“At noon, they came, and on a stretcher they took me, and I thought how I had just given birth? They took me to do tests, and I asked them on the way, ladies, where are they taking me? “Don’t be afraid we’re not going to do anything.” I woke up like this and I listened, and there was a group that applauded and said “it was a success, a success”. I started with the discomfort, and when I touched myself and said what is this? My husband came at 2 in the afternoon, and I said to him “you don’t want to find out, it hurt me a lot and I have this wound, I don’t know what happened”. He went to find out, and when he returned he was upset, “because you let them do this to you” he said. I said they have done this to me and they had already brought my baby to me, but said I have not signed, I have not signed any paper!”
Maria (not her real name) speaking on the forced sterilisation carried out on her after her first pregnancy. Her husband left her soon after finding out she was forcibly sterilised.
Last year marked 15 years since the release of the Peruvian truth commission (CVR) report on the conflict and the Fujimori regime. Despite documenting the atrocities committed by state forces, Sendero Luminoso and to a lesser extent the MRTA, including sexual violations, it neglected the state policy of forced sterilisation of poor campesinos and Quechan people. Sunneva Gilmore sets out the nature of the forced sterilisation in Peru, analysing how it has been left out of the transitional justice process and involves complex victimisation and responsibility of healthcare practitioners. In particular, this post hopes to contribute to a broader appreciation of the hidden nature of reproductive violations, the silencing of such victims and how these violations can be symptomatic of more structural violations against marginalised groups.
Forced Sterilisation in Peru
In 1985, Peru declared a National Population Policy, which aimed to educate and provide health services to individuals and couples in order to assist them in their decision-making about family size and inter-pregnancy interval. However, a ten year delayed response ensued and appeared counter-intuitive when serious concerns about its implementation and emphasis on surgical methods emerged. The campaign on forced sterilisation was termed ‘surgical voluntary contraception’ during which there was a decrease in the Peruvian birth rate from 3.7 in 1995 to 2.5 in 2011. The programme mainly targeted rural indigenous women and to a lesser extent man (some 25,000).
The introduction of the sterilisation programme was praised by the international community, which was represented as an attempt to improve perinatal and maternal outcomes, as well as assert sexual and reproductive rights. As a result, approximately 300,000 persons were sterilised. Whilst Peru made significant progress on these goals, it was the result of a series of health and education sector reforms complemented by the work of non-governmental agencies rather than one single intervention. One example is the Good Start Programme, which improved coverage of maternal healthcare and infant nutrition, yet urban-rural disparities in perinatal outcomes remain. For many women, forced sterilisation caused other physical consequences, due to the lack of medical follow up, alleged inadequate surgical standards and ill-equipped operating theatres. While some already had children, others did not undermine their cultural identity of motherhood, as well as their own self-worth and dignity.
The Ministry of Health advocated their policy through sterilisation quotas expected of healthcare professionals, as well as promotional and outreach activities to rural Andean and Amazonian communities. A distinct theme emerged from the information presented at ‘health festivals’ and victims’ recollections of their consultation or encounter with a healthcare professional: that is permanent contraception (sterilisation) was advocated over other reversible methods, which are divided into short and long-acting contraception. An interview with a Peruvian doctor newly qualified at the time of the programme remembered sterilisation as being heavily promoted above other contraceptive methods. It is also unclear whether criteria to determine an individual’s medical eligibility were routinely employed. Whilst some sterilisations were voluntary, it is estimated that most of these procedures were forced. It is difficult to gauge a precise number given the inaccessibility of rural communities and low socio-economic status that limits travel or legal costs in the event of criminal proceedings.
The Peruvian government in 2015 established a register for victims of forced sterilisation, which is separate from transitional justice’s victim’s registry (RUV). This development came over a decade after a friendly settlement was reached between the Peruvian government and the Inter American Commission of Human Rights on the forced sterilisation case of Maria Mestanza, who died as a result of complications of forced sterilisation and associated medical negligence. The agreement outlined Peru’s commitment to investigate allegations of abuses of sexual and reproductive rights. Yet the following years were characterised by repetitive shelving or dismissal of forced sterilisation cases by prosecutors due to insufficient evidence.
Victims and beneficiaries of transitional justice
The resistance by some of Peru’s NGOs, the CVR at the time of its operation and the State to accept victims of forced sterilisation as part of the wider systematic abuses of the conflict suggests transitional justice mechanisms can to adopt a narrow perspective on conflict-related victimhood. Victim-perpetrator dichotomies are insufficient in explaining why Peruvian’s transitional justice adopted an inconsistent approach to victim eligibility, which does not necessarily centralise around responsibility and blame. For instance, it is difficult to contend the innocence of forced sterilisation victims, who are excluded alongside members of subversive groups who suffered sexual and reproductive violations. During fieldwork, a number of participants spoke of how these members of armed groups were often viewed as victims irrespective of their perpetration or combatant membership. However, they are not entitled to reparation in the domestic programme. This indicates the difficult reality of being a victim, but not a beneficiary.
Nonetheless, a shift in what crimes and victims thereof are considered within the context of the conflict may be starting to emerge. One of the commissioners in the CVR during a fieldwork interview expressed that their primary regret was excluding forced sterilisation victims from the scope of the truth commission. Since these victims continue their struggle for accountability and redress, there may be a sense that the CVR recommendations could have provided a more timely adoption of reparations and reduced their moral and material suffering. It is important that transitional justice views the entirety of systematic crimes, and identifies patterns of victimisation that be may be important in establishing pre-existing inequalities and prevalent discrimination in the reconstruction of society. In Peru, the profile of forced sterilisation victims of rural indigenous and Quechan speaking citizens draws parallels to a significant percentage of those who were forcibly disappeared or killed during the conflict.
There is an established discourse of sexual violence as a weapon of war (sometimes above other motivations that exist), which narrows the experience of such violations for victims to be prioritised for transitional justice. Yet the Peruvian state continues to insufficiently link and trivialise how forced sterilisation was used a form of depriving specific population groups of their liberty and infringe upon their rights to family and private life. Transitional justice can also be accused of neglecting these crimes despite the appearance of a successful process. As demonstrated in Peru, victims have been deselected from transitional justice processes, reducing the chance to fulfil promotion of transformation and forcing them to go through different evidential standards to victims who suffered other forms of sexual violence. Distractions from conflict activities may contribute to the relative ease the state (and its institutions such as health) to commit such crimes under the guise of sexual and reproductive health rights.
Bystanders or perpetrators?
There has been little focus on the role of both healthcare institutions (state level) and individual practitioners in transitional justice, which creates a grey zone that comprises of bystanders, perpetrators, victims. It could be argued that medical professionals were just doing their job under the public health policy, but healthcare practitioners are still bound by their ethical codes. The International Federation of Gynaecology and Obstetrics (FIGO), which represents national professional societies in the speciality, has stated it is unethical for medical practitioners to perform sterilization procedures within a government program or strategy that does not include voluntary consent to sterilization. Simply seeing healthcare practitioners who carried out forced sterilisation also overlooks the coercive forms or incentives that facilitated these violations, such as threats or promotion. Some doctors did refuse to carry out the sterilisation procedures and reported it to the local prosecutors, but often these were in a minority of cases.
Health service providers have not always been neglected in transitional justice processes, the South African TRC (p250) found that while they did not commit gross violations of human rights, they were guilty through ‘apathy’ for creating an environment in which the health of millions of South Africans was neglected which compromised their moral and ethic codes that facilitated violations of human rights. There is a space for healthcare to be engaged with in transitional justice to not only understand its role and practice during conflict and authoritarian regimes, but also as part of the accountability and remedial process, including guarantees of non-repetition.
During my Peru fieldwork earlier this year, some healthcare practitioners felt that the public health campaign on sterilisation was justified and consent for procedures were usually adequate. To the extent, senior healthcare professionals considered documentation of partner consent (as well as written consent alone) as reliable evidence of informed consent. This is in contrary to the FIGO stipulating that consent from the person’s partner or other family member should not be required, and principles ensuring freely informed consent must be adopted. This demonstrates that guarantees of non-repetition still need to be embedded in the working culture of healthcare practitioners in Peru.
The continuing justification of forced sterilisation also points to more structural causes of the violence: discrimination against poor Quechan Peruvians. Recent litigation by First Nations women in Canada for forced sterilisation has highlighted the discriminatory intent as a means to reduce the indigenous population. Whilst Peru and Canada targeted different marginalised groups, both contained discriminatory elements in order to control reproduction based on ‘inferior’ ideologies. Coercive strategies often looked to increase the number of situations of vulnerability to increase the successfulness of their aims. For instance, women were coerced immediately postpartum, or intrapartum during caesarean section when in the trusted care of medical professions, sometimes under regional or general anaesthesia or sedation and at a period of physiological change, that require specific standards of consent taking in this peripartum context. Principles include counselling, ideally significantly in advance of delivery and with an opportunity to confirm or change the decision.
While there are efforts underway in Peru by victims to seek redress and accountability, there remain bigger questions on how forced sterilisation was a facet of broader structural violence against mostly poor and indigenous Quechan communities, and the complicity of healthcare practitioners to be implicated in such violations. These issues transcend the Peruvian context, to raise more difficult questions for transitional justice and its place in framing sexual and reproductive violations and the role of other actors and bystanders beyond the binary of victim and perpetrator.