Iris Lopez,
"Sterilization and the Ethics of Reproductive Technology: An Integral Approach"
(page 3 of 5)
Realms of Influence on Sterilization
The high rate of sterilization among Puerto Rican women living in New
York was maintained through their cultural familiarity with la
operación, their poverty, their lack of access to quality health
care services, inadequate family planning counseling, and women's
misinformation about the permanent nature of tubal ligation. I describe
these factors in depth elsewhere.[11]
Here, I briefly summarize the four
realms that I found to influence and limit women's fertility options.
Though the conceptual separation is useful, it is important to note that
in everyday life these forces converge and are inseparable. After
introducing the realms, I present a case study to illustrate the complex
interaction of all these realms of influence on Puerto Rican women's
experiences with sterilization.
Women I interviewed often cited personal reasons for getting
sterilized. Many desired to control their fertility because they wanted
to do other things with their lives in addition to having children;
limiting the number of children was especially important given that, as
women, they are primarily responsible for birth control, the rearing of
their children, and domestic work even when they worked outside of the
home. Although some of these women do not accept the conventional idea
that women are responsible for birth control, the women in the
granddaughters' generation said they preferred
to be in charge of it, ensuring they had control over their own
reproduction. They also believed that they could take better care of
their children by having a smaller family. When Puerto Rican women
achieve their desired family size, a significant number opt for
la operación as a way to end their fertility. Women also get
sterilized as a last resort when they have had more children than they
desire. Finally, women also said that they did not want to bring
more children into problematic parental relationships.
Two predominant culturally transmitted factors that contributed to
the high rate of sterilization among Puerto Rican women were women's
familiarity with sterilization, which they passed on to one another
through generations, along with the high rate of misinformation about
the permanent nature of tubal ligation. Among themselves and between
aunts, sisters, mothers, and daughters, Puerto Rican women refer to
la operación as the "tying and cutting" of the tubes. They
mistakenly believe that if their tubes are "tied," they will
automatically become untied within a period of five to seven years.
However, if their tubes are "cut" they consider this a permanent
operation. Of the 96 sterilized women in this study, 50% claimed their
tubes were "tied," and the other half that they were "cut." The women
who regretted their fertility decisions were those who claimed to have
them "tied."
In terms of social factors, women cited the cost of raising children
and other economic problems as one of the primary reasons they were
sterilized, although many women claimed that they would not have been
sterilized solely because of economics. Another social force that
leads to a high rate of tubal ligation among Puerto Rican women is the
lack of access to quality health care. In part this is related to the
inadequate services women receive in family planning clinics. A factor
that contributes to the high rate of misinformation among Puerto Rican
women is the medical language health professionals use to discuss
sterilization in hospitals. For example, a tubal ligation is referred
to as a bikini cut or band aid operation. This simplistic language
compounds women's misinformation about the permanent nature of tubal
ligation.
Historical factors include international and national contexts, as
well as more local, familial, and personal histories. Puerto Rico has
been a colony of the United States since 1898. Throughout its history
the Puerto Rican government has justified the massive migration and
widespread sterilization of Puerto Rican women through eugenic and
neo-Malthusian population ideologies (e.g. there are too many poor that
should not continue to reproduce). For this reason by the 1950s more
than one third of Puerto Ricans had immigrated to the United States, and
by 1982, 39% of the female population between the ages of 15-45 had been
surgically sterilized island-wide. It is striking that Puerto Rico did
not receive federal funds island-wide for contraceptives until 1968.
However, sterilization was always available either free, at a nominal
cost, or as a political favor while abortion did not become legal
until 1973.[12]
Like other reproductive technologies, sterilization may be used
either as birth control or as population control. Birth control is the
ability for women and men to space births and prevent pregnancy. When
birth control is designed to meet the requirements of the state, it is
population control. Population control can be official or unofficial
policy mandated by the government. Puerto Rico's policies on population
are considered unofficial because the Puerto Rican government has
consistently denied that they ever had an official policy on
sterilization and migration. Yet, by 1982, 39% of the female
population was surgically sterilized.[13]
Sterilization technology was introduced to Puerto Rico in 1937,
decades before it was marketed in the United States as a method of birth
control. Sterilization was discussed and promoted in the context of
explicit fears about "overpopulation," especially among the island's
poor.[14]
This discourse enabled a decades-long pattern of using Puerto
Rico as a testing ground for contraceptives. In the same way that
Puerto Rican women were used as experimental subjects for the pill and
Emko contraceptive foam,[15]
sterilization technology was tested on
Puerto Rican women.[16]
In the 1950s, Puerto Rican women were
stereotyped as "baby makers" who came to New York to take advantage of
the welfare system and thus were represented as a burden on the
state,[17]
in spite of the already-high rates of sterilization among
this group [e.g., half of the sterilized women in my survey (48 out of
96 sterilized women) were sterilized before they migrated to New York
City].
After sterilization was legalized as a method of birth control in the
late 1960s, it was quickly dispersed as a method of fertility control
worldwide. As a result, the rate of sterilization continued to increase
among Puerto Ricans in the United States and in other parts of the Third
World. For example, by 1995, Hispanic women in New York City had a rate
of sterilization of 50% in comparison to 27.6% for white women, 25.8%
for black women, and 2.4% for Asian women.[18]
In 1982, I found that
47% of Puerto Rican women 21 years of age or older in the neighborhood I
surveyed were surgically sterilized.[19]
In 1982 another study found
that 51% of Puerto Rican women in New Haven, Connecticut were surgically
sterilized.[20]
But high sterilization rates don't answer the question
of the extent to which we should understand this technology as
"abusive." To answer that ethical question, we need to ask: "what
meaning does la operación have for Puerto Rican women and what
forces drive its use?"
One of the most significant differences between the experiences of
the women in the mothers' generation and their daughters and
granddaughters was that the first generation did not always have access
to temporary methods of birth control, and even when contraceptives were
available, they were not always accessible. The women in each
generation had a different conception of an ideal family size. For
example, the ideal family size for women in the mothers' generation was
ten or more children; they had large families because of the economic
value of children and a significant number of these infants died due to
the high rate of infant mortality. In my study the ideal family size
changes over generations. The women in the daughters' generation wanted
between three and four children, and in the granddaughters' generation
only one or two.
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