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date: 19 April 2024

Female Sterilization in Costa Rica, 1940 to 2020free

Female Sterilization in Costa Rica, 1940 to 2020free

  • María CarranzaMaría CarranzaInstituto Costarricense de Investigación y Enseñanza en Nutrición y Salud

Summary

Sterilization is an increasingly familiar phenomenon to women worldwide, and it is the most prevalent contraceptive practice in the world. Costa Rica, where the use of contraceptives is generalized, is among those countries in the world with the highest prevalence of female sterilization. In Costa Rica, female sterilization is homogeneously distributed, common among women living in rural and urban zones, as well as among those of diverse educational levels. In contrast to what one may expect given the legacy of abusive birth control practices in Latin America, the “problem” of sterilization in Costa Rica has been framed by women and doctors alike not as the “need” for curbing its use but rather as a “struggle” for broadening access as much as possible. Interestingly, current rates of sterilization have been attained in the absence of a formal program offering sterilization for contraceptive purposes and in the context of a very restrictive legal framework for its provision. It was not until July 1999 that sterilization for contraceptive purposes was explicitly regulated and permitted. Before that year, it was only so-called therapeutic sterilization that was legally allowed. Sterilization was supposed to be offered only for health reasons. Notably, successive moves intended precisely to broaden access to this surgery within the state hospital system have been realized through regulation formally restricting its provision. This sometimes counterintuitive history of the provision and regulation of sterilization in Costa Rica is analyzed.

Subjects

  • History of Central America
  • Science, Technology, and Health
  • Gender and Sexuality

Female sterilization is the most prevalent contraceptive practice in the world. In 2013, 19 percent of women aged 15 to 49, married or in union in the world, had undergone sterilization.1 In 2015, female sterilization accounted for 30 percent of the contraceptive use among married or in union women aged 15 to 49 in the world.2 Although sterilization for contraceptive purposes is an increasingly familiar phenomenon to women worldwide, its use is higher in developing regions, especially in Latin America and the Caribbean.3 Many countries in the world, particularly those of developing regions, have experienced serious abuses of sterilization. The irreversible character of this surgery makes it “ideal” for controlling reproduction, and women, and less frequently, men, in countries such as Peru, Brazil, Chile, Mexico, the United States, Canada, India, and Slovenia have been sterilized against their will, have been coerced to accept sterilization, or have been misinformed about its irreversible character in the name of eugenics, population control, and public health, among other reasons.4

Costa Rica is among those countries in the world with the highest prevalence of female sterilization, with 25.5 percent of women (married or cohabiting) between the ages of 15 and 49 sterilized in 2015.5 Located in Central America, relatively poor in terms of GDP per capita and small in size and population, Costa Rica is well known for the high standard of living of its population, which is the result of a huge social investment that started during the 1940s.6 In Costa Rica, people have an average of 8.7 years of formal education, with 57.8 percent having attended high school and higher levels of studies, and the population is served by a socialized system of medicine that covers 95 percent of citizens.7 Women have had access to contraceptives since the late 1960s; contraceptives are mostly provided by the state in various forms.8 At present, 77.8 percent of the women in union of reproductive age make use of contraceptives.9 In Costa Rica, sterilization is homogeneously distributed, common among women living in rural and urban zones, and with diverse education levels.10 The great majority of sterilizations have been provided at public hospitals as opposed to private institutions, with 95 percent of all the women who in 1999 reported being sterilized having undergone the surgery at social security hospitals.11

In Costa Rica then, one finds to a much smaller degree those factors that in other poor countries appear to easily explain high sterilization rates (e.g., a lack of alternatives, low formal education, and private provisions for surgery), making it easier to get some distance from the conventional way of framing sterilization as a “problem,” and instead focusing on a broader tendency toward its use.

Many factors have contributed toward making sterilization popular in Costa Rica. The propagation of sterilization has occurred concomitantly with the expansion of a strong socialized medical system, which, besides making women increasingly familiar with an array of medical interventions in their reproductive bodies , has been responsible for the propagation and increasingly homogeneous distribution of sterilization. Foreign interests intended to diminish population growth by means of the promotion of surgical sterilization have had an impact, particularly during the1970s. The invocation of diverse conceptions of “health” in presidential decrees and statements by physicians and women (among others) made the provision of sterilization justifiable and also legal.12 In addition, the fact that this surgery fits easily into the country’s particular notions of family, gender, and reproduction importantly contributed to situate sterilization in most women’s reproductive horizons.13

Unlike many other countries in Latin America, except for one formal complaint of massive sterilizations that was issued (and dismissed) in the mid-1970s, rates of sterilization in Costa Rica have not been perceived as problematic, at least not in the sense one would imagine. What has indeed been constituted as a problem in Costa Rica is restricted access to sterilization, and it is around this issue that the population has mobilized.14 This problem has to do with the particular ways in which women have gained access to this surgery.

Interestingly, current rates of sterilization (as mentioned, among the highest in the world), have been attained in the context of a very restrictive legal framework for its provision. It was not until July 1999 that sterilization for contraceptive purposes was explicitly regulated and permitted in Costa Rica. Until that time, there was not a formal program offering sterilization for contraceptive purposes, and only so-called therapeutic sterilization was permitted, which meant that this surgery had to be practiced only on women who had serious health issues as a way to prevent them from getting pregnant again. However, given that in 1999 21 percent of women of reproductive age were already sterilized, it is easy to conclude that sterilization was not only performed in cases of life or death.15 Sterilization for contraceptive purposes was a daily practice in the health services (public and private), and it was precisely through an appeal to health that this surgery became widely distributed.16 Notably, successive moves intended to broaden access to this surgery have been realized through regulation formally restricting its provision. This article traces this sometimes counterintuitive history of the provision and regulation of sterilization in Costa Rica.17

Popular and Prohibited Sterilization

Although not mentioning sterilization explicitly, Article 123 of the Costa Rican Penal Code declares “injuries causing sterility” a crime punishable by 3 to 10 years in prison and could be interpreted to regulate sterilization.18 Article 129 of the same code declares such an injury not punishable if undertaken with the consent of the “injured” and with the objective of improving health, limiting sterilization to the realm of the “therapeutic.” The tight association between sterilization and health marked by the Penal Code has limited the terrain of “legally” conceivable sterilization in Costa Rica. It has also placed sterilization under the control of the medical profession. Until 1999, the College of Doctors and Surgeons (CDS), the physicians’ professional association, dictated the norms for the provision of sterilization and also supervised their application. As employees of the social security system (the Caja Costarricense de Seguro Social) where most sterilizations have taken place, and also in their private medical consultations, medical doctors have been in charge of putting sterilization norms into practice. They have played the role of gatekeepers of sterilization, and it is the sum of their actions that has given life and shape to the politics of Costa Rican sterilization.19

1940s–1960s: Increasing, Informal, but Uneven Access

Since sterilization was introduced in Costa Rica in the early 1940s, access to it has become highly generalized and yet more difficult for some women than for others.20 Those women who could pay, whether within the private health services or illegally within the social security system, could “decide” and readily get the procedure done.21 Within the realm of public health services where the majority of sterilizations were carried out, access to this surgery has always been formally restricted to women meeting specified conditions, which have varied through time. Indications for sterilization, which initially were quite general, became more specific and apparently restrictive as the vulnerability felt by the medical profession vis-à-vis the law increased over time. Regulative restrictions on access to the surgery, and the consequent establishment of “unofficial” but publicly recognized and accepted ways to circumvent those restrictions, have been the source of important perceived inequities in the distribution of sterilization.

Prior to the 1960s, there were no national regulations on sterilization, and the practice of this surgery was established by each doctor, hospital department, and hospital. In both private and public institutions, sterilizations were mostly performed during cesarean sections and for health reasons. Even if the decision to sterilize was that of the medical doctor, private patients had much more input in the decision. They could frequently negotiate sterilization prior to surgical childbirth, if not for pure contraceptive purposes, at least for minor health motives, even at early stages in their reproductive lives. In public institutions, women could not choose a doctor and depended entirely on the doctor on duty’s stance toward this surgery. And doctors’ personal stances toward sterilization appear to have varied significantly from one public institution to the other, among doctors within the same public institutions, and even between the same doctor’s public and private practice.

That sterilization got circumscribed to the realm of the therapeutic, and that it was used together with caesarean sections, were in great measure consequences of the high risks entailed by the surgery. Nonetheless, its use was not unrelated to its contraceptive potential. Requirements were established, to some extent arbitrarily, by leading gynecologists in each hospital concerning the age a woman should have reached and the number of children she should have borne before undergoing sterilization. Some hospitals during the 1960s, required a minimum of seven children, while others required a minimum of five. Other institutions would not “officially” perform sterilizations at all.22

In spite of hospital-by-hospital regulations of the procedure, there is ample evidence (coming from the author’s interviews and earlier studies) that such limitations on sterilization functioned as frames of reference rather than exact measures.23 Individual medical doctors working within public hospitals always found ways to sterilize women whom they considered in need of sterilization. If established parameters proved fragile case by case, these parameters also shifted across generations. Young professionals did not always agree with the parameters established by their old bosses, and even less so when they seemed as capricious as previously stated. Generational disagreements were also fueled by the presence of diverse “schools of thought” among gynecologists, all of whom were trained abroad until the mid-1960s (when the specialty of Gynecology and Obstetrics began to be taught in Costa Rica).24

The positive stance toward sterilization as well as the relative ease with which it was increasingly performed are evident in a wide variety of studies that signal a steady increase in its use. The first reproductive survey carried out in 1964 in the Costa Rican metropolitan area showed that 6.1 percent of women (married or cohabiting) between 20 and 50 years old were sterilized.25 Data from research conducted in 1970 showed that sterilization was also becoming a common practice outside the capital city, with 9 percent of women interviewed in the province of Heredia and the city of Limón saying they had been sterilized.26

During the 1960s, Costa Rica put in practice one of the most effective programs of family planning in the region. The provision of contraceptives was the result of a concerted effort on the part of government and private institutions aimed at providing the population with access to contraception and reducing population growth.27 Just as in many other Latin American countries at the time, this enterprise received significant help from foreign entities interested in diminishing population growth in poor countries.28

Between 1960 and 1975, the total fertility rate declined from 7.3 to 3.7 children, with the decline being attributed in great measure to the provision of modern contraceptive methods by state health institutions.29 Interestingly, sterilization was not included among the contraceptives offered. The majority of people the author interviewed who were involved in these family planning efforts suggested that including female sterilization as a contraceptive would have meant having an unnecessary conflict with the Church.30 It can also be supposed that since sterilization at that time entailed major abdominal surgery (laparoscopy was introduced in Costa Rica only in the mid-1970s), it was not the kind of intervention that nurses and general practitioners could easily distribute, as would be the case with other forms of contraception. It is important to keep in mind as well that with few exceptions, the acceptance, promotion, institutionalization, and consequent increase of contraceptive sterilization tended to happen worldwide from the 1970s on.31 Nonetheless, in spite of not being formally offered, sterilization grew. A study that analyzed sterilizations performed between 1959 and 1969 in the twenty-five private and public hospitals of the country, although probably underestimated, signaled a significant increase in the surgery during those years (from 836 in 1959 to 3,189 in 1969).32

In an attempt to standardize the practice of sterilization and in the context of the approval of a new Code of Medical Morals, in December 1969 the College of Doctors and Surgeons set the first general guidelines for the provision of sterilization. In clause 10, part III of the code, “Duties of the Doctor with the Sick,” the code stated that “neither a woman nor a man should be sterilized without a medical indication.” However, even if the code confined the use of sterilization to medical reasons, this did not restrict its provision. If the doctor so wished, medical reasons could always be found to justify sterilization. As an example, the existence of “varicose veins” was frequently used as a justification, with “vascular causes” comprising 47 percent of the medical reasons justifying sterilizations performed in one of the two social security hospitals between 1969 and 1971.33 The use of varicose veins as grounds for sterilization continued unaltered until 1999, when sterilization for contraceptive purposes was formally permitted in Costa Rica.

The 1970s: Laparoscopes, Family Planning, and Alarm

During the first half of the 1970s, the provision of sterilization within the hospitals of the social security system grew to unprecedented levels. On the one hand, the percentage of women covered by the social security institutions, and hence potential users of sterilization, increased significantly.34 On the other, during this decade, foreign agencies promoted the performance of laparoscopic sterilization as a way to diminish population growth. The laparoscope offers the possibility to perform sterilizations through tiny incisions in the abdominal wall. By obviating the necessity of abdominal surgery, general anesthesia, and hospital admission, this apparatus allowed the practice of quick ambulatory surgeries which, as contemporary research noted, was ideal if the goal was to carry out massive programs of sterilization.35 Between 1972 and 1978, Costa Rica received from the United States Agency for International Development (USAID) and the Program for International Education in Gynecology and Obstetrics of the Johns Hopkins University (JHPIEGO) a total of twenty-two laparoscopes and training for doctors in their use.36 The introduction of laparoscopes certainly generated an increase in the number of sterilizations. As mentioned, the laparoscope facilitated the performance of a greater number of these surgical procedures. At the same time, the apparatus was attractive in and of itself, and the possibility of using it moved doctors to operate.37 The number of sterilizations practiced per year in twenty-five hospitals of the country rose from 3,397 in 1970 to 5,489 in 1975, and the annual rate of sterilizations during the first half of the 1970s doubled over that of the second half of the 1960s.38 During the mid-1970s, for the first and only time in the history of the country, the excessive provision of female sterilization was perceived as a problem. The supply of contraceptives by the state as well as their effects on the fertility rate were a source of growing preoccupation to left-wing political activists and to Catholics, albeit for different reasons, but both ended up converging on the attack on population control and sterilization. The increasing use and provision of sterilization was interpreted and denounced as a strategy of population control. On July 30th, 1976, in response to newspaper denunciations that massive sterilizations were being committed in the country, the Legislative Assembly instituted a Special Commission to investigate the possible existence of a massive sterilization campaign. While the commission concluded that there had not been such a campaign, the investigation had significant effects. Sterilizations stopped being practiced, although not for long, and the College of Doctors and Surgeons (CDS) responded by issuing that same year a very specific and apparently restrictive regulation for the provision of the surgery.39 The “Regulation on Male and Female Sterilizations” listed the pathologies that justified the performance of sterilization and established the creation of hospital committees in state and private institutions responsible for deciding on requests for the surgery. It also created a national committee in charge of reconsidering sterilization applications rejected by local committees and of periodically reviewing the indications for the surgery. In 1988, with minimum changes, this regulation acquired the status of an executive decree and ruled the practice of sterilization until 1999 when, also by means of an executive decree, sterilization was finally recognized as a contraceptive method.

Restricting Sterilization as a Way of Broadening Access

Gynecologists were conscious that the listing of medical conditions that merited sterilization made the regulation formally very restrictive and that the majority of sterilizations they had been performing to date did not strictly fit those medical conditions. Notwithstanding, they knew indications would be easy to “interpret,” and indeed, from the very moment that the regulation was signed, they started doing so on the basis of a shared medical as well as implicit social agreement regarding the diverse circumstances that justified sterilization. “Social reasons” constituted one of them, and the compact to sterilize between women and doctors at state hospitals was frequently sealed in their name. Although the regulation did not make any reference to “socioeconomic conditions” among justifications for sterilization, there was broad agreement among women, doctors, and the general public that poverty should be considered a criterion for sterilization. Women could generally count on doctors’ sensitivity to the plight of poverty, and with this in mind they would often state, verbally or in letters requesting the surgery, the economic circumstances that made sterilization necessary.40 So if the doctor felt that a woman needed the surgery or simply wanted to help her get it, there was always a way to find a physical (pathological) motive in the long list of conditions to justify sterilization. A doctor’s main strategy for the provision of this surgery consisted of making contraceptive sterilization invisible or, in other words, reconfiguring every contraceptive sterilization as one that fit the regulations—that is, as a therapeutic one. Multiple births, obstetric risk, and, of course, varicose veins continued to be common justifications for sterilizations. The regulations did not intend to restrict sterilization to certain diseases but instead to present certain diseases as access roads to sterilization. For this aim, the regulations relied on medical discretion.

Medical discretion, however, did not always favor the woman patient. If the doctor’s stance toward sterilization was not favorable, no health condition appeared severe enough to justify its performance. Such circumstances created a wide range of situations, from almost free access to sterilization for those women who could afford to pay for it privately to cumbersome and restricted access for those who had to undergo sterilization within public institutions. And among women using public hospitals, there were some who had less of a chance of being approved for the operation. Those not considered to be old, poor, or sick enough or were thought to not have had enough children were the ones who generated less empathy among medical doctors. Not having medical “problems,” and lacking social ones as well, they were frequently told to use another contraceptive method or to have a third child and then ask for sterilization again. Few doctors saw in them sufficient reason for running the risk of practicing this surgery against the “law.”

In the process, individual doctors, hospitals, and even cities became known for the relative ease with which sterilization could be obtained. However, particular doctors as well as entire hospitals became famous for their strict application of the regulation and consequent high percentage of refusal of social security sterilizations. Interestingly, some of those same doctors would easily practice sterilizations at their private consultations or at the state institutions in exchange for an illegal payment. To complicate matters more, in some social security hospitals, doctors asked women for written proof of their partner’s consent in spite of the fact that the regulation was quite clear that the only signature needed was that of the woman herself.41 Yet (among the women using contraception at all) the proportion of sterilized women increased to 14.7 percent in 1976, and from 16.7 percent in 1986 to 19.7 percent in 1993, with sterilization turning into the most used contraceptive method in the country.42 At the same time, the percentage of sterilizations performed within the institutions of the social security system increased from 90 to 95 percent.43 In a tortuous way, the regulation appears to have generally facilitated a whole range of social arrangements that in turn enabled wider access to sterilization.

The Road to Contraceptive Sterilization

The 1990s ushered in the involvement of women’s groups in the issue of sterilization. This culminated in 1999 with sterilization being recognized as one more of the contraceptive options to be offered to adult women and men alike. It could be said that up to the early 1990s, women and feminism were fairly absent from public discussion about sterilization. Up until that time, sterilization was mostly a doctor’s issue. The little evidence there is (mainly coming from newspapers) of women making public statements about sterilization and family planning tends to be from times when these services (and their providers) were under attack; such mobilizations could even be said to have been supportive of medical doctors. In the early 1990s, this stance began to change. In 1991, in the midst of a growing climate of discontent regarding inequity in access to sterilization, Rosemary Madden, a lawyer belonging to CLADEM (the Latin American Committee for the Defense of Women’s Rights), asked the Supreme Court of Justice to declare unconstitutional doctors’ practice of requesting the husband’s consent for sterilization. Although the legal claim of unconstitutionality was denied, it gave discontent regarding access to sterilization a particular shape: it became a women’s issue.44 The issue of sterilization was framed in terms of who in fact made the decision to undergo sterilization and who had the legitimate right to do so. In 1997, the medical committee that at a national level supervised the practice of sterilization unintentionally gave women’s groups a much wanted opportunity to get involved with the provision of sterilization and put up the first fight for reproductive rights in Costa Rica in the post-Cairo era.45 That year, the committee decided to revise the regulations for the provision of sterilization and broaden the list of conditions justifying the surgical procedure.46 By means of effective media pressure (television and radio programs and newspapers), lobbying of key personalities, letters, meetings, and public acts, the women’s movement, for the first time in history, was effective in taking the regulation for the provision of sterilization out of medical hands. It was also effective in getting the Ministry of Health involved in the issue (up to that time, the ministry had been very reluctant to engage in such a potentially contentious subject). On May 14th 1999, the president of the republic signed Decree No. 27913-S on Reproductive Health, which, for the first time in Costa Rica, formally recognized sterilization as a contraceptive method and granted access to the surgery to all women (and men) 18 years or older.47 The new decree established as prerequisites for the surgery attendance at a consejería (explanatory session) and a signed informed consent form.

Among the population, the television news about sterilization generated a rush of women requesting sterilization at social security hospitals. Because capacity in general did not increase, significant queues of women appeared in all the hospitals and clinics offering this surgery.48 As of the year 2020, waiting lists for sterilization have diminished but not disappeared, and delays in the provision of sterilization have become one important source of right to health litigations. Female sterilization continues to be the most used contraceptive method in Costa Rica. As mentioned, its use increased from 23 percent in 1999 to 25.5 percent in 2015.49 The use of male sterilization has also increased, from 0.5 percent of women (in reproductive age in union) protected by this method in 1999 to 5.1 in 2015, although it is still today considerably smaller than the use of female sterilization.50

Discussion of the Literature

In spite of contraceptive sterilization’s high use, remarkably little work has been conducted by the social sciences to study it (in stark contrast to the case of enforced and, more specifically, eugenic sterilization). The study of contraceptive sterilization has been mainly left to demographers, researchers, and organizations working on family planning and population control, who have written a vast amount on the subject describing the worldwide (although not uniform) rise in its use, as well as its effects on fertility rates.

What little work has been done on the subject in the social sciences started mostly during the 1970s, mainly in the United States.51 Interest in contraceptive sterilization arose in intimate association with a broader critique of the “export” of population control to so-called Third World countries and its application within the United States to particular groups of people (poor, black, indigenous, and Latino women).52 Allegations of abuses, by that time common in many underdeveloped areas (including India and Puerto Rico), began to resonate inside the United States as well.53 The interest of the social sciences in sterilization as a means of contraception developed in intimate relationship with the abuses that were being committed.

In Latin America and the Caribbean, most work dealing with sterilization has addressed sterilization among Puerto Rican or Brazilian women, populations among which the use of this surgery (given its high prevalence and the context within which this prevalence was attained) has become locally and internationally recognized as a problem.54 Most of this research has addressed sterilization among poor women for whom other alternatives are limited.55 More recently, some studies have addressed, from a historical point of view, the use of sterilization for contraceptive purposes in the United States and Canada over the second half of the 20th century, particularly the way in which eugenic sterilization constituted at times the only possible venue for contraceptive sterilization.56 Ian Dowbiggin (2008) has traced the propagation of the sterilization movement during the 20th century and the legitimization of the use of this surgery for contraceptive purposes.57

Primary Sources

In Costa Rica, the Archives of the Committee on Human Reproduction (CHR) of the Costa Rican College of Doctors and Surgeons (CDS), housed at the Costa Rican National Archives, and the Archives of the Costa Rican Legislative Assembly hold most information regarding the evolution of the regulation of the provision of sterilization.

For the promotion of laparoscopic sterilization in Costa Rica and other Latin American countries, important sources of information are The Association for Voluntary Sterilization Records, 1929–1981, housed at the Social Welfare History Archives at the University of Minnesota Libraries, and USAID documents, part of which are housed at the US National Archives Record Group 286. Many USAID documents can be consulted online at USAID Development Experience Clearinghouse.

Further Reading

  • Carranza, María. “Making Sense of Common Sense: Female Sterilisation in Costa Rica.” PhD diss., Cambridge University, 2003.
  • Carranza, María. “The Therapeutic Exception: Abortion and Sterilization in Costa Rica.” Developing World Bioethics 7, no. 2 (2007): 55–63.
  • Dalsgaard, Anne Line. Matters of Life and Longing. Female Sterilisation in Northeast Brazil. Copenhagen: Museum Tusculanum Press, 2004.
  • Dowbiggin, Ian. The Sterilization Movement and Global Fertility in the Twentieth Century. New York: Oxford University Press, 2008.
  • EngenderHealth. Contraceptive Sterilization: Global Issues and Trends. New York: EngenderHealth, 2002.
  • Hartmann, Betsy. Reproductive Rights & Wrongs: The Global Politics of Population Control, rev. ed. Boston: South End Press, 1995.
  • Henderson, Peta. “Population Policy, Social Structure and the Health System in Puerto Rico: The Case of Female Sterilization.” PhD diss., University of Connecticut, 1976.
  • Hunter de Bessa, Gina. “The Culture of Sterilization: Understanding the Desire for Female Surgical Sterilization Among Women in Brazil.” PhD diss., University of Illinois at Urbana-Champaign, 2001.
  • Lopez, Iris. “Sterilization among Puerto Rican Women: A Case Study in New York City.” PhD diss., Columbia University, 1985.
  • Pollack Petchesky, Rosalind. “‘Reproductive Choice’ in the Contemporary United States: A Social Analysis of Female Sterilization.” In And the Poor Get Children: Radical Perspectives on Population Dynamics, edited by Karen. L. Michaelson. New York: Monthly Review Press, 1981.
  • Presser, Harriet B. La Esterilización y el Descenso de la Fecundidad en Puerto Rico. New York: The Population Council, 1974.
  • Shapiro, Thomas. Population Control Politics. Women, Sterilization, and Reproductive Choice. Philadelphia: Temple University Press, 1985.

Notes

  • 1. United Nations, World Contraceptive Patterns 2013 (New York: United Nations, 2013).

  • 2. United Nations, World Contraceptive Patterns 2015 (New York: United Nations, 2015).

  • 3. In Latin America and the Caribbean, female sterilization accounts for 36 percent of contraception among married or in union women aged 15–49 (United Nations, World Contraceptive Patterns 2015). Most of the countries with the highest rates of female sterilization are located in this region (United Nations, World Contraceptive Patterns 2013).

  • 4. There is a significant body of literature that analyzes enforced sterilization for eugenic purposes. For eugenic sterilization in the United States, see Philip R. Reilly, The Surgical Solution: A History of Involuntary Sterilization in the United States (Baltimore: The Johns Hopkins University Press, 1991). In the case of enforced sterilization for public health motives in the United States, see Alexandra Minna Stern, “Sterilized in the Name of Public Health: Race, Immigration, and Reproductive Control in Modern California,” American Journal of Public Health 95, no. 7 (2005): 1128–1138. For enforced sterilization in Latin America, see Ainhoa Molina Serra, “Esterilizaciones (forzadas) en Perú: Poder y configuraciones narrativas,” Revista de Antropología Iberoamericana 12, no. 1 (2017): 31–52; Tamil Kendall and Claire Albert, “Experiences of Coercion to Sterilize and Forced Sterilization among Women Living with HIV in Latin America,” Journal of the International AIDS Society 18 (2015): 1–7. For enforced sterilization in minority women, see Ariadna Aguilera Rull and Marian Gili Saldaña, “La esterilización forzosa de mujeres romaníes en la República eslovaca: ¿no hay discriminación?” InDret 4 (2012): 1–22.

  • 5. United Nations, Trends in Contraceptive Use Worldwide 2015 (New York: United Nations, 2015), 30, fig. 17; MS, ADC, CCP, UNFPA, Informe de Resultados: II Encuesta Nacional de Salud Sexual y Salud Reproductiva. Costa Rica, 2015 (San José, Costa Rica, 2016), 31, table 5.2.

  • 6. Iván Molina and Steven Palmer, Historia de Costa Rica. Breve, actualizada y con ilustraciones, 3rd ed. (San José: Editorial Costa Rica, 2017). For a history of medical practice in Costa Rica from late colonial times to the 1940s, see Steven Palmer, From Popular Medicine to Medical Populism: Doctors, Healers, and Public Power in Costa Rica, 1800-1940 (Durham, NC: Duke University Press, 2003). For an account of the development of the social security system in Costa Rica, see Guido Miranda Gutiérrez, La Seguridad Social y el Desarrollo en Costa Rica, 2nd ed. (San José, Costa Rica: EDNASS/CCSS, 1994).

  • 7. Instituto Nacional de Estadística y Censos (INEC), X Censo Nacional de Población y VI de Vivienda 2011: Características Sociales y Demográficas (San José, Costa Rica: INEC, 2012), 303, table 48; data from 2016, Indicadores de la Seguridad Social 2012–2016 (San José, Costa Rica: Caja Costarricense de Seguro Social, 2017), 39, 7, table 1.

  • 8. The last data available indicate that in 1999, 69 percent of women in union and of reproductive age who were using contraceptives had received them from the public sector (Chen Mok et al., Salud Reproductiva y Migración Nicaragüense en Costa Rica 1999-2000: Resultados de una Encuesta Nacional de Salud Reproductiva (San José, Costa Rica: Copieco, 2001), 59, table 11; 77.8 percent of the women in union and of reproductive age using contraception are composed of the following: 22.7 percent on the pill; 3.2 percent using an IUD; 9.2 percent using injectables; 9.2 percent using male condoms; 2.7 percent using traditional methods; and 25.5 percent having female sterilization (MS, ADC, CCP, UNFPA, Informe de Resultados: II).

  • 9. MS, ADC, CCP, UNFPA, Informe de Resultados: II.

  • 10. The exception was those without any formal education among whom the prevalence of sterilization was considerably higher (Johnny Madrigal Pana, Esterilización Femenina en Costa Rica: Evolución, Impacto y Determinantes, master’s thesis, University of Costa Rica, 1995, 77, 78, 80, 81, tables 5.7, 5.8). It is important to mention, nonetheless, that illiteracy in Costa Rica was only 2.4 percent in 2011 (INEC, X Censo Nacional de Población, 17, 303, table 48).

  • 11. Chen Mok et al., Salud Reproductiva, 60, table 12. In comparison, in 1986 in Colombia, one of the countries with the highest prevalence of sterilization (United Nations, World Contraceptive Patterns 2013), 72 percent of these surgeries were provided by PROFAMILIA, a private non-profit family planning organization; see Timothy Williams, “An Evaluation of PROFAMILIA’s Female Sterilization Program in Colombia,” Studies in Family Planning 21 (1990): 251–264, 252.

  • 12. María Carranza, “Sobre una Relación ‘Prolífica’: El Papel de ‘la Salud’ en la Propagación de la Esterilización Contraceptiva en Costa Rica,” Dynamis 24 (2004): 187–212; and María Carranza, “Making Sense of Common Sense: Female Sterilisation in Costa Rica, PhD diss., Cambridge University, 2003.

  • 13. For an analysis of the reasons that move women in Costa Rica to request sterilization, see Carranza, “Making Sense of Common Sense.”

  • 14. Carranza, “Sobre una Relación ‘Prolífica.’

  • 15. Chen Mok et al., Salud Reproductiva, 56, note 3, table 7.

  • 16. Carranza, “Sobre una Relación ‘Prolífica.’

  • 17. The main data were obtained from the archives of the Committee on Human Reproduction of the College of Doctors and Surgeons of Costa Rica, available at the National Archives, and also by means of interviews conducted by the author over a 15-year period with gynecologists, nurses, and social workers who actively participated from the 1950s onward in the provision of female sterilization in Costa Rica, with women who sought sterilization, and with members of different women’s organizations who fought for the liberalization of this surgery.

  • 18. “Injury causing sterility” in Spanish is literally: “pérdida de la capacidad de engendrar o concebir”; Article 123 belongs to the 1970 Penal Code. Nonetheless, lesions causing sterility were also included as criminal acts in previous penal codes (1941 and 1918), albeit in different articles (202, 258, respectively); see Francisco Castillo, La Esterilización Voluntaria en el Derecho Penal Costarricense (San José, Costa Rica: PASDIANA, 1984), 7, n. 15.

  • 19. María Carranza, “Una política subrepticia: La provisión de la esterilización contraceptiva en Costa Rica,” Diálogos: Revista electrónica de historia 7 (2006): 208–241.

  • 20. Most of the gynecologists interviewed dated the introduction of sterilization in Costa Rica to the early 1940s, and indeed, some of the women interviewed recalled sterilization in their families as far back as that. Notwithstanding, it is reasonable to imagine that sterilizations could have been performed earlier if one takes into consideration that in places like Puerto Rico, its use (even for contraceptive purposes) dates back to the 1930s; see Harriet B. Presser, La Esterilización y el Descenso de la Fecundidad en Puerto Rico (New York: The Population Council: 1974), 26.

  • 21. The 1993 reproductive survey calculated that 10 percent of sterilizations were paid for (illegally) within the social security services; see Caja Costarricense de Seguro Social, Encuesta Nacional de Salud Reproductiva de 1993: Fecundidad y Formación de la Familia (San José, Costa Rica: Caja Costarricense de Seguro Social, Programa de Salud Reproductiva, 1994), table 10.8.

  • 22. Although arbitrary, the parameters used to grant women access to sterilization were not only established by Costa Rican doctors. The Manual of the American College of Obstetricians and Gynecologists (ACOG) recommended in its 1965 edition that in order for a woman to be sterilized, she had to be at least 25 years of age and have five children, 30 years old and have four living children, or 35 years old with three living children. These recommendations were known as the rule of thumb and, according to them, a woman’s age multiplied by the number of her children had to be equal to or greater than 120 in order for her to be sterilized. See Thomas Shapiro, Population Control Politics: Women, Sterilization, and Reproductive Choice (Philadelphia: Temple University Press, 1985), 87; and Harriet B. Presser, “Contraceptive Sterilization as a Grassroots Response: A Comparative View of the Puerto Rican Experience,” in Behavioral-Social Aspects of Contraceptive Sterilization, ed. Sidney. H. Newman and Zanved. E. Klein (Lexington, MA: Lexington Books, 1978), 40–41.

  • 23. See Tin Myaing Thein and Jack Reynolds, Esterilización Femenina en Costa Rica 1959–1969 (San José, Costa Rica: Universidad de Costa Rica, Centro de Estudios Sociales y de Población, 1973).

  • 24. The author uses the term “schools of thought” in the sense used by Charles E. Phelps, to denote the way in which beliefs and practices get established among particular groups of medical doctors (Charles E. Phelps, “Diffusion of Information in Medical Care,” Journal of Economic Perspectives 6, [1992]: 23–42, 31).

  • 25. As defined in the study, the “metropolitan area” included the central canton of San José province and eight surrounding cantons. In Costa Rica, provinces are divided into cantons; Miguel Gómez, Informe de la Encuesta de Fecundidad en el Área Metropolitana (San José, Costa Rica: Universidad de Costa Rica, Instituto Centroamericano de Estadística, 1968), 115, table 34.

  • 26. Miguel Gómez, Carlos Raabe, and Vera Bermúdez, Práctica Anticonceptiva y Uso de los Servicios de Planificación Familiar en Costa Rica Según Encuestas Recientes (San José, Costa Rica: Universidad de Costa Rica, Departamento de Estadística, Escuela de Ciencias Económicas. Asociación Demográfica Costarricense, 1971).

  • 27. See María Carranza, “‘In the Name of Forests’: Highlights for a History of Family Planning in Costa Rica,” Canadian Journal of Latin American and Caribbean Studies, 35, no. 69 (2010): 119–154; María Carranza, “A Brief Account of the History of Family Planning in Costa Rica,” in Demographic Transformations and Inequalities in Latin America, ed. Suzana Cavenaghi (Rio de Janeiro, Brazil: ALAP, 2009), 307–313.

  • 28. Mayone Stycos, Ideology, Faith, and Family Planning in Latin America: Studies in Public and Private Opinion on Fertility Control (New York: McGraw-Hill, 1971), 31–32; Carranza, “‘In the Name of Forests’.”

  • 29. Luis Rosero Bixby, El Descenso de la Natalidad en Costa Rica (San José, Costa Rica: Asociación Demográfica Costarricense, 1979), 4, 13; and Luis Rosero Bixby, “Determinantes de la Fecundidad Costarricense,” in Octavo Seminario Nacional de Demografia, September, 1983 (San José, Costa Rica: Asociación Demográfica Costarricense, Dirección General de Estadísticas y Censos, Escuela de Estadística Universidad de Costa Rica, Instituto de Estudios Sociales en Población, 1986), 70–71.

  • 30. No study has analyzed the attitude of the Catholic Church toward the introduction of family planning in Costa Rica. The evidence that the author collected points toward the absence of an intense opposition.

  • 31. In Latin America and the Caribbean, such exceptions are Puerto Rico and Panama, where as early as the 1960s, 35.5 and 23.3 percent of women in union using contraception were sterilized, respectively; see Mary Beth Weinberger, “Changes in the Mix of Contraceptive Methods During Fertility Decline: Latin America and the Caribbean,” in The Fertility Transition in Latin America, ed. José M. Guzmán, Susheela Singh, German Rodríguez, and Edith A. Pantelides (Oxford: Clarendon Press, 1996), 159, table 8.3; see Mayone Stycos, “Sterilization in Latin America: Its Past and Its Future,” International Family Planning Perspectives 10 (1984): 58–64, 58–59; and John A. Ross, Sawon Hong, and Douglas H. Huber, Voluntary Sterilization: An International Fact Book (New York: Association for Voluntary Sterilization, 1985).

  • 32. Thein and Reynolds signaled that sterilization was frequently disguised under a false “appendectomy” or, when performed during a cesarean section, not registered at all (Esterilización Femenina en Costa Rica 1959–1969, 2).

  • 33. Oscar Solís and Vilma Solís, Análisis de Ochocientas Veintidos Salpingectomías Realizadas en Hospital Dr. Calderón Guardia (San José, Costa Rica: Asociación Demográfica Costarricense, 1971).

  • 34. The social security system expanded significantly during the 1970s, as did the percentage of the population it covered; see Guido Miranda, La Seguridad Social y el Desarrollo en Costa Rica (San José, Costa Rica [EDNASSS/CCSS], 1988). See Carranza. “Una política subrepticia.”

  • 35. See Joseph Speidel, “The Role of Female Sterilization in Family Planning Programs,” in Female Sterilization: Prognosis for Simplified Outpatient Procedures, eds. Duncan Gordon, Richard Falb, and Joseph Speidel (New York: Academic Press, 1972), 93.

  • 36. USAID has been one of the main promoters as well as financers of the activities of population control. See Matthew Connelly, Fatal Misconception: The Struggle to Control World Population (Cambridge, MA: Belknap Press, 2008), 289. See also Peter Donaldson, Nature Against US: The United States and the World Population Crisis 1965–1980 (Chapel Hill: University of North Carolina, 1990); Betsy Hartmann, Reproductive Rights & Wrongs. The Global Politics of Population Control (Boston: South End Press, 1995); María Carranza. “The Seductive Laparoscope: or How This New Medical Technology Helped Propagate Female Sterilization in Costa Rica” (paper presented at the Hygiene/Creole Sciences Symposium, University of Manchester, September 2009).

  • 37. Carranza, “The Seductive Laparoscope.”

  • 38. Bogan and Carvajal, n.d., quoted in Miguel Gómez. “Aspectos Demográficos de la Esterilización Femenina en Costa Rica,” in Octavo Seminario Nacional de Demografía (San José, Costa Rica: Asociación Demográfica Costarricense, Dirección General de Estadísticas y Censos, Escuela de Estadística Universidad de Costa Rica, Instituto de Estudios Sociales en Población, 1986), 104, table 2; Luis Rosero Bixby, “Dinámica Demográfica, Planificación Familiar y Política de Población en Costa Rica,” Demografía y Economía 15 (1981): 59–84, 70, table 51.

  • 39. Session 177 of the Board of Government of the CDS, 9/8/1976, file 151, 51, archives CHR.

  • 40. Women were asked to request the surgery by means of a letter to the hospital.

  • 41. José Blanch, Zaday Pastor, and Carlos Prada, Estudio de Mujeres Esterilizadas (San José, Costa Rica: Asociación Demográfica Costarricense, 1975).

  • 42. Up to that time, and since at least 1976, the contraceptive pill had been the most prevalent method (Caja Costarricense de Seguro Social, Encuesta Nacional de Salud Reproductiva de 1993, 1994, 9–25, table 9.11).

  • 43. Caja Costarricense de Seguro Social, Encuesta Nacional de Salud Reproductiva de 1993, 10, table 10.2.

  • 44. Sala Constitucional de la Corte Suprema de Justicia, Voto No. 2196-92, August 11, 1992.

  • 45. International Conference on Population and Development, held in Cairo, Egypt, September 1994. It set out a plan of action for the next twenty years, with specific agreements in the field of reproductive health. For more details on the role played by women´s groups in the liberalization of sterilization in Costa Rica, see Carranza, “Sobre una Relación ‘Prolífica.

  • 46. At the time, discontent with the 1988 Decree was also evident among doctors.

  • 47. The decree was published in the government official newspaper, La Gaceta (June 9 1999); 18 is the age at which Costa Ricans acquire legal adulthood.

  • 48. By way of example, see Angela Ávalos, “Decreto disparó demanda: 1000 hacen fila en Hospital de las Mujeres,” La Nación, January 11, 2000, 1, 4A, San José, Costa Rica.

  • 49. In 2010, 30 percent of the women in union of reproductive age were sterilized. The reasons for the decrease in the percentage of women using sterilization in 2015 (25.5 percent) are still unclear given that the use of other contraceptive methods did not increase (Ministerio de Salud, Encuesta Nacional de Salud Sexual y Reproductiva, Costa Rica, 2010. Informe de resultados [San José Costa Rica: El Ministerio, 2011]).

  • 50. MS, ADC, CCP, UNFPA, 2016: 31, table 5.2.

  • 51. Puerto Rico and India constitute exceptions. In the former, increasing reliance on sterilization, starting in the 1930s, generated a significant amount of attention. For a review of the literature, see Peta Henderson, “Population Policy, Social Structure and the Health System in Puerto Rico: The Case of Female Sterilization” (PhD diss., University of Connecticut, 1976); Harriet Presser, La Esterilización y el Descenso de la Fecundidad en Puerto Rico: Asociación Colombiana para el Estudio de la Población (New York: The Population Council, 1974). For a more recent interpretation, see Laura Briggs, Reproducing Empire: Race, Sex, Science, and U.S. Imperialism in Puerto Rico (Berkeley, CA: University of California Press, 2002); and Lourdes Lugo-Ortiz, “Relatos de la Esterilización: Entre el Acomodo y la Resistencia,” Revista de Ciencias Sociales 6 (1999): 208–226. In India, the government promoted sterilization, mostly vasectomies, from the 1950s on. Enforced vasectomies brought India global attention during the 1970s.

  • 52. See Shapiro, Population Control Politics; Iris Lopez, “Sterilization among Puerto Rican Women: A Case Study in New York City” (PhD diss., Columbia University, 1985).

  • 53. Claudia Dreifus, “Sterilizing the Poor,” The Progressive 39 (1975): 13–19; Helen Rodriguez Trias, “Sterilization Abuse,” Women and Health 3 (1977): 10–15.

  • 54. Much has been published about sterilization in Brazil from a “quantitative” point of view.

  • 55. See Suzanne Serruya, Mulheres Esterilizadas: Submissão e Desejo (Belem. Brazil: NAEA/UFPA/UEPA, 1996); Gina Hunter de Bessa, “The Culture of Sterilization: Understanding the Desire for Female Surgical Sterilization Among Women in Brazil” (PhD diss., University of Illinois at Urbana-Champaign, 2001); Anne Line Dalsgaard, Matters of Life and Longing. Female Sterilisation in Northeast Brazil (Copenhagen: Museum Tusculanum Press, 2004). For an analysis of the possible reasons for this lack of attention, see Carranza, “Making Sense of Common Sense.”

  • 56. Rebecca, Kluchin, Fit to Be Tied: Sterilization and Reproductive Rights in America, 1950–1980 (New Brunswick, NJ: Rutgers University Press, 2009); Johana Schoen, Choice & Coercion: Birth Control, Sterilization, and Abortion in Public Health and Welfare (Chapel Hill: University of North Carolina Press, 2005); Molly Ladd-Taylor, “Contraception or Eugenics? Sterilization and ‘Mental Retardation’ in the 1970s and 1980s,” CBMH/BCHM 31 (2014): 189–211; Erika Dyck, “Sterilization and Birth Control in the Shadow of Eugenics: Married, Middle-Class Women in Alberta, 1930–1960s,” CBMMH/BCHM 31 (2014): 165–187.

  • 57. Ian Dowbiggin, The Sterilization Movement and Global Fertility in the Twentieth Century (New York: Oxford University Press, 2008).