Meera Vashisht: Forced and Coercive Sterilization of Native American Women
Eugenics and the Family Planning Services and Population Research Act 1970-1976
The introduction of the Family Planning Services and Population Research Act (Title X) caused infringements on the reproductive rights of Native American women for decades after it was initially introduced in 1970, culminating in health disparities that continue to this day. As a direct result of Title X, an estimated 25-50% of Indigenous women of childbearing age were sterilized between 1970-1976. The initiation of Title X subsidized forced or coercive sterilization procedures through the Indian Health Service, a division within the US Department of Health and Human Services, perpetuating a federally-funded form of genocide. Even after legislation designed to protect Native American women from sterilization was finally passed, these procedures, often performed without the patient’s consent or knowledge, were still taking place(1)(2). This was in stark disagreement with the Native American communities’ value of autonomy in healthcare decisions regarding family planning and reproduction. The implementation of Title X failed to consider these cultural practices, traditions, and values. Moreover, it ignored indigenous perspectives, undermining the self-determination and agency of Native women, leading to further cultural erasure and disempowerment.
Title X was enacted in 1970 with the aim of providing access to comprehensive family planning services for all Americans. (3) While the act was intended to offer support and resources for underserved communities, it has had lasting negative consequences for Native Americans. Title X perpetuated and widened already existing health disparities for Indigenous people, and these were further exacerbated by a lack of culturally competent healthcare providers, as well as limited access to comprehensive reproductive healthcare services. Many Native American women faced economic and geographic barriers, preventing an access to the necessary resources that supported a woman’s reproductive healthcare needs.Moreover, the act's focus on population control, rather than finding the root causes of health disparities, failed to adequately address the complex, systemic factors contributing to the reproductive health challenges faced by Indigenous women in the first place.
Title X directly resulted from pervading early to mid-20th century eugenicist medicine and the desire to control the genetic quality of the human population. The science of eugenics had implicit historical connections to extinguishing marginalized populations and ethnic groups throughout the 19th and 20th centuries, and it intersected with existing systems of colonialism and oppression, having a significant impact on Native populations. It first emerged as a movement that aimed to improve the genetic quality of populations through selective breeding and sterilization, but it also served to protect already dominant groups within the population.
The history of American eugenics highlights the ethical complexities surrounding reproductive rights for Native women, and it is important to note just how eugenicist theories influenced population control policies throughout the 20th century. Eugenicist policies were often implemented with the intention of promoting certain socially desirable traits or reducing the occurrence of perceived undesirable traits within a population. Eugenicist theories often categorized Native Americans as racially inferior, depicting Indigenous populations as biologically unfit and intellectually incapable, perpetuating harmful stereotypes that influenced medical and political decisions that further marginalized and stigmatized Native communities. Native American women were disproportionately targeted for sterilization programs throughout the 20th century (4).
The eugenicists’ notions of “fit” and “unfit” were determined by race and class. IQ tests were often used by eugenicists to determine social value, and hence became indicative of a person’s genetic fitness. The interrelatedness between class and racial hierarchy gave credence to the explanation as to why those of upper socioeconomic standing were predominately white, thus causing further suppression of those with less social mobility. Such ideas led to dangerous theories that poverty was justified by genetic inferiority. (5)
Historical trauma, cultural assimilation efforts, and discriminatory practices have long impacted Native health and reproductive rights for over three centuries, but during the mid-20th century, the United States implemented aggressive sterilization policies targeting various marginalized groups, and these measures were often rooted in misguided attempts to control population growth. Thus, forced sterilization can only be understood within the broader context of U.S. history, as well as the policies that targeted indigenous populations. In the case of Indigenous peoples, these practices became another attempt to further assimilate and depopulate tribal communities (6)(7)(8)(9).
Reports indicate that between the 1960s and 1970s, the Indian Health Service engaged in a series of coercive practices to sterilize Native American women, including providing misleading information about sterilization and pressuring women to be sterilized immediately after giving birth without providing other alternatives or gaining informed consent. These malpractices, which were part of a larger pattern of reproductive rights violations, raised significant ethical and human rights concerns. From 1970-1976, it is estimated that as many as 70,000 Native American women underwent coerced hysterectomies and other reproductive interventions, often without adequate medical consultation beforehand (10)(11).
The Relf v. Weinberger case of 1974 played a pivotal role in shedding light on the Indian Health Service’s aggressive sterilization practices endured by Native American women. This case became the first to challenge sterilization practices that disproportionately targeted Indigenous women. It involved six women from the Choctaw and Chickasaw Nations who had undergone sterilization procedures at Indian Health Service hospitals and facilities without their informed consent. The women all alleged that they were misled, coerced, or inadequately informed about the consequences of the procedure (12). The case marked a significant turning point concerning discussions and changes surrounding the sterilization of Native women, and revealed a history of systemic discrimination and the violation of Native women’s reproductive rights with the controversial treatment. Its impact rippled beyond the courtroom, prompting legal reforms and heightened public awareness to fight for reproductive rights not only for Indigenous women, but for all underserved groups facing similar mistreatment by physicians and healthcare practitioners (13).
Relf v. Weinberger exposed significant flaws within the Indian Health Service system’s funding, staffing, and healthcare protocols, leading to crucial reforms. It brought long-needed attention for cultural competency training, improved medical ethics, the inclusion of Indigenous voices in healthcare decision-making, and stricter regulations regarding medical procedures. The case also galvanized Indigenous activists, organizations, and communities to mobilize against ongoing violations. It not only provided a needed platform for Native American women to voice their concerns and demand accountability, but also led to the formation of advocacy groups working to end coercive, sexist and racist medical procedures without informed consent. Relf v. Weinberger not only brought to light the larger pattern of systemic discrimination and abuse faced by Native women, but the landmark decision also prompted the development of protective measures, such as the Indian Health Care Improvement Act of 1976 and Title X regulations, which aimed to safeguard Indigenous women from coercive treatment by medical professionals in the future.
Throughout the 1960’s and 70’s, sterilizations of Native women increased, but there was no legislation restricting or prohibiting it, and for many physicians, it became simply another form of contraception. Finally, in 1976, The General Accountability Office (GAO) launched an investigation against four Indian Health Service jurisdictions, finding they were in nonobservance of consent to sterilization. The GAO found that forms were either not given to the patient or were in violation of Indian Health Service protocol. In one jurisdiction, the GAO found 36 cases where women under the age of 21 were sterilized despite an issued moratorium. The study also concluded that Indian Health Service physicians were overworked and underpaid, with the average doctor making under $20,000 per year while working almost 60 hours per week. Throughout the 1970’s, the average Indian Health Service doctor was responsible for nearly 1700 people, and sterilization procedures were viewed as providing less future work for underfunded and overpopulated IHS facilities. Moreover, during the early to mid-1970’s, the number of physicians working for the Indian Health Service decreased sevenfold, increasing the patient workload for already taxed and underpaid physicians (14).
Eventually, as more Native women were sterilized, Indigenous birth rates decreased from 3.29 in 1970 to 1.30 by 1980. It should be pointed out that although the low birthrate can be attributed to a law subsidizing sterilizations for patients who used the Indian Health Service, there was no financial incentive for Indian Health Service physicians to perform sterilizations, so other considerations were probably defining factors. Indian Health Service doctors were distinguished from those who performed sterilizations through a contractual agreement with the IHS. Those under contract received payments whenever they sterilized Native women, and although there was not a financial incentive for IHS physicians to perform sterilizations, it was still viewed as a viable form of contraception for low-income women. Worse still, the additional sterilization surgeries were viewed as positive training for novice physicians, dehumanizing the women who sought the assistance of Indian Health Service physicians (15) (16).
The infringement of reproductive rights, cultural insensitivity, and the perpetuation of health disparities continues to create significant barriers that undermine the well-being and autonomy of all Native women. To address these issues, it is crucial to integrate cultural competence into healthcare practices, engage with indigenous communities in policy-making processes, and prioritize the empowerment and self-determination of Native women. By doing so, we can work towards a more inclusive and equitable approach to reproductive healthcare that respects the unique needs and experiences of Indigenous women. The Indian Health Service’s sterilization of Native women represents an extremely dark and racist chapter in the history of healthcare in the United States. It highlights the need for ongoing efforts to address past injustices, plus ensure the protection of reproductive rights.
We should be working towards a more equitable and inclusive healthcare system that respects the autonomy, dignity, and well-being of all individuals, regardless of cultural background. The forced sterilization of Native American women by the Indian Health Service serves as a chilling reminder of the historical injustices faced by indigenous communities. It is imperative to continue advocating for culturally sensitive healthcare practices, informed consent, and the protection of reproductive rights for everyone.
Today, the lingering effects from the inception of the Family Planning Services and Population Research Act are still evident. The act disregarded the unique cultural and historical contexts of Native American communities, and Native women still face challenges in accessing competent and appropriate healthcare services due to a lack of understanding and respect for traditions, languages, and healing practices. Such cultural insensitivity perpetuates further marginalization, hindering a woman’s ability to make informed decisions about autonomous reproductive health. Family planning policies that are integrated with population research should always place emphasis on equity and a patient’s right to make informed decisions about reproductive health.
Finally, the forced sterilization of Native American women violated their fundamental right to reproductive self-determination. The violation of reproductive rights not only further perpetuated historical injustices and undermined the trust between Native Americans and the healthcare system, but legally, the procedures performed without informed consent countered the basic principles of medical ethics since they violated the fundamentals of justice, beneficence, and non-maleficence. While lawsuits were filed against the Indian Health Service, leading to policy changes and reparations for some victims, the healing process for affected individuals and communities remains ongoing, and many of these effects, such as the depopulation within Indigenous communities has had lasting and permanent repercussions.
Meera Vashisht is a Junior at Yale University in Ezra Stiles College
Citations
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3.) "Title X of Public Law 91-572, Section 1008". Title 42 – The Public Health and Welfare. U.S. Government Printing Office. December 24, 1970.
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5.) James Q. Whitman, Hitler's American Model: The United States and the Making of Nazi Race Laws, Princeton University Press 2003, 22-50.
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11.) Ralston-Lewis, D. Marie (2005). "The Continuing Struggle against Genocide: Indigenous Women's Reproductive Rights". Wíčazo Ša Review. 20 (1): 71–95.
12.) Jarrell, RH (1992). "Native American and Forced Sterilization, 1973-1976". Caduceus. 8 (3): 45–58.
13.) "Relf v. Weinberger". Southern Poverty Law Center.
14.) McGarrah Jr., Robert (1979). "Voluntary Female Sterilization: Abuses, Risks and Guidelines". Hastings Center Report: Institute of Society, Ethics and Life Sciences. 9 (5): 5–7.
15.) "Investigation of Allegations Concerning Indian Health Service" U.S. Government Accountability Office: A Century of Non-Partisan Fact-Based Work. November 4, 1976.
16.) Jones, A. (2000). "Effect of eugenics on the evolution of populations". European Physical Journal B. 17 (2): 329–332.
