Faith, 28, an HIV-positive single mother and supermarket cashier living in the Gauteng province of South Africa, was 36 weeks pregnant with her first baby when a doctor suggested sterilization as the best form of contraception for her. The doctor wasn’t explicit about the reason, but Faith (not her real name) is sure it had something to do with her HIV status. She hadn’t been considering permanent birth control, but her family insisted that she go ahead with the procedure. Since she was not married, they told her, they didn’t want to take on the burden of caring for her children if – meaning when – she died. “They said they would be unable to take care of a hundred children when I’m gone, and I felt I needed to do the procedure as I was not working at the time and they were taking care of me,” she says.
Faith reluctantly agreed to undergo tubal ligation, when a woman’s fallopian tubes are severed or sealed. Almost a decade later, she still regrets her decision, saying she worries she may never be able to get married now. “I will not be able to give [a future husband] any children, and in our culture, that is a huge problem,” she says.
Over recent years, reports from various U.N. agencies and advocacy organizations have revealed that, across Africa, HIV-positive women are being forced or tricked into being sterilized. In most cases, health workers tell the women that sterilization is the best way to stop the spread of the virus, despite the fact that medication specifically for the prevention of mother-to-child transmission of HIV is widely available. Sometimes, HIV-positive women are told that, because of their status, pregnancy is a risk to their health. And then there are families like Faith’s, who pressure their daughters to undergo the procedure to avoid having to take on any more children if the disease kills their mother.
Now, rights campaigners in Kenya are closely watching two cases that could make it harder for doctors to sterilize women without their full consent. The country’s high court is due to hear lawsuits involving five HIV-positive women who were allegedly forcibly sterilized, and its decision could set a precedent for future fights against the practice.
In 2014, the WHO and six other U.N. agencies issued a joint statement saying that vulnerable groups, including HIV-positive women, disabled women and women from ethnic minorities, are being sterilized without their “full, free and informed consent.” Rights advocates say forced sterilization is a problem across Africa. A recent study carried out in nine districts of Uganda by the International Community of Women living with HIV Eastern Africa (ICWEA) found that of the 72 HIV-positive women surveyed who had been sterilized, 20 of them had been forced to undergo the procedure or had the procedure carried out without their consent. The 2014 South Africa HIV Stigma Index revealed that 7 percent of HIV-positive women surveyed reported being sterilized against their will.
A 2012 report by the African Gender and Media Initiative (GEM) documented the stories of 40 HIV-positive women in Kenya who were coerced or forced into sterilization. One was Alice, a married woman from Nairobi who was 28 when researchers spoke to her. In 2008, pregnant and in labor, Alice went to a Nairobi hospital where she says she was coerced into signing consent forms for sterilization.
“While I was groaning in pain, the doctor looked at my file and said to me, ‘Woman, you are still giving birth and you are HIV positive?’” she told the researchers. The doctor then told her to sign consent forms authorizing a tubal ligation. “When they insisted on tubal ligation, I signed the documents so that they could attend to me and relieve me of the pain I was going through,” Alice said in the report. “I was not able to reach my husband as he had no phone.”
By taking away the ability of HIV women to conceive, doctors also sentence them to possible ostracization, say activists. In many African communities (as in other parts of the world), motherhood is at the core of femininity and social status. According to the GEM report, when a woman with HIV is sterilized, the stigma of her health status is compounded by the fact that she is no longer considered a woman by her community. When the report was published, four years had passed since Alice’s sterilization, but she hadn’t yet told her husband. She was afraid that he would abandon her to marry a woman who could give him more children.
According to GEM spokeswoman Gladys Eiio, nothing has changed in those four years. The government has failed to introduce new policies and guidelines to address the issue of forced sterilization, and her organization regularly encounters new cases. “Women we have supported have gone back into their communities and shared their stories. Now, other women are coming forward and sharing their experiences as well,” she says.
In an attempt to bring attention to the practice and obtain compensation for some of the victims, GEM decided to take the issue to court, employing the services of the Kenya Legal & Ethical Issues Network on HIV and Aids (KELIN) to represent five of the women documented in the GEM report.
The case is the first of its kind in Kenya. However, in a similar case in Namibia in 2012, a judge found that the state could not prove that three HIV-positive women gave informed consent to sterilization when, in late stages of labor, they signed forms for what they believed were caesarean sections. He also ruled, however, that the women’s claim that they were sterilized because they were HIV positive didn’t hold up due to lack of evidence. More recently, in 2014, the Gauteng health department in South Africa agreed to pay a settlement of almost half a million rand ($36,000) to an HIV-positive woman for the pain and suffering she endured as a result of being coercively sterilized in a state hospital. Because the case was settled out of court, there was no official finding on the allegation that the sterilization was undertaken due to her HIV status.
Later this year, the High Court of Kenya will hear two separate cases against four health institutions, as well as the county executive committee member in charge of health services, the cabinet secretary in the Ministry of Health, and the attorney general. GEM and KELIN have asked the court to declare the act of forced sterilization unconstitutional and to order the institutions to pay damages to the five plaintiffs. They also want the Ministry of Health to put in place guidelines, measures and training for healthcare providers and social workers on sterilization and informed consent.
A change in policy and better training are the first major steps in putting a stop to forced sterilization, says Tabitha Saoyo, KELIN’s program manager on sexual and reproductive health rights. But the practice won’t end until women are empowered to make their own choices about contraception. “We need a strong policy from the Ministry of Health to address this issue,” says Saoyo. “And we also need a lot of self-awareness by women and girls on their reproductive rights.”
The names of some of the women in this article have been changed to protect their identities.