Sterilization Abuse: A Task for
the Women's Movement
Sterilization abuse is an issue that should be taken up by the women's movement as a whole, for it is not just an issue of reproductive choice and freedom, but one which encompasses a whole range of other issues as well, including the economic nature of the U.S. health care delivery system, the nature of medical education, patient rights and informed consent, as well as national and international questions of genocidal population control policies. But before analyzing the actual political context of sterilization abuse, I will first outline the nature and scope of the problem.
Within the last 20 years, there has been a dramatic rise in programs aimed at sterilizing women, both in and outside the U.S. It is the most risky and fastest growing method of contraception in the U.S. today.1 Female sterilization increased by 350% from 192,000 in 1970 to 674,000 in 1975. 2 Some estimated 8 million men and women in the U.S. today are sterilized,3 and approximately one million women undergo sterilization operations each year.4 In 1970, 16.3% of all couples using some form of 5 contraception were sterilized. In 1973, the percentage had increased to 23.5.
Sterilization is increasingly being touted as the 'perfect' method of contraception for those who desire no more children. However, it involves a decision which must be considered carefully, its risks and benefits weighed and compared with those of other methods of contraception- for it is basically a permanent and irreversible operation.
Medical indications for therapeutic sterilizations, which usually require hysterectomies should be considered even more carefully, as it is a more dangerous operation, and should not be performed solely for contraceptive reasons.
Sterilization procedures vary somewhat. In women, it is accomplished by tubal ligation, in which the fallopian tubes are tied, blocked, or removed to prevent the passage of eggs. Tubal ligation is either done during a 2 to 3 day hospital stay with traditional surgical procedures, reaching the tubes through the vagina or abdomen, or by a new out-patient procedure called laparascopy, in which a tiny incision is made in the abdomen and the tubes are burned or clipped. This procedure is often deceptively known as "band-aid" surgery, as the incision is covered by one after the operation. It implies that there is little risk or few complications inherent in the procedure, which is not necessarily the case. A new procedure called a mini-laporatomy is now being perfected, and does not require special laparascopic training and equipment, It permits direct visualization of the fallopian tubes, and can be performed in 10-30 minutes.6 This procedure, however, is not risk free either, and has not been adequately perfected to permit its indiscriminate use.
Tubal ligations, by whatever method, always involve some element of risk, more so than in other methods of contraception. It is considerably more dangerous than the I.U.D. or diaphragm, and is not any safer than the continued use of oral contraceptives. For every million tubal ligation operations, for example, 1000 run the risk of dying from the procedure, compared to 31 and 9 deaths for every million pill or I.U.D. users.7 Serious complications per million women are as high as 15,000 for tubals, 600 for the pill, and 400 for the I.U.D.8 Some of the common side effects from this operation include bleeding, uterine perforation, accidental burning or bowel trauma, and abdominal pain or pain during menstruation. It is obviously not the safest method of contraception available to women.
Hysterectomies, which involve removal of the uterus, are a much more dangerous operation than tubals. Despite this, many physicians are encouraging the use of hysterectomies solely for contraceptive purposes. It is the second most frequently performed operation in the U.S. today--second only to tonsillectomies. In 1975, 690,000 hysterectomies were performed.8 The complication rate for hysterectomies is 10 to 20 times higher than for tubal ligations, with between 3000 and 5000 deaths per 1 million operations.9 Recovery from a hysterectomy also usually requires at least six weeks.
Four different studies, have in fact, shown that approximately one-third of all hysterectomies performed in the U.S. have been unnecessary, that is, the medical indications did not require the procedure.10 And the number of 11 elective" hysterectomies performed has been increasing. At one major teaching hospital in L.A. for example, a 742% increase in "elective" hysterectomy has been documented between 1968 and 1970. A professor of gynecology there said that sterilization by hysterectomy had become a commonplace and widely accepted operation.11 Some gynecologists have even suggested that hysterectomies be performed as a preventive measure--as way of preventing uterine cancer for example.12 -They neglect to remind us however, that the risk of contracting uterine cancer is much less than the risk of dying from a hysterectomy.13 Would these physicians also suggest removal of the breasts to prevent breast cancer, or removal of the prostrate to ward off cancer of the prostrate gland? The analogies are obvious and endless.
If then, sterilizations, either tubal ligations or hysterectomies, involve many more risks and complications than other methods of contraception, why has there been such a tremendous increase in the numbers performed? Undoubtedly, some of the increase has been due to increase demand on the part of women who do want to permanently end their childbearing, and have made an informed decision to be sterilized with knowledge of the potential risks and benefits of the operation in comparison to other birth control methods. However, many women, in and outside the U.S., are often deceived or coerced into undergoing sterilization operations, often without even knowing that they had been sterilized. And most often, the subjects of such abuse are the poor, the Black, the Latino, the American Indian--those already abused by our health care system. But before going into more depth into the whys of sterilization abuse, I will first describe in more specific detail, the nature of sterilization abuse.
Sterilization abuse first gained national attention in 1973 with the revelation that two black sisters, the Relf sisters, aged 12 and 14, had been deemed mentally incompetent by an Alabama physician who subsequently sterilized them using Federal funds to pay for the procedures.14 Their mother, who could not read or write, had been deceived into signing her "x" on the consent forms. A federal lawsuit followed; one result being that a Federal judge ordered DHEW to stiffen its then newly formed guidelines in order to prevent such abuse from occurring again.
Sterilization abuse, however, can occur on many different levels, and it will take much more than a federal order to prevent it from occurring again. When a woman does not know she had been sterilized or is knocked out and sterilized against her will, this is sterilization abuse in its most blatant form. However, more subtle forms of coercion or deception are often used. Misinformation is one tool of abuse--women are not told that the operation is permanent and irreversible, or are not counseled about other methods of birth control. Or women are wrongly told that if they don't consent, their welfare benefits will be cut off. And illegal as well as legal immigrants are sometimes threatened with deportation if they refuse the sterilization. The lack of interpreters in health care institutions makes it especially problematic for non-English speaking women to be fully informed of their rights and the nature of the procedure itself. The issue of informed consent is particularly important when hysterectomies are encouraged for reasons not medically justifiable. One particular Chicago hospital15 for example, routinely suggests hysterectomies for women with Class III Pap smear results, which only indicate non-malignant abnormal cell growth of the cervix, and would not usually require removal of the uterus.
Sterilization abuse also occurs when the operation is suggested to women in stressful situations when they are not usually capable of making an informed decision and when they are not given an adequate period of time in which to consider their decision. At L.A. County Hospital, for example, some women were routinely asked during labor whether they wanted their tubes tied.16 Sterilization is increasingly being described as appealing and hassle-free, and is even suggested as a way of improving your sex life in a new pamphlet issued by DHEW.
A few examples should serve to illustrate the types of abuse I've been discussing. In L.A. in 1975, 10 Chicana women sued L.A. County Hospital and state officials. One of the women had refused to give her consent to a sterilization. She was punched in the stomach by a doctor and then sterilized. Some of the women signed consent forms after being in labor for many hours and under heavy medication immediately prior to undergoing childbirth by caesarian sections. Two were led to believe that the consent forms they signed were for temporary sterilizations. One of the women was not aware that a sterilization had been performed and wore an intrauterine device for 2 years afterwards.17
Then there is the case of the South Carolina physician who refused to deliver a black welfare mother's fourth child unless she agreed to be sterilized postpartum. He subsequently sterilized 28 women in three months, all of them Black.18
Norma Jean Serena, an American Indian, was also a victim of sterilization abuse. An excerpt from her "Statement of Need for Therapeutic Sterilization" reads "We find from observation and examination of Norma Serena that she is suffering from the following ailment of condition"...'socio-economic reasons'... and that another pregnancy in our opinion, would be inadvisable. Therefore, we are of the opinion that it is medically necessary to perform the sterilization."19 Ms. Serena thought that she had been sterilized for medical reasons. It wasn't until later that she discovered that she had been sterilized because she was poor.
It is no accident that all of these victims of abuse were poor and nonwhite women. In fact, the prevalence of sterilization among non-whites is higher than that of whites, even though non-white women make up a smaller percentage of the U.S. population than white women. Twenty percent of all married Black women in the U.S. have been sterilized and 14% of all. Native American women, compared to 7% of all married white women. 20 A recent Government Accounting Office (GAO) study commissioned by Senator James Abourezk of South Dakota, discovered that more than 3400 Native American women of childbearing age had been sterilized over a three year period in four different Indian Health Service areas in the Southwest.21 This figure is particularly frightening given the declining population of Native Americans--today there are fewer than 800,000 in this country. It would be comparable to sterilizing 452,000 non-white women in the U.S. The study also found that many of the consent forms to be illegal and not in compliance with Indian Health Service regulations. It also found that 36 women under the age of 21 and been sterilized, despite the court ordered moratorium on such sterilizations.
In fact, the sterilization regulations issued by DHEW as a result of the Relf case have been ignored by many physicians and institutions. In part, 'these regulations specify a 72 hour waiting period between the time of consent and the actual operation, a full explanation of the operation as well as other methods of contraception in the patients own language; and, to be written prominently at the top of the consent form, a statement which says that refusal to undergo the sterilization would not result in the loss of any Federal or state benefits.22
Even these minimal regulations, however, have been ignored by many hospitals and physicians, for DHEW provided no means of enforcing them. A 1974 survey of 42 large teaching hospitals across the country found that 27, or 64% of them to be in gross violation of the regulations, including two Chicago hospitals who subsequently claimed to be in full compliance. Fourteen of the hospitals were not even aware that such regulations even existed.23
The response of the women's movement to these abuses has been varied, and not always successful. Women in several cities are demanding the implementation of these guidelines, and in some cases, are fighting for better and more comprehensive guidelines. In New York City, after a 9 month battle, the Committee to End Sterilization Abuse (C.E.S.A.) was successful in getting better guidelines adopted by municipal hospitals. The major improvements over the federal guidelines include a 30 day waiting period, a detailed consent form, and counseling in the women's own language.
Implementation, however, is always a key problem, and enormous resistance has come from the medical and population control establishments. Six M.D.'s in New York's major teaching hospitals have filed suit against the city, state, and federal sterilization regulations. They claim the rights of physicians are violated by the New York City guidelines, particularly their freedom of speech, since the regulations state that a doctor cannot be the first one to suggest sterilization to a woman.
In order to effectively fight against sterilization abuse, not only in this country, but throughout the non-Socialist Third World, we first have to put it in its proper political perspective. The following is such an attempt. I will briefly outline three major reasons which I see as contributing to such abuse: (1) the population control establishment--its policies and ideologies; (2) the economic nature of the U.S. health care delivery system; and (3) the nature of medical education in this country, especially intern and residency training requirements. I will deal with the last two issues first.
It should be fairly obvious that physicians and hospitals stand to gain more economically by pushing sterilizations as opposed to other methods of birth control, especially when welfare patients are involved. DHEW has been funding 90% of sterilization costs in Federally funded family planning clinics since 1974. When placed in such a conflict of interest position, it is not surprising that economic interests might obscure patients' best interests. We certainly do not lack for studies which show that surgery rates are highest when economic interests to perform surgery exist. Federal employees under pre-paid group health plans, for example, had a 16.8% probability of having a hysterectomy by age 70. The odds of getting this operation under largely unregulated Blue Cross plans is about 35%. 24
The nature of physician education and medical training in this country also contributes to abuse of the poor and non-white, who often make prime targets for the surgical knives of interns and residents, who need to perform a minimal number of operations in order to fulfill certification requirements. The use of public patients as teaching "material" is an issue that many of are aware of, and is particularly relevant to the issue of sterilization abuse. Back in 1957, a physician at a New York teaching hospital proclaimed that "Sterilization by hysterectomy is encouraged on the ward service in order to offer the resident staff experience in the operation puerpural hysterectomy." 25 Such practices were not confined to the pre-sixties era, however. Dr. Lester Hibbard of L.A. County Hospital admits in 1972 that vaginal tubal ligations were sometimes selected over abdominal tubal ligations because of their "instructional value," even though the vaginal procedure often led to serious complications.26 And in 1975, the acting director of a municipal hospital in New York City informs us that "In most major teaching hospitals in New York City, it is the unwritten policy to do elective hysterectomies on poor, Black, and Puerto Rican women with minimal indications, to train residents ... at least 10% of gynecological surgery in New York is done on this basis. And 99% of this is done on Blacks and Puerto Rican women."27
The most pervasive influence on the practice of sterilization abuse, however, is the population control ideology which lends academic and political credence to the "blame the victim" strategy which justifies such coercive practices. For "overpopulation" has been used to explain everything from poverty, unemployment, and starvation to revolutionary unrest. Population control has become an important part of the foreign policy of the U.S. It rests on the assumption that population growth may wipe out not only agricultural growth but all economic development. Beyond this, the population control programs rest on particular sets of priorities about the needs of the poor. With birth rate reduction as the highest priority, the policies assume that the prevailing class structure should not be altered, that only gradual, non-revolutionary political change is to be encouraged, that relations between the sexes should be allowed to shift only gradually and within the existing class structure. Thus population control becomes a force against revolutionary change.
This is not to say that real problems of overpopulation do not exist in some parts of the world--the point is, is that overpopulation is by and large a result of poverty, not a cause of poverty.28 Historically, birth rate decline has been a consequence, not a cause of, economic development. In every instance of industrialization, birth rates fell after changes in mode of production lowered infant mortality, made children less valuable and more expensive economically, and increased demands and opportunities for women's employment outside their homes. Even the most conservative of academic demographers would be hard pressed to deny that it is rising living standards which create the primary inducements for fewer children and so declining birth rates--not the other way around. In a rural economy governed by peasant agricultural production and social organization, children are often a family's most valuable asset.
However, it became increasingly clear to many formerly colonized peoples in the Third World, that capitalist exploitation of their resources, destruction of peasants livelihood, and creation of an economically helpless working class, could only be resolved through independence and economic development through nationalist and often socialist economic reorganization. Such revolutionary undertakings would have limited and even ended the continued economic exploitation of Third World countries by Western capitalists, such has already occurred in many places such as Vietnam, Cuba, and Mozambique, to name just a few. Population control provided a rationalization for the failure of capitalism to provide economic growth for the peoples of the Third World and a proposed solution to their poverty and underdevelopment. Born of the Cold War, the population controllers considered stopping communism not only their highest priority, but also, according to their propaganda, the main reason that economic progress in the Third World was desirable. For example, "The Population Bomb,'' a pamphlet of the Hugh Moore fund of the Dixie Cup fortune, first published in 1954, and reprinted frequently until the mid-sixties, featured such arguments as, "There will be 300 million more mouths to feed in the world 4 years from now--most of them hungry. Hunger brings turmoil, and turmoil, as we have learned, creates the atmosphere in which the communists seek to conquer the earth."29
Thus, in the 1960's, population control received first priority within U.S. nonmilitary foreign aid. In fact, receiving foreign aid usually obligated receiving nations to undertake population control programs in accordance with U.S. State Department specifications. So it was that Lyndon Johnson remarked that $5 spent on family planning was worth more than $100 spent on development. Today, approximately 67% of all U.S. outlays for health care are now earmarked for population planning.29 And the Agency for International Development (A.I.D.) has increased its population control budget 40% over the last three years to $144 million in 1976--at the expense of other health programs.30
However, the U.S. State Department is not the only financial backer of U.S. population control programs. Some of the top ruling financiers in the U.S. have been funding such programs since the early fifties and before. For example, the exclusively ruling class Population Council is one of the Rockefeller family's main legacies to the family planning field. The council, along with the Rockefeller and Ford foundations has been the most active in providing funds for research in bio-medicine, improved delivery systems, and more efficient means of disseminating current population control techniques. Most of the prominent population groups like the International Planned Parenthood Federation (IPPF) are headed by ruling financiers like the Carnegies and Mellons, and have barraged us with all sorts of racist publicity and mass advertising campaigns to check the so called population explosion.31
One particularly racist ad which appeared in 1969, that was put out by the Committee to Check the Population Explosion began by asking, "How many people do you want in your country? Already the streets are packed with youngsters. Thousands of idle victims of discontent and drug addiction. You go out after dark at your peril ... the answer? Birth control. The ever mounting tidal wave of humanity challenges us to control it, or be submerged along with all of our civilized values."32 The implication is clear. Civilized values belong to Western Europeans and white Americans, while the black, brown, red, and yellow people of the world account for the tidal wave of humanity.
Ads such as these were designed to generate popular and governmental support for population control programs both in and outside the U.S. And health workers are obviously not immune to this ideology, as evidenced in their own attitudes and practice. These attitudes are most prevalent among the top elite of the health professions--white, male physicians, many of whom believe that poor and non-white women should be sterilized for their own good, as well as the "good" of the country. And they are not hesitant about admitting it. At a conference of obstetricians and gynecologists in 1966, one physician panelist asserted that, "After working with these so called poor, especially with minority groups, the Negro and Spanish American, I have the impression that these people have the view that nothing in the past has ever worked and nothing is going to work now. They bring you a feeling of hopelessness unless 'if I have THE operation' as it is known among the Puerto Ricans."33 He further went on to suggest that sterilization of the poor would be a way of reducing the number of broken families and ADC recipients.
Planned Parenthood survey of 226 physicians in 1972 provides us with further evidence of the prevalence of such attitudes among U.S. physicians. Thirty-four percent of them favored the withholding of any public assistance for any subsequent pregnancies of welfare mothers with 3 'illegitimate' children, and 30, favored withholding public assistance to such women if they refused to be sterilized.34
Population control propaganda is promoted far beyond the borders of the U.S. however. It often reaches people in the Third World in the form of the pictures below:
Get the message? You too, can have a nice home, a car, and even a DOG, but only if you stop having so many kids! The working and peasant people of the Third World, however, are not so naive as the population experts would like to think. These women know that having their tubes tied is not going to bring them instant wealth complete with a color T.V. set. In fact, they know that their survival very often depends on having enough children survive to an age where they can provide economic support to the family.
It should come as no surprise then, that, by and large, most family planning programs in the Third World have been failures, at least in terms of reducing the birth rate. Population controllers have been increasingly suggesting that effective population control can never happen voluntarily. One of the chief architects of family planning programs in Latin America, for example, writes that there has been no evidence of any birth rate reductions there after a decade of such programs. Women who attend the family planning clinics there are primarily those who have used contraception without the clinics, and who have already had an average of 5 children.35
As a result of this kind of evidence, population controllers have increasingly advocated various kinds of coercion in their programs. In India, for example, the government first tried to bribe people into sterilizations by handing out transistor radios or cash payments. 36 As that didn't work, some states in India have passed legislation requiring sterilizations for government employees with two or three children. Last year, up to 150 people were shot in protests over the new sterilization laws. 37 Some reports tell of men being forced off buses and transported to vasectomy camps.38 Women are thus not the only victims of sterilization abuse.
Coercion has also increasingly become a part of family planning programs in Latin America. The Ford Foundation, for example, donated one million dollars for an experimental sterilization program there, in which individuals would be guaranteed $5, $6, or $7 a month for the rest of their lives if they agreed to be sterilized.39 Between 1963 and 1965, 40,000 women in Columbia were sterilized by Rockefeller funded programs. These women were coaxed by gifts of lipstick, artificial pearls, small payments of money, and promises of free medical care.40 And in Bolivia, a U.S. population control program administered by the Peace Corps sterilized native Quechua women without their knowledge or consent.41
An A.I.D. sponsored program in the U.S. has been training Third World physicians to perform laparascopic tubal ligations. At the end of the course, each physician is flown home with a $5000 laparascope. Since these foreign M.D.'s do not have a license to practice medicine in the U.S., they could only practice using the laparascope on rabbits, which obviously do not have the same kind of gynecological problems and pelvic structures as women.42
The International Association for Voluntary Sterilization (A.V.S.) is now providing mini-laparotomy instruments to government and medical institutions in the Third World. A quote from the A.V.S. newsletter is quite revealing of their practices; "Women living in rural areas deficient in physicians and electricity may be safely sterilized by minilaparotomy. Whether performed in a modern hospital or a converted one table shack, minilaparotomy is a simple, 10 minute procedure requiring inexpensive equipment and minimal training."43
No mention is made of its experimental nature; no mention of its surgical nature, or the problems involved in performing any type of surgery on women who are most likely already undernourished and in bad physical condition.
Instead of providing health workers to these underserved areas, the A.V.S. supplies laparotomy instruments. They have so far sent supplies to Guatemala, El Salvador, Peru, Brazil, Chile, Bolivia, Columbia, Costa Rica, Ecuador, Guyana, Haiti, Honduras, and Mexico. Among their programs in Latin America, the total number of minilaporotomy procedures performed in 1976 has exceeded the total performed in 1974 and 1975 combined.44 So much for progress.
Probably one of the most insidious U.S. population control programs in the Third World has been in Puerto Rico, which has the highest incidence of sterilization in the world. A government issued survey found that 35% of all women of childbearing age there had been sterilized--more than one out of every three such women.45 Thousands of women are sterilized each month in U.S. funded family planning clinics there, which provides them free of charge.46 many sterilizations are performed postpartum, which is standard procedure in some teaching hospitals for women with two or more children. Welfare women, people on food stamps, and people who want housing are all receiving special orientations about overpopulation and sterilization.
It is so common on the island that it is commonly referred to as "the operation."
The primary goal behind this U.S. population plan is to reduce the working class population on the island in order to make way for U.S. corporations. A report of a Puerto Rican economic policy making group proposes reducing the working sector of the population in order to reduce unemployment, which is by some estimates, as high as 30%.47 Heavy industries, mainly U.S. petroleum and petro chemical industries, have moved onto the island in recent years, displacing many rural and light industry workers. These heavy industries require a relatively small workforce--the excess working population must somehow be "disposed" of, either through sterilization or forced migration.
The fact that sterilization programs in Puerto Rico are being carried on in a colonial context in a nation where people do not have control over their own lives and their government makes the term "voluntary" sterilization totally inapplicable. It is our responsibility to put an end to these kinds of programs, just as it is our responsibility to put an end to the forced sterilizations in this country as well.
WHAT IS TO BE DONE?
There are a variety of ways in which the issue of sterilization abuse can be attacked. We can agitate for enforcement of the HEW guidelines as they now exist, or demand even more stringent Guidelines to be enforced, as was done by New York C.E.S.A. However, as the medical and population control establishments have such enormous power in this country, it becomes important to forge health worker, patient and community alliances in order to fight them. The New York experience has taught us that we can not solely rely on health care workers to fight against such abuses, but we certainly need their support in order to discover where abuse is occurring. Many of the cases of abuse we know about were first brought to light by concerned health workers in institutions where coercion and deception were commonplace. In fact, the M.D. at L.A. County Hospital who publicized and exposed many of the sterilization atrocities that had occurred there is now being threatened with revocation of his license by the state of California on the charge of "moral depravity."48
We cannot, then, simply wage a legal battle against sterilization abuse, for the forces of law can easily be turned against us. It is clear to me that we need to reach out to communities in the form of health care forums and educationals on such issues as patient rights, patient education, the nature of the health care system, as well as on issues of reproductive freedom. The work that the Chicago chapter of C.E.S.A. has done has taught us that we cannot simply wage a battle on the issue of sterilization abuse alone, but that we need to combine it with other issues of more pertinent concern to women. If the women's health movement combines its forces and resources with those of other community health organizations in order to provide innovative health education programs in targeted communities, we can begin to get feedback from people in those communities about the issues that might encourage active struggles around them. Sterilization abuse could become just one part of building active community struggles around broader issues of health and community control of the institutions that wield so much power over our lives.