Appendix

SEXUAL STERILIZATION.

FOUR YEARS EXPERIENCE IN ALBERTA.^*

By C. A. Baragar, B.A., M.D.C.M., Geo. A. Davidson, M.D., M.R. C.P. London, W. J. McAlister, M.D. C.M., and D. L. McCullough, B.A., M.B.B.CH., D.P.M. London.

Human sterilization is not by any means new. Ever since surgery became antiseptic and aseptic, operations such as oophorectomies, hysterectomies, salpingectomies, castrations and prostatectomies have frequently been performed of which sterilization was one of the results, though not usually the main result or even a desired result. Sterilization for eugenical purposes, notwithstanding its tremendous significance, is of relatively recent origin, though it is reported that in Switzerland sterilization has been practiced in selected mental cases for many years as a matter of course.

In the United States sexual sterilization has been legalized in certain states since 1907. According to Landman in 1932 30 states of the union had sterilization laws on their books and of these in 27 the statutes were held as valid. In 23 of the 30 states sterilization operations have been performed varying from 9 in Washington to 7548 in California.

With respect to the British Commonwealth of Nations, Alberta is the pioneer in legislation of this character, and to the Honorable George Hoadley and a group of active supporters—chiefly organizations of women—must be given the credit for the vision and courage that has placed this statute on the books of the province. This statute, known as the Sexual Sterilization Act, being Chapter 37 of the Statutes of the Province, was assented to March 21, 1928. It is brief and simplicity itself. Therein lie many of its merits. In some respects it may be thought not to have gone far enough, but as a first statute, for its educational value and for its simplicity, it is indeed admirable.

The operation of the act is under the direction of a specially named board of four well-known residents of Alberta. Prof. J.M. MacEachran, head of the Department of Philosophy of the University of Alberta, is chairman Dr. E.L. Pope, professor of medicine, Dr. E.G. Mason, and Mrs. Jean H. Field, constitute its membership. All, by reason of past experience and wide humanitarian interests, are particularly well qualified to understandingly and sympathetically adjudicate upon the cases presented to them. The Board is the sole authority having power to sanction the operation for eugenical sterilization, and names the hospital and surgeon for each operation. It meets quarterly and if necessary in each of five or more different centers in the province.

The act provides for the sexual sterilization of certain inmates of mental hospitals whom it is proposed to discharge if the Board is unanimously of the opinion that this may safely be done providing the danger of transmission of the disability to progeny were eliminated. Under “mental hospitals” are included not only the provincial institutions for mental disease and defect, but also special wards in certain general hospitals. Thus suitable cases for whom there is no accommodation in one of the mental hospitals, or whose admission is not yet expedient may be presented to the Board.

The classes of persons coming within the scope of the act are:

Patients who are conva1escent from a psychosis.

Patients sufficiently improved from a psychosis to justify discharge with or without supervision.

Patients who though unimproved might be cared for outside an institution.

Mental defectives of all grades whose discharge from institutional care might be reasonably considered were the danger of reproduction removed.

By virtue of Section 6 of the act the operation cannot be performed unless the patient has consented thereto; or, in the case of patients considered by the Board to be mentally incompetent to give consent, the husband or wife; or, if unmarried, the parent or guardian has consented thereto; or, where there is no parent or guardian resident in the province, the Minister of Health has consented thereto.

Safeguards against abuse of the law are ensured not only by the provisons of the act itself, but also by the procedure adopted by the Board.

Consent is necessary.

All authority rests with a board composed of persons of high repute.

Application to the Board for the sexual sterilization of a patient is made by a responsible medical officer, a psychiatrist in the Public Health Service, and his recommendation must be supported by at least one other psychiatrist, also in the public service.

A concise but comprehensive summary of each case must be submitted to the Board setting forth the facts with respect to family and personal history, physical and mental state, and with the reasons for recommending sterilization.

The patient is presented in person to the Board and examined by the medical members.

Both surgeon and hospital act only when they receive the written authority of the Board for the operation.

With respect to discharge while many of the convalescent patients operated on would have been discharged in any event whether sterilized or not, notwithstanding the risk of procreation, the fact that procreation is no longer possible has facilitated discharge. Many cases, however, especially mental defectives, have been discharged who would not otherwise have been discharged.

While no special operation is prescribed in the act a vasectomy of the male and a salpingectomy in the female are the operations invariably performed. At times at the request of the parents or with consent the appendix has been removed and pathological conditions have been dealt with. In one case at the request of the parents a double oophorectomy was done in addition to the salpingectomy. The patient was a deteriorated paralytic epileptic girl with hypererotic tendencies.

As to immediate surgical results there have been no fatalities and no serious complications. In two or three cases there have been stitch abscesses and in one case a protracted convalescence.

The operation when performed on a female in reasonably good physical health, while a serious one like all laparotomies, in reality entails less risk than childbirth itself. In the male it is, of course, a minor operation and need not incapacitate the patient for more than a very few days.

With few exceptions there have been no complaints following the operation. One man complained of a variable dragging sensation of the testes afterwards, but it does not seem to have caused him any loss of time. Two women—both neurotic—complained of menstrual disturbances, in one case developing a year or more after the operation and in the other associated with numerous other complaints of a functional nature. These were not considered by the examining physician as related in any way to the operation.

One schizophrenic patient operated on during an improved interval relapsed into the former catatonic state following the operation.

One girl, a defective with a slowly developing schizophrenic reaction, was sterilized. Her psychosis continued to develop and later she had to be admitted to a mental hospital. As she had shown tendencies to promiscuity the operation was a very desirable precautionary measure.

Another patient, a high-grade defective who had made a very unsatisfactory moral, social and economic adjustment complained that she had lost her womanhood and expressed the idea that as the Eugenics Board had directed the operation the government should support her.

A social worker thought she noted a tendency in a number of the female patients to gain in weight and in a general feeling of well being.

Not sufficient time has elapsed to ascertain definitely whether there have been any effects whatever with respect to potency, sex desire and sex satisfaction. Certainly no complaints or adverse reports have been received from any of the patients, 31.9 per cent of whom were married. Judging from the California reports none of importance need be expected. In their experience the great majority of both males and females experienced no change whatever, in a few there was a slight increase in libido and satisfaction, and in a rare case a slight decrease. Undoubtedly in married females the removal of all fear of pregnancy may have the psychological effect in some cases of heightening satisfaction.

NOTES ON CASES PRESENTED.

As stated above the statute was assented to March 21, 1928. On May 10, 1929, the first operation—a vasectomy—was performed, and the second—a salpingectomy—on December 9, 1929. Since then the work has been steadily increasing as shown below:

This report, however, covers only the cases presented or operated on up to December 31, 1933.

Of the 288 cases 87 were males and 201 females. Of these 48 males and 158 females—a total of 206—have been operated on. Of the 288, 150, or 52.1 per cent, were presented from the Provincial Mental Hospital, two from the Provincial Mental Institute (an institution caring mainly for chronic patients), 33, or 18.4 per cent, from the Provincial Training School, and 12 from the psychopathic ward, a total from these institutions of 217, or 75.4 per cent. Seventy-one, or 24.7per cent, have been presented through the three mental health clinics at Edmonton, Calgary and Lethbridge.

Of the 206 operations 98, or 47.6 per cent, have been performed in the University Hospital, Edmonton; 56, or 27.2 per cent, in the Calgary General Hospital, Calgary; 24, or 11.8 per cent, in the Municipal Hospital, Red Deer; 14, or 6.8 per cent, in the Galt Hospital, Lethbridge; and 14, or 6.8 per cent, in the recently organized surgical center at the Provincial Mental Hospital, Ponoka.

The ages of patients varied from 12 to 45, but as might be expected nearly 77 per cent are under 30 years of age, that is early in the reproductive period; and the largest group—30.2 per cent—fall within the half decade—16 to 20. (table A1)

Of the 288 patients, 87 were males (30.2 per cent) and 201 females (69.8 per cent), 190, or 66 per cent, were single; 92, or 31.9 per cent, were married; two were widowed and four separated or divorced. (table A1)

At least 189, or 65.6 per cent, had never got beyond public school, and of these 19, or 6.6 per cent, were so low in intelligence that they were incapable of any public school work. With respect to race and nationality the attention of the Board has been pretty evenly applied.

It is noteworthy that only 14.2 per cent of the 288 patients were regarded as self-supporting, and 24 per cent as potentially self-supporting, 34 per cent partially self-supporting and 27.8 per cent were dependent. Of these some were dependent by reason of their immaturity chronologically, and some by reason of their low intelligence rating.

In the matter of diagnostic classification 156, or 54.2 per cent, were defective. (table A2) To this defect were in many cases added other problems such as sexual delinquency and other behavior problems, epilepsy and congenital syphilis. If one adds to these the 36 cases of mental deficiency with psychosis the total of those diagnosed as mental defectives with or without other complications amounts to 192, or 66.7 per cent, just two-thirds of the total. Formal psychometrics on those cases in which such a step was indicated or possible revealed that according to these tests 205 (71.2 per cent) of all cases were defectives with intelligence quotients of 75 or less. Of the 205 about two-thirds were morons and hence in the socially more difficult class, and one-third in the imbecile group, while six patients (2 per cent) were in the idiot group. It is noteworthy that at least one of these idiots as well as several with intelligence quotients below 30 had had illegitimate children.

On the other hand, 123, or 42.7 per cent, were or had been psychotic, the manic-depressive and schizophrenic cases especially of the catatonic group predominating. The future of the defective is in general more easily predicted than of the psychotic and hence a larger proportion of defectives presented to the Board have been operated on.

Of the 288 cases passed by the Board conditionally or unconditionally 206 (71.5 per cent) had been operated on by December 31, 1933. Various reasons, such as refusal or withdrawal of consent, consent not yet obtained, patient pregnant or not recovered, accounted for the fact that the operation had not yet been done in the other 82 cases. (table A3) In 18 of the 82, consent was subsequently obtained, and the operation performed in the early months of 1934. Refusal, withdrawal or cancellation of consent account for failure to have the operation performed in 39 cases, or 47.6 per cent, of the 82. There is a greater reluctance on the part of males than of females to seek or submit to operation.

A consideration in some detail of the sexually moral reactions and childbearing records of the 201 female patients brings out in sharp relief some of the most cogent reasons for sterilization. Of these patients 122 were single and 79 were married. Of the single women 22 were regarded as having been promiscuous, 45 had had one or more illicit sexual experiences described throughout the report as irregularities though not apparently promiscuous, nine were doubtful in this respect and only 46, or 37.7 per cent, had clear moral records. It is to be remembered that the majority of these patients were defective and the rest had had mental breakdowns, and hence their conduct was to be interpreted as a symptom of impaired ability to make a social adjustment, and of lack of judgment and inhibition. Of these 122 single women 40, or 32.8 per cent, had given birth to 58 children, an average of 1.45 children each. Of the 40 unmarried mothers 27 had had one child each, 11 two children each, one three children and one six illegitimate children. The ages of the 82 nulliparous single women varied from 12 to 30 with an average of 20.9 years. The ages of the 40 unmarried mothers varied from 15 to 38 with an average of 22.7 years, hence the reproductive life of both groups had only just commenced.

Of the 79 married women (including widowed, separated and divorced) there was a history of promiscuity in 10 and of irregularity in 11, while in 56 the records were clear. Here again, however, with an unsatisfactory moral record in 29.1 per cent of cases the evidence of lowered power of social adjustment is clear.

Of these 79 patients 75, or 94.9 per cent, had borne a total of 300 children, an average of four children each. Of these children 28 (9.3 per cent) were illegitimate. Eleven mothers had one child each, 12 two, 15 three, 10 four, 13 five, 5 six, 2 eight, 2 nine, 4 ten and 1 eleven children.

Adding these 28 illegitimate children to the previous 58 gives us a total of 86 unwanted homeless children, or 24 per cent of the 358 children born to the 115 of the 201 female patients.

The ages of the 75 married multipara varied from 18 to 41 with an average of 30.9. The ages of· the other four married women varied from 25 to 30 with an average of 28.2 years. This group was, therefore, in general in the middle of the child bearing period of life.

As mentioned above the great majority of the single females were defectives (73.8 per cent), or if one includes mental defectives with psychosis, 86.1 per cent. While not so large a percentage of married women belonged to this group, of the 201, married and single, 135, or 67.2 per cent, belonged to the diagnostic groups of mental deficiency with and without psychosis, and hence to a great extent their inability to make a satisfactory social adjustment. In support of this is the fact that of the 86 illegitimate children 79, or 91.9 per cent, were born to this group of defective women.

There was a definite history of venereal disease in 15, and a probable history of it in seven—a total of 22 (10.9 per cent) of the female cases.

In parenthesis one may add that definite information about their 358 children would be of great value and interest. A limited social service personnel, great distances, the expense and the newness of the work have all prevented obtaining much in that respect. Considering the average age of the mothers, the average age of the children must be low, and as a matter of fact many are only infants. It is, therefore, utterly impossible to guess at the incidence of future psychoses among them or even to any extent at their mental developments. Of 281 (78.5 per cent) little or nothing is known, 20 (5.6 per cent) are dead, 9 (2.5 per cent) are weak physically, 20 (5.6 per cent) are at present normal and 28 (7.8 per cent) are known to be defective—certainly a large percentage even if all the rest were normal. We can only guess at what proportion of the 281 are defective or doomed to a mental breakdown later on. It may not be large, and it may not be small, but certainly it will be above the average.

The question will surely be asked, what of the moral conduct of those patients who have been operated on? One operative case of the doubtful group drifted into questionable habits after discharge, due, it is thought, to the influence of her sister. One of the irregular group, a defective who had had two illegitimate children, became promiscuous after discharge. These have both been readmitted. Four of the promiscuous group have, it is feared, returned to their former ways. But these are few indeed as compared with the number of pre-admission moral problem cases.

The situation is summarized well in, Fig. 19-6 [not reproduced], where it will be seen that of the 158 operative cases 98 (62.0 per cent) had been discharged and were making a good moral adjustment when last reported as against 71 (44.9 per cent) before admission; and only 2 (1.3 per cent) and 4 (2. 5 per cent) were causing worry on account of doubtful and questionable promiscuous behavior after discharge as compared with 11 doubtful (6.9 per cent), 49 (31 per cent) irregular, and 27 (17.7 per cent) promiscuous before. There were in institutions at the end of 1933 47, or 29.7 per cent.

This very reassuring improvement is doubtless due in part if not to a great extent to the effect of institutional training and to the follow-up contacts, though these contacts are admittedly inadequate. But of one thing we are convinced, sterilization does not lead to increased immorality.

A word about the moral reactions of the male patients. Information in this respect is inadequate, and the problem is not after all so important socially as in the case of the female sex. 47.1 per cent had previously good moral records which compares favorably with the 44.9 per cent of the female patients. 20.5 per cent had been doubtful, 23 per cent irregular and 9.2 per cent promiscuous. We have assembled no information about their children. The great majority of the men were, of course, single. There was a history of venereal disease in only seven cases.

In passing it is interesting to report that in two cases—one male and one female—sterilization has had the effect of keeping together a family that would inevitably have been broken up through separation. In two other cases sterilization has certainly prevented further mental breakdowns, and in the case of one mentally defective woman making a very satisfactory adjustment under the circumstances it enabled her to continue to do so.

Another interesting fact is that six patients who were operated on subsequently married. They were all females—morons except one, an imbecile, with I.Q.’s varying from 45 to 64. Two are making a very satisfactory adjustment according to last reports, due it is thought to the training they had received in the Provincial Training School; two a fair adjustment; one (I.Q. 45) rather a poor adjustment, on relief since marriage; and one very soon drifted away from home and back into her former unsatisfactory mode of living. She had been one of the promiscuous group.

A few observations are necessary with respect to one aspect of the study of these cases that is exceedingly important from a eugenics standpoint, and that is the evidence of morbid heredity As shown in Fig. 22-7 [not reproduced], in 16 per cent of the cases there was evidence of insanity; in 2.1 per cent of epilepsy; in 9 per cent of alcoholism; in 15.6 per cent mental deficiency and in 18 per cent other evidence of neuropsychopathic disturbances. Altogether in 60.8 per cent of the cases there was evidence of a mental morbidity, a taint if you like, in the family, and a further study of the detail will show more convincingly how overwhelmingly significant these facts are. In many of the families there was a multiplicity of significant historical facts.

The nature of the problems dealt with and the appropriateness of procedure adopted may very well be illustrated by the citation of four specimen cases which are not by any means unique:

(a)   Male: 27, married, a defective (M.A. 8 years, I.Q. 50), psychotic attacks, shiftless, delinquent. Father and mother both psychotic and in mental hospital. Sister psychotic. Wife—a defective, M.A. 6 years 10 months, I.Q. 45, repeatedly in hospital. Only child a defective and in the Provincial Training School.

(b)   Male: 30, single, a defective (M.A. 10 years 3 months, I.Q. 64), promiscuous. Father was insane and in hospital; one brother insane; one brother suicided; several brothers defective.

(c)   Female: 17, single, a defective (M.A. 8 years 10 months, I.Q. 55), promiscuous, venereal disease. Father and paternal uncle alcoholic; paternal uncle a drug addict. Mother and maternal grandmother psychotic, suicided. Brothers—one retarded; one deserted wife and five children. Sisters—one retarded; one died status epilepticus; one has six illegitimate children and has venereal disease.

(d)   Female: 35, married, borderline defective and psychoneurotic and physically weak. Maternal grandmother insane. Husband a defective with irritable spells. Children—four defective (two deaf and dumb as well), one a physical weakling, and one only apparently normal.

GENERAL REMARKS.

So much for the cases in detail. From a study of them certain general conclusions may be drawn. First, there are two great psychiatric problems involved—problems more or less closely interwoven and yet distinct. They are the problems of mental deficiency on the one hand, and of mental disease on the other. Associated with these problems, especially mental deficiency, and frequently arising out of them are those very grave problems of social maladjustment—moral, antisocial, economic—and of unmarried motherhood and illegitimacy.

Of the two mental deficiency is socially the more serious for here by reason of the mental defect we find individuals more or less incapable of profiting by ordinary systems of training, often incapable of making a satisfactory economic adjustment especially as parents, lacking in the discretion and inhibitions that enable individuals to conform properly to the requirements of the social group and yet reacting in a primitive and unacceptable manner to the urge of fundamental emotions, unduly prolific both within and without marriage and prone to pass on to posterity their own defects and to bring into the world children doubly handicapped by both heritage and early environment. Clearly they should not be permitted to assume the burdens nor the responsibilities of parenthood. And yet again by reason of their defect neither prohibition, supervision nor ordinary preventive measures are likely to prove effective. Sterilization is for them the only rational, the only logical procedure.

As for mental disease the situation is somewhat different. Not only is there the risk or tendency to pass on to posterity the predisposition to psychosis, instability or defect, there is the environmental effect of broken homes, of the frequent deprivation for children of at least one parent or of the undesirable presence in the home of a mentally diseased person. In the case of females who have had a breakdown there is the menace to continued good mental health that the stress that child bearing and rearing impose. Certainly the person who has had a mental breakdown should have the right to exemption from assuming or increasing the burden of parenthood and without sacrificing altogether the right to a normal married life.

In addition, as child welfare officials know, there is the growing and understandable disinclination on the part of prospective foster parents to accept a child with a bad family history whether of insanity or of defect.

To us these appear unanswerable reasons in favor of sterilization in properly selected cases.

In cases of mental disease rarely does the physician fail to advise against marriage if marriage means parenthood, and yet marriage might under some circumstances be permitted if there were no such risk. Ordinary measures of contraception consistent with normal married life are, even for intelligent people, notoriously unreliable. Where prevention of conception is so important sterilization is the only logical and absolutely dependable procedure especially where it involves no appreciable risk for the male and for the female less risk than childbirth. As previously suggested rarely does a man or woman hesitate to sacrifice not only procreative power, but even the essential organs of reproduction when necessary for the sake of physical health, and rarely under the circumstances does the surgeon hesitate to operate. The mental health of the individual and of the race are fully as important and especially so when weighed against the sacrifice of mere procreative ability alone. The question of mental health is one of great significance; it is in many respects a matter of life or death for the race.

Apart from an unfortunate and thoughtless tendency in some quarters not excluding our own profession to treat sexual sterilization with levity its great importance is becoming more and more widely recognized. There have been no criticisms of this work in Alberta and it is progressing steadily and smoothly. This is perhaps largely due to the composition of the Board, and to the great care exercised in the selection and preparation of cases, and also to the fact that invariably every effort is made to secure the intelligent cooperation of the patient or responsible guardian. Among those in this province who are carrying social welfare responsibilities, and have daily to deal in a practical way with the problems involved there is a steadily growing faith in sterilization as an effective and reasonable method of bringing about at least a partial solution, recognizing of course that neither sterilization nor any other one procedure will prove a complete cure. Sterilization does not, of course, take the place of hospital treatment in the case of patients with mental disease, nor does it make any the less necessary the very essential training carried out by institutions for the mentally subnormal. Neither does it make less desirable the very important contact work and supervision carried on by the corps of social workers in any adequate mental health program. Though a wise provision sterilization as a policy is one that should be put into practice with the utmost care and deliberation and without expecting too rapid progress especially during the early stages, and until public opinion has become fully appraised. of its undoubted wisdom and practicability.

In the mental institutions of Canada there are now some 35,000 patients. It is probable that there are as many more, chiefly defectives, outside or in other institutions, many of them constituting serious social problems. Medical science through its achievements is performing miracles in the preservation of life, but is doing little or nothing to counteract the growing menace that these great problems constitute, and which are probably actually aggravated by these very achievements. Many of the mentally and physically unfit are now being preserved for parenthood who would in the old days have perished in the struggle for existence. And yet sexual sterilization, rationally applied, in selected cases offers within limits an effective means of dealing with these growing problems, and this without effect on the personal health or liberty of the individual. Thus may be taken at least one step toward racial improvement.

The greatness of a country depends not so much upon the numbers of its people as upon the high mental and physical standards of its citizenship.

SUMMARY.

1. The Sexual Sterilization Act of Alberta was assented to March 21, 1928.
2. Up to the end of 1933, 288 cases—87 males and 201 females—had been passed by the Eugenics Board, and are dealt with in this report. Of these 206—48 males and 158 females—had at that time been operated on.
3. These operations—a vasectomy or salpingectomy—have been followed by no serious sequelæ.
4. No complaints have been received as to any change in libido or sex satisfaction, and none are expected.
5. Of the 288 cases 156, or 54.2 per cent, were diagnosed as mentally defective; 36, or 12.5 per cent, as mental deficiency with psychosis and 87, or 30.2 per cent, as otherwise psychotic and 9, or 3.1 per cent, as borderline cases including one with an exceedingly bad family history though otherwise normal.
6. Social problems, such as immorality, illegitimacy, delinquency, dependence, partial or complete, were prominent features in many of the histories.
7. Contrary to frequently expressed fears there is at present no evidence that sterilization will lead to promiscuity or a lowering of moral standards.
8. On the other hand, the treatment and training of patients and the maintenance of an adequate follow up system are still essential.
9. Facts indicating an hereditary taint or predisposition, in many cases to a startling extent, were found in 60.8 per cent of cases.
10. Sexual sterilization is undoubtedly a logical and acceptable method of coping with the great problems of mental disease and defect and their associated problems and should in properly selected and safeguarded cases be as readily resorted to as similar operations for physical disease.

TABLE A1.
AGE GROUPS, SEX, AND CIVIL STATE OF ALL PATIENTS PRESENTED AND APPROVED BY THE EUGENICS BOARD, 1929–1933.

Note: The married group includes two common law wives.

TABLE A2.
DIAGNOSTIC CLASSIFICATION OF CASES PRESENTED TO EUGENICS BOARD, 1929–1933.

¹ Percentages refer to proportions of cases operated on or not in each diagnostic group.

² Refers to proportion of cases in each of the columns.

TABLE A3.
REASONS FOR OPERATION NOT HAVING BEEN PERFORMED ON THE 82 OF THE 288 CASES PRESENTED TO THE BOARD, 1929–1933.

TABLE A4.
FEMALE CASES–MORAL REACTIONS ACCORDING TO DIAGNOSIS, 1929–1933.

100M—Includes married, widowed, separated and divorced.

*This article originally appeared in the American Journal of Psychiatry 91 (1935): 897–923. It is reprinted here with selected tables with permission from the American Journal of Psychiatry (Copyright © 1935). American Psychiatric Association. All rights reserved.