In Kenya, doctors are force-sterilizing HIV-positive women—in some cases, without their knowledge.
Image courtesy Karl Mueller
I met Ruth and Priscka at Women Fighting Aids (WOFAK) in Kenya, one of the country’s first HIV advocacy organizations. Their Nairobi offices are in a modest, two-story building under the shadow of an imposing Baptist church next door. There could hardly be so odd a pair: Priscka was a tiny, bony figure who walked with a pronounced limp, her small frame jarred by each step she took. Ruth was a tall, curvaceous woman with an impressive mound of braided hair, who waltzed through WOFAK’s door, high-fiving staff members as she passed. Friendships are usually born of common circumstance. For Ruth and Priscka, it was one born from misfortune.
When Pricksa woke up from her surgery, she had a lot of pain in her stomach, below the scar from her C-section. So she flagged down a doctor and demanded an explanation. “Didn’t you know?” she remembers a passing doctor responding casually. “You’ve had tubal ligation.”
“Doc told me I was HIV-positive, and no reason to get more children,” Ruth told me. Ruth had been a fruit vendor, but she was fired when her boss found out she was HIV-positive. Ruth had dreamed of having five children, but the miscarriage of her third child changed that. She was hospitalized after the miscarriage, and her doctors told her she needed surgery. She assumed it was meant to treat the trauma she had just suffered. “I didn’t know anything,” Ruth said, “They didn’t tell me anything.” When she woke up, she had been sterilized, her fallopian tubes seared shut.
Like Ruth, Priscka experienced pregnancy complications with her third child; she was taken to the hospital in agony by her mother and rushed to an operating room for an emergency C-section. Priscka had likely never heard of the United Nations Human Rights Committee, which calls forced sterilization a form of torture, and was probably not aware that forced sterilization is also considered a crime against humanity under the Rome Statute.
But when she woke up from her surgery, she knew something was wrong. She had a lot of pain in her stomach below the scar from her C-section. So she flagged down a doctor and demanded an explanation.
“Didn’t you know?” she remembers a passing doctor responding casually. “You’ve had tubal ligation.”
Priscka did not know. She had never even heard of tubal ligation until that moment. She was disabled and unemployed, and lived in one of Africa’s largest slums. Because she spoke only broken English, she asked for a translation into Swahili. The word she was given was kufunga, closing. Having children could only “bring problems to her community,” she recalls her doctor saying, because she was infected with HIV.
There is a Swahili word for women who cannot be mothers: ukebe. It means “empty can.” And when the men in Priscka and Ruth’s lives realized they had “empty cans” for partners, they did what one does with useless articles.
They threw them away.
Priscka and Ruth live in a society which ties a woman’s value to her ability to give birth, a society where children are not only cherished as blessings from God but are also a form of social security: they can help around the house or the family business and take care of their parents when they grow old. For women like Priscka and Ruth, a large family was not a burden. It was hedging one’s bets. People here don’t marry for love, one Kenyan woman told me. They marry to have children.
There is a Swahili word for women who cannot be mothers: ukebe. It means “empty can.” And when the men in Priscka and Ruth’s lives realized they had “empty cans” for partners, they did what one does with useless articles. They threw them away.
In Nairobi’s most famous shantytown, Kibera, you can buy anything you like. You can go to the butcher, visit a pharmacy, or purchase a sofa. All these routine things are possible, which almost lends the slum an air of normality. But it is not normal: there are feces lying in coagulated pools of water; there is a small child playing with a plastic container in a filthy white dress; there is a dead dog by the side of the road baking in the heat, legs stretched out as if sunbathing.
Kibera is Ruth and Priscka’s home, and the place where the government had requested a panel convene to investigate the AGMI’s reports that coerced sterilization “appeared to be systemic” in state-run hospitals. A specialist in reproductive health from the Ministry of Health headed the three-doctor panel. He opened the session by looking at his watch, shifting uncomfortably in his chair, and asking, “Can we make this quick? It’s Friday.” The thirty-five women who showed up to the little concrete compound in the slums to testify obligingly stood up one by one, introduced themselves, and tried to contain the stories of their lives collapsing to exactly two minutes each. The chief doctor hurried them along as politely as his impatience would allow.
His attitude to the affair may have seemed casual, yet, as I told friends and family back home about the story, it was hard to ignore a certain sympathy that sometimes cropped up for these embattled surgeons. A woman turns up at their hospital in the throes of labor, perhaps one of the few times she will ever visit a formal medical institution. She is HIV-positive, uneducated, maybe physically disabled. She is scraping by in a shantytown or relying on the charity of others. Life is brutish, nasty and short. What does she have to offer her unborn children?
A number of women told me they had taken their doctor’s recommendation to stop giving birth seriously, and would have considered other family planning solutions. But they were denied that option, and they did not understand why.
These attitudes aren’t limited to the developing world: indeed, forced sterilization is, in a way, a Western invention. Just over one hundred years ago, the procedure enjoyed unprecedented popularity in the state I was born in. California began neutering the “feebleminded,” “habitual criminals,” “insane,” “idiots,” and “mental deficients” in 1909, just two years after the practice was legalized in Indiana—the first place in the world to allow the surgery. Washington State also legalized it in 1909, but later included “moral degeneracy” as a pretense for sterilization—as did many of the other thirty-odd states which at some point or another adopted sterilization policies. Alexander Graham Bell, the inventor of the telephone, and Irving Fisher, the eminent economist, sat on the scientific board at the Eugenics Records Office, the main research and propaganda hub for the eugenics movement and the origin of the “Model Forced Sterilization” law that served as a template for many of the states that adopted the policy. The Eugenics Record Office (ERO) received funding from John Harvey Kellogg (who in addition to inventing Cornflakes, also founded the eugenics-focused Race Betterment Foundation) and for around a decade, the Carnegie Institute assumed full responsibility for the ERO’s expenses, at about $25,000 a year, or roughly $486,000 today. Even Martha Gellhorn, the strident opponent of Fascism and the darling of foreign correspondents everywhere, lamented a North Carolina doctor she encountered in 1934 who “refused to sign sterilization warrants” for “imbeciles” because “[i]t’s a man’s prerogative to have children.” In a compilation of her works and letters, The View From the Ground, Gellhorn listed this among “tragic” medical scenarios, although perhaps she would have been encouraged by the fact that North Carolina’s eugenics program lasted until 1974. In fact, between 1907 and 1981, over 60,000 Americans were sterilized under laws that would partly inspire similar programs Nazi Germany.
But forced sterilization in the United States was not necessarily conducted or supported by advocates of genocide. It was encouraged by gentlemanly scientists, intellectuals, and philanthropists, and carried out by doctors who no doubt genuinely believed they knew best. Like the three doctors sitting in front of me in Kibera, luminaries in their field of reproductive health, who checked their watches as the women stumbled through stories of their misery.
The African Gender and Media Initiative (AGMI), a Kenyan NGO focusing on women’s rights, launched an investigation into the forced sterilization of HIV-positive women in Kenya in the fall of 2011, speaking to hundreds of women in HIV support groups in three regions of the country. One year later, the report, the first of its kind in Kenya, revealed that forced sterilization “appears to be systemic” in Kenya’s state run hospitals. It concluded that health care providers in Kenya had violated the reproductive rights of their patients by forcing them into unwanted surgery, misinforming the women about the procedure, working with families and spouses to pressure them into accepting it, and threatening to withhold life-saving antiretroviral medication and breast milk if they did not.
In addition, many of the forty women interviewed for the report had been abandoned by their husbands after their surgeries, even though in some cases, the men had signed consent forms for their wives to undergo the procedure. One woman claimed in the report that her husband took her to the hospital for a “family planning surgery.” Although she had no idea what that meant, she said she was scared her husband would beat her if she asked. She finally learned about the sterilization from a nurse during a medical check-up, three days after the surgery had taken place.
Abuse is a common thread throughout the testimonies: one woman claims that her husband threatened to cut her to pieces with a machete after he found out she could no longer give birth.
Another woman in the report said doctors persuaded her husband to sign the consent form because she had a history of stillbirth. Her husband told her the procedure was for her own good, then became serially abusive after the surgery, telling her repeatedly that she had a “rotten stomach.”
Abuse is a common thread throughout the testimonies: one woman claims that her husband threatened to cut her to pieces with a machete after he found out she could no longer give birth. Another woman, with claims of being bullied by medical staff into consenting to the surgery during labor, was abandoned at the hospital by her husband and mother after they discovered she had been sterilized. Her baby died a few hours after birth; her family refused to bury it.
I asked Ruth and Priscka if they had experienced any physical side effects. They said the surgery had wreaked havoc on their bodies such that it prevented them from engaging in almost any kind of work available to women living in the slums of Nairobi.
Ruth was trying to scrimp by cleaning clothes, but she had one major handicap: since her “TL,” as she referred to it, she could no longer climb stairs, which meant she could only work in one-story homes. Priscka, too, suffered from crippling backaches and nausea. She worked, when she could, for a volunteer organization helping people with disabilities, in exchange for food when she had none to give her children. Otherwise, at thirty-one, she was entirely dependent on her mother.
This pain has puzzled doctors and advocates. According to Beatrice Kirubi, a Kenyan doctor with Doctors Without Borders (known by its French acronym MSF), this surgery is a minor procedure that should not have any serious side effects. Carol Odada, a program officer for Women Fighting Aids In Kenya, explained that there was no conclusive evidence linking Ruth and Priscka’s surgeries to their present physical state. Odada doesn’t understand why the side effects of the surgery were so severe in the cases of the women included in the AGMI report, which she helped compile. She said she had never heard of consensual operations having such repercussions.
Nonetheless, ten of the women in the report testified to having symptoms similar to Ruth and Priscka’s. The complaints included lower abdominal pains, the inability to walk long distances or lift heavy objects, irregular menstrual cycles, and in one case, incontinence. One woman said in the report that her stomach had swollen permanently after the surgery to such an extent that people frequently mistook her for pregnant. But linking those symptoms conclusively to the tubal ligation was difficult to do, Odada said. Several of the women, including Ruth, have been refused access to their medical files.
According to the AGMI report, most of the sterilizations have occurred in public hospitals in Kenya. But the phenomena did not seem to be exclusive to them; several women testified to the AGMI that they had been coerced into being sterilized at clinics run by Marie Stopes International, a global not-for-profit family planning organization based in the United Kingdom. Marie Stopes has promised to investigate the claims, and sent me a statement claiming that if the allegations were accurate, they would be “wholly inconsistent with our principles of voluntarism, informed choice, and informed consent.”
Another woman told AGMI that an employee of an MSF clinic advised her that she would be denied her breast milk supply and antiretroviral medication if she did not undergo tubal ligation. Dr. Kirubi said MSF does not perform the procedure itself, but has referred patients to a network of partners who did. A team from Paris is examining records of MSF partners in Kenya, and has not yet found any evidence that any of the surgeries were coerced. But it is very difficult, Dr. Kirubi added, to retroactively establish whether consent was given, especially when some of the allegations date back several years.
For some time after, she clung to the belief that she would one day be able to bear a child; but, she told me, the procedure left her without a sex drive or regular menstrual cycle.
According to Odada, the problem appeared to extend beyond the women quoted in the report. “We used the testimonies of forty women who were very sure that they had been forcibly sterilized. But there were more than a hundred women in our focus group in Nairobi,” said Odada. They or their families were told by doctors that sterilization was necessary because of their HIV status. But the science behind their logic is shaky: according to the World Health Organization and UNAIDS, women with HIV are at minimal risk—less than 5 percent—of transmitting HIV to their child if they are given antiretroviral medication during their pregnancy and if they do not breastfeed. (If these precautions are not taken, the risk of transmission is of course higher.)
But that nuance can be easily lost. “Many of them don’t know their rights,” Odada said of the women her organization interviewed, “and just believe their doctors. We have a saying here: the doctor is a second god.”
After the panel session, the women milled around outside the concrete barracks. I couldn’t tell by their demeanor if they had registered the doctors’ apathy, nor whether reliving their experiences was cathartic or traumatic. What I did sense as I chatted to them afterwards was resentment—resentment that their right to decide their own future had been unilaterally taken away. A number of women told me they had taken their doctor’s recommendation to stop giving birth seriously, and would have considered other family planning solutions. But they were denied that option, and they did not understand why. Nonetheless, not one woman who I spoke to that day wanted sympathy; several did, however, use the opportunity to ask me to find them work, or to peddle me their goods (would I like to buy a shell purse, or three?). Getting by in the slums requires hustle, and hustle leaves no time for self-pity.
But there was a little time for hope. Lorna Nyandat, a lawyer for KELIN, the Kenya Legal and Ethical Issues Network on HIV & AIDS, told me she had come to the Kibera panel to gather evidence in the hopes of suing the government and the health facilities singled out in the AGMI report, inspired by a Namibian court that recently ruled that three women who had alleged forced sterilization had indeed been operated on without their consent. KELIN hopes to find a high-profile Kenyan advocate to argue up the case, but KELIN is waiting to file until the Ministry of Health finalizes its report—and until it can find a doctor willing to conduct medical examinations of the victims and to testify about the physical impact of the operation on their bodies. KELIN has contacted four Kenyan doctors to ask them to participate, but they refused.
Joyce, a participant in the Kibera hearing, said the ordeal shook faith in the medical profession in Kenya. She told me that her husband wanted her to be sterilized because they were both HIV-positive; she, on the other hand, told her doctor that she steadfastly opposed the idea. But according to Joyce, the doctor had simply responded by calling her husband “very knowledgeable” and giving him consent forms to sign. The doctor also assured her that some women went on to give birth even after undergoing the procedure. Buoyed by that promise—and embattled by family pressure—Joyce underwent the surgery. For some time after, she clung to the belief that she would one day be able to bear a child; but, she told me, the procedure left her without a sex drive or regular menstrual cycle. Eventually, she realized that she would never give birth again. “The doctor was on my husband’s side,” she said, “I can’t give birth now.”
Sara Mojtehedzadeh is a journalist currently working for the Daily Nation in Nairobi, Kenya, as an Aga Khan Foundation of Canada media fellow. Previously, she worked at Sky News in the United Kingdom. Her work has been published by the Guardian, Tehran Bureau, and openDemocracy among others.