They choose permanent contraception

In 2017, none of the participants in the Swiss Health Survey aged 15 to 24 had mentioned tubal ligation as a means of contraception. Five years later, 0.2% do mention it. In the two major university hospitals in the French-speaking part of Switzerland, as well as the family planning centres in the Valais region, some young women have confirmed that they are interested in the operation. “Since about 2018, five to six patients in their twenties and without children come to us every year for sterilisation, notes Patrice Mathevet, head of Gynecology in the Woman-Mother-Child Department at CHUV. Although limited, these cases have led us to seek the opinion of the Clinical Ethics Commission, which has decided that we can support this issue.”

Claiming to be “Childfree”

There are several reasons for the growing interest of young women in sterilisation. “Between my beginnings twenty years ago and today, the demand to live a childless life, felt as childfree and not childless, has increased,” says Angela Walder-Lamas, sexual health counsellor and midwife at HUG’s Sexual Health and Family Planning Unit. In Switzerland, 16.4% of women between the ages of 20 and 29 do not wish to have any children, according to the FSO. “Patients who consult for sterilisation want this non-desire to have children, often felt since adolescence, to be considered, points out Patrice Mathevet. The ecological argument against raising a child in today’s world or contributing to overpopulation on the planet is raised regularly. The co-chair of Santé Sexuelle Suisse, responsible for the five sexual health centres in Valais (SIPE), faces the same justifications. “In our society, there is still a pressure to procreate, reminds Jacqueline Fellay Jordan. In the face of these injunctions, these young women also give a strong response, one that is quite determined, as is often the case at this age.” 

Mistrust towards hormones also plays a role. The 15-34 age group is taking fewer pills than it did ten years ago and is increasingly turning to non-hormonal contraceptives such as copper intrauterine devices (IUDs), natural birth control methods, condoms or vasectomies. “Young women who wish to perform a ligation often question the contraceptive mental burden and possible side effects to endure. They also fear that their contraception may fail, even if it is considered very effective, and that they will have to terminate a pregnancy,” says Walder-Lamas. 

A sensitive subject

Until recently, tubal ligation for a childless young woman was not an option. At the Hospital of the Canton of Fribourg, with a few exceptions in very specific cases, no procedure has ever been performed on patients under the age of 35. “The situation did not present itself, but if it were to happen, we would take maximum precautions,” says Nordine Ben Ali, Deputy Head Physician in the Gynaecology and Obstetrics department at the Hôpital Fribourgeois (HFR). Indeed, we would be concerned that the patient is experiencing an emotional crisis or that she is among the small percentage of women who might regret her decision.”

The Co-Chair of Santé Sexuelle Suisse acknowledges that this is a sensitive subject. “Of course, we would like to tell these young women that life is unpredictable and that sometimes these decisions are revisited, but we must respect their wishes. Society trusts 18-year-olds enough to let them marry, drive, and have children. We help a young man or woman who wants to focus on their career before having a child freeze their oocyte or straws. However, it is as if we could not hear this opinion on sterilisation. Perhaps by affecting fertility, we are afraid to affect the very survival of the human species.” 

A marked course

Aware of the stakes of such a request, Patrice Mathevet usually receives women in their twenties who wish to perform a tubal ligation. During this interview, the doctor explains what happens if you change your mind. “If an operated person eventually wants to have children, she will have to undergo a new operation whose chances of success are around 65-70%. If this does not work, we have to resort to in vitro fertilisation.” The head of the department also explains the details of the operation performed on an outpatient basis. “After general anaesthesia, we access the tubes with an endoscopy (insertion of an optical tube with a lighting system and a video camera) through an abdominal or vaginal approach. We attach a clip to each tube, which blocks the blood supply and creates scar tissue that prevents fertilisation.” The doctor also goes over existing long-term contraceptive alternatives, such as IUDs, with the patient. Following this discussion, the young woman will receive some forms. “These were carried out based on the opinion of the ethics committee.” A two-month reflection period is provided after the documents are signed.

A framework is also being developed at the CHUV for requests for hysterectomies without medical necessity. “This is a much more aggressive surgery; the uterus is removed, and usually the fallopian tubes and ovaries, too. It lasts almost four hours, and it is completely impossible to be pregnant afterwards. The motivations among young women are similar, with, in addition, the desire to eliminate menstruation. We received several requests last year and sought the opinion of the ethics committee, whose conclusions are similar to those regarding tubal ligation.” 

Declining among older women

For all ages (15-74), the proportion of women using female sterilisation as a means of contraception in Switzerland has tended to decrease in recent years. In 2022, 4.48% of women used it, compared to 4.92% in 2017. “Most of the tubal ligations performed at HFR are done at the same time as cesarean sections,” says Dr. Nordine Ben Ali. These are women who have already had several children and do not wish to have another pregnancy. It is less expensive than sterilisation done alone, and medical reasons may justify this as the risks associated with multiple C-sections.” Conversely, the proportion of vasectomies among Swiss men increased from 8.6% in 2017 to 10.1% in 2022. The cost of the operation is lower, at about 800 francs, compared to 2,500 francs for women. The procedure, partially reimbursed by some insurance plans, is done under local anaesthesia. According to the co-chair of Santé Sexuelle Suisse, these include men who wish to carry the burden of contraception, whereas their partner has taken care of it for many years and, for example, experienced the inconvenience of several pregnancies.