Atlas›Domain XVI · Historical, discredited & harmful›Guide 058
Guide XVI-058

Compulsory sterilisation and Buck v. Bell

1907United States
A 32 · L 52 · M 1620 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the historical record as courts, memorial institutions, government inquiries, UN agencies and major news report it: the US Supreme Court opinion in Buck v. Bell, 274 U.S. 200 (1927); the United States Holocaust Memorial Museum (USHMM) Holocaust Encyclopedia on Nazi forced sterilisation; German Bundestag papers; the California State Auditor (2014); the Standing Senate Committee on Human Rights of Canada; the 2014 UN interagency statement; and Reuters, NPR, CBC and US local news reports of compensation schemes. The guide covers the psychotherapist's own work with this history, not the practice.

Compulsory sterilisation was a state practice, not a therapy. Under eugenic laws in the first two thirds of the 20th century, governments in the United States, Canada, Germany, Sweden and elsewhere ordered or pressured people to be made permanently unable to have children because officials judged them hereditarily "unfit": people with psychiatric diagnoses, intellectual disabilities, epilepsy, deafness or blindness, alcohol problems, and people labelled "asocial" or criminal, with racial and ethnic minorities and poor women over-represented [source: USHMM, Forced sterilization; Encyclopedia Virginia; Reuters via Deseret News 1999; Senate of Canada]. In Buck v. Bell (1927) the US Supreme Court upheld Virginia's 1924 sterilisation statute; in July 1933 Nazi Germany enacted its Law for the Prevention of Offspring with Hereditary Diseases, under which an estimated 400,000 people were sterilised [source: Justia; USHMM]. UN agencies state that forced, coercive and otherwise involuntary sterilisation still occurs, affecting people with disabilities, people living with HIV, Indigenous peoples and ethnic minorities, and transgender and intersex people [source: WHO 2014 interagency statement].

The eugenic theory of change was that a population could be "improved" by preventing certain people from reproducing; the state, physicians and courts presented this as public health and as a saving of public money [source: Justia, the statute's stated grounds; USHMM, The Biological State]. The psychotherapist's theory of change is different: people harmed by this practice, and their descendants and communities, recover a sense of worth, agency and connection when the wrong is named as a state wrong, their grief and anger are witnessed, their trust in care is rebuilt through consent-based practice, and they are supported to seek truth, redress and remembrance on their own terms [synthesis, drawing on the Senate of Canada's call for a culturally appropriate, trauma-informed process and the UN statement's emphasis on autonomy and remedies].

2. Framework

Historical phases (outline, for orientation)

  • Early US laws (from 1907). About 8,515 Americans were sterilised under state laws between 1907 and 1927 [source: Encyclopedia Virginia]. Virginia passed its Eugenical Sterilization Act in March 1924 [source: Justia; Encyclopedia Virginia].
  • Buck v. Bell (1927). Argued 22 April and decided 2 May 1927; Justice Oliver Wendell Holmes Jr. wrote for the Court; Justice Pierce Butler dissented without opinion; the vote was 8 to 1 [source: Justia; Encyclopedia Virginia]. The Court held that the statute was within state power under the Fourteenth Amendment and that confining it to people in state institutions did not breach equal protection. Holmes wrote: "Three generations of imbeciles are enough" [source: Justia]. Historian Paul A. Lombardo found that the court-appointed defence in the case did little to contest it, and later historians found no evidence for the diagnosis on which the order rested [source: Encyclopedia Virginia, citing Lombardo 2008]. Nearly 28,000 Americans were sterilised in the decade after the ruling [source: Encyclopedia Virginia]. A national total of more than 60,000 across over thirty states is often cited [uncertain: not verified].
  • Canada. Alberta (1928) and British Columbia (1933) passed Sexual Sterilization Acts, in force until 1972 and 1973; over 3,000 people were sterilised under them, with Indigenous people over-represented in Alberta [source: Senate of Canada report].
  • Nazi Germany (1933–1945). The law of 14 July 1933 took effect on 1 January 1934 and named nine conditions assumed to be hereditary; doctors and health officials nominated people, and hereditary health courts (a judge and two physicians) decided, ruling for sterilisation in the vast majority of cases; police could compel attendance [source: USHMM; Stiftung Denkmal]. Physician Arthur Gütt and psychiatrist Ernst Rüdin helped write the law, and nearly all better-known geneticists, psychiatrists and anthropologists sat on these courts at some point [source: USHMM, The Biological State]. Estimates are about 400,000 (USHMM, Bundestag motion 2022) or more than 350,000 (Stiftung Denkmal 2009). Hundreds of people, mostly women, died as a result [source: USHMM]. Black, multiracial, Roma and Sinti people were also sterilised outside the law, and some men accused under Paragraph 175 were castrated (see the related guides on castration and hormone experiments on homosexual men under Nazism, and on Aktion T4) [source: USHMM].
  • Sweden. About 63,000 people were sterilised between 1935 and 1975; from 1941 the law required consent, but sterilisation was in practice a condition of release from prisons and institutions and of some benefits and child custody [source: Reuters via Deseret News 1999]. Other accounts date the laws 1934–1976 [uncertain: sources differ on dates].
  • Post-war continuation and repeal. Virginia sterilised about 8,300 people from 1927 to 1972 and repealed its law in 1974 [source: Encyclopedia Virginia]; North Carolina sterilised more than 7,000 people between 1929 and 1976 [source: NPR 2014]. At the Nuremberg trials several Nazi defendants cited the US ruling in their defence [source: Encyclopedia Virginia].
  • Recognition and redress. Sweden began compensation in 1999 [source: Reuters via Deseret News]; Virginia's governor apologised on 2 May 2002 and the state agreed compensation in 2015 [source: Encyclopedia Virginia; WTKR 2015]; North Carolina passed a compensation law in 2013 and paid the first claims in 2014 [source: NPR]; the Bundestag condemned the 1933 law in 2007 [source: Stiftung Denkmal; Bundestag Drucksache 20/2429].
  • Continuing coercion. The California State Auditor (2014) found consent failures in sterilisations of women in state prisons; Canadian Senate reports (2021, 2022) found that coerced sterilisation of Indigenous women continues; the 2014 UN interagency statement documents current cases in several countries [source: California State Auditor; Senate of Canada; CBC; WHO 2014].

Phases of the psychotherapist's work [synthesis]

Session number and length follow the client's needs and the setting; pace is set by the client [synthesis].

  1. Preparation and recognition. Goal: the clinician knows the history and can recognise its traces in a client's account, records or family story. Move on when the client has disclosed, or the clinician has heard an indicator and opened space for it.
  2. Safety, assessment and safeguarding. Goal: establish emotional and physical safety, assess impact (grief, trauma symptoms, depression, suicide risk, health-care avoidance), and check for any current coercion of the client or someone in their care. Move on when risk is managed and any current safeguarding issue has been referred.
  3. Processing and repair. Goal: grief, shame and anger are worked through; the client's account is witnessed; trust in consent-based care is rebuilt. Move on when the client can hold the history without being overwhelmed and wants to act or rest.
  4. Truth, redress and remembrance. Goal: if the client chooses, support access to records, compensation or legal routes, testimony, and commemoration. Move on when the client's own goals for this are met or set aside.
  5. Follow-up and ending. Goal: consolidate, plan for anniversaries, medical encounters and news triggers, and leave a route back.

3. Guiding principles

  • It was a state wrong, not a treatment. Practical meaning: never describe sterilisation laws as "care of their time"; name them as the courts, inquiries and UN agencies now do [source: WHO 2014; Bundestag 2007 condemnation via Stiftung Denkmal].
  • Full, free and informed consent is the yardstick. Practical meaning: assess past and present reproductive care against this standard, which UN agencies say no spouse, parent, guardian, provider or official can give on someone's behalf [source: WHO 2014 interagency statement].
  • Trauma-informed and culturally appropriate. Practical meaning: let the client choose how much to tell and when; retelling can retraumatise [source: Senate of Canada report].
  • Shame belongs elsewhere. Practical meaning: expect self-blame; the Senate committee heard that many Indigenous survivors feel shame and blame themselves [source: Senate of Canada report].
  • Mistrust is earned, not pathological. Practical meaning: treat mistrust of hospitals, courts and helpers as a reasonable response to systems that failed people, and earn trust through transparency [source: Senate of Canada report; synthesis].
  • Disability is not a reason to remove reproductive choice. Practical meaning: use supported, not substituted, decision-making with disabled clients [source: WHO 2014 interagency statement].
  • Survivor-led redress. Practical meaning: the client decides whether to seek records, compensation or publicity; the Senate committee called for survivor-led compensation and anonymity options [source: CBC 2022 on the Senate report; Senate of Canada report].
  • Never name or expose. Practical meaning: protect survivors' and families' anonymity in notes, teaching and advocacy; use role descriptions [synthesis].
  • The profession's own history is part of the work. Practical meaning: know that psychiatrists, physicians and geneticists drafted and administered these laws, and bring that awareness to supervision [source: USHMM, The Biological State; Encyclopedia Virginia].
  • Medical questions go to medical professionals. Practical meaning: questions about fertility, reversal or assisted reproduction are referred to a physician; the clinician never advises on medicines or procedures [synthesis; the UN statement lists reversal or assisted reproduction among remedies where possible].
  • No side-taking beyond the evidence. Practical meaning: support a client's choices about advocacy without imposing the clinician's politics [synthesis].
  • Safety first, including suicide risk. Practical meaning: screen for suicide risk when grief, shame or retraumatisation are high; follow safe-messaging principles [synthesis].

4. Intervention inventory

The interventions below are the psychotherapist's own work; steps not drawn from a cited source are marked [synthesis]. Nothing here describes how sterilisation was or is carried out.

4.1 Building historical literacy before the client arrives

  • Purpose / when: before working with disabled, Indigenous, Black, Roma, institutionalised or older clients, or anyone whose family passed through state institutions; so the clinician can recognise references without making the client teach them [synthesis].
  • Steps: (1) Learn the outline in section 2 and the jurisdictions relevant to your clients (for example Virginia and North Carolina in the US; Alberta and British Columbia in Canada; Germany; Sweden) [source: section 2 sources]. (2) Note the legal language clients may meet in records ("feebleminded", "hereditary", "eugenical") and that these were official categories, not valid diagnoses [source: Justia; USHMM]. (3) Learn current forms named by the UN agencies and the Senate of Canada: sterilisation as a condition of other care, pressure during labour or abortion requests, third-party consent, quota-driven programmes [source: WHO 2014; Senate of Canada]. (4) Keep a short local list of redress schemes, legal-aid routes and survivor organisations, checking each is current [synthesis].
  • Example language (illustrative): to a colleague: "Before we see this client, it may help to know that this province had a sterilisation law until the early 1970s."
  • Watch for: treating the history as only German or only past; the Senate committee found the practice is not confined to the past [source: CBC on the Senate report]. It is working when you can recognise an indicator without needing the client to explain it.

4.2 Recognising indicators in a client's account

  • Purpose / when: at intake or in history-taking, when a client mentions unexplained infertility after institutional care, surgery "they never explained", release from an institution, a prison stay, a birth in a federal or state hospital, or family stories of relatives who "couldn't have children" [synthesis, drawing on the Senate report's finding that sterilisation was often a condition of release, and on the California auditor's findings].
  • Steps: (1) Listen for the indicator without leading. (2) Ask an open question about what the client understood at the time. (3) Do not suggest a conclusion the client has not reached; offer to explore it. (4) Record the client's own words.
  • Example language (illustrative): "You said you were never told what the operation was for. Would you like to say more about that, or leave it for now?"
  • Watch for: suggestive questioning that plants a belief; overwhelming shame at the first mention. It is working when the client sets the pace and keeps talking.

4.3 Receiving a first disclosure

  • Purpose / when: when a client first tells you they were sterilised without consent, or under pressure, or that a relative was [synthesis].
  • Steps: (1) Thank them and believe them. (2) Name it plainly as a wrong done to them, not something they caused. (3) Ask what they want from telling you now. (4) Offer choice about detail; the Senate committee warned that retelling can retrigger trauma and suggested private, confidential settings [source: Senate of Canada report]. (5) Agree what will and will not be written in notes.
  • Example language (illustrative): "Thank you for telling me. What was done to you was wrong, and it was not your fault. You decide how much we talk about it, and when."
  • Watch for: dissociation, sudden silence, apologising for "making a fuss". It is working when the client looks steadier and chooses the next step.

4.4 Assessing impact

  • Purpose / when: after disclosure, to map the effects that matter to this client [synthesis].
  • Steps: (1) Ask about grief for children not born and family not formed. (2) Ask about intrusive memories, avoidance of hospitals or gynaecological care, sleep, mood and anger. (3) Ask about relationships, identity, sexuality and body image in the client's own terms, without asking for sexual detail. (4) Ask about trust in health and legal systems; the Senate committee heard that mistrust discourages reporting [source: Senate of Canada report]. (5) Use validated screening measures where licensed and appropriate, without reproducing their items [synthesis]. (6) Screen for suicide risk (4.5).
  • Example language (illustrative): "People who went through this describe many different effects: on grief, on trust, on how they feel in their bodies. Which of those, if any, fit for you?"
  • Watch for: assuming infertility grief is the only or main loss; some clients' main injury is the betrayal or the lie. It is working when the formulation is in the client's language.

4.5 Suicide-risk assessment and safety planning

  • Purpose / when: whenever shame, hopelessness, retraumatisation, isolation or news coverage raises distress [synthesis].
  • Steps: (1) Ask directly and calmly about suicidal thoughts. (2) Assess intent, plans, history and protective factors following your service's standard protocol. (3) Make a collaborative safety plan covering warning signs, coping steps, people to contact and how to make the environment safer (storage and removal, not method detail). (4) Give crisis resources: 988 Suicide and Crisis Lifeline (US); Samaritans 116 123 (UK and Ireland). (5) Arrange follow-up and medical routing where risk is high.
  • Example language (illustrative): "Sometimes when people talk about something this painful, thoughts of not wanting to be alive come up. Has that happened for you?"
  • Watch for: safe-messaging: no method details, no framing of suicide as a response to injustice. It is working when the client can name a plan for difficult moments.

4.6 Psychoeducation: placing responsibility where it belongs

  • Purpose / when: when the client blames themselves or believes the labels in their records [synthesis, responding to the self-blame the Senate committee heard].
  • Steps: (1) Ask what the client was told about why it happened. (2) With consent, share in plain terms what the courts, governments and historians now say: for example, that Virginia's governor apologised in 2002, that the Bundestag condemned the German law in 2007, that historians found no evidence for the diagnosis behind Buck v. Bell, and that UN agencies call such sterilisation a violation [source: Encyclopedia Virginia; Stiftung Denkmal; WHO 2014]. (3) Separate the person from the category written about them. (4) Check what the client makes of it.
  • Example language (illustrative): "The word in your file was an official label used to justify the law. Courts and governments have since said the law itself was wrong."
  • Watch for: lecturing; facts offered before the client is ready. It is working when the client's self-description softens.

4.7 Grief work for reproductive and family loss

  • Purpose / when: when grief for children, lineage or a hoped-for family is central [synthesis].
  • Steps: (1) Name the loss as real and as often unrecognised by others. (2) Invite the client to describe what was lost (hopes, roles, relationships). (3) Allow anger alongside sorrow. (4) Explore meaning and continuity the client already has or wants (other relationships, community, creative or cultural work), without suggesting these replace the loss. (5) Mark anniversaries and triggers such as pregnancy announcements.
  • Example language (illustrative): "This is a loss many people around you may never have seen. Here it can be spoken about."
  • Watch for: rushing to consolation; complicated grief that warrants specialist input. It is working when the client can speak of the loss with less collapse.

4.8 Trauma-focused processing, where indicated

  • Purpose / when: when the client has trauma symptoms tied to the events and wants to address them [synthesis].
  • Steps: (1) Stabilise first: grounding, routines, supports. (2) Agree goals and a right to stop at any point. (3) Use an evidence-supported trauma therapy in which you are trained, adapted to the client's culture and context. (4) Do not seek graphic detail of the procedure; the focus is on the client's experience and meanings. (5) Review progress together.
  • Example language (illustrative): "We can work on these memories at your pace. You can tell me to stop at any time, and I will."
  • Watch for: overwhelm, dissociation, re-enactment of powerlessness in the room. It is working when intrusive symptoms ease and the client feels more in control.

4.9 Rebuilding trust in health care and consent literacy

  • Purpose / when: when the client avoids medical or reproductive care, or fears being pressured again [synthesis, drawing on the UN statement's elements of informed consent].
  • Steps: (1) Explore what makes a medical encounter feel safe or unsafe. (2) Share, in plain terms, what the UN agencies say informed consent includes: accurate information on permanence, alternatives and risks; time to decide; freedom from pressure or incentives; the right to withdraw; and that sterilisation is never a condition for other care and is not to be sought during labour [source: WHO 2014 interagency statement]. (3) Help the client prepare questions and decide whether to bring a support person or advocate. (4) Refer medical questions (fertility, reversal, assisted reproduction) to a physician; never advise on medicines or procedures.
  • Example language (illustrative): "You have the right to ask what a procedure is for, to take time, and to say no. Would it help to write down your questions before the appointment?"
  • Watch for: the clinician acting as medical adviser. It is working when the client attends needed care with less dread.

4.10 Supporting access to records and testimony

  • Purpose / when: when a client or descendant wants to know what is in institutional, court or medical records, or wants to give an account to an inquiry. The UN agencies list access to medical records among the remedies states owe [source: WHO 2014 interagency statement].
  • Steps: (1) Clarify what the client hopes to find and what they fear finding. (2) Help them identify who holds records (hospital, state archive, court, prison health service) and whether an advocate or lawyer should request them. (3) Plan the reading of records: when, where, with whom, and a debrief afterwards. (4) If giving testimony, check confidentiality and anonymity options; the Senate committee recommended anonymity and de-identification for survivors [source: Senate of Canada report]. (5) Note that records may be missing; North Carolina claims were denied where no Eugenics Board record existed even when other documents showed the operation [source: NPR 2014].
  • Example language (illustrative): "Some of what is written may be hurtful or untrue. Shall we plan how you will read it and who will be with you?"
  • Watch for: the stigmatising language of old files re-wounding the client; absent records experienced as disbelief. It is working when the client feels the search is theirs.

4.11 Supporting engagement with redress and legal routes

  • Purpose / when: when the client is considering compensation, an apology process, a complaint or a legal claim [synthesis].
  • Steps: (1) Map the options in the client's jurisdiction, from official sources: for example, North Carolina's 2013 compensation law, administered by the state Industrial Commission and limited to operations under the state Eugenics Board [source: NPR 2014]; Virginia's 2015 compensation of $25,000 per surviving victim [source: WTKR 2015]; Sweden's 1999 scheme [source: Reuters via Deseret News]; German hardship payments, which the Bundestag motion of 2022 called "second-class" because victims were excluded from the 1956 Federal Compensation Law [source: Bundestag Drucksache 20/2429]; and in Canada, class actions and calls for a survivor-led compensation framework [source: Senate of Canada report; CBC]. Check current status, as schemes close or change [uncertain: may have changed]. (2) Refer to a lawyer or legal-aid service for advice; the clinician does not give legal advice. (3) Prepare the client for delays, eligibility limits and possible denial. (4) Offer to write a clinical letter only within your competence and with consent.
  • Example language (illustrative): "You do not have to apply for anything. If you want to, we can think about how to look after yourself through the process."
  • Watch for: the process re-enacting powerlessness; compensation framed as closing the matter. It is working when the client feels supported whatever the outcome.

4.12 Working with descendants and families

  • Purpose / when: when a client learns that a parent, grandparent or relative was sterilised, institutionalised or killed under the related Nazi programmes, or when family silence surrounds a relative [synthesis].
  • Steps: (1) Explore what the family knew, said and did not say. (2) Name intergenerational effects the client notices (silence, shame about disability, fear of institutions) without assuming them. (3) Help the client decide what, if anything, to share with relatives. (4) Support research into the relative's history if wanted, and the emotions that follow. (5) Offer family or group work where appropriate. The Bundestag motion of 2022 asked that relatives and descendants be involved in memorial work [source: Bundestag Drucksache 20/2429].
  • Example language (illustrative): "It sounds as though your grandmother's story was not spoken about. What has it been like to discover it?"
  • Watch for: the client feeling they must carry the family's grief alone; conflict between relatives about disclosure. It is working when the client can hold the story as part of their history without being defined by it.

4.13 Working with disabled clients: reproductive autonomy and supported decisions

  • Purpose / when: with disabled clients, especially those with intellectual or psychosocial disabilities, whose families or services may raise contraception, menstruation or sterilisation [source: WHO 2014 interagency statement].
  • Steps: (1) Ask the client directly what they want, in accessible language and formats. (2) Use supported decision-making: help them understand options and voice their own choice; the UN agencies say menstrual management cannot be a pretext for sterilisation and that no guardian or parent can consent on an adult's behalf [source: WHO 2014]. (3) Meet carers separately and together if the client agrees. (4) If you suspect pressure toward an irreversible decision without the person's own consent, follow 4.15.
  • Example language (illustrative): "This is your body and your choice. I can help you understand the options and say what you want."
  • Watch for: talking to carers over the client; your own assumptions about disability and parenting. It is working when the client's voice leads.

4.14 Culturally safe work with Indigenous, Black, Roma and other racialised clients

  • Purpose / when: with clients from communities that UN agencies and the Senate of Canada name as targeted [source: WHO 2014; Senate of Canada; CBC].
  • Steps: (1) Acknowledge the history at the level the client wants. (2) Ask about the client's own frameworks for healing and whether they want community, Elder or cultural supports involved. (3) Offer services in the client's language. (4) Know local Indigenous-led or community-led services and refer when the client wishes. (5) Reflect on your own position and the institution you represent.
  • Example language (illustrative): "Many people from your community have good reasons not to trust services like this one. What would help this feel safer for you?"
  • Watch for: tokenism; asking the client to educate you. It is working when the client brings their own meanings and supports into the work.

4.15 Safeguarding where coercion may be current

  • Purpose / when: when a client, or a person in their care, is being pressured toward sterilisation: as a condition of release, treatment, benefits or custody; during labour or an abortion request; through third-party consent; or in prison health care [source: WHO 2014; Senate of Canada; California State Auditor].
  • Steps: (1) Listen and record facts in the person's own words. (2) Make sure they know they may refuse, take time and seek independent advice [source: WHO 2014]. (3) For an adult at risk, follow your local adult-safeguarding procedure; for a child (including disabled and intersex children), follow mandatory reporting and child-protection routes; UN agencies say children with disabilities should not undergo non-therapeutic sterilisation [source: WHO 2014]. (4) Connect the person with an independent advocate or lawyer. (5) Consider a complaint to the hospital or licensing body; the California auditor recommended reporting the hospitals and physicians involved to the state's public health department and medical board [source: California State Auditor].
  • Example language (illustrative): "No one can make agreeing to this a condition of your release or your treatment. Would you like help to get independent advice before anything is decided?"
  • Watch for: urgency (a procedure scheduled soon); consent for minors and assent from the child. It is working when the person has time, information and an advocate.

4.16 When a colleague or institution is involved

  • Purpose / when: when you learn that a colleague, service or institution you work with pressures, recommends or facilitates sterilisation without full, free and informed consent [synthesis].
  • Steps: (1) Record what you know and how you know it. (2) Raise it through your organisation's clinical governance or safeguarding lead. (3) Report to the relevant regulator or licensing body using its published route. (4) Consult your professional ethics code, for example the APA Ethics Code, and an ethics adviser [synthesis]. (5) Never take part in, supervise or refer to such a procedure. (6) Support the affected person through 4.15.
  • Example language (illustrative): to a manager: "I have a concern about consent for a sterilisation in our service, and I need to raise it formally."
  • Watch for: pressure to stay silent; your own fear of reprisal. It is working when the concern is formally recorded and acted on.

4.17 Memory and commemoration work

  • Purpose / when: when a client wants to honour a relative or their own history, or is affected by an apology, anniversary or memorial [synthesis].
  • Steps: (1) Explore what remembrance would mean to them. (2) Share options: official memorials such as the memorial and information site for the Nazi "euthanasia" murders at the former T4 site in Berlin, opened in 2014, and the regional memorials [source: Bundestag Drucksache 20/2429; Stiftung Denkmal]; apology events; private rituals; writing or art. (3) Plan for the emotional effects of visiting or of public apologies. (4) Debrief afterwards.
  • Example language (illustrative): "Some people find it helps to mark what happened in some way. Is that something you would want, and what would feel right?"
  • Watch for: apologies experienced as hollow; anniversaries bringing up grief. It is working when remembrance feels chosen and meaningful.

4.18 Reflective practice on the profession's own history

  • Purpose / when: in supervision and training, so the clinician can work honestly with clients who know that physicians and psychiatrists drafted and administered these laws [source: USHMM, The Biological State; Encyclopedia Virginia].
  • Steps: (1) Learn the documented roles: for example, that psychiatrist Ernst Rüdin helped write the 1933 law and that psychiatrists and geneticists sat on hereditary health courts [source: USHMM]; that a state institution superintendent sought the Buck v. Bell test case [source: Encyclopedia Virginia]. (2) Reflect on how current practice can reproduce coercion (diagnostic labels, power over discharge). (3) Be ready to acknowledge this history if a client raises it, without defensiveness. (4) Bring your own reactions to supervision.
  • Example language (illustrative): "You are right that people in my profession took part in this. I want to make sure nothing like that pressure happens here."
  • Watch for: guilt that turns the session toward the clinician. It is working when the client experiences acknowledgement without having to look after you.

4.19 Working with a client drawn to eugenic ideas

  • Purpose / when: when a client voices views that some people should not have children because of disability, diagnosis or ancestry, or is pressuring a relative toward sterilisation [synthesis].
  • Steps: (1) Stay curious about where the views come from (fear, family experience, caregiving strain, online material). (2) Explore the client's underlying concerns. (3) Offer factual context where useful: these ideas underpinned laws now condemned by courts, governments and UN agencies [source: Encyclopedia Virginia; Stiftung Denkmal; WHO 2014]. (4) If a specific person is at risk of coercion, follow 4.15.
  • Example language (illustrative): "It sounds as though you are very worried about what would happen if your sister had a child. Can we talk about that worry?"
  • Watch for: colluding, or a shaming confrontation that ends engagement. It is working when the client separates their fear from a decision about someone else's body.

4.20 Advocacy and ending

  • Purpose / when: when the client wants to take part in advocacy, and at the end of therapy [synthesis].
  • Steps: (1) Support the client's own advocacy choices (testimony, survivor groups, education) without steering them. (2) Where you advocate as a professional, do so for the remedies official bodies have named: apology, compensation, data collection, complaint mechanisms, training of health workers [source: CBC on the Senate report; WHO 2014]. (3) At ending, review gains, plan for triggers (medical visits, news coverage, anniversaries) and leave a route back.
  • Example language (illustrative): "You have done a great deal of hard work here. If something brings this back up, you can come back."
  • Watch for: the client feeling they must become a spokesperson. It is working when the client's involvement is freely chosen.

5. Handling problems

The sources document survivors' self-blame, mistrust, fear of retraumatisation and the obstacles in redress processes [source: Senate of Canada report; NPR 2014]; the responses below are [synthesis] unless cited.

  • The client will not name it, or avoids the topic. Do not push. Say that the subject is welcome whenever they choose, and return to present concerns. Silence may protect against shame the Senate committee heard many survivors carry [source: Senate of Canada report].
  • Overwhelm or dissociation while talking about it. Stop the narrative, ground in the present, shorten the session's focus, and return to stabilisation (4.8). Check suicide risk (4.5); give 988 (US) or Samaritans 116 123 (UK and Ireland) if needed.
  • Mistrust of the therapist. Treat it as reasonable. Be transparent about notes, confidentiality limits and reporting duties, and offer control over pace. Do not interpret mistrust as resistance.
  • Anger at the profession or at you. Acknowledge the documented role of physicians and psychiatrists (4.18) without defensiveness; take your own reactions to supervision.
  • Rupture after a misstep (a stigmatising word, a leading question, an assumption about disability). Name it, apologise, ask what would repair it, and change course.
  • Redress denied or delayed. Validate the injury of denial, which in North Carolina followed from missing records and eligibility limits [source: NPR 2014]; help the client decide whether to appeal with legal help, and separate the official outcome from the truth of what happened.
  • Hollow apology or commemoration. Allow ambivalence; an apology can both matter and fall short. In Germany the 2007 condemnation did not recognise victims as persecutees of National Socialism, a gap victims' groups have pressed to close [source: Stiftung Denkmal; Bundestag Drucksache 20/2429] [uncertain: status may have changed since 2022].
  • Family conflict over disclosure. Support the client's choice; explore the costs of each option; consider family sessions only with everyone's consent.
  • A current-coercion disclosure mid-therapy. Switch to safeguarding (4.15) at once; therapy goals wait.
  • The client is drawn to eugenic thinking about a relative. Use 4.19; if a specific person is at risk, safeguarding takes priority.
  • Medical questions (fertility, reversal, effects of past surgery). Refer to a physician; do not advise on procedures or medicines.
  • Media or research requests. Help the client weigh anonymity, consent and possible exposure; never pass on identifying information.
  • Clinician burden. Hearing about state-sanctioned harm can be heavy; use supervision and peer support, and watch for over-identification or avoidance.

Harm account

What was actually done

  • United States. State laws, beginning from 1907, authorised the sterilisation of people judged hereditarily unfit; Virginia's 1924 Act let institution superintendents order it after a hearing for patients deemed to have hereditary forms of "insanity" or "imbecility" [source: Justia; Encyclopedia Virginia]. In Buck v. Bell (1927) the Supreme Court upheld the Act, 8 to 1; historians later found no evidence for the diagnosis on which the order in the case rested [source: Justia; Encyclopedia Virginia]. Virginia sterilised about 8,300 people between 1927 and 1972, and North Carolina more than 7,000 between 1929 and 1976 [source: Encyclopedia Virginia; NPR 2014]. Between 2005-06 and 2012-13, 144 women in California state prisons were sterilised; for 39 the State Auditor found consent-process failures, and it found approval failures to be systemic [source: California State Auditor 2014].
  • Canada. Alberta (1928–1972) and British Columbia (1933–1973) laws allowed sterilisation of people with intellectual disabilities without consent; over 3,000 people were sterilised, often as a condition of release from institutions. The Senate committee also heard of about 1,150 Indigenous women sterilised in federal "Indian hospitals" up to the early 1970s, and of Indigenous women coerced in Saskatchewan hospitals mostly between 2005 and 2010, with more coming forward from several provinces [source: Senate of Canada report]. A later Senate report found the practice continues and affects Black and racialised women, people with disabilities, intersex children and institutionalised people [source: CBC on the Senate report].
  • Nazi Germany. Under the 1933 law, hereditary health courts of a judge and two physicians ordered the sterilisation of an estimated 400,000 people with nine conditions assumed to be hereditary, and of people labelled "asocial"; police could compel attendance; hundreds, mostly women, died; Roma, Sinti, Black and multiracial Germans were also sterilised, some without any legal basis [source: USHMM]. The law preceded the "euthanasia" killings of about 300,000 people (see the Aktion T4 guide) [source: Stiftung Denkmal; Bundestag Drucksache 20/2429].
  • Sweden. About 63,000 people were sterilised between 1935 and 1975, many against their will, with sterilisation a condition of release from prisons and institutions, of some benefits and of child custody [source: Reuters via Deseret News 1999].
  • Elsewhere and now. UN agencies report sterilisation of Indigenous women in Peru to meet government quotas [uncertain: dates not verified], of Roma women in the Czech Republic and Slovakia without informed consent, of women living with HIV, and legal requirements of sterilisation for gender recognition of transgender people [source: WHO 2014 interagency statement].

What it looked like to the people sterilised. Under the Nazi law, men were usually sterilised by vasectomy and women by tubal ligation, after a hereditary health court of a judge and two physicians had ruled, most often in favour of sterilisation; some people were sterilised without knowing it, and police could compel those who refused to attend [source: USHMM, Forced sterilization]. The Senate of Canada committee heard that Indigenous women were asked to consent during labour or just after giving birth, in one account after an epidural; some were told they were obliged to sign, some were given an ultimatum of sterilisation or having their children taken into care, some were never shown a consent form, and women who said they did not want it were taken to surgery anyway [source: Senate of Canada report, pp. 16, 21-22]. Women giving birth far from home and family, and those facing language barriers or without interpreters, were most exposed, and many stayed silent for years out of shame, self-blame, distrust and fear of not being believed [source: Senate of Canada report, pp. 19-22]. Warning signs today: consent sought during labour, under medication, or as a condition of release, benefits or custody; consent forms that are not explained or interpreted; and a person who learns only afterwards that an operation left them unable to have children [synthesis, drawing on the Senate of Canada report and the 2014 UN interagency statement].

How it caused harm

  • Permanent loss of the ability to have children, imposed without full, free and informed consent, which UN agencies describe as a violation of human rights; under current international law forced sterilisation can be prosecuted as a war crime or crime against humanity [source: WHO 2014; USHMM].
  • Deaths: hundreds of people died from forced sterilisations in Germany [source: USHMM].
  • Shame and self-blame, mistrust of health systems, reluctance to report, and retraumatisation when retelling, as survivors told the Senate committee [source: Senate of Canada report].
  • Stigmatising labels written into court and institutional records, some based on false diagnoses [source: Encyclopedia Virginia].
  • Unequal redress: German victims were excluded from the 1956 compensation law and later offered hardship payments; in 2013 only 428 forcibly sterilised people received ongoing payments [source: Bundestag Drucksache 20/2429]; North Carolina's scheme excluded people sterilised outside the state board [source: NPR 2014].
  • Legal legitimation spread: several Nazi defendants at Nuremberg cited the US ruling in their defence [source: Encyclopedia Virginia].
  • Effects on families and descendants (silenced histories, intergenerational grief) are widely described by clinicians but were not quantified [uncertain: not verified].

Recognising it today

  • A client's or relative's history of unexplained sterilisation after institutional care, imprisonment, a disability label or a birth in hospital [synthesis from the sources above].
  • Records using categories such as "feebleminded", "hereditary" or "eugenical" [source: Justia; Encyclopedia Virginia].
  • Current red flags named by the UN agencies: sterilisation made a condition of treatment, release, benefits or custody; consent sought during labour, right after delivery or with an abortion request; consent given by a spouse, parent, guardian or official; targets, quotas or incentives; sterilisation of disabled children without therapeutic need; sterilisation required for legal gender recognition [source: WHO 2014].
  • Consent paperwork missing, signed by the wrong person, or without the required waiting period, as in the California prisons [source: California State Auditor].

What to do instead and how to help those harmed

  • Supported alternative: UN agencies say sterilisation should be available only with full, free and informed consent, with non-directive counselling, accessible information, time to decide, supported (not substituted) decision-making for disabled people, and no conditions, targets or incentives [source: WHO 2014].
  • Survivors' support: trauma-informed, culturally appropriate care at the survivor's pace, with anonymity options [source: Senate of Canada report]; see 4.3 to 4.9.
  • Family support: work with descendants and relatives (4.12) and commemoration (4.17).
  • Reporting duties and legal routes: adult safeguarding and child-protection procedures for current coercion; complaints to hospitals and to medical licensing bodies, as the California auditor recommended; referral to lawyers or legal aid for compensation schemes and claims [source: California State Auditor; NPR 2014; synthesis].
  • Remedies states owe: UN agencies list prevention, prosecution, apology, compensation, legal aid, access to medical records, and reversal or assisted reproduction where possible [source: WHO 2014]; the Senate committee recommended a federal apology, survivor-led compensation, data collection, complaint mechanisms and criminalisation of the practice (Bill S-250) [source: CBC on the Senate report].
  • Survivor and victims' organisations: in Germany, the Bund der »Euthanasie«-Geschädigten und Zwangssterilisierten (BEZ), with Gegen Vergessen – Für Demokratie e.V., has campaigned for victims' recognition [source: Stiftung Denkmal] [uncertain: current activity not verified]. Check local survivor-led groups as they describe themselves.
  • Crisis resources: 988 Suicide and Crisis Lifeline (US); Samaritans 116 123 (UK and Ireland).

Sources

← Previous · XVI-057Castration and testosterone implants of homosexual men under NazismNext · XVI-059 →Kellogg's Race Betterment Foundation