sterilization

sterilization

Voluntary sterilization: the clinical possibilities

Sterilization refers to the procedure performed to stop fertility permanently, in either the male or the female. It is the most reliable type of contraception; consequently it is the most common form of contraception in couples over the age of 35 in the UK who have completed their families.

Fertilization occurs when a man's sperm reaches and joins an egg released from the ovary of a woman. The released egg is picked up by one of the two Fallopian tubes, which transports it to the uterus. Fertilization usually occurs in the Fallopian tube; if fertilized, the egg then implants into the wall of the uterus to establish a pregnancy. Sterilization interrupts this process permanently, either by preventing the release of sperm or by stopping fertilization by blocking the Fallopian tube.

Female sterilization

may be achieved by a number of techniques, over a hundred having been described since Lungren performed what is thought to be the first tubal sterilization in 1880. Operations on women are commonly called tubal ligation, as the procedures aim to occlude or ‘ligate’ (tie) the Fallopian tubes. The majority of operations described involved cutting the Fallopian tube and oversewing the cut end so that it was hidden. These operations required an incision either on the abdominal wall or through the top of the vagina to gain access to the tubes. The early operations are thought to have had a failure rate of around 1 in 200.

Sterilization can be performed at the time of Caesarean section, which allows easy access to the Fallopian tubes. This is seldom done now, as the failure rate is higher than with other techniques applied after the womb has returned to its non-pregnant state.

Modern surgical techniques have been developed and now include laparoscopic (telescopic) procedures to occlude the Fallopian tubes. These may use diathermy (burning) of the tubes to damage them and seal them. Alternatively, one of two common types of device are used to block the tubes. The first type involves placing small rubber bands over a pinched-up portion of each tube. The second type involves placing a crushing clip across them.

If a sterilization procedure fails there is an increased risk of the pregnancy implanting outside the womb. This is known as an ectopic pregnancy, which most commonly occurs in the Fallopian tube and can sometimes, if the pregnancy grows, result in the tube rupturing and causing internal bleeding.

Male sterilization

is achieved by the operation of vasectomy: cutting or ligating, on both sides, the vas deferens, which transports sperm from the testicles to the penis. The major advantage to a couple of a vasectomy is that it is a much simpler operation than female sterilization, due to the easy access to the vas within the scrotum. Vasectomy can easily be performed as an outpatient operation under local anaesthetic. After the operation the man must wait for around twelve weeks before the sperm count falls to sterile levels. Normally doctors ask for two sperm samples to check the operation has worked before alternative contraception can be abandoned.

Men and women requesting sterilization are usually seen at least twice by doctors prior to being sterilized, as the operation is designed to be permanent. Although reversal may be possible, sterilization should not be performed if either of the partners is unsure. It is also important that the doctor excludes any medical reason why the operation should not be performed. Women who have been taking the contraceptive pill because of painful periods are warned that these may recur if the Pill is stopped.

Current research is investigating reversible forms of contraception such as foam plugs for the Fallopian tubes or for the vas deferens.

Eugenical sterilization as a solution to social problems

Eugenicists in the US were particularly active in lobbying for the passage of state eugenical sterilization laws in the 1920s and 30s. Similar movements occurred in Canada, Britain, and Germany, but no laws were passed. Scandinavian countries — Denmark, Norway, Sweden, and Finland — passed laws in the 1930s. In the US, Harry H. Laughlin, of the Eugenics Record Office in Cold Spring Harbor, had drawn up a ‘Model Sterilization Law’ that served as a prototype for local use at home or abroad. Although the earliest such laws had been passed before World War I, the majority were established in the inter-war period. Eugenical sterilization laws were considered quite different from the punitive sterilization laws that existed in many states and countries in the nineteenth century. Although both types were compulsory, eugenical sterilization was aimed at prevention of future problems rather than serving as a punishment for past ones.

Eugenical sterilization was always couched in medical and scientific terms, and was justified as a means of saving the taxpayer money. In most countries it was aimed specifically at those individuals in mental or penal institutions who, from family pedigree analysis, were considered likely to give birth to socially defective offspring. In the US, sterilization could be ordered only after a patient had been examined by a eugenics committee, usually composed of a lawyer or family member representing the individual; a judge; and a doctor or other eugenic ‘expert’. Lobbyists often included members of the local state American Eugenics Society and a network of progressive enthusiasts who thought this was the way to cure social problems at their roots — it was the prime example of ‘social efficiency’.

Between 1907 (when the first law was passed, in Indiana) and 1941, over 38 000 eugenical sterilizations were performed in the US, with California in the lead. By the early 1960s the number had risen to over 60 000. The most famous sterilization case was that of Carrie Buck in Virginia, where a test case was set up to determine whether the law which had been passed was constitutional. Buck v. Bell was tried in 1925 in the Virginia Circuit Court. When the lower court ruled in favour of the law, an appeal was sent to the Supreme Court of the US, where Justice Oliver Wendell Holmes wrote the majority report. In upholding the lower court ruling Holmes made his oft-repeated assertion: ‘Three generations of imbeciles are enough.’ More to the legal point, Holmes claimed that ‘The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes.’

Laughlin's model law served also as a basis for a similar law in Germany, passed by the National Socialist government in 1933. For this effort, as well as for his enthusiastic support of Nazi eugenics programmes, Laughlin was awarded an honorary doctorate from Heidelberg University in 1936 — three years after the Nazis had come to power, and two years after their sweeping sterilization act had gone into effect.

While it would not be historically accurate to claim that state sterilization laws were repealed en masse after World War II and the disclosure of Nazi eugenic excesses, the general trend in 1945–55 was a decline in their application, increasing challenges to their constitutionality, and repeal of laws in some states — but it was not, for example, until 1977 that New Jersey outlawed the compulsory sterilization of the ‘developmentally disabled’. More telling, perhaps, than legislative changes, is the history of the actual application of sterilization laws in the post-war era — where they were not repealed, there was a dramatic decrease in the number of sterilizations reported. This decline was partly due to changing attitudes about the actual genetic effectiveness of sterilization — the acceptance that feeblemindedness might not have such a hereditary basis as had been supposed.

Influenced by their proximity to the Nazi experience, the Scandinavian countries repealed their laws after World War II. However, related issues of sterilization and control of reproduction in other guises continued, and gained considerable momentum after 1950, with respect to world population growth. Funded by the Rockefeller Foundation, pilot population control programmes were initiated in India, Puerto Rico, and other Third World countries; by 1960 these had been taken over and expanded by the US government funded bodies. Some post-war proponents of population control had been involved in eugenics in the 30s and 40s, and they used comparable arguments to those advanced earlier for eugenical sterilization — the differential birthrate of non-Western, non-European/American peoples. Now on a global scale, population control was, in the words of historian and critic Allan Chase ‘aimed at the gonads of the poor’.

Linda Cardozo,, Philip Toozs-Hobson,, and Garland E. Allen

Bibliography

Allen, G. E. 1986. The eugenics record office at Cold Spring Harbor: an essay in institutional history. Osiris 2 (2nd Series), 224–64.
Chase, A. 1977. The legacy of Malthus. Alfred A. Knopf, New York.
Reilly, P. 1992. The surgical solution: a history of involuntary sterilization in the United States. Johns Hopkins University Press, Baltimore.

See also castration; eugenics; vasectomy.