Towards an Integral Model of Health: Documenting the Sterilization of Puerto Rican Women

Salvador Herrera // The camera slowly pans up a dry and cracked dirt road before settling on a set of large stone pillars. Each bears the outlines of the Taíno goddess of fertility and water, Atabey. The scene quickly cuts to a woman in labor, with jíbaro-style music playing in the background all the while. After the baby is born, the woman is wheeled into an operating room, where la operación commences.

This opening sequence is from the 1982 documentary La Operación, directed by Ana María García.[i] The documentary draws its name from a colloquialism for partial bilateral salpingectomy: a procedure that removes a part of each fallopian tube to prevent conception. In truth, la operación included any number of procedural measures in the name of birth control, where salpingectomies or tubal ligations were accompanied by invasive hysterectomies to further the ends of population control. These procedures were so common that between the 1940s and 1970s, more than a third of Puerto Rican women were sterilized.[ii]

As Helen Rodríguez Trías, the first Latina president of the American Public Health Association (APHA) makes clear in an interview spliced throughout the film: “When birth control is really carried out, people are given information and the facilities to use different kinds of modalities of birth control. Population control is really a social policy that is instituted with the thought in mind that there are some people who should not have children.”[iii] During her work at the island’s medical school in the 1960s, she and her colleagues came to believe “that Puerto Rico was being used as a laboratory, and it was being used as a laboratory for the development of birth control technology.”[iv] The confluence between population control as public policy and birth control as an individual right circumscribed the agency of Puerto Rican women in this “laboratory.” Women actively sought out la operación, but they did so under many external pressures, economic hardships, and with a lack of information or misinformation.

These conditions furthered “the development of birth control technology” for the United States at the expense of the reproductive health of women of color. For example, as Margaret Sanger teamed up with Dr. Gregory Pincus and the Procter & Gamble corporation, early trials of the first birth control pill at twenty-times the strength of current standards were tested on Puerto Rican women who were living in public housing on the island in 1956; many of these women suffered from severe side effects.[v] Margret Sanger was a leading feminist and advocate of eugenic ideas at the time, Clarence Gamble of Procter & Gamble was a wealthy eugenicist, and Dr. Pinchus could not conduct his experiments with progesterone in the United States. The trio, in collaboration with health officials on the island, saw the so-called overpopulation and poverty of Puerto Rico as an opportune experiment and worthy business venture.

As is evident, these procedures and birth control products emerged at a complex historical nexus of social ideologies, policies, agendas, colonization, economic inequalities, market manipulation, and patriarchal orders across cultures. In her longitudinal study of five Puerto Rican families in the Bronx, New York, Iris Lopez notes that some of these ideologies included neo-Malthusianism, which merged with social Darwinism at the turn of the twentieth century [vi]. The synthesis of these classist and racist ideas, along with the biopolitical burden placed on women, created the perfect storm on the island.

The notion of Puerto Rico as “laboratory” emerging from La Operacíon, of course, runs the risk of eliding the complexities of women’s decisions with conspiratorial tones. The informational documentary at times plays on the social anxieties and drama of speculative imaginaries—not unlike The Handmaid’s Tale (1985) by Margaret Attwood and its 2017 remediation on Hulu—even as it reacts to real, ongoing political injustices. While overarching systems of control are convenient metaphors for conceptualizing systemic inequalities, Lopez’s Matters of Choice: Puerto Rican Women’s Struggle for Reproductive Freedom (2008), emphasizes that everyday reality is far more complex for the range of Puerto Rican women who underwent the procedure. Lopez argues that “[s]terilization as a reproductive technology,” like any technology, is only a moral evil when deployed as a form of population control without fully informing patients; in other instances, less invasive procedures are deployed as valid forms of birth control around the world.[vii] Furthermore, her study moves beyond a strict binary of agents and victims, and away from a discourse of human or reproductive rights:

“How can a woman avail herself of reproductive rights if she believes that men are to be obeyed, or that a person of authority must always be right, or that she couldn’t possibly go against what her mother, sisters, and elders think about things? Would reproductive rights be sufficient in such a case?”[viii]

Lopez’s questions get at the heart of limitations in liberal conceptions of individual rights which do not holdup across cultures; nor do they equally apply to all groups of women, particularly as the United States has forced territories such as Puerto Rico into neocolonial statuses. In place of a discourse of rights, Lopez advocates for “an integral model of reproductive freedom,” one that is attuned to “the lived experience of women” and “the complex influences shaping reproductive decisions” [ix]. The four factors of this integral model—“personal, cultural, social, and historical” spheres—intersect in such a way as to promote contextualized understandings of reproductive freedom.

Following her model, I take this to mean that we must understand women’s decision making from their perspective, and foster material conditions that enable informed, equitable choices without violent repercussions. For example, the sole value cultures often place on women as child bearers, and the enshrinement of said value in religious doctrines and governmental structures alike, should be understood as a violent exercise of patriarchal, biopolitical power. In that respect, any control necessarily engenders unequal bodily limitations along the lines of sex, and in the case of Puerto Rican women with respect to sterilization, race. Moving towards an integral model of health means revisiting the historical past to understand the current sociocultural conditions that undermine equal access to healthcare. From there, we can move forward in a way that ensures that women’s personal decisions are equally protected and enabled under law and public health policy.


[i] See García.

[ii] See Lopez 8–9.

[iii] See García.

[iv] Ibid.

[v] See Liao and Dollin; Roberts MD.

[vi] See Lopez 4–6. This occurred just as Puerto Rico became a territory of the United States after the Spanish-American war. “Puerto Rican women” were caught in a unique situation as they “became the first subjects for implementing Malthusian ideologies of overpopulation,” which would then be applied to all “Third World women” (Lopez 152–53). Thomas Robert Malthus was an English political economist who believed that overpopulation is the source of poverty; social Darwinists of the American eugenics movement adopted notions of heritable fitness and natural selection to explain human development and promote racial hierarchies. Charles Darwin himself believed “that the white races—especially the Europeans—were evolutionarily more advanced than the black races, thus establishing race differences and a racial hierarchy” (Rose).

[vii] See Lopez 153.

[viii] Ibid. 152.

[ix] Ibid. 144.

Works Cited

García, Ana María. La Operación. 1982.

Liao, Pamela Verma, and Janet Dollin. “Half a Century of the Oral Contraceptive Pill.” Canadian Family Physician, vol. 58, no. 12, Dec. 2012, pp. e757–60. PubMed Central,

Lopez, Iris. Matters of Choice: Puerto Rican Women’s Struggle for Reproductive Freedom. Rutgers University Press, 2008.

Roberts MD, William Clifford. “‘The Pill’ and Its Four Major Developers.” Proceedings (Baylor University. Medical Center), vol. 28, no. 3, July 2015, pp. 421–32. PubMed Central,

Rose, Steven. “Darwin, Race and Gender.” EMBO Reports, vol. 10, no. 4, Apr. 2009, pp. 297–98. (Atypon), doi:10.1038/embor.2009.40.

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