On November 11, an Indian surgeon used infected instruments to sterilize 83 women in about six hours, leaving 10 of them dead and another 69 hospitalized in the central state of Chhattisgarh. The doctor breached guidelines that limit surgeons from performing more than 30 sterilizations a day and also failed to disinfect the instruments before using them between patients. This is not an isolated case; according to India’s previous health minister, Harsh Vardhan, from April 2010 to March 2013 the government paid about 510 million rupees (US$8 million) for 15,264 deaths or failed surgeries.
This incident arises in the context of India’s efforts to control population growth and of its voluntary sterilization drives, where couples choose between a tubectomy or vasectomy.
However, this raises questions of whether these operations can really be regarded as voluntary and whether there is a genuine choice to opt for a vasectomy instead. The Indian statistics show that while 35.8% of women ages 15 to 49 in India have chosen sterilization, a marginal 1.1% of men have chosen the same. This is despite a vasectomy being a simpler procedure that receives more generous financial compensation; in most states, men who choose to have a vasectomy are paid $33 by the Indian government. Women, on the other hand, typically receive less than $23. The advantages of no scalpel vasectomy are many, doctors say; it is an outpatient procedure that can be done within five minutes and has no side effects. A woman who undergoes a tubectomy must be hospitalized for eight days and risks more side effects and future complications. Tubectomies are overall more expensive and much more invasive.
Despite all of this, as a result of cultural taboos, men are still reluctant to get vasectomies. Poonam Muttreja, executive director of the Population Foundation of India, states that “Indian men think that their virility will be affected and that they become weak. That’s a myth, and the government has done nothing to correct that.” Leaving men out of the family planning conversation has put the burden of population control entirely on women. Contraceptive counselors, Muttreja said, do not discuss vasectomies as suitable alternatives to female sterilization. Sterilization campaigns by the government focus solely on women instead of men. Women, furthermore, are considered less politically powerful and more susceptible to pressure.
Apart from the gender stereotypes that pressure women instead of their partners to get sterilized, women come under other subtle and not-so-subtle forms of pressure. The women sterilized on Saturday, all from poor villages, were paid between $10 and $23, according to various media reports. There are also implicit penalties; some Indian states deny government services to people who reject sterilization, or refuse government jobs to people with more than two children. Additionally, health workers are penalized for not meeting government quotas for female sterilization, and often resort to intimidation tactics, the 2012 Human Right Watch report said. While India officially ended female sterilization quotas in 1996, there have been consistent allegations that states still require health workers to meet targets. India’s family planning policies hit the country’s poor and underprivileged women hardest.
These practices are not limited to India. In fact, female sterilization is the most common form of contraception globally; the 2013 UN report on contraceptive patterns found that female sterilization is the most common method of contraception, used by 19% cent of women aged 15 to 49. The report notes that female sterilization is most popular in developing nations, while the contraceptive pill (18%) and the male condom (18%) are most commonly used in developed countries. Short-acting and reversible methods are more commonly used than other methods in developed regions whereas longer-acting and highly effective clinical methods are used more frequently in the developing regions. Rates are highest in the Dominican Republic, where 47% of women use sterilization as contraception, followed by Puerto Rico at 39% and India with 36%. The following table illustrates regional rates of female sterilization compared to that of male vasectomies. Only in Oceania are vasectomies slightly higher. From the list of 180 countries in the report only eight countries have higher rates of male sterilization with Canada (22%), the UK (21%) and New Zealand (19.5%) having the highest rates. Table 1. Sterilization rates around the world
Latin America and the Caribbean
In 2014, the WHO and other UN agencies released a report, Eliminating forced, coercive and otherwise involuntary sterilization, stating that sterilization “should only be provided with the full, free and informed consent of the individual”. What the Indian case shows is that voluntary consent is not as black and white as it may appear. Cultural and societal norms can add direct or indirect pressure to women around the world to undergo these processes, all the while adding risks like infected instruments or doctor quotas. Sterilization is an important option for individuals and couples to control fertility but seeing as it is the number one method of birth control, it is crucial to assure that it is not done in an unsafe or discriminatory manner, where women and girls are disproportionately impacted.
The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.