I was responding to a thread on a discussion board that began with a question about the possibility of sterilizing a young woman with developmental disabilities who had just begun menstruating...

Dear [Mom] 

Please don't take this as a 'lecture', or as criticism or condemnation. I'm offering it in the spirit of a respectful and calm analysis...

It might help to remember that you're dealing with a number of separate issues here, and you may find it useful to take the time to think through what would be the most effective, status-enhancing, and least invasive approach to each issue...

1) Your daughter is menstruating

Three cheers! It means that her body is working right.

2) Menstrual hygiene

Every woman knows that there are several effective approaches to staying clean, comfortable and healthy at all stages of the menstrual cycle. Tampons, pads, panties all work. Some women find tampons physically or subjectively uncomfortable; others are quite comfortable with this method. Chemical or surgical sterilization would be considered an over-response to this issue.

The question of whether or not someone can perform hygienic routines by themselves is another issue entirely and doesn't by itself determine the choice of hygienic methods.

3) Conception control

Every woman knows that there are many approaches to this issue, ranging from the least physically intrusive (abstinence) to the most physically intrusive (surgical sterilization). I'll talk more about this later...

4) Protection against sexually transmitted diseases

Every woman knows that there are several approaches to this issue, ranging from relatively effective to relatively ineffective. However, it's important to note that chemical or surgical sterilization offers no protection against STDs.

5) Protection against sexual exploitation

Think about how you learned to protect yourself against sexual exploitation. Take the time to read David Hingsburger's book, Just Say Know: Understanding and Reducing the Risk of Sexual Victimization (available on Amazon).  Also read David's article, The Ring of Safety

Note that chemical or surgical sterilization provides no protection against victimization. This is a crucial issue, and deserves your absolute attention. But the solutions are, by definition, environmental and social, rather than physical in nature.

6) Pregnancy, childbirth, child-rearing

If you do a good enough job on 3, 4, and 5 above, this won't be an issue.

Back to conception control...

First, this child is 14 years old. Any sexual interference is by definition sexual abuse / victimization. She deserves systematic, effective, reliable environmental / social protection against being victimized.

Second, if in the future she makes a conscious decision to become sexually active, she must also make a conscious decision about conception control. She might make a decision to opt for sterilization (I chose that for myself when I was 35 years old), but most physicians would probably encourage a young woman to opt for a non-permanent approach, partly on the basis of the massive hormonal changes that result from either chemical or surgical sterilization of women (men have it easier in this regard).

Third, it may be that she is so cognitively impaired that she is unable to make a conscious, informed decision to become sexually active and to choose a method of conception control. In that case, it seems to me that one would sustain the environmental / social protection against sexual victimization that we afford to young children. The more she participates in this protective pattern, the better (refer back to Dave Hingsburger's book).

I'm not just making this up. Faye and I share our lives with an adopted daughter who just had her first menstrual period! She's delighted. We're delighted. So what are we doing about...

1) Menstruation? - we're celebrating
2) Menstrual hygiene? - the same diapering system that she's always used, plus a few extra baths
3) Conception control, protection against sexually transmitted diseases, protection against sexual exploitation, pregnancy, childbirth and child-rearing? - one of us is with her all the time; when she has an assistant, it's a woman who we have known for years, and we don't send her to places where she would be unprotected.

Notice that I haven't said anything about 'protection against intimacy' or 'protection against sex'.

Right now, our daughter is not romantically or sexually involved. If she were to begin moving in that direction, we would begin to deal with the issues in a pre-emptive way beginning with protection against sexual exploitation. We would work with her as she thought through how she would handle her relationship, how she would protect against exploitation, how she would protect against STDs, how she would protect against conception. In all of these decisions, we would work in the direction of solutions that were safe, effective, and least invasive (but remember, also effective).

Like many women, if she were moving in the direction of becoming sexually active, she would have to become skillful in negotiating the relationship with her partner, deal with questions of prior sexual history, and preemptively choose and use safe and effective methods of disease control and conception control.

With our assistance and her doctor's assistance we would encourage her to choose methods of conception control that were effective, did the least harm to her body, and were the least invasive.

She might decide that she never wants to have children or that her body is simply not 'made' to have children. In that case, a permanent method of conception control might make sense; otherwise, effective and reversible methods would meet the criteria for 'least invasive'.

I know this doesn't meet your original request for a referral to someone who would perform a sterilization, and I'm sorry for that. I would hope that a less drastic option (actually a combination of options, as I outlined above) would be appealing and make sense.

With respect, and with admiration for your courage in raising this important question,

Dave Wetherow

David, thanks for lowering the tone of the rhetoric a little. The problem with your position is, I think, that it assumes that [my daughter would understand the complex moral decisions involved in protecting herself]. Very, very doubtful. At the age of 14 she understands and responds to only the most rudimentary instructions. She can, of course, be trained. She does, of course, have her own personality. But she will never understand what this is all about. Morality will never be a concept she will comprehend.

Hello!

I believe you, and I understood that from the beginning. I hope that you understood that my post was intended to provide a way of looking at the questions regardless of the person's current (or even future) capacity to understand, express themselves, etc.

The fact that your daughter is very limited in her understanding and expression means that you are in the position of making the decisions that I was talking about re: menstrual hygiene, protection from exploitation, conception control, etc.

I wasn't assuming that your daughter would be the one to absorb and work with what Dave Hingsburger is saying; David's understanding is just as important for someone who is acting as a parent.

I am indicating that there is some real value in making these decisions with a view towards alternatives that are effective but also minimally invasive. Why? Because this is what you would do for yourself. There is value in applying the same principles in making a decision for/with/about someone who is vulnerable that we would apply to ourselves.

I did not at all assume that you daughter will be able to effectively consider whether or not to become intimate or to have relationships. That's why I spent some time talking about the kind of protection we offer to children (and adults) who have major challenges in understanding and expression. It's also why I said that in the case of young children, and adults who carry the same kind of vulnerability as young children carry, it is imperative that we provide them with outside protection.

When I used the term 'social protection', I didn't mean 'talk therapy' or 'morality training'. I meant that we control the social context with vigor and reliability (exactly as we would do with a very young child). Putting it in very clear terms (which I probably should have done in the first place), we keep them out of the hands of predators and pedophiles. We don't put them into situations where they could be molested. And if we're not there to do that, we make sure that someone is there who will provide the same kind of fierce protection that we would -- someone who will act in 'place of the parent'.

I think that if you carefully go through all of the issues and all of the options, and if you deal with each issue separately and completely, you might find that sterilization is not necessary and the pressure to move in that direction will go away of its own accord. Here's what I mean:

If you provide solid, effective protection against sexual victimization, the issues of conception control, pregnancy, childbirth, child-rearing, and sexually transmitted diseases simply disappear. That leaves menstrual hygiene. If that is the remaining issue, I suggest that sterilization is a rather dramatic response to that problem.

My guess is that this is why you might be finding it so hard to locate a physician who will do the procedure. This is because in addition to a mandate to assist patients to make fully informed decisions about treatment options, physicians are also enjoined to work within the boundaries of 'accepted medical practice', which includes a (conservative) principle of using methods that are effective but which at the same time preserve other aspects of the patient's health and bodily integrity.

What would happen if a parent of a 14 year old girl without mental disabilities took her to a doctor and requested sterilization on the grounds that it would save her a lot of trouble (in terms of menstrual hygiene, conception control, child-rearing, etc.)? The fact is that a physician who proceeded with sterilization in that circumstance would be convicted of malpractice, even if the parents said they were operating with fully informed consent and the girl herself agreed to the procedure.

I'm not at all condemning or disrespecting your pursuing this possibility. I'm just (hopefully) offering a way of thinking about the real challenges that you face -- an analysis that may, in the long run, offer you and your daughter a healthy, happy solution -- a solution with integrity.

As always, with respect, compassion for your struggle, and warm regards,

Dave Wetherow