Jay Levine, a 34-year-old in California, has tried to get her tubes tied three times over the course of 15 years. She still hasn’t been successful.

“The first time I casually mentioned it, I was 19 and a newlywed. My doctor told me that I had to either have kids already or be 25 to even consider it, that she would never do it on a teenager,” Levine says. “The second time, I was 26. That doctor told me that he didn't want to do it because he said, 'your husband is active duty [military]. What would you do if he was killed and you got remarried to a man who wanted kids?’” Levine walked out of the office and filed a complaint about him.

She ended up not having a ligation the third time she asked because of the way she was treated. “When I was 32, my doctor said that she only felt comfortable doing it because I have a history of mental illness and probably shouldn't have kids anyway,” she says. “As of now, at 34, I'm still trying to find a doctor who won't make me feel bad about being mentally ill or try to tell me I'm still too young.”

People who want their tubes tied (formally known as tubal ligation) can be denied the procedure for a multitude of reasons at various stages of their lives: because they’re too young, childless, only have one child, are not married, are married to someone with a risky job—the list goes on. Then there are insurance barriers: For those who have Medicaid, there’s a required 30-day waiting period between signing the consent form and having the procedure, whereas women with more expensive private insurance (and a willing doctor) can schedule it right away.

There is no good data on how many people are denied tubal ligation, as records on those matters aren’t kept in any kind of centralized database. In the most recent academic review of tubal ligations in the US, published in 2010, the authors found that the number of procedures performed annually declined from 687,000 in 1995 to 643,000 in 2006, despite a 4 percent population growth of women of child-bearing age during that period. (It’s worth noting, though, that an alternative—the sterilization implant Essure—was approved in 2004.)

Ariel Tazkargy, a health law attorney in Kansas City, Missouri, says these obstacles boil down to systemic patriarchal ideals and norms, and sexism at its base level. “People have so many opinions about women choosing to reproduce or not, and I think physicians in the position to make that decision are hesitant because they think a woman might regret it later,” she says. “And that comes down to: We don’t trust women. We don’t trust women to make choices for themselves.”

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Tazkargy authored the 2014 paper “From Coercion to Coercion: Voluntary Sterilization Policies in the United States” while at the University of Michigan Law School. She says a lot of the policy in place surrounding things like the month-long waiting periods and signed permission forms months in advance were originally meant to prevent doctors from coercing women into sterilization against their will.

“They were well-intentioned to prevent the involuntary pressure for women to get sterilized,” Tazkargy says. “Women can have tubals sprung on them after birth or an unrelated surgery because doctors are already in there. The writing and waiting are meant to protect from that.”

Still, the policies that are in place vary by state, which means every experience will be different because there is so little regulation nationwide.

“There are states that don’t say anything about sterilization, and then it really is up to the physician to decide, and there is no check on that power,” Tazkargy says. “There are these rules that are unwritten, and whatever belief the physician holds, they get to evaluate whether or not the patient has legitimate reason.” People with low incomes, genetic disorders, and mental illnesses can be particularly discriminated against when seeking to get their tubes tied.

Even if women asking to get their tubes tied already have children, it might not make a difference—like in the case of Erin Thompson in Raleigh, North Carolina, who had the one child she wanted with her husband when she was 20.

“They told me I would need to see a psychologist to get cleared, and I had to write a two-page paper defending my need for this surgery,” Thompson says. “I spent two years trying to get them to give me one while I tried one terrible birth control [method] after another.”

Finally, her husband went to his doctor to ask for a vasectomy, which was completed a mere week later.

April Leamy was 24 with two children when she had a procedure to alleviate her endometriosis. She begged her North Carolina doctor to tie her tubes during that surgery, but he wouldn’t do it.

“I had my second child at 20. He was born with a severe brain malformation so I knew I didn't want any more kids after him,” Leamy says. “The doctor said he could not [perform the procedure] because I wasn’t 25, and I wasn’t married, and my [future] husband may want kids one day, and I'd change my mind.”

Leamy has since had three more children, none planned. She can’t be on the pill because of stroke risk, and other methods didn’t work for her. “We did try the progesterone-only [pill] but the breakthrough bleeding was constant,” she says. “Honestly, I love my kids, but I am also 100 percent sure I would not have planned for them.”

Melanie Greeke, who lives in Florida, had three children by the time she asked to get her tubes tied in her early 30s. Shortly after the Greekes found out they were pregnant with their third, they decided on vasectomy but they wanted to “double down” on protection, she says. Greeke had a tubal ligation right after her C-section and, later, she opted for a hysterectomy to treat endometriosis.

But her doctors made her husband give permission for both of the surgeries she wanted. “Pete had to sign off on my tubal, but I didn’t have to sign off for his vasectomy. He also had to give consent for my hysterectomy,” she says. Greeke blames her experience on being in the South and having military doctors and insurance.

Incredibly, having a medical need for ligation doesn’t interfere with a doctor’s right to refuse the procedure. Alexandra Sloan has a rare disorder called abetalipoproteinemia, also known as Bassen-Kornzweig syndrome, which makes getting pregnant dangerous and possibly fatal.

“There are only about 100 cases in the world,” Sloan says. “I don't digest fats or vitamins. I'm basically starving; getting pregnant could risk my life, plus I’m at high risk for bleeding.” She’s tried several different forms of the pill, an IUD, and the shot, none of which were right for her—they all made her feel sick, she says.

Sloan says she had to fight multiple doctors and insurance agents in central New York to get her tubes tied. It took her nearly ten years.

“The first time I was 25 or so...That time both the doctor and insurance refused, citing age, no children, no husband,” Sloan says. “The second time was at 33. The doctor wanted a full hysterectomy, but insurance said no, despite letters from my team of specialists. They refused multiple times because I was too young, and wasn't married. They made me sign plenty of papers and even called my boyfriend at the time and my mother, before they finally caved.”

Whatever the reason, many people just give up after being repeatedly denied permanent sterilization. That’s what Jackie Faulk Dotson did.

“I tried in vain to get my tubes tied when I was in my 20s,” Faulk Dotson says. “Back then, they wouldn’t even give you an IUD if you’d never given birth. Now I’m 45 and just running down the clock on the pill.”

She still doesn’t have kids. Because she never wanted kids.

When I asked to get my tubes tied, the doctor proceeded to ask me questions unlike any I’d ever heard at a medical appointment. “What if both your children were to die in a house fire?” he asked. “Are you sure you wouldn’t want more?”

He kept going. “You’re sure you understand that if we do this, you can never have children again? You definitely don’t want any more babies? You’re not going to change your mind? Have you talked to your husband about this?”

After asking me to imagine my children burning to death, and confirming that my husband was OK with my choice about my body, he scheduled me for the procedure. While my experience felt invasive and paternalistic, I was still approved after a single appointment. It was likely this straightforward because I’m 36, have two kids, and have been married to my husband for ten years—it seemed like my age and family status made the two male doctors and one male tech who interviewed me comfortable with allowing me to make this decision. But what about people who don’t meet the apparent benchmarks?

The American College of Obstetricians and Gynecologists (ACOG) notes in a Committee Opinion that “until reproduction is equitable, or ‘unstratified’ (a long-term vision that requires the undoing of many social inequalities), some protections of women with publicly funded health insurance may be warranted. How to craft protections that do not also create barriers is unclear; the tension between liberal access and protective safeguards is difficult to ethically navigate and operationalize."

ACOG spokesperson and OB/GYN Alison Edelman says that, in her practice, they listen to women, provide all the options, and make a decision together with the patient. That decision, however, is sometimes hindered by federal and state insurances, including Medicaid, TriCare, The Indian Health Service, and the grant program Title X, which mandate a waiting period.

“Even though people believe in their rational mind that women should be allowed to determine their own families, this subconscious, two-parent, two-child family is pervasive,” Tazkargy says. “Doctors don’t want to permanently alter someone, but they do it all the time for other procedures, so what is it about women and birth?”

Edelman agrees that the well-intentioned rules now act more as barriers to bodily autonomy than protectors of it.

“In my experience, most women have thought about it for a long period. They give themselves their own waiting period [before bringing it up to their doctor],” says Edelman, who’s also a professor of obstetrics and gynecology at Oregon Health & Science University. “There’s also a double standard because women on private insurance don’t have the [Medicaid] waiting period, and this creates a class barrier.”

“The hard part about contraception is that it’s preventing health outcomes like pregnancy, but it’s also a choice,” Edelman says. “Here is a shared decision between the doctor and patient. You are not treating a medical issue now, but preventing one.” Some doctors, she says, don’t feel comfortable aiding a preventative measure in such a permanent way.

So, what can people do if they want their tubes tied? “The people who can advocate for themselves better often do get the better care,” Edelman says, “and [doctors] need to be aware of helping women who don’t have that ability or capacity to advocate for themselves. We need to be able to say, ‘Here are your choices, here are your pros and cons. It sounds like you’ve been thinking about this forever.’”

Edelman also advises patients get a second opinion if they’re turned down, emphasizing that the goal is for people to feel secure in their choices and comfortable with their doctor. To that end, she stresses that people should have a relationship with their doctors, if they can. “It’s more likely you’ll get a procedure from someone you have a long-standing relationship with than someone you are seeing for the first time,” Tazkargy agrees, also noting that being able to regularly see a doctor is a privilege many don’t have.

“Unfortunately, it’s also a matter of being really articulate and convincing to a physician, which means only certain women have the ability to make that case—which women shouldn’t even have to make for themselves, but it is what it is right now.”