The global proliferation of radical gynaecological surgeries: A history of the present

ABSTRACT

This paper asks questions about the resilience of radical gynaecological surgeries, such as hysterectomy and ovariectomy, from the moment of their widespread use in Western European and American practices of the late nineteenth century, to their renewed increase in the Indian subcontinent and Africa into our own time.

KEYWORDS:

• Gynaecology in India
• European history of gynaecology
• medical anthropology of women’s health
• history and sociology of women’s sexual health
• global history of hysterectomy

This paper is about how radical gynaecological surgeries (hysterectomy and oophorectomy) were developed in several Western medical contexts of the late nineteenth century and how techniques and concepts of them have since proliferated throughout the global South into our own time.¹ We trace an internationally diffuse phenomena to consider several different past and present contexts. This is crucial for understanding how gynaecological surgeries have proliferated across the globe and have been re-interpreted and instrumentalized for shifting purposes across time and place, with ongoing implications both for the wellbeing of women in the global South and for the future health of ageing populations everywhere. Our project considers both the explicit and implicit purposes that radical gynaecological surgeries such as hysterectomy and oophorectomy have served both historically and in the present: As therapeutic interventions in the management of childbirth and the treatment of gynaecological disorders; in the alteration of gender expression; as a form of non-consensual sterilization of women with disabilities, of low social class or caste or of ethnic minorities; and as a form of cancer prophylaxis. Such surgeries are perceived by most gynaecologists today as an essential therapy in specific clinical presentations such as in the treatment of uterine cancer or in painful, non-cancerous conditions that have not responded to other treatments. However, there are also clearly many ways they are still being used in multiple biomedical contexts for reasons falling well outside such rationales, alongside a lacuna of consideration of the long-term effects for patient health and wellbeing.

Part I considers the inter-cultural Western European and North American origins of the widespread medical practice of hysterectomy/oophorectomy and of the specific historical pathways through which these surgeries became globalized. Part II is a wide-ranging interdisciplinary contextualization of the current global state of such surgeries in medical research and practice, taking India as our primary focus, with some discussion of Ghana and South Africa, and mention of existing bodies of research in other specific locations (Italy, Finland, the US). The broad and yet selective scope of our paper reflects specific bodies of archival and ethnographic research of the authors to date, as part of our pilot study for an ongoing large-scale, interdisciplinary research project. Much research remains to be done in most world regions with regard to documenting the historical and current practices of radical gynaecological surgeries. While we can observe the important therapeutic role of such surgeries in specific cases, when conducted with informed consent and presented alongside other available treatments, our research to date indicates a consistent historical pattern throughout the period 1880–2020 in that all populations have not fared equally in their exposure to hysterectomy/oophorectomy and their risks. The historical trends of poor reproductive-health treatment we identify persist, and are even growing, albeit asymmetrically, in contemporary biomedical practice globally. This indicates a need for more conscious reflection about the practice in the pedagogic and clinical cultures of contemporary medicine, as some gynaecology researchers themselves have recently argued (Stewart, Missmer, and Rocca 2021).

Our paper is informed by preliminary archival historical investigations by the lead author using French, German, Swiss, English, American and Canadian medical sources of the 1890s–1940s, and by recent ethnographic fieldwork conducted by two of the authors in India, Pakistan, and in Ghana, respectively.² The five authors being one medical historian, one medical anthropologist, one health-policy historian, and two health sociologists, all with expertise in women’s sexual health and medicine, have also consulted numerous biomedical scientific research papers, drawing our understandings about the long-term effects of gynaecological surgical treatment from our reading of recent scientific evidence and discussions (Rocca et al. 2016; Ding et al. 2018; Laughlin-Tommaso et al, 2017; Rahman et al. 2021). The lead author’s historical research in 2019–2020 in Paris at the French National Library (BNF), the French Interuniversity Health Library (BIUS), the French national archives, the Wellcome Library for the History of Medicine in London and the Berlin State Library (SBB) accounts for the reconstruction of European and trans-Atlantic gynaecological debates about hysterectomy/oophorectomy and of the pathways of its global dissemination between 1880 and 1940. The second author’s account of the South Asian context draws from anthropological fieldwork and archival research in India between 2009 and 2012 in the context of research on the global circulation of biomedical technologies and research practices related to female reproductive cancers and cervical cancer prevention practices in the era of the HPV-vaccines. This fieldwork entailed multiple interviews with ethicists, scientists, medical doctors, academicians, demographers, feminists, and public health activists in New Delhi, Mumbai, Ahmadabad, Bangalore, Mysore, and Pune as well as WHO scientists in Geneva; conversations with rural women in Mysore and Andhra Pradesh; participation in cervical cancer screening camps; and review of the relevant scientific literature. The third author’s historical and ethnographic research conducted in 2017–2019 provides an insight into twentieth-century population control and its related gynaecological procedures in Africa, particularly Ghana, entailing multiple oral history interviews carried out with women aged between 50 to over 90 years in rural Ghana; and archival research carried out in the Public Records and Archives Administration Department (PRAAD) in Accra, as well as in the collections of the Ford Foundation and Population Council at the Rockefeller Archive Center (RAC) in New York. Authors four and five have both conducted multiple sociological interviews with patients of gynaecological procedures in Australia between 2018 and 2020, including Indigenous women, refugee women, women living with disabilities, as well as transgender and non-binary-gender persons. This work is not directly discussed here but has informed the analytic concepts and concerns of the paper.

The historical patterns we identify constitute a past that is not past, prompting our uptake of Michel Foucault’s concept of a ‘history of the present’ in which historical inquiry seeks to explicate current human problems through the disentanglement of how we came to think/act the way we do, as a pathway toward being able to choose more freely our future orientation (Foucault 2012; Fuggle, Lanic, and Tazzioli 2015; Moore 2021, 2020). In considering why hysterectomy has been such a popular surgery for gynaecologists and doctors to perform in the past and present of Western Europe, North America and in the global South increasingly today, we have also reflected on historical, philosophical and sociological studies of ‘biopower’ – defined as those interventions made by modern states in the vital dimensions (births, deaths, reproduction, ageing and bodies) of their subjects or citizens; and of ‘biopolitics’ – defined as the conceptual grounds made in favour of such interventions and the debates they elicit, along with the practical implementation of them by health professionals (Rabinow and Rose 2006; Esposito 2008; Bashford and Levine 2010; Foucault 2012; Bashford 2014; Folkers and Lemke 2014).

Our approach is temporally bi-directional – a confluence of present-based and future-orientated anthropological and public-health research with historical investigations conducted from an archival ground. It is neither driven solely by ongoing concerns, but nor is it of purely antiquarian interest, instead ‘problematizing’ (Castel 1994) gynaecological surgeries from the moment of their widespread historical appearance up to the present, attending to both the continuities and discontinuities of context, clinical rationale and practice. Surgeries entailing the removal of women’s internal reproductive organs (uterus, cervix, ovaries, fallopian tubes) have constituted the vast majority of gynaecological surgeries throughout their history (Lepine et al. 1997; Chen, Choudhry, and Tulandi 2019). Our inquiries suggest a highly diffuse set of networks through which gynaecological surgeons and researchers have been entangled in biopolitics, at times non-deliberately and unconsciously through clinical research and practice, without being part of the explicit structures of the state; at other times through eugenic or other conceptual commitments in their management of specific ‘populations’, in state-funded clinics. As in Foucault’s reflections about the multidirectional character of biopower as a locus for the production of knowledge beyond the direct control of the state, we find medical ideas about gynaecological surgeries discursively elaborated by doctors, by patients themselves, by commercial vendors of medical technologies, as well as by international health-policy and development organizations.

Part I: the controversial origins of hysterectomy and oophorectomy 1880–1940

Abdominal surgeries were rarely practiced in the history of medicine before the late-nineteenth century due to the almost guaranteed death resulting from them (King 1998). By the final decades of the nineteenth century, with the widespread use of anaesthetic and aseptic techniques, surgical methods for such surgeries were sufficiently developed to reduce mortality dramatically, permitting the unsubstantiated claim that women who survived hysterectomy suffered no impaired function afterwards. A new modern biomedical model of health, wherein the body was viewed as a mechanical functioning of parts helped to frame the female reproductive organs as faulty parts of the machine that could be discarded to improve the overall functioning of the body (Mishler et al. 1981, 218–245). A view of the uterus and ovaries as physiologically dispensable emerged in French, German and English medicine and resulted in a sudden enthusiasm for hysterectomy and oophorectomy as solutions to a wide variety of common gynaecological conditions, especially menstrual disorders (dysmenorrhoea, menorrhagia, amenorrhoea), fibroids, endometriosis and both uterine and vaginal prolapse, for which few other satisfactory treatments existed from the perspective of biomedicine at the time. Nonetheless, in 1883, of all the 93 published cases of hysterectomy in the international medical literature, including all variants of this surgery conducted in Europe and North America, mortality remained a high as 67% (Moscucci 2016, 67). Even in 1941, during the period when hysterectomy became massively more common and globalized, mortality from it in England (where the techniques were relatively advanced) was still 14% – making nearly 1 in 6 such surgeries lethal (Moscucci 2016, 82). Unsurprisingly then, they were controversial throughout the period between 1880 and 1940, and vociferous opposition to them was expressed repeatedly by major medical figures in France, England, the US and Germany, resulting in a wide variability in the ubiquity of surgical practices throughout these countries. Numerous doctoral dissertations and books on surgical techniques of hysterectomy and oophorectomy were written by late-nineteenth-century French, German and English doctors (Hegar 1877; Gavilan 1888; Irish 1890; Ramon 1893; Le Moinet 1894; Pigeonnat 1896; Caboche 1897; Eustache 1900; Zvibel 1900). At the same time, there was a first wave of the minimally invasive surgery movement which has grown in Europe and North America in recent times as well (Wen et al. 2018). In the late nineteenth century, numerous French, German, American and English gynaecologists condemned the new rash enthusiasm for women’s reproductive-organ removals, developing alternative constructive surgical or non-surgical treatments for common benign conditions, such as fibroids and dysmenorrhoea, that were already being widely treated with hysterectomy or oophorectomy (Apostoli 1888; Martin 1897; Morély 1899; Ferendinos 1900; Molk 1901; Bonier 1904). A major French gynaecology textbook (published in multiple editions between 1900 and 1922) sniped repeatedly throughout its 500 pages about the overuse of hysterectomy. The authors deemed such surgeries worthless in all but a few cases on the grounds that ¾ of gynaecological diseases were ‘fausses utérines’ – disturbances of menstrual function actually deriving from systemic physiological disorders (diabetes, under-nutrition, digestive disorders or infectious diseases) that did not originate from the uterus and therefore could not be cured by its removal (Robin and Dalché 1900, 23, 104, 124, 468, 471).

Questioning the unmitigated resort to hysterectomy

In 1897, the Ottowa gynaecologist Léandre Coyteux, himself a fervent advocate of hysterectomy for a wide range of purposes, admitted that the new freedom provided by patients’ improved survival due to the introduction of the aseptic technique ‘sometimes conceals a certain number of unnecessary surgical procedures’, complaining that many had already ‘compromised hysterectomy by indiscriminately resorting to it’ (Coyteux 1897, 303–304). This is striking from our present perspective since the emergent minimally invasive gynaecological surgery trend of our current era in Europe and North America for certain groups of privileged women (discussed in the second section of this paper) was in fact preceded by an equally substantial resistance to the practice of ubiquitous hysterectomy around 1900, the tone of which is detectable in Coyteux’s description of the claims he faced against his practices by other doctors who accused him of mutilating women, rendering them sterile and denigrating the importance of the very organs that nurtured new human life (Coyteux 1897, 304).

An important context in the early development of both hysterectomy and oophorectomy in French, German, Austrian and Swiss medicine of the 1890s was the exhaustive documentation of patients’ reported negative symptoms of hysterectomy and oophorectomy, by some of the very same gynaecology researchers who advocated the use of these surgeries. Women complained of iatrogenic symptoms such as Hot flushes, night sweats, nightmares, intense fatigue, abdominal pains, unexplained fat gain, acne, gastric complaints, disturbed mood, despair, body aches, and nervous trembling (Jayle 1898; Chobrak 1896; Latzko and Schnitzler 1897; Lissac 1896; Muret 1896). The French researcher Félix Jayle who worked at the Broca hospital in Paris and was the editor of the Revue de gynécologie et chirurgie abdominale (Review of gynaecology and abdominal surgery) focused his efforts on documenting the physiological effects of what he and others called the ‘castration’ of women, developing ovarian organotherapy medications to reduce the iatrogenic symptoms produced by these surgeries so that the new surgical enthusiasm for performing them, enabled by them becoming more safe with aseptic technique, could continue advancing (Jayle 1898, 239). In May 1895, he began giving crude sheep/veal-ovary extracts to women whose ovaries and uterus had been surgically removed in his clinic, later developing an ovarian serum, which could be injected, as well as a desiccated powder that could be dissolved in a hot drink and orally ingested, called Ovarine (Jayle 1898). But he also experimented with giving these extracts to women who retained their organs but had ceased menstruating due to age, finding that some women suffering menopausal symptoms found them relieving and hard to stop taking: An exciting new commercial opportunity thus presented itself. Similar treatments were around the same time studied and used by the Austrian researcher Rudolf Chobrak, by a Berlin physician named Mainzer, by a Swiss physician named Muret, and by a Munich physician named Mond who developed his own Ovariin extract produced by the German chemical company Merck (Mainzer 1896; Mond 1898; Muret 1896; Chobrak 1896).

Explosion of hysterectomies in the global North and its proliferation to the global South

It was this early twentieth-century European context of animal ovarian organotherapy treatments being used as therapies for hysterectomised and oophorectomised women, but also older women who had no such surgeries, that lead to the biochemical discovery of folliculine by the French biochemist Robert Courrier in 1924 (Courrier 1945). Later renamed Oestrone, it was followed by the German and American synthesis of pharmaceutical Oestrogenic compounds in 1938, which were immediately used clinically as menopausal hormone replacement therapy (HRT) in Western Europe and North America from this time onwards (Sengoopta 2006; Watkins 2009). Ovarian therapies were initially developed for women of menstruating ages who had undergone hysterectomy and oophorectomy but were then very quickly extrapolated to all postmenopausal women who were now theorized to be ‘hormone deficient’ according to a presumed (though never defined) endocrine norm of young (non-hysterectomised/ovariectomised) women. From this moment onwards, the surgical removal of uteruses and ovaries knew no bounds in West European and American gynaecology. A 1960 American gynaecological society narrative about the history of the discipline acknowledged that the ‘sudden burst of endocrines’ after 1929 was responsible for the massive increase in gynaecological surgeries there throughout the mid-twentieth century (Cianfrani 1960, xi). Hysterectomy/oophorectomy and pharmaceutical HRT thus represented a mutually reinforcing medico-technological complex, with this entanglement of the two forms of treatment becoming rapidly globalized in the second half of the twentieth century.

French, Swiss, German, English and American practices of the early twentieth century of treating gynaecological disorders with various forms of hysterectomy and oophorectomy were disseminated globally between 1880 and 1940 through the work of intermediary figures moving between European medical schools and colonial health institutions, who derived their training in gynaecological surgeries and women’s reproductive disorders in the West. During the period from the 1880–1940 increasingly students from the Baltic regions, Eastern Europe, the Middle East, North and West Africa completed their doctoral studies in gynaecology in France, returning to practice medicine in their home countries afterwards, equipped with modern Western European medical concepts and surgical techniques (Zalzal 1885; Chahinian 1899; Vartazaroff 1913; Migalli 1925; Cohen Solal 1938). From as early as the 1890s onwards, numerous Indian women studied medicine in either Brussels, Philadelphia or in the Calcutta Medical College where English medicine was taught (Forbes 1994), and English medical practices relating to women’s health were exported throughout the British empire with the help of British women doctors and philanthropic health advocates (Witz 2001; Guha 2016).

Another important pathway of global proliferation was via the development of hysterectomy and oophorectomy in sex reassignment surgeries between c.1911 and c.1966 in the US, Germany, Denmark and Morocco, and in multiple other global centres of transsexual medicine (now more commonly referred to as transgender medicine) after this (Meyerowitz 1998; Cotton 2012). International travel and global dissemination have been features of transgender medicine from its very beginnings (Aizura 2018). Female-to-male (FTM) transgender patients throughout the twentieth and twenty-first centuries have frequently received hysterectomy and oophorectomy on the grounds of it permitting lower amounts of exogenous Testosterone supplementation needed to override feminine traits and stimulate masculine expression (Benjamin 1966, 89). These surgeries were first conducted for such purposes in Germany from the first decades of the twentieth century in combination with sheep-testes organotherapy for masculinization (Herzer 2017, 308). The Berlin surgeon Richard Mühsam (1872–1938), in a 1926 scientific paper, described what was probably the first sex reassignment surgery which he had provided to a young painter who had already lived his entire youth as a boy/man before undergoing mastectomy and hysterectomy conducted by Mühsam in 1912 (Mühsam 1921, 1926). A commercial hormonal product emerged shortly after this, called Testifort, developed by Magnus Hirschfeld with the Hamburg pharmaceutical company Chemische Fabrik Promonta (Hirschfeld and Schapiro 1927, 1345). This was later rebranded as Titus-Perlen and made available for mail-order purchase without medical prescription or supervision from at least 1929 from the Friederich-Wilhelmstädchen Apotheke in Berlin, though it remained difficult to obtain outside of Europe before the end of the Second World War, after which synthetic pharmaceutical Testosterone products made in both Switzerland and the US took its place (Hirschfeld 1932; Herzer 2017, 31). Here again hysterectomy and oophorectomy were developed in conjunction with the commercial sale of hormonal products, in this case, relative to people actively seeking gender transformation.

Hysterectomy and oophorectomy were also performed for gender change purposes during the 1960s at the Johns Hopkins University clinic of John Money and colleagues, in the ‘correction’ of intersex children born genetically female with ambiguous genitalia, removing the internal reproductive organs of such infants so that they may be raised as boys (Dreger 2000; Kessler 1990). Money was closely connected to the development of German procedures of this kind via his collaborations with the German-American sex-reassignment clinician Harry S. Benjamin, who in turn had studied with Hirschfeld and travelled frequently between West Germany and New York during the 1960s and 1970s (Benjamin 1966; Haeberle 1985). German intersex writers have reported being given these same ‘corrective’ surgeries in infancy and hormonal treatments in adolescence without consent or even disclosure during the 1960s and 1970s (Völling 2010).

In many countries today, including Iran, Finland, Japan and Turkey, gonadal-organ surgical removal is a condition for legal sex-change, effectively requiring both transgender and intersex people to be sterilized if they wish to live legally as a different gender to that which is stated on their birth certificate (Dunne 2017). Numerous legal challenges to such policies have been made since c.2000, as well as to other forms of denial of rights to full legal parentage of ‘seahorse’ fathers’ – men with complete female reproductive internal organs who give birth to infants (Alaattinoğlu and Rubio-Marín 2019; Dickens 2020). Both intersex and transgender studies scholars have queried why gonadal-organ removal has even been considered automatically necessary, noting the denial of reproductive rights it entails, reflecting the medical view of both transgender and intersex parenting as inadmissible (Lowik 2018). The unique violence of the modern biomedical approach to such matters has been well demonstrated by comparative historical and anthropological scholarship (Herdt 1996; Moore 2019, 2018). Again, while such surgeries in transgender and intersex people may be valuable when conducted with informed consent, they have often been prescribed without this.

The population control nexus

On the African continent, gynaecological surgeries were primarily spread via population and fertility control measures advocated by missionaries and colonial agents as a means for increasing ‘civility’, decreasing the ‘primitive’ nature of Black Africans and ensuring a strong hold on their socio-political and economic power in the region (Mpofu et al. 2011; Dune and Mapedzahama 2017). Sexual behaviour marked a distinction between Europeans and Africans and a way to impose European ideas of sexual morality upon Africans who were frequently defined with reference to polygyny and sexual excess (Erlank 2001). Sterilization surgeries were performed on those who persistently diverged from European moral expectations of minimizing births per family. By the 1970s, the primary reproductive goal of the apartheid South African state was to curtail Black population growth, as advocated by notable government officials. In 1972, the Prime Minister Balthazar Johannes Vorster stated his ambition to increase the white population with pro-natal monetary incentives, while reducing the Black population though sterilization and abortion (Republic of South Africa, Department of Health 2002, 6). South African gynaecologists with extensive experience in the public health sector remark that Black women have especially been the focus of late twentieth-century efforts to control South African population growth (Hodes 2013). As Rebecca Hodes notes, a preference for invasive surgical interventions to reduce the Black population is evident in articles published by the South African Medical Journal throughout the 1970s, whose editors complained about the national press coverage suggesting racism in medical programmes that disproportionately targeted Black women, referring to the urgency of the over-population problem (Walker 1978).

From the 1940s onwards, the proliferation of gynaecology into West Africa and India was enabled by imperialist medical networks and later the influence of international entities such as the World Bank, the Ford Foundation, the Population Council, the WHO, the League of Nations and the International Planned Parenthood Federation which all contributed to the global economic discourse of ideas about the need for contraception, including sterilization, to limit population growth, pressuring aid-recipient and debtor nations to undertake population-control measures (Bashford 2006; Bashford 2014; Ashford 2020a; Towghi and Randeria 2013). These entities were responsible for embedding ‘family planning’ institutions into the so-called ‘developing world’ (Sharpless 1998). A discourse of a symbiotic relationship between population-control and economic and social development grew from the 1940s onwards, based on the authority of demographic transition theory – the idea that economic development was contingent on limiting population-growth (Szreter 1993). This led to a proliferation of family-planning measures, endorsed by the United Nations (UN) and made possible through international donors and experts. In Ghana, Africa’s first national population control policy was announced in 1969, followed by the National Family Planning Programme which quickly spread through Ghana’s existing hospitals and clinics in the 1970s. Although the provision of family planning offered women and men more choice over their reproductive lives, the Programme’s principal aim was political: It promised to promote economic development in the country (Ashford 2020a, 2019). The programme also included coercive elements such as monetary incentives for family-planning fieldworkers (Ashford 2020b).

By the second half of the twentieth century, the global medical account of women’s reproductive organs as cancer-prone also played a role in the ongoing use of both hysterectomy and oophorectomy, viewed increasingly as methods of cancer prophylaxis, particularly in older women in whom cancer incidence is higher (Moscucci 2016), though in India since the 1970s even women in the 1920s and 1930s have also frequently been prescribed them with this same rationale (Khunte et al. 2018). In 1970s, health economic arguments about the advantages of hysterectomy as a sterilization method were explicitly advanced by some medical researchers on the grounds of the additional public-health cost-saving associated with eliminating risk of future uterine cancer (van Nagell and Roddigk 1971; Deane and Ulene 1977). Recently UK oncology researchers have expressed similar concern about the decline of hysterectomy due to the global minimally invasive surgery trend as a factor leading to higher population levels of uterine cancer (Temkin, Minasian, and Noone 2016; Unzurrunzaga et al. 2019). In all these discussions there has been little consideration of a patient-centred view of human wellbeing, or of the absolute risk of these cancers for most women, which are in the range of 1 in 78 lifetime risk for cancer of the ovary, mostly concentrated in the period after 63 years of age (American Institute for Cancer Research 2018), and around 3.1% lifetime risk for uterine cancer (National Cancer Institute 2014–2018).

Part II: a troubling present

Current medical debates about the consequences of hysterectomy

A group of Canadian ob-gyn researchers referred to hysterectomy in 2019 as a continuing ‘cornerstone of gynaecological surgery’, noting that the surgery remains widely recommended to women considered peri- or post-menopausal, seeking removal of fibroid leiomyomas (non-cancerous benign tumours) despite alternative treatments such as myomectomy being well developed (Chen, Choudhry, and Tulandi 2019). Such benign tumours have been estimated to occur in more than half of all women by the age of 50 years (Wang et al. 2016). The prevalence of hysterectomy and oophorectomy globally today is highly varied within and between national contexts. One in three women in Australia and the US have had a hysterectomy by the age of 60 years, including 30% who have bilateral oophorectomy (Forsgren and Altman 2013; Wilson et al. 2019). In 2013, 17.5% of all German women, and 39.4% of German women aged between 70 and 79 years were identified as having had a hysterectomy (Prütz et al. 2013). In Finland, 25% of all women surveyed in 1992 reported having had a hysterectomy (Luoto et al. 1992). In Canada in 2008, 35% of women over 50 years reported having had a hysterectomy (Stankiewicz, Pogany, and Popadiuk 2014). Rates of hysterectomy in India vary significantly between regions, with the highest levels at 16% of all women over 39 years found in Andhra Pradesh where private clinics dominate the health landscape (Shekhar, Paswan, and Singh 2019; Desai et al. 2019). In Pakistan, one of the few national-level studies found 20% of women had a hysterectomy by 60 years of age, and 40% of these for dysfunctional uterine bleeding with no gynaecological pathology (Maresh et al. 2002; Pherson, Metcalfe, and Herbert 2004).

Nigerian gynaecology researchers report much lower rates of hysterectomy throughout Africa due both to women’s fear of surgery (where the risk of death remains higher than in the West), concerns about loss of femininity, and women’s desire to maintain fertility for the afterlife (Onyeabochukwu et al. 2014). But throughout Africa there is a much higher rate of emergency peripartum hysterectomies than in the West because many women with problematic pregnancies receive inadequate care, only attending hospital at the point where there is no other choice than to perform a hysterectomy (Kwame-Aryee, Kwakye, and Seffah 2007). Non-emergency hysterectomies are most likely lower in Africa too due to even fewer surgical facilities than in either Europe or in India. As medical anthropologist/historian Julie Livingston has noted in Botswana, cervical cancer accounts for ¼ of all female cancers linked to HIV infection but, at the hospital where she carried out ethnographic research, most women’s genital cancers become too advanced to be treated with alternatives to hysterectomy due to delays in test results and waiting times on surgeries (Livingston 2012, 9–10, 44).

The long-term health effects of hysterectomy remain subject to a significant lack of current medical consensus. Several studies have shown that women close to menopause whose uterus is removed while still menstruating experience the physiological effects of menopause on average 3.7 years earlier, while women whose uterus and ovaries are both removed experience them 4.4 years earlier than women undergoing natural menopause (Farquhar et al. 2005; Shuster et al. 2010). Menopause itself is considered an independent risk-factor for cardiovascular disease, osteoporosis and Alzheimer’ disease, making its surgically-induced early onset a non-trivial matter. Hysterectomy with ovarian conservation but without subsequent hormone replacement therapy (HRT) has been found to result in accelerated bone-loss, particularly of the femur (Simões et al. 1995). Hysterectomy with oophorectomy during the menstrual years has been found to elevate risk for a wide range of women’s diseases of ageing (Shuster et al. 2010; Bove et al. 2014; Hogervorst 2014). Some gynaecology researchers have sharply distinguished between hysterectomy, viewed as benign and inconsequential for hormone status, and oophorectomy which induces precipitous deficiencies of Oestradiol, Progesterone and Testosterone since the ovaries are the primary sex-steroid endocrine organ in women (Langenberg et al. 2017). Other researchers note the common accelerated ovarian atrophy occurring in women after even partial hysterectomy with ovarian conservation, possibly due to loss of neuronal or endocrine feedback between the uterus and ovaries (Watson et al. 1995).

Advocates of hysterectomy/oophorectomy typically refer to a complete loss of function of the uterus and ovaries in natural menopause indicating the pointlessness of retaining them, while those querying the necessity of such surgeries refer to the continuing endocrine functions of the ageing ovary and to the pelvic structural support and sexual-sensory dimensions of retaining the uterus (Laughlin-Tommaso et al. 2017; Blandon et al. 2007). A 2005 metareview of existing research up to that time on the psychosocial effects of hysterectomy found that while most women in Europe and the US ‘tolerated it well’, a substantial subgroup between 10% and 20% reported negative outcomes of loss of sexual interest and pleasure, as well as depressive symptoms and reduced self-esteem (Flory, Bissonnette, and Binik 2005). Moreover, tolerability is diversely defined across different medical research studies that make claims about it, with less than half referring to the more holistic measure of Health-related quality of life (HRQoL), and very few studies in gynaecology considering long-term wellbeing across the lifespan (Basch and Yap 2021; Forsgren and Altman 2013). Advocates of hysterectomy typically also refer to the benefits of hormone replacement therapy, citing correlative epidemiological studies as evidence that women on HRT post-hysterectomy have even better health outcomes than women who undergo no surgeries and experience natural menopause, though they acknowledge this may reflect differences in ‘health conscientiousness’ (Studd 2009; Iversen et al. 2005). Arguably though, the HRT/hysterectomy model medicalises women’s ageing unnecessarily, serving commercial interests in the suggestion for all women to undergo expensive elective surgeries in their 1940s, and then adhere to lifelong pharmaceutical hormone dependency. Clearly too, many of the poorer women in the global South currently being given hysterectomies and oophorectomies as first-line treatments for benign gynaecological complaints are not likely to be able to afford or access HRT treatments to compensate for their loss of endogenous hormones.

There is a striking lack of large-scale, ethnographic or qualitative and comparative research on the truly long-term effects on women’s health and wellbeing from reproductive organ removals, particularly for those women located outside the most affluent healthcare systems of the world. Most studies comparing women who have had hysterectomy/oophorectomy to women who have no such surgeries in the affluent world have found no significant differences in mortality (Wilson et al. 2019; Merritt, Riboli, and Murphy 2015; Iverson et al. 2005), but many have found elevated ill-health and disease risks (diabetes, stroke, kidney and thyroid cancers, depression, dementia and urinary incontinence) in the surgery groups – clearly not sufficient to be lethal in affluent contexts, but significant for ageing wellbeing (Phung et al. 2010; Li et al. 2018; Laughlin-Tommaso et al. 2017; Wilson et al. 2018; Appiah et al. 2014). The 1994 Maine Women’s Health Study that is widely cited by hysterectomy enthusiasts as evidence that 71% of all women can expect improved wellbeing after this surgery, was in fact only a small prospective cohort study of 418 American women between the ages of 25 and 50 years, with the follow-up extending only to 1 year post-surgery; and even this study also found 29% of women in the hysterectomy arm who reported marked detriments to their wellbeing resulting directly from the surgery, including hot flushes (13%), weight gain (12%), depression (8%), and lack of interest in sex (7%) (Carlson et al. 1994). An age-stratified systematic review of existing research published in the Lancet in 2000 indicated that urinary incontinence is a common side-effect of hysterectomy (particularly via abdominal laparotomy), which is unlikely to be detected in most follow-up studies since it can be delayed by many years – Taiwanese women over 60 years who had previously received hysterectomies up to 25 years earlier were observed to have a 60% higher prevalence of urinary incontinence in old age (Brown et al. 2000).

Hysterectomy declining in the North, while rising in the global South

In numerous affluent contexts, many gynaecologists continue to prefer hysterectomy as a treatment where other options exist since it is both a less technically demanding surgery, entails less blood loss than many others, and is seen as cancer prophylactic. Nonetheless, there have been variable declines in hysterectomy since the 1990s in several affluent countries with long histories of their ubiquity, such as France, Denmark, the USA and Canada, due to the development of alternative procedures for the treatment of non-cancerous uterine fibroids – the single most common condition for which hysterectomy is prescribed (Theobald 2008; Gimble, Settnes, and Tabor 2001; Chen, Choudhry, and Tulandi 2019; Farris et al. 2019). Laparoscopic or hysteroscopic myomectomy (minimally invasive removal of the fibroid but not the uterus, by abdominal or vaginal entry) is now considered ‘the gold standard surgical treatment option for fibroids’ (Malick and Odejimi 2017). A recent movement among gynaecologists has also called for a revision of the discipline in response to rising obesity and ageing populations, reducing surgical solutions in favour of an increasingly preventative approach to reproductive disorders through lifestyle interventions (Joneja and Chopra 2012; Fong, Singh, and Ratnam 2000). In Germany, the US, Greece and India, there have been calls by leading gynaecology, neuroscience and public health experts to end the still-common routine practice of removing the ovaries with hysterectomy, as it is not supported by the research on effective treatment for most conditions, and recent findings have indicated that hysterectomy with oophorectomy before menopause, particularly in young women, increases mortality, heart disease, osteoporosis, dementia, stroke, Parkinson’s and cognitive impairment risk significantly 20–30 years post-surgery (David et al. 2012; Erekson, Martin, and Ratner 2013; Bove et al. 2014; Hogervorst 2014; Georgakis et al. 2019).

However, the large-scale international minimally invasive gynaecology trend of recent decades has not translated into transforming normative practices of radical hysterectomy in the global South. In fact, such surgeries have recently become more common over the same period in which they have declined throughout the affluent world, particularly in specific regions where private clinics have replaced impoverished state-funded health services in contexts of rapid population growth. In India, Pakistan, Bangladesh, Sri Lanka, Nepal, Bhutan and the Maldives, there is evidence of a recent increased use of hysterectomy in remote private medical clinics as a treatment for a wide variety of gynaecological complaints even in young women, specifically in women of lower caste and class who often have to borrow money to pay for the surgery (McGivering 2013; Mamidi and Pulla 2013; Desai et al. 2019). Emergency peripartum hysterectomies have increased in both Ghana and Nigeria since 1990, linked to the increase in previous caesarean births which make pregnant women more prone to uterine rupture (Gibney, Mock, and Visser 1991; Umezurike, Feyi-Waboso, and Adisa 2008). Since the early 2000s, medical ethicists have remarked upon an alarming ‘mushrooming’ of laparoscopic gynaecological surgery clinics in major cities of India (Hebbar and Nayak 2006). While rates of overall hysterectomy among the total Indian population remain relatively low compared to the US, Australia and Germany, they are higher than anywhere in the world among women under 35 years of age (Desai et al. 2019). There is also great variability between regions. In some towns, such as Bandikui in Rajasthan, almost the entire female population between 30 and 49 years had their uterus removed in the 2000s – a pattern not observed anywhere else in the world (Prayas et al 2013; Kalaiselvi and Brundha 2016; Prusty, Choithani, and Gupta 2018).

Clinical rationales for hysterectomy in India

A 2013 report on the sudden increase in hysterectomies prepared for an Indian joint health organization inquiry reveals some of the unique clinical rationales underpinning the new enthusiasm for hysterectomy. This inquiry entailed interviews with women from the Dausa district in rural Rajasthan, following media reports of ubiquitous hysterectomy, to ascertain from the women how their surgeries came to be prescribed and performed (Prayas et al. 2013; McGivering 2013). Sixteen women agreed to be interviewed by civil society workers, reporting a very similar story in each case. Within 1–5 years of receiving tubal ligation at a local government camp, they all developed abdominal pain and irregular bleeding. When they consulted either the local public hospital or a private clinic, they were given only an ultrasound (sonography) examination of the abdomen (no serum tests, vaginal swabs or internal examination), and were told that their uterus was ‘sick’ and that they must undergo emergency hysterectomy to prevent a deadly cancer from developing. They were not offered any alternative treatments and were admitted that same day for this radical procedure. Following their recovery from the surgery, their pain symptoms did not improve, though their irregular bleeding ceased (Prayas et al. 2013, 29–42). Indian gynaecology researchers have identified that almost all of the conditions for which radical hysterectomy is currently being prescribed in rural India are treatable by other safer and less invasive means (Kameswari and Vinjamuri 2009).

There is so far little sign that Indian subcontinent health services have assimilated the critical attempts by numerous local scholars, clinicians and health organizations to challenge the dominance of hysterectomy/oophorectomy in the treatment of common gynaecological complaints. A recent article by Bangladeshi gynaecology researchers begins by cheerfully announcing that ‘laparoscopic hysterectomy is achieving great popularity nowadays’ in the treatment of fibroids, enlarged uterus and abnormal uterine bleeding, posing questions about how to make it even more popular in Bangladesh for these common conditions that are treatable by other means (Ila et al. 2018). Free and low-cost services provided in 2016–2017 to women aged between 31 and 50 years, suffering from mild gynaecological conditions at the Government Medical College Rajnandgaon and at a tertiary care referral-hospital in central Chhattisgarh (East-Central India) prescribed total abdominal hysterectomy with bilateral salpingo- oophorectomy to 59% of the women treated – the most radical form of complete reproductive-organ removal which induces instant early menopause, has the longest recovery-time, the highest risk of complications, and the most negative effects on both immediate and long-term ageing health (Khunte et al. 2018).

There is limited existing ethnographic research in Pakistan and India, but previous work conducted by one of the authors of the current paper in Balochistan where women until recently were cared for entirely by traditional midwives with local herbal formulas, found a recent increased prevalence of hysterectomy, with women frequently reporting that their pre-operative pain and symptoms do not disappear following the surgery (Towghi 2012). In Pakistan, gynaecologists working in private hospitals in Karachi and Quetta showed low awareness of potential post-hysterectomy complications and long-term negative effects experienced by women. In a clinical study in Pakistan tracking 30 cases of peripartum hysterectomy over two years, the average hospital stay due to pre- and postoperative complications was 12 days and could last up to 21 days (Tahir, Mohmood, and Akram 2003). Uterine rupture is a major indication for emergency peripartum hysterectomy in Pakistan and is linked to the injudicious use of Syntocin (Oxytocin) during the third stage of labour to relax pelvic muscles (Towghi 2014, 2018; Nisar and Sohoo 2009). In a large percentage of cases, the cervix has also been removed with peripartum hysterectomy, increasing risk of later uterine prolapse (Ahmad and Wasti 2001; Bashir et al. 2005). During surgery, ligaments and nerves are frequently damaged or severed, leading to problems such as constipation, urinary incontinence, and disturbed sexual response. If women and families are eager to leave a day after the surgery, they rarely return for follow-up due to constraints of cost and distance, as reported by doctors (Towghi 2012). In general, we have little information about rural South Asian women’s postoperative status, and none whatsoever regarding their long-term health following radical gynaecological surgeries.

Indian women interviewed by Towghi in Andhra Pradesh and Mysore in 2011 and 2012 regarding their post-hysterectomy experience in the context of a broader cervical cancer prevention anthropological study in India, discussed experiencing severe chronic lower back and general body pain five or more years following their hysterectomy (Towghi 2013). In India, too, the removal of the cervix was common in hysterectomy surgeries as noted by the gynaecologists and oncology surgeons interviewed. Cancer specialists routinely received referrals from gynaecologists of post-hysterectomy cases of women experiencing severe pain. One oncologist was seeing at least one such case each week, explaining that women are in pain and even still bleeding after the hysterectomy who then are sent to them by gynaecologists, noting that, ‘the cure rate is much lower than if we had caught them first-hand before the hysterectomy’ (Author field-notes).

Oncology researchers have also identified the recent growth of hysterectomy as a first-line surgery to treat cervical cancer in India, due to the lack of specialist gynaecological oncology services in remote areas (Dreyer 2019). A number of gynaecologists have described the inadequate medical care context and overlapping problems of preventing and treating cervical cancer in India and the unnecessary resort to hysterectomies to address uterine disorders and bleeding. On the one hand, the lack of access to primary care and early detection of cervical lesions such as with Pap smear can lead to unnecessary late-stage cervical cancer (Towghi 2013). On the other hand, the resort to unnecessary hysterectomy administered to ‘treat’ uterine disorders can result in the masking of underlying cancer. Gynaecologists noted that even when women undergo such a surgery to save their life, it is done without proper diagnoses, not even a Pap test or a plain inspection of the cervix before the removal of the uterus. Some of these hysterectomies are not even being done by gynaecologists, but rather by oncology or general surgeons who as one gynaecologist explained ‘should not even be touching the gyne-cases. They don’t know how to do a gynaecological examination’ (Author field-notes).

In Andhra Pradesh since the early 2000s, hysterectomies have both become the most expensive gynaecological surgery, therefore most lucrative to the clinicians performing them, and have also emerged as first-line treatment for a wide variety of gynaecological complaints that are treatable by other means (Desai, Sinha, and Mahal 2011; Pulla 2018). In both India and Bangladesh, such practices may be seen as continuous with population control of the 1970s in which governments offered property incentives to women for undergoing surgical tubal sterilization and bonuses to the clinicians who convinced people to undertake them, except that now such procedures, having become part of the private commercial domain, use exaggerated warnings about the risk of uterine and ovarian cancer to induce even asymptomatic women to pay for their organs’ surgical removal (Ray and Sonnad 2017). Cancer risk is still frequently cited as the rationale for prescription of emergency hysterectomies, without any information provided about the percentage risk of such diseases, and without any internal examination or imaging of the uterus supporting such prescription. Gynaecologists promoting hysterectomy in India have sometimes referred to the 1994 Maine Women’s Health Study as evidence that most Indian women now can expect long-term improved wellbeing from this surgery, but they fail to mention that this study, conducted 16 years ago, was only a small, short-term study of affluent, literate, overweight US women, most whom also received hormone replacement therapies and substantial post-surgery follow-up care (Carlson et al. 1994). In the poor rural regions of India where total hysterectomy with oophorectomy has emerged as a first-line treatment, by contrast, women are commonly under-nourished, have low levels of literacy, work in hard physical labour and have minimal or no post-operative follow-up care (Mamidi and Pulla 2013).

Inequalities of medical care are not only to be found between different geographic zones, distinguishing the affluent global North from the global South, but indeed between different sub-populations as well. In India, hysterectomy is far more commonly performed on rural than on urban women, and on women with minimal literacy and of lower socio-economic status (Desai et al. 2017; Desai et al. 2019; Geetha et al. 2019). While general elective hysterectomies have decreased in most affluent countries, several studies have indicated that Black women are still more likely than any other US women to receive them (Dillaway 2016; Beavis, Gravitt, and Rositsch 2017). A 2006 study found that Aboriginal women in Western Australia were more likely than non-Indigenous women to be given hysterectomy for the treatment of mild gynaecological disorders, particularly in rural areas (Spilsbury et al. 2006). Peripartum hysterectomy (a high-risk surgery conducted immediately after childbirth) increased between 2010 and 2016 in the US and was more likely to be performed on Black women, with complications resulting from it more frequently in Black- Hispanic- and Asian-American women than in White women (Martin et al. 2018; Ryan et al. 2018). Racial-minority women of all kinds in the US have also been identified as less likely than White women to receive minimally invasive gynaecological procedures (Ranjit et al. 2017). The most common single condition for which hysterectomy is recommended – uterine fibroid leiomyoma removal – is more common in women of African descent compared to all other populations, and is also more common with ageing, suggesting that the classification of fibroids as automatic surgical targets itself may represent an intersectional pathologisation of Black older women’s bodies (Dillaway 2016; Marshall et al. 1997). The second author of this paper observed a similar trend in Pakistan where hysterectomies were performed and justified as a normal treatment protocol because people are ‘‘poor’’ and live in ‘‘remote’’ areas. Gynaecology surgeons interviewed rationalized the hysterectomy in cases of ‘benign’ uterine tumours, fibroids, and irregular bleeding on the assumption that ‘rural’ poor women would not return for follow up treatment in case of less radical treatments. Doctors were up front about the fact that the procedure is largely medically unnecessary, and a vague concern about the structural conditions and constraints of the lives of women provided them the social – not the medical – rationale they required to sign off on the ‘ethical’ clause (Towghi 2012, 244).

Conclusion

From our selective survey of the practices and clinical rationales of radical gynaecological surgeries in several world regions and different eras, it is clear that a consistent element of their use has been a prioritization of both commercial and state interests in population health-expense (these two elements often being deeply entangled) over individual long-term patient wellbeing, suggesting the need for further humanistic and social-science analysis of the historical and current biopolitics of hysterectomy and oophorectomy. These trends do not follow identical patterns everywhere: In India, Ghana and Réunion, and in most contexts relative to women with intellectual disabilities, state-funded health clinics in the twentieth century were the sites for the proliferation of gynaecological interventions such as hysterectomies, tubal ligations, IUD insertions and pharmaceuticals such Quinacrine pellets for sterilization (George 2004). But in several contexts, such as in late nineteenth-century London, in 1950s USA, and in recent Andhra Pradesh, the preferential prescription of hysterectomy for a wide range of benign gynaecological conditions has allowed doctors performing them to generate higher income than those prescribing alternative treatments (Frampton 2018; Dowbiggin 2008; Desai, Sinha, and Mahal 2011), suggesting a more complex interplay of biopolitics as a fluid entity moving between state and commercial interests, as might be expected in capitalist states infused with corporate privatization. Population control rationales for hysterectomy have undoubtedly fuelled its proliferation among poor women both in North America of the 1950s–1970s, and in the global South since the 1970s.

However, hysterectomy cannot be reduced only to sterilization agendas, even though it has sometimes also served this purpose since it has also commonly been performed on older, non-reproductive women through the rationale of cancer prophylaxis in affluent societies with increased life-expectancy, fuelled by the view that ‘ageing populations’ with their attendant cancer risk constitute an alarming state expense that must be managed (Moscucci 2016). In India, this same rationale has been used to justify emergency procedures without proper examination even in young women (Towghi and Vora 2014). Throughout the history of their development, hysterectomy and oophorectomy have also been paired with Oestrogenic hormone replacement, making the surgeries lucrative for pharmaceutical companies as well. Biopolitics then does not only describe the production by medical practitioners of eugenic ideals, nor only their direct employment by the state in delivering deliberate policies of population control, but also the interests of private commercial health entities in surgical development for financial gain, congruent with the neoliberal orientation of both national and international authorities.

In current and future medical practice, hysterectomy may indeed sometimes be preferred for reasons of considered clinical indication. We would certainly not wish to imply that people who choose such treatments are necessarily deceived into doing so or have always been treated improperly since many who are affluent choose such surgeries for the resolution of bleeding disorders, or as a cancer prophylaxis for their own piece of mind (Wen et al. 2018), while FTM forms of these surgeries are frequently eagerly sought after by patients themselves. Clearly too, as several researchers have observed, some women in poor rural areas of the global South also actively seek out this surgery because of the lack of both alternative treatments, contraception and of access to accurate information about the risks of cancer (Lopez 2008). Another kind of situation of limited knowledge and alternatives was also the reality for French, English and German women at the end of the nineteenth century – the context that first normalized the biomedical reliance on hysterectomy/oophorectomy as routine procedures. Patients are not simply passive victims of such surgeries, but they have very commonly, both in the past and in the present, received either inaccurate diagnosis, incomplete treatment-option context, or cancer-risk exaggeration leading to their over-prescription.

Acknowledgements

Thanks are owed to the Freiburg Institute of Advanced Studies in Germany for the January-February 2021 Alumni fellowship provided to the lead author in developing the foundations of this paper and research project.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1 In several European, American and African historical contexts, women’s external reproductive organs (clitoris, vulva, labia, vaginal opening) have also been surgically altered and removed (Thomas 1996; Park 1997; Kandji 1999; Rodriguez 2014). While these procedures, commonly called female genital mutilation or female genital cutting, are also gynaecological in nature, they are outside the scope of this paper which focuses on the inheritance of the far more common surgeries, hysterectomy and oophorectomy.

2 Research on how gynaecological surgery has/is being practiced throughout the global South is extremely limited and much work remains to be done on this question. The current paper begins a large interdisciplinary project investigating how surgical procedures and medical concepts relating to reproductive health that were developed in Europe in the late nineteenth century have influenced medical surgical practices and standards in Africa, the Indian Subcontinent, Asia-Pacific and Australasia from the late twentieth century onwards.