Twenty-year-old Ms. C was urgently rushed to Steve Biko hospital after experiencing labour pains. Blood was found in her urine and she was told she had to give birth through caesarean section. The doctor advised her to get sterilised to prevent her from bleeding to death during future pregnancies. Ms. C said she didn’t understand what it meant to be sterilised but, through excruciating pain in labour, she signed the forms placed before her. 

A year later, the son Ms. C had given birth to passed away from tuberculosis, and efforts to bear children again were fruitless. A private gynaecologist informed her that she had been sterilised and that her fallopian tubes were irreparably damaged. She would no longer be able to have children. 

Since learning this, Ms. C has been experiencing bouts of depression.

Rights violation

Ms. C’s story is one of 48 documented cases of forced or coerced sterilisation contained within the Commission for Gender Equality (CGE) report released on February 24. This report and subsequent investigation followed a complaint lodged by the Women’s Legal Centre (WLC) five years ago. 

In 2015, WLC laid a complaint with the Commission on behalf of the Her Rights Initiative (HRI) and International Community of Women Living with HIV (ICW) organisations. HRI and ICW maintain that the sexual and reproductive rights (and myriad other rights) of their clients were violated when they were forced into sterilisation at public hospitals. In the same year as the complaint was filed, Health-e News reported from the 2015 SA Aids Conference on South Africa’s first HIV stigma index, which showed that seven percent of HIV-positive women surveyed reported being sterilised against their will.

Sterilisation is a medical procedure that permanently blocks women’s fertility. It’s performed either by tubal ligation, where the fallopian tubes are tied, or a hysterectomy — removal of the uterus. Forced sterilisation, however, happens when an individual is sterilised without their knowledge, is forced into giving consent or consent is derived via incomplete or false information.  

WLC prepared the complaint on behalf of the two organisations and 48 women following HRI’s research. The Commission then sampled 15 hospitals in KwaZulu Natal and Gauteng — the provinces where most complainants live. The Commission’s approach into investigating the complaint was three-part: it sought additional details from the complainants; met with the department; and carried out on-site inspections.

Threatened and humiliated into sterilisation

The affidavit of the report shows that all the women who had lodged the complaints were Black women, most of them were living with HIV and, at the time of the alleged forced sterilisations, were pregnant and seeking medical care at various state hospitals. 

Either before giving birth, while in labour or experiencing extreme pain, these women were either coerced or forced to sign forms without knowing that these were consent forms allowing the hospital to sterilise them. These women only learned the implications of signing the forms at a later stage. All of these women also gave birth through caesarean section.  

Going through the women’s statements show that medical personnel either humiliated or threatened them. Some were told they would not be treated if they did not sign the forms. Others said they were experiencing extreme pain and did not understand the contents and consequences of the documents they were signing. 

It is not the government’s policy to carry out forced or coercive sterilisation. The Sterilisation Act is clear that sterilisation should not happen without informed consent. Using force, or any other type of coercion, is prohibited and considered a violation of human rights. 

The report refers to the Tubal Ligation Guidelines of 2014 set out for the Department of Health in KwaZulu-Natal, which also clarifies the provisions of those who undergo ‘female sterilisation’ for healthcare practitioners. The guidelines stipulate that those who choose sterilisation should have access to it, and that no person should be coerced into being sterilised or should be sterilised without an appropriate consent procedure.

Those undergoing sterilisation must have gone through an informed consent procedure including counselling, advantages and disadvantages of the procedure, and information on other forms of contraception available. Obtaining consent should be conducted in the language the patient understands and witnessed by at least one other health worker.

But despite the law and these provisions, this type of discrimination against women living with HIV is not new in South Africa. Research contained in a study by Ann Strode, Sethembiso Mthembu, and Zaynab Essack on women living with HIV, indicates patterns of forced sterilisation in South Africa. In the study, 32 HIV positive women were screened in Gauteng and KwaZulu Natal using a questionnaire, and according to the results of the questionnaire, 25 women (which amounts to 68%) had undergone forced sterilisation.

After investigating the WLC’s complaints, the Commission concluded that the forced or coerced sterilisation for women living with HIV in South Africa’s public hospitals amounted to “cruel, torturous or inhuman and degrading treatment”. It also accused medical staff of breaching their “duty of care”.

Forced sterilisation is a direct attack on constitutionally enshrined rights and must be stopped.  

Informed consent is a must

The Commission has referred its report to the Health Professions Council of South Africa (HPCSA), the South African Nursing Council and the National Department of Health (NDOH).

The HPCSA is set to investigate the professional conduct and behaviour of the implicated medical professionals.

One of the recommendations the report makes is to include petitions to the South African Law Reform Commission for an amendment to legislation to ensure consent is properly obtained in this practice. The Commission also recommended that those who agreed to sterilisation must be given a ‘cooling off’ period to understand the risks and consequences of the procedure.

The NDOH is recommended to investigate consent forms for sterilisations to ensure that the provisions contained in those forms provide for the principle of informed consent in all respects. The health department has been given three months to confirm receipt of this report, and is required to put concrete steps in place to ensure that the harmful practice of forced sterilisation is eliminated.– Health-e News