Iris Lopez participated in "Global Dimensions of ART," a panel discussion at The Scholar & Feminist Conference 2009, "The Politics of Reproduction: New Technologies of Life," held on February 28 at Barnard College in New York City.

Listen to a podcast of "Global Dimensions of ART."

Reproductive technologies have enabled millions of infertile couples to have children. While assisted reproductive technologies such as in vitro fertilization and surrogate motherhood can be beneficial, they have also been criticized as privileging the nuclear family, being pro natalist, and expensive, therefore inaccessible to the poor.[1] A key concern raised at the Scholar & Feminist Conference at Barnard College (February 28, 2009) was that we should provide reproductive technology to marginalized women, and the question posed was how do we go about doing it? The implicit assumption of this question is that reproductive technology is positive, or at least neutral, and therefore all women and men should have equal access to it.

Prior to addressing the important question of equality through accessibility, I believe broader questions need to be raised about what makes the technology valuable (or harmful) to users. Reproductive technology does not exist in a vacuum. It is used within a social context of power relations based on the intersections of race, class, gender, and sexual orientation.[2] The use of reproductive technology therefore raises ethical concerns that must be explicitly addressed. The goals of my paper are first to challenge the technocratic ethos that would readily apply any and all reproductive technologies to women's lives, and second to examine the ethical implications of how technologies are actually used in specific contexts. In whose interest is it to use this technology in this context? Is it democratic, ethical, non-coercive, and used for the greater good? Is it respectful of women's desires, or is it imposed upon women in the interests of those with more power?

My work is situated in a reproductive justice framework, exemplified by groups such as Latina Institute for Reproductive Health, The Caribbean Initiative on Abortion and Contraception, California Latinas for Reproductive Justice, SisterSong, DAWN and Asian Communities for Reproductive Justice as well as scholarly work such as Rosalind Pollack Petchesky's cutting edge international research on reproductive rights.[3] I seek to transcend a binary agent/victim perspective, develop an integral interpretation that gives voice to what women think and need, and contextualize women's fertility experiences within a critical cultural, social, and historical framework. I aim to make my research available to Puerto Rican women and other communities who strive for reproductive and social justice and to work with them in creating a better society.

In this paper I limit my discussion of the ethics of reproductive technology to female sterilization (tubal ligation), which has been used in Puerto Rico since the 1930s. Puerto Rican women have one of the highest rates of sterilization of any population/community.[4] The explanations for the high rate of sterilization among Puerto Rican women have traditionally been conceptualized in a binary framework. One school of thought argues that Puerto Rican women are active agents who make voluntary decisions, and therefore exercise reproductive freedom.[5] The other school advocates that Puerto Rican women are victims of sterilization abuse.[6] My research reformulates this oppositional framework. I reject the notion that Puerto Rican women are either voluntary agents or powerless victims because neither of these poles presents an adequate picture of most Puerto Rican women's reproductive experiences. I propose a third model, an integral model of reproductive freedom and social justice that allows us to situate agency, resistance, choice, and constraints in the broader socio-political and historical framework that is based on race, class, and ethnicity.[7]

Sterilization is the most popular method of fertility control in the 21st century.[8] In most cases, both female sterilization (tubal ligation) and male sterilization (vasectomy) renders an individual incapable of having more children. As a reproductive technology, sterilization is neither good nor bad; its ethical status depends on how it is used. An integral analysis sheds light on how reproductive technologies such as sterilization can be both harmful as well as beneficial to women depending on their historical, personal, cultural, and social conditions. For example: the sterilization policy developed out of a legacy of colonialism, eugenics, and neo-Malthusian ideologies that supported population control in Puerto Rico based on the idea that only the "fit" should reproduce.[9] However, as my research reveals, a significant number of Puerto Rican women accepted and even actively sought sterilization because it enabled them to control their fertility, which they were desperate to do. This was especially true during the early part of the 20th century when temporary methods of birth control were not readily available to Puerto Rican women on the island.

I anchor my discussion of the ethics of sterilization in a 25-year study that I undertook of Puerto Rican women that shows how sterilization, originally a method of population control in Puerto Rico, was adopted as a popular method of fertility control partially by the women themselves. My study focuses on Puerto Rican women living in New York, whom I term the first, second, and third generations. These are the mothers, daughters, and granddaughters in the households I followed. As the stories I relay below demonstrate, even poor, racialized women who were targeted by population control strategies sometimes sought out or welcomed sterilization, and derived benefits from it.

Methodology

In undertaking this study it was important to use a method that would reveal the richness of experience captured by the ethnographic approach while making my findings more broadly generalizable (quantifiable) in terms of class and ethnic comparisons. To do this I combined participant observation, oral histories, and an in-depth survey of a selected sample of the female population, based on a systematic listing of the residents in the neighborhood (a census). Because this is a longitudinal ethnographic investigation I interviewed women and collected their oral histories at different phases of the study. In 1981 I compiled a master list of all of the residents in the neighborhood by knocking on 880 apartment doors in one census tract with the aid of several community women I trained. The goal of taking a census was to compile a master list of Puerto Rican households and to determine the total number of sterilized Puerto Rican women, 21 years of age and older, living there. Out of a census track of 880 households I chose a random survey sample size of 128 women because I thought that number of women would enable me to include women from different parts of the neighborhood and provide me, the sole researcher, with a manageable number of women whom I could interview. In order to select the women randomly I asked every third sterilized woman for an interview and every eighth non-sterilized woman.[10]

After completing the survey of 128 women I continued to work with five families. I collected oral histories from the mothers and grandmothers in the same family (3 generations per family x 5 families = 15 women). I kept in touch with these families over a span of 23 years and intermittently interviewed them. Between the years 2001 and 2002, I re-interviewed the mothers and grandmothers of all five families that I had initially included in the survey. Between 2003 and 2004 I interviewed and collected oral histories from the women in the granddaughters' generation who had now come of age.

The women I interviewed range in age from 24 to 92 (1981 and 2006). The mothers' generation was born in an agrarian society but witnessed the industrialization of Puerto Rico. With one exception they only had a second or third grade level of education because they left school to work and help their parents on farms and in the household. As children some of them worked in the needlework industry and later in the garment industry. Most of the women in the daughters' generation were born in New York. They lived there when the city shifted from an industrial to a service economy, and lived through the Civil Rights and Women's Liberation Movements. Some of these women graduated from high school but most did not. The majority of them worked in factories, as sales ladies in clothing stores, waitresses, and in other blue-collar jobs. The granddaughters' generation grew up in a post-industrial and post civil-rights era. They lived in the inner city and witnessed gentrification and the challenges of a new economic and social structure. Most of these young women graduated from high school but a few did not. Some went to college.

As a Latina born and raised nearby, on the border between Brooklyn and Queens, I had certain advantages that facilitated my entry and acceptance into the neighborhood. It was indispensable that I speak Spanish fluently and that my family still lived in the general area. Confidentiality was of utmost importance in this study. I assured the women that they would not be identified and everything they said would be kept confidential. In some cases women gave me permission to record our conversations. Surprisingly, some of the women said that they wanted to be identified because they were proud to be a part of my study.

The methodology for my analysis grew organically from my conceptualization of the problem I had found in my research. The integral model of reproductive freedom and social justice does not focus on the binary framework of choice and constraint but provides a more nuanced analysis of how and why women make their fertility decisions. In order to understand Puerto Rican women's fertility decisions from an integral perspective, we need an analysis of reproductive freedom that considers four major realms affecting women's fertility experiences: personal, cultural, social, and historical. In addition, we need a synthesis that incorporates and transcends the individual by connecting the different realms in a dialectical way without reducing any of these to one unit of analysis. This avoids conceptualizing women's realities in a linear, hierarchical, and reductionist mode. This model also includes an analysis of agency within constraints, which reveals how women negotiate and resist on a micro level.

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.

A Case Study: The Robles Family

The Robles family provides a good example of a family in which the women's sterilization experiences range from agency to abuse. Doña Rosario is the matriarch of the Robles family. She grew up in an agricultural society where it was the norm for peasants to have large families. Her family was so poor there were times when she could barely feed her children. In doña Rosario's era, temporary methods of birth control were not readily available. Therefore, she was sterilized after she had ten children, a larger family than she desired. Doña Rosario was sterilized in Puerto Rico before she migrated to New York City. She waited until her husband migrated so that she could get sterilized without his knowledge. This occurred in the context of an unethical practice that took place in Puerto Rico during the election period for the mayor of a small town: women would exchange a vote for free tubal ligation.

Carmen, doña Rosario's eldest daughter, wanted to have her tubes "cut" in New York but because her English was limited she told the doctor she wanted an operation so that she would not have any more children. Instead of performing a tubal ligation the doctor removed her uterus. Carmen was outraged that the doctor would perform an unnecessary hysterectomy on her and felt violated. According to Carmen she never fully recovered from the trauma. Ironically, Carmen actively sought to be surgically sterilized, but since she was given unnecessarily invasive surgery she ended up being a classic victim of sterilization abuse.

Doña Rosario's youngest daughter, Nancy, dropped out of high school at 17 when she became accidentally pregnant. Her ideal family size was three but she had four children because her third pregnancy resulted in twins. Nancy was unhappy in her marriage. She worked around the clock and her husband did not help her with the children or housework since he felt that was her responsibility. Nancy was sterilized because of economic reasons but also as a way to resist her sexist husband and gain some control over her life.

Sonia, Carmen's daughter and doña Rosario's granddaughter, graduated from high school and wanted to do other things in life in addition to raising children. Sonia only wanted one child. When we met she was pregnant with her second. Her grandmother warned her to get sterilized before "se llenará de hijos," which literally translates as "being filled with children." The implication of this parable is that Sonia would ruin her life if she continued to have so many children. After she gave birth in the hospital, Sonia decided to get sterilized there because she felt it was the only way she could gain control of her life. However, she delayed getting sterilized because her son was born prematurely and she wanted to make sure he was safe and healthy before she had her tubes "cut." Despite her decision to wait to get sterilized, after she gave birth Sonia claimed that numerous nurses and doctors stopped by her room to ask her if she wanted a tubal ligation.

With the exception of Carmen, all the women in the Robles family exemplify how women exert agency within constraints. Even though Nancy and Sonia were aware of temporary methods of birth control, neither of them was well-educated about them. In Sonia's case her second unplanned pregnancy precipitated her decision to get sterilized. Even Carmen, who was a victim of sterilization abuse, wanted to have la operación ever since she had her second child but her husband was against it until she had her sixth.

The Robles women and their families lived below the poverty level in New York and worked hard to improve their lives. They discussed and recommended sterilization to one another. For example, doña Rosario encouraged her daughters and granddaughter to get sterilized because she felt if they were not careful they would end up having more children than they desired. The Robles women had a keen sense of gender consciousness and they resisted women's gender subordination. Their stories show the powerful influence culture and social conditions played in shaping and limiting their fertility decisions.[21]

The Robles family reveals how important it is to use an integral model of reproductive freedom and social justice because it provides us with a broader scope to see the myriad forces that influence and limit Puerto Rican women's fertility experiences. In the case of the Robles family, their reproductive experiences ranged from agency within constraints to sterilization abuse. Their stories are similar to those of the many women I interviewed, leading me to conclude that Puerto Rican women make the best fertility decisions they can within the parameters of their difficult lives.

Beyond Victimization and Toward an Integral Approach

I am always struck by the continued high level of misinformation among Puerto Ricans, Dominicans, and other Latinos on this important topic. These misconceptions are reflected in the attitudes of the women in my study[22] as well as among white, black, and Latina populations citywide.[23] I also see these misconceptions among the students I teach at City College/CUNY. When I teach about sterilization, at the beginning of my lecture I ask my students to raise their hands if they believe that a woman can still have children after she has been sterilized. In my predominantly Latino class of thirty to thirty-five students, almost all but one or two raise their hands.

To avoid making the sterilized students in my class feel like victims, I prepare them with a more nuanced analysis. I distinguish between victims of sterilization abuse and women who are proactive in their fertility decisions (i.e., those who make the best fertility decisions they can under difficult conditions). I educate my students from an integral perspective (e.g. personal, cultural, social, and historical) and show them Ana María García's popular film, La Operación, to discuss its strengths and weaknesses. The strength of this film is García's powerful rendition of the history of sterilization in Puerto Rico and her presentation of Puerto Rican women's stories. But because none of the women in her film clearly states that she was sterilized because she wanted fewer children, this lends itself to a pronatalist interpretation, that it is natural and good for all women to have children. The only exception is an older Puerto Rican woman who excitedly inquires in the street about how she can get sterilized when she finds out that other woman in her town have had la operación [see Excerpt 5 from La Operación in this issue]. Based on my research among Puerto Rican women in New York City, this woman's experience is more representative of the majority of sterilized Puerto Rican women.

García represents most Puerto Rican women as victims of sterilization abuse. Even though one woman in the film explicitly states that no one forced her to get sterilized, all these women are cast as helpless victims. When my students watch this film they walk away in a rage, or, if they are sterilized, feeling like victims themselves. Consider this example in the film where García might have shown the nuances of women's sterilization experiences: a young woman holds up two plastic tubes in her hands; she tells the audience that the doctor inserted these tubes in her uterus, that she had a tubal pregnancy, and that everything exploded and fell apart. What this young woman does not share with the audience is that she had an operation to try to reverse sterilization. We learn about this from her distraught mother or grandmother, an older woman to whom the director pans; she starts to cry and says that she does not understand why (her daughter or granddaughter) had to have another operation since she already has children. She ends by saying that the young woman could have died from this operation. It is clear from the older woman's statement that she disapproves of this young woman's decision to have a reversal operation.

A film with an integral perspective would have shown the role the young woman herself played in having this reversal operation rather than portraying her solely as a victim. It is quite possible for example that she wanted to have another child to solidify her relationship with the father of the child, a common reason among women who sought a reversal operation, something I found often in my study. A film with an integral perspective also would have translated the mother or grandmother's disapproval of her decision. My point is that an integral perspective enables us to see the co-existence of agency and constraints and does not reduce anyone to a helpless victim. It also recognizes that just because Puerto Rican women make decisions about their own fertility, that does not mean they are exercising complete reproductive freedom.

Conclusion

An integral model of reproductive freedom challenges and expands common thinking about reproductive technology. Sterilization is neither good nor bad; its outcome depends on how it is used. For example, the integral model of reproductive freedom and social justice shows that although most Puerto Rican women make decisions and are not victims of sterilization abuse in the classic sense, this does not mean that they are or were not oppressed, or that they are exercising full reproductive freedom. High rates of sterilization are driven by the marginalized and impoverished social conditions of Puerto Ricans on the island and in the United States. The circular migration of Puerto Ricans to and from the United States, the unofficial population policy that promoted sterilization, and the impoverished social conditions in both places reflect their dependent position in a transnational global economy based on colonialism and inequality.[24] Yet an integral model of reproductive freedom and social justice shows that even though poor women are targets of population control they do not follow population policy blindly; most women exercise a certain degree of agency.

Undoubtedly, sterilization was unethically implemented in Puerto Rico as a form of population control to ameliorate a problem that was created not by overpopulation but by Puerto Rico's dependence on the United States.[25] However, an examination of the personal, cultural, and social realms shows how Puerto Rican women themselves use sterilization to cope with poverty, lack of access to quality health care, and experiences with sexism, and to negotiate their own reproduction. An integral analysis elucidates how the State's goal to lower the rate of population growth intersected with Puerto Rican women's needs to control their fertility, thus increasing the rate of sterilization among Puerto Rican women on the island and in the United States.

In summary, Puerto Rican women make reproductive decisions; however, choosing between sterilization and continuing to have children under adverse conditions, or getting sterilized as a last resort after having more children than they desire, does not constitute full reproductive freedom. What's more, although all women's reproductive choices are constrained, poor women's reproductive freedom is even more limited because of their poverty and lack of access to quality health care, which limits their knowledge about contraceptives and reinforces their misinformation about the permanent nature of tubal ligation. My study shows that low-income Puerto Rican women do not have complete access to the full range of birth control methods on the market today and available to other women. This reproductive disparity is an ethical issue.

An integral model of reproductive freedom and social justice also builds in a notion of optimal reproductive freedom as an ethical goal. Reproductive freedom consists of the personal/gender consciousness and political capability to decide if, when, how, and with whom a person may want to have children, free of coercion or violence. It also entails having social conditions that enable an individual to have children, for example having: viable birth control options, quality health care, prenatal care, and childcare, the right to a legal abortion, and a support system that allows women and men to raise children in a healthy environment.

As long as sterilization continues to be used as population control in the Third World, justified by representations of Puerto Rican and other poor racialized women in the U.S. as burdens on the State, and as long as these women do not have access to adequate living conditions and access to quality health care services, Puerto Rican women and other poor, marginalized women will not exercise true reproductive freedom. But this breach of freedom cannot be ethically answered by painting Puerto Rican or other women as mere victims or dupes of racist, classist, sexist, and colonialist policies. Solidarity and change requires that we see—and help others to see—how women have resisted, too, and have found some space to exert their own will as they make their way and build their families under oppressive circumstances.

Podcast

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Global Dimensions of ART - Podcast Description
Iris Lopez introduces and moderates this panel discussion on "Global Dimensions" of ART practices which features speakers Dana-Ain Davis, Laura Briggs and Claudia Castañeda. Increased demand for assisted reproductive technology (ART) and transnational adoption has been propelled by a number of factors, including the development of new technologies and changes in familial form - such as childrearing in second or third marriages; lesbian, gay, and transgendered families; and delays in childbearing and subsequent difficulties in conception - that make ART helpful. Other relevant factors include environmental changes that have negatively affected fertility levels, new levels of transnational migration and interaction that have fueled awareness of babies available for and in need of adoption, and concerns about genetic diseases and disabilities. Effectively, the various imperatives and the desires, both cultural and personal, that the use of ART fosters and responds to, have created a "baby business" that is largely unregulated and that raises a number of important social and ethical questions. Do these new technologies place women and children at risk? How should we respond ethically to the ability of these technologies to test for genetic illnesses? And how can we ensure that marginalized individuals, for example, people with disabilities, women of color, and low-income women, have equal access to these new technologies and adoption practices? And, similarly, how do we ensure that transnational surrogacy and adoption practices are not exploitative? These questions and many others on the global social, economic and political repercussions of these new forms of reproduction were the focus of this year's Scholar and Feminist Conference, "The Politics of Reproduction: New Technologies of Life," which took place on February 28, 2009 at Barnard College.

Endnotes

1. D. Roberts, Killing the Black Body: Race, Reproduction, and the Meaning of Liberty (New York: Pantheon Books, 1997). [Return to text]

2. I. Lopez, Matters of Choice: Puerto Rican Women's Struggle for Reproductive Freedom (New Brunswick: NJ: Rutgers University Press, 2008); L. Mullings, "Resistance and Resilience: The Sojourner Syndrome and the Social Context of Reproduction in Central Harlem," in Gender, Race, Class, and Health: Intersectional Approaches, Amy J. Schulz and Leith Mullings, eds. (San Francisco, CA: Jossey-Bass, 2008): 345-370; and Roberts, 1997. [Return to text]

3. R.P. Petchesky, Global Prescriptions: Gendering Health and Human Rights (New York: Zed Books, 2003). R. Petchesky and K. Judd, eds, Negotiating Reproductive Rights: Women's Perspectives Across Countries and Cultures (London and New York: Zed Books, 1998). [Return to text]

4. Lopez, 2008; I. Lopez (1983), "Extended Views: Social Coercion and Sterilization Among Puerto Rican Women," in Sage Relations 8 (3): 27-40. I. Lopez (1998), "An Ethnography of the Medicalization of Puerto Rican Women's Reproduction," in Pragmatic Women and Body Politics, ed. M. Lock and P.A. Kaufert, 240-259 (Cambridge, UK: Cambridge University Press). I. Lopez (1993), "Agency and Constraint: Sterilization and Reproductive Freedom Among Puerto Rican Women in New York City," in Urban Anthropology and Studies of Cultural Systems 22 (3-4): 299-343. [Return to text]

5. H.B. Presser, H.B, Sterilization and Fertility Decline in Puerto Rico (Westport, CT: Greenwood Press, 1973); and J.M. Stycos, R. Hill, and K. Back, The Family and Population Control: A Puerto Rican Experiment in Social Change (Chapel Hill: University of North Carolina Press, 1959). [Return to text]

6. B. Mass, "Emigration and Sterilization in Puerto Rico in Population Target: The Political Economy of Population in Latin America," Toronto: Latin American Working Group, 1976: 66-95; and CESA, "Workshop on Sterilization Abuse," Bronxville, NY: Sarah Lawrence College, 1976; and A.M. García, 1982. La Operación. Directed and produced by Ana María García with Latin America Film Project. New York: Cinema Guild [Return to text]

7. Lopez, 2008. [Return to text]

8. A. Chandra, "Surgical Sterilization in the U.S.: Prevalence and Characteristics, 1965-95," Department of Health: Vital Statistics 23.20 (1998): 1-33. [Return to text]

9. L. Briggs, Reproducing Empire: Race, Sex, Science, and U.S. Imperialism in Puerto Rico (Berkeley: University of California Press, 2002); and García, 1982. [Return to text]

10. I included a small control group of 32 non-sterilized women in order to explore their perceptions of tubal ligation. Of the sterilized women 78 had tubal ligations, 11 only had hysterectomies, and 7 had a combination of tubal ligations and hysterectomies. After spending approximately two months in the field doing participant observation, I developed an in-depth questionnaire that contained 150 open-ended and closed questions. I divided the questionnaire into four sections, which helped me to ask women specific questions about their particular fertility experiences. [Return to text]

11. Lopez, 2008. [Return to text]

12. Ibid. Colon-Warren, A., and E.P. Larrinaga, eds. Silencios, Presencias, y Debates Sobre El Aborto en Puerto Rico y el Caribe Hispaño (San Juan: Universidad de Puerto Rico, 2001). Cólon Alice, Ana Luisa Dávila, Maria Dolores, Fernós, y Esther Vicente. Póliticas, Visiones Y Voces En Torno Al Aborto en Puerto Rico (San Juan: Universidad de Puerto Rico, Centro de Investigaciones Sociales, 1999). Crespo-Kebler, E. "Ciudadanía y nación: Debates sobre los derechos reproductivos en Puerto Rico," Revista de Ciencias Sociales 10: 57-84 (2001). [Return to text]

13. J.L. Vasquez-Calzada and Z. Morales del Valle, La Esterilización Feminina y su Efectividad Demográfica: El de Puerto Rico (Escuela de Salud Pública, Recinto de Ciencias Medícas, San Juan: Universidad de Puerto Rico, 1981); and J.L. Vasquez-Calzada and J. Carnivalli, 1982. El uso de métodos anticonceptivos en Puerto Rico: Tendencias recientes. Centro de Investigaciones Demograficás Escuela de Salud Pública, Recinto de Ciencias Médicas, Monografia número III. San Juan: Universidad de Puerto Rico. [Return to text]

14. Lopez, 2008, and García, 1982. [Return to text]

15. A. Arellano and C. Seipp, Colonialism, Catholicism, and Contraception: A History of Birth Control in Puerto Rico (Raleigh, NC: The University of North Carolina Press, 1983). J. Schoen, "Taking Foam Powder and Jellies to the Natives: Family Planning Goes Abroad," in Choice and Coercion: Birth control, Sterilization, and Abortion in Public Health and Welfare (Raleigh, NC: The University of North Carolina Press, 2005). [Return to text]

16. Lopez, 2008. [Return to text]

17. Briggs, 2002. [Return to text]

18. See: F. Laraque, G. Graham, and E. and K. Roussillon, "Sterilization in New York City 1995," New York: Bureau of Maternity Services, New York City Department of Health, 1995. Also, the rate of sterilization for Hispanic women may be higher than 50% because they were counted in both the black and white categories. Because Puerto Rican women still constitute a large number of Hispanics in New York City and have such a long history of sterilization, it is reasonable to assume that a large percentage of these sterilized women are Puerto Rican. [Return to text]

19. Lopez, 2008. [Return to text]

20. S. L. Schensul, M. Borrero, V. Barrera, J. Backstrand and P. Guarnaccia, "A Model of Fertility Control in a Puerto Rican Community," in Urban Anthropology 11.1: 81-99. [Return to text]

21. To read the stories of these women in their own voices please see Lopez, 2008. [Return to text]

22. I. Lopez, 1983. "Extended Views: Social Coercion and Sterilization Among Puerto Rican Women," in Sage Relations 8 (3): 27-40. I. Lopez, 1998. "An Ethnography of the Medicalization of Puerto Rican Women's Reproduction," in Pragmatic Women and Body Politics, M. Lock and P.A. Kaufert, eds., 240-259. Cambridge, UK: Cambridge University Press. I. Lopez, 1993. "Agency and Constraint: Sterilization and Reproductive Freedom Among Puerto Rican Women in New York City," in Urban Anthropology and Studies of Cultural Systems 22 (3-4): 299-343. [Return to text]

23. J. Carlson and G. Vickers, 1982. "Voluntary Sterilization and Informed Consent: Are Guidelines Needed?" Manuscript available from United Methodist Church, 475 Riverside Drive, New York, NY 10115. [Return to text]

24. Lopez, 2008. [Return to text]

25. For a detailed analysis, see Lopez, 2008. [Return to text]