Holdren stated in his confirmation hearing that he no longer supports the creation of an optimum population by the U.S. government. [ 20 ]  However, the population control policies suggested in the book are indicative of the concerns about  overpopulation , also discussed in  The Population Bomb  a book written by  Paul R. Ehrlich  and Anne Ehrlich predicting major societal upheavals due to  overpopulation . As this concern about overpopulation gained political, economic, and social currency, attempts to reduce fertility rates, often through compulsory sterilization, were results of this drive to reduce overpopulation. [ 21 ]  These coercive and abusive population control policies impacted people around the world in different ways, and continue to have social, health, and political consequences, one of which is lasting mistrust in current family planning initiatives by populations who were subjected to coercive policies like forced sterilization. [ 22 ]  Population control policies were widely critiqued by women's health movement in the 1980s and 1990s, with the International Conference on Population and Development in 1994 in Cairo initiating a shift from population control to  reproductive rights  and the contemporary  reproductive justice  movement. [ 23 ] [ 24 ]  However, new forms of population control policies, including coercive sterilization practices are a global issue and a reproductive rights and justice issue. [ 25 ]


The  Istanbul Convention  prohibits forced sterilization in most European countries (Article 39). [ 26 ]
Widespread or systematic forced sterilization has been recognized as a  Crime against Humanity  by the  Rome Statute of the International Criminal Court  in the explanatory memorandum. This memorandum defines the jurisdiction of the  International Criminal Court . [ 27 ] [ 28 ]  It does not have universal jurisdiction, with the United States, Russia and China among the countries to exclude themselves. [ 29 ]  Rebecca Lee wrote in the  Berkeley Journal of International Law  that, as of 2015 [update] , twenty-one  Council of Europe  member states require proof of sterilization in order to change one's  legal sex  categorization. Lee wrote that requiring sterilization is a human rights violation and that LGBTQ-specific international treaties may need to be developed in order to protect LGBTQ human rights. [ 30 ]


Bangladesh  has a long-running government-operated civilian sterilization program as a part of its population control policy, which targets mainly poor women and men. The government offers 2,000  Bangladeshi Taka  (US$18) for women who are persuaded to undergo  tubal ligation  and for men who are persuaded to undergo  vasectomy . Women are also offered a  sari  and men are offered a  kurta  to wear for undergoing sterilization. The referrer, who persuades the woman or man to undergo sterilization gets 300 Bangladeshi Taka (US$2.70). [ 31 ]


In 1965, the targeted number of sterilizations per month was 600–1,000 in contrast to the insertion of 25,000  IUDs , which was increased in 1978 to about 50,000 sterilizations per month on average. [ 32 ]  A 50% rise in the amount paid to men coincided with a doubling of the number of vasectomies between 1980 and 1981. [ 33 ]


One study conducted in 1977, when incentives were only equivalent to US$1.10 (at that time), indicated that between 40% and 60% of the men chose vasectomy because of the payment, who otherwise did not have any serious urge to get sterilized. [ 34 ]


The "Bangladesh Association for Voluntary Sterilization", alone performed 67,000 tubal ligations and vasectomies in its 25 clinics in 1982. The rate of sterilization increased 25 percent each year. [ 35 ]


On 16 December 1982, Bangladesh's military ruler  Lieutenant General   Hussain Muhammad Ershad  launched a two-year mass sterilization program for Bangladeshi women and men. About 3,000 women and men were planned to be sterilized on 16 December 1982 (the opening day). Ershad's government trained 1,200 doctors and 25,000 field workers who must conduct two tubal ligations and two vasectomies each month to earn their salaries. The government wanted to persuade 1.4 million people, both women and men to undergo sterilization within two years. [ 36 ]  One population control expert called it 'the largest sterilization program in the world'. [ 37 ]  By January 1983, 40,000 government field workers were employed in Bangladesh's 65,000 villages to persuade women and men to undergo sterilization and to promote usage of birth-control across the country. [ 35 ]


Food subsidies under the group feeding program (VGF) were given to only those women with certificates showing that they had undergone tubal ligation. [ 38 ]


There are reports that often when a woman had to undergo a  gastrointestinal surgery , doctors took this opportunity to sterilize her without her knowledge. [ 39 ]  According to Bangladesh governmental website "National Emergency Service", the 2000 Bangladeshi Taka (US$24) and the sari/lungi given to the persons undergoing sterilizations are their " compensations ". Where Bangladesh government also assures the poor people that it will cover all medical expenses if complications arise after the sterilization. [ 40 ]


For the women who are persuaded to have IUD inserted into  uterus , the government also offers 150 Bangladeshi Taka (US$1.80) after the procedure and 80+80+80=240 Bangladeshi Taka (0.96+0.96+0.96=2.88 USD) in three followups, where the referrer gets 50 Bangladeshi Taka (US$0.60). And for the women who are persuaded to have  etonogestrel birth control implant  placed under the skin in upper arm, the government offers 150 Bangladeshi Taka (US$1.80) after the procedure and 70+70+70=210 Bangladeshi Taka (0.84+0.84+0.84=2.52 USD) in three followups, where the referrer gets 60 Bangladeshi Taka (US$0.72). [ 31 ]


In the 1977 study, a one-year follow-up of 585 men sterilized at vasectomy camps in Shibpur and Shalna in rural Bangladesh showed that almost half of the men were dissatisfied with their vasectomies. [ citation needed ]


58% of the men said their ability to work had decreased in the last year. 2–7% of the men said their sexual performance decreases. 30.6% of the Shibpur and 18.9% of the Shalna men experienced severe pain during the vasectomy. The men also said they had not received all of the incentives they had been promised. [ 34 ]


According to another study on 5042 women and 264 men who underwent sterilization, complications such as painful urination, shaking chills, fever for at least two days, frequent urination, bleeding from the incision, sore with pus, stitches or skin breaking open, weakness and  dizziness  arose after the sterilization. [ citation needed ]


The person's sex, the sponsor and workload in the sterilization center, and the dose of  sedatives  administered to women were significantly associated with specific postoperative complaints. Five women died during the study, resulting in a death-to-case rate of 9.9/10,000 tubectomies (tubal ligations); four deaths were due to  respiratory arrest  caused by overuse of sedatives. The death-to-case rate of 9.9/10,000 tubectomies (tubal ligation) in this study is similar to the 10.0 deaths/10,000 cases estimated on the basis of a 1979 follow-up study in an Indian female sterilization camp. The presence of a complaint before the operation was generally a good predictor of postoperative complaints. Centers performing fewer than 200 procedures were associated with more complaints. [ 41 ]


According to another study based on 20 sterilization-attributable deaths in  Dacca  (now Dhaka) and  Rajshahi  Divisions in Bangladesh, from 1 January 1979, to 31 March 1980, overall, the sterilization-attributable death-to-case rate was 21.3 deaths/100,000 sterilizations. The death rate for vasectomy was 1.6 times higher than that for tubal ligation.  Anesthesia  overdosage was the leading cause of death following tubal ligation along with  tetanus  (24%), where intraperitoneal hemorrhage (14%), and infection other than tetanus (5%) was other leading causes of death. [ citation needed ]


Two women (10%) died from  pulmonary embolism  after tubal ligation; one (5%) died from each of the following:  anaphylaxis  from anti-tetanus serum,  heat stroke ,  small bowel obstruction , and aspiration of vomitus. All seven men died from scrotal infections after vasectomy. [ 42 ]


According to a second epidemiologic investigation of deaths attributable to sterilization in Bangladesh, where all deaths resulting from sterilizations performed nationwide between 16 September 1980 and 15 April 1981, were investigated and analyzed, nineteen deaths from tubal ligation were attributed to 153,032 sterilizations (both tubal ligation and vasectomy), for an overall death-to-case rate of 12.4 deaths per 100,000 sterilizations. This rate was lower than that (21.3) for sterilizations performed in Dacca (now Dhaka) and Rajshahi Divisions from 1 January 1979 to 31 March 1980, although this difference was not statistically significant. Anesthesia overdosage, tetanus, and  hemorrhage  (bleeding) were the leading causes of death. [ 43 ]


These civilian sterilization programs are funded by the countries from  northern Europe  and the  United States . [ 39 ]   World bank  is also known to have sponsored these civilian exploitative sterilization programs in Bangladesh. Historically, World Bank is known to have pressured 3rd World governments to implement population control programs. [ 44 ]


Bangladesh has the highest  population density  in the world among the countries having at least 10 million people. The capital Dhaka is the 4th  most densely populated city  in the world, which ranked as the world's 2nd most unlivable city, just behind  Damascus ,  Syria , according to the annual " Liveability Ranking " 2015 by the  Economist Intelligence Unit  (EIU). [ 45 ] [ 46 ]


Bangladesh is planning to introduce a sterilization program in its overcrowded  Rohingya  refugee camps, where nearly a million refugees are fighting for space, after efforts to encourage birth control failed. Since 25 August 2017, more than 600,000 Rohingya Muslims have fled from  Rakhine state ,  Myanmar  to neighboring Bangladesh, which is a Muslim majority country, following a military crackdown against Rohingya Muslims in Rakhine. Sabura, a Rohingya mother of seven, said her husband believed the couple could support a large family. [ 47 ]


I spoke to my husband about birth control measures. But he is not convinced. He was given two condoms but he did not use them. My husband said we need more children as we have land and property (in Rakhine). We don't have to worry to feed them.


District family planning authorities have managed to distribute just 549 packets of condoms among the refugees, amid reports they are reluctant to use them. They have asked the government to approve a plan to provide vasectomies for men and tubectomies (tubal ligation) for women in the camps. [ 47 ]


One volunteer, Farhana Sultana, said the women she spoke to believed birth control was a sin and others saw it as against the tenets of Islam. [ 47 ]


Bangladeshi officials say about 20,000 Rohingya refugee women are pregnant and 600 have given birth since arriving in the country, but this may not be accurate as many births take place without formal medical help. [ 47 ]


Every month 250 Bangladeshis undergo sterilization routinely under the government's sterilization program in the border district of  Cox's Bazar , where the Rohingya refugee Muslims have taken shelter. [ 47 ] [ 48 ]


During the 1970s–80s, the U.S. government sponsored family planning campaigns in Brazil, although sterilization was illegal at the time there. [ 49 ]  Dalsgaard examined sterilization practices in Brazil; analyzing the choices of women who opt for this type of reproductive healthcare in order to prevent future pregnancies and so they can accurately plan their families. [ 50 ]  While many women choose this form of contraception, there are many societal factors that impact this decision, such as poor economic circumstances, low rates of employment, and Catholic religious mandates that stipulate sterilization as less harmful than abortion. [ 51 ]


An important case in the legal history of compulsory sterilization in Brazil is the 2018 São Paulo case. [ 52 ]  Prosecutors filed to have a mother of eight forcibly sterilized after she was arrested on charges of drug trafficking. [ 53 ]  This motion was justified by the mother's poverty, substance abuse disorder, and inability to care for her children, and the judge ruled in favor of sterilization. [ 54 ]  The surgery was carried out, reportedly against the woman's will. [ 53 ]  Legal experts discussing the case have stated the sterilization of a woman in Brazil is legal when determined absolutely necessary, but it is not clear what qualifies as necessary. [ 53 ]


Compulsory sterilization in Canada  of individuals deemed mentally unfit or "socially inadequate" was widespread in the early to mid-20th century. [ 55 ]  The belief was that by preventing these individuals from reproducing, society would be protected from the perceived negative impact of their genes. This led to compulsory sterilization of thousands of people, many of whom were Indigenous women, individuals with disabilities, and those deemed to have "undesirable" traits. [ 56 ]


The legal basis for compulsory sterilization in Canada can be traced back to the passage of the  Sexual Sterilization Act  in Alberta in 1928. [ 57 ]  This legislation allowed for the sterilization of individuals deemed mentally deficient or mentally ill without their consent. [ 57 ]  Similar legislation existed in British Columbia, although records on sterilizations there are incomplete. [ 58 ]  Additionally, sterilizations occurred in Saskatchewan, Quebec, Manitoba, Ontario and other regions without specific legal frameworks. [ 59 ] [ 60 ] [ 61 ]  These laws remained in place until the 1970s, when public opinion began to shift and the practice was eventually deemed unethical and inhumane. [ 62 ]


In 1978, Chinese authorities became concerned with the possibility of a baby boom that the country could not handle, and they initialized the  one-child policy . In order to effectively deal with the complex issues surrounding childbirth, the Chinese government placed great emphasis on family planning. Because this was such an important matter, the government thought it needed to be standardized, and so to this end laws were introduced in 2002. [ 66 ]  These laws uphold the basic tenets of what was previously put into practice, outlining the rights of the individuals and outlining what the Chinese government can and cannot do to enforce policy.


However, accusations have been raised from groups such as  Amnesty International , who have claimed that practices of compulsory sterilization have been occurring for people who have already reached their one child quota. [ 66 ]  These practices run contrary to the stated principles of the law, and seem to differ on a local level.


The Chinese government appears to be aware of these discrepancies in policy implementation on a local level. For example, The National Population and Family Planning Commission put forth in a statement that, "Some persons concerned in a few counties and townships of Linyi did commit practices that violated law and infringed upon legitimate rights and interests of citizens while conducting family planning work." This statement comes in reference to some charges of forced sterilization and abortions in Linyi city of Shandong Province. [ 67 ]


The policy requires a "social compensation fee" for those who have more than the legal number of children. According to Forbes editor Heng Shao, critics claims this fee is a toll on the poor but not the rich. [ 68 ]  But after 2016, the country has allowed parents to give birth to  two children . In 2017, the government offered to surgically remove the IUDs that had been implanted in women to force them to adhere to the one child policy, if they qualified to have a second child. The removal of these long used IUDs is a major surgery and many women are not informed of the risks that are associated with the surgery, such as bleeding, infection, and removal of the uterus. [ 69 ]


Beginning in 2019, reports of forced sterilization in  Xinjiang  began to surface. [ 70 ] [ 71 ] [ 72 ]  In 2020, public reporting continued to indicate that large-scale compulsory sterilization was being carried out. [ 73 ] [ 74 ]  While national sterilization rates have fallen since the passing of the two child policy in 2016, there has been a sharp increase in the amount of sterilizations in Xinjiang. [ 75 ]  Many of these surgeries have been forced according to reports, but this is difficult to confirm due to the closed off nature of the area. [ 75 ]   These measures have sometimes been characterised as part of an ongoing  Uyghur genocide  in the province.


Czechoslovakia  carried out a policy to  sterilize  some  Romani  women, starting in 1973. In some cases, the sterilization was in exchange for social welfare benefits, and the people who were affected were given written agreements which described what was to be done to them, but which they were unable to read due to their illiteracy. [ 76 ]  The dissidents of the  Charter 77 movement  denounced these practices in 1977–78 as a  genocide , but this practice continued through the  Velvet Revolution  of 1989. [ 77 ]  A 2005 report by the Czech government's independent ombudsman,  Otakar Motejl , identified dozens of cases of coercive sterilization between 1979 and 2001, and called for criminal investigations and possible prosecution against several healthcare workers and administrators, re Law on Atrocities relevant pre-1990, CR (ChR). [ 78 ]


The time period of 1964–1970 started Colombia's population policy development, including the foundation of PROFAMILIA and through the Ministry of Health the family planning program promoted the use of IUDs, the Pill, and sterilization as the main avenues for contraception. By 2005, Colombia had one of the world's highest contraceptive usage rates at 76.9%, with female sterilization being the highest percentage of use at just over 30% (second highest is the IUD at around 12% and the pill around 10%) [ 79 ]  (Measham and Lopez-Escobar 2007). In Colombia during the 1980s, sterilization was the second most popular choice of pregnancy prevention (after the Pill), and public healthcare organizations and funders (USAID, AVSC, IPPF) supported sterilization as a way to decrease abortions rates. While not directly forced into sterilization, women of lower socio-economic standing had significantly less options to afford family planning care as sterilizations were subsidized. [ 49 ]


11,000 people were sterilized in Denmark from 1929–67, about half were sterilized against their will. [ 80 ]  The forced sterilization program was "mainly was directed at people who were mentally handicapped" because of the popularity of eugenics at the time in Denmark. [ 80 ]  During the 1960s and 1970s, thousands of  Greenlandic Inuit  women and girls had IUDs placed without their consent. The birth rate in Greenland was reduced by around 50%. In 2022, Denmark and Greenland agreed to hold a two-year investigation into the program, known as the  spiral case . [ 81 ]


Until 11 June 2014, sterilization was requisite for legal sex change in Denmark. [ 82 ] [ 83 ] [ 84 ]


Finland required forced sterilization for adults to legally change their sex, until 3 April 2023  [ 85 ]


One of the first acts by  Adolf Hitler  after the  Reichstag Fire Decree  and the  Enabling Act of 1933  gave him de facto legal dictatorship over the  German  state was to pass the  Law for the Prevention of Hereditarily Diseased Offspring  ( Gesetz zur Verhütung erbkranken Nachwuchses ) in July 1933. [ 86 ] [ 87 ]  The law was signed by Hitler himself, and over 200 eugenic courts were created specifically as a result of this law. Under it, all doctors in the  Third Reich  were required to report any patients of theirs who were deemed  intellectually disabled , characterized  mentally ill  (including  schizophrenia  and  manic depression ),  epileptic , blind, deaf, or physically deformed, and a steep monetary penalty was imposed for any patients who were not properly reported. Individuals with  alcoholism  or  Huntington's disease  could also be sterilized. The individual's case was then presented in front of a court of  Nazi  officials and public health officers who would review their medical records, take testimony from friends and colleagues, and eventually decide whether or not to order a sterilization operation performed upon the individual, using force if necessary. Though not explicitly covered by the law, 400 mixed-race " Rhineland Bastards " were also sterilized beginning in 1937. [ 88 ] [ 89 ] [ 90 ]  The sterilization program went on until the war started, with about 600,000 people sterilized. [ 91 ]


By the end of  World War II , over 400,000 individuals were sterilized under the German law and its revisions, most within its first four years of being enacted. When the issue of compulsory sterilization was brought-up at the  Nuremberg trials  after the war, many Nazis defended their actions on the matter by indicating that it was the United States itself from which they had taken inspiration. The Nazis had many other eugenics-inspired  racial policies , including their  T-4 euthanasia program , in which around 70,000 people who were institutionalized or had birth defects were killed. [ 92 ]


Guatemala is one country that resisted family planning programs, largely due to lack of governmental support, including  civil war  strife, and strong opposition from both the Catholic Church and Evangelical Christians until 2000, and as such, has the lowest prevalence of contraceptive usage in Latin America. In the 1980s, the archbishop of the country accused USAID of mass sterilizations of women without consent, but a President Reagan backed commission found the allegations to be false. [ 93 ]


Since 2019, nonconsensual sterilization is forbidden in Iceland unless deemed medically necessary. However, this law only addresses the procedures of tubal ligation and surgical blocking of the fallopian tubes, excluding hysterectomies from the ban. Iceland's laws surrounding legalization of sterilization practices also do not address consent of the disabled individuals undergoing these procedures. In March 2023, mother Hermina Hreidarsdottir authorized a hysterectomy for her severely cognitively impaired 20-year-old daughter due to her abnormal menstrual cycle. Ms. Hreidarsdottir took liberty of this decision for her daughter without consulting her because she believed that this sterilization procedure would improve her daughter's quality of life. [ 7 ]


The Emergency  in India from 1975 and 1977 resulted from internal and external conflict for the country, and resulted in misuse of power and human rights violations from the government. [ 94 ]   On 6 August 1976, the state of  Maharashtra  became the first governmental unit to enact legislation mandating compulsory sterilization of men and women after the birth of a third child, passing the Family (Restrictions on Size) Bill on its third reading and sending it to the President of India for the required assent.  The President reacted favorably and sent the bill back to the Maharashtra government with suggested amendments that would be necessary for an enactment, but before the measure could be passed, new elections were called and the legislation was not passed. [ 95 ]


Stopping short of forced sterilization, the national government enacted an incentive program for a family planning initiative that began in 1976 in an attempt to lower the exponentially increasing population. This program focused on male citizens and used propaganda and monetary incentives to impoverished citizens to get sterilized. [ 96 ]  People who agreed to get sterilized would receive land, housing, and money or loans. [ 97 ]  This program led millions of men to receive vasectomies, and an undetermined amount of these were coerced. There were reports of officials blocking off villages and dragging men to surgical centers for vasectomies. [ 98 ]  However, after much protest and opposition, the country switched to targeting women through coercion, withholding welfare or ration card benefits, and bribing women with food and money. [ 99 ]  This switch was theorized to be based on the principle women are less likely to protest for their own rights. [ 98 ]  Many deaths occurred as a result of both the male and the female sterilization programs. [ 98 ]  These deaths were likely attributed to poor sanitation standards and quality standards in the Indian sterilization camps.


Sanjay Gandhi , son of the then-Prime Minister  Indira Gandhi , was largely responsible for what turned out to be a failed program. [ 94 ]  A strong mistrust against family planning initiatives followed the highly controversial program, the effect of which continues into the 21st century. [ 100 ]  Sterilization policies are still enforced in India, targeting mostly indigenous and lower-class women who are herded into the sterilization camps. [ 99 ]  The most recent abuse of family planning systems was highlighted by the death of 15 lower-class women in a sterilization center in  Chhattisgarh  in 2014. [ 99 ]  Despite these deaths, sterilization is still the highest used method of birth control with 39% of women in India turning to sterilization in 2015. [ 101 ]


According to  Human Rights Law Network :


In September 2016, the Supreme Court of India directed the Union Government to ensure the discontinuation of 'sterilization camps' within the following three years and to induce the state governments to follow suit. It also charged the government to ensure proper monitoring of the programme, investigate sterilization failures, complications or deaths, and increase the compensation amount in these cases. It further ordered the implementation of established legal, medical and technical standards for sterilization [...] Women were made to lay on bare mattresses for the surgeries, with no post-surgery recuperation facilities. Often the women were made to wait up to five hours after registering, and by the time they reached the operating table their an aesthetic would have worn off. In places like Bhubaneshwar, Odisha and Ferozpur, Uttar Pradesh, the doctors conducting surgeries would use bicycle pumps instead of an insufflator, to introduce air into the women's abdomens (as reported by Shreelatha Menon). The doctor in Bhubaneshwar stated that he had done over 60,000 tubectomies and many of them with bicycle pumps. In Kaparfora, Bihar, a woman was operated upon, even though she was pregnant, and suffered a miscarriage as a result. [...] Today, while laws may not announce eugenic aims, hidden agenda to dispose of "undesirables" in society can still be discovered by looking beyond the face of the law. While many population control policies may appear benign on their face, upon further investigation the stated medical reasons for sterilization and the identification of groups to which the law applies are revealed to be morally and legally suspect. For example, compulsory sterilization law laws often target LGBT+ people, especially transgender people. [ 102 ] [ excessive quote ]


Forced sterilization has been an issue that has also affected the disabled population of women in  India . In 2016, the Right to Persons with Disabilities Act (RPWD) was introduced to legally address the problems faced by the disabled community and ensure equitable access to justice for all members of society: [ 103 ]


"While the RPWD Act took a step towards recognizing the issue of forced abortions under Section 92(f)[1] which states that any medical procedure performed on a disabled woman without her express consent that leads to the termination of pregnancy is punishable with an imprisonment term, there is still no specific mention of forced sterilization as a problem." [ 104 ]


There is no clause in the RPWD that addresses the notion of "expressed consent." [ 103 ]  Consent in relation to family planning and sterilization practices has been a point of contention in India's history of reproductive justice of disabled individuals.


In the late 2000s, reports in the Israeli media claimed that injections of long-acting contraceptive Depo-Provera had been forced on hundreds of  Ethiopian-Jewish immigrants  both in transit camps in Ethiopia and after their arrival in Israel. [ 105 ]  In 2009, feminist NGO  Haifa Women's Coalition  published a first survey on the story, which was followed up by  Israeli Educational Television  a few years later. [ 106 ]  Ethiopian-Jewish women said they were intimidated or tricked into taking the shot every three months.


In the first part of the reign of Emperor Hirohito, Japanese governments promoted increasing the number of healthy Japanese, while simultaneously decreasing the number of people who were afflicted with mental retardation, disability, genetic disease, and other conditions that led to inferiority in the Japanese genepool. [ 107 ] [ 108 ]


The  Leprosy Prevention laws  of 1907, 1931, and 1953 permitted the segregation of patients in sanitariums where forced abortions and sterilization were common, and authorized punishment of patients "disturbing peace". [ 109 ]  Under the colonial Korean  Leprosy prevention ordinance , Korean patients were also subjected to hard labor. [ 110 ]


The "National Eugenic Law" was promulgated in 1940 by the  Konoe  government, after rejection of the original "Race Eugenic Protection Law" in 1938. [ 107 ]  From 1940 to 1945, sterilization was done to 454 Japanese persons under this law. Appx. 25,000 people, including 8,500 under (forced or spontaneous) consent, were surgically processed until 1995. [ 111 ]


According to the  Eugenic Protection Law  (1948), sterilization could be enforced upon criminals "with genetic predisposition to commit crime", patients with genetic diseases including mild ones such as total color-blindness,  hemophilia ,  albinism ,  ichthyosis , and mental affections such as schizophrenia, manic-depression possibly deemed occurrent in their opposition and epilepsy. [ 112 ]  The mental sicknesses were added in 1952.


In early 2019, Japan's supreme court upheld a requirement that transgender people must have their reproductive organs removed. [ 113 ] [ 114 ] [ 115 ]


In March 2019, Japan's legal policy about transgender people was:


In Japan, transgender people who want to legally change their gender must appeal to a family court under the GID Act, which was introduced in 2004. The procedure is discriminatory, requiring applicants to be single and without children under age 20, to undergo a psychiatric evaluation to receive a diagnosis of "gender identity disorder," and to be sterilized. The requirements rest on an outdated and pejorative notion that a transgender identity is a mental health condition, and compel transgender people to undergo lengthy, expensive, invasive, and irreversible medical procedures. [ 116 ] [ 115 ] [ 117 ]


The last stipulation of the GID Act concerning forced sterilization was recently overturned in October 2023. Japan’s supreme court ruled that requiring transgender people to undergo sterilization so that they can legally change their gender identity is unconstitutional. The court stated that forcing the sterilization of the plaintiff, a transgender woman, as a requirement to change her gender on her Japanese family registry certificate was a restriction on "her freedom not to harm herself against her will". [ 118 ]  The court did not address the other requirement under the GID Act, which outlines that transgender people must undergo transition surgery in order to legally register as the gender with which they identify. [ 118 ]


In July 2024, the  Supreme Court of Japan  ruled that the Eugenic Protection Law passed in 1948 was unconstitutional, and eliminated the 20-year statute of limitations for those affected by the law. [ 119 ] [ 120 ]


In Kenya, HIV was considered an ongoing issue, and the governor believed that compulsory sterilization of women infected with HIV could stop the spread of the virus. In 2012, a report titled "Robbed of Choice" sparked outrage. The report outlined the experiences of 40 women infected with HIV that had been sterilized against their will. 5 of the 40 women filed a lawsuit against the government of Kenya, claiming violations of their Health and Human Rights. [ 121 ] [ 122 ]  The majority of the women who were sterilized knew nothing about the procedure or its consequences, which was one reason they did not push the issue. The President thought it would be good to keep a list of women who had been infected with HIV, but by naming these women, many of them did not to want to receive medical treatment due to the shame associated with the virus. "The authors concluded that punitive and restrictive laws related to pregnancy have numerous adverse consequences—both health-related and socioeconomic—for women, and urged human rights groups to work with government institutions to protect and fulfill women's fundamental reproductive rights." [ 121 ] [ 122 ]


Laws in Ghana, Nigeria, and Tanzania involve references to medical operations where the intended benefit for the patient is not tied to any legal consequences for medical professionals involved. Specifically, the criminal Code of Nigeria States that: “Performing with good faith and with reasonable care and skill a surgical operation upon any person for his benefit, if the performance of the operation is reasonable, having regard to the patient’s state and to all the circumstances of the case.” [ 123 ]


In Nigeria, young girls with intellectual disabilities are susceptible to non consensual sterilization. No current laws explicitly prevent involuntary sterilization. And the laws that currently surround and may apply to the issue are not helpful in preventing it. The African Commission on Human and People’s Rights declared that involuntary sterilization violates the right to “equality and non-discrimination, dignity, liberty and security of the person.” [ 124 ]


Involuntary sterilization in Nigeria is more common for girls with intellectual disabilities than for boys with intellectual disabilities and more common for those with intellectual disabilities specifically in comparison to other disabilities. Involuntary sterilization commonly occurs when relatives initiate it. In several studies involving parents of girls with disabilities who had initiated involuntary sterilization, respondents said that the primary reason for sterilization was to prevent pregnancy either for financial reasons or due to risk of offspring with intellectual disabilities. However, similar motivations for sterilization were not common for girls without intellectual disabilities. There is also a gendered element sterilization as the Nigeria law code penalizes emasculation, which makes it so that men cannot reproduce. There is no such penalization for sterilization of women. [ 124 ]


Civil Society Organizations such as Balance, Promocion para el Desarrollo y Juventud, A.C., have received in the last years numerous testimonies of women living with HIV in which they inform that misinformation about the virus transmission has frequently lead to compulsory sterilization. Although there is enough evidence regarding the effectiveness of interventions aimed to reduce mother-to-child transmission risks, there are records of HIV-positive women forced to undergo sterilization or have agreed to be sterilized without adequate and sufficient information about their options." [ 125 ]


A  report  made in El Salvador, Honduras, Mexico, and Nicaragua concluded that women living with HIV, and whose health providers knew about it at the time of pregnancy, were six times more likely to experience forced or coerced sterilization in those countries. In addition, most of these women reported that health providers told them that living with HIV cancelled their right to choose the number and spacing of the children they want to have as well as the right to choose the contraceptive method of their choice; provided misleading information about the consequences for their health and that of their children and denied them access to treatments that reduce mother-to-child HIV transmission in order to coerce them into sterilization. [ 126 ]


This happens even when the health norm  NOM 005-SSA2-1993   Archived  31 August 2009 at the  Wayback Machine  states that family planning is "the right of everyone to decide freely, responsibly and in an informed way the number and spacing of their children and to obtain specialized information and proper services" and that "the exercise of this right is independent of gender, age, and social or legal status of persons". [ 125 ]


In  Peru , President  Alberto Fujimori  (in office from 1990 to 2000) has been accused of  genocide  and  crimes against humanity  as a result of the  Programa Nacional de Población , a sterilization program put in place by his administration. [ 127 ] [ 128 ]  During his presidency, Fujimori put in place a program of forced sterilizations against  indigenous people  (mainly the  Quechuas  and the  Aymaras ), in the name of a " public health  plan", presented on 28 July 1995. The plan was principally financed using funds from  USAID  (36 million dollars), the  Nippon Foundation , and later, the  United Nations Population Fund  (UNFPA). [ 129 ]  On 9 September 1995, Fujimori presented a Bill that would revise the "General Law of Population", in order to allow sterilization. Several contraceptive methods were also legalized, all measures that were strongly opposed by the  Roman Catholic Church , as well as the Catholic organization  Opus Dei . In February 1996, the World Health Organization (WHO) itself congratulated Fujimori on his success in controlling demographic growth. [ 129 ]


On 25 February 1998, a representative for USAID testified before the U.S. government's  House Committee on International Relations , to address controversy surrounding Peru's program. He indicated that the government of Peru was making important changes to the program, in order to:


In September 2001, Minister of Health  Luis Solari  launched a special commission into the activities of the voluntary surgical contraception, initiating a parliamentary commission tasked with inquiring into the "irregularities" of the program, and to put it on an acceptable footing. In July 2002, its final report ordered by the Minister of Health revealed that between 1995 and 2000, 331,600 women were sterilized, while 25,590 men submitted to vasectomies. [ 129 ]  The plan, which had the objective of diminishing the number of births in areas of poverty within Peru, was essentially directed at the indigenous people living in deprived areas (areas often involved in internal conflicts with the Peruvian government, as with the  Shining Path  guerilla group). Deputy Dora Núñez Dávila made the accusation in September 2003 that 400,000 indigenous people were sterilized during the 1990s. Documents proved that President Fujimori was informed, each month, of the number of sterilizations done, by his former Ministers of Health, Eduardo Yong Motta (1994–96), Marino Costa Bauer (1996–1999) and  Alejandro Aguinaga  (1999–2000). [ 129 ]  A study by sociologist  Giulia Tamayo León  [ es ] ,  Nada Personal  (in English: Nothing Personal), showed that doctors were required to meet quotas. According to  Le Monde diplomatique , "tubal ligation festivals" were organized through program publicity campaigns, held in the  pueblos jóvenes  (in English: shantytowns). In 1996 there were, according to official statistics, 81,762 tubal ligations performed on women, with a peak being reached the following year, with 109,689 ligatures, then only 25,995 in 1998. [ 127 ]


On 21 October 2011, Peru's Attorney General José Bardales decided to reopen an investigation into the cases, which had been halted in 2009 under the statute of limitations, after the  Inter-American Commission on Human Rights  ruled that President Fujimori's sterilization program involved crimes against humanity, which are not time-limited. [ 131 ] [ 132 ]  It is unclear as to any progress in matter of the execution (debido ejecución sumaria) of the suspect in the course of any proof of their relevant accusations in the legal sphere of the constituted people in vindication of the rights of the people of South America. It may carry a parallel to any suspect cases for international investigation in any other continent, and be in the sphere of medical genocide. As of 12 December 2021:


A Peruvian judge ruled last week that the 83-year-old could not be brought to court because of the forced sterilization, as the allegation was not included in an old extradition request for Fujimori. The ex-president was extradited from Chile to Peru in 2007. According to the judge, Chile's Supreme Court, which gave the go-ahead for extradition at the time, must agree to Fujimori's charge of forced sterilization. [ 133 ]


Since children cannot legally live in psychoneurologic internats in Russia, and there are no institutions where internats' patients can live with their children, almost all pregnant women are aborted in PNIs. During abortions, PNI patients are also often subjected to forced sterilization - their  fallopian tubes are tied , motivated by allegedly detected "serious complications". [ 134 ]


In  South Africa , there have been multiple reports of HIV-positive women sterilized without their informed consent and sometimes without their knowledge. [ 135 ]  The Commission for Gender Equality investigated 48 sterilizations that were performed in fifteen state hospitals without patient consent from 2002 to 2005. [ 136 ]  This investigation into these hospitals revealed that medical providers threatened to not assist women during birth if they did not sign consent forms to being sterilized. [ 136 ]  In most cases these forms were not explained to patients by medical personnel. However, the inquiry was hampered by hostile hospital staff and the sudden "disappearance" of patient files. An interview with one of these patients revealed that she did not learn that she had been sterilized during her C-section until a physician told her eleven years after that she had no uterus. [ 137 ]  She went to the hospital were the surgery was performed and was told by a physician that it was done to save her life and consent was received from her mother. [ 137 ]  The patient did not have HIV or any other life-threatening condition, and her mother had not consented to the removal of her uterus. [ 137 ]  The report from the Commission for Gender Equality noted that some of the patients interviewed were given consent forms that they did not understand and were coerced to sign. [ 138 ]  The bulk of these operations were performed to prevent women who are HIV-positive from having more children. [ 138 ]  The HIV epidemic in South Africa has a prevalence of 13% and has largely affected the family structures in the country. [ 138 ]  Medical staff of these hospitals have justified their actions as an effort to stop the growing HIV numbers in the country that exhaust the healthcare systems. [ 136 ]  The Commission urged Health Minister Zweli Mkhize to take action against these state hospitals and to provide some form of redress to the many affected women. [ 138 ]


The eugenics program in Sweden was enacted in 1934 and was formally abolished in 1976. According to the 2000 governmental report, 21,000 were estimated to have been forcibly sterilized, 6,000 were coerced into a 'voluntary' sterilization while the nature of a further 4,000 cases could not be determined. [ 139 ]  Of those sterilized 93% were women. [ 140 ]  The reasons given for these sterilizations included mental slowness, racial differences, antisocial behavior, promiscuous behavior, and other behaviors deemed inappropriate. [ 141 ]  At the time, the government saw itself as a forward-thinking and enlightened welfare state. [ 141 ]  The Swedish state subsequently formed a commission of inquiry to determine victims that could claim compensation for trauma at the hands of the state. The sterilization program ended in the government paying over $22,000 in compensation to victims. [ 142 ]


Until December 2012, Swedish law forced transgender individuals to be sterilized before having their legal documents updated. [ 143 ]  After the law was repealed, those who were forcibly sterilized under the law began to demand compensation. [ 143 ]  In 2017, the government announced that it will pay these compensations. [ 144 ]


In 1911, while he was serving as  Home Secretary ,  Winston Churchill  favored the sterilization of  feeble-minded  persons.  Reginald McKenna , who succeeded Churchill as Home Secretary, introduced the  Feeble-Minded Control Bill , a bill that would enact forcible sterilization of such individuals; the bill gained the support of the  Anglican  archbishops of  Canterbury  and  York , that included forced sterilization. Despite support for the bill by the Anglican  primates , English writer  G. K. Chesterton  and the  Catholic Church in the United Kingdom  led a successful effort to defeat that clause's inclusion in what would eventually become the  1913 Mental Deficiency Act , though the final act did create a scheme for state-enforced  confinement of mentally disabled persons  in specialized institutions. [ 145 ]  In 1934, the  Brock Report  recommended sterilisation of people who were mentally and physically disabled, but its proposals did not gain enough support to be made law. [ 146 ]


In one specific case in 2015, the  Court of Protection  of the  United Kingdom  ruled that a woman with six children and an IQ of 70 should be sterilized for her own safety because another pregnancy would have been a "significantly life-threatening event" for her and the fetus and was not related to eugenics. [ 147 ]


During the  Progressive Era  ( c.  1890  to 1920), the United States was the first country to concertedly undertake compulsory sterilization programs for the purpose of eugenics. [ 148 ]   Thomas C. Leonard , professor at Princeton University, describes American eugenics and sterilization as ultimately rooted in economic arguments and further as a central element of Progressivism alongside minimum wage laws, restricted immigration, and the introduction of  pension  programs. [ 149 ]  The heads of the programs were avid proponents of eugenics and frequently argued for their programs which achieved some success nationwide mainly in the first half of the 20th century.


Eugenics had two essential components. First, its advocates accepted as axiomatic that a range of mental and physical handicaps—blindness, deafness, and many forms of  mental illness —were largely, if not entirely, hereditary in cause. Second, they assumed that these scientific hypotheses could be used as the basis of social engineering across several policy areas, including family planning, education, and immigration. The most direct policy implications of eugenic thought were that "mental defectives" should not produce children, since they would only replicate these deficiencies, and that such individuals from other countries should be kept out of the polity. [ 150 ]  The principal targets of the American sterilization programs were intellectually disabled people and the mentally ill, but also targeted under many state laws were the deaf, the blind, people with epilepsy, and the physically deformed. While the claim was that the focus was mainly the mentally ill and disabled, the definition of this during that time was much different from today's. At this time, there were many women that were sent to institutions under the guise of being " feeble-minded " because they were promiscuous or became pregnant while unmarried.


A relative minority of sterilizations targeting crime took place in  prisons and other penal institutions . [ 151 ]  In the end, over 65,000 individuals were sterilized in 33 states under state compulsory sterilization programs in the United States. [ 152 ]


The first state to introduce a compulsory sterilization bill was  Michigan , in 1897, but the proposed law failed to pass. Eight years later  Pennsylvania 's state legislators passed a sterilization bill that was vetoed by the governor.  Indiana  became the first state to enact sterilization legislation in 1907, [ 153 ]  followed closely by  California  and  Washington  in 1909. Several other states followed, but such legislation remained controversial enough to be defeated in some cases, as in Wyoming in 1934. [ 154 ]  In the 1920s, Eugenicists were particularly interested in black women in the South and Latina women in the Southwest in order to break the chain of welfare dependency and curb the population rise of non-white citizens. [ 155 ] [ 3 ]


After World War II, public opinion towards eugenics and sterilization programs became more negative in the light of the connection with the  genocidal  policies of  Nazi Germany , though a significant number of sterilizations continued in a few states through the 1970s. Between 1970 and 1976, Indian Health Services sterilized between 25 and 42 percent of women of reproductive age who came in seeking healthcare services. [ 156 ]  In California, ten women who delivered their children at LAC-USC hospital between 1971-1974 and were sterilized without proper consent sued the hospital in the landmark  Madrigal v. Quilligan  case in 1975. [ citation needed ] [ 157 ]  The plaintiffs lost the case, but numerous changes to the consent process were made following the ruling, such as offering consent forms in the patient's native language, and a 72-hour waiting period between giving consent and undergoing the procedure. [ citation needed ]


The  Oregon  Board of Eugenics, later renamed the Board of Social Protection, existed until 1983, [ 158 ]  with the last forcible sterilization occurring in 1981. [ 159 ]  The U.S.  commonwealth  of  Puerto Rico  had a sterilization program as well. Some states continued to have sterilization laws on the books for much longer after that, though they were rarely if ever used. California sterilized more than any other state by a wide margin, and was responsible for over a third of all sterilization operations. Information about the California sterilization program was produced into book form and widely disseminated by eugenicists  E. S. Gosney  and  Paul Popenoe , which was said by the government of Adolf Hitler to be of key importance in proving that large-scale compulsory sterilization programs were feasible. [ 160 ]


In recent years, the governors of many states have made public apologies for their past programs beginning with Virginia and followed by Oregon [ 158 ]  and California. Few have offered to compensate those sterilized, however, citing that few are likely still living (and would of course have no affected offspring) and that inadequate records remain by which to verify them. At least one compensation case,  Poe v. Lynchburg Training School & Hospital  (1981), was filed in the courts on the grounds that the sterilization law was unconstitutional. It was rejected because the law was no longer in effect at the time of the filing. However, the petitioners were granted some compensation because the stipulations of the law itself, which required informing the patients about their operations, had not been carried out in many cases.
 [ 161 ]
The 27 states where sterilization laws remained on the books (though not all were still in use) in 1956 were:  Arizona ,  California ,  Connecticut ,  Delaware ,  Georgia ,  Idaho ,  Indiana ,  Iowa ,  Kansas ,  Maine ,  Michigan ,  Minnesota ,  Mississippi ,  Montana ,  Nebraska ,  New Hampshire ,  North Carolina ,  North Dakota ,  Oklahoma ,  Oregon ,  South Carolina ,  South Dakota ,  Utah ,  Vermont ,  Virginia ,  Washington , [ 162 ]   West Virginia  and  Wisconsin . [ 163 ] [ better source needed ]  Some states still have forced sterilization laws in effect, such as Washington state. [ needs update ] [ 162 ]


As of January 2011, discussions were under way regarding compensation for the victims of forced sterilization under the authorization of the  Eugenics Board of North Carolina . Governor Bev Perdue formed the NC Justice for Sterilization Victims Foundation in 2010 in order "to provide justice and compensate victims who were forcibly sterilized by the State of North Carolina". [ 164 ]  In 2013 North Carolina announced that it would spend $10 million beginning in June 2015 to compensate men and women who were sterilized in the state's eugenics program; North Carolina sterilized 7,600 people from 1929 to 1974 who were deemed socially or mentally unfit. [ 165 ]


The inability to pay for the cost of raising children has been a reason courts have ordered coercive or compulsory sterilization. In June 2014, a Virginia judge ruled that a man on probation for child endangerment must be able to pay for his seven children before having more children; the man agreed to get a vasectomy as part of his plea deal. [ 166 ]  In 2013, an Ohio judge ordered a man owing nearly $100,000 in unpaid child support to "make all reasonable efforts to avoid impregnating a woman" as a condition of his probation. [ 167 ]  Kevin Maillard wrote that conditioning the right to reproduction on meeting child support obligations amounts to "constructive sterilization" for men unlikely to make the payments. [ 168 ]


As of 19 July 2021 it was reported that:


"under new provisions signed into California's budget this week, the state will offer reparations for the thousands of people who were sterilized in California institutions, without adequate consent, often because they were deemed "criminal", "feeble-minded" or "deviant"." [ 169 ]


and that


"The program will be the first in the nation to provide compensation to modern-day survivors of prison system sterilizations, like Dillon, whose attorney obtained medical records to show that, while she was an inmate in the Central California women's facility in Chowchilla, surgeons had removed her ovaries during what was supposed to be an operation to take a biopsy and remove a cyst.


The investigations sparked by her case, which is featured in the documentary Belly of the Beast, showed hundreds of inmates had been sterilized in prisons without proper consent as late as 2010, even though the practice was by then illegal.


The new California reparations program will also seek to compensate hundreds of living survivors of the state's earlier eugenics campaign, which was first codified into state law in 1909 and wasn't repealed until 1979." [ 170 ] [ 169 ]


In 2020, four  non-profit organizations  (which are listed below) joined Dawn Wooten to accuse a  privately-owned  U.S. immigration detention center in the U.S. state of  Georgia  of forcibly sterilizing women. The reports claimed that a doctor conducted unauthorized medical procedures upon women who were detained by Immigration and Customs Enforcement. [ 171 ]  Dawn Wooten was a nurse and former employee. She claims that a high rate of sterilizations were performed upon spanish-speaking women and women who spoke various indigenous languages that are common in Latin America. Wooten said that the center did not obtain proper consent for these surgeries, or lied to women about the medical procedures. More than 40 women submitted testimony in writing to document these abuses. [ 172 ]


In September 2020,  Mexico  demanded more information from U.S. authorities about medical procedures that were performed upon illegal immigrants in detention centers, after allegations that six Mexican women were sterilized without their consent. The ministry said that consulate personnel had interviewed 18 Mexican women who were detained at the center, none of which "claimed to have undergone a hysterectomy". Another woman said that she had undergone a gynecological operation, although there was nothing in her detention file to support that she agreed to the procedure. [ 173 ]


The nurse said that detained women told her they did not fully understand why they had to get a hysterectomy.


Project South , the Georgia Detention Watch, the Georgia Latino Alliance for Human Rights, and South Georgia Immigrant Support Network filed a complaint to the government on behalf of detained immigrants and the nurse.


The U.S. congresswoman  Pramila Jayapal  has called for an urgent investigation into allegations that at least 17 women were subjected to unnecessary gynecological procedures that she called "the most abhorrent of human rights violations". [ 174 ]


As stated previously, eugenics in the United States spread to target mentally disabled persons. Sterilization rates across the country were relatively low, with the sole exception of California, until the 1927  U.S. Supreme Court  decision in  Buck v. Bell , which upheld under the  U.S. Constitution  the forced sterilization of patients at a  Virginia  home for intellectually disabled people. [ 175 ]  In the wake of that decision, over 62,000 people in the United States, most of them women, were sterilized. [ 176 ]  The number of sterilizations performed per year increased until another Supreme Court case,  Skinner v. Oklahoma , 1942, complicated the legal situation by ruling against sterilization of criminals if the equal protection clause of the constitution was violated. That is, if sterilization was to be performed, then it could not exempt  white-collar criminals . [ 177 ]  This case, however, does not directly overturn the decision made in  Buck v. Bell . [ 178 ]  Instead, it invalidates the central argument of the decision, and has been used in several cases to deny guardians the right to sterilize the disabled person under their care. [ 178 ]


The  Congress of Obstetricians and Gynecologists  (ACOG) believes that mental disability is not a reason to deny sterilization. The opinion of ACOG is that "the physician must consult with the patient's family, agents, and other caregivers" if sterilization is desired for a mentally limited patient. [ 179 ]  In 2003, Douglas Diekema wrote in Volume 9 of the journal Mental Retardation and Developmental Disabilities Research Reviews that "involuntary sterilization ought not be performed on mentally retarded persons who retain the capacity for reproductive decision-making, the ability to raise a child, or the capacity to provide valid consent to marriage." [ 180 ]  The  Journal of Medical Ethics  claimed, in a 1999 article, that doctors are regularly confronted with requests to sterilize mentally limited people who cannot give consent for themselves. The article recommend that sterilization should only occur when there is a "situation of necessity" and the "benefits of sterilization outweigh the drawbacks." [ 181 ]


The  American Journal of Bioethics  published an article, in 2010, that concluded the interventions used in the  Ashley treatment  may benefit future patients. [ 182 ]  These interventions, at the request of the parents and guidance from the physicians, included a  hysterectomy  and surgical removal of the  breast buds  of the mentally and physically disabled child. [ 183 ]  Proponents of the treatments argue that it protects disabled persons from sexual assault, unwanted pregnancy, and difficulties of menstruation. [ 184 ]  The interventions are still legal in many states, despite the argument that it violates a person's constitutional right to avoid unwanted intrusions. [ 184 ]  Discussion on the involuntary sterilization of disabled persons is now largely focused on the right of a guardian to request sterilization.


In addition to eugenics purposes, sterilization was used as a punitive measure against sex offenders, people identified as homosexual, or people deemed to masturbate too much. [ 185 ]  California, the first state in the U.S. to enact compulsory sterilization based on eugenics, sterilized all prison inmates under the 1909 sterilization law. [ 185 ]  In the last 40 years, judges have offered lighter punishment (i.e. probation instead of jail sentences) to people willing to use contraception or be sterilized, particularly in child abuse/endangerment cases. [ 186 ]  One of the most famous cases of this was  People v. Darlene Johnson , during which Johnson, a woman charged with child abuse sentenced to seven years in prison, was offered probation and a reduced prison sentence if she agreed to use  Norplant . [ 187 ]


In addition to child abuse cases, some politicians proposed bills mandating Norplant use among women on public assistance as a requirement to maintain welfare benefits. [ 187 ]  As noted above, some judges offered probation in lieu of prison time to women who agreed to use Norplant, while other court cases have ordered parents to cease childbearing until regaining custody of their children after abuse cases. Some legal scholars and ethicists argue such practices are inherently coercive. [ 187 ]  Furthermore, such scholars link these practices to eugenic policies of the 19th and early 20th century, highlighting how such practices not only targeted poor people, but disproportionately impacted minority women and families in the U.S., particularly black women.


In the late 1970s, to acknowledge the history of forced and coercive sterilizations and prevent ongoing eugenics/population control efforts, the federal government implemented a standardized informed consent process and specific eligibility criteria for government funded sterilization procedures. [ 188 ]  Some scholars argue the extensive consent process and 30-day waiting period go beyond preventing instances of coercion and serve as a barrier to desired sterilization for women relying on public insurance. [ 188 ]


Though formal eugenics laws are no longer routinely implemented and have been removed from government documents, instances of reproductive coercion still take place in U.S. institutions today. In 2011, investigative news released a report revealing that between 2006 and 2011, 148 female prisoners in two California state prisons were sterilized without adequate informed consent. [ 189 ]  In September 2014, California enacted Bill SB 1135 that bans sterilization in correctional facilities, unless the procedure shall be required in a medical emergency to preserve an inmate's life. [ 190 ]


Puerto Rican physician Lanauze Rolón founded the League for Birth Control in  Ponce, Puerto Rico , in 1925, but the League was quickly squashed by opposition from the  Catholic church . [ 191 ] [ 192 ]  A similar League was founded seven years later, in 1932, in  San Juan  and continued in operation for two years before opposition and lack of support forced its closure. [ 191 ] [ 192 ]  Yet another effort at establishing birth control clinics was made in 1934 by the  Federal Emergency Relief Administration  in a relief response to the conditions of the  Great Depression . [ 192 ]  As a part of this effort, 68 birth control clinics were opened on the island. [ 192 ]  The next mass opening of clinics occurred in January 1937 when American  Clarence Gamble , in association with a group of wealthy and influential Puerto Ricans, organized the Maternal and Infant Health Association and opened 22 birth control clinics. [ 192 ]


The Governor of Puerto Rico,  Blanton Winship , enacted Law 116, [ 193 ]  which went into effect on 13 May 1937. [ 194 ]  It was a  birth control  and eugenic sterilization law that allowed the dissemination of information regarding birth control methods and legalized the practice of birth control. [ 191 ] [ 192 ]  The government cited a growing population of the poor and unemployed as motivators for the law. Changers were made to the Penal Code in 1937 which made abortion effectively legal. It was allowed for health reasons, without specifying details in the law. This gave doctors discretion to interpret what constituted a health reason, effectively legalizing abortion. [ 195 ]  By 1965, approximately 34 percent of women of childbearing age had been sterilized, two thirds of whom were still in their early twenties. The law was repealed on 8 June 1960. [ 191 ]


Unemployment and widespread poverty would continue to grow in Puerto Rico in the 40s, both threatening U.S. private investment in Puerto Rico and acting as a deterrent for future investment. [ 191 ]  In an attempt to attract additional U.S. private investment in Puerto Rico, another round of liberalizing trade policies were implemented and referred to as " Operation Bootstrap ." [ 191 ]  Despite these policies and their relative success, unemployment and poverty in Puerto Rico remained high, high enough to prompt an increase in  emigration  from Puerto Rico to the United States between 1950 and 1955. [ 191 ]  The issues of  immigration , Puerto Rican poverty, and threats to U.S. private investment made population control concerns a prime political and social issue for the United States. [ 191 ]


The 50s also saw the production of social science research supporting sterilization procedures in Puerto Rico. [ 191 ]  Princeton's  Office of Population Research , in collaboration with the Social Research Department at the University of Puerto Rico, conducted interviews with couples regarding sterilization and other birth control. [ 191 ]  Their studies concluded that there was a significant need and desire for permanent birth control among Puerto Ricans. [ 191 ]  In response, Puerto Rico's governor and Commissioner of health opened 160 private, temporary birth control clinics with the specific purpose of sterilization. [ 191 ]


Also during this era, private birth control clinics were established in Puerto Rico with funds provided by wealthy Americans. [ 191 ] [ 192 ]   Joseph Sunnen , a wealthy American Republican and industrialist, established the  Sunnen Foundation  in 1957. [ 191 ] [ 192 ]  The foundation funded new birth control clinics under the title "La Asociación Puertorriqueña el Biensestar de la Familia" and spent hundreds of thousands of dollars in an experimental project to determine if a formulaic program could be used to control population growth in Puerto Rico and beyond. [ 191 ]


From beginning of the 1900s, U.S. and Puerto Rican governments espoused rhetoric connecting the poverty of Puerto Rico with overpopulation and the "hyper-fertility" of Puerto Ricans. [ 196 ]  Such rhetoric combined with eugenics ideology of reducing "population growth among a particular class or ethnic group because they are considered...a social burden," was the philosophical basis for the 1937 birth control legislation enacted in Puerto Rico. [ 196 ] [ 197 ]  A Puerto Rican Eugenics Board, modeled after a similar board in the United States, was created as part of the bill, and officially ordered ninety-seven involuntary sterilizations. [ 197 ]


The legalization of sterilization was followed by a steady increase in the popularity of the procedure, both among the Puerto Rican population and among physicians working in Puerto Rico. [ 197 ] [ 198 ]  Though sterilization could be performed on men and women, women were most likely to undergo the procedure. [ 191 ] [ 192 ] [ 197 ] [ 198 ]  Sterilization was most frequently recommended by physicians because of a pervasive belief that Puerto Ricans and the poor were not intelligent enough to use other forms of contraception. [ 197 ] [ 198 ]  Physicians and hospitals alike also implemented hospital policy to encourage sterilization, with some hospitals refusing to admit healthy pregnant women for delivery unless they consented to be sterilized. [ 197 ] [ 198 ]  This has been best documented at Presbyterian Hospital, where the unofficial policy for a time was to refuse admittance for delivery to women who already had three living children unless she consented to sterilization. [ 197 ] [ 198 ]  There is additional evidence that true  informed consent  was not obtained from patients before they underwent sterilization, if consent was solicited at all. [ 198 ]


By 1949 a survey of Puerto Rican women found that 21% of women interviewed had been sterilized, with sterilizations being performed in 18% of all hospital births statewide as a routine post-partum procedure, with the sterilization operation performed before women left the hospitals after giving birth. [ 191 ]  As for the birth control clinics founded by Sunnen, the Puerto Rican Family Planning Association reported that around 8,000 women and 3,000 men had been sterilized in Sunnen's privately funded clinics. [ 191 ]  At one point, the levels of sterilization in Puerto Rico were so high that they alarmed the Joint Committee for Hospital Accreditation, who then demanded that Puerto Rican hospitals limit sterilizations to ten percent of all hospital deliveries in order to receive accreditation. [ 191 ]  The high popularity of sterilization continued into the 60s and 70s, during which the Puerto Rican government made the procedures available for free and reduced fees. [ 197 ]  The effects of the sterilization and contraception campaigns of the 1900s in Puerto Rico are still felt in Puerto Rican cultural history today. [ 196 ]


There has been much debate and scholarly analysis concerning the legitimacy of choice given to Puerto Rican women in regard to sterilization, reproduction, and birth control, as well as with the ethics of economically motivated mass-sterilization programs.


Some scholars, such as Bonnie Mass [ 191 ]  and Iris Lopez, [ 196 ]  have argued that the history and popularity of mass-sterilization in Puerto Rico represents a government-led eugenics initiative for  population control . [ 191 ] [ 196 ] [ 198 ] [ 199 ]  They cite the private and government funding of sterilization, coercive practices, and the eugenics ideology of Puerto Rican and American governments and physicians as evidence of a mass-sterilization campaign. [ 196 ] [ 198 ] [ 199 ]


On the other side of the debate, scholars like Laura Briggs [ 197 ]  have argued that evidence does not substantiate claims of a mass-sterilization program. [ 197 ]  She further argues that reducing the popularity of sterilization in Puerto Rico to a state initiative ignores the legacy of Puerto Rican feminist activism in favor or birth control legalization, and the individual agency of Puerto Rican women in making decisions about family planning. [ 197 ]


A system was proposed by the California state senator  Nancy Skinner  to compensate victims of the well-documented examples of  prison sterilizations that resulted from California's eugenics programs , but this did not pass by the bill's 2018 deadline in the legislature. [ 200 ]


When the United States took census of Puerto Rico in 1899, the birth rate was 40 births per one thousand people. [ 192 ]  By 1961, the birth rate had dropped to 30.8 per thousand. [ 191 ]  In 1955, 16.5% of Puerto Rican women of childbearing age had been sterilized, this jumped to 34% in 1965. [ 191 ]


In 1969, sociologist  Harriet Presser  analyzed the 1965 Master Sample Survey of Health and Welfare in Puerto Rico. [ 201 ]  She specifically analyzed data from the survey for women ages 20 to 49 who had at least one birth, resulting in an overall sample size of 1,071 women. [ 201 ]  She found that over 34% of women aged 20–49 had been sterilized in Puerto Rico in 1965. [ 201 ]


Presser's analysis also found that 46.7% of women who reported they were sterilized were between the ages of 34 and 39. [ 201 ]  Of the sample of women sterilized, 46.6% had been married 15 to 19 years, 43.9% had been married for 10-to-14 years, and 42.7% had been married for 20-to-24 years. [ 201 ]  Nearly 50% of women sterilized had three or four births. [ 201 ]  Over 1/3 of women who reported being sterilized were sterilized in their twenties, with the average age of sterilization being 26. [ 201 ]


A survey by a team of Americans in 1975 confirmed Presser's assessment that nearly 1/3 of Puerto Rican women of childbearing age had been sterilized. [ 191 ]  As of 1977, Puerto Rico had the highest proportion of childbearing-aged persons sterilized in the world. [ 191 ]  In 1993,  ethnographic  work done in New York by  anthropologist  Iris Lopez [ 196 ]  showed that the history of sterilization continued to effect the lives of Puerto Rican women even after they immigrated to the United States and lived there for generations. [ 196 ]  The history of the popularity of sterilization in Puerto Rico meant that Puerto Rican women living in America had high rates of female family members who had undergone sterilization, and it remained a highly popular form of birth control among Puerto Rican women living in New York. [ 196 ]


According to reports, as of 2012 [update] , forced and coerced sterilization is the current governmental policy in  Uzbekistan  for women with two or three children, as a means of forcing population control and to improve maternal mortality rates. [ 202 ] [ 203 ] [ 204 ] [ 205 ] [ 206 ]  In November 2007, a report by the  United Nations Committee Against Torture  reported that "the large number of cases of forced sterilization and removal of reproductive organs of women at reproductive age after their first or second pregnancy indicate that the Uzbek government is trying to control the birth rate in the country" and noted that such actions were not against the national Criminal Code. [ 207 ]  In response to that, the Uzbek delegation to the associated conference was "puzzled by the suggestion of forced sterilization, and could not see how this could be enforced". [ 208 ]


Reports of forced sterilizations,  hysterectomies , and  IUD -insertions first emerged in 2005, [ 202 ] [ 203 ] [ 204 ] [ 209 ]  although it is reported that the practice originated in the late 1990s, [ 210 ]  with reports of a secret decree dating from 2000. [ 209 ]  The current policy was allegedly instituted by  Islam Karimov  under Presidential  Decree  PP-1096, which is titled: "on additional measures to protect the health of the mother and child, the formation of a healthy generation", [ 211 ]  and which came into force in 2009. [ 212 ]  In 2005, Deputy Health Minister Assomidin Ismoilov confirmed that doctors in Uzbekistan were being held responsible for increased birth rates. [ 209 ]


Based upon a report by the journalist Natalia Antelava, doctors reported that the Ministry of Health told doctors that they must perform surgical sterilizations upon women. One doctor reported: "It's ruling number 1098, and it says that after two children, in some areas after three, a woman should be sterilized.", in a loss of the former surface decency of Central Asian mores in regard of female chastity. [ 213 ]  In 2010, the Ministry of Health passed a decree stating all clinics in Uzbekistan should have sterilization equipment ready for use. The same report also states that sterilization is to be done on a voluntary basis with the informed consent of the patient. [ 213 ]  In the 2010 Human Rights Report of Uzbekistan, there were many reports of forced sterilization of women along with allegations of the government pressuring doctors to sterilize women in order to control the population. [ 214 ]  Doctors also reported to Antelava that there are quotas they must reach every month on how many women they need to sterilize. These orders are passed on to them through their bosses and, allegedly, from the government. [ 213 ]


On 15 May 2012, during a meeting with the Russian president  Vladimir Putin  in  Moscow , the Uzbek president Islam Karimov said: "we are doing everything in our hands to make sure that the population growth rate [in Uzbekistan] does not exceed 1.2–1.3" [ 215 ]  The Uzbek version of  RFE/RL  reported that, with this statement, Karimov indirectly admitted that forced sterilization of women is indeed taking place in Uzbekistan. [ 215 ]  The main Uzbek television channel, called O'zbekiston, cut-out Karimov's statement about the population growth rate while broadcasting his conversation with Putin. [ 215 ]


Despite international agreement concerning the inhumanity and illegality of forced sterilization, it has been suggested that the government of Uzbekistan continues to pursue such programs. [ 202 ]


Eugenics programs including forced sterilization existed in most of the Northern European countries, as well as in other more-or-less  Protestant countries . Other countries that had notably active sterilization programs include  Denmark  ("that country's forced sterilization of 60,000 people in 1935-76"), [ 80 ] [ 216 ]   Norway , [ 217 ] [ 218 ] [ 216 ]   Finland [ 219 ] [ 220 ] [ 221 ] [ 222 ] ("In Finland, to change one's gender markers in the juridical system (also known as gender recognition), trans people are, still,  forcibly sterilised.  In the laws regarding gender recognition, this requirement is called the 'inability to reproduce', a choice of words that makes it sound a lot less threatening than 'forced sterilisation'"), [ 222 ]   Estonia , [ 223 ]   Switzerland , [ 224 ] [ 225 ]   Iceland , [ 226 ]  and some countries in  Latin America  (including  Panama ). [ citation needed ]


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The  Concept Foundation  is a  non-profit   foundation  which was established by the UNDP/UNFPA/WHO/WB Special program in Reproductive Health (WHO/HRP),  PATH , the  World Bank  in 1989 in Bangkok, Thailand, "as a mechanism through which WHO’s rights associated with an injectable contraceptive, Cyclofem, could be licensed to potential producers in  developing countries ". [ 1 ]   Estradiol cypionate/medroxyprogesterone acetate  (brand names Cyclofem, Lunelle; code name Cyclo-Provera), is a once-a-month  combined injectable contraceptive  which contains 25 mg of  medroxyprogesterone acetate —the same ingredient in Depo Provera—and 5 mg of  estradiol cypionate . [ 2 ]


Since its inception in 1989, more than 120 million doses of Cyclofem have been manufactured and sold worldwide. Concept Foundation products have been manufactured in 8 different countries and are made available in more than 30 developing countries.


Medabon is another product developed by the Concept Foundation which induces  medical abortion .  Medabon combines  mifepristone  and  misoprostol , two  abortifacients  which health organizations had already deemed safe and effective.  Implementation and initial research of the Medabon regimen was done by  PATH  and  Ipas . [ 3 ]


Official website


A  contraceptive implant  is an  implantable   medical device  used for the purpose of  birth control . The implant may depend on the timed release of  hormones  to hinder  ovulation  or  sperm  development, the ability of  copper  to act as a natural  spermicide  within the  uterus , or it may work using a non-hormonal, physical blocking mechanism. As with other contraceptives, a contraceptive implant is designed to prevent  pregnancy , but it does not protect against  sexually transmitted infections .


The contraceptive implant is hormone-based and highly effective, approved in more than 60 countries and used by millions of women around the world. The typical implant is a small flexible tube measuring about 40 mm (1.6 in) in length. It is most commonly inserted subdermally in the inner portion of the upper, non-dominant arm by a trained and certified health care provider. [ 3 ]  After insertion, it prevents pregnancy by releasing progestin which inhibits ovulation. [ 3 ] [ 4 ]  The two most common versions are the single-rod  etonogestrel implant  and the two-rod  levonorgestrel implant . [ 5 ]   Brands include: Norplant, Jadelle (Norplant II), Implanon, Nexplanon, Sino-implant (II), Zarin, Femplant and Trust.


Some brands of the contraceptive implant, including Nexplanon, are over 99% effective. [ 6 ]  The benefits of the contraceptive implant are dependent on the active ingredients. Depending on the type of implant, benefits of the implant may include fewer, lighter periods, improved symptoms of  premenstrual syndrome , long-lasting up to three to five years, and the convenience of not needing to remember to use it every day. The implant is also useful for women who cannot use contraception that contains oestrogen. The implant can also be removed at any time and natural fertility will return very quickly. [ 7 ]


When the implant is first inserted, it is common to have some bruising, tenderness or swelling around the implant. [ 7 ]  In some cases, adverse effects do occur, the most common being irregular bleeding or  amenorrhea . [ 3 ]  Although irregularity in bleeding can be troublesome for some women, this also allows for use in treatment of  dysmenorrhea ,  menorrhagia , and  endometriosis . [ 3 ]  Less common symptoms include change in appetite,  depression , moodiness, hormonal imbalance, sore breasts, weight gain, dizziness, pregnancy symptoms, and  lethargy . [ 8 ] [ 9 ]  Although rare, there is also a risk of complications occurring during insertion or removal of the implant. [ 3 ]  In rare cases, the area of skin where the implant has been inserted can become infected, which can require antibiotics. [ 7 ]


Most commonly reported from the levonorgestrel-releasing intrauterine system LNG-IUG contraceptive; breast tenderness, headaches, swelling, and skin irritation. [ 10 ]  contraceptive also corresponds with earlier waking, frequent mood swings, impaired concentration, and strain. [ 10 ]  Irregular vaginal uterus lining shedding is a common pattern with Norplant users; if this occurs it will be seen during the first 60 days of use but it can subside or disappear over time. [ 11 ]  The Implanon also has these negative side effects causing a considerable amount of vaginal bleeding irregularities, and amenorrhea in about 30–40% of its users during the following 90 days of starting use. [ 11 ]


With regard to helping women space their pregnancies appropriately, there is some debate about the most effective time to insert contraceptive implants after pregnancy. It is likely that implant insertion immediately following childbirth increases the number of postpartum implant users compared to when insertion occurs four to six weeks after childbirth (because some patients do not return for their six-week checkup). [ 12 ]  However, there may be little or no difference between immediate and delayed insertion in terms of continued use of implants at six months or in terms of women's satisfaction, [ 12 ]  even though some studies found higher continuation rates at six months if the implant was inserted immediately after childbirth. [ 13 ]  Progestin containing implants (specifically etonogestrel) are safe for immediate insertion in both postpartum individuals and those post-abortion. [ 3 ]


An intrauterine device (IUD) is a small contraceptive device, often T-shaped, which is  implanted  into the uterus. They can be hormonal or non-hormonal are  long-acting, reversible , and the most effective types of reversible birth control. [ 14 ]  As of 2011, IUDs are the most widely used form of reversible contraception worldwide. [ 15 ]  Among types of birth control they, along with birth control implants, result in the greatest satisfaction among users. [ 16 ]  IUDs also tend to be one of the most cost-effective methods of contraception for women. [ 17 ]  Cons of intrauterine devices, similarly to implants, is the need for a trained healthcare professional for both insertion and removal.


Brands include: Paragard, Kyleena, Liletta, Mirena, and Skyla. [ 18 ]


Hormonal IUDs  contain the hormone  levonorgestrel  which is a progestin. Most commonly, products are inserted for 5 years, allowing them to release a low dose of hormones over that time frame. [ 3 ]  The mechanism of action of both hormonal and non-hormonal IUDs is similar, plus the additional benefit of progestin causing a thickening of the cervical mucus. [ 19 ]


The  levonorgestrel IUD  is highly efficacious and has a failure rate of only 0.2% in the first year of use. [ 20 ]  An additional benefit of hormonal IUDs is decreased blood loss, which 20-30% of patients will experience  amenorrhea . [ 3 ]  Within 1–3 months of removing the intrauterine device, however, patients should experience a return to their normal menstrual cycle. [ 3 ]  The most common side effect of levonorgestrel containing IUDs is spotting during the first 3 months. [ 3 ]


Use in patients immediately postpartum can be discussed but the greater potential for expulsion and perforation must be carefully considered. [ 3 ]


Non-hormonal IUDs, also known as  copper IUDs , are a hormone-free option of contraception available and work by two main mechanisms of action. They are thought to slow the rate at which  sperm  reaches the  fallopian tubes  or decreases  fertilization  of the egg. [ 19 ]  An increase of  copper  ions, along with other cells and enzymes, is what affects functioning of the sperm and the prevention of pregnancy. [ 19 ]


Although they do have a higher risk of pregnancy compared to hormonal IUDs, failure rates with the copper IUD are still only approximately 0.8%. [ 20 ]  They also provide protection from anywhere between 2.5 to 10 years depending on the brand and manufacturer. [ 19 ]  Potential adverse effects of copper IUDs include heavier  menses  and increased  menstrual cramping . [ 19 ]


Copper IUDs have the ability to be inserted anywhere from 10 minutes to 48 hours postpartum. [ 21 ]  The disadvantage of this immediate insertion is the associated higher risk of expulsion or  uterine perforation , however, the benefits greatly outweigh any potential risk. [ 21 ]  They also are safe to use in  lactation . [ 21 ]


An additional benefit of copper IUDs is their use in  emergency contraception . Not only are they able to be used as a form of emergency contraception but a Cochrane review noted that they are the most effective method of emergency contraception as well. [ 19 ]  When inserted within 7 days of unprotected intercourse, they are able to reduce the risk of pregnancy by 99% and provide the added benefit of ongoing contraception in the patient too. [ 19 ]


Several barriers exist to expanding research into implantable and other contraceptive methods for men, including vague regulatory guidelines, long device development timelines, men's attitudes towards convenience, and a significant lack of funding. [ 22 ] [ 23 ] [ 24 ]  Several implantable devices have been attempted, both hormonal and non-hormonal.


In 2001, Dutch pharmaceutical company   Organon  announced clinical trials of its implantable  etonogestrel -based male contraceptive would begin in Europe and the U.S., anticipating a marketable product as early as 2005. [ 25 ] [ 26 ]  Despite promising results, research development stopped, with outside speculation that lack of marketability was a factor. Organon representative Monique Mols stated in 2007 that "[d]espite 20 years of research, the development of a [hormonal] method acceptable to a wide population of men is unlikely". [ 27 ]   Schering / Bayer  had been working on a similar annual implant with quarterly injections but cancelled the research in 2006/2007, [ 27 ]  declaring that men would most likely view it as "not as convenient as a woman taking a pill once a day." [ 24 ]


In 2005, a collaboratory project led by the  Population Council , the  University of California, Los Angeles , and the  Medical Research Council  began researching a matchstick-sized implant that contains MENT (7α-methyl-19-nortestosterone or  trestolone ), a "synthetic steroid that resembles testosterone." [ 28 ]  Clinical trials were set to begin in 2011 or 2012, [ 22 ]  and the project was ongoing as of 2016, with hopes of gaining approval as the first reversible male contraceptive. [ 28 ]


In 2006, Shepherd Medical Company received FDA approval for a clinical trial of its non-hormonal implant called an  intra vas device  (IVD), which consists of two plugs that block sperm flow in the vas deferens. Working on the success of its pilot study and solid results from its clinical trials, the company announced it would expand its trials to three U.S. cities later that year. Questions remained about how reversible the procedure would be in the long-term; however, it was expected to be more reversible than a vasectomy. In 2008, the company disbanded due to the economic crisis but has stated it would restart its research with proper funding. [ 29 ] [ 30 ] [ 31 ]


In January 2016,  news broke of a non-hormonal, implantable valve—the Bimek SLV. It included a switch that attaches to the  vas deferens , allowing the owner to stop and resume the flow of sperm on demand. A clinical trial of 25 participants was announced to further test the efficacy of the device. [ 32 ] [ 33 ]


Implantable contraception is also an option for animals, particularly for animal managers at zoos and other captive animal facilities who require reversible contraception methods for managing population growth in limited captive habitat. [ 34 ]  The  Association of Zoos and Aquariums ' (AZA) Reproductive Management Center (formerly known as the AZA Wildlife Contraception Center) at the  Saint Louis Zoo  in  St. Louis , Missouri, has played a major role in researching and disseminating contraception information, via its Contraception Database. It houses over 30,000 records for hundreds of species. [ 34 ] [ 35 ]  One of the most popular contraceptive methods used by zoos (as well as in domestic animals) is the  melengestrol acetate  (MGA) implant, a  progestin -based hormonal contraceptive developed in the mid-1970s. Other progestin-based implants that have been placed in animals include  Norplant ,  Jadelle , and  Implanon .  Androgen -based implants that use  agonist  (stimulating)  gonadotropin-releasing hormone  (GnRH) and, to a lesser degree,  IUDs  have also seen use in several domestic and exotic species. Whatever the implant, some care must be taken to minimize the risk of implant migration or loss. [ 34 ] [ 36 ] [ 37 ]


Contraceptive security  is an individual's ability to reliably choose, obtain, and use quality  contraceptives  for  family planning  and the prevention of  sexually transmitted diseases . [ 1 ]  The term refers primarily to efforts undertaken in  low and middle-income countries  to ensure contraceptive availability as an integral part of family planning programs. [ 2 ]  Even though there is a consistent increase in the use of contraceptives in low, middle, and high-income countries, the actual contraceptive use varies in different regions of the world. The World Health Organization recognizes the importance of contraception and describes all choices regarding family planning as human rights. [ 3 ]  Subsidized products, particularly  condoms  and  oral contraceptives , may be provided to increase accessibility for low-income people. Measures taken to provide contraceptive security may include strengthening contraceptive supply chains, forming contraceptive security committees, product quality assurance, promoting supportive policy environments, and examining financing options. [ 4 ]


Contraception has been an active practice that dates back to ancient Egypt. [ 5 ]  It has played an important role in history and over time led to the development of organizations that provide contraceptive methods to the general public. [ 5 ]  In the United States, during the late 1800s contraception was often prohibited and deemed illegal in some states. This was largely driven by religion and other social misconceptions, often believed to promote recreational sex. [ 6 ]  However, more individuals across the world came to realize the importance of contraception and the benefit it could provide to individuals.


The first family planning clinic was opened in 1882 in the Netherlands by Aletta Jacobs. [ 6 ]  Activists in the early 1900s, such as  Margaret Sanger , allowed contraception to become an option to couples that were not ready to conceive. In 1916, Sanger opened the first family planning clinic in Brooklyn, New York. It received a great deal of backlash from numerous individuals and was forced to close down a few days after opening.


Contraception became an even greater topic in the 1960s, after the creation of birth control and the intrauterine device (IUD). [ 7 ] [ 8 ]  Both acted as a safer and more convenient method of contraception. Shortly thereafter in 1965, the United States Supreme Court ruled it unconstitutional for states to prevent married couples from attaining birth control during the Griswold versus Connecticut case.


In the mid-1960s, the United States government began to understand the importance of contraception in helping decrease the rapid acceleration in the world population. [ 9 ] [ 10 ]  Access to contraception was only further strengthened by the passage of Title X of the Public Health Service Act in 1970, which aimed to help further establish contraceptive security in the United States. [ 11 ]  In the 1970s, numerous organizations, including governmental and nongovernmental, were formulated to help more individuals obtain family planning methods and services. [ 1 ]


Over the years, this led to the development of non-government organizations such as the International Planned Parenthood Federation (IPPF), Marie Stopes International, Population Services International (PSI) and Women Deliver as well as bilateral organizations such as the Danish International Development Agency (DIDA), United Kingdom Department for International Development (DFID) and the United States Agency for International Development (USAID). [ 12 ]  These organizations work to provide contraceptive security in numerous countries via donations, tools, policies and frameworks. Additionally, the USAID partners with numerous private and public companies across the world to expand access to information and resources needed for family planning. [ 13 ]  Today contraceptive security is still an important topic, especially given its capability of reducing child and maternal mortality in some low and middle income countries. [ 14 ]


Contraceptives  can prevent unintended pregnancies in individuals with uteruses, as well as protect individuals from contracting  sexually transmitted infections and/or diseases  (STIs/STDs). [ 15 ]  A person's access to contraception is critical for ensuring their optimal health and achieving their reproductive goals as it allows individuals to have control over their body and freedom to decide when to become a parent. It also gives couples the ability to chose how many children to raise and the spacing between each child. [ 16 ]  Moreover, contraceptive security can improve the socioeconomic conditions for individuals and their families, and advances their right to education and/or a career. [ 17 ]


According to the United Nations Department of Economic and Social Affairs' Population Division in 2019, roughly 58% of 1.9 billion reproductive-age women (15–49 years) globally needed contraceptive methods; of these, roughly 17% of women have an unmet need for family planning. [ 18 ]  Contraceptive security is one way to improve  maternal mortality rates . According to the CDC, the maternal mortality rate for 2020 increased 3.7% between 2019 and 2020. [ 19 ]  In 2017, about 295,000 women worldwide died during and following pregnancy or childbirth which occurred in low and lower middle-income countries. [ 20 ]  These death rates reflect inequalities in access to health services, such as access to contraceptives. Maternal mortality risk is higher in adolescents under 15 years of age and pregnancy/childbirth complications are higher among adolescent biological females ages 10–19 as compared to individuals with uteruses aged 20–24. [ 20 ]  Contraceptives can also prolong interbirth intervals, since short interbirth/interpregnancy intervals are associated with higher maternal mortality risk. [ 17 ]


Contraceptive security relies on various governmental policies and programs to provide affordable, high-quality contraceptive products for individuals to choose, obtain, and use at their discretion. [ 16 ]  Strengthening contraceptive security requires routine monitoring of donor and government commitment, policies, stakeholder coordination, and supply chain information. Tools including the contraceptive security indicators [ 21 ]  and the contraceptive security index offer ways of measuring contraceptive security, and allow comparisons over time and across countries. [ 22 ]


Access to healthcare is one barrier to contraceptives in North America. [ 23 ]  Access to healthcare includes cost, health and prescription insurance, having a healthcare provider, and being able to access a family planning clinic or facility, all of which vary among the countries in North America. [ 23 ]  Many forms of contraceptives require some form of interaction with a healthcare provider, such as a doctor or pharmacist, as they require a procedure or a prescription. Condoms are the most commonly used form of contraceptives since they are available over-the-counter and do not require a prescription. [ 23 ]  In the study, participants also stated they were less likely to access healthcare and reproductive services due to the fear of perceived stigma, including the stigma around being an immigrant or being a sex worker. [ 23 ]  Another important barrier to other forms of contraceptives is the limited education individuals have. Sex workers, for example, stated they learned about their contraception options from other sex workers or from healthcare providers after they had gotten pregnant. [ 23 ]


In the United States, several contextual factors create barriers for contraceptive accessibility. These factors include, but are not limited to, race, sexuality, socioeconomic status, and gender identity. [ 24 ]


While many other continents have relatively open access to contraceptives, individuals in Africa have a difficult time getting contraception. This is a result of poor funding, lack of social support, and unaffordable contraceptives. [ 25 ]  In Africa, around 80% of women do not use any form of contraception at all. [ 25 ]  One of the biggest reasons for this is because of how unaffordable contraceptives are for the average person in Africa. [ 26 ]  The majority of countries within Africa are considered LMIC (low-middle income countries). [ 25 ]  This makes it difficult for most working-class individuals to purchase contraception as, in Uganda, condoms can cost as much as 3000 Ugandan shillings (about 0.75 United States dollars). [ 26 ]  A singular condom would cost half of the monthly income of the average person living in sub-Saharan Africa. [ 27 ]  This cost also does not factor in transportation costs that individuals would incur getting to the urban areas which sell these contraceptives. [ 26 ]


Religion and culture also play a very large role into the decision that many women make on whether or not to use contraception in Africa. [ 28 ]  In Luweero, it is typically desirable to have very large families and thus affects decisions on family planning and contraceptive use. [ 26 ]  On top of this, many Catholic and Muslim communities believe that God have a set plan for each individual and that contraceptive use directly goes against those beliefs. [ 26 ]