have children, the doctors tell them they’re being selfish, and they don’t understand the importance of having children. Their right to make reproductive choices is not respected and they are shamed for their decision."Dr Shaibya SaldanhaIt was this disrespectful treatment that really frustrated 33-year-old Mahima Lakshmi (name changed) when she and her partner were seeking a vasectomy for him. Over four years, they tried six different doctors in Bengaluru before they finally found a private chain of clinics that was willing to provide the procedure. “I felt very frustrated for my partner. It’s already a big move and being second-guessed and shamed did not help.”Mahima LakshmiIndia's 'Population Explosion' & Two-Child Policy: Myths Versus FactsTo navigate this unfriendly healthcare landscape, childfree people often rely on crowdsourced and personal recommendations on doctors willing to perform sterilisations.On Reddit, there is a 10,000 member-strong ‘Childfree India’ community where people exchange notes on doctors and hospitals in India where they can get the procedure. There are also several WhatsApp, Telegram, and Facebook channels where childfree people in India interact.Raphael Samuel, who co-organised the first national meet of childfree people in 2019, said that he often got enquiries for doctors from people in the network. When asked if anyone had considered challenging the guidelines in court, Samuel said it wasn’t worth it since there are other contraceptive methods—and because they now know a few doctors who are reliable.Yet, childfree people face judgement, dismissal, and pressure to have children, even when seeking contraceptive methods other than sterilisation.Since they couldn’t get a vasectomy, Payal wanted to take oral contraceptive pills and consulted several gynaecologists to find a suitable option. "I did not get any cooperation from doctors. One gynaecologist told me, 'Why do you want to have the pills? You should have a baby. The first baby is very important'," Payal said. Another doctor prescribed pills to her reluctantly, along with plenty of advice on why she shouldn’t take the pills in the long term because it could lead to infertility. “I told her, I am not planning to get pregnant. The doctor laughed at me and said, 'You have a uterus, what is the use of that?'"‘It Happens a Lot’: The Flaws in India’s Sex Ratio Data and 'Gender Test' LawReproductive rights activist Barpanda linked the challenges faced by childfree people with the larger abuse that women experience when trying to access reproductive care in India, where they are patronised and their bodily integrity is not respected. “Choice and consent. These two Cs are not there anywhere in our reproductive health services in India. I doubt if people even know what it means to be childless by choice. Even though generations have advanced in their understanding, service providers and the system have not understood this.”Sarita BarpandaBeing denied an effective contraceptive like sterilisation can have very real consequences for people, especially women, who bear the burden when birth control methods fail. One childfree woman who spoke to The Quint got accidentally pregnant three times over several years. She did not wish to share any identifiable information due to the sensitive nature of her experience.She and her husband wanted a vasectomy but were forced to rely on methods like condoms and birth control pills (which carry a higher risk of failure than sterilisation), because they couldn’t find a doctor willing to perform the procedure.The woman recounted the traumatic experience of terminating the unwanted pregnancies. "It was really difficult to get a doctor to prescribe abortion pills. Even the person doing the ultrasound once tried to emotionally blackmail me into keeping the pregnancy, saying, 'Look at this dot, it’s going to become a beautiful baby and you will cuddle it'."But she and her husband were very confident in their decision to not have children, so they got through it each time.“Prevention is better than cure. Had we got a good urologist who could have done a vasectomy for us, we would not have to go through this,” she said.'Contraception Still a Woman's Duty': Why Men in TN Don't Turn Up for VasectomyJudgements and social censure aside, is there a way for doctors to balance the risks and benefits of sterilisation and to reasonably assess if someone is serious about their decision to forgo childbearing?This is the thought that Mahima was left with after the dismissive and rude behaviour from the doctors she and her partner experienced. “It was frustrating to deal with doctors who didn’t have objective methods of assessing if people were making sound, informed choices. That leads them to be sceptical and judge everyone by their own biased standards.”MahimaDr Saldanha said that it’s difficult to assess this objectively. “Personal choice is important, but I would talk to the patients to understand their reasons for deciding not to have children. After some questioning, you can make out if someone is serious and has given it thought. It may not be objective but it tells you the reasoning behind their choice. Then it’s about applying my judgement. I need to be sure they won’t change their mind,” she said.But with no standard practice or guidelines for medical professionals to follow in the case of people who do not want children, couples are left to scramble in search of a doctor who can offer such balanced judgement.(Meghana Choukkar is an independent journalist and researcher based in Bengaluru, Karnataka.)Is It Time for Women to Question the Birth Control Pill?

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'Is Your Family Complete?' How Childfree Couples Seeking Birth Control Face Bias

More often than not, doctors deny sterilisation because they are judgmental about their patients’ choices.

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