In 2013, thanks to the Center for Investigative Reporting, it came to light that dozens of female inmates in California had been illegally sterilized in recent years. The story was a salient reminder that forced sterilization, an issue that tends to be viewed as a tragic-but-past occurrence, continues today.
Sterilization abuse includes situations in which a woman does not know she is being sterilized as well as when she is coerced or deceived in order to obtain her consent to the procedure. Misinformation is a common tool; women are often told that their status — related to immigration, housing, government benefits, or parenting — will be negatively impacted if they do not consent to the procedure. Many women are told that the procedure is temporary or reversible.
Women in the United States and beyond have historically been subjected to coordinated efforts to control their fertility, including sterilization abuse. The burgeoning women’s movement in the 1960s, and growing concerns over limits to women’s reproductive rights at that time, helped focus concerns over sterilization abuse into action.
The Puerto Rican Experience
A 1965 survey of Puerto Rican residents found that about one-third of all Puerto Rican mothers, ages 20-49, were sterilized. To put this figure in context, women of childbearing age in Puerto Rico in the 1960s were more than 10 times more likely to be sterilized than women from the United States. These shocking findings suggested that systematic bias influenced the practice of sterilization, not just in Puerto Rico, but in the United States as well.
Since the United States assumed governance of Puerto Rico in 1898, population control had been a major effort. The United States, citing concerns that overpopulation of the island would lead to disastrous social and economic conditions, instituted public policies aimed at controlling the rapid growth of the population. The passage of Law 116 in 1937 signified the institutionalization of the population control program.
This program, designed by the Eugenics Board, was intended to “catalyze economic growth,” and respond to “depression-era unemployment.” Both U.S. government funds and contributions from private individuals supported the initiative.
Instead of providing Puerto Rican women with access to alternative forms of safe, legal and reversible contraception, U.S. policy promoted the use of permanent sterilization. The procedure was so common in Puerto Rico at the time that it was simply referred to as “la operacion.”
Institutionalized encouragement of sterilization through the use of door-to-door visits by health workers, financial subsidy of the operation, and industrial employer favoritism toward sterilized women pushed women towards having a hysterectomy or tubal ligation (i.e., “tying the tubes”). The coercive strategies used by these institutions denied women access to informed consent.
More than one-third of the women in the 1968 study did not know that sterilization through tubal ligation was a permanent form of contraception. The euphemism “tying the tubes” made women think the procedure was easily reversible.
The practice of sterilization abuse was challenged by local coalitions. Puerto Rican women’s groups, along with the movement for Puerto Rican independence, took up the fight against the injustices of the campaign. The economically disadvantaged women of Puerto Rico lacked access to information that would make contraceptive alternatives available to them. By denying access to reproductive health services for the women who were most in need of them, U.S. policy exerted its control over the growth of the Puerto Rican population, as well as over the lives of many Puerto Rican women.
A warrior in the fight for women’s reproductive rights, Dr. Helen Rodriguez-Trias, summarized the situation in Puerto Rico: “Women make choices based on alternatives, and there haven’t been many alternatives in Puerto Rico.”
The American Experience
U.S. women also are not strangers to forced sterilizations. As early as 1907, the United States had instituted public policy that gave the government the right “to sterilize unwilling and unwitting people.”
Laws, similar to Law 116, were passed in 30 states. These policies listed the “insane,” the “feeble-minded,” the “dependent,” and the “diseased” as incapable of regulating their own reproductive abilities, therefore justifying government-forced sterilizations. Legitimizing sterilization for certain groups led to further exploitation, as group divisions were made along race and class lines.
Some states, notably including North Carolina, set up Eugenics Boards in the early 20th century. These boards reviewed petitions from government and private agencies to impose sterilization on poor, unwed, and/or mentally disabled women, children and men. North Carolina alone sterilized over 7,600 individuals between the 1930 and 1970s.
In the early 1970s, Rodriguez-Trias was invited by a New York University Law School student organization to give a short talk about Puerto Rican sterilization abuse after viewing a related film. After her talk, Rodriguez-Trias was approached by a handful of audience members. Some were hospital workers who recalled stories of minority and disadvantaged women who were coerced into signing sterilization consent forms; full information on the procedure and its alternatives was not provided.
The case of a young woman, incarcerated by the New York City Police, was brought up in discussion. While being detained, the woman discovered she was pregnant and wished to have an abortion. She was taken to a public city hospital for the procedure. During counseling for the abortion, sterilization was offered as the best prevention of future unwanted pregnancies. Uninformed and misled, the young woman signed the papers and later regretted the procedure. In response to the treatment of this young woman and the many other disadvantaged women who had been coerced into giving up their reproductive rights, Rodriguez-Trias and a handful of other New Yorkers formed CESA, the Committee to End Sterilization Abuse.
As awareness of abuses increased, the calls for action became stronger. In 1974, the U.S. Department of Health, Education and Welfare (HEW) — now the Department of Health and Human Services — published guidelines for sterilization procedures. These guidelines established a moratorium on sterilization of women under the age of 21 and on others without the legal ability to provide consent. A 72-hour waiting period between the signing of a consent form and the procedure was mandated.
A written statement that women would not lose their welfare benefits if they refused the sterilization procedure and reserved a woman’s right to change her mind and refuse the procedure anytime up until the surgery, even after granting original consent, served as informed consent. However, studies conducted by the ACLU and the Center for Disease Control in 1975 showed that noncompliance with the guidelines was widespread.
In the 1970s, New York City public hospitals were bearing the brunt of regional complaints. These hospitals were the major source of health care for the city’s economically disadvantaged, and consequently provided reproductive services for many of the city’s poor women. The Health and Hospitals Corporation (HHC), the group that oversees the City’s hospitals, became an important tool in the study, identification, and monitoring of sterilization abuse practices.
In early 1975, the HHC called on members of CESA, including Rodriguez-Trias and members of other reproductive rights organizations, to serve on an ad hoc Advisory Committee on Sterilization Guidelines. The goal of the advisory committee was to set guidelines, like the HEW guidelines, for the public hospitals of New York City. These local guidelines hoped to promote the successful monitoring of sterilization practices.
By identifying the weaknesses of the HEW guidelines, the advisory committee drafted a more effective set of regulations that were aimed at protecting the rights of women who were mistreated in the past. The committee’s guidelines required a 30-day waiting period between the signing of the consent and the procedure. During this time, HHC hospitals were required to offer counseling services. These services were to be provided in the language that the woman spoke, and would not be given by the doctors themselves, but by a counselor removed from the clinical experience.
As part of the consent, the patient described her understanding of the procedure and the alternatives available, so that there was no doubt that she understood the permanence of the procedure. The guidelines suggested by the advisory committee became effective HHC rules on Nov. 1, 1975.
The guidelines set forth by the HHC could only be applied to the city’s public hospitals. In response, Public Law #37 was passed by the New York City Council in April of 1977, making the HHC guidelines the law of the city, applicable to both public and private facilities. Failure to comply with these regulations would result in a penalty. Public Law #37 was unique in that past guidelines were expanded to include the regulation of the practice of sterilization on men as well as women.
Beyond New York City, groups in other regions were pursuing similar goals. In Los Angeles, a group of 10 Mexican-American women successfully sued the County Hospital for denying them informed consent. These women, who only spoke Spanish, were coerced into signing consent forms in English; some were in labor and others were under anesthesia at the time of providing consent. After successful settlement of this case, L.A. County became more militant about following informed consent guidelines for sterilization.
In response to regional action, HEW redesigned its national guidelines for sterilization practices to embody the provisions of New York’s Public Law #37 in 1978. The national guidelines received widespread support from CESA as well as over 100 other regional and national organizations but also faced opposition from organizations that saw the guidelines as limiting women’s access to sterilization as a choice for contraception.
In response to recognition of past government abuse in North Carolina, the state set up the Office of Justice for Sterilization Abuse in 2011. This government entity seeks to identify victims of forced sterilization at the hands of the State’s Eugenics Board, and compensate them for the state’s actions against them.
ETHNICITY, Race and Sterilization Abuse
Latina women in Puerto Rico, New York City, and California were specifically targeted by the government for sterilization throughout the 20th century. Black women have also long been the targets of population control and have been disproportionately affected by sterilization abuse. In North Carolina, a state noted for its discriminatory sterilization practices in the 20th century, 65 percent of sterilization procedures were performed on black women, even though only 25 percent of the state’s female population is black.
An often-cited 1973 case example of racism and sterilization abuse involves the Relf sisters. Katie, Minnie Lee and Mary Alice Relf, ages 17, 14 and 12 respectively, were the victims of discriminatory policies and programs funded by the U.S. government. Since they were receiving government benefits, the Relf family was determined to be ideal candidates for the Montgomery Community Action Committee’s Family Planning Service.
Katie, under the age of consent in Alabama at the time, was offered and given a series of Depo-Provera contraceptive shots. At that time, the shots were still in the investigational phase and not yet approved for administration on adult women, let alone adolescents. Katie was also scheduled for insertion of an IUD (intrauterine device). All forms of contraception were provided to Katie without parental permission, which was required in Alabama at the time. Minnie Lee and Mary Alice received tubal ligations; their mother was under the impression they were being seen for routine inoculations.
The Relf lawsuit uncovered hundreds of thousands of similar cases in the region. Many of the women who were sterilized were sought out by these local federally funded centers, and threatened with the loss of government benefits for failure to comply. The women involved were overwhelmingly black women.
The court’s decision in the Relf case set guidelines for the use of federal funds for sterilization, and outlined the illegality of the use of coercion, especially through threats of loss of government benefits, for failure to participate in these programs.
The Experiences of Native American Women
Similar to the experiences of Puerto Rican women and Black women in the United States, Native American women were subjected to coercive population control practices through much of the 20th century. The Indian Health Service, functioning under the control of HEW and the United States Public Health Service, began providing family planning services to Native American families in 1965. Instituting similar practices to those experienced in Puerto Rico, as many as 25% of Native American women between 15-44 years old were sterilized by the 1970s.
In the early 1970s, two Cheyenne girls in Montana entered an IHS hospital, on two separate occasions, for emergency appendectomies. While sedated the physicians sterilized both girls, without consent from the patients themselves, nor from their parents.
In many Native American cultures children are important for tribal survival. A woman’s ability to procreate is often seen as an important way for her to secure her place within her tribe. Sterilization abuse not only took away women’s rights to control their fertility, but negatively impacted their social and emotional health.
Concerns for the Present and Future
The less fortunate and poorly educated continue to be denied the reproductive freedoms available to other women, and entitled by all.
Recent concerns regarding sterilization abuse involve incarcerated women. A 2013 report found that almost 150 women were illegally subjected to sterilization in California prisons between 2006-2010. The procedures were often discussed with women during childbirth, or other medical procedures, when they were most vulnerable.
Federal law, from the HEW guidelines of the 1970s, prohibits the use of federal funds for sterilization of any incarcerated woman. California state law allows state funds to be used on sterilization of incarcerated women, but special procedures for approval must be utilized prior to the procedure. In the cases found in the 2013 report, those procedures were not followed.
Rodriguez-Trias believed that although the organization of local groups was effective in the sharing of information as well as in applying pressure to policy makers, only with raised consciousness, informed consent, and the existence and accessibility to real alternatives, can freedom of choice become a reality for all women.