Women seeking permanent contraception on the NHS have been subjected to an unfair and discriminatory policy that treated their requests with suspicion while offering men a straightforward route, the health ombudsman has ruled.
The Parliamentary and Health Service Ombudsman (PHSO) issued a critical ruling against the Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board (ICB), now part of NHS Thames Valley, after investigating a complaint from Leah Spasova, a psychologist from Oxfordshire. The ombudsman found that the ICB had denied women NHS funding for female sterilisation based on the risk of “regret” – a criterion that was not applied to men seeking vasectomies.
The ruling concluded that the policy was unfair, inconsistent and based on subjective reasoning, and that women were not being given the same opportunity as men to make informed decisions about their own bodies. The ombudsman also found that the ICB had failed to explain why it ignored clinical guidance from the National Institute for Health and Care Excellence (NICE), which states that sterilisation should be available to women and that counselling – not blanket refusal – is the appropriate way to address potential regret.
A decade of refusal
Leah Spasova spent ten years fighting to obtain female sterilisation, a surgical procedure that blocks or seals the fallopian tubes to prevent pregnancy. She was repeatedly refused funding by her local trust, which cited concerns about potential regret and cost-effectiveness.
“I have been enquiring about sterilisation for 10 years and was just passed back and forth between services,” Spasova said. “Rejecting my application on the basis of regret means they were taking responsibility for my feelings. Someone else is making decisions about your body based on criteria you can’t even see.”
She said she realised from a young age that she did not want children. “I was probably about 22 when I realised children weren’t for me. It’s a lifestyle, it’s forever work … I understood quite young that I didn’t want that level of anxiety in my life.” When she first asked in her early 20s, she was told she was too young to make that decision.
In a letter to the trust in 2023, Spasova described the situation as a “healthcare postcode lottery”. She noted that female sterilisation is approved by NICE, funded nationally, and yet felt that decision-makers in Oxfordshire were playing games with people’s bodily autonomy by not offering the procedure. She pointed out that having the operation done privately can cost between £2,000 and £4,000, while the NHS cost was around £1,000 based on 2017 committee meeting notes. By contrast, she calculated that funding the contraceptive pill for 20 years would cost the NHS £5,289.60.
Unequal treatment of men and women
The core of the ombudsman’s investigation exposed a stark disparity in how permanent contraception is treated on the NHS. Female sterilisation, or tubal ligation, is a surgical procedure usually performed under general anaesthetic via keyhole surgery, requiring a few weeks of recovery. In contrast, a vasectomy is a minor outpatient procedure typically carried out under local anaesthetic in under 30 minutes.
While both procedures serve the same purpose, the ombudsman found that the NHS was in effect treating them as different tiers of care, placing significant barriers in front of women while offering men a more straightforward pathway. The ICB’s policy denied women funding based on the risk of “regret” – a subjective criterion that was never applied to men. The ombudsman also found inconsistent use of cost-effectiveness arguments: male sterilisation was recommended for funding without updated cost data, while female sterilisation was rejected due to a lack of recent evidence, despite older studies suggesting it could be more cost-effective over time.
An advisory committee responsible for policy across six integrated care boards in south-east England reviewed the issue in 2024 after Spasova’s complaint. Four of the six ICBs already funded female sterilisation. The committee recognised the equality issues created by funding male but not female sterilisation and recommended that female sterilisation should now be funded. Regret and the availability of alternative contraception are no longer considered valid grounds for refusal.
Data from the NHS shows the scale of the gap. In 2024-25, there were 10,793 female sterilisations – a 22% decrease from a decade earlier – while 26,385 vasectomies were carried out, a 16% increase year-on-year. In 2023-24, NHS hospitals performed 10,588 female sterilisations (a 1% decrease) but 22,775 vasectomies (a 113% increase, partly due to a new provider submitting data).
Charlotte Glynn of the British Pregnancy Advisory Service (BPAS) said there is a “real problem with women not being trusted to make decisions about their own bodies” and called the situation a form of “medical misogyny”. She argued that if a woman is given the right information and wants the procedure, it should be respected. However, emeritus professor Anna Glasier of the University of Edinburgh argued that women have the same access as men, citing long waiting times for vasectomies and the effectiveness of long-acting reversible contraception (LARC) for women.
Barriers remain
Despite the ombudsman’s ruling and the ICB’s agreement to revise its policy, Spasova said significant obstacles persist. “As of today, I see that my local NHS trust is expanding access for men who seek vasectomies, making it even easier to self-refer on the NHS budget without even a GP referral,” she said. “Yet even with the latest female sterilisation policy, women are required to prove they’ve tried long-acting contraception to show that it’s unsuitable for them. That’s the same as forcing men to use condoms for a ‘therapeutic-trial’ when they are requesting a vasectomy. The bottom line is: men are granted the right to bodily autonomy and healthcare on the NHS and women are not.”
PHSO chief executive Paula Sussex said the issues raised in Spasova’s case are not isolated. “We are concerned that there may be similar wider problems affecting multiple areas of healthcare, and that the system is not consistently meeting people’s needs.” She added that the case demonstrates the power of the patient voice, as the ICB is now reviewing its sterilisation policy.
The ombudsman also criticised the ICB’s handling of Spasova’s complaint, citing delays, unclear communication and a failure to properly engage with her concerns. The ICB has since agreed to apologise and review its commissioning and complaints processes.
A spokesperson for NHS Thames Valley said: “NHS Thames Valley accepts the findings of the parliamentary and health service ombudsman regarding historical decision‑making in this case. Since that time, NHS Thames Valley has introduced a new policy to ensure that patients who meet the criteria are able to access female sterilisation. As a new ICB, we are also redesigning our complaints function to ensure concerns about local services are responded to more effectively and in a timely way.”
The PHSO, which upholds approximately 60% of cases that receive a detailed investigation, has launched a new five-year strategy focused on using complaints to drive public service improvement. Only 722 cases – less than 2% of all complaint decisions – received a detailed investigation in 2024-2025.
Spasova’s own struggle is emblematic of a broader pattern. Across England, ICB policies vary widely. NHS Gloucestershire routinely funds female sterilisation only for women with a medical condition making pregnancy dangerous where LARC is contraindicated. LLR ICB funds the procedure if specific criteria are met, with careful consideration for younger women due to higher incidence of regret. Mid and South Essex ICB commissions it on a restricted basis. The Thames Valley Priorities Committee previously stated that due to associated levels of regret and availability of more cost-effective methods, female sterilisation was not normally funded.
“The procedure is available nationwide, it is funded and it is approved by Nice, and yet it feels like the decision makers were playing ‘healthcare postcode lottery’ with people’s bodily autonomy by not offering, and defunding, the procedure in Oxfordshire,” Spasova wrote in her 2023 letter. She said the struggle has taken a decade of her life, and that even now, the system continues to treat women differently from men.
