It Never Stopped: The Continued Violation of Forced, Coerced, and Involuntary Sterilization

Jayleen Patterson; Becky Anthony; alithia zamantakis

7 It Never Stopped: The Continued Violation of Forced, Coerced, and Involuntary Sterilization

Julissa Coriano, LCSW, M.Ed

Noah J. Duckett, LCSW

In September 2020, alarming details emerged from the Irwin County Detention Center in Georgia outlining the mistreatment of immigrant detainees under Immigrations and Customs Enforcement (ICE) custody. In a report issued by Project South, The Institute for the Elimination of Poverty & Genocide, a complaint was filed on behalf of the detained immigrants held at the Irwin County Detention Center, citing lack of proper access to language translation, medical neglect, unsanitary conditions, safety issues, and other human rights abuses and violations (Project South, 2020). One of the biggest red flags brought forward by the complaint was the alarming rate of hysterectomies that were being performed of the women under ICE custody (Project South, 2020).

Project South conducted several interviews with immigrant detainees who reported undergoing medical procedures without a clear understanding as to why the procedure needed to be done (Project South, 2020). Initially, the women were experiencing issues with heavy periods, cramping, or other gynecological concerns. According to detainee interviews, many women did not receive proper education and information from the doctor and the medical staff and were not able to properly consent to medical treatment (Project South, 2020). Additionally, detainees reported that there were no Spanish speaking medical staff available to explain and clarify the doctor’s orders; instead, medical staff resorted to using improper Spanish translation measures such as Google Translate to communicate with the detainees (Project South, 2020).

Horrifically, the recent ICE detention story is just a continuation of a long history of forced, coerced sterilization, intrusive gynecological practices, and “medically necessary” procedures that still exist in this country and globally. Eugenics, the practice of selective reproduction, has been used since the beginning of the 1900s to control and limit certain communities deemed undesirable (Roelcke, 2004).

History of Sterilization in the United States

The arrival of the 20^thcentury marked the beginning of forced reproductive sterilization (Reilly, 1987). The main purpose of this government imposed tactic was for population control while other governments used sterilization to prevent those considered socially unsatisfactory from reproducing (Roelcke, 2004). Indiana became the first state to adopt involuntary sterilization statutes in 1907; from 1907-1939, 30 states followed with their own sterilization laws (Reilly, 1987).

In the South, sterilization was used as a means of racial control and as a way to break the dependency of residents on welfare (Kluchin, 2009). Up until 1977, nearly 7,600 individuals were sterilized in North Carolina; the vast majority were Black (Klutchen, 2009; Gartner, Krome-Lukens, & Delamater, 2020). Girls and boys as young as ten years old were deemed “feebleminded” and declared unfit to be parents, according to state records (Klutchen, 2009; Brophy & Troutman, 2016). In order to aggressively promote the sterilization agenda, the government used tactics such as threats of losing welfare benefits and other assistance provided by the state if sterilization consent forms were not signed (Klutchem, 2009; Gartner, Krome-Lukens, & Delamater, 2020).

As an effort to reduce immigration in California, Mexican men and women were sterilized at a significantly higher rate than non-Latinos between 1920-1945 (Novak, Lira, O’Connor, Harlow, Kardia, & Stern, 2018). According to accounts from several California eugenics programs, Mexican women were classified as “hyperfertile, inadequate mothers, criminally inclined, and more prone to feeblemindeness” therefore, sterilization was justified in order to control the spread of these undesirable qualities Novak, et.al., 2018).

Forced sterilization was a key tactic of government funded assimilation campaigns that targeted Indigenous and Native communities throughout the 19th and 20th centuries (Annett, 2001). Native women describe coercion and non-consensual surgical sterilization; chemical sterilization, such as ingestion of radioactive iodine, was administered often on a daily basis (Annett, 2001). Between 1970 and 1976 alone, it is estimated that over 3,400 Native women had been sterilized, forced to abort, or received “medically necessary” hysterectomies; some reservations reported a sterilization rate of 80% or higher (Rutecki, 2011). Additionally, the creation of residential schools in the 1800s saw the forcible removal of Native children from their families and their land, as an attempt to force children to assimilate into White society (Annett, 2001). Upon reaching puberty, administrators of the residential schools were given the right to sterilize any Native student that was under their care (Annett, 2001).

Global Cases of Sterilization

All over Latin America, women and men have been reproductively violated in order to comply with their government’s strategy to eliminate poverty by limiting family size (Vasquez del Aguila, 2006). As a tactic, many governments began to limit access to forms of birth control as a way to promote a more permanent solution in the way of sterilization (Vasquez del Aguila, 2006). Additionally, there is evidence that many governments developed financial incentives that were awarded to health care workers for every woman they brought in for sterilization (Vasquez del Aguila, 2006). These types of claims have also been made in Honduras, Mexico, Guatemala, Argentina, and other Spanish-speaking countries (Reggiani, 2010).

In recent years, the government of Peru launched an investigation based on claims that 300,000 women were subjected to forced sterilization under the ten year reign of former president Alberto Fujimori (Vasquez del Aguila, 2006). It had been reported that poor, uneducated women were lured into medical offices with promise of free medical checkups; once the women were on the examination table, the medical staff allegedly restrained the women, anesthetized them, and then performed the tubal ligation (Vasquez del Aguila, 2006).

For over two decades, Puerto Rico had the highest rate of coerced sterilization in the world (Salvo, Powers & Cooney, 1992). It was determined that by 1954, 16% of the women on the island had been sterilized (Presser, 1969) and that “no other country-industrialized or developing had sterilization ever achieved such popularity” (Presser, 169, p. 344). Research and studies have concluded that the reason sterilization was so popular on the island was due to the adamant encouragement, persistence, and coercion by American physicians who practiced on the island (Presser, 1964; Salvo, et.al., 1992).

In parts of Africa, there have been thousands of cases of involuntary sterilization occurring with women living with HIV/AIDS. Based on presumptions, miseducation, and stereotyping, the African government pursued sterilization as a method of preventing the transmission of the virus to unborn children (Mamad, 2009). Without proper information and consultation, women have reported being forced to sign consent forms under stress and duress (Mamad, 2009).

Adopting American ideology on the matter, perhaps the biggest proponents of sterilization were the German Nazi leaders (Roelcke, 2004). Known as Rassenhygiene, or racial hygiene, Nazi German doctors performed involuntary sterilization for the sake of eradicating the inferior from society (Roelcke, 2004). Medical documentation accounted for the sterilization of 400,000 men and women but scholars believe the numbers are much higher (Annas & Grodin, 1992; Roelcke, 2004); it had been argued that “as many as 10-15 percent of the population were defected and ought to be sterilized (Annas & Grodin, 1992, p. 21). Feeling that surgical sterilization was too slow of a process for mass efforts, the Nazis experimented with medicinal methods that would allow sterilization via ingestion or injection (Annas & Grodin, 1992).

Sterilization for Targeted Groups

In the United States, sterilization was used for depopulation but it was also heavily used to prevent those considered to be “retarded and insane” from reproducing (Reilly, 1987, p.153). Labeled “feebleminded,” individuals who were mentally and physically differently-abled were subjected to sterilization in order to remove the option of family planning (Diekema, 2003). Although sterilization of these communities still occurs today, new guidelines have been created by human interest groups such as The World Health Organization in order to lobby for the best interest of the person (Diekema, 2003).

Up until 1987, the American Psychological Association (APA) considered gender and sexual orientation variance a mental illness in its Diagnostic and Statistical Manual of Mental Disorders (DSM); therefore, for those who identified as LGBTQ, sterilization was justified under those criteria (Drescher, 2015). Currently in the US, there are ten states that actively mirror coercive sterilization against transgender and gender non-conforming individuals by requiring a Trans individual to be sterilized as part of the transition process (Lowik, 2018). Adopting American’s lead, many other countries followed in enacting laws sterilizing LGBTQ-identified individuals (Honkasalo, 2018; McLelland, 2004); many countries such as Japan and Finland also require sterilization before an individual is able to legally and medically transition (Honkasalo, 2018; McLelland, 2004).

“Medically Necessary” Hysterectomies

According to Yale Medicine, approximately 500,000 hysterectomies are performed in the United States every year (Yale Medicine, 2023); hysterectomies are the second most common surgery for women in the US (Yale Medicine, 2023). Medical recommendations for hysterectomies include abnormal bleeding, gynecological cancers, and unmanageable pain from fibroids, cysts, or endometriosis (Yale Medicine, 2023). The two most common types of hysterectomies are the total hysterectomy and the radical hysterectomy (Yale Medicine, 2023). Both types of procedures are considered common treatments to address gynecological concerns; the radical hysterectomy is the full removal of all reproductive organs such as the uterus, ovaries, fallopian tubes, and cervix (Yale Medicine, 2023).

As expected, the removal of reproductive organs such as the ovaries and womb, leaves the patient unable to conceive and carry a child (Yale Medicine, 2023). Often leaving the patient emotionally distressed over the dilemma of choosing between continuing to deal with the underlying medical condition, patients feel pressured to choose between loss of fertility or a life of chronic pain (Leppert, Legro, & Kjerulff, 2007). Patients have reported saddeness, regret, and sought counseling over their loss of fertility (Leppert, Legro, & Kjerulff, 2007). These patients would have likely benefited from pre hysterectomy therapy to help navigate the feelings of loss and their grief.

Additionally, one of the biggest issues with the removal of the ovaries in hysterectomies is that it immediately places the patient into menopause, requiring hormone replacement therapy (Aninye, Laitner, & Chinnappan, 2021). This presents clients with many unexpected symptoms such as hot flashes, vaginal dryness, and low sexual desire (Aninye, Laitner, & Chinnappan, 2021). Recent studies have shown that doctors are not fully preparing their hysterectomy patients for the realities of menopause (Aninye, Laitner, & Chinnappan, 2021). Patients report frustrations with inadequate information around the challenges of transitioning into and navigating menopause (Aninye, Laitner, & Chinnappan, 2021); as so, patients feel isolated, depressed and anxious (Aninye, Laitner, & Chinnappan, 2021).

It appears that hysterectomies have been and continue to be used as a frontline treatment to solve gynecological issues. By presenting a hysterectomy as the foremost intervention, the patient is denied the agency to decide over their own body and reproductive future. The prevalence of hysterectomies combined with significant reports of regrets should be seen as an indicator that alternative, less intrusive, gynecological methods should be explored.

As we broaden our understanding of experiences with intrusive gynecological procedures, a series of moral and ethical questions arise:

Are medical recommendations grounded in what is actually best for the patient or are drastic gynecological procedures simply being performed as the first and only intervention as opposed to a last resort after exhausting all other possibilities?
Historically, why do reproductive organs continue to be viewed as expendable by the medical profession and not as an extension of one’s holistic identity?
Why do we continue to be denied reproductive anatomy?

It Must Stop

The latest allegations of what has occurred in the ICE detention center in Georgia should not be perceived as new news; it should not be received as shocking. The recent reports are just another reminder of the continued systemic acts of violence against women, the LGBT community, and so many other targeted groups. Human rights organizations such as The Campaign to Stop Torture in Health Care, The National Latina Institute for Reproductive Justice, Human Rights Watch, and Amnesty International, continue to fight against forced, coerced sterilization, intrusive gynecological practices, and “medically necessary” procedures. Globally, advocates, activists, and world leaders are tirelessly working to end injustices to ensure reproductive freedom and proper informed consent for all communities.

Clinical Considerations

A recent study has shown that a significant percentage of those surveyed reported immediate regret after an elective hysterectomy and also reported an increase in depressive symptoms and anxiety post procedure (Sangha, Bossick, Su, Coleman, Chavali, & Wegienka, 2020). Patients cited loss of fertility, negative impact on intimacy, and decreased self image as reasons for their feelings of regret, depression, and anxiety (Sangha, Bossick, Su, Coleman, Chavali, & Wegienka, 2020).

There is a dearth of qualitative and quantitative studies investigating the emotional impact of the post-hysterectomy experience. The body of research that does exist tends to focus on medical measures of pain and healing while ignoring emotional impact of depression, loss of fertility, shifts in sexual identity, bodily agency, and sense of self (Leppert, Legro, & Kjerulff, 2007). In addition to the aforementioned issues, patients who have undergone a hysterectomy have reported changes in libido, weaker orgasms, loss of interest in masturbation and sex, difference in sexual sensation, and feeling disconnected from their partner (Rehan, Qasem, El Malky, & Elhomosy, 2023).

As expected, medical practitioners are most likely strictly prioritizing the medical aspect of the procedure and not the emotional and sexual impact of the patient’s new, post hysterectomy reality (Odey, 2009). Education around expectations typically stops at medical aftercare instructions, while therapy is rarely recommended or mentioned (Odey, 2009). Most support groups, literature, discussion, or even therapeutic approaches around this topic focus on the concepts of survivorship and gratitude. While these themes can and often do feel true for people who have experienced medical traumas, many times supports do not leave room for grief, regret, or other negative feelings.

For many clients, the experience of gynecological intrusiveness is likely to be viewed as a medical trauma, therefore, clinical treatment should be viewed through a trauma-focused lens. Clinicians should be prepared to treat clients using the lens of grief therapy to address loss of autonomy, the changing of identity, the feelings surrounding the function of their body, and their sexual identity and satisfaction. Clinicians should consider working to balance themes of empowerment and a patient’s reclamation of their body and life while giving space for exploration of grief, loss, and even self blame or doubt.

Healing from the trauma of an intrusive gynecological practice may impact intimate relationships, mistrusts of medical providers, and the ability to connect with one’s own body in a healthy and fulfilling way (Rehan, Qasem, El Malky, & Elhomosy, 2023). Concerns regarding post-procedural sexual function and satisfaction may arise, causing feelings of inadequacy, anxiety, and depression; fears of both emotional and physical discomfort surrounding intercourse post procedure are very common (Rehan, Qasem, El Malky, & Elhomosy, 2023).

In essence, broader multidisciplinary conversations are needed between sexuality and medical providers to address the holistic impact of medical procedures on clients. Recommendations for pre and post procedure counseling should be required in order to respond to a client’s non-medical questions, concerns, and expectations. Oncosexology is a discipline of sex therapy that focuses specifically on the sexual wellness and intimacy of cancer patients, which includes hysterectomies. Clinicians should become familiar with the modalities used in the branches of sexology that focus on chronic illness, oncology, and gynecological issues, as these are best suited to address the impact of medical procedures on a client’s sexuality.

Assisting clients explore new sexual norms such as introducing lubricants and additional forms of sexual expression aside from penetrative sex as a way of reconnecting to their intimacy will be very important in helping the client process and release any fears they may be harboring as they work towards reestablishing their new sexual identity.

Finally, validating, normalizing, and encouraging a client’s right to question a medical professional’s opinion is a significant way of empowering a client. Recognizing the need to expand their fullest informed consent, explicitly understanding the impact on all aspects of their procedure – the medical, emotional, physical, and sexual – is crucial in establishing reproductive agency. Moreover, identifying gaps in the patient’s knowledge will contribute to creating a personalized care plan that will increase their cognizance. Motivating the client to work collaboratively with their medical team to achieve the most optimum outcome for their situation is paramount.

As social workers and psychotherapy clinicians, engaging in multidisciplinary opportunities is essential. Reaching out to local medical professionals and hospitals to do sexuality trainings, representing the clinical profession in committees, and speaking to the importance of pre and post procedure therapy, would all be ways of advocating for a patient’s holistic care. Providing the perspective of how medical procedures impact a client’s sexual identity and function will contribute to the implementation of a holistic care model within the medical profession.

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Sexuality Social Justice Copyright © 2024 by Jayleen Patterson; Becky Anthony; and alithia zamantakis is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, except where otherwise noted.