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Violating Women’s Rights: Forced Sterilization, Population Control and HIV/AIDS

FRIDAY FILE – Last July, a high court sentenced the Namibian state for the forced sterilization of three HIV-positive women. In Uzbekistan, authorities continue to deny reported cases. AWID looks into forced sterilizations in both countries and what it means for women’s reproductive rights.

By Ani Colekessian*

Though sterilization can be an effective family planning option for many women, when performed without their prior and full informed consent, it is a serious violation of women’s human rights, specifically their sexual and reproductive health and rights (SRHR). The outcome of the 2012 Commission on the Status of Women (CSW56) on SRHR in which fundamentalist backlash blocked the Agreed Conclusions and – more recently – the 46thsession of the Commission on Population and Development (CPD46) in which SRHR language was watered down, are examples of some of the contentions that continue to exist in ensuring that women, especially young women, have universal access to SRHR. As the women’s movement struggles to maintain existing agreed upon rights, it is important to pay careful attention to policies and practices that undermine such rights.

Forced sterilization, a coercive family planning method, which involves surgically removing or disabling reproductive organs without full or informed consent, is a clear violation of bodily integrity and autonomy. According to Radhika Coomaraswamy, former UN Special Rapporteur on Violence Against Women, “forced sterilization is a method of medical control…essentially involving the battery of a woman – violating her physical integrity and security, forced sterilization constitutes violence against women.”

Manipulating a woman’s body against her will takes away her agency to make choices about her body, including the number of children she will have; and is a violation of fundamental rights, including the right to health, that are supposed to be protected by international treaties and instruments, including: the International Covenant on Civil and Political Rights (Article 7); the Convention on the Elimination of All Forms of Discrimination Against Women (Articles 10h, 12, 16e, Gen. Rec. 19); and the Beijing Declaration and the Platform for Action (Women and Health par., 94). And within the confines of a systematic or widespread attack, the Rome Statute, which specifically identifies forced sterilization as a crime against humanity.

Discriminatory practices are central to forced sterilization, which are often prescribed to young women living with HIV/AIDS, gender non-conforming women, young women and girls with disabilities and indigenous women (among others), who are often forced into sterilization and other procedures. In Uzbekistan, population control has meant that many such women are at risk of sterilization, while Namibia has evidenced clear discrimination against women living with HIV/AIDS and forced into sterilization.

Uzbekistan: Population Control

Despite media reports and concern raised in the United Nations Committee Against Torture (CAT), Uzbek authorities continue to deny the reality of forced sterilization in their country. Until a recent two-month long investigation by the BBC and Radio 4, there has been very little reporting on these human rights abuses. In a political environment in which dissent is not tolerated,[i] this has also meant that interviews with affected women, doctors and health ministry officials are scarce and generally anonymous.

The cases that have been documented suggest that the surgical procedure is often done during pregnancy labour. Several physicians acknowledged a recent rise in Caesarean sections (C-sections). One chief surgeon believes the number to be upward of 80% of pregnancies, he adds, “this makes it very easy to perform a sterilization and tie the fallopian tubes.” Another doctor specifically referred to “ruling 1098 [ii]…and it says that after two children, in some areas after three, a woman should be sterilized.”

Forced sterilization in Uzbekistan is thought to be part of a population control programme. With a population of almost 30 million it is the largest in Central Asia; and considering other Uzbek government attempts to regulate births, including quotas which physicians are required to meet to curb the high fertility rate [iii], the theory is not unlikely. A gynaecologist from Tashkent told the BBC, “Every doctor is told how many women we are expected to give contraception to; how many women are to be sterilised…there is a quota. My quota is four women a month.”

A concerning trend is that family planning and reproductive rights language is being manipulated against the very principles they stand for. SRHR implies sexual and reproductive choice, free from violence or coercion; Uzbekistan’s Improvement of Mother and Child Health Services programme, a joint effort with UNICEF and the European Union, seeks to “improve quality of care for mothers and children, and promote health-seeking practices among families and communities,” but the reality seems to have had the adverse effect. To achieve reproductive health goals, the government appears to have pushed for a quick-fix approach that violates women’s bodies and autonomy as a way to “protect” maternal health. "It's a simple formula – less women give birth, less of them die," said one surgeon in the BBC report. So instead of supporting real SHRH as a more sustainable and rights based option through access to services and information, including access to diverse family planning options, the Uzbekistan government is missing the point.

Namibia: High HIV/AIDS Rates

In Namibia, a country with a significant prevalence of HIV/AIDS cases, the high court ruling, which sentenced the state for the forced sterilization of three HIV-positive women, is just a small step toward justice. A government appeal was lodged last September and the claim that the forced-sterilization was related to the women’s HIV-status – a clear example of HIV-discrimination – was dismissed on the basis of inconclusive evidence.

In each of the three cases, the women were told that sterilization was a requirement for labour, thereby coercing their consent. While the court was unable to link the abuses to HIV-discrimination, between 2008-2012 the Legal Assistance Center, a Namibian public interest law firm based in Windhoek, documented 15 cases of women with HIV who were forcibly sterilized. The International Community of Women Living with HIV/AIDS (ICW) further documents 40 cases in its 2009 report on The Forced and Coerced Sterilization of HIV Positive Women in Namibia.

Judicially recognizing that women are being sterilized without their consent is an important step toward justice, but it fails to address a legislative knowledge-gap in SRHR – a cause for disappointment on top of the court’s refusal to acknowledge the related HIV-discrimination and a government unwilling to accept responsibility.

The ICW report concludes, “the government of Namibia is complicit in the unethical practice of sterilizing [HIV] positive women.” A point that has been further argued by Jennifer Gatsi-Mallet in a 2012 Think Africa Press report in which she explains how doctors and an HIV programme officer revealed they had been sterilizing (without consent) under the directive of health ministry guidelines. They further explained that parameters are based on the World Health Organisation (WHO) advices “to ensure that women getting infected would not get pregnant and infect their babies.” Interestingly, according to Think Africa Press, only one WHO publication on HIV/AIDS significantly speaks to sterilization, indicating that “special care must be taken to ensure that every woman makes a voluntary informed choice of method…health care workers should ensure that women are not pressured or coerced to undergo the procedure.” Still, the health ministry denies having issued directives to sterilize women with HIV or having knowledge that forced sterilizations were taking place in the country.

As in Uzbekistan, SHRH language (in this case from the WHO) is being coopted to serve a government “health” strategy that lacks a sustainable and rights based approach. Language that is meant to provide women with choice, information and access to SRHR services is manipulated to drive state-sponsored violations of women’s bodies and their fundamental rights. Instead of responding to the spread of HIV with real solutions, including access to SRHR information, education and diverse family planning options, the state-regulated “quick-fix” undermines basic human rights principles; stripping women of their bodily rights, their right to health, their autonomy and their security.

Access to information and long-term solutions

While the alleged reasons for forced sterilization in both countries are different, the outcome for women is the same: gross abuses of their bodies and rights. Instead of addressing the real issues that underlay over-population and rising HIV/AIDS rates, forced sterilization becomes a superficial measure for government-control; all the while violating women and the international agreements that seek to protect them.

In Uzbekistan, awareness of family planning options is limited. A maternal and child health worker revealed in a recent IWPR report that “these are taboo subjects…so instead of educating the public, the government [is] taking the simple path of reducing the birth rate by force.”

In Namibia, deep-seeded gender inequalities have meant imbalanced power-relations in which men dictate contraception use, leaving women “especially at risk for contracting HIV because, as a rule, their relatively weak social and economic positions inhibit them from avoiding sex with an HIV/STIs infected partner or enforcing the use of condoms.”

In both cases, supporting women’s rights organizations that are working to increase awareness on SRHR and understand the reality of gender power-imbalances, working with both women and men to overcome global challenges like over-population and the spread of HIV/AIDS, is a real solution that protects women and their fundamental rights above all.

*The author would like to thank Marisa Viana for her input.

[i] According to a report by Open Society Foundation, few women who have undergone forced sterilization are willing to speak out for fear of retribution.

[ii] No documentation of “ruling 1098” available at time of writing

[iii] Measures from President Islam Karimov's Decree No. PP-1096on additional measures to protect the health of the mother and child, the formation of a healthy generation.