Sterilization and the Ethics of Reproductive Technology: An Integral Approach

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.¹ 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 1973.²

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.³

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.⁴ 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,⁵ sterilization technology was tested on Puerto Rican women.¹ 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,⁶ 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.⁷ In 1982, I found that 47% of Puerto Rican women 21 years of age or older in the neighborhood I surveyed were surgically sterilized.¹ In 1982 another study found that 51% of Puerto Rican women in New Haven, Connecticut were surgically sterilized.⁸ 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.

1. Lopez, 2008. [↩] [↩] [↩]
2. 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). [↩]
3. 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. [↩]
4. Lopez, 2008, and García, 1982. [↩]
5. 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). [↩]
6. Briggs, 2002. [↩]
7. 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. [↩]
8. 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. [↩]