The Degenerating Sex: Female Sterilisation, Medical Authority and Racial Purity in Catholic Brazil.

This article examines female sterilisation practices in early twentieth-century Rio de Janeiro, Brazil. It argues that the medical profession, particularly obstetricians and psychiatrists, used debates over the issue to solidify its moral and political standing during two political moments of Brazilian history: when the Brazilian government separated church and state in the 1890s and when Getúlio Vargas's authoritarian regime of the late 1930s renewed alliances with the Catholic church. Shifting notions of gender, race, and heredity further shaped these debates. In the late nineteenth century, a unified medical profession believed that female sterilisation caused psychiatric degeneration in women. By the 1930s, however, the arrival of eugenics caused a divergence amongst physicians. Psychiatrists began supporting eugenic sterilisation to prevent degeneration - both psychiatric and racial. Obstetricians, while arguing that sterilisation no longer caused mental disturbances in women, rejected it as a eugenic practice in regard to race. For obstetricians, the separation of sex from motherhood was more dangerous than any racial 'impurities', both phenotypical and psychiatric. At the same time, a revitalised Brazilian Catholic church rejected eugenics and sterilisation point blank, and its renewed ties with the Vargas regime blocked the medical implementation of any eugenic sterilisation laws. Brazilian women, nonetheless, continued to access the procedure, regardless of the surrounding legal and medical proscriptions.

Esterilização feminina / Female sterilization

Nesta edição do programa recebeu Sérgio Yamamoto, médico ginecologista do Hospital e Maternidade Leonor Mendes de Barros, para falar sobre esterilização feminina. O convidado desenvolveu a pesquisa com o tema: "Esterilização cirúrgica feminina no Brasil: controvérsias na interpretação e desafios na aplicação da Lei 9263". A pesquisa qualitativa entrevistou 27 profissionais de saúde divididos em médicos, assistentes sociais, enfermeiros e psicólogos. Estes servidores formam um grupo multiprofissional responsável pelo atendimento de mulheres que procuram a esterilização. Um dos grandes problemas para a realização da laqueadura ou vasectomia no Brasil é a intervenção da igreja católica que se posiciona contra métodos contraceptivos. Para que não haja arrependimento, é importante que a mulher ou o casal, procure o serviço de planejamento familiar nas unidades de saúde antes de realizar a esterilização. Um dos principais resultados apontados pela pesquisa é a divergência existente na interpretação da lei por parte dos profissionais que realizam este serviço. O artigo mais importante da Lei 9263 afirma que qualquer mulher maior de 23 anos ou com pelo menos dois filhos vivos pode realizar a esterilização. A interpretação da lei causa polêmicas e dificulta o trabalho e a realização do serviço.

A esterilização cirúrgica feminina no Brasil, controvérsias na interpretação e desafios na aplicação da Lei 9263 / Surgical sterilization in Brazil: controversies in the interpretation and challenges in application of Law 9263/96

Introdução: A esterilização cirúrgica foi historicamente considerada como importante problema de Saúde Pública, dada sua alta prevalência em nosso país. Em 2006 (MS), era o método contraceptivo mais utilizado, entre as mulheres de 15 a 49 anos, sendo sua prevalência de 25,9 por cento. Esta prática aconteceu no Brasil em um cenário de clandestinidade, como crime e conduta antiética, salvo em algumas situações de risco de vida, acompanhadas de distorções como a cesárea para fins exclusivos de esterilização. A regulamentação da Lei 9263/96 representou abertura ao direito e ao acesso das mulheres à esterilização cirúrgica. No entanto, seu texto foi considerado ambíguo, induzindo a diferentes interpretações por profissionais, notadamente em relação a sua aplicação a mulheres muito jovens. Objetivos: Identificar como profissionais de saúde conhecem e interpretam a Lei 9263/96; que artigos da Lei apresentam controvérsias na sua interpretação e aplicação; as questões éticas, morais, sociais e clínicas relacionadas com tais controvérsias e que desafios se colocam para cumprimento da mesma como resposta aos direitos das mulheres. Procedimento Metodológico: Pesquisa de natureza qualitativa, com entrevistas de 27 profissionais de saúde da cidade de São Paulo. Na interpretação das narrativas foi utilizada a Análise de Discurso. Resultados: Nos discursos dos vários profissionais há um reconhecimento positivo de que a Lei se apresenta como disciplinadora da prática médica, retirando o procedimento de sua condição de ilegalidade. São identificadas controvérsias em relação ao texto da Lei, sobretudo no que se refere à idade de 25 anos ou dois filhos vivos e, também, à sua realização no momento do parto. Os discursos permitem revelar a complexidade de que se reveste a aplicação da lei, tendo em vista o peso que os critérios sociais assumem no processo de aprovação e execução da esterilização, na medida em que a mesma passa a caracterizar-se, em nível de serviços de saúde, como um procedimento ao mesmo tempo clínico e de intervenção social.

[Provision of voluntary surgical sterilization in the Campinas Metropolitan Area, São Paulo State, Brazil: perceptions of public health services managers and professionals]. / Atendimento à demanda pela esterilização cirúrgica na Região Metropolitana de Campinas, São Paulo, Brasil: percepção de gestores e profissionais dos serviços públicos de saúde.

This study describes the perceptions of public health services managers and professionals concerning provision of voluntary surgical sterilization in the Campinas Metropolitan Area, São Paulo State, Brazil. The study adopted a qualitative approach in four municipalities (counties), where semi-structured interviews were conducted with 26 health professionals and health services managers involved in the provision of surgical sterilization. The interviewees identified difficulties in scheduling visits at Outpatient Family Clinics or Reference Centers (APF/CR), and the number of available surgeries in the accredited hospitals was insufficient. They emphasized the lack of physical infrastructure and human resources for conducting family planning activities in the primary health units as well as in the APF/CR.They also criticized the legal criteria for authorizing surgical sterilization, and mentioned adaptations to make them more appropriate to the each municipality's situation. According to the health services managers and professionals, despite the efforts, meeting the demand for surgical sterilization in the Campinas Metropolitan Area was jeopardized by its centralization in the APF/CR, which in practice had to cover the gap in family planning activities in each municipality's primary care units.

Atendimento à demanda pela esterilização cirúrgica na Região Metropolitana de Campinas, São Paulo, Brasil: percepção de gestores e profissionais dos serviços públicos de saúde / Provision of voluntary surgical sterilization in the Campinas Metropolitan Area, São Paulo State, Brazil: perceptions of public health services managers and professionals

A presente pesquisa descreve a percepção de gestores e profissionais de serviços públicos de saúde de municípios da Região Metropolitana de Campinas, São Paulo, Brasil, acerca do atendimento à demanda pela esterilização cirúrgica voluntária. Trata-se de estudo qualitativo, em quatro municípios, onde se realizaram entrevistas semi-estruturadas com 26 gestores e profissionais de saúde envolvidos no atendimento às solicitações de esterilização cirúrgica. Apontaram-se dificuldades para agendamento de consultas nos ambulatórios de planejamento familiar ou centros de referência e número insuficiente de cirurgias que podiam ser agendadas semanalmente nos hospitais credenciados. Enfatizou-se a falta de estrutura física e recursos humanos tanto nas unidades básicas de saúde, quanto nos ambulatórios de planejamento familiar ou centros de referência. Houve críticas aos critérios legais para autorizar a esterilização, bem como se mencionaram adaptações para torná-los mais adequados à situação de cada município. Gestores e profissionais de saúde entendiam que, apesar dos esforços empenhados, o atendimento à demanda pela esterilização cirúrgica na Região Metropolitana de Campinas estava prejudicado pela centralização em ambulatórios de planejamento familiar ou centros de referência, que, na prática, tinham que suprir as deficiências da oferta de ações de planejamento familiar em geral na rede básica de cada município.

This study describes the perceptions of public health services managers and professionals concerning provision of voluntary surgical sterilization in the Campinas Metropolitan Area, São Paulo State, Brazil. The study adopted a qualitative approach in four municipalities (counties), where semi-structured interviews were conducted with 26 health professionals and health services managers involved in the provision of surgical sterilization. The interviewees identified difficulties in scheduling visits at Outpatient Family Clinics or Reference Centers (APF/CR), and the number of available surgeries in the accredited hospitals was insufficient. They emphasized the lack of physical infrastructure and human resources for conducting family planning activities in the primary health units as well as in the APF/CR.They also criticized the legal criteria for authorizing surgical sterilization, and mentioned adaptations to make them more appropriate to the each municipality's situation. According to the health services managers and professionals, despite the efforts, meeting the demand for surgical sterilization in the Campinas Metropolitan Area was jeopardized by its centralization in the APF/CR, which in practice had to cover the gap in family planning activities in each municipality's primary care units.

Motivos de solicitud de la ligadura tubaria: estudio exploratorio desde la perspectiva de las usuarias gran multíparas que asisten a un hospital público de la Ciudad de Buenos Aires / Motives of request of the tubal ligation: exploratory study from the perspectives of the users great multiparous that they are present at a public hospital of the Buenos Aires City

En la Argentina, desde agosto de 2006 está vigente la Ley Nacional Nº 26.130 que garantiza el derecho a las mujeres mayores de edad, que no desean tener más hijos, a acceder en forma gratuita a la ligadura tubaria. Objetivo: Describir los motivos que explicitan las mujeres gran multíparas para solicitar la ligadura tubaria. Material y métodos: El diseño fue exploratorio-descriptivo y la metodología cualitativa. Se realizaron entrevistas en profundidad a una muestra intencional de 30 usuarias gran multíparas (> 5 partos) que solicitaron la anticoncepción quirúrgica en el Área de Salud Sexual y Reproductiva del HMI Ramón Sardá de la Ciudad Autónoma de Buenos Aires, y a 10 profesionales de la salud, considerados informantes clave. Resultados: La mitad de las mujeres entrevistadas había solicitado la ligadura tubaria previamente y 22 de 26 mujeres (84,6 por ciento) que estaban embarazadas al momento de solicitar la práctica, señalaron que su embarazo no era deseado. Entre algunos resultados, la mayoría era argentina y la edad promedio fue de 34,6 años. El temor a sufrir complicaciones en la salud en caso de un nuevo embarazo y la situación de un embarazo inesperado, aparecen como motivos determinantes para la solicitud de la práctica. Conclusiones: Si bien la sanción de la ley es muy reciente y su implementación está sujeta a diversas barreras, depende de la voluntad de los actores sociales para que dichos obstáculos sean visibilizados, a fin de optimizar la calidad de atención de las beneficiarias de los Programas de Salud Sexual y Reproductiva de la Argentina.

In Argentina, a National Law 26.130 was passed in August, 2006. This law gives the right to women over 21 years old who do not want to have more children to ask for the tubal sterilization without having to pay for the practice. Objective: Describe the reasons that grand multiparous women give to petition for a tubal sterilization. Material and methods: The design was descriptive exploratory and the methodology was qualitative. Interviews in depth were conducted to an intentional sample of thirty grand multiparous women (>5 partos) who arrive to the Reproductive and Sexual Health Area of the Ramón Sardá Hospital in the City of Buenos Aires asking for tubal sterilization, plus ten professionals in the health field, considered key informants. Results: Half of the women interviewed had already asked for the practice previously, and 22 of 26 women (84,6 per cent) that were pregnant talked that this pregnancy was unwanted. So me results establishes that most of them were argentinians and the average age was 34,6 years old. Conclusions: The fear of suffering health complications in the case of a new pregnancy or a new unwanted pregnancy appear to be the most important reasons to ask for the tubal sterilization. The visualization of the obstacles mentioned before depends on the willingness of the social actors. They will optimize the quality of the service offered to the patients of the reproductive and Sexual Health Program of Argentina.

Motivos de solicitud de la ligadura tubaria: estudio exploratorio desde la perspectiva de las usuarias gran multíparas que asisten a un hospital público de la Ciudad de Buenos Aires / Motives of request of the tubal ligation: exploratory study from the perspectives of the users great multiparous that they are present at a public hospital of the Buenos Aires City

En la Argentina, desde agosto de 2006 está vigente la Ley Nacional Nº 26.130 que garantiza el derecho a las mujeres mayores de edad, que no desean tener más hijos, a acceder en forma gratuita a la ligadura tubaria. Objetivo: Describir los motivos que explicitan las mujeres gran multíparas para solicitar la ligadura tubaria

In Argentina, a National Law 26.130 was passed in August, 2006. This law gives the right to women over 21 years old who do not want to have more children to ask for the tubal sterilization without having to pay for the practice. Objective: Describe the reasons that grand multiparous women give to petition for a tubal sterilization. Material and methods: The design was descriptive exploratory and the methodology was qualitative. Interviews in depth were conducted to an intentional sample of thirty grand multiparous women (>5 partos) who arrive to the Reproductive and Sexual Health Area of the Ramón Sardá Hospital in the City of Buenos Aires asking for tubal sterilization, plus ten professionals in the health field, considered key informants. Results: Half of the women interviewed had already asked for the practice previously, and 22 of 26 women (84,6 per cent) that were pregnant talked that this pregnancy was unwanted. So me results establishes that most of them were argentinians and the average age was 34,6 years old. Conclusions: The fear of suffering health complications in the case of a new pregnancy or a new unwanted pregnancy appear to be the most important reasons to ask for the tubal sterilization. The visualization of the obstacles mentioned before depends on the willingness of the social actors. They will optimize the quality of the service offered to the patients of the reproductive and Sexual Health Program of Argentina.(AU)

Esterilización quirúrgica humana y legislación argentina: aspectos biomédicos, jurídicos y éticos / Human sterilization surgery and argentinian law: biomedical, legal and ethical aspects

El Congreso argentino dictó recientemente la Ley 26.130-2006 sobre el régimen para las intervenciones de contracepción quirúrgica de varones y mujeres. Este documento revisa esta situación legislativa de este capítulo del ejercicio de la medicina en Argentina y el mundo y plantea observaciones críticas sobre su articulado, resaltando el derecho de las personas al acceso a otros métodos anticonceptivos no quirúrgicos; la conveniencia de que la pareja sexual del interesado conozca la decisión elegida; la necesidad de que se verifique la capacidad y la competencia de los candidatos, previo a la intervención quirúrgica por parte de un equipo profesional interdisciplinario; el deber de regular la situación por la que atraviesan las personas judicialmente incapacitadas; la oportunidad de fijar un tiempo prudente entre la información recibida y el consentimiento otorgado por el paciente; la obligación de que la esterilización no resulte la única práctica médica costeada por el sistema público de salud, las organizaciones de la seguridad social y las entidades de medicina prepaga, y sobre el alcance y la naturaleza de una objeción de conciencia que atienda a las circunstancias particulares de cada caso concreto.

Argentine's congress recently dictated the 26.130-2006 law about the procedure for sterilization surgery interventions in men and women. This work offers a review of the legal situation in Argentine and in the world. It points out critical observations to its items, highlighting the right to access to other non surgical contraceptive methods; the advisability for the interested sexual partner to know which decision was taken; the need to determine the competence of candidates prior to surgical intervention stated by an interdisciplinary professional team; the duty to regulate the special situation of legally incompetent persons; the importance of establishing an adequate time between the information and the patient's consent; to prevent sterilization to become the only medical practice paid by the public health system, social security organizations and prepaid medical entities; and to be careful about the reach and nature of conscientious objection in each specific circumstance.

O Congresso Argentino aprovou recentemente a Lei no. 26.130-2006 a respeito das intervenções de contracepção cirúrgicas de homens e mulheres. Este trabalho oferece uma revisão d situação legislativa deste capítulo do exercício da medicina na Argentina e no mundo, apresentando os antecedentes das províncias e a recente lei nacional. Levanta observações críticas sobre seu conteúdo, ressaltando o direito das pessoas ao acesso a outros métodos anticoncepcionais não cirúrgicos; a conveniência de que o casal sexual do interessado conheça a decisão eleita; a necessidade de que se verifique a capacidade e a competência dos candidatos, antes da intervenção cirúrgica por parte de uma equipe profissional interdisciplinar; o dever de regular a situação especial que atravessam as pessoas judicialmente incapacitadas; a oportunidade de fixar um tempo prudente entre a informação recebida e o consentimento outorgado pelo paciente; a obrigação ode que a esterilização não resulte como a única prática médica custeada pelo sistema pública de saúde, as organizações de seguro social e as entidades de medicina de grupo e sobre o alcance e a natureza de uma objeção de consciência que atenda às circunstâncias particulares de cada caso concreto.

The therapeutic exception: abortion, sterilization and medical necessity in Costa Rica.

Based on the case of Rosa, a nine-year-old girl who was denied a therapeutic abortion, this article analyzes the role played by the social in medical practice. For that purpose, it compares the different application of two similar pieces of legislation in Costa Rica, where both the practice of abortion and sterilization are restricted to the protection of health and life by the Penal Code. As a concept subject to interpretation, a broad conception of medical necessity could enable an ample use of the therapeutic exception and a liberal use of both surgeries. The practice of therapeutic sterilization has been generalized in Costa Rica and has become the legitimate way to distribute contraceptive sterilization. In contrast, therapeutic abortion is very rarely practiced. The analysis carried out proposes that it is the difference in social acceptance of abortion and sterilization that explains the different use that doctors, as gatekeepers of social morality, make of medical necessity.

Medicalization, reproductive agency, and the desire for surgical sterilization among low-income women in urban Brazil.

This article draws on data from ethnographic fieldwork in an urban housing project to examine the social context and meanings of surgical sterilization for low-income women in Brazil. Low-income women resort to sterilization because they distrust or are unsatisfied with alternative methods and because it helps them to fulfill the requirements of modern, responsible motherhood. Although sterilization is an option among few alternatives, and one that has subjected women to greater medical management and intervention, I argue that sterilization also represents poor women's active struggle to improve their lives and to resist the burdens placed on them by unequal gender relations. This article contributes to a growing anthropological literature that demonstrates how reproduction has become a central site where social values are constituted and contested, and it details women's diverse responses to the process of medicalization.

[Female sterilization, AIDS, and medical culture in São Paulo and Porto Alegre, Brazil]. / Esterilização feminina, AIDS e cultura médica: os casos de São Paulo e Porto Alegre, Brasil.

This paper explores the factors associated with reproductive choices by HIV-positive pregnant women in two settings in Brazil, and particularly how health care providers and the local medical culture can affect these choices. Requesting and submitting to postpartum sterilization provide the focus of the analysis. The data come from a study conducted in prenatal care services in two cities, São Paulo and Porto Alegre. We employed two data collection strategies: collection of information from 427 patient records for HIV-positive women who had received prenatal care, and in-depth interviews with 60 women. While most women in both cities requested tubal ligation after delivery, a much higher proportion of women in Sao Paulo were actually sterilized, as compared to a tiny proportion of women in Porto Alegre. The local medical culture regarding sterilization and organization of prenatal care emerged as important factors for understanding the differences between the two cities.

[Reproductive rights of women and men in light of new legislation on voluntary sterilization in Brazil]. / Direitos reprodutivos de mulheres e homens face à nova legislação brasileira sobre esterilização voluntária.

This paper aims to analyze the impacts and possible changes that the implementation of a new Brazilian family planning law has on reproductive practices, especially voluntary sterilization, and to determine whether men's and women's reproductive rights are being respected. The methodological approach is based on a six-month follow-up survey taken monthly, applied to a sample of 159 individuals in six contextually different State capitals. Besides verifying whether the health sector is complying with the criteria set by the law, we analyze the waiting time between the request for sterilization and the surgery itself, utilizing survival analysis. We also conduct interviews with health professionals, shedding light on the procedures adopted in the practice of sterilization. For various reasons, the law has produced little change in the usual practice of sterilization, besides failing to satisfy individual reproductive rights.

Vasectomía en los tribunales argentinos / Vasectomy in the argentine tribunal

La esterilización masculina permanente (vasectomía) fue incorporada recientemente a la legislación de algunas provincias argentinas, mientras que en otras han comenzado movimientos sociales pidiendo su aceptación como práctica médica. Mientras tanto, algunas solicitudes se han planteado ante los Tribunales y obtenido respuestas disímiles. El presente artículo repasa estas cuestiones y analiza con detalle la primera causa judicial registrada en la Provincia de Buenos Aires. Asimismo estructura una crítica a la sentencia dictada en base a una racionalidad estratégica,donde desfila la noción de indicación terapéutica en sentido amplio, el concepto comprensivo de salud, la idea de necesidad terapéutica y el principio ético de globalidad. (AU)

O arrependimento após a esterilizaçäo feminina: é possível prevenir? / Regret after female sterilization: is it preventable?

O arrependimento após a esterilizaçäo tem sido um objeto de estudo de diversas pesquisas realizadas no Brasil e no mundo com o objetivo de avaliar as consequências da esterilizaçäo. Apesar de ser um objeto de difícil definiçäo e medida vários fatores têm sido recorrentemente encontrados associados ao arrependimento, tornando-o um evento de possível prevençäo. Este artigo faz uma revisäo da literatura nacional e internacional discutindo os fatores associados ao arrependimento, a sua prevalência no Brasil e no mundo, as formas de prevençäo do arrependimento, as recomendaçöes de organizaçöes internacionais, a situaçäo legal brasileira e questöes éticas relacionadas aos direitos reprodutivos. Aborda também vários aspectos relacionados à sua prevençäo, em particular a orientaçäo ou aconselhamento, que tornou-se um requisito legal para esta cirurgia.

[Legal secrecy: abortion in Puerto Rico from 1937 to 1970]. / Clandestinaje legal: el aborto en Puerto Rico de 1937 a 1970.

The essay discusses abortion in Puerto Rico from 1937 to 1970, concentrating in its legal status as well as its social practice. The research documents the contradictions between the legality of the procedure and a social practice characterized by secrecy. The essay discusses the role of the Clergy Consultation Service on Abortion in promoting the legal practice of absortion in Puerto Rico. It also discusses the ambivalent role of medical doctors who, despite being legally authorized to perform abortions to protect the life and health of women, refused to perform the procedure arguing abortion was illegal. The essay concludes with a brief discussion on perceptions of illegality regarding abortion, emphasizing the contradictions between the practice of abortion and that of sterilization in Puerto Rico.

PIP: The legal status and occurrence of abortion in Puerto Rico are examined for the years from 1937 (when abortion under some conditions was legalized) through 1970. A series of legislative initiatives in 1937 repealed laws prohibiting interstate transportation of contraceptive materials and information, legalized contraceptive sterilization, and permitted abortion to conserve the health or life of the woman. The effective legalization of abortion in 1937 was not publicly recognized at the time or in later decades, and the legal changes apparently did not lead immediately to a significant increase in the number of abortions, unlike sterilizations, which did increase significantly. The requirement that indications for therapeutic abortion be identified by physicians excluded the nurses and midwives who had traditionally been responsible for most births and abortions. Foreign organizations such as the Clergy Consultation Service promoted the legal practice of abortion in Puerto Rico. Efforts in 1964 to amend the penal code to curtail abortion were less successful than the passage by New York in 1970 of the most liberal abortion law in the US, which greatly reduced the number of abortions in Puerto Rico. Puerto Rican women able to pay obtained abortions from trained professionals, despite the perception of abortion as illegal, but poor women had recourse to poorly trained midwives and nurses at best. A training program for midwives during the 1930s provided instruction and equipment necessary for safe deliveries, but the knowledge gained was reflected in safer abortions and declining maternal mortality.

Clandestinaje legal: el aborto en Puerto Rico de 1937 a 1970 / Legal status: the abortion in Puerto Rico from 1937 to 1970

The essay discusses abortion in Puerto Rico from 1937 to 1970, concentrating in its legal status as well as its social practice. The research documents the contradictions between the legality of the procedure and a social practice characterized by secrecy. The essay discusses the role of the Clergy Consultation Service on Abortion in promoting the legal practice of absortion in Puerto Rico. It also discusses the ambivalent role of medical doctors who, despite being legally authorized to perform abortions to protect the life and health of women, refused to perform the procedure arguing abortion was illegal. The essay concludes with a brief discussion on perceptions of illegality regarding abortion, emphasizing the contradictions between the practice of abortion and that of sterilization in Puerto Rico