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Sterilization in the United States: The Dark Side of Contraception

Sandrine Piorkowski Bocquillon

Résumés

L’histoire de la stérilisation aux États - Unis est révélatrice des courants idéologiques relatifs à la perception du corps des femmes. A travers une étude comparative de cette pratique sur la période 1907-1963 et durant les années 1970, cet article vise à mettre au jour les similitudes entre ces deux périodes. Il analyse la façon dont la stérilisation, qui était initialement un mode de contraception coercitif à visées eugénistes, se transforma en un moyen de contraception financé par l’État après 1969. En se basant sur des analyses statistiques, il entend mettre au jour l’héritage eugéniste qui influença le discours concernant la stérilisation des femmes issues de minorités ethniques dans les années 1970. L’étude du rôle joué par les médecins durant ces deux périodes révèle leur influence, et parfois aussi leurs préjugés raciaux et sociologiques. Enfin, cet article examine le positionnement idéologique du mouvement féministe, mettant ainsi au jour ses tensions internes autour des notions de race et de classe, ce qui renvoie à l’ambiguïté de Margaret Sanger vis-à-vis du mouvement eugéniste dans les années 1920.

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1In contemporary America, sterilization, that is, salpingectomy, also called tubal litigation, or vasectomy for men, is considered as a radical, but safe method of contraception. Actually, it is quite an old practice, since the first sterilization law was adopted in 1907 in Indiana. The history of sterilization practices in the United States is quite telling, for it reveals the ideological currents at work in society throughout the twentieth century. One might think that from the beginning of the twentieth century, when it was a punitive and eugenic practice first experimented on men, to the 1960s and 1970s, when it was a contraceptive device, sterilization had evolved from an evil practice to a means of freeing women from unwanted pregnancies. But reality has proven to be different, and sterilization reveals the existing tensions between race, gender, and class, raising the question of who is in power when it comes to controlling reproduction. In fact, a comparative analysis of compulsory sterilization under states’ eugenic laws until the 1950s and federally funded sterilization in the 1970s unveils the ideological legacy of the eugenic movement, but it also reveals the power exercised by physicians in the field of reproduction and the ambiguity of the feminist movement on this question.

2Ideologically, sterilization first had a punitive and a eugenic aspect since it targeted “confirmed criminals,” “idiots,” and “imbeciles,” as they were then called. It concerned institutionalized “retarded” persons, and the first 1907 law stressed the fact that “heredity plays an important part in the transmission of crime, idiocy and imbecility” (Sharp 1907). With eugenic proponents becoming more influential, the idea that the “unfit” represented a burden on society became more and more popular. Since it was believed that “poverty,” “crime” and “insanity” could not be cured and were the results of mental deficiency, institutionalized patients and prisoners came to be seen as a threat, called “the menace of the feeble-mined” (Goddard 1920). Thus, eugenicists supported the idea of sterilizing those who were deemed “unfit” to reproduce, arguing that it would reduce the tax payer’s burden. Eugenicists drafted a model sterilization law, which served as a basis for many states. This practice was even justified by the Supreme Court in 1927, in the Buck v. Bell case, stating that, “The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes […]. Three generations of imbeciles are enough.” Thus, forced sterilization was justified in the name of public health, just as compulsory vaccination had been before. It is estimated that between 1907 and 1963, more than 60,000 persons were sterilized in the United States under these laws. However, it is only in “the 1960s [that] the practice of sterilizing retarded persons in state institution virtually ceased” (Reilly 1987). These data might seem surprising, since one might think that the horrors perpetrated by the Nazi regime during World War II put an end to such practices, but “[a]lthough sterilization reached its zenith during the 1930s, several states vigorously pursued this activity through the 1940s and the 1950s” (Reilly 1987). Moreover, in 1941, when the Supreme Court was called upon once again to discuss forced sterilization, in Skinner v. Oklahoma, it did not invalidate the decision rendered in Buck v. Bell. Instead, it questioned the equity of Oklahoma sterilization law, “Sterilization of those who have thrice committed grand larceny, with immunity for those who are embezzlers, is a clear, pointed, unmistakable discrimination.” However, when delivering the opinion of the Court, Justice Douglas warned against the evils which might result from compulsory sterilization, thus making a marked allusion to Nazi Germany, “Marriage and procreation are fundamental to the very existence and survival of the race. The power to sterilize, if exercised, may have subtle, far reaching and devastating effects. In evil or reckless hands, it can cause races or types which are inimical to the dominant group to wither and disappear.”

3The 1960s, which represent a revolution in American contraceptive practice, can be seen as the decade during which sterilization evolved from a coercive method of forced contraception used in state institutions to a federally funded contraceptive device. Prior to 1969, physicians had assumed that sterilization used as a contraceptive device was illegal, but a 1969 federal court case, Jessin v. County of Shasta, eased doctors’ fears when it stated that “sterilization [was] an acceptable method of family planning” (Lawrence 2000). And “on May 18, 1971, the Office of Economic Opportunity began funding sterilizations” (Dorr 2011). At the same time, Medicaid was permitted to reimburse up to 90% of the operation (Minna Stern 2005). As a result, “[b]y 1975, 7.9 million Americans had undergone sterilization, and sterilization had become the most popular method of contraception used by married couples” (Kluchin 2011). However, concerns and protests over the resurgence of coerced sterilization arose all around the country, thus revealing the dark side of this contraceptive device.

4In fact, when taking a closer look at sterilization during the 1970s, it can be noticed that some ethnic groups are overrepresented when it comes to sterilization data. Native American, Black or Mexican women were, thus, more likely to undergo sterilization than white women. Concerning Native American women, it appears that the Indian Health Service (an agency within the Department of Health, Education and Welfare) provided for a very significant number of sterilizations on Indian reservations, to such an extent that Senator James Abourzek of South Dakota asked the Government Accounting office (GAO) to launch an investigation in 1976, after numerous complaints were made that sterilization was being used as a birth control procedure on Indian women of child-bearing age without their informed consent. As the GAO officials explained in their report, they found out that when carrying out the operation, there was no informed consent obtained from the patients, that the patients were not informed of their right to withdraw consent, and that sterilizations had been carried out on women under 21 years old. Even though the GAO report insisted on the lack of informed consent from the patients, it did not stress the fact that the number of sterilizations was particularly alarming (Comptroller of the U.S. 1976). But other sources emphasized this issue and accused the GAO report of underestimating the phenomenon: “Cheyenne tribal judge Marie Sanchez questioned fifty Cheyenne women and discovered that IHS doctors had sterilized twenty-six of them. She announced her belief that the number of women the GAO reported sterilized was too low and that the percentage was much higher than 25 percent” (Lawrence 2000). Though the percentage of Native American women who were sterilized in the 1970s may still be questioned, it is clear, from the GAO report, that those women did not always make a free choice.

5Nevertheless, these abuses were not confined to Indian reservations and could be observed nationwide. In 1973, Dr. Bernard Rosenfeld coauthored a report on sterilization abuse across the nation. Its abstract is quite telling: “Evidence is presented indicating that in many instances of surgical sterilization, the operation is carried out without the informed consent of the patient. Cases in which surgeons ‘are selling’ disadvantaged patients on sterilization without informing them of reversible methods are presented. There is an epidemic of sterilization in almost every major American teaching hospital today. Hysterectomies are being performed unnecessarily because the operation is more of a challenge for the surgeon and provides good experience for the junior resident.” (Rosenfeld 1973). The point made by Dr. Rosenfeld concerning hysterectomy, that is, the complete or partial removal of the uterus, is noteworthy here, since it is not indicated for sterilizing a patient. Normally, hysterectomy is done when there is an indication of cancer, or a disease related to this part of the body. In part, Rosenfeld was prompted to write this report after witnessing these bad practices when he was a resident at Los Angeles County Hospital. This hospital came under public attention for its treatment of Mexican women, when, in 1975, in Madrigal v. Quilligan, a suit was filed against the hospital by twelve women of Mexican origin, who had been sterilized without their consent. They were all “poor, usually on welfare, and of a racial minority.” Their stories, told by their attorney, are shocking: one of them “was presented with sterilization consent forms while in labor, and after being assured that the operation could be easily reversed […] was sterilized.” Another one was given general anesthesia after the delivery of her child. “While under this unconscious state, she was surgically sterilized by a staff doctor without her consent. She was not informed about the sterilization until six weeks later.” Still another one, who was “given general anesthesia in preparation for a delivery by caesarean section [...] was approached by a staff doctor who told her she should have her “tubes tied,” because her children were a burden on the government” (Hernandez 1976). The twelve stories in this case all reveal the prejudices of the medical staff against Mexican-American women, perceived as hyper-breeders living on welfare benefits who needed to be sterilized to prevent overpopulation and to protect the tax payer. As we can see, a kind of neo-eugenics was at work, equating minority women with welfare benefits, and their having children with a burden imposed on the state.

6This view was also upheld in the case of black women. In the Relf v. Weinberger case (1974), two black girls of twelve and fourteen years old were sterilized in an Alabama hospital, after their mother, who was illiterate, had signed a consent form with a cross. She thought she was signing a form allowing her daughters to get access to an experimental, long-term birth control drug (Dorr 2011). When District Court Judge Gesell gave the verdict of the court, he recognized that sterilization abuses were a reality: “Although Congress has been insistent that all family planning programs function on a purely voluntary basis, there is uncontroverted evidence in the record that minors and other incompetents have been sterilized with federal funds and that an indefinite number of poor people have been improperly coerced into accepting a sterilization operation under the threat that various federally supported welfare benefits would be withdrawn unless they submitted to irreversible sterilization. Patients receiving Medicaid assistance at childbirth are evidently the most frequent targets of this pressure” (Relf v. Weinberger 1974). According to physician Helen Rodriguez-Trias, “In 1970, it was found that 43% of the women sterilized in federally-financed family planning programs were black, although they represented only one-third of the patient population” (Rodriguez-Trias, 1976).

7But the Department of Health, Education, and Welfare (DHEW) also funded sterilizations in Puerto Rico. In a 1973 study, demographer José Vasquez Calzada found that 35% of Puerto Rican women were sterilized, compared to 16.5% in 1953-54 (Vasquez Calzada 1973). American sociologist and demographer Harriett B. Presser demonstrated that sterilization in Puerto Rico played a major role in the population control of the island (Presser 1969). The Puerto Rican Decolonization Committee published articles on this issue, assimilating it to a kind of neocolonialism.

8As we can see through these examples, forced sterilization—which had been practiced following eugenic laws in various state institutions such as prisons or asylums from the beginning of the twentieth century to the 1950s—became a federally funded practice financed by the American government, which came to target minority women in the 1960s and 1970s. Such practices raise the question of who is in power when it comes to women’s access to contraception.

9The first sterilization laws voted on between 1907 and 1913 reveal the implication of physicians in the promotion of this eugenic practice, “Advocacy within the medical profession for eugenic sterilization grew steadily; between 1909 and 1910, twenty-three papers on eugenic sterilization were listed in the Index Medicus. Every medical article published between 1899 and 1912 on eugenic sterilization favored this practice. These papers often had a most activist tone” (Reilly 1991).

10Moreover, sterilization laws enabled the medical profession to increase its power within public institutions since most sterilization laws provided for the creation of a committee in charge of analyzing potential cases of sterilization. In their vast majority, these committees were composed of physicians.

11The role of physicians in coerced sterilizations in the 1970s, cannot be denied either. After the Relf case broke, sterilization guidelines were edited by the government: they provided for the creation of local review committees, which were to decide on the sterilization of people under 21 or considered incapable under state law. Though these guidelines were much needed, they did not cover the whole population, and officials doubted that it would be sufficient. Dr. Carl Shultz, director of H.E.W.'s office of population affairs, declared in the August 12th, 1973 edition of the New York Times that “until we adequately police them, the guidelines aren't going to be fully effective.” And since coerced sterilizations continued well into the 1970s, we may conclude that many physicians did not take into account these procedures, perhaps considering themselves as the ones who were to be in power when it came to the reproductive rights of women. And even as incomplete as they were, the guidelines were challenged in court by six chairmen of gynecology and obstetrics (Kluchin 2011). Since physicians were predominantly white males, their prejudices and class bias often influenced their practices. It may be argued that the popular figures of “the welfare queen” and “the pregnant pilgrim” in the 1960s influenced physicians in deciding that minority women were to stop having babies who would supposedly become welfare recipients.

12Finally, it is only in 1978 that comprehensive guidelines were issued, requiring the patient’s signature of a form in her own language, requiring the physicians to certify in writing that the patient had been informed of the nature of the operation and that she would still be eligible to welfare benefits if she did not accept sterilization, extending the waiting period from 72 hours to 30 days, prohibiting payment of sterilization for persons under 21, prohibiting hysterectomy as a form of birth control and prohibiting the sterilization of mentally incompetent persons (Evanoff 1978). It also stated that consent could not be obtained during labor, or before or after an abortion (Petchesky 1979). If these guidelines triggered heated debates between anti-sterilization abuses groups and physicians before being adopted, they also did so within the feminist movement.

13The Committee to End Sterilization Abuse (CESA) was established in the winter of 1974 in New York City, and included many prominent reproductive rights activists, among whom Helen Rodriguez-Trias. A member of the feminist movement, she recalled a 1974 conference in Boston, attended by thousands of women, during which the issue of sterilization abuse came up: “we got a lot of flack from White women who had private doctors and wanted to be sterilized […] they had been denied their request for sterilization because of their status (unmarried), or the number of their children (usually the doctor thought they had too few). They therefore opposed a waiting period or any other regulation that they interpreted as limiting access […]. While young white middle class women were denied their request for sterilization, low income women of certain ethnicity were misled or coerced into them.” (Wilcox 2002).

14We can find another example of this opposition in the creation of the Committee for Abortion Rights and Against Sterilization Abuse (CARASA) in 1977. Involved in feminist reproductive rights, it rejected the single issue of abortion defended by the National Organization for Women (NOW), the National Abortion Rights Action League (NARAL) and Planned Parenthood. CARASA wanted to include in the debate over reproductive freedom “a wide range of other issues ranging from women’s health to sexuality to class and race.” It also defined reproductive freedom as “the freedom to have, as well as not have children” (Kluchin 2011). Thus, CARASA strongly defended the establishment of the guidelines the Health, Education, and Welfare adopted in 1978. But NOW and NARAL refused to support them, arguing that the extension of the waiting period and the establishment of a minimum age of 21 would deny women their right to reproductive choice. NOW’s executive board even adopted a formal statement against the proposed regulations in the summer of 1978.

15This ambiguity of the feminist movement in the 1970s reminds us of the ambiguity of Margaret Sanger towards the eugenic movement in the 1920s. If Sanger fought for women’s rights to contraception, she sometimes endorsed the eugenicists’ views on the subject, “[W]e permit our feeble-minded to set the path in child-bearing. Nothing can so rapidly or so inevitably drag down a civilization as an increasing population of mental defectives. They form a terrific burden on American society. We are only beginning to realize the immediate necessity of sterilization” (Sanger 1925).

16If the eugenic sterilizations of the beginning of the twentieth century revealed the states’ desire to control reproduction, those of the 1970s reveal the federal state’s lack of protection of women’s rights. In both cases, the prevalence of eugenic thinking within the medical profession is a striking element. Theodore Roosevelt, alarmed by “race suicide,” had warned that undesirable immigrants were reproducing faster than more valuable old stock Americans. Thus compulsory sterilization was imposed upon “the unfit,” while access to contraceptive devices were refused to women. In the 1970s, sterilization was imposed on minority women out of fear of overpopulation and raising welfare expenditures, while sterilization was denied to middle class women in private practices. And though the feminist movement organized itself to protect women’s reproductive rights, some ambiguities concerning sterilization could still be felt in both cases.

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Bibliographie

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Sandrine Piorkowski Bocquillon, « Sterilization in the United States: The Dark Side of Contraception », Revue de recherche en civilisation américaine [En ligne], 8 | 2018, mis en ligne le 17 décembre 2018, consulté le 22 juillet 2019. URL : http://journals.openedition.org/rrca/1169

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Sandrine Piorkowski Bocquillon

Membre associé du Centre de Recherche sur l’Amérique du Nord (CRAN), Université Sorbonne Nouvelle – Paris 3

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