Women Under the Knife: A Look at Sterilization Abuse

A FEW MONTHS AGO, a woman walked into the hospital with cramps. The doctors thought she had appendicitis and decided to do exploratory surgery. The surgeon, an intern rotating through GYN, thought her appendix looked fine, so I thought we were going to close her up. But then he started to look at her tubes. He said, 'We should take her tubes; they don't look good.' I couldn't see anything wrong with them, so I said that we shouldn't do a tubal ligation until we got a second opinion. But this inter-surgeon kept insisting that her tubes be tied right then. Not knowing what to do, I got really angry and made them call the head GYN. A message came back to close her up. If I hadn't gotten angry, who knows what would have happened. The woman was only 23 years old."

HELEN HORNER is an operating room technician at Boston City Hospital. In her over fifteen years of experience, she has aided countless surgeons and seen hundreds of patients.

Horner has also witnessed numerous cases of actual or near sterilization abuse like the one she describes above.

For most Americans the idea of sterilization abuse conjures up images of Nazi Germany and Hitler's push for a pure race. Few Americans would believe that sterilization abuse continues in their public hospitals, as well as on Native American reservations. Fewer still would realize that hysterectomy (removal of the uterus and tubal ligation) is fast becoming the most frequently performed operation on this nation's women.

Whether from government audits of public hospital files of research conducted by private groups, evidence of massive sterilization and its abuse in this country abounds. Last month, the American College of Surgeons reported that in 1979 (the latest statistics available) hysterectomy was the second most frequently performed operation on women, the fourth most performed surgical procedure overall. The Surgeons listed tubal ligation fifth overall. In terms of actual numbers, out of 23.8 million operations performed in 1979, 639,000 of them were hysterectomies while 610,000 were tubal ligations.

Yet, despite the pervasiveness of sterilization, surgeons perform hysterectomies and tubal ligations on some ethnic groups more than others. In fact, the Committee to End Sterilization Abuse (CESA) and the Committee for Abortion Rights and Against Sterilization Abuse (CARASA), two of the most active reproductive rights groups, estimate that 37 per cent of Puerto Rican women (in Puerto Rico), 25 per cent of Native American women and 20 per cent of married Black women have been sterilized, many by hysterectomy. By comparison, only 7 per cent of white women have been sterilized.

"Doctors have this attitude with Blacks. If a woman comes in with cramps, they automatically assume she is diseased and they are ready to snatch her tubes out," Horner said.

Although some women require sterilization for medical reasons--a hysterectomy may be necessary to remove cancerous tissue, for example-- many of these women had no such medical problem. Moreover, some of these women were sterilized not only without medical reason without their consent.

DAWN GORE, a 31-year-old Native American woman from Holyoke, Massachusetts, entered Franklin County Public Hospital in Greenfield in 1969 for an appendectomy. She woke up in the recovery room with her doctor standing at her beside. While still in an anesthetic haze, she listed as her doctor explained that he had removed her appendix. Then, she cried as she learned that her doctor had also without her consent removed her fallopian tubes because he felt she already had enough children. At the time, she was a twenty-one year old mother of three. Unable to bear the male child she says her husband wanted, Gore divorced a year and a half after the 'operation; she has never remarried.

Many Native American women have faced a similar fate of sterilization without "informed consent," that is, knowledge of exactly what sterilization means and acceptance of never being able to have children. A 1976 General Accounting Office study of Indian Health Service records revealed that between 1973 and 1976, 3,406 Native American women had been sterilized without the patients' informed consent. In 1978, Dr. Connie Uri, a Chocktaw-Cherokee physician, estimated that only 100,000 fertile Native American women remained.

The reason for so much surgery remains unclear, but people involved with the issue, both doctors and activists, offer explanations. "There is a difference of value systems," an ex-worker at a Boston abortion clinic, who asks not to be identified, says. "Many people don't think big families are okay for people, especially for Third World women," she adds.

A physician at Boston City Hospital agrees. "Patients tell me that the reason why so much sterilization takes place is that some doctors give ultimatums," Dr. Kenneth Edelin, director of Obstetrics and Gynecology at Boston City Hospital, says.

"These doctors tell their patients, many of whom are pregnant, that I won't deliver your baby unless you have your tubes tied. You've had enough children," he adds.

But some activists lay the blame squarely on physicians' hunger for extrasurgical practice. Hysterectomy, the most drastic of sterilization procedures remains a complex and dangerous operation. According to a 1972 American Journal of Obstetrics and Gynecology, for every one million who undergo a hysterectomy, 1000 die and 150,000 have serious complications. This compares to 31 deaths and 600 serious complications for the pill and 9 deaths and 400 serious complications for IUD's. Nevertheless, many physicians actually encourage hysterectomy instead of tubal ligations or nonsurgical contraceptives.

In 1973, the Public Citizen Health Research Group, formed by Ralph Nader and Dr. Sidney Wolfe ten years ago, released a report of conversations among physicians at three major medical teaching facilities, Boston City Hospital, Los Angeles County Hospital and Baltimore City Hospital. In the report, a Boston City Hospital resident said, "We like to do a hysterectomy, it's more of a challenge...you know a well-trained chimpanzee can do a tubal ligation."

Similarly, a conversation between two residents at Boston City Hospital proceeded as follows:

Resident: "...if you can talk her into it (hysterectomy), get the papers and have me sign them...If she won't agree to a hysterectomy, get me and I'll talk her into it."

Student: "Are the fibroids?"

Resident: "We don't know. The guy that sent her in thought there might be, but we don't believe that unless we can find them ourselves. She's 42 and doesn't need a uterus."

A Los Angeles County Hospital staff doctor reportedly said, "Let's face it, we've all talked women into hysterectomies who didn't need them during residency training."

The report, which quotes numerous other phsycians, cites this type of "sterilization sell" as the cause of the significant rise in sterilizations, particularly hysterectomies, performed. Edelin said, however that in the last few years he has seen a marked decrease in sterilization abuse and sterilization by hysterectomy at the Boston City Hospital.

In addition, the group in a 1979 report pinpointed teaching hospitals as widespread violators of Federal sterilization regulations. The report found that in that year 70 per cent of the more than 80 hospitals surveyed violated 1974 sterilization consent regulations even though they had been in effect for five years. Dr. Sidney Wolfe, chairman of the Health Research group, says these hospitals, which primarily service the poor, serve as training grounds for sterilization abuse practices, which then spread elsewhere.

"Doctors learn their bad habits on the poor, but they don't forget their bad habits, they take them to the private sector. In private practice, there are far fewer regulations that a doctor has to contend with," Wolfe adds that there is no method which exists to monitor the extent of private sector abuse.

Last July, the Health Research Group released a report which stated that many states--especially California, Colorado, Connecticut, the District of Columbia, Georgia, Illinois, Kansas, Maine, Michigan, North Carolina, Oregon, Pennsylvania, Virginia, and West Virginia--persist in violating Federal regulations concerning sterilization of low-income Medicaid patients.

Although Massachusetts was not mentioned in the group's report, a Medicaid specialist working with the Massachusetts program, who asked not to be identified, said that the state has not been complying with Federal regulations. The specialist added that the greatest percentage of errors occurred with hysterectomies where, among other things, a consent form and certification that the operation has been completely explained to the patient are required. During the period from July 1980 to March 1981, some 60 per cent of these were improperly handled. "The state has made some effort to clean up, but we won't see any improvement until the quarter beginning with last April," says the specialist.

Still, most activists and medical practitioners agree that the poor bear a large share of the sterilization abuse problem. Both Horner and Wolfe cite educational barriers as a main obstacle to communication between doctors and patients.

"Some doctors don't explain what is going on," Horner says. "Doctors don't use lingo: they don't talk the patient's language. A woman will ask a doctor if she has her uterus out, can she have children. Harvard (which used to be affiliated with Boston City Hospital) has not been able to communicate to poor people, like using the word 'womb' instead of 'uterus' to explain," she adds.

THE PUSH for Federal sterilization regulations and public awareness of the problem began when the parents of Minnie Lee Relf, age 12 and her sister Mary Alice, just two years older, charged an Alabama clinic with sterilizing their daughters without their consent in 1973. In that year, the HEW implemented regulations stressing the need for consent forms to govern sterilizations performed with Federal funds. Under pressure from activist groups, the department amended its regulations in 1974, and again in 1979. These new laws extended the waiting period between time of consent and the operation from 72 hours to 30 days, prohibited hysterectomy for primarily sterilization purposes, and forbade doctors from obtaining consent during childbirth labor, a common practice among sterilization abusers.

In the Boston area, the activist groups against sterilization abuse, such as CESA, which recently disbanded, and the Massachusetts Childbearing Alliance, have sought to familiarize the public with the special plight of poor and Third World women.

"Groups like CESA started around the country because of the realization in the women's health movement that working for certain health care rights for women was a problem for Third World women. While women, primarily white women, were saying that they had a right to be sterilized, sterilization was being pushed on poor women and women of color," Kim DeAndrade, a former member of the Boston chapter of CESA, said.

CESA, which along with Dawn Gore testified in the 1978 hearings for new HEW regulations, helped bring in the current regulations now enforced.

Other groups also stress the problems of Third World and poor women. The Massachusetts Childbearing Alliance, working under the Reproductive Rights National Network, hopes to sponsor a slide show with Women of All Red Nations to dramatize the situation faced by Native American Women. To publicize sterilization abuse in Puerto Rico, the Latin Health Book Collective distributes the film "The Operation."

Nevertheless, members of these groups still feel that abuse against other women runs rampant in the area. "It is hard for me to believe that given the situation a few years ago, that sterilization abuse has stopped," Ann Bookman Buehrens, a member of the Massachusetts Childbearing Alliance, said.

Moreover, some activists do not think that Federal guidelines which only apply to Federally-funded procedures truly address the problem. Edelin, for example, takes particular exception to the mandatory 30-day waiting period between the time of consent and the operation. He says the guidelines punish the victim, not the abuser.

"Are they saying that poor and Black women, who are essentially the ones covered by these guidelines, don't have the intelligence to make a decision about sterilization while middle class women do?" Edlin said, adding that if a three month pregnant welfare mother with desperate financial problems came in tomorrow and begged for an abortion followed by a tubal ligation, according to existing guidelines, he couldn't perform the procedure. Such a woman, Edline says, would have to wait a month and risk a second-trimester abortion.

"Instead, the penalty should be against the abuser, they should fine him or revoke his license. When doctors know that there livelihood is going to be cut off if they abuse women, they will stop."

But even if stiffer Federal regulations are implemented, changes in the attitudes of doctors toward their patients will take time. Some poor Third World groups, however, feel that time is the one element they lack. As one Native American Doctor explained in a recent article in America: "We are not like other minorities. We have no gene pool in Africa or Asia. When we are gone, that's it."