Rosa González and Tamil Kendall
In May 2022, the President of Chile made a historic public apology to Francisca, a woman living with HIV who was sterilized without her consent. The apology came 20 years after Francisca’s forced sterilization and followed a decade of litigation before the Inter-American Court of Human Rights.[1]
Forced and coerced sterilization is recognized as a human rights violation under international law.[2] In 2021, the Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS) acknowledged that “this practice is still happening in many countries and efforts to stop it and bring justice to more women must be stepped up.”[3]
Stepping up justice and stopping this serious human rights violation includes shortening the time women wait for justice to be done. For example, when will justice will be done for Maria, a Honduran woman living with HIV who was forcibly sterilized in 2005?
Five points about Maria’s case and six similar instances of forced sterilization of women living with HIV documented in Honduras between 2006 and 2020 that align with patterns of forced sterilization identified in Central America and globally are relevant.[4]
First, none of the women provided informed consent: consent was procured when women were under anesthesia from family members or no consent was given. In Maria’s case, despite pressure from the attending physicians to accept tubal ligation, she refused. Her medical file documents that she was sterilized but does not include her informed consent.
Second, the relationship between HIV-related stigma and forced sterilization is revealed by the discriminatory and medically incorrect statements made by healthcare providers when demanding that women living with HIV accept sterilization. Antiretroviral treatment, which Maria was taking, reduces and can effectively eliminate the possibility of vertical HIV transmission.[5] Yet, attending physicians pressured Maria to accept sterilization, saying “you should have the operation [tubal ligation] because women like you shouldn’t bring children into the world to die, they are born sick and die.”
Third, the women living with HIV were young-under 25 years and some had not even reached the age of majority. Maria was 21, and delivering her first child (who tragically died after childbirth) when she was forcibly sterilized. International guidelines state that because sterilization is permanent, healthcare providers’ duty to ensure informed consent for this contraceptive method is especially important and that additional diligence is warranted when counselling young people and people who do not have children.[6]
Fourth, forced sterilization took place at the time of cesarean delivery in public healthcare institutions. In Maria’s case, consent for sterilization was sought immediately after cesarean delivery, and was performed without her knowledge after she had refused. Implementing international guidelines that recommend against routine elective cesarean delivery for women living with HIV and against healthcare providers seeking consent for sterilization after onset of labour or immediately after delivery can contribute to reducing coerced and forced sterilization.[7]
The final point is that the state is responsible for ensuring that healthcare workers respect and maintain human rights standards including non-discrimination and freedom from non-consensual medical treatment. These were clearly violated in Maria’s case and in other cases of forced sterilization of women living with HIV.[8]
Yet, despite international recognition of forced sterilization as a human rights violation, it is challenging for women to obtain redress. First, women are frequently not aware of their rights or opportunities to seek accountability. For Maria, it was only after participating in a peer-run programme promoting sexual and reproductive rights education and access to legal services, that she decided to make a national criminal complaint alleging forced sterilization in September 2015.[9]
Even if women are able to access legal aid, at best the legal system may be slow to respond and imposes costs that are significant barriers. For Maria, the first hurdle after meeting with the prosecutor in October 2015 to record her testimony was to provide, at her own expense, proof that she had been sterilized. The supporting civil society organizations fundraised for Maria’s medical exam and travel costs. In November 2015 the medical evidence of the tubal ligation was provided to the prosecutor.
At worst, justice systems are non-functional or actively obstructionist. From February 2016 until January 2022, Maria’s complaint was assigned to six different prosecutors. None responded to emails, letters, freedom of information requests, or multiple personal visits by Maria and her lawyer requesting a copy of her complaint and the associated evidence or progress updates.
Seventeen years after she was forcibly sterilized and over five years since she made a national criminal complaint, the wheels of the Honduran justice system have not begun to turn for Maria. Maria, with the support of ASONAPVIHSIDA and Fundación Llaves is petitioning the Inter-American Court of Human Rights to accept that she has exhausted her avenues to procure justice in Honduras and to hear her case.
Rosa González is the Co-Executive Director of Fundación Llaves in San Pedro Sula, Honduras. Tamil Kendall, PhD is an Adjunct Professor in the School of Population and Public Health at the University of British Columbia, Vancouver, Canada.
Please address correspondence to the authors c/o Tamil Kendall, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada V6T 1Z3 tkendall@mail.ubc.ca
References
[1] UNAIDS, “UNAIDS welcomes Chile’s public apology in landmark case of involuntary sterilization of women living with HIV” (May 27, 2022). Available at https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2022/may/20220527_chile-involuntary-sterilization-women-living-with-HIV
[2] OHCHR, UN Women, UNAIDS, UNDP, UNFPA, UNICEF and WHO. Eliminating forced, coercive and otherwise involuntary sterilization: an interagency statement. (Geneva: WHO, 2014). Available at https://www.unaids.org/sites/default/files/media_asset/201405_sterilization_en.pdf
[3] UNAIDS, “UNAIDS welcomes Chile’s recognition of responsibility for violating the rights of a woman living with HIV sterilized without her consent” (August 11, 2021). Available at https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2021/august/20210811_chile
[4] M. Bucardo, and J. Pérez Reynosa, Estudio sobre vulneración de derechos con énfasis en derechos sexuales y reproductivos de mujeres jóvenes que viven con VIH en los municipios de La Ceiba y Tela en el Departamento de Atlántida, Honduras (Study on rights violations with an emphasis on sexual and reproductive rights of young women living with HIV in the municipalities of La Ceiba and Tela in the Atlantic Department of Honduras) (La Ceiba, Honduras: CEPROSAF, 2021) Available at https://www.organizacionllaves.org/post/estudio-sobre-vulneraci%C3%B3n-de-derechos-sexuales-yreproductivos-de-mujeres-jovenes-con-vih; T. Kendall and C. Albert. Experiences of coercion to sterilize and forced sterilization among women living with HIV in Latin America, 2015, Journal of the International AIDS Society 18/19462; L. Siikanen and M. Alberto, Investigación para la vinculación de la violencia contra las mujeres y niñas, feminicidio, el VIH y el impacto del COVID-19 (Research on the links between violence against girls and women, femicide, HIV and the impact of COVID-19) (San Pedro Sula, Honduras: Fundación Llaves, 2020) Available at. https://www.slideshare.net/FundacionLlaves15/investigacin-para-la-vinculacin-de-la-violenciacontra-las-mujeres-y-niasfemicidio-el-vih-y-el-impactodel-covid19; International Community of Women Living with HIV. Submission to the UN Working Group on the Issue of Discrimination against Women in Law and in Practice (OHCHR: Geneva, no date). Available at: https://www.ohchr.org/Documents/Issues/Women/WG/righthealth/WS/ICW_HIV.pdf
[5] L. Mandelbrot et al., “No perinatal HIV-1 transmission from women with effective antiretroviral therapy starting before conception”, 2015, Clinical Infectious Diseases 61/11 pp. 1715-1725.
[6] WHO. WHO recommendation: Elective C-section should not be routinely recommended to women living with HIV. (Geneva: WHO, 2018). Available at https://apps.who.int/iris/bitstream/handle/10665/272454/WHO-RHR-18.08-eng.pdf?ua
[7] WHO. Family Planning: A global handbook for providers. (Geneva: WHO: 2018), pp. 2019-220. Available at https://www.who.int/publications/i/item/9780999203705; OHCHR, UN Women, UNAIDS, UNDP, UNFPA, UNICEF and WHO (see note 2, p. 14).
[8] OHCHR and WHO. The right to health. Fact sheet no. 31. (Geneva: OHCHR and WHO, 2008). Available at https://www.ohchr.org/en/publications/fact-sheets/fact-sheet-no-31-right-health.
[9] T. Kendall, J. Avalos Capin, N. Damji and E. Lopez Uribe, “Community mobilization to promote and protect the sexual and reproductive rights of women living with HIV in Latin America,” Health and Human Rights Journal 22/2 (2020), pp. 213-226.