Precarious Lives: Forced sterilisation and the struggle for reproductive justice in Peru

ABSTRACT

It is estimated that more than 200,000 women were sterilised without giving free, prior and informed consent in Peru between 1996 and 2000 during the Fujimori regime. This paper places forced sterilisation within the frameworks of precarity and reproductive justice to understand policies that legitimised the violation of women's rights irrespective of the type of political regime: forced sterilisations during a dictatorial regime and denial of access to sexual and reproductive rights during a period of democracy. Through document analysis, this paper examines narratives around sterilisation and reproduction produced by policymakers, political and religious leaders and health care practitioners during these two political periods. This paper shows the continuity of the struggle that marginalised populations face in exercising their reproductive rights in the context of symbolic and structural inequalities.

KEYWORDS:

• Forced sterilisation
• precarity
• reproductive justice
• feminine capital
• symbolic and structural inequalities

Introduction

Forced or coerced sterilisation have been used across numerous countries as a mechanism to limit the reproduction of marginalised and ‘undesirable’ groups in terms of factors such as race and ethnicity, sexuality, age, social class, disability, health status and criminal background (Briggs, 2003; Kasiva, 2012; Winters & McLaughlin, 2020). Extensive research has demonstrated that forced sterilisations carried out in Peru between 1996-2000, during the Fujimori regime, were part of an organised state policy targeted at rural, Indigenous, illiterate, impoverished women of reproductive age (Ballón, 2014; Rendon, 2017; Tamayo, 1999). Through intimidation and coercion, the regime's family planning programme sterilised disadvantaged women, who as a direct consequence, were ostracised from their families and communities, suffered adverse medical conditions and even death.

Data indicates that over 200,000 women were sterilised without giving free, prior and informed consent between 1996–2000 (DP, 1998; 1999; 2000; 2002). Since the exposure of the first cases of forced sterilisation in the late 1990s, no Peruvian court has held any individual perpetrators accountable. In 2018, a penal court sought to charge former president Fujimori and three of his health ministers who directly participated in the sterilisation campaign, but it was not formalised. Nongovernmental initiatives such as La Madre provides comprehensive archival research to support the case for justice and reparations for survivors¹, and governmental bodies such as the Register of Victims of Forced Sterilisations (REVIESFO) were established to register and support victims to seek reparations. However, the impact of these initiatives has been limited by an absence of financial support, political will and a lack of recognition in Peruvian criminal law of forced sterilisations as a violation of human rights (Alvarado, 2019; Carrasco, 2018; Montoya et al., 2014). Despite the overwhelming evidence that sterilisations were part of a pattern of human rights violations with no precedent in Peru, a culture of impunity remains in the country in this regard.

The paper starts by opening a dialogue between the concepts of precarity and reproductive justice as theoretical umbrellas to analyse narratives and metaphors around forced sterilisation and the struggle for reproductive justice during two political regimes in Peru: the Fujimori dictatorial regime (1990-2000) and the Toledo democratic regime (2001-2006). Precarity highlights the structural and symbolic conditions that creates oppression of marginalised populations while reproductive justice places intersectionality at the centre of its analysis and seeks to link reproductive rights to the broader framework of social justice. The paper then introduces the Peruvian health system in the context of race and class hierarchies. The paper goes on to focus on forced sterilisation during the Fujimori regime, followed by the denial of reproductive services under the Toledo administration. The paper analyses policies and discourses that legitimised the violation of women's rights irrespective of the type of political regime. Finally, the paper analyses discourses produced by healthcare practitioners and the Catholic Church that illustrate a shared ‘common sense’ about the denial of the rights of poor and marginalised populations produced by powerful actors and institutions.

Methods

Document analysis generates rich, detailed and complex accounts from diverse perspectives and sources about a particular social phenomenon (Nowell et al., 2017). This method allows the identification of emerging themes and categories such as metaphors and discourses. Documents provide evidence of the ways in which individuals and organisations represent social settings and account for themselves and others (Coffey, 2014). Therefore, documents also provide a means of understanding and making sense of social and organisational practices. The data collected represents ‘social facts’, which are produced, shared and used in socially organised ways and become versions of reality (Bowen, 2009). Documents are not produced in isolation, they inform and influence other documents and events, becoming part of an ‘intertextuality of documents’ (Coffey, 2014).

This paper uses document analysis to examine narratives around forced sterilisation and reproduction during dictatorial and democratic regimes in Peru. Four main themes are explored: forced sterilisation; women's reproductive rights; reproduction; and gender ideologies. These themes are informed by documents generated by four groups of actors: politicians; health care practitioners; religious leaders; and human rights scholars and activists. These narratives were collected from a wide array of sources: official reports and archives from NGOs and governmental organisations, empirical local research and the Peruvian media. This triangulation of different sources validates the analysis of such complex phenomena. The Peruvian media analysed were El Comercio, Expreso, La República, Peru21, the Official Journal, El Peruano, and the magazine Caretas. The analysis of this data took place in two periods, from 2004 to 2006 during a wave of media reports (Vasquez del Aguila, 2006) and in 2019-2020. The principle of saturation was used to determine the scope of the data to be collected for the four chosen themes. Careful consideration concerning the reliability of the sources was given in order to distinguish between facts provided by reputable sources and opinions provided by actors in the media (online and written). In order to minimise the researcher's own bias, an interpretation of the narratives was shared with colleagues at Columbia University during the first period and with colleagues at Universidad Mayor de San Marcos, Lima and University College Dublin during the second period of analysis. All documents analysed are publicly available and ‘second hand’ sources, hence no issues of confidentiality were involved. The documents analysed illuminate a complex interplay of biomedical knowledge, religious values, gender ideologies, race and class hierarchies, and apparent ‘progressive’ discourses constructed around sterilisation and reproductive rights in Peru.

Precarity and reproductive justice

The concept of precarity provides a useful framework for research on social marginalisation and inequalities. Drawing on Standing's foundational work, the precariat suffers from chronic uncertainty, insecurity and unstable living conditions. In terms of their relations with the state, the precariat has limited range and depth of civil, cultural, social, political and economic rights, which transform them into ‘denizens’ rather than subjects with the right to ‘proper citizenship’ (Standing, 2011). Butler defines precarity as ‘the politically induced condition in which certain populations suffer from failing social and economic networks of support and become differentially exposed to injury, violence and death’ (Butler, 2009, p. 25). Looking at the intersections between precarity and performativity, Butler distinguishes between ‘precariousness’ as our ontological condition as humans that depends on a shared interdependency, and ‘precarity’ that refers to the structural conditions that institutionalise the marginalisation of particular populations. Some scholars have analysed precarity in the context of neoliberal conditions as the juxtapositions of increasing radical individualisation, insecurity and the decline of social traditions (Millar, 2014; Woltersdorff, 2011). Precarity in these contexts is closely linked to the notions of symbolic and structural violence. Symbolic violence refers to complex forms of social and cultural domination that often operates without the presence of physical violence, the imposition and perpetuation of power and subordination through forces that are unnoticed and seem ‘invisible’ in everyday social interactions (Bourdieu, 1990). Meanwhile, structural violence has the power to become part of people's social relations, institutional practices, economy, among others, which creates forms of suffering and injustice that are deeply embedded in people's everyday lives (Farmer, 2001; Padilla et al., 2007). Symbolic and structural violence(s) legitimise structural inequalities and ‘invisibilise’ the subordination of populations based on different systems that operate together such as race/ethnicity, class and gender.

In this article, I use precarity as a framework to understand symbolic and structural inequalities that place particular persons or groups in situations of heightened vulnerability as a product of their historic state of exclusion and marginalisation. This form of precarity is embedded in ubiquitous structures and normalised by institutions, culture, and everyday experiences. This situation creates a ‘culture of precarity’ that legitimises a shared ‘common sense’ of unequal power relations. Drawing on the classic understanding of ‘common sense’ of Geertz (1975) and Gramsci (1971) as a collection of relatively organised ideas and beliefs that produce ideologies and practices sustained by hegemonic institutions, I argue that this culture of precarity reproduces and maintains permanent and systemic inequalities that impact the lives of certain individuals and communities. In concert with Butler (2009), I argue that this culture of precarity produces a ‘selective empathy’ towards bodies and sufferings that matter, and others that are disposable and invisible. This selective empathy is based on the proximity to shared experiences and backgrounds such as social class, race or ethnicity.

Reproductive justice places its analysis at the intersections of race, class and gender and seeks to link reproductive rights to the broader framework of human rights and social justice (Luna & Luker, 2013). Feminist scholars see reproductive justice as rooted in the belief that systemic inequality shapes people's reproductive choices, particularly in the case of women of colour. For Ross (2017), systemic inequality refers to institutional forces such as racism, sexism, colonialism, and poverty that constrain people's individual freedoms in societies. Winters and McLaughlin (2020) argue that the framework of reproductive rights has focused on the needs of middle class and wealthy women, that is why reproductive justice seeks to move the research and activist agenda to the lives of women of colour and communities who suffer from symbolic and structural inequalities.

Reproductive justice uses intersectionality as a framework to highlight the diversity of marginalised social identities at the interplay of a complex matrix of oppressions around race, class, sexuality, citizenship or other power relations (Cho et al., 2013; Collins, 2000; Crenshaw, 1991). Feminist scholars, such as Zavella (2020), analyse the internal diversity and unique challenges faced by women of colour negotiating experiences, identities and subjectivities as they confront the complex dimensions of their oppression. The reproductive justice framework centres unequal power relations reproduced by the state as part of an interconnected system, which is pivotal to promote the recognition to access comprehensive health care (Winters & McLaughlin, 2020). This intersectional approach explains why human rights violations and abuses, such as forced sterilisation, are not isolated cases but the result of systemic inequalities that deny women their human right to sexual and reproductive services. This approach is more comprehensive than the mere ability to decide upon fertility and its timing and involves questioning traditional notions of motherhood as an obligatory life project for women and, in parallel, fatherhood as a necessary part of men's lives.

The Peruvian health system: race, class and gender hierarchies

Three centuries of Spanish colonisation have produced a ‘hierarchy of bodies’ in Peru, based on a marked racial and social symbolic classification, that implies the subordination of Indigenous populations by the hegemonic blanco (white) elite. The formation of a republic and democracy did not eliminate the subordination of racial minorities as the white and criollo (Spanish ancestry) hegemony persisted (Sulmont & Callirgos, 2014). Public debates about the so-called ‘Indian Problem’ posited the indian (Indigenous) subject as an obstacle to national progress, while whiteness became associated with the ‘improvement’ of the racial profile of the nation (Boesten, 2007). Categories such as Mestizo/a, Campesino/a, Andino/a, Cholo/a and Indigenous express the complexity of the notion of race and ethnicity in Peru. This is made more complex at its intersections with gender.

Peruvian feminist historian Mannarelli (2018) elucidates the control of women's sexuality and reproduction since colonial times in Peru. The Peruvian state aligned with patriarchal and religious ideologies that seek to relegate women, particularly marginalised women, to positions of domesticity and subordination. According to scholars such as Weismantel (2001), the interplay of race, class and gender manifests in violence towards the Indigenous female body, who is the subject of complex forms of inequalities in Peru. As a consequence of this systemic inequality, race and ethnicity are written in the female body more than in the male body. De la Cadena (1996) offers an illuminating phrase: ‘women are more Indigenous than men’: while many Indigenous women wear traditional clothes, speak Quechua or Aymara, men wear Western clothes, speak Spanish and more often migrate to Spanish-speaking urban areas. Men are identified as ‘mestizos’ while their sisters, mothers and wives remain as ‘Indigenous’.

The post-colonial Peruvian public health system focused interventions on subordinated groups in society: women, the poor and Indigenous populations, which resulted in a stigmatisation of the system as the place for marginalised populations. Pro-natalist policies during the early republic prioritised mother–child health in the public health sector and the growth of the population was viewed as economically beneficial. The female body was reduced to its reproductive potentiality, domesticity and women's symbolic place as caregivers and the source for the economic progress of the nation (Contreras, 2004; Ewig, 2012). However, from the 1970s, large families were viewed as ‘culturally primitive’, morally irresponsible, harmful to women's health and a threat to democratic stability (Necochea, 2016).

Historically, family planning in Peru is a field of constant dispute among diverse actors and institutions, with opposing narratives around controlling population growth, ‘imperialist’ agendas, and recognising the right of individuals to voluntarily regulate their fertility (Coe, 2004; Rousseau, 2007). The first legislation on family planning was introduced in 1988. However, as Rousseau (2007) argues, only during the Fujimori regime did the Peruvian state take an active role in the field of family planning. Fujimori's Family Planning programme was embraced as a long-awaited policy by both national and international progressive organisations in a context of historic neglect of comprehensive reproductive policies in Peru. What follows is the analysis of narratives on forced sterilisation and reproduction produced during the Fujimori and Toledo regimes.

Fujimori's dictatorial regime: fertility, poverty and progress

Alberto Fujimori was first elected president of Peru in 1990 in the context of a collapse of Peru's traditional parties, a spiralling economic crisis and a campaign of political violence perpetrated by the guerrilla group Sendero Luminoso (Shining Path). In 1992, Fujimori suspended the constitution, closed Congress, and began to rule by decree – an increasing authoritarianism labelled dictablanda (soft-dictatorship). Steady economic growth during 1993–1995 through authoritarian reforms, neoliberal policies and aggressive privatisation of public companies as well as the repression of Sendero Luminoso configured a discourse of progress and stability supported by the media, a reconstituted Congress, the judiciary, and many other institutions under Fujimori's control. He was re-elected in 1995 for another five-year period. This second term is when forced sterilisations took place.

Fujimori was the first president to introduce policies that promoted a vast choice of cost free, modern contraceptive options for the general population (Rousseau, 2007). In 1995, the Peruvian Congress, controlled by Fujimori, legalised sterilisation as part of the Family Planning programme. The official goal of the programme was to reduce the population growth rate, fertility rate and maternal and child mortality rates (Coe, 2004; MINSA, 2002). The programme discourse was framed by a progressive rhetoric unprecedented in Peruvian society. In 1995, at a United Nations conference, Fujimori vigorously defended women's access to information and the provision of contraceptive methods, gender equality and women's reproductive rights (Boesten, 2007). Moreover, Fujimori's speech decried the Catholic Church as an obstacle to progress and family planning (Fujimori, 1995). Fujimori used a polarised rhetoric between modernity and tradition. He portrayed himself as a modern leader against the ‘obscurantism’ of the Catholic Church that firmly opposed contraceptive methods, which was celebrated by many progressive voices in the international community. However, underlying the Fujimori regime's discourse was an explicit assumption that economic growth was not possible with high levels of fertility, which as Winters and McLaughlin (2020) argue, was a strategy to protect the economic interests of the ruling elite.

Fujimori's approach to equate population control with progress and modernisation echoed the eugenic legacy of the Peruvian public health system and the notion of the female reproductive role described above. A media controversy orchestrated by Fujimori during his first term (1990-1995) created a conducive environment for his future sterilisation campaign.

Festivales de Salud (Health Festivals): the Fujimori Sterilisation Campaign (1996-2000)

In 1991, Fujimori declared the Year of Austerity and Family Planning and promulgated the National Programme of Population 1991–1995 in which the main goal was the ‘reduction of the growing population to a level no more than 2% per year by 1995’ (Rousseau, 2007). In 1992 the Health Ministry introduced surgical interventions in cases of ‘reproductive risk’, which was the antecedent to sterilisations in public clinics throughout Peru. In 1995, the National Programme of Reproductive Health and Family Planning (NPRHFP) included for the first time Voluntary Surgical Contraception (VSC): sterilisations and vasectomies became part of free contraceptive methods provided by the state, with only abortions excluded from this programme (MINSA, 2002). As Ewig (2012) shows, strategic measures were taken by Fujimori to closely control the Family Planning programme to achieve its target of 2.5 children per woman by 2020. There was no clarification on how this ambitious goal would be implemented (Carrasco, 2018). The discourse of the ‘right to health’ was the frame in which sterilisation became legal in Peru. The following table summarises the number of cases per contraceptive method under the NPRHFP (1996-2000), which were known as Festivales de Salud (Health Festivals) as part of the Fujimori sterilisation campaign.

The total number of sterilisations and vasectomies under the NPRHFP are unclear. Table 1 shows official data of 260,874 sterilisations and 21,494 vasectomies during the six years of the Programme, but several other sources estimate that more than 300,000 sterilisations were conducted (Bassel, 2020; CEJIL, n.d.; Rendon, 2017). 1997 represents the most ‘successful’ year for surgical methods: 109,689 sterilisations and 10,397 vasectomies. Julia Tamayo from the feminist NGO Flora Tristán published a pioneering report about the Fujimori ‘Health Festivals’ sterilisation campaign. The conclusion of Tamayo's report is that only 10% of the 314,967 women were sterilised with free, prior and informed consent. Tamayo argues that surgical contraception was carried under the supervision of the Health Ministry with bonuses of U.S.$4 to $10 paid to healthcare practitioners for each woman brought in for sterilisation. Additionally, professional promotion ensued for ‘good’ practitioners, with the threat of losing promotions and incentives for those who did not fulfil quotas (Tamayo, 1999). These ‘Health Festivals’ were substantial interventions especially in rural and poor communities where people suffered economic, geographic and cultural barriers in accessing public health services and exercising their reproductive rights.

Table 1. Contraceptive methods during the Fujimori National Programme of Reproductive Health and Family Planning NPRHFP (1996-2000).

Contraceptive Method	Year					Total
	1996	1997	1998	1999	2000
Intrauterine devices (IUD)	170,487	135,879	105,142	104,695	79,203	595,406
Pills	151,129	172,925	195,616	246,181	284,948	1’050,799
Injections	250,344	286,275	322,330	473,903	572,806	1’905,658
Condom	106,189	101,384	110,235	171,830	165,571	655,209
Vaginal tablets	38,931	36,249	37,822	45,958	39,211	198,171
Sterilisation (1)	81,762	109,689	25,995	26,788	16,640	260,874
Vasectomy (2)	6,313	10,397	2,001	1,982	801	21,494
*VSC: sterilisation + vasectomy (1 + 2)	88,075	120,086	27,996	28,770	17,441	282,368

Dfrom Defensoría del Pueblo (2002).

The VSC element of the NPRHFP programme was designed to provide surgical intervention to both women and men, and even though vasectomies are safer and less costly than sterilisations, rural, Indigenous women in conditions of poverty and ‘high reproductive risk’ were the default target of this programme (Brown & Tucker, 2017; Rendon, 2017; Rousseau, 2007). These women illustrate complex forms of precarities that are embedded in private and public patriarchies that deny women access to power, influence, resources and rights at private and public levels (Hearn, 2017). Research indicates that a fear of loss of virility and perceived masculinity lead many men to reject a vasectomy (Palomino et al., 2003). Despite women's fear of their husbands’ opposition to contraception because of an association with potential female infidelity, women were the ones responsible for managing contraception (Coe, 2004). There were cases whereby male partners consented and authorised healthcare practitioners to sterilise their female partners after an initial female rejection (Ballón, 2014; Molina, 2017). In these situations of male partners’ complicity with healthcare practitioners, women's voices were not only absent but subjugated by their partners and the state.

Drawing from the notion of ‘masculine capital’ (Vasquez del Aguila, 2014), I define ‘feminine capital’ as a form of cultural capital that women have to acquire, accumulate and display in culturally appropriate ways to be respected as ‘proper women’. This capital represents an asset for women and allows them to maximise their life conditions and opportunities in the context of private and public patriarchies that conceive women as subjects under the tutelage of their husbands, their communities and the state. Notions of sexual reputation, ‘decency’, reproductive capacity, caring and motherhood constitute a currency for this feminine capital. Sterilised women in Peru saw their social value and position in society as potential mothers and wives reduced due to the loss of their feminine capital. Several studies have shown how women associated sterilisation with physical and emotional harm which is permanent and irreversible. Women were afraid of ‘being burned’ and ‘emptied’ by such a definitive method of fertility control that threatened their role and gender currency in society. Several sources have shown that sterilised women lost the respect of their partners, families and communities. They became the target of gossip and rumours about their sexual reputation for seeking a contraceptive method that would allow for ‘infidelity’, which in some cases translated into domestic violence or abandonment by their partners.

Most sterilisations were under ‘deceit manifesto, coercion or serious threat to women’ (Ballón, 2014; Boesten, 2007). This type of intervention was enacted when Indigenous women were being treated for health conditions such as flu, or presented for vaccination, or simply soliciting information. For example, Hilaria Supa attended a rural clinic to be treated for flu and without her knowledge or consent, was anaesthetised and sterilised. Many others were sterilised after a caesarean (Boesten, 2007).

By 1998, 8.0% of the Peruvian population was illiterate. The regions with the highest proportions of illiteracy were areas with elevated concentration of Indigenous and rural populations, places where forced sterilisations were also prevalent (Mantilla, 2001). The vast majority of women were not only illiterate but also had limited Spanish language skills, dealing with Spanish speaking healthcare practitioners who implemented policies through Spanish, a language they did not understand. A common form of coercion and manipulation was an allowance for clothing and food to women and their families following their agreement to be sterilised. Given the conditions of poverty that the majority of these women and their families lived in, these ‘incentives’ played an important role in women's ‘decisions’:

[Healthcare practitioners] always look for the poorest women, especially those who don't understand Spanish […] they make them put their fingerprint on a sterilisation paper they don't understand because they can't read. If the women refuse, they threaten to cut off the food and milk programmes. (Testimony registered by Tamayo, 1999)

There are cases where healthcare practitioners falsified or hid information from female patients, for instance informing them that sterilisation was the only birth control method available (Ballón, 2014). There are also documented cases of intentional misinformation or verbal manipulation:

They [healthcare practitioners] told her don't worry, we can do it right now and tonight you will be back home cooking and your husband will never realise what happened. (Testimony of husband of a dead woman registered by Tamayo, 1999)

Other forms of intimidation were the threat of police intervention, the loss of health services, or deprivation of liberty. Maria Mamérita Mestanza Chávez, an Indigenous woman with seven children, was 33 years old when healthcare practitioners began visiting her home in 1996 to pressure her into receiving a tubal ligation. She was threatened that if she refused, she and her husband could be imprisoned. After receiving approximately ten visits, Mamérita Mestanza acquiesced in March 1998 without being informed of the risks of the procedure by the health officials. In April 1998, Mamérita Mestanza died from an aggravated infection due to an absence of postoperative medical care, despite requesting such attention on five occasions (CEJIL, n.d.). Mamérita Mestanza is an emblematic story of forced sterilisation in Peru, and to date, her case is the only one that has reached the Inter-American Commission on Human Rights.²

Publicly, Fujimori's health ministers rejected criticisms of the VSC programme as part of an ‘international conspiracy’ and local enemies who ‘do not care for poor people's health’. In a discourse at the United Nations, Fujimori ridiculed the organisations that had denounced forced sterilisations saying that these organisations were displeased because they did not receive budgetary support from the state (Mogollón, 2003). Many Peruvian and international institutions echoed Fujimori's discourses as their own. This time is marked by the Fujimori regime's total alienation from many institutions, ranging from the media to the judicial system and Congress. Any opposition to a Fujimori policy was associated with ‘antinationalism’, intentions of ‘political instability’, and even ‘terrorism’ (Lerner, 2009). However, feminist groups, journalists, NGOs, and other human rights movements amplified women's contested voices and linked the fight for democracy with the respect for human rights.

Despite the symbolic and structural inequalities that poor and Indigenous women experienced in Peru, they were not passive actors but rather they denounced and demanded justice in different forms and forums. However, only extreme cases were heard. Political violence by the guerrilla group Sendero Luminoso and the repressive response by the state put Indigenous people in the centre of a deadly war (Bassel, 2020; TRC, 2003).³ As Segato (2013) argues, patriarchal societies produce gender ideologies and institutionalised practices of complicit relations among men and hegemonic institutions that legitimise complex forms of violence against women. In this context of political violence and private and public patriarchies, the notion of informed consent or the respect of women's wishes was a luxury reserved only for middle class, well-educated, urban, white people. On the other hand, the Fujimori government orchestrated a very effective state of constant threat of terrorism and economic crisis that produced a culture of silence and forged an implicit pact between mainstream Peruvian society and the Fujimori regime. Fujimori was succeeded by Alejandro Toledo in 2001, a democratic regime that condemned forced sterilisations, but was responsible for other forms of reproductive rights violations.⁴

Toledo's democratic regime: the ‘Freedom’ of neoliberal conservativism

Alejandro Toledo led the democratic mobilisations that ended the Fujimori dictatorial regime and was elected in 2001 with the promise for democracy, social justice and symbolic vindication for Indigenous populations.

Despite being a democratic regime, powerful members of the Toledo administration who denounced the Fujimori sterilisation campaign were strongly linked to the most conservative groups in the Catholic Church. These anti-choice Peruvian politicians aligned with members of the U.S.A. Bush administration ‘abstinence only’ approach and sought to limit support to family planning by implicating the United Nations Population Fund (UNFPA) as ‘directly responsible’ for forced sterilisations in Peru (Chávez & Coe, 2007). The U.S. conservative Population Research Institute argued that ‘UNFPA brought not only special financing but also demographic goals, for the specific aim of reducing the Peruvian population’ (PRI, 2000). Influential members of the Bush administration compared ‘forced abortion’ and ‘forced sterilisation’ in China and Peru and used these arguments to cut all funding to UNFPA that were contrary to their conservative agenda.

The Toledo regime used the findings of forced sterilisation during the previous administration as a tactic to diminish women's family planning options. They refocused attention on vaccination and ‘important’ diseases and limited men's and women's access to ‘modern’ contraceptive methods such as IUD and the morning-after pill, alleging that these methods were ‘abortionist’. Toledo's administration also instituted the ‘National Day of the Unborn Child’, challenging reproductive rights and skewing family planning towards an anti-choice agenda (Rousseau, 2007). Many decades of historic achievements by the women's movement were dismantled under the narrative of defending ‘women's freedom’ (Sims, 1998). In this context of a health and illness hierarchy, sexual and reproductive health were relegated to ‘superficial’ concerns.

Metaphors and discourses about reproduction are in constant creation and transformation in the Peruvian context. In some cases, these social meanings changed and incorporated other discourses that seemed to be ‘progressive’. As Fujimori presented record statistics on sterilisation as a ‘success’, the Toledo government presented the increased number of ‘natural’ methods of contraception used as a measure of success of its family planning campaign. An official statement from the Toledo regime showed this triumphalist discourse in the Peruvian Official Journal:

The number of people who used natural methods such as rhythm, billing and maternal nursing increased from 73,447 women in 2000–82,839 in 2001 and 102,908 women in 2003. (El Peruano, 2003)

Another powerful discourse presented by members of the Toledo regime was the protection and defence of women's rights. From this perspective, women are dependent subjects who needed to be ‘protected’, resulting in the disempowerment of women because they are not ‘full’ adults and citizens, and others (i.e. the state, the Catholic Church or simply a man) have the responsibility and the obligation to protect them. This discourse of the victimisation and protection of women is simultaneously strong and subtle and is deeply rooted in gender-unequal societies such as Peru.

The following sections analyse discourses produced by healthcare practitioners and the Catholic Church on sterilisation and reproductive rights. Most data come from the Fujimori and Toledo regimes, but there are also some additional, more recent, documents produced by these two sources.

Healthcare practitioners: patriarchy and hegemonic professions

The role of medical doctors, nurses and medical technicians in forced sterilisations varied according to their hierarchical position, job stability and moral values (Boesten, 2007; Molina, 2017). Some practitioners, mainly medical doctors, enjoyed job stability and were exempt from the government's pressure to fulfil quotas, while others with precarious contracts feared losing their jobs if they didn't reach the stipulated quotas. Miller (2019) recounts the story of a medical doctor who received complaints from colleagues who were forced to perform 250 sterilisations in four days:

There was a lot of fear among doctors because these were orders from the state […] you knew it was wrong, you knew it increased the risk, but you did it, because if not, you could be dismissed … it was really like a sterilisation factory. (Male doctor interviewed by Miller, 2019)

While the Peruvian public health system was associated with marginal populations, extensive research shows how historically healthcare practitioners distanced themselves from low income, rural Indigenous people in Peru (Anderson, 2001; Ballón, 2014; CLADEM, 1998; Yon, 2000). A common narrative is to refer to Indigenous men and women as gente del campo (rural people) which creates a sociocultural distance between urban medical professionals and their patients. Symbolic and structural inequalities in Peru produce socio-cultural clashes between urban and rural areas, between white, mestizos and Indigenous populations and between men and women. Several scholars have shown that indigenous women have positive attitudes towards family planning and ‘modern’ contraception methods, but distrust health practitioners due to their discriminatory practices (Anderson, 2001; Yon, 2000). Many healthcare professionals, whether white or mestizo, have participated according to their ‘discriminatory scripts’ of disrespect for Indigenous women's subjectivities and rights (Apaza et al., 2018; Reyes, 2000). In many cases, healthcare practitioners publicly humiliated these women for their ‘irresponsibility’, for having ‘too many’ children, or for not agreeing voluntarily to sterilisation (Villegas, 2009; Yon, 2000). As Boesten (2007) argues, an environment of humiliation and disrespect for their patients was evident. Molina (2017) states that many medical doctors felt they were ‘fulfilling a work duty’, ‘a good job’ helping disadvantaged men and women with large numbers of children:

We never forced anyone, nor did we ever think we were doing something bad, because family planning is necessary, isn't it? Because with so many children these families cannot survive, parents cannot provide education or food. (Female medical doctor interviewed by Molina, 2017)

Another narrative presented among healthcare practitioners is the common assumption that gender inequality and private patriarchy are more prevalent among Indigenous and poor people. Indigenous men are ‘machistas’ and Indigenous women were too ‘ignorant’ or ‘naïve’ to understand how to use contraceptives, which justifies healthcare practitioners taking decisions concerning these men and women's lives (Boesten, 2007; Gianella, 2014; Molina, 2017). Many of these practitioners mentioned that sterilisation without consent was a necessary strategy due to the context of poverty and gender oppression in which poor Indigenous women live:

I think [sterilisation] was a good thing, because in these areas they have too many children, six, seven, eight … and many times women don't want to take care of themselves [use contraception] because of fear of their husbands … the machismo continues, you know. (Female nurse interviewed by Molina, 2017)

This hegemonic approach to limit the reproduction of marginalised populations echoed the ‘common sense’ that many Peruvians from urban areas shared about their rural compatriots. The comment below was taken from a Peruvian newspaper after media coverage of the claims for reparations by sterilisation survivors and human rights activists in 2011. The testimony illustrates the interplay of gender ideologies and symbolic and structural inequalities:

In the highlands, mothers without resources, LITERALLY give away their children … because they cannot support their children. They have unplanned children and if you want to help them to plan their pregnancies, they will be mad at you … because for men, the more children they have the better men they are … What is the value of them having children like cuyes (guineapigs) to treat them badly, living in terrible conditions? Is that fair? Nooo. I don't support what Fujimori did, but we have to consider also the other side. Why they are bringing more children into this world? To have them suffer? to kill them with hanger? To exploit them working, begging in the combis (buses) selling candies? … They expose their children to danger and even rape. Is that fair? (Newspaper reader, Peru21, 9 June 2011)

More recently, as more cases and the tragic consequences on men's and women's lives are highlighted in the media, some healthcare practitioners have expressed remorse for the damage they have caused:

It was difficult for me being involved in convincing women, and even more [knowing] the consequences of these interventions … I feel bad … because I had to do it and this is something that … never goes away, it is a weight on my conscience. (Female nurse interviewed by Molina, 2017)

The Peruvian Medical Association recognised forced sterilisation as a violation of patients’ rights, but also stated that medical doctors were pressured and obliged by the state and they had to conduct these interventions without consent under the threat of job loss. As Gianella (2014) argues, this argument places medical doctors as victims of a structural system and excuses their personal and professional responsibilities.

The Catholic Church: mutilation, sin, and genocide

Members of the Catholic Church were one of the first voices to denounce sterilisations during the Fujimori regime, even before feminists and other activists (Lerner, 2009). However, Catholic leaders had a different agenda from the human rights organisations that also opposed forced sterilisations. They were (and continue to be) against the entire notion of a sexual and reproductive health policy. Catholic leaders warned their congregations that they would be committing a ‘grave sin’ if they chose ‘modern’ contraceptive methods. Sin, guilt, and shame were the main narratives that the Catholic Church used in order to discourage their ‘flocks’ from planning and limiting their reproduction.

The Peruvian Catholic Church integrated into its conservative discourse many progressive notions from human rights and public health frameworks in order to oppose family planning. In terms of human rights, the Catholic Church used the discourse of women's freedom to oppose the family planning campaign, ‘it violates our people's freedom’ was their coordinated response to the local and international media. Another common narrative was the defence of ‘women's rights to motherhood’ (Yon, 2000). This call for ‘freedom’ and ‘rights’ did not address the exercise of these women's human rights and their access to sexual and reproductive services. In relation to the use of public health narratives, religious leaders emphasised the ‘health risk’ of cancer and other diseases and even death that contraceptive methods were alleged to pose to women.

A strong metaphor used by Peruvian Catholic religious leaders to condemn sterilisation was ‘mutilation of the poor’. This narrative was echoed by the Catholic World News, a conservative international media organisation that stated that Peruvian authorities were ‘manipulating the poor by buying their consciences with material rewards and making them accept the risk of being mutilated for the rest of their lives’ (CWN, 2003). This discourse while apparently focused on the wellbeing of the female body, masked the ulterior motive which was concern about the interruption of conception.

The Catholic Church across the globe has historically opposed family-planning campaigns that promote methods that are not seen to be ‘natural’ and are considered contrary to moral values that defend the ‘sanctity of life’ (Natividad, 2019). Another metaphor used by Peruvian religious leaders to oppose VSC was genocide. They defended the notion that life begins at fertilisation and condemned sterilisation and vasectomy for the termination of potential births. From this perspective, sterilisation as abortion is considered a ‘sin’ and ‘sinners’ were called ‘murderers’ who are not subjects of rights.

The Catholic Church's opposition to condom use, despite clear evidence of its efficacy in combatting the transmission of HIV/AIDS, and to women's access to ‘modern’ contraceptive methods is also a reproductive rights abuse that needs to be addressed in the discussion of reproductive justice. Additionally, as described in relation to other countries in the region where abortion is also illegal, only low income and marginalised women are penalised (Shepard, 2006). As Yamin (2003) states these anti-choice policies have direct consequences on maternal mortality and it should be conceptualised as an afront to human rights, gender equality and citizenship. International data show that voluntary and informed sterilisation is a widely used contraceptive method throughout the world (Dickens, 2011; Pillsbury, 1990). The voluntary access to definitive contraceptive methods, such as sterilisation and vasectomy is a reproductive right and only coercion, or involuntary participation constitutes an abuse or violation. The Catholic Church's narratives of sin, mutilation, murder and genocide associated with the interruption of conception leaves women at a crossroads between their religious values and their reproductive needs in terms of access to contraceptives.

Conclusion

There is sufficient data to confirm human rights violations of women's right to choose and the denial of the right to decide voluntarily and without coercion regarding their reproductive choices within the Fujimori's Family Planning Programme. Strong evidence is presented that illustrates the Fujimori administration's participation in sterilisations through established quotas, national goals, incentives and punishment for healthcare practitioners and for women and their families.

Fujimori mastered a ‘populist feminist’ rhetoric to advance the implementation of vasectomies and sterilisations in the context of popular support through a dictatorial apparatus of controlled institutions that persecuted any dissident voices. As Ewig (2012) argues, Fujimori's family planning programme is a case study of the instrumental use of women in which policy makers successfully used local and global feminist discourses to legitimise their neo-Malthusian agenda to equate population control with progress and modernisation. The programme echoed an extended patriarchal perception in Peruvian society that Indigenous and poor people (particularly women) are ignorant, naïve and irresponsible, hence women's bodies and their reproductive decisions should be controlled by their families, communities, institutions and society, who ultimately ‘know better’ what is good and bad for them.

Under Toledo's neoliberal conservative democratic regime, healthcare practitioners were discouraged from delivering modern contraceptives, which represented a second reproductive rights violation for low-income and Indigenous women (CRR, 2002). The Peruvian feminist movement saw themselves in the middle of a complex crossfire, between the opportunity to advance a long fought for reproductive policy under the umbrella of Fujimori's family planning programme (Escobar, 2013), and conservative politicians and religious leaders who tried to use forced sterilisations as a platform to advance their conservative agendas and oppose any progressive policy on sexual and reproductive health.

In terms of the role of healthcare practitioners, the historical legacy of state policies, particularly related to sexual and reproductive health, is based on the control of women's bodies and the dismissal of their needs and voices due to ideological and economic agendas (Jordan, 1997). The relationship between healthcare practitioners and service users is shaped by symbolic and structural inequalities that provides evidence of the precarious lives of the women sterilised and men who were coerced into having vasectomies. Many women who denounced the violation of their rights had to face the judgement, stigma and discrimination of their own families and communities. Police officers discouraged women from pursuing offenders and the judicial system also failed to prosecute the perpetrators. Despite this unfavourable environment, women's movements and human rights organisations have been tirelessly denouncing these abuses in national and international courts.

Sexual and reproductive rights are under constant attack by the Catholic Church, and most recently, by evangelical groups who are gaining an increasing presence in politics in Peru and the region. Con Mis Hijos No te Metas (Don't touch my children) is an ultra-conservative movement that seeks to dismantle sexual and reproductive rights and gender equality policies in the region under the discourse of protecting society from the ‘attack of gender ideology’. At the same time, sexual and reproductive justice movements are experiencing an unprecedented visibility as a result of reported cases of gender based violence throughout Latin America. Feminist movements such as Ni Una Menos (No Woman Less) or the Chilean protest song Un Violador en Tu Camino (A Rapist in Your Path) written by Lastesis and based on the work of feminist scholar Rita Segato, have articulated a regional demand to end sexual violence and patriarchy.

The dramatic increase in the number of vasectomies during the Fujimori family planning programme needs further research. The voices of poor Indigenous men from rural areas of Peru who were forced, manipulated and coerced to undergo vasectomies remain to be heard. The interplay between the reproductive justice framework and Critical Studies of Men and Masculinities (CSMM) should involve the participation of men in fighting against gender inequality.

This paper establishes a dialogue between precarity and reproductive justice to explain symbolic and structural inequalities in Peru. Disadvantaged women in Peru were denied appropriate access to quality health care, which directly limited their citizenship and reinforced the precarity of their lives. The framework of precarity explains how forced sterilisation was the result of symbolic and structural inequalities in the lives of marginalised women. Ballón (2014) argues that sterilisation resulted in many rural women becoming physically weaker and unable to work on the land forcing them to migrate to urban areas, which created geographical displacement and a loss of feminine capital and cultural identity. Symbolic and structural inequalities create a ‘selective empathy’ that masked the abuses and violations of these women's rights in public health services and in the domestic sphere.

The implementation of reproductive justice in a country such as Peru faces the challenges of a long history of authoritarian regimes, fragile institutionalisation, and weak separation between the state and organised religion. The intersectional approach of the reproductive justice framework shows that sexual and reproductive health policies need to be woman-centred and to consider the multiple systems of discrimination in which women live. As Ross (2017) argues, reproductive justice goes beyond fertility control to the promotion of wellbeing in conditions in which men and women can exercise their reproductive choices with dignity and real autonomy, while at the same time highlighting the role of health systems in enabling and vindicating the exercise of these rights.

Women's rights in Peru have been violated irrespective of the type of political regime. This paper argues that Fujimori's sterilisation campaign was not only a state policy, but part of a shared ‘common sense’ among policymakers, healthcare practitioners, the judicial system and the general population, regarding the need to sterilise low-income, Indigenous rural women whose ‘tradition’ of ‘large’ families was jeopardising economic progress. Peruvian society needs to transcend this hegemonic ‘common sense’ that reproduces and sustains symbolic and structural inequalities in the lives of poor Indigenous women and men. Forced sterilisation and the denial of access to sexual and reproductive health care and services were not isolated events associated with particular political regimes, but they constitute a continuity of the oppression of women in Peru – most particularly poor and marginalised women. This continuity constitutes a flagrant violation of these women's reproductive rights and illustrates the symbolic and structural precarity in their lives. These lives deserve not only justice and reparations, but also for their stories to be told, heard and to become part of the collective memory surrounding global reproductive justice.

Disclosure statement

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

Notes

1 La Madre is a non-governmental initiative that archives the collective memory of the women and men who were sterilised against their will during the Fujimori regime. Academics and activists who are part of this initiative collect information that supports those seeking justice and reparations for the victims. http://www.lamadre.pe

2 In 2003, an agreement was reached to settle Mamérita Mestanza's case through an ‘amicable settlement’ between the Peruvian state and the petitionary organisations. Despite this historic outcome, many of the commitments by the Peruvian state remain to be implemented, including its promise to further investigate and sanction the perpetrators and deliver justice and reparations to victims like Mamérita Mestanza (IACHR, 2002). The IACHR's full verdict in the case can be seen at www.cidh.oas.org/women/Peru.12191sp.htm.

3 Peruvian symbolic and structural inequalities have its extreme exemplification in the context of the internal armed conflict which occurred between 1980 and 2000, when according to The Truth and Reconciliation Commission, almost 70,000 Peruvians disappeared, and of the total victims reported, 79 percent were ethnic minorities who lived in rural areas (TRC, 2003). As a social impact, this report was a ‘surprise’ to the mainstream urban hegemonic society that didn't ‘notice’ this enormous number of disappeared human beings.

4 Fujimori orchestrated a fraudulent third re-election in 2000, but strong local movements denounced the corruption and he absconded to Japan. He subsequently returned to Peru, and in 2009 was sentenced to 25 years in prison for corruption and human rights violations. Fujimori's successor, Alejandro Toledo, is currently facing corruption charges in Peruvian and USA courts.