The History of Female Surgical Sterilization: A Social and Ethics Perspective

History

Surgical sterilization is an important option for women who desire permanent contraception and continues to be one of the most used contraceptive methods in the United States and globally. ¹ Despite its historical importance and continued appraisal, the development and dissemination of procedures and surgeries for permanent contraception have roots in racism, misogyny, and eugenics. Acknowledging this history is critical and is the impetus for this companion review, which accompanies our concurrent technical review: “The History of Female Surgical Sterilization.”

Coerced Sterilization: A Product of the Eugenics Movement

In the early 20th century, surgical sterilization gained momentum in the United States in parallel with the eugenics movement. At the time, disproportionately low birth rates among white Protestants in comparison with immigrant Catholic Italian and Irish communities, who were considered “tainted whites” because they were not of Anglo-Saxon descent, led to a growing concern about the replacement of the white race by an “inferior” race. Eugenics is a belief system aimed at creating “better” humans. Eugenics implements social practices and policies that encourage people considered to have “desirable” qualities to reproduce, whereas discouraging or preventing people with “undesirable” qualities from reproducing, especially through coercive sterilization practices. Many eugenicists considered people to be unfit to reproduce if they were poor, had a mental illness, had low intelligence, or suffered from addiction. They also considered poverty, prostitution, and homelessness as potentially inherited traits that could be stopped through preventing reproduction. In the United States, eugenics flourished during the first three decades of the 20th century.^2,3

Between 1907 and 1932, 30 states passed statutes permitting forced sterilization of people who were labeled as “feebleminded.”^2–4 These statutes led to the involuntary sterilization of ∼60,000 Americans between 1927 and 1957, 60% of whom were women. ³ Because of the pervading belief in white intellectual superiority, intelligence was measured against the standard that the white race was intellectually superior to other races. ³ The term “feebleminded” was used informally to refer to those considered to be cognitively deficient; however, intelligence was measured using methods whose results were only considered accurate if they supported white intellectual superiority. ³ Because of this socially constructed connection between intelligence and race, the “feebleminded” white person was thought to be racially tainted; he or she was considered an impure white and, therefore, a threat to a system of white supremacy. In addition, the labeling of “feeblemindedness” was disproportionately attached to women, particularly in the case of sexual activity outside of marriage or sexual promiscuity. ⁴ The idea provided the setup for the later disproportionate sterilization of women from southern and eastern Europe, black women, Native American women, Hispanic, and Latinx women.

Popular interest in eugenics grew in the 1920s and 1930s stemming from the publicized policies of segregation and sterilization at The Sonoma State Home for the Feebleminded in California, which is considered to have performed the most forced sterilizations on “mental defectives’’ in the world. ⁴ The institution began as a place to assist in the care of children with mental disabilities, but as the eugenics movement grew, so did the institutionalization of women who were considered morally degenerate, especially those who were sexually promiscuous. When eugenicists realized that sexual activity could not be curbed through segregating these women from the rest of the population, the focus shifted to state control of procreation. In their minds, institutionalizing sexually promiscuous women (especially working-class and immigrant women) was not necessary, if they could be sterilized. ⁴

Eugenics was so ingrained into American culture that the American Medical Association supported eugenic sterilization until 1960.^3,4 In the early 20th century, obstetrician and gynecologist Dr. Robert Dickinson paved the way for acceptance of surgical sterilization by the American Medical Association through his research, which included the involuntary surgical sterilization of >5800 California inmates at eight California state hospitals between 1909 and 1928. ⁴ He reviewed sterilizations performed on men and women considered either “insane” or “feebleminded,” and who were required by the state to undergo sterilization before discharge from state institutions. Surgical methods he observed included vasectomy, partial salpingectomy, and transcervical tubal occlusion through thermal and chemical methods. His findings emphasized the safety and effectiveness of surgical sterilization methods, with the purpose of providing support for eugenic sterilization. Surgical sterilization used selectively for eugenic purposes would thus be recognized by organized medicine as a legitimate procedure. ⁴

California has had the highest rate of involuntary sterilizations, performed mainly on prison inmates, patients in mental health institutions, and women considered to be bad mothers. ² From the early 1900s to the early 1950s, ∼20,000 people in state institutions were sterilized, accounting for approximately one third of the total number of sterilizations in the United States at the time.^5,6

Coercive Sterilization Practices in the 1960s and 1970s

After the 1950s, eugenic sterilizations unfortunately continued, although not mandated by the state and in less conspicuous forms. During the 1960s, physicians at the Los Angeles County Medical Center performed postpartum tubal ligations on working-class women of Mexican origin who had recent cesarean deliveries without their knowledge or consent. The procedures were financed by federal funds dispersed as part of the family planning initiatives of the War on Poverty, initiated in 1964 by the Lyndon B Johnson administration.^5,6 Madrigal v, Quilligan was a civil rights class action lawsuit pursued by 10 Mexican American women who underwent sterilization without their consent at Los Angeles County Hospital.^7,8 The women lost the case, as the California federal court judge ruled in favor of the medical center, concluding that the sterilizations resulted from miscommunication between the patients and the physicians. Despite such a loss, the case resulted in the development of bilingual sterilization consent materials by the California Department of Health. ⁸

In the 1970s, >3000 Native American women were sterilized without adequate counseling or informed consent. Low-income women of color, including Native American women, were presented with sterilization as an optimal form of birth control. Frequently, when Native American women were counseled on sterilization, no interpreter was present to ensure the patient was counseled appropriately, and patients were frequently not informed of the irreversibility of the procedure. Public and private welfare agencies threatened to stop benefits or to remove an individual's children if they had additional children; thus, many women agreed to sterilization. ⁹

The 21st Century: Persistent Coercive Practices

Surgical sterilization of California female inmates without proper authorization nor appropriate informed consent has been reported as recently as 2013, when an investigation found that 144 female inmates in California state prisons were sterilized by bilateral tubal ligation without appropriate authorization nor with an appropriate informed consent process. ⁵ Most women affected were low-income women of color, reminiscent of the involuntary postpartum tubal ligations performed at Los Angeles County Hospital on women of Mexican origin in the 1960s. In 2014, the California legislature passed and signed into law a bill banning sterilizations in state prisons except in cases of life endangerment or in which the patient has a medical need otherwise not met with another treatment. ⁵

Unfortunately, coerced sterilization in the United States is not relegated to history, but still occurs today. As recent as 2020, allegations of forced hysterectomies performed in 2019 on women in a Georgia immigration detention center emerged. A nurse at the facility disclosed that immigrant women had undergone hysterectomies without their consent between October and December of 2019. The nurse reported that health care providers at the facility did not use appropriate translation services to obtain informed consent for gynecologic surgery, resulting in several hysterectomies performed for which the patient was not adequately counseled or consented. In one case, a woman was supposed to undergo a left-sided unilateral salpingo-oophorectomy for a cyst. The surgeon reportedly removed her right ovary inadvertently, requiring reoperation to remove the correct adnexal structures. Upon removal of the left adnexa, the surgeon performed removal of the uterus without the patient's knowledge.^10,11

Barriers to Obtaining a Desired Sterilization

Whereas low-income and minority women have been disproportionately affected by coercive sterilization practices, historically women who desired a “voluntary” sterilization, particularly white women with private insurance, had a difficult time finding a physician who would perform the procedure. In the 1970s, to perform a “voluntary” sterilization, gynecologists followed the guideline that the product of a patient's age multiplied by her parity should equal 120 before considering sterilization. ¹² More recently, differences in elective sterilization practices remain.

The U.S. Collaborative Review of Sterilization (CREST), conducted from 1978 to 1986 comparing the efficacy of sterilization methods, found that women <30 years and those who were not married had a significantly higher risk of regret after the procedure ¹³ ; physicians may use these findings as reason to deny women their right to permanent sterilization. Although providers present factual data regarding permanent sterilization, they may present the procedure as unappealing because it is permanent and steer women toward long-acting reversible contraceptives based on their age, marital status, and/or parity. Women may come away from these conversations feeling a lack of respect for their decision-making capabilities and bodily autonomy. ¹⁴

Similarly, the creation of a standard sterilization consent for patients with Medicaid has led to barriers to obtaining permanent contraception. In response to reports of coerced sterilization of minority women,^15–18 the U.S. Department of Health, Education, and Welfare created a standard informed consent and set of regulations for publicly funded sterilizations with the intent of protecting vulnerable individuals from coercive sterilization. ¹⁹ The regulations and consent process were last updated in 1978, and restrict the procedure to patients aged ≥21 years, and require that consent be obtained at least 30 days in advance, lasting for a maximum of 180 days. ²⁰ Unfortunately, these restrictions have become barriers to obtaining a desired method of permanent contraception for low-income and minority women.^21–23 Although the intent of these regulations was to protect vulnerable populations from forced sterilization, they present another obstacle toward women achieving reproductive autonomy, which disproportionately affects low-income and minority populations. An improved approach would be to provide individualized counseling, with acknowledgment of how patients' unique, diverse personal and sociocultural contexts might inform what may be the best decision for themselves.

A more recent development that has led to restrictions on an individual's ability to make their own reproductive decisions is the growth in Catholic-based health care systems throughout the United States. From 2001 to 2020, there was a 50% growth in Catholic-based hospital systems, which now account for 4 of the 10 largest health care systems in the United States. ²⁴ These health care institutions are governed by a specific set of guidelines created by Catholic church leaders called The Ethical and Religious Directives for Catholic Health Care Services. ²⁵ When strictly interpreted, the guidelines prohibit provision of contraception, including sterilization. Patients whose primary health care facility is a Catholic-based institution may not even be aware of the affiliation and, therefore, are unaware of the potential restrictions on their ability to obtain permanent contraception. Because of the growth in Catholic-affiliated institutions, a greater number of patients face barriers to making their own reproductive health decisions, particularly in areas where the only hospital in the region is Catholic-affiliated. Similar to coerced sterilization, a refusal to provide permanent contraception based on a set of religious beliefs only serves to restrict a patient's autonomy and ability to make reproductive health care decisions.

Final Thoughts

Surgical sterilization is one of the most effective and relied upon options for patients who do not or no longer desire to become pregnant. However, the vast difference throughout history in the provision of surgical sterilization based on race, ethnicity, social class, and income elucidates the value placed on certain women and their ability to have children. Surgical sterilization unfortunately has been and continues to be intertwined with racism and eugenics, from coerced sterilization to the creation of federal and religion-based barriers to obtaining a desired sterilization. Today, there are still reports of providers who may decline performing the procedure or perform the procedure without explicit patient consent undermining a woman's autonomy and ability to make informed decisions regarding her reproductive health.

The American College of Obstetrics and Gynecology has officially stated that “It is critical that health care providers refrain from inserting their own biases or judgments about the appropriateness of a patient's decision to proceed with sterilization.” ²⁶ Accordingly, obstetrician-gynecologists have an obligation to acknowledge the role of surgical sterilization in historical physical and social harm. Only by doing so can clinicians begin to understand how some of their patients may view the procedure beyond its clinical benefit, and counsel accordingly, as well as begin to advocate for better practices and policies that will ensure the protection of their patients' reproductive choice and dignity.