9.2: Case Study 1 - Forced Sterilization Programs

From the early part of the 20^th century into the 21^st century—as recent as 2020—ISAs within the United States have forcibly sterilized more that 65,000 women. This process is an echo of the eugenics movement started by Francis Galton.[6] Galton, the “father of eugenics,” created what was referred to as negative eugenics—programs designed to hinder particular groups from procreating and thus negatively investing in the human gene pool—in response to the work of Thomas Malthus, who wrote heavily on the notion that the planet would eventually be unable to support unlimited population growth and the allocation of resources.[7] As such, according to Galton, the sterilization of undesired populations--considered unfit for society—was important to protecting the race of man (the human species) and the overall public health of society.[8],[9]

More specifically, before WWII, more than sixty percent of the country and its applicable legislatures enacted compulsory sterilization laws primarily targeting poor, minoritized, or differently abled people. For example, in 1927, an eighteen-year-old girl by the name of Carrie Buck (considered to be “feebleminded” by the state of Virginia) was told by Justice Holmes of the U.S. Supreme Court, during a case against the mental institution of which she was a ward, that her desire to keep her unborn child was unsound on the basis that “three generations of imbeciles was enough.” In that moment, Buck v. Bell (as the case was titled) became a landmark case of medical ethics and reproductive rights with the applicable phrasing by Justice Holmes ringing throughout the country as a dog whistle for the proliferation of reproductive paternalism on the grounds of protecting the gene pool of man—thereby providing a solid foundation and framework to be echoed in other states. The case was also a succinct characterization of society’s perceptions of women (and young girls) deemed to be unfit or unworthy of motherhood now or in the future. As such, it was the stark application of Darwinian fitness into one’s reproductive rights. After WWII, the vast majority of sterilization laws focused solely on minoritized women or women in prisons.

For example, the National Fertility Study in noted that roughly “twenty percent of all married Black women had been (unknowingly) sterilized; about the same percent of Chicana women had been sterilized; and over thirty-five percent of women of childbearing age in Puerto Rico had been sterilized.”[10] Just under one hundred of such women were coerced--via a lack of informed consent--into receiving postpartum tubal ligations (also known as having one’s tubes tied) immediately after giving birth by cesarean section, asked to sign documents while in labor, or forced to sign consent when being treated for labor pains at the Los Angeles County USC Medical Center. In fact, in the mid-twentieth century, California did more than twice as many sterilizations than any other state—with Virginia and North Carolina being in second and third at 8,000 at 7,600 sterilizations, respectively.

However, in the early 1970’s, ten Mexican American women sued the Los Angeles County USC Medical Center on the grounds that the applicable concession documents were not in a language that they were proficient in, that they had not been counseled on the risks or consequences of having their tubes tied, that several physicians waived consent asserting exigent circumstances, and that the federally funded medical center (supported by the California Department of Health) had racially targeted them as Mexican American women and economically targeted them under the assumption that they were on state assistance programs. The case was known as the Madrigal v. Quilligan (1973). Within one patient’s testimony, a doctor is quoted as telling her that “Mexican people were very poor and that she should not have any more children because she could not support them” and later that “you better sign those papers or your baby could probably die here.”[11] Nonetheless, in 1978, federal court Judge Jessie W. Curtis ruled in favor of the hospital due to cultural differences which precipitated miscommunication and language barriers.[12] However, because of the Madrigal case, the United States Department of Health, Education, and Welfare (HEW) began to require federally funded hospitals to restructure the process and procedures for developing and monitoring bilingual medical forms—this occurred on the heels of the thousands of coerced sterilizations of poor and minoritized women whose procedures were paid for by the HEW each year.[13]

In a similar case in 1973 (Relf v Weinberger)[14], teen sisters Mary Alice Relf and Minniue Lee Relf were surgically sterilized after their mother (who was poor and unable to read or write) put an X on the signature line of a document that she was told agreed to her daughters receiving birth control shots. Like the women in the Madrigal case, the sterilizations were funded by the U.S. Department of Health, Education, and Welfare (now the Department of Health and Human Services), the Public Health Service, and the Social and Rehabilitation Service. Many of the mothers approached by social workers and aids during the time were told that they would lose their welfare benefits if they did not sign the document. Also, given that the average age of menarche during the late 20^th century was approximately twelve to thirteen years of age, the Relf sisters would have likely been sterilized shortly after starting puberty.

Nonetheless, forced sterilizations continued to be practiced throughout the United States—with specific maleficence occurring at State or Federally funded institutions. For example, in 2020, complaints were filed by the human rights organization Project South against the Irwin County Detention Center (ICDC) in Ocilla, Georgia on the grounds that the immigrant women held in custody there by the U.S. Immigration and Customs Enforcement Agency (ICE) were given hysterectomies at “alarming rates,” that there was a lack of informed consent, that the women were forced to live in unsanitary living conditions, that they lacked adequate medical and mental health care,[15] and that they were subject to varied human rights violations.[16] Approximately 42% of the women were told by Dr. Mahendra Amin (a non-board certified physician) that they had benign ovarian cysts that required surgery—although this condition can generally be resolved without intervention.

According to the Staff Report of the United States Senate on the Medical Mistreatment of Women in ICE detention, Dr. Amin accounted for at least one in three obstetric and gynecological procedures done, he received approximately half of all ICE payments for obstetric and gynecological procedures between 2018 and 2020, and he accounted for the greatest percentage of obstetric and gynecological referrals, visits, and procedures within the ICE system.[17] Since discovery of the medical abuses at the ICDC, ICE has been instructed to no longer use the facility for the custody of immigrant detainees.

Similar cases, such as one brought about by Kelli Dillon, a formerly incarcerated woman at the California Women’s facility in Chowchilla, California, state that more than 150 African American and Hispanic female inmates in the California Department of Corrections had been sterilized without their consent (approximately 148 of those occurred in violation of prison rules and regulations). In addition, a 2014 prison audit conducted by the state of California found that almost 800 sterilizations had been performed throughout the state.[18]

Thus, the ideological and physical practice of eugenics continue to disproportionately impact minoritized women—particularly when they are wards in a state or federal governmental institution or when they are perceived as being impoverished monetarily or genetically. Because women in these situations have been sterilized without their consent, have not been provided adequate forms of health literacy, and have typically been denied appropriate consultations relating to the potential medical complications or risks of the surgeries performed on them, their health outcomes continue to be shaped by the normalization of health disparity, medical paternalism, and the social determinants of health.

Ethical questions to consider:

1. What is the responsibility of the medical community to ensure the wellbeing, safety, and health literacy of their patients? How would you define “wellbeing” within the context of this case study?
2. If a physician performs a surgery that harms their patient but is approved by the state or federal government, is it medical maleficence? Does the probability of this change with different racial or ethnic groups, social classes, or educational levels?
3. What role does racialized medicine play in perpetuating the social and structural determinants of health?

Historically, the social determinants of health relative to women’s reproductive health outcomes, have also been tethered to the exploitation and experimentation of their bodies. For example, the “father of American obstetrics and gynecology,” was an American surgeon names James Marion Sims. In the early 19^th century, Sims perfected the repair of the vesiocovaginal fistula, developed what is called the lateral Sims position,[19] and invented both the Sims speculum and the Sims sigmoid catheter. The former device is used to examine an individual’s vagina and cervix while also allowing for the unrestricted movement of bodily fluids or secretions. The latter of the devices is a S-shaped tube that is inserted into a women’s body through her urethra and into her bladder. Each of these surgical processes and their concomitant devices were perfected through more than 100 surgeries and five years of medical experimentation on approximately twelve enslaved girls and women without the use of anesthesia.

While Sims’ work created the foundation for the contemporary field of obstetrics and genecology, it also developed a normalized framework for the exploitation and medical trauma of poor, enslaved, incarcerated, and minoritized women. More specifically, his failure to use anesthetics when experimenting with fistula treatments­‑‑‑even though anesthesia had already been invented----and his use of enslaved women (whom could not appropriately give their consent) helped to inform contemporary practices within obstetrics and gynecology that negatively impact the health outcomes of minoritized women.

For example, the maternal mortality rates for African American women have continued to increase for the last hundred years or so. Contemporarily, according to the Center for Disease Control (CDC), the maternal deaths per 100,000 live births for African American women in the United States have increased by 56.6% in the last three years. In fact, African American women are three times as likely to die from a preventable condition within one month of giving birth compared to their European American counterparts. The CDC goes on to state that “multiple factors contribute to these disparities, such as variation in quality healthcare, underlying chronic conditions, structural racism, and implicit bias.”[20] Thus, the increase in the maternal mortality rate of African American women is not only about one’s socioeconomic factors such as income, amount of education, or housing. The enduring maternal mortality rates for African American women are not only due to the social determinants of health. They are, instead, the result of structural violences that hinder African American women’s ability to access equitable health care—thus facilitating their negative health outcomes. A similar fate exists for minoritized children born in the United States—noting a five-fold difference in the IMR (infant mortality rate) per 1,000 live births in the last hundred years.

The health and well-being of children is largely imbricated with the health of the mother, her access to healthcare, reproductive justice, and whether or not they (mom and baby) are perceived as being “fit” for society. The notion of “fitness” is an echo of social Darwinism and is counterintuitive to social justice or the acknowledgement of the common humanity of all people. And yet, varied aspects of social Darwinism, adjacent forms of reproductive injustice, and the issue of paternalism versus parental rights continue to be embedded in the epistemologies and practices of medicine. The following case study elaborates on these issues.

References

[6] Eugenics is a Greek word meaning “good birth.” Galton was also the cousin of Charles Darwin (who contributed the idea of natural selection to the scientific community), and was friends with Herbert Spencer (who coined the phrase “survival of the fittest” which applied the theory of natural selection to social, economic, and population-based engagement.

[7] Thomas Robert Malthus, An Essay on the Principle of Population (London, England: J.M. Dent, 1973). Thomas was an economist, cleric, and demographer from England.

[8] Philip R. Riley, “Eugenics and Involuntary Sterilization: 1907-2015,” Annual Review of Genomics and Human Genetics no. 16 (2015): 351-368. Also note Philip R. Reilly, “Involuntary Sterilization in the United States: A Surgical Solution,” The Quarterly Review of Biology vol. 62, no. 2 (1987): 153-170.

[9] Alexandra Minna Stern, Sterilized in the Name of Public Health: Race, Immigration, and Reproductive Control in Modern California,” American Journal of Public Health vol. 95, no. 7 (2005): 1128-1138.

[10] Maya Manian, “The Story of Madrigal v. Quilligan: Coerced Sterilization of Mexican American Women,” University of San Francisco School of Law (2018): 2. Virginia Espino, “Women Sterilized as They Give Birth: Forced Sterilization and the Chicana Resistance in the 1970s,” In Vicki Ruiz & Chon Moriega eds, Las Obreras: Chicana Politics of Work and Family (2002): 65-82.

[11] Manian, “Madrigal v. Quilligan” (2018): 6.

[12] Stern, “Sterilized in the Name of Public Health” (2005).

[13] Lisa C. Ikemoto, “Infertile by Force and Federal Complicity: The Story of Relf v. Weinberger,” In Elizabeth M. Schneider & Stephanie M. Wildman eds Women and the Law Stories, New York, New York: Foundation Press/Thomson Reuters (2011): 189-191.

[14] The case was Relf v. Weinberger because Casper Weinberger was the Secretary of the U.S. Department of Health, Education, and Welfare (HEW) at the time. This case is a landmark case because it led to hospitals being required to get informed consent before sterilization procedures. The U.S. District Court for the District of Columbia also stated that federal funds could not be used for the involuntary sterilization of certain people. HEW agreed in an appeal to change its regulations and thus the case was dismissed in 1977.

[15] More than 689 reports of delayed or deficient medical care were noted between 2018 and 2020.

[16] Ghandakly EC, Fabi R, “Sterilization in US Immigration and Customs Enforcement's (ICE's) Detention: Ethical Failures and Systemic Injustice,” Am J Public Health vol. 111, no 5 (2021): 832-834.

[17] United States Senate Permanent Subcommittee on Investigations Committee on Homeland Security and Government Affairs, Medical Mistreatment of Women in ICE Detention Staff Report Released 2022: 70-77.

[18] California State Auditor, Sterilization of Female Inmates: Some Inmates Were Sterilized Unlawfully, and Safeguards Designed to Limit Occurrences of the Procedure Failed Report 2013-120. Sacramento, California (2014).

[19] James Marion Sims, Silver Sutures in Surgery: The Anniversary Discourse Before the New York Academy Medicine, New York, New York: Samuel S. William Wood Publishing (1857). https://collections.nlm.nih.gov/bookviewer?PID=nlm:nlmuid-66910990R-bk

[20] Center for Disease Control, “Working Together to Reduce Black Maternal Mortality,” Health Equity (Apr. 2023): https://www.cdc.gov/healthequity/features/maternal-mortality/index.html.