The surgical thread used in tubal sterilization is so heavy!: tubal sterilization and new reproductive technologies¹

Abstracts

Tubal sterilization is a method of female sterilization, consisting of the surgical severance of the fallopian tubes which connect the ovaries to the uterus. This method, the rates for which have doubled in Brazil since 2003, is considered safe and irreversible. This study is a qualitative research project which seeks to describe and analyze the thought process and assessment of sterilization by women who have subsequently sought the help of new reproductive technologies to enable them to conceive. Sixteen sterilized women were interviewed at a hospital within the public health system in São Paulo, southeastern Brazil. As a result, the following themes emerged from the study: women’s lack of care regarding their reproductive life; sterilization and (constitution) habitus, and the remorse expressed in the phrase proffered by Rosa: “The surgical thread used in tubal sterilization is so heavy!” The study highlighted the need for women to be better informed about the surgical procedures available to them: whether about tubal ligation or about treatments in the field of new reproductive technology. Access to this information can promote greater understanding of the terms and greater confidence in dealing with the choices involved.

Tubal Sterilization; New Reproductive Technologies; Women’s Health

A laqueadura é um método de esterilização cirúrgica feminina, que consiste em cortar cirurgicamente as trompas, que unem os ovários ao útero. É um método considerado seguro, irreversível, cujas taxas dobraram desde 2003, no contexto brasileiro. O presente estudo é pesquisa qualitativa com o objetivo de descrever e analisar os pensamentos e as avaliações acerca da laqueadura entre as mulheres que buscavam auxílio das novas tecnologias reprodutivas para conceber novamente. As entrevistas foram realizadas em um hospital da rede pública de saúde, na região Sudeste do Brasil, São Paulo, com 16 mulheres esterilizadas. Como resultados, as seguintes temáticas emergiram do estudo: o não cuidado com a vida reprodutiva; laqueadura e habitus; e o arrependimento traduzido pela frase proferida por Rosa: “O fio cirúrgico da laqueadura é tão pesado!”. O estudo desvelou a necessidade de que as mulheres sejam mais bem informadas sobre os procedimentos cirúrgicos que desejam aceder: seja à laqueadura, seja a tratamentos na área das novas tecnologias reprodutivas. O acesso às informações pode promover melhor familiaridade com os termos e mais segurança ante as escolhas.

Laqueadura; Esterilização; Novas tecnologias Reprodutivas; Saúde da Mulher

Introduction

An art form which started in China around the year IV to C, which involved using lacquer in giving finishing touches to furniture, was an innovative process at that time. It rendered the rough wood into real objects of art, including floral fragments of stories and motifs that marked the famous Ming Dynasty. The lacquer varnish, obtained by refining tree-sap, gave the furniture, objects and various utensils (everyday objects such as boxes, safes, musical instruments etc.), a smooth, mirrored appearance on the surface; such that the better the technique of the art was applied, the better the grains of wood were hidden.

The art of lacquer and varnishing had another function besides the beauty created through patient management of their techniques; protecting the pieces from corrosion and disintegration. This technique sealed the furniture and other objects, resulting in preservation of the aesthetic qualities of the pieces, conserving their brilliance, softness and color and also increasing longevity.

In another universe in the distant past, a brightness of similar intensity could be observed in the face of a woman searching for a family planning service and authorizing sterilization having envisaged all the associated problems disappearing. At that time the attraction of tubal sterilization was that it symbolized freedom. The difficulties with facing the adverse effects of oral or intravenous contraceptives, issues with negotiating condom use with their partner, lack of guidance or even ignorance in the use of the female condom or diaphragm and the difficulties in acquiring the intrauterine device (IUD); would be overcome through a single surgical intervention. The solution seems simple, but, as many studies since the 1970s have shown, the problem remains far from having a conclusion. (Vieira, 2007; Carvalho et al., 2006; Moreira and Araújo, 2004; Osis et al., 2003; Fernandes et al., 2001; Osis et al., 1999; Dias et al., 1998; Minella, 1998).

As Durkheim (2008) said, to understand a practice or an institution, it is necessary to return as close as possible to its origins. What is tubal sterilization; this procedure that has such a particular terminology in Brazilian society?

The ligation or ‘tubal ligation’ is a surgical method of female sterilization, offered to women who do not wish to have children: due to health reasons, for example the excessive number of cesareans which cause uterine scars; or perhaps due to the discovery of congenital problems transmitted through the mother’s genes such as hemophilia and Wolf Willebrand disease, among others. The method involves cutting or surgically disconnecting the fallopian tubes which connect the ovaries to the uterus. It is a method considered to be safe and irreversible, the risk of getting pregnant after the procedure being less than 1%. According to medical literature, there are several ways to perform this ligation, such as placing plastic rings in the tubes, cauterizing them, cutting them, and performing tubal ligation with suture or by using titanium clips.

Throughout this discussion, which focuses only on the technical and practical aspects, there is a certain simplicity in the terms used on a daily basis, to describe the procedures, that renders them more palatable but does not reflect their true meaning or depth of consequence. In the day to day life of medical consultants in Brazilian hospitals, it is not customary to say that a woman has been sterilized; it is more common to hear that she has been ‘lacquered’. This word, as previously mentioned, originally referred to the field of art, beauty and shine, is used here to soften the sound of a medical procedure that is essentially hard and final, requiring a lot of skill in the case that in the future the woman may regret the surgery she underwent. The technique has to be applied well, in this instance, not for aesthetic beauty but to limit the damage.

Throughout recent decades, the characteristics of the women who sought sterilization as a method to end their reproductive life have changed. In Europe in the 1940s for example, women from the poorer classes, from large families and immigrants were the groups who most sought tubal ligation. In the following decade, around 1950, post-partum sterilization became common. Entering the 1960s, with the appearance of the contraceptive pill, it was first thought that the drug would inhibit the number of sterilizations (Neyrand, 2004). However, it was observed that the request rates for sterilization did not change significantly, quite the opposite. Unlike Brazil; Europe has a less confident view of sterilization, it being contemporaneously associated with ethnic cleansing and therefore disliked by most women. It is immigrants, in particular, who maintain this form of managing their reproductive life. In the case of Brazil, the change took place a decade later. At first, around the 1970s, the women who agreed to tubal ligation came from the poor classes and large families, even though they could not afford the surgery costs. Access to the surgery was free to women from higher classes, who were discretely given the procedure in private hospitals. However, during election balloting, in the Midwest, North and Northwest regions of the country, many women received the surgery free of cost, questioning or repercussions. In the 1980s, sterilization surgeries immediately following births became more common (Berquó, 1993). Unlike Europe, sterilization in Brazil had been growing mostly in association with family planning, as a form of contraception. The procedure gained visibility and confidence through having been given a softer more palatable name; women wanted ‘lacquering up’. Lacquering also brought another aspect, this being the freedom to manage their sex life without the added worry of pregnancy however; this was only discussed behind closed doors.

But what about methods of contraception? What can be said of them in this scenario? According to Vieira (2007), between 1986 and 1996, according to the National Demographic and Health Survey (DHS) from this period, there was a significant increase in the use of contraceptives which places Brazil at the same level as developed countries. However, this author states that the difference could be seen in the choice of contraceptive methods: while women in developed countries were opting for reversible methods, in Brazil there was a progressive opting for female sterilization. Also according to this author, the rates of female sterilization had less significant growth in São Paulo than in the North, Northeast and Midwest regions of the country, with a particular emphasis on a decrease in the age of the patient at the moment of sterilization. Public opinion at the time therefore perceived an increase in the radicalism of intervention in the female body.

According to Alvarenga and Schor (1998), the discussion of female sterilization has always been permeated by controversy, as with questions of abortion and contraception in Brazil, and it has now become highlighted for general debate in the country since 1994.

The PNDS, published in 2009, analyzing the data regarding the use of contraceptives during the decade 1996 to 2006, shows that there was a marked increase in the use of contraception during this period, a fact that was considered a determining factor in the decline of fertility in Brazil. Another important finding in this study was that, although there was a rapid decline in the number of female sterilizations, this procedure continued to be used as a method of contraception, most commonly amongst women with low education and income (Brasil, 2009).

Sterilization grew with more force up to 1996, even though legislation had been passed curbing the indiscriminate use of the surgery to end reproductive life. Law restricts the surgical procedures to cases where there may be risks to a woman’s health, such as cases of multiple cesarean deliveries or those with gestational risks.

Why was surgical sterilization still such a popular method?

The technological advances in the field of health aid the understanding of this process: an example being the widespread practice of laparoscopy. Doctors considered it a safe and quick procedure. This is because only a check-up is required and it is a relatively painless procedure as well as being less costly. From the point of view of the patient, the process takes place on one day in hospital with only two small scars and is thus considered to be a simple and safe procedure. All of these factors were agreeable to women, particularly young women². In Brazil, most sterilizations took place post cesarean (this continues to be so in most cases, albeit ‘unofficially’), shortly after the baby’s birth.

Another side to the choice of sterilization is that it represents a dissatisfaction with the contraceptive methods available: often Doctors request a brief interruption in the use of the pill for example, due to reports of adverse effects such as weight gain, discomfort, headaches, nausea, dizziness: also in the case of women who smoke, their association with contraceptives is known to be discourage by the evidence in the field of development of cancers and stroke (CVA).

A final aspect to be considered is the fact that sterilization in Brazil is widely considered to be a ‘simple’ effective method and a quick resolution to family planning problems. Since Brazil is a country of large territorial extension, monitoring the circumstances of surgical sterilization operations is challenging, since they continue to occur outside the criteria established by the Ministry of Health. In this context, the result is a contingent of women who were sterilized when they were young. In the case that they want to go back and build a new family after divorce proceedings, the premature decision of their younger years becomes cause for suffering: should they want to have children in a new relationship, or should they want to continue the family line to meet the expectations of the family. Given these considerations, this article seeks to describe and analyse the thoughts and evaluations of sterilization among women who, after being sterilized, returned to seek the help of assisted human reproduction in order to conceive again.

Methods

This study was conducted in the qualitative research method of the descriptive and analytical type (Minayo, 2000). It is a method that provides an understanding of the thoughts and assessments of sterilization in the context in which the women are embedded. The study was conducted at Hospital Pérola Byington, in São Paulo. Open interviews were carried out with 16 women awaiting In Vitro Fertilization (IVF) treatment in an assisted human reproduction clinic. Some of the guiding questions were: how do you perceive/see tubal ligation after all these years? How do you evaluate tubal ligation in this new family context? What kind of feelings does this evoke? The interviews, which were about an hour long, were recorded and later transcribed.

This study was submitted to the research ethics committee of the hospital and to the Faculty of Public Health, University of São Paulo (USP). The participants of the study were sterilized married women who had passed through screening and diagnostic tests and were awaiting the first cycle of IVF. The participants were between 30 and 45 years of age and agreed to participate by signing a consent form, prepared in accordance with the recommendations of Resolution 196/96 of the National Health Council 196/96.

A thematic content analysis was conducted based on the women´s dialogues. The perception and historical location of the sterilization event in their lives, in place of this surgical act in this new family context and the habitus (Bourdieu, 1998, 1979) that was being built around sterilization.

To protect the identity of the participants, following ethical precepts, the decision was made to use fictitious names.

Results and discussion

Treatment and analysis of empirical material revealed themes evoked in the discourse of the women. The analysis will focus primarily on two of them: the lack of care for reproductive life: tubal ligation and constitution; and the pained and bitter regret, translated into a phrase uttered by Rosa: “The surgical thread used in sterilization is so heavy!”

The disregard for reproductive life

The responsibility for the administration of sexual and reproductive life was an attribute which appeared very early in the lives of the women who took part in this study; during adolescence. Lacking guidance, they soon became pregnant, and with an additional responsibility came the realization of a child in the womb and the ongoing romantic relationship, from one moment to another in their lives.

The lack of concern for their reproductive health was reflected in their dialogue when explaining that at the time of their first marriage, not all of them used contraception even after the birth of their first baby. It was found that, before seeking surgical sterilization, the information the women had relating to family planning and contraception was inconsistent.

Some testimonials show one pregnancy following another, as a result of the lack of management of their sexual and reproductive lives, as demonstrated in the table below:

Table 1
Characteristics of woman according to age, contraception and sterilization

Woman	Age at the time of study	Contraception used before sterilization	Age at the time of sterilization	Knowledge of reversibility?	Reason for failure of reversal
1) Acácia	36	-	17	No	Removed tubes
2) Camélia	43	Pill, IUD	22	Yes	Fallopian tubes damage/blocked
3) Dália	38	Pill	25	Yes	Removed tubes
4) Deise	45	-	26	Yes	Reversal not attempted
5) Flora	36	Pill	26	Yes	Removed tubes
6) Gardênia	38	Pill	21	No	Removed tubes
7) Hortênsia	33	Pill	22	Yes	Removed tubes
8) Íris	30	Pill	19	No	Removed tubes
9) Jasmim	41	-	22	Yes	Damage Fallopian tubes
10) Magnólia	30	Pill, IUD	22	No	Removed tubes
11) Margarida	36	-	18	No	Removed tubes
12) Maria Flor	36	-	27	Yes	Obstructed Tubes
13) Perpétua	39	-	24	No	Removed tubes
14) Petúnia	33	-	19	Yes	Obstructed Tubes
15) Rosa	42	-	33	Yes	Damage tubes
16) Violeta	38	-	24	Sterilization carried out against her will	Damage tubes

It was observed that, of the sixteen women who participated in the study, nine of them had never used any contraceptive method before tubal sterilization. When asked about the possibility of using them, some confirmed during the interview having some knowledge, ‘having heard about’ the Pill or condoms, for example. They alleged that this was because of immaturity and lack of guidance and said they were very young at the time of their first marriage. Thus, those who made use of contraception did so following the advice of their mothers, neighbors, cousins and aunts etc.

I tried to take the Pill, like my cousin but it didn’t work, I didn’t know how to take it properly, I forgot… I was 19 when I was sterilized. And I had three children. My mother thought it best that I got sterilized (Íris, age 30).

Another group of women justified the demand for sterilization with complaints of abundant issues relating to use of the IUD, such as menstrual cramps. When the diaphragm was mentioned, it was deemed difficult to use and unreliable; some of the women had neither seen nor heard of the diaphragm. Condoms were considered difficult to negotiate with the partner, above all for trust issues: if the couple were together and faithful within the relationship, why use a condom? In a relationship in which fidelity prevails, the use of a condom seemed unnecessary to them. Popular socially constructed prejudices were also mentioned which still have a status of ‘truth’, such as reducing the enjoyment of the sexual act and even questions relating to the exercise of the partner’s manhood.

I was scared because when I remembered to take the medication... I didn’t feel well, I felt pains, headaches, lots of things, so I got to a point when I decided to get sterilized (Hortênsia, age 33). Ah... This thing about condoms was difficult. He didn’t like to use them so things (planning of the couple’s sex life) were left to me (Perpétua, age 39). Because it was like that, it was quick. The child was conceived. It was quick. I forgot the medication one day and it was over. I was already pr egnant. That’s why at the time I preferred the operation (sterilization) (Margarida, age 36). [...] I also had problems when I took the medication, I felt sick (Petúnia, age 33).

On the one hand, there is difficulty in managing the reproductive life owing to what they termed immaturity and on the other, there is the aspect related to the character of the low rate of reversibility of sterilization against other forms of contraception. (Cunha et al., 2007; Fernandes et al., 2006; Reis et al., 2006; Machado et al., 2005; Marcolino, 2004; Faúndes et al., 1998). Medical literature points to the difficulties of the tubal ligation procedure. Not so much because of its effectiveness but more for the extreme care required during the surgical procedure itself: a tubal ligation done hastily, misguided, or even performed by a less experienced professional, would result in the impossibility of anastomosis (reconnection). This in itself already has a very low success rate (Fernandes et al., 2001) “with a baby at home”, to use the current expression in the medical field (Olmos, 2003).

When questioned whether or not they had knowledge about the finality of sterilization, almost half of the women claimed to know that the choice was final. They understood that once the operation was carried out, they could never have another pregnancy. Some even confirmed that they received explanations from the doctors about the consequences of the surgery. This initial confirmation changed throughout the course of the meetings: demonstrated by the fact they could not describe the procedure, for example, or because they claimed to know that the surgery was definitive then later expressed some hope of becoming pregnant because they had seen cases on television of sterilized women who became pregnant, or perhaps because they had not really understood the finality of sterilization.

Because when I got sterilized, I wasn’t really aware of what I was doing. No, no, no. I wasn’t aware because I waited seven years to see if I could get pregnant again. (from my second husband) . Seven years! (Acácia, age 36). When I went (to do the) sterilization, nothing was made clear to me. I went because in my mind, my understanding was that when I wanted (another child)  I would just have to look for (a doctor). Others didn’t even seek, because when a woman gets fat, that knot becomes undone and I thought that would happen to me. And I’m waiting for it for twelve years (Perpétua, age 39).

This is an important issue in the emotional and psychological context of tubal sterilization: the permanent nature of sterilization, its finality and the fact that the decision cannot be reversed. The contours of this decision become far more dramatic when it is ill-considered or taken very young. In the table above, it is verified that the later diagnosis confirmed that reversal of the procedure was not possible. In the case of these women, the road to pregnancy can only be viable by means of IVF. Evidence shows that a high level of dexterity and technical knowledge is required to perform a procedure which is commonly regarded as trivial. However, throughout this study, it is clear that the hasty decision, coupled with limited skills, results in sadness, grief, regret and emotional suffering.

At the moment a woman decides to be sterilized, she confirms that in no space, time or contingency in her lifetime does she want to have more children: neither in that moment, nor in the future.

I thought that for me and for him two children were ok. They were two girls, but for us it was ok, it was ideal, for us to take care of. I had to produce a lot of paperwork to prove that this was our decision. And it really was (the right decision), at the time, it was. So the tubal ligation was done during the caesarean with my second daughter. I was content with the sterilization at that time  (Flora, age 36). After all (the rape), I thought I would spend the rest of my life alone with my daughters, so at the time it was the right decision: never have more children. Under no circumstances (Rosa, age 42).

Still observing Table 1, another aspect can be highlighted: when the decision was made to proceed with the surgery, these women were age between 18 and 27. It can be considered that these women had at least 15 years of potential fertility ahead of them at that stage.

There appears to be a set of complex reasons, from both the health point of view and the social point of view: on all sides, there seems to have been suffering. Bringing the apparent ‘problem’ of their reproductive life to term then years later with the start of a new love, and wanting to resume reproduction and finding many obstacles in their path, the women look for other possibilities within the community to reconstruct a family.

Tubal Ligation and habitus

Habitus, according to Pierre Bourdieu (1998, 1979), is a way of thinking which is determined by the practices of a group. It is the internalization of objective structures of the social group to which a person belongs, producing tactical and objective or subjective answers to the daily questions posed socially on thoughts of reproduction.

In other words, habitus corresponds to a matrix determined by the social position of the individual, which allows you to think, see and operate in the most varied of occasions. It translates lifestyles, political, ethical and moral judgments. It is also a course of action which permits elaboration or development strategies on an individual level as well as on a collective level.

In the light of this train of thought, for some time, generations before the interviewees (mothers, grandmothers) a culture around tubal ligation was being constructed and cemented in the social environment within which these women were born and raised. In spite of having come to settle in São Paulo, the women brought with them certain notions and definitions about reproductive life and behaviors which had been tried and tested for a long time in their family network and their surroundings. Such networks that have expanded and information that is passed down, have, throughout the years, generated a ‘culture’ in municipalities of Midwest and Northeast Brazil. What ‘culture’ are we talking about? The lack of sufficient information remains a shadow over these families. This results in ineffective management of reproductive life which often ends on a surgical operating table. Some of them returned to their home towns to do the ‘lacquering’, following in the footsteps of their mothers, cousins and aunts, especially during elections.

This symbolic order tends to ratify tubal ligation as the best solution to the question of contraception: a habitus, the evidence for which initially appears to cover up the mishaps of before and after the surgery.

This means that pre-operative care, for example, is minimal if not “invisible”, described with expressions such as: the doctor said it was just a day in hospital (Camélia); it was quick, I would be admitted on the night of one day and be home the next day (Margarida). Nowhere in the discussions with the women were any of the risks of the nature of the surgical procedure mentioned such as possible allergic reactions to the anesthetic, post-operative setbacks, exposure to infections in hospital, etc. Even though some of them reported that at the time of the tubal ligation they actually suffered the effects of such risks: they didn’t leave hospital the next day as promised. Margarida, for example, reported being hospitalized for 15 days:

Where I had the operation was in a city close to Maceió. There it’s like this: at the time of the election, you could do this... Anything you want to do, you had the right to do, so you did it. If it was surgery you wanted, you just had to say: “I will vote for whichever candidate and so will my family” and you could do everything. That is what happened. I didn’t do any kind of test. I just went there and had the surgery. When I had the surgery, I had a bad reaction. The anesthetic almost killed me. Because I hadn’t done any tests before to find out. If I had done tests, I would have known whether or not I had any allergy or not... I almost died, I was so close. I spent... I went to spend a day, two days (admitted) ... I spent 15 days in hospital. I almost died because I didn’t do any tests, I did nothing. I should have died.

The social network and the family environment they belong to, build up and propagate thoughts and notions that form part of daily life for generations, creating apparent “truths” that always seem to have been so. They seem natural.

In my family women have always done it (sterilization), it’s automatic and we always found it much easier: you don’t want more kids? Get lacquered up! (Hortênsia, age 33).

At a particular moment during the course of a woman’s life, there is the perception of a problem that is ‘I need to stop having children’ and this promotes the search for a definitive solution which is found through intervention into the flesh of the body. The ligation that is desired as a path to freedom, reveals itself years later to be a prison instead. There is a new meaning to the same event which translates sterilization from a process of liberation – from the Pills, IDU, and fear of another pregnancy – to a social and physical violation which generates emotional suffering by not being able to conceive.

Surgical intervention gained ground with the spread of the idea of it being a simple, fast and effective procedure and in addition to the fact it has been given the more acceptable nickname in Brazil of “lacquering”, rather than sterilization. This term of diverse origins, as mentioned previously, puts the women in symbolically different places: the first relates to beauty; the second, to barrenness. The seriousness of the procedure is played down through the use of this term. Its use also minimizes the emotional effects which could accompany such a symbolic act, as much for the women as for the doctors since, according to them, the doctors commonly use the term in the consultancies. Whilst the doctors have the scientific knowledge and could use the appropriate term for the procedure (sterilization) in the cold, harsh daily routine of the hospitals and surgical clinics, they use the term “lacquering” as it is more readily understood in the world of the women who request the surgery.

The social definition of tubal ligation, far from being a simple reference or another way of naming a surgical procedure, is the product of a construction effected at the cost of a series of targeted choices by accentuating certain aspects (speed, efficiency) and keeping others hidden (irreversibility). Thus, it takes its place in the routine and social lives of the women in such a natural fashion, perpetuating a habitus which does not raise larger questions.

The construction of the image is not reduced to simple allocation of the name; it is through the practical, legitimate use of the body to exclude the reversible methods of contraception (deemed complicated, difficult to use, requiring specific knowledge and discipline) and offer sterilization (as a faster, simpler solution)³.

Thus, in Brazil, the habitus crystallizes the idea of sterilization as a method of contraception. This surgical procedure is used not only as a medical tool for more delicate and specific situations (risks which involve the health of the woman) but rather as a general procedure performed in gynecological clinics on a day to day basis in this country.

“The surgical thread of sterilization is so heavy!”4

During the meetings which took place with the women throughout this research, they often referred to the pain suffered from having opted for tubal ligation. They were popular expressions, well-known by the general public, but as painful and original as the opening title of this section.

These expressions that are laden with emotion, harbor significant symbolic value. They reflect an attitude taken in an ill-informed and untimely manor, and serve to analyze the profundity of the suffering that sterilization infringes on the woman who opts for this alternative as a form of contraception. Below, some of the expressions used by the women during the interviews which brought attention due to the sharpness of the marked pain in their speech as well as in their facial expressions.

It is well known that a woman’s reproductive life is a complex theme influenced by biological, psychological, cultural and social elements. This arena is crossed by the discussion about gender, which is of great importance for the understanding of a social phenomenon such as tubal ligation. It is known that planning the reproductive life is directly related to the family situation. One must think about the number of children to have and how to care for them. The specific function of care has always been associated with the feminine universe: it is up to the woman to plan, organize and look after the reproductive life, as though the man were not an active participant, just a supporter. Someone who accepts the ideas and decisions, with an attitude that ‘if the woman doesn’t want to get pregnant, she should take care of her body...’

Thus, gender relations are personified in the realm of reproduction. And this stereotyping (Goffman, 1988) of the reproductive life, the woman having the ‘privilege’ of being responsible is a reflection of the vision of the role of women in the traditional family. These patriarchal roles are played out in the hospital corridors. Discussions have been raised at several conferences and seminars in the field of human reproduction, as to the possibility of the disappearance of the boundaries between the responsibilities of men and women in the planning and care for the reproductive life of the couple, since both are necessary for the success of fertility treatments in general. However, the strength behind this stereotyping of the reproductive life has remained, despite the advancements in the domain of reproduction (contraceptive control, new reproductive technologies etc.)

The general nature of gender divisions in this field is well established: men and women occupy distinctly different places. This difference of ‘place’ is evident in the hospital, outpatient clinic and even in human reproduction clinics in the family planning section where, instead of couples, one finds single women, ostentatiously boasting gold rings on their left hand. The times when the partner attends a doctor’s consultant in order to decide the best contraceptive method for them both, are rare. In most cases, when the partner happens to be present during a consultation, it is due to the insistence of the medical department that they be notified about the sterilization being undertaken.

According to Wajcman (1998), it is increasingly common, for example, that a woman occupies positions of employment which require specific abilities. However, occupation of the traditionally male positions is another conversation: “In high-tech jobs such as programming, women tend to be segregated to the positions at the lower end of the occupations hierarchy.” (p. 219). The same occurs in the field of reproduction, in which there is a whole discourse about a change in the attitudes of men and women. There has been an appeal to bring the man into the main scene in order to share in the decision-making process; although, in practice, it is still the woman who makes the decisions and takes action regarding the reproductive future of the couple and as a consequence, of herself. The product of this construction, cemented into the symbolic field, crossed by the socio-cultural dimension of gender, the word sterilization arises in the words of the women, combined with the verb in the present, showing traces of pain, anguish and suffering.

Table 2
Meanings of Tubal Ligation

Words associated with tubal ligation
I bitterly regret.
If I could go back in time, I would never do tubal ligation again.
I do not feel good having been sterilized.
I regret because I really wanted to give him a child and now I can’t.
I have the feeling of worthlessness. I’m useless.
I carry with me a very great sorrow.
The surgical thread of sterilization is so heavy.
The thread of tubal ligation hurts more than the word ever could.
I cried a lot. I lay my head on the pillow and cried a lot. (when I found out that sterilization was not reversible)
When my sister-in-laws or friends had children, when they were pregnant, it was horrible for me because it reminded me of the sterilization which had tied my uterus.
Sterilization means a lack of will to live.
Sterilization means pain.

This is one of the reasons why divorces followed by remarriage eventually become common ground for regrets and/or questioning in relation to the procedures carried out in the past (Vieira, 2007; Carvalho et al., 2006; Machado et al., 2005; Fernandes et al., 2001). The women feel a desire to form a new family and society demands legitimacy of this nucleus. The woman, states in her repertoire, that this family will only be complete with the birth of a child.

We want a child in our family and we’re seeing right? Let’s see what God will do for us to complete this family (Petúnia, age 33). We have this dream of having a child together (Hortênsia, age 33).

During the course of the interviews and/or other meetings, even though most women confirmed at first, that it was their decision to be sterilized when they sought medical assistance, complementary information appeared. Such as the fact that the suggestion had come from their mother, father or another relative, for example. It is important to mention again at this point, the minimal participation of the husband. Even in the doctor’s consultation when the decision to proceed with the sterilization is made, the man has no participation, although the law requires him to be present at the time the decision is made. The consent should be mutual. Ideally, an interview with the couple together with the doctor would be most appropriate with regards giving information relating to both the procedure as well as post-op support⁵ (Law 9263 of 1996).

If repentance manifests itself after a process of separation, divorce, followed by resumption of a new love life through remarrying and renewing vows of creating a family, the sadness that hits the woman has little importance compared with that which confronts the couple that could not have children. (Moreira et al., 2004; Chaves et al., 2002). The questioning, the anxiety, the waiting, the psychological and emotional distress are very intense.

I think the only difference is that we work on expectations, right? Especially when the treatment time comes because the doctor says that anxiety hinders the success of the treatment (Deise, age 45). Here in this group there isn’t anyone who isn’t anxious, just wanting to get on with the treatment. But this anxiety is just wanting to see their belly grow again, go through it all again. And they say that time counts, the clock is working against us; we want the phone to ring soon to tell us to go to the hospital to make the baby  (Jasmim, age 41). The most difficult part, I mean, the most painful part of this, having a child again, is having to wait... If it could be faster, it would be ideal. What do we do whilst waiting? It is bad for the nerves (Hortênsia, age 33).

Some women might use sterilization as a means of solving problems of a marital nature or sexual violence.

Well, my reason for doing the sterilization.... I’m going to get emotional because... I don’t even like to remember it... One day, he

(the ex-husband) broke into my house, where I was with my daughter and just... ended up hurting me, raping me and he beat me a lot that night. And then he left (Rosa, age 42).

In some cases, the use of sterilization has been used as an exercise of power, on the part of the man, to control the number of children the couple will have and thus forcing the woman to live exclusively in a home under his control and domination, and on the part of the woman who had the surgery done in secret, to remove the need to keep taking oral contraceptives.

My husband made me have the operation when I was 24, without me saying, right? When I woke up the doctor said: “Violeta you have had an operation” and I said how? He said: “Your husband paid and you will not have any more children” (Violeta, age 38). [...] I did the sterilization. Because he (the husband) would not let me take the medicine. I would buy the medicine to avoid getting pregnant and he threw it away. So, I could not take the medicine during this time because I stayed with him for 4 years, in 4 years with him I manage to take one packet. Because I was hiding them and when he found the pills he threw them away (Gardênia, age 38).

Among the women interviewed, the current discussion around the reasons for deciding to be sterilized revolved around situations of violence and disagreements within the context of the marriage. The marital relationship had been worn out and the resulting product of this was a desire not to have any more children. A secondary reason is the character of incompatibility with other forms of contraception: for the side effects of the pills; for the incompatibility with the IUD, for the difficulty of negotiating the use of a condom with their partners and for the lack of knowledge regarding other forms of contraception.

Some women made the decision to be sterilized because they felt unable to find another solution to their problems or to manage them differently within the marriage. The sparse knowledge about the management of contraception, as well as the lack of information regarding the variety of contraceptive methods were the motives which contributed to the growth in demand for the procedure. This results in the choice of sterilization as a quick way out of the conflict.

I decided to get sterilized because at the time, my husband had a child on the streets, right? And I could no longer stand the headaches of the contraceptive (Maria Flor, age 36). It didn’t even enter my head  (to make use of contraceptive methods) ... there in my state its all politics, right? So I went there and asked to be sterilized quickly, to free me from having any more children. (Perpétua, age 39).

The women expressed repentance in their narratives when they talked about being in a different family and social situation, with a new partner and in a better financial situation. In these circumstances the desire to resume fertility increases, being driven by the demand of the families. They realise, within the context of everyday conversations that they need to adapt to a family ideal advocated by the social environment in which they live.

Final considerations

These women, who reside in the outskirts of São Paulo, found out about pregnancy and its consequences very early on in their lives, in their home towns. Without having access to consistent guidelines or more information about the reproductive field, they ended up giving birth again as a result. In order to constrict these multiple births, eventually they ended up yielding to the appeal of sterilization, a process so familiar to them: the efficiency being felt and declared in the experiences of women in their family and their success stories. They all saw surgery as the most effective and speedy solution, devoid of further concerns. It was “natural” to get sterilized.

This abdication of the reproductive life in a surgical clinic is a social constitution that has slowly embedded itself within the discourses, weaving its thread throughout the years. A custom that is built, takes roots and spreads into the imaginations. A habitus appearing to be a quick and effective alternative, then reveals itself as bitter and heavy, leaving the woman feeling useless.

The thought process and the evaluations that come from this habitus were unveiled in this study in the form of a pained and anguished speech; a speech cemented in the feelings which cause a certain degree of social isolation and result precisely from the regret of having undergone the surgical operation of sterilization.

They evaluate still, that the search for technological help to conceive again seemed a feasible solution in order to realize their desire, so much so that they went ahead and brought an end to the possibility for future pregnancies.

It is important that women are better informed about the surgical procedures they wish to access: tubal ligation and treatments in the area of new reproductive technologies. Access to such information could promote better familiarity with the terms and more certainty before making the choices.

Referências

• ALVARENGA, A. T.; SCHOR, N. Contracepção feminina e política pública no Brasil: pontos e contrapontos da proposta oficial. Saúde e Sociedade, São Paulo, v. 7, n. 1, p. 87-110, 1998.
• BERQUÓ, E. Brasil, um caso exemplar: anticoncepção e partos cirúrgicos à espera de uma ação exemplar. Campinas: Unicamp, Nepo, 1993.
• BOURDIEU, P. La distinction du goût. Paris: Minuit, 1979.
• BOURDIEU, P. La domination masculine Paris: Seuil, 1998.
• BRASIL. Ministério da Saúde. Centro Brasileiro de Análise e Planejamento. Desigualdade socioeconômica na utilização de métodos anticoncepcionais no Brasil: uma análise comparativa com base nas PNDS 1996 e 2006. In:______. Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher - PNDS 2006: dimensões do processo reprodutivo e da saúde da criança. Brasília, DF, 2009. p. 87-104.
• CARVALHO, L. E. C. et al. Número ideal de filhos e arrependimento pós-laqueadura. Revista da Associação Médica Brasileira, São Paulo, v. 52, n. 5, p. 293-297, 2006.
• CHAVES, A. M. et al. Representação social de mães acerca da família. Revista Brasileira de Crescimento e Desenvolvimento Humano, São Paulo, v. 12, n. 1, p. 1-8, 2002.
• CUNHA, A. C. R.; WANDERLEY, M. S.; GARRAFA, V. Fatores associados ao futuro reprodutivo de mulheres desejosas de gestação após ligadura tubária. Revista Brasileira de Ginecologia e Obstetrícia, Rio de Janeiro, v. 29, n. 5, p. 230-234, 2007.
• DIAS, R. et al. Síndrome pós-laqueadura: repercussões clínicas e psíquicas da pós-laqueadura. Revista Brasileira de Ginecologia e Obstetrícia, Rio de Janeiro, v. 20, n. 4, p. 199-205, 1998.
• DURKHEIM, E. La prohibition de l’enceste et ses origines Paris: Payot & Rivages, 2008.
• FAÚNDES, A. et al. Associação entre prevalência de laqueadura tubária e características sócio-demográficas de mulheres e seus companheiros no Estado de São Paulo. Cadernos de Saúde Pública, Rio de Janeiro, v. 14, p. 49-57, 1998. Suplemento 1.
• FERNANDES, A. M. S. et al. Seguimento de mulheres laqueadas arrependidas em serviço público de esterilidade conjugal. Revista Brasileira de Ginecologia e Obstetrícia, Rio de Janeiro, v. 23, n. 2, p. 69-73, 2001.
• FERNANDES, A. M. S. et al. Laqueadura intraparto e de intervalo. Revista da Associação Médica Brasileira, São Paulo, v. 52, n. 5, p. 323-327, 2006.
• GOFFMAN, E. Estigma: notas sobre a manipulação de identidade deteriorada. Rio de Janeiro: Guanabara Koogan, 1998.
• MACHADO, K. M. M.; LUDERMIR, A. B.; COSTA, A. M. Changes in family structure and regret following tubal sterilization. Cadernos de Saúde Pública, Rio de Janeiro, v. 21, n. 6, p. 1768-1779, 2005.
• MARCOLINO, C. Planejamento familiar e laqueadura tubária: análise do trabalho de uma equipe de saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 20, n. 3, p. 771-779, 2004.
• MINAYO, M. C. S. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Hucitec; Rio de Janeiro: Abrasco, 2000.
• MINELLA, L. S. Aspectos positivos e negativos da esterilização tubária do ponto de vista de mulheres esterilizadas. Cadernos de Saúde Pública, Rio de Janeiro, v. 14, p. 69-79, 1998. Suplemento 1.
• MOREIRA, M. H. C.; ARAÚJO, J. N. G. Planejamento familiar: autonomia ou encargo feminino? Psicologia em Estudo, Maringá, v. 9, n. 3, p. 389-398, 2004.
• NEYRAND, G. Sexualité, maternité, paternité, pouvoir: un espace en cours de restructuration. La Pensée, Paris, n. 339, p. 39-50, juil./sept. 2004.
• OLMOS, P. E. Quando a cegonha não vem: os recursos da medicina moderna para vencer a infertilidade. São Paulo: Carrenho, 2003.
• OSIS, M. J. D. et al. Consequências do uso de métodos anticoncepcionais na vida de mulheres: o caso da laqueadura tubária. Cadernos de Saúde Pública, Rio de Janeiro, v. 15, n. 3, p. 521-532, 1999.
• OSIS, M. J. D. et al. Fertility and reproductive history of sterilized and non-sterilized women in Campinas. Cadernos de Saúde Pública, Rio de Janeiro, v. 19, n. 5, p. 1399-1404, 2003.
• REIS, R. M. et al. Resultados de fertilização in vitro em mulheres submetidas previamente à laqueadura tubária. Revista Brasileira de Ginecologia e Obstetrícia, Rio de Janeiro, v. 28, n. 12, p. 715-720, 2006.
• VIEIRA, E. M. O arrependimento após a esterilização cirúrgica e o uso das tecnologias reprodutivas. Revista Brasileira de Ginecologia e Obstetrícia, Rio de Janeiro, v. 29, n. 5, p. 225-229, 2007.
• WAJCMAN, J. Tecnologia de produção: fazendo um trabalho de gênero. Cadernos Pagu, Campinas, v. 10, p. 201-256, 1998.

• 1
  Research financed by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).
• 2
  See: Population Reports, series E, number 6, May 1982, E-4.
• 3
  “The action of training which operates in the social construction of the body has a way to express and explicit pedagogical action”. (Bourdieu, 1998, p. 37 – free translation).
• 4
  Rosa, age 42.
• 5
  “Criteria for the carrying out of surgical sterilization (tubal ligation and vasectomy), according to the law 9.263, of 12th January 1996: Art. 10.

Publication Dates

• Publication in this collection
  apr-jun 2014

History

• Received
  11 Mar 2013
• Accepted
  11 Oct 2013