Book Review

The Sterilization Movement and Global Fertility in the Twentieth Century

N Engl J Med 2008; 359:1854-1855October 23, 2008

Article

The Sterilization Movement and Global Fertility in the Twentieth Century
By Ian Dowbiggin. 262 pp., illustrated. New York, Oxford University Press, 2008. $49.95. ISBN: 978-0-19-518858-5

Sterilization is a medical procedure that can immediately evoke concern about violations of medical ethics. Enthusiasm for sterilization may start with beneficence and the desire for social justice, but sterilization has often led to outrageous violations of autonomy. In his history of sterilization, Ian Dowbiggin chronicles the activist movement — often led by physicians — to increase the acceptance and use of contraceptive sterilization. Drawing from traditional scholarly sources, including personal letters and institutional archives, Dowbiggin presents the sterilization movement mainly in the form of brief biographies of passionate individuals.

Many of the key figures in the movement were donors, board members, or staff members of a single organization that is now known as EngenderHealth. This organization began in 1937 as the Sterilization League of New Jersey and went through many name changes in tandem with — or in reaction to — the changing political landscape. The scope both for individual advocates of sterilization and for this organization expanded from local to national to international, and the focus of EngenderHealth changed over the decades from sterilization alone to wider issues of reproductive health. This book is primarily an examination of sterilization as it has been used for eugenic purposes and population control; it does not explore the prevalent use of voluntary, elective sterilization by the American middle class during the past 30 years.

The chronicle begins early in the 20th century, when the surgical sterilization of women had limited availability and was banned by some state legislatures, hospitals, and medical associations. Sterilization at that time required laparotomy. (The less invasive approaches currently in use did not begin to appear until the 1970s.) The only use of sterilization was eugenic — with the specific goal of preventing reproduction by the mentally retarded — and this thinking was often extended to include inmates of prisons and mental hospitals as well as those who were simply poor. Quotes from the educated and prosperous advocates of sterilization, including gynecologists, are shocking to read from the current perspective on human rights. The frank desire to prevent “inferior” people — however that word is defined — from reproducing seems to have been ubiquitous. Throughout the book, the limited discussion of the autonomy of individuals is conspicuous. Perhaps those who were concerned with autonomy were few or silent, or perhaps their voices are simply not included. The resulting narrative is alarming.

The reactions to human rights abuses in fascist Europe during World War II led to the reinvention of the movement for eugenic sterilization. The proponents of eugenic sterilization revised their strategy and pressed to both dismantle hospital regulations and change the medical culture that restricted voluntary (in contrast to eugenic) sterilization. Marriage counselors and gynecologists in the sterilization movement stoked demand for tubal ligation and vasectomy by publishing articles in popular magazines. These cultural and regulatory changes, which coincided with the development of laparoscopic tubal ligation in the 1970s (and its shortened recovery time), unleashed enormous demand for sterilization in the larger population of the United States. Concurrently, increasing outrage about forced sterilization of the mentally retarded, inmates, poor women, and women who were members of minority groups finally led to specific consent requirements that were designed to ensure autonomy. Sterilization remains overwhelmingly popular among American couples, and more than 1 million operations are performed each year on men and women across the social spectrum. The attractions of voluntary sterilization are outside the scope of the history that is chronicled in this book.

After eugenic sterilization largely disappeared, the population explosion became the target of sterilization advocates, who were particularly active in Asian countries. Dowbiggin describes the development of the strategy for population control in India, which included mass sterilization camps, the use of incentives and quotas, and yet again, a lack of informed consent. By 1977, these tactics led to the downfall of Indira Gandhi's government, which had declared a population emergency and started a forced sterilization program in 1975. Despite the backlash, similar tactics reemerged in India in a short time. Other countries, less well described in this book, also enthusiastically adopted mass sterilization as a means of addressing unmanageable rates of population increase. The advocates of population control who endorsed mass sterilization often neglected the principles of informed consent. Moreover, women's reproductive rights did not enter the discussion until the 1994 Cairo conference on population and development.

Overall, prevalence of the use of contraception has increased enormously during the past 30 years, and sterilization is the dominant method of birth control in only a few countries. Sterilization thus explains a portion of the decreasing birth rates, particularly in Asia and Brazil, but it is rarely the principal, and by no means the sole, explanation — increasing prosperity and increased use of reversible contraceptive methods are far more responsible for the decrease in birth rates.

The “birth dearth,” a term used to describe birth rates that are below the replacement rate, appears largely in countries where sterilization is not a major part of contraceptive use. Among developed countries in which fertility is low, sterilization is most popular in the United States, where birth rates remain well above the replacement rate. Dowbiggin's worry that sterilization is directly responsible for birth rates that are below the replacement rate, which he expresses both in the prologue and in the final chapter of the book, is not supported by the data.

Negative population growth is a major new policy challenge for many European countries and for Japan, but sterilization is not the cause of the problem. In contrast, the rapid growth of the populations in many less developed countries is a continuing source of individual misery and a long-standing policy challenge. As this book demonstrates, advocacy of sterilization as a solution to population growth leads to serious problems when that agenda overrides individual values and individual autonomy. Voluntary sterilization, however, deserves its great popularity and will remain valuable as one part of a broader menu of options for family planning.

Carolyn L. Westhoff, M.D.
Columbia University, New York, NY 10032