Sterilization
By the late 1970s in the United States, surgical sterilization had become the most prevalent form of contraception among women over the age of twenty-five.21 A good deal has been written about sterilization, and my purpose here is not to analyze it in depth but to understand the nature of its relationship to abortion. Common sense and a glance at the demography of sterilization suggest that that relationship should be remote. For surgical sterilization remains an irreversible method of fertility control that ends a woman’s fertility permanently, whereas abortion is aimed at ending a given pregnancy. Procedures have been developed for reversing surgical sterilizations, but they are extremely expensive and difficult and have a very unreliable rate of success.22 Its virtual irreversibility puts sterilization into a different category of fertility control from abortion or nonpermanent contraception. The great majority of women getting sterilized for contraceptive purposes are different from most women getting abortions. Women who seek sterilization are married at the time of being sterilized (87 percent), and their peak ages are around 30-34 (as opposed to 18-19 among women getting abortions).23 They do not want or expect to have any more children (unless they have been sterilized involuntarily or have not been informed that the operation is irreversible). Since most of the women who get abortions are unmarried, have had no children, and are under twenty-five, one would assume that for them, sterilization is not an acceptable alternative to abortion.
Some family planners apparently do not agree. Hypothesizing a model of "rational" fertility control in which most women will use the pill or the IUD (the "medically preferred" methods) for several years, followed by one or two children spaced closely together, followed by sterilization, they regard sterilization as a reasonable alternative to abortion for women of all ages—those who have "had all the children they want" plus those who do not want any.24 This view of "family planning rationality" is abstracted from reality. People change their minds, and have a right to change their minds, about childbearing; life circumstances change in ways one cannot always foresee. Studies of women who regret their sterilization, for example, have found that many chose this avenue to resolve a troubled marriage, later got divorced, and wished to have more children in a subsequent relationship.25
Moreover, while sterilization and abortion rates rose along a similar curve during the 1970s, and reflect a similarly complex weave of economic, medical, and social conditions, they are nonetheless clearly distinct phenomena. For one thing, the medical histories of sterilization and abortion are extremely different. Sterilization was always an alternative initiated through institutionalized medical means. Today it is an increasingly technical and complicated procedure, administered necessarily in a medical setting and requiring specialized surgical skill. Abortion was traditionally a procedure that remained in women’s and lay practitioners’ hands and only belatedly was incorporated—and then halfheartedly—into regular medical practice. Although technically defined as surgery, abortion in the early stages of pregnancy is a relatively simple procedure that could be performed adequately by trained nurse-midwives working under sanitary conditions with good hospital backup in case of complications. As explained in earlier chapters, the legalization of abortion grew out of a rising popular demand resisted by many in the medical profession; abortion providers are predominately freestanding clinics, not hospitals. The shift in sterilization trends and policies, however—from a cautious, restrictive policy twenty years ago to one of strong advocacy beginning in 1970—was largely initiated by physicians and family planners. This shift directly reflects adverse reports and women’s own fears about the health hazards of the pill, particularly for older women, and the search by clinicians for a medically controlled substitute.26 Thus, while they represent parallel trends, the recent increases in sterilization and abortion really grow out of different dynamics in the political dialectic of reproductive control.
An important part of the history of sterilization that sets it apart from abortion is the incidence of coercive sterilization and sterilization abuse among mainly poor, immigrant, and minority women in the United States. While instances of coercion or pressure on women to get an abortion surely occur, they have nothing of the systematic, state-sanctioned character of involuntary sterilization, as a look at public policy immediately makes clear. Legislative proposals to allow the involuntary sterilization of certain groups on eugenic grounds have a long history, linked to private upper-class organizations promoting "racial betterment and WASP purity."27 Today sterilization programs are more subtle but nonetheless motivated by population control objectives aimed at particular groups—the "surplus" poor. A deliberate policy of manipulation if not coercion is involved when medical associations and family planning agencies advocate sterilization as a preferred form of birth control, particularly to low-income women and women of color, while withholding or minimizing information about other methods of fertility control. Such a policy is evident in the continued reimbursement by Medicaid, along with most commercial and employment-related health insurance, of 90 percent of the costs of contraceptive sterilization, while funds for abortions are cut off in most states.28 Practices such as the failure to inform patients adequately, in their own language, that sterilization is irreversible; the failure to provide full information about nonpermanent alternatives (including abortion); the threat of withholding welfare or Medicaid benefits to a woman or her children if she refuses "consent" to sterilization; making permanent sterilization the condition of a voluntarily sought abortion (the notorious "package deal"); using hysterectomy—with its enormously increased risks and drastic consequences—as a form of sterilization; or sterilizing minors or the mentally incompetent are all forms of sterilization abuse prohibited by the 1978 Federal Sterilization Regulations.29 Yet auditors’ reports on federally funded sterilizations in a number of states suggest that such abuses continue in many hospitals that service the poor, largely because of the lack of effective government enforcement machinery.30
Nearly all of the documented or court-adjudicated instances of sterilization abuse during the 1970s involved women who were poor and either black, Mexican-American, Puerto Rican, or Native American, or women who were incarcerated or mentally incompetent. Neo-eugenic policies and abusive practices may have played a part in effecting class and race differences in sterilization rates. National survey data from 1975-76 indicate that low-income women and women with little education (high school or lower) have significantly higher rates of sterilization than their middle — class counterparts. Moreover, among low-income, black, and Hispanic groups, it is much more likely to be women rather than men who become sterilized, for reasons that have to do with ethnic culture and history as well as clinical practices; vasectomies occur primarily among white middle-class married men.31 A recent report by researchers with the federal Health Care Financing Administration shows that female Medicaid recipients are between two and four times more likely (depending on geographical region) to be sterilized than are women not dependent on Medicaid; and nearly all Medicaid sterilizations are performed on women.32
Abortion rates too tend to be higher among Medicaid-dependent and minority women than among white middle-class women. How, then, can we argue that these differentials indicate women’s self-determination in the one case and abuse or nonchoice in the other? Surely the higher rates of sterilization among poor women reflect some of the same social and economic constraints and class divisions within the medical care system that structure the abortion decision among poor women (who are disproportionately women of color). In both cases, the decision is more often than not the product of a conscious, rational determination by poor women to deal with the situation at hand, rather than of manipulations or lies by doctors. In some cases sterilization may be viewed by a woman as a definite relief, a solution to her birth control problems that eliminates fear of pregnancy and hassles with men.
Generally speaking, it is not the technology of a birth control method that makes it abusive or malevolent, but the social arrangements in which that technique is embedded—the degree to which those arrangements allow for the user’s conscious participation and control and respond to her personal and biological needs. Sterilization or even hysterectomy may satisfy these criteria in particular cases, depending on the situation.33 The same may be said for abortion. Yet, recognizing this, we also have to recognize that sterilization has been and remains distinct from abortion both in its historical uses and its practical consequences for women. In the case of sterilization, it is possible to imagine, as some demographers do, that logically, because the method is permanent, its use always connotes voluntary choice to terminate childbearing.34 In reality, we have to deal with a well-documented history in which surgical sterilization has been imposed on women without their knowledge or consent, or without their understanding that the procedure was permanent. This has not occurred with abortion, at least not in the United States or Western Europe. Involuntary sterilization, not involuntary abortion, has been the nucleus of state-sponsored eugenic and neo-eugenic population control policies precisely because it is medically controlled and is permanent. It eliminates a potential "breeder," not just a potential child; and it does not have a long-standing tradition of popular practice behind it. From the point of view of a neo-eugenicist public policy the coincidence of antiabortion and prosterilization programs is not contradictory but rather class and race specific.
Given recurrent patterns of abuse and worsening economic conditions for poor women in the United States, it seems reasonable to expect that denial of abortion funding and further restriction of legal abortions will result in higher rates of sterilization among poor women; abortion cutbacks and sterilization abuse are in this sense "opposite sides of a coin."35 Yet, at this writing—it may be too soon to predict what will happen—Medicaid-dependent women denied abortion funds do not seem to have turned to sterilization as an alternative.36 Rather, they continue to seek abortions using any means they can. This indicates that sterilization is not an adequate substitute for abortion for most women, in most circumstances; its irreversibility entirely transforms the meaning of "costs" and "risks," putting not a pregnancy but a woman’s whole reproductive capacity on the line. It also indicates that political struggles over sterilization abuse by feminists and Third World groups apparently have had an impact on women’s consciousness.
Irreversibility is the major fact distinguishing sterilization from abortion, but the risks are different in other ways as well. The mortality, morbidity, and complication rates for tubal ligation are much higher than the rates for a first-trimester induced abortion. For a tubal ligation, the estimated annual mortality rate is 25-30 per 100,000 users, whereas that for a first-trimester abortion is 2.5-3.0 per 100,000.37 Standard female sterilization operations involve hospitalization of up to a week and general anesthesia, which always increases surgical risk, whereas first-trimester abortions are done on an outpatient basis. Even the new outpatient methods of sterilization involving laparoscopy and hailed by population planners as easy and safe ("Band-Aid surgery") involve risks of ectopic pregnancies (which may be fatal to a woman), menstrual irregularities, and, in the case of electrocoagulation, "extraordinary" destruction of tissue and burns to the abdominal wall and bowel that have resulted in several deaths.38 Even an older woman who wishes to have no more children might think twice about preferring sterilization to the combination of (nonchemical) contraception and abortion.