Annie* had just given birth to a baby boy when she made what she describes as “the worst decision of my life.”

Now a mom of two, she’d chosen to have her tubes tied while she was still in the hospital. A doctor came into her room with paperwork, marked in big letters: TUBAL LIGATION. Her decision was made, and she signed swiftly. But as the hour for her procedure approached, Annie began having second thoughts.

“I had that feeling I was making a big mistake, and I told them, “I’m scared.” So I was given a sedative to calm my nerves,” she told me. She still has nightmares about what happened next.

“They come in, get me ready to go back, and as I’m being wheeled away backwards, I see my husband, daughter, and newborn son,” Annie says. “I wanted so badly to scream, ‘I don’t want this anymore!’ But the sedative already set in, and I was unable to talk.” She woke up from the surgery in so much agony, she still couldn’t speak.

More than a year later, Annie was still hurting. She was constantly sore and exhausted, and it didn’t help that her period, which came back after weaning her baby, was painful and terribly heavy. She returned to her doctor, who told her she could go on birth control and get scheduled for a hysterectomy.

“Whoa! Wait a second here, was I asked if I wanted a hysterectomy? No! And birth control? I got my tubes tied so I wouldn’t have to be on birth control,” Annie says. “I wanted a second opinion. So I scheduled a [virtual] appointment with another doctor in the same office. She said the same thing: birth control and hysterectomy.”

It was at that moment that Annie learned something very wrong happened in the operating room that day.

“I asked, could I get a reversal? The answer was ‘no,’ the type [of surgery] I had done was not reversible.” When Annie asked for more detail about the type of surgery she had had, Annie explains, the doctor “was not able to answer because the doctor’s notes weren’t in my file. I started to question things right before the call ‘got disconnected,’” says Annie, who could see the first doctor in the background of the video call.

Tubal ligations, which involve the tying off of fallopian tubes, can for some women be reversed. “Tubal ligation reversal is a procedure to reverse a tubal ligation—when the fallopian tubes are cut or blocked to permanently prevent pregnancy,” the Mayo Clinic states. “During a tubal ligation reversal, your doctor removes the obstructed area of the fallopian tubes and reattaches the fallopian tubes to allow pregnancy.”

But it turned out that Annie’s doctor had taken the opportunity to give her a salpingectomy. In this form of sterilization, the fallopian tubes aren’t “tied”; they are removed entirely.

“I am not able to reverse this, because not only did the doctor only leave a very small amount of tubes, but also took my fimbriae [the fringe that guides the egg from the ovary into the fallopian tubes]. I did not consent to have any[thing] more than a tubal ligation,” Annie says. “[I thought] that my tubes would be cut, tied, and burned. There was no talk of taking tubes out, let alone my fimbriae.”

Annie is now on the hunt for a doctor willing to treat Post Tubal Ligation Syndrome, or PTLS. It’s a little known disorder with symptoms like hers: chronic fatigue, heavy periods, weight gain, loss of sex drive, hot flashes, dizziness, pain, and more. Even as women come forward with their stories of suffering, many doctors deny the syndrome exists. Annie’s own doctor dismissed the idea that she could be suffering from PTLS, although her pain began immediately after surgery. “It is not all in our heads, it is real!” she says. “It has ruined my life. I regret it one hundred percent!”

Annie is not alone. Female sterilization is the most common type of contraception, with more than 200 million women affected globally. In the United States, it’s second only to the Pill in popularity. Despite that ubiquity, sterilization is inseparable from its historical role as a weapon of racism and misogyny. Most disturbing of all, evidence suggests that the procedure is still functioning like that in many cases—like a punishment for being poor, nonwhite, female, or all three. The closer we look at the practice of sterilization today, the more we can hear a corrupt past finding echoes in the present.

A wrong never righted

Carrie Buck, a woman from Virginia, was a young mother herself in the 1920s when she became the target of a campaign to confirm the constitutionality of a new state eugenics law. The term “eugenics” was coined in the 1880s, around the same time a physician in Toledo, Ohio, performed the world’s first tubal ligation. By preventing so-called “undesirable” families from having children, eugenics advocates believe crime, poverty, health problems, and other kinds of suffering can be eliminated. Needless to say, “undesirable” often really means “different.”

Carrie had a rough start in life. Her mom was an indigent drifter, and Carrie was mostly homeless until she moved into a foster home. By the time she was 17, she was pregnant, the result of a rape by her foster mother’s nephew, Clarence. Carrie’s unwed pregnancy (and its cause) was a major problem for the foster family, who decided to cover it up by having her institutionalized.

With the help of a crude IQ test, she was designated a “middle grade Moron” (though Carrie got As, Bs, and Cs in school) and was sentenced to live in the Colony for Epileptics and the Feebleminded near Lynchburg, Virginia. The real reason was hinted at in the clinical notes in her file, which labeled her a “moral degenerate” for her single motherhood.

The Colony was a hybrid mental hospital, prison, and working plantation. Unfortunately for Carrie, it was run by Dr. Albert Priddy. Priddy didn’t think much of his patients, many of whom, like Carrie, wound up at the Colony because of poverty and presumed promiscuity. Priddy compared them to prostitutes in one biennial report and diagnosed them as “nymphomaniacs,” “sexual degenerates,” and “man-crazed.” He firmly believed that sterilization could eventually rid society of the burden imposed by such “genetically compromised” females.

Priddy wasn’t alone. The Presbyterian, Episcopalian, and Methodist churches at the time were involved in campaigns to push eugenics. Planned Parenthood founder Margaret Sanger lectured Ivy League students about “the rapid multiplication of the unfit and undesirable.” The Journal of the American Medical Association and Scientific American routinely published articles advocating sterilization, and a new surgery for men—vasectomy—was developed by a Chicago physician with the express goal of preventing former prisoners from having children.

Dr. Priddy worked with Virginia state politicians to pass a law allowing hospital superintendents like him to sterilize patients. But his lawyer advised that before procedures could be routinely carried out, a test case was needed to prove that the law would stand up in court. Priddy settled on Carrie as his victim. She had only been living at the Colony for two months.

The case, which wound its way to the Supreme Court, was a sham. The lawyer appointed to represent Carrie was a friend of Dr. Priddy and on the record as supporting sterilization himself. At the country’s highest court, the justices ruled 8-1 against her, including the former U.S. president, Chief Justice William Howard Taft, and Justice Oliver Wendell Holmes, supposedly the greatest jurist in American history. Holmes’s majority opinion in Buck v. Bell included the brutal phrase, “three generations of imbeciles is enough”—a cruel judgment that included Carrie’s baby daughter, who, by the way, grew up to make the honor roll in school. The only dissenting vote belonged to Justice Pierce Butler, a practicing Catholic. On October 19, 1927, Carrie Buck’s horror story reached its climax. Her fallopian tubes were tied under general anesthesia.

It took 75 years, but in 2002, the governor of Virginia issued an official apology for the state’s role in the eugenics movement. In the wake of Buck v. Bell, more than 60,000 Americans had their fertility forcefully taken from them. But although the Supreme Court has revisited other atrocities in its history, it has never overturned the precedent set in Buck v. Bell. The case would later be cited by Nazi defense lawyers at the Nuremberg trials to support their eugenic movement to cleanse their society of Jewish people.

Coerced sterilization is still happening

Sadly, sterilization continues to be used as a weapon around the world, especially against poor women and women of color. In Canada, for instance, indigenous women are still having their tubes tied after being coerced by healthcare professionals, with more than 100 plaintiffs filing a recent class action lawsuit seeking justice. In China, human rights advocates have expressed outrage as the government has targeted Uighurs, an ethnic Muslim minority, with forced abortion, sterilization, and other types of contraception in what amounts to an ethnic cleansing campaign.

Dr. Steven Pilkington, a board certified OB/GYN who practices at Dignity Women’s Center in San Antonio, Texas, has seen the fall out. “I have cared for patients that were forcibly or unknowingly sterilized in Mexico,” he says. “I’ve been told by medical students from Mexico, whom I mentor, that they have witnessed these activities. Women have been told that unless they agreed to be sterilized, they would not receive pain medication while in labor.” These are not free choices.

If you thought such terrifying scenarios couldn’t also happen in the twenty-first-century United States, sadly, you’re mistaken. In 2013, it emerged that nearly 150 pregnant women in California prisons had been recently sterilized without the required state approval. The Center for Investigative Reporting (CIR) spoke with some former inmates, all of them women of color, who said they were coerced into surrendering their fertility. One woman described being pressured to consent as she lay strapped to an operating table. The doctor who performed some of the surgeries, Dr. James Heinrich, justified the program, and its nearly $150,000 cost, in starkly eugenic terms. “Over a 10-year period, that isn’t a huge amount of money,” he told CIR. “Compared to what you save in welfare paying for these unwanted children—as they procreated more.”

Even in the absence of outright coercion, studies show how women who are trying to plan their families wind up with different treatment. If you have a better education, you’re less likely to be sterilized. If you have a higher income, you’re less likely to be sterilized. If you’re a white woman or have private health insurance, you’re less likely to be sterilized than a woman of color or a woman who has state insurance. This is not a coincidence. Researchers call it “reproductive stratification.”

Amy Kat Barnette-Haycraft sees a similar exploitative dynamic at play in the procedure she underwent. “I personally was on state Medicaid for low-income single mothers at that time. I have no doubt the truth [informed consent about risks] was kept from me to decrease the burden any future children might place on the welfare system. . . . Who wants a bunch of poor people overcrowding, reproducing, and taking advantage of public assistance?” she told me, characterizing the attitude of medical authorities.

Amy was a healthy 29-year-old mom when she and her OB/GYN decided to include sterilization in her C-section operation. “I knew I couldn’t afford any more kids at the time, and I was putting off marriage until I could finish my college courses,” she says. “The decision to trust my doctor and not research it further changed my entire life.”

Amy woke up from surgery in terrible pain, which didn’t go away with time. She spoke with her obstetrician the day after, who reassured her that her discomfort was merely the inevitable aftermath of birthing a large, breech baby. “That was the last time I saw her,” says Amy. “I had numerous follow-ups in the weeks and months after, but her office instead booked me with a nurse practitioner.”

As months passed by, scan after scan revealed no answers as to why this young mother was still in a constant state of misery. Finally she was told not to come back unless the pain got worse. Amy wound up in the ER, where the attending physician laughed in her face, rolled his eyes, and tried to give her a prescription for pain medicine. When she finally convinced him she wanted answers, not medication, he ordered a CT scan, which, like all her previous tests, showed nothing wrong.

Amy was eventually able to get relief from her PTLS symptom—by having her tubal ligation reversed.

Sidney Makahununiu of New Zealand told me a similar story about being ghosted by her caregivers. As her medical team prepped her for an emergency C-section, she was offered sterilization. “I was in labor for 11 hours since the induction had started, so I was exhausted, in pain, and could not think rationally,” she says. “I signed the paper, no discussion of side effects were mentioned, no discussion on type of tubal [ligation], no counseling either.”

Sidney experienced post-surgery effects including panic attacks, hot flashes, incontinence, rage, and suicidal feelings. Her hair fell out in clumps. Sidney sought help but found that “no doctor took me seriously or believed me when I said this is not right; something has happened to me because of the tubal ligation.” She was in her thirties, but blood tests showed her hormones had plummeted to post-menopausal levels.

“I was a registered nurse of 12 years right up to 10 days prior to the birth and subsequent tubal ligation. Sadly, I have never been able to return to work. My career ended,” Sidney told me. “Mostly I felt ignored by the gynecologist over my complaints. I wrote an email, I rang up to have meetings as well. It was then I realized I had to be my own biggest health advocate.” She wound up having to travel to the United States to get a reversal.

The Essure catastrophe

In 2002 a sterilization device called Essure hit the market. Introduced by a company with the dismally ironic name, Conceptus, it was promoted with cheery ads featuring the shiny smile of Trista Sutter, the original Bachelorette star. Although approved by the FDA as a modern, twenty-first-century contraceptive option, the way Essure works is nothing short of barbaric: a doctor inserts two metal coils inside a woman’s fallopian tubes. The metal causes so much irritation to her body that scar tissue forms inside the tubes, growing thick enough to effectively block the path for egg and sperm to meet. The Essure experience was nevertheless supposed to be less painful than surgical sterilization, and more convenient as an outpatient procedure. It was also conveniently cheaper for insurance companies. More than 750,000 women worldwide were subsequently implanted with the device.

Needless to say, Essure frequently damages much more than women’s fallopian tubes. The device has a nasty habit of puncturing the tubes, migrating through women’s abdomens, and leaving a trail of scar tissue in its wake. Patients from all over the world reported heavy metal poisoning, substantial bleeding, and pain, pain, and more pain. On top of that, women are still getting pregnant after Essure—and they are more likely to have a potentially deadly ectopic pregnancy.

For years the FDA and Bayer Pharmaceuticals, which acquired Conceptus in 2013, brushed off desperate complaints from women about what they were experiencing—the PTLS experience, redux. “We have been banging on the door with information and data, begging and pleading with them to do something,” one patient, Angie Firmalino, told NBC News. “We don’t understand, if all of these women are reporting the same symptoms, why aren’t we being taken seriously?" NPR quoted another woman, Amanda Dykeman, who also said, “Physically, [Essure] has permanently ruined my body inside and out.” More than 40,000 patients joined a Facebook group to get support and demand answers.

Sixteen years after it was put on the market in the United States, the FDA put a black box warning on the device, pointing out the serious risks of using it, and requiring doctors to discuss and have patients sign a multipage document before prescribing the device. Sales of Essure plummeted, and in 2018 Bayer announced production would cease, just ahead of the debut of a Netflix documentary, The Bleeding Edge, that brought wider public attention. In 2020 the company came to a $1.6 billion settlement with most of the women who had sued.

Federal records show Bayer paid nearly 12,000 doctors from throughout the United States millions of dollars in “consulting fees,” a technically legal practice that is ethically slimy. Research has proven that physicians who are paid by pharmaceutical companies are likely to prescribe accordingly. And court filings revealed that Conceptus, and later, Bayer, failed to properly report thousands of consumer complaints to the FDA, particularly complaints about pain. Informed consent is nonexistent when the truth about a procedure is hidden from patients and regulators are massaged for the sake of a payday.

One study of mostly Hispanic women receiving the Essure device epitomized how women’s “choice” for sterilization often isn’t much of a choice at all, given how the decision is often made under duress. Some of the study participants told clinic researchers that their partners wouldn’t share responsibility for family planning or seemed likely to stray, and others said they wanted to get Essure to secure a better future for their children. They wagered that having a foreign object inserted inside their bodies to scar their organs and cripple their reproductive systems was a necessary trade-off to a potential better life for themselves and their families. And that’s if Essure worked as designed. It’s a calculation no woman should have to make.

The truth about regret

Ironically, when sterilization comes up these days, the conversation is often about how it’s supposedly so hard to get. Women who are happily child free and convinced they’d like to stay that way for life report their doctors try to talk them out of the procedure. Patients on Medicaid have to get through a mandatory waiting period before they can have their tubes tied. How patronizing and sexist, goes the complaint.

But the science shows doctors are right to pump the brakes. Young women, like many of those grumbling about their paternalistic gynecologists, are at the greatest risk for regretting sterilization. Study after study has shown a relationship between age at the time of the procedure and regret, with women under 30 about twice as likely to be sorry they went under the knife, and eight times more likely to attempt a reversal.

Various studies have shown women regret their sterilization at rates ranging from about 6 percent to 20 percent. With about 700,000 women sterilized annually in the United States alone, even the low-end estimate means tens of thousands of women are currently scheduled for a life-changing surgery that they will eventually wish never happened.

Of course, there’s another side to regret: the frustration of having an invasive procedure that doesn’t prevent pregnancy, after all. Women contemplating sterilization as “permanent contraception” may not know that a surprise pregnancy is rare, but still possible. In fact, about 1 in 200 women will conceive after their surgery, meaning there are likely thousands of post-tubal babies toddling around.

Dr. Pilkington, who performs an average of three to four tubal reversals per month, says that many of his patients have disclosed the deep wounds that sterilization left on their spirits. “Many report that they were at a vulnerable time and feel they have been taken advantage of and betrayed. . . . Often times this pressure came from their spouses, family members, and even health care professionals,” he says. “Sadly many were in an abusive relationship with the very partner who was encouraging them to be sterilized. In many cases, their partner was not willing to undergo vasectomy, but was encouraging them to be sterilized.”

The tragedy of regret is particularly frustrating given that there are many effective, nonpermanent family planning strategies that provide more flexibility for women. Fertility Awareness-Based Methods (FABM), for instance, are highly effective family planning methods that equip women and couples to reconsider their family-planning goals on a monthly basis, with no damaging side effects. Most of all, FABMs shower women with information about their bodies and their reproductive health, data they can track, record, and interpret themselves. It’s a modern, conscious approach, in contrast to sterilization, which fundamentally remains the same procedure that developed more than a century ago in the age of eugenics: a woman laying her unconscious body down in an operating room, to be cut, burned, tied, or scarred by a doctor’s sharpened instruments.

“I would not ever want to see any woman suffer as I have,” Sidney Makahununiu says. “Please research any procedure that you are thinking of having done. . . . It’s not worth the risk.”

*Annie is a pseudonym