Eugenics in the United States – Wikipedia

Eugenics, the set of beliefs and practices which aims at improving the genetic quality of the human population,[2][3] played a significant role in the history and culture of the United States prior to its involvement in World War II.[4]

Eugenics was practiced in the United States many years before eugenics programs in Nazi Germany,[5] which were largely inspired by the previous American work.[6][7][8] Stefan Khl has documented the consensus between Nazi race policies and those of eugenicists in other countries, including the United States, and points out that eugenicists understood Nazi policies and measures as the realization of their goals and demands.[9]

During the Progressive Era of the late 19th and early 20th century, eugenics was considered a method of preserving and improving the dominant groups in the population; it is now generally associated with racist and nativist elements, as the movement was to some extent a reaction to a change in emigration from Europe, rather than scientific genetics.[10]

The American eugenics movement was rooted in the biological determinist ideas of Sir Francis Galton, which originated in the 1880s. Galton studied the upper classes of Britain, and arrived at the conclusion that their social positions were due to a superior genetic makeup.[11] Early proponents of eugenics believed that, through selective breeding, the human species should direct its own evolution. They tended to believe in the genetic superiority of Nordic, Germanic and Anglo-Saxon peoples; supported strict immigration and anti-miscegenation laws; and supported the forcible sterilization of the poor, disabled and “immoral”.[12] Eugenics was also supported by African Americans intellectuals such as W. E. B. Du Bois, Thomas Wyatt Turner, and many academics at Tuskegee University, Howard University, and Hampton University; however, they believed the best blacks were as good as the best whites and “The Talented Tenth” of all races should mix.[13] W. E. B. Du Bois believed “only fit blacks should procreate to eradicate the race’s heritage of moral iniquity.”[13][14]

The American eugenics movement received extensive funding from various corporate foundations including the Carnegie Institution, Rockefeller Foundation, and the Harriman railroad fortune.[7] In 1906 J.H. Kellogg provided funding to help found the Race Betterment Foundation in Battle Creek, Michigan.[11] The Eugenics Record Office (ERO) was founded in Cold Spring Harbor, New York in 1911 by the renowned biologist Charles B. Davenport, using money from both the Harriman railroad fortune and the Carnegie Institution. As late as the 1920s, the ERO was one of the leading organizations in the American eugenics movement.[11][15] In years to come, the ERO collected a mass of family pedigrees and concluded that those who were unfit came from economically and socially poor backgrounds. Eugenicists such as Davenport, the psychologist Henry H. Goddard, Harry H. Laughlin, and the conservationist Madison Grant (all well respected in their time) began to lobby for various solutions to the problem of the “unfit”. Davenport favored immigration restriction and sterilization as primary methods; Goddard favored segregation in his The Kallikak Family; Grant favored all of the above and more, even entertaining the idea of extermination.[16] The Eugenics Record Office later became the Cold Spring Harbor Laboratory.

Eugenics was widely accepted in the U.S. academic community.[7] By 1928, there were 376 separate university courses in some of the United States’ leading schools, enrolling more than 20,000 students, which included eugenics in the curriculum.[17] It did, however, have scientific detractors (notably, Thomas Hunt Morgan, one of the few Mendelians to explicitly criticize eugenics), though most of these focused more on what they considered the crude methodology of eugenicists, and the characterization of almost every human characteristic as being hereditary, rather than the idea of eugenics itself.[18]

By 1910, there was a large and dynamic network of scientists, reformers, and professionals engaged in national eugenics projects and actively promoting eugenic legislation. The American Breeder’s Association was the first eugenic body in the U.S., established in 1906 under the direction of biologist Charles B. Davenport. The ABA was formed specifically to “investigate and report on heredity in the human race, and emphasize the value of superior blood and the menace to society of inferior blood.” Membership included Alexander Graham Bell, Stanford president David Starr Jordan and Luther Burbank.[19][20] The American Association for the Study and Prevention of Infant Mortality was one of the first organizations to begin investigating infant mortality rates in terms of eugenics.[21] They promoted government intervention in attempts to promote the health of future citizens.[22][verification needed]

Several feminist reformers advocated an agenda of eugenic legal reform. The National Federation of Women’s Clubs, the Woman’s Christian Temperance Union, and the National League of Women Voters were among the variety of state and local feminist organization that at some point lobbied for eugenic reforms.[23]

One of the most prominent feminists to champion the eugenic agenda was Margaret Sanger, the leader of the American birth control movement. Margaret Sanger saw birth control as a means to prevent unwanted children from being born into a disadvantaged life, and incorporated the language of eugenics to advance the movement.[24][25] Sanger also sought to discourage the reproduction of persons who, it was believed, would pass on mental disease or serious physical defects. She advocated sterilization in cases where the subject was unable to use birth control.[24] She rejected euthanasia.[26] For Sanger, it was individual women and not the state who should determine whether or not to have a child.[27][28]

In the Deep South, women’s associations played an important role in rallying support for eugenic legal reform. Eugenicists recognized the political and social influence of southern clubwomen in their communities, and used them to help implement eugenics across the region.[29] Between 1915 and 1920, federated women’s clubs in every state of the Deep South had a critical role in establishing public eugenic institutions that were segregated by sex.[30] For example, the Legislative Committee of the Florida State Federation of Women’s Clubs successfully lobbied to institute a eugenic institution for the mentally retarded that was segregated by sex.[31] Their aim was to separate mentally retarded men and women to prevent them from breeding more “feebleminded” individuals.

Public acceptance in the U.S. was the reason eugenic legislation was passed. Almost 19 million people attended the PanamaPacific International Exposition in San Francisco, open for 10 months from 20 February to 4 December 1915.[32][33] The PPIE was a fair devoted to extolling the virtues of a rapidly progressing nation, featuring new developments in science, agriculture, manufacturing and technology. A subject that received a large amount of time and space was that of the developments concerning health and disease, particularly the areas of tropical medicine and race betterment (tropical medicine being the combined study of bacteriology, parasitology and entomology while racial betterment being the promotion of eugenic studies). Having these areas so closely intertwined, it seemed that they were both categorized in the main theme of the fair, the advancement of civilization. Thus in the public eye, the seemingly contradictory[clarification needed] areas of study were both represented under progressive banners of improvement and were made to seem like plausible courses of action to better American society.[34][verification needed]

Beginning with Connecticut in 1896, many states enacted marriage laws with eugenic criteria, prohibiting anyone who was “epileptic, imbecile or feeble-minded”[35] from marrying.[36]

The first state to introduce a compulsory sterilization bill was Michigan, in 1897 but the proposed law failed to garner enough votes by legislators to be adopted. Eight years later Pennsylvania’s state legislators passed a sterilization bill that was vetoed by the governor. Indiana became the first state to enact sterilization legislation in 1907,[37] followed closely by Washington and California in 1909. Sterilization rates across the country were relatively low (California being the sole exception) until the 1927 Supreme Court case Buck v. Bell which legitimized the forced sterilization of patients at a Virginia home for the mentally retarded. The number of sterilizations performed per year increased until another Supreme Court case, Skinner v. Oklahoma, 1942, complicated the legal situation by ruling against sterilization of criminals if the equal protection clause of the constitution was violated. That is, if sterilization was to be performed, then it could not exempt white-collar criminals.[38] The state of California was at the vanguard of the American eugenics movement, performing about 20,000 sterilizations or one third of the 60,000 nationwide from 1909 up until the 1960s.[39]

While California had the highest number of sterilizations, North Carolina’s eugenics program which operated from 1933 to 1977, was the most aggressive of the 32 states that had eugenics programs.[40] An IQ of 70 or lower meant sterilization was appropriate in North Carolina.[41] The North Carolina Eugenics Board almost always approved proposals brought before them by local welfare boards.[41] Of all states, only North Carolina gave social workers the power to designate people for sterilization.[40] “Here, at last, was a method of preventing unwanted pregnancies by an acceptable, practical, and inexpensive method,” wrote Wallace Kuralt in the March 1967 journal of the N.C. Board of Public Welfare. “The poor readily adopted the new techniques for birth control.”[41]

The Immigration Restriction League was the first American entity associated officially with eugenics. Founded in 1894 by three recent Harvard University graduates, the League sought to bar what it considered inferior races from entering America and diluting what it saw as the superior American racial stock (upper class Northerners of Anglo-Saxon heritage). They felt that social and sexual involvement with these less-evolved and less-civilized races would pose a biological threat to the American population. The League lobbied for a literacy test for immigrants, based on the belief that literacy rates were low among “inferior races”. Literacy test bills were vetoed by Presidents in 1897, 1913 and 1915; eventually, President Wilson’s second veto was overruled by Congress in 1917. Membership in the League included: A. Lawrence Lowell, president of Harvard, William DeWitt Hyde, president of Bowdoin College, James T. Young, director of Wharton School and David Starr Jordan, president of Stanford University.[42]

The League allied themselves with the American Breeder’s Association to gain influence and further its goals and in 1909 established a Committee on Eugenics chaired by David Starr Jordan with members Charles Davenport, Alexander Graham Bell, Vernon Kellogg, Luther Burbank, William Ernest Castle, Adolf Meyer, H. J. Webber and Friedrich Woods. The ABA’s immigration legislation committee, formed in 1911 and headed by League’s founder Prescott F. Hall, formalized the committee’s already strong relationship with the Immigration Restriction League. They also founded the Eugenics Record Office, which was headed by Harry H. Laughlin.[43] In their mission statement, they wrote:

Society must protect itself; as it claims the right to deprive the murderer of his life so it may also annihilate the hideous serpent of hopelessly vicious protoplasm. Here is where appropriate legislation will aid in eugenics and creating a healthier, saner society in the future.”[43]

Money from the Harriman railroad fortune was also given to local charities, in order to find immigrants from specific ethnic groups and deport, confine, or forcibly sterilize them.[7]

With the passage of the Immigration Act of 1924, eugenicists for the first time played an important role in the Congressional debate as expert advisers on the threat of “inferior stock” from eastern and southern Europe.[44][verification needed] The new act, inspired by the eugenic belief in the racial superiority of “old stock” white Americans as members of the “Nordic race” (a form of white supremacy), strengthened the position of existing laws prohibiting race-mixing.[45] Eugenic considerations also lay behind the adoption of incest laws in much of the U.S. and were used to justify many anti-miscegenation laws.[46]

Stephen Jay Gould asserted that restrictions on immigration passed in the United States during the 1920s (and overhauled in 1965 with the Immigration and Nationality Act) were motivated by the goals of eugenics. During the early 20th century, the United States and Canada began to receive far higher numbers of Southern and Eastern European immigrants. Influential eugenicists like Lothrop Stoddard and Harry Laughlin (who was appointed as an expert witness for the House Committee on Immigration and Naturalization in 1920) presented arguments they would pollute the national gene pool if their numbers went unrestricted.[47][48] It has been argued that this stirred both Canada and the United States into passing laws creating a hierarchy of nationalities, rating them from the most desirable Anglo-Saxon and Nordic peoples to the Chinese and Japanese immigrants, who were almost completely banned from entering the country.[45][49]

Both class and race factored into eugenic definitions of “fit” and “unfit.” By using intelligence testing, American eugenicists asserted that social mobility was indicative of one’s genetic fitness.[50] This reaffirmed the existing class and racial hierarchies and explained why the upper-to-middle class was predominantly white. Middle-to-upper class status was a marker of “superior strains.”[31] In contrast, eugenicists believed poverty to be a characteristic of genetic inferiority, which meant that those deemed “unfit” were predominantly of the lower classes.[31]

Because class status designated some more fit than others, eugenicists treated upper and lower class women differently. Positive eugenicists, who promoted procreation among the fittest in society, encouraged middle class women to bear more children. Between 1900 and 1960, Eugenicists appealed to middle class white women to become more “family minded,” and to help better the race.[51] To this end, eugenicists often denied middle and upper class women sterilization and birth control.[52]

Since poverty was associated with prostitution and “mental idiocy,” women of the lower classes were the first to be deemed “unfit” and “promiscuous.”[31]

In 1907, Indiana passed the first eugenics-based compulsory sterilization law in the world. Thirty U.S. states would soon follow their lead.[53][54] Although the law was overturned by the Indiana Supreme Court in 1921,[55] the U.S. Supreme Court, in Buck v. Bell, upheld the constitutionality of the Virginia Sterilization Act of 1924, allowing for the compulsory sterilization of patients of state mental institutions in 1927.[56]

Some states sterilized “imbeciles” for much of the 20th century. Although compulsory sterilization is now considered an abuse of human rights, Buck v. Bell was never overturned, and Virginia did not repeal its sterilization law until 1974.[57] The most significant era of eugenic sterilization was between 1907 and 1963, when over 64,000 individuals were forcibly sterilized under eugenic legislation in the United States.[58] Beginning around 1930, there was a steady increase in the percentage of women sterilized, and in a few states only young women were sterilized. From 1930 to the 1960s, sterilizations were performed on many more institutionalized women than men.[31] By 1961, 61 percent of the 62,162 total eugenic sterilizations in the United States were performed on women.[31] A favorable report on the results of sterilization in California, the state with the most sterilizations by far, was published in book form by the biologist Paul Popenoe and was widely cited by the Nazi government as evidence that wide-reaching sterilization programs were feasible and humane.[59][60]

Men and women were compulsorily sterilized for different reasons. Men were sterilized to treat their aggression and to eliminate their criminal behavior, while women were sterilized to control the results of their sexuality.[31] Since women bore children, eugenicists held women more accountable than men for the reproduction of the less “desirable” members of society.[31] Eugenicists therefore predominantly targeted women in their efforts to regulate the birth rate, to “protect” white racial health, and weed out the “defectives” of society.[31]

A 1937 Fortune magazine poll found that 2/3 of respondents supported eugenic sterilization of “mental defectives”, 63% supported sterilization of criminals, and only 15% opposed both.[61][62]

In the 1970s, several activists and women’s rights groups discovered several physicians to be performing coerced sterilizations of specific ethnic groups of society. All were abuses of poor, nonwhite, or mentally retarded women, while no abuses against white or middle-class women were recorded.[63] Several court cases such as Madrigal v. Quilligan, a class action suit regarding forced or coerced postpartum sterilization of Latina women following cesarean sections, and Relf v. Weinberger,[64] the sterilization of two young black girls by tricking their illiterate mother into signing a waiver, helped bring to light some of the widespread abuses of sterilization supported by federal funds.[65][66]

In 1972, United States Senate committee testimony brought to light that at least 2,000 involuntary sterilizations had been performed on poor black women without their consent or knowledge.[67] An investigation revealed that the surgeries were all performed in the South, and were all performed on black welfare mothers with multiple children.[67] Testimony revealed that many of these women were threatened with an end to their welfare benefits until they consented to sterilization.[67] These surgeries were instances of sterilization abuse, a term applied to any sterilization performed without the consent or knowledge of the recipient, or in which the recipient is pressured into accepting the surgery. Because the funds used to carry out the surgeries came from the U.S. Office of Economic Opportunity, the sterilization abuse raised older suspicions, especially amongst the black community, that “federal programs were underwriting eugenicists who wanted to impose their views about population quality on minorities and poor women.”[31]

Native American women were also victims of sterilization abuse up into the 1970s.[68] The organization WARN (Women of All Red Nations) publicized that Native American women were threatened that, if they had more children, they would be denied welfare benefits. The Indian Health Service also repeatedly refused to deliver Native American babies until their mothers, in labor, consented to sterilization. Many Native American women unknowingly gave consent, since directions were not given in their native language. According to the General Accounting Office, an estimate of 3,406 Indian women were sterilized.[68] The General Accounting Office stated that the Indian Health Service had not followed the necessary regulations, and that the “informed consent forms did not adhere to the standards set by the United States Department of Health, Education, and Welfare (HEW).”[69]

In 2013, it was reported that 148 female prisoners in two California prisons were sterilized between 2006 and 2010 in a supposedly voluntary program, but it was determined that the prisoners did not give consent to the procedures.[70] In September 2014, California enacted Bill SB1135 that bans sterilization in correctional facilities, unless the procedure is required to save an inmate’s life.[71]

Edwin Black wrote that one of the methods that was suggested to get rid of “defective germ-plasm in the human population” was euthanasia.[7] A 1911 Carnegie Institute report explored eighteen methods for removing defective genetic attributes, and method number eight was euthanasia.[7] The most commonly suggested method of euthanasia was to set up local gas chambers.[7] However, many in the eugenics movement did not believe that Americans were ready to implement a large-scale euthanasia program, so many doctors had to find clever ways of subtly implementing eugenic euthanasia in various medical institutions.[7] For example, a mental institution in Lincoln, Illinois fed its incoming patients milk infected with tuberculosis (reasoning that genetically fit individuals would be resistant), resulting in 3040% annual death rates.[7] Other doctors practiced euthanasia through various forms of lethal neglect.[7]

In the 1930s, there was a wave of portrayals of eugenic “mercy killings” in American film, newspapers, and magazines. In 1931, the Illinois Homeopathic Medicine Association began lobbying for the right to euthanize “imbeciles” and other defectives.[72] The Euthanasia Society of America was founded in 1938.[73]

Overall, however, euthanasia was marginalized in the U.S., motivating people to turn to forced segregation and sterilization programs as a means for keeping the “unfit” from reproducing.[7]

Mary deGormo, a former classroom teacher was the first person to combine ideas about health and intelligence standards with competitions at state fairs, in the form of “better baby” contests. She developed the first such contest, the “Scientific Baby Contest” for the Louisiana State Fair in Shreveport, in 1908. She saw these contests as a contribution to the “social efficiency” movement, which was advocating for the standardization of all aspects of American life as a means of increasing efficiency.[21] deGarmo was assisted by the pediatrician Dr. Jacob Bodenheimer, who helped her develop grading sheets for contestants, which combined physical measurements with standardized measurements of intelligence.[74] Scoring was based on a deduction system, in that every child started at 1000 points and then was docked points for having measurements that were below a designated average. The child with the most points (and the least defections) was ideal.[75][verification needed]

The topic of standardization through scientific judgment was a topic that was very serious in the eyes of the scientific community, but has often been downplayed as just a popular fad or trend. Nevertheless, a lot of time, effort, and money was put into these contests and their scientific backing, which would influence cultural ideas as well as local and state government practices.[76][verification needed]

The National Association for the Advancement of Colored People promoted eugenics by hosting “Better Baby” contests and the proceeds would go to its anti-lynching campaign.[13]

First appearing in 1920 at the Kansas Free Fair, Fitter Family competitions, continued all the way up to World War II. Mary T. Watts and Dr. Florence Brown Sherbon,[77][78] both initiators of the Better Baby Contests in Iowa, took the idea of positive eugenics for babies and combined it with a determinist concept of biology to come up with fitter family competitions.[79]

There were several different categories that families were judged in: Size of the family, overall attractiveness, and health of the family, all of which helped to determine the likelihood of having healthy children. These competitions were simply a continuation of the Better Baby contests that promoted certain physical and mental qualities.[80] At the time, it was believed that certain behavioral qualities were inherited from your parents. This led to the addition of several judging categories including: generosity, self-sacrificing, and quality of familial bonds. Additionally, there were negative features that were judged: selfishness, jealousy, suspiciousness, high temperedness, and cruelty. Feeblemindedness, alcoholism, and paralysis were few among other traits that were included as physical traits to be judged when looking at family lineage.[81]

Doctors and specialists from the community would offer their time to judge these competitions, which were originally sponsored by the Red Cross.[81] The winners of these competitions were given a Bronze Medal as well as champion cups called “Capper Medals.” The cups were named after then Governor and Senator, Arthur Capper and he would present them to “Grade A individuals”.[82]

The perks of entering into the contests were that the competitions provided a way for families to get a free health check up by a doctor as well as some of the pride and prestige that came from winning the competitions.[81]

By 1925 the Eugenics Records Office was distributing standardized forms for judging eugenically fit families, which were used in contests in several U.S. states.[83]

Concerns about eugenics arose in the African American community after the implementation of the Negro Project of 1939, which was proposed by Margaret Sanger who was the founder of Planned Parenthood.[84] In this plan, Sanger offered birth control to Black families in the United States to give them the chance to have a better life than what the group had been experiencing in the United States.[85] She also noted that the project was proposed to empower women. The Project often sought after prominent African American leaders to spread knowledge regarding birth control and the perceived positive effects it would have on the African American community, such as poverty and the lack of education.[86] Because of this, Sanger believed that African American ministers in the South would be useful to gain the trust of people within disadvantaged, African American communities as the Church was a pillar within the community.[86] Also, political leaders such as W.E.B. Dubois were quoted in the Project proposal criticizing Black people in the United States for having many children and for being less intelligent than their white counterparts:

the mass of ignorant Negroes still breed carelessly and disastrously, so that the increase among Negroes, even more than the increase among Whites, is from that part of the population least intelligent and fit, and least able to rear their children properly. [85]

Even though The Negro Project received a lot of praise from white leaders and eugenicists of the time, it is important to note that Margaret Sanger wanted to clear concerns that this was not a project to terminate African Americans.[86] To add to the clarification, she received support from prominent African American leaders such as Mary McLeod Bethune and Adam Clayton Powell Jr.[85] These leaders and many more would later serve on the Negro National Advisory Council of Planned Parenthood Federation of America in 1942. Still, many modern activists criticize Margaret Sanger for practicing eugenics on the African American community. Angela Davis, a leader who is associated with the Black Panther Party, made claims of Margaret Sanger targeting the African American community to reduce the population:

Calling for the recruitment of Black ministers to lead local birth control committees, the Federations proposal suggested that Black people should be rendered as vulnerable as possible to their birth control propaganda.[87]

After the eugenics movement was well established in the United States, it spread to Germany. California eugenicists began producing literature promoting eugenics and sterilization and sending it overseas to German scientists and medical professionals.[7] By 1933, California had subjected more people to forceful sterilization than all other U.S. states combined. The forced sterilization program engineered by the Nazis was partly inspired by California’s.[8]

The Rockefeller Foundation helped develop and fund various German eugenics programs,[88] including the one that Josef Mengele worked in before he went to Auschwitz.[7]

Upon returning from Germany in 1934, where more than 5,000 people per month were being forcibly sterilized, the California eugenics leader C. M. Goethe bragged to a colleague:

You will be interested to know that your work has played a powerful part in shaping the opinions of the group of intellectuals who are behind Hitler in this epoch-making program. Everywhere I sensed that their opinions have been tremendously stimulated by American thought . . . I want you, my dear friend, to carry this thought with you for the rest of your life, that you have really jolted into action a great government of 60 million people.[7]

Eugenics researcher Harry H. Laughlin often bragged that his Model Eugenic Sterilization laws had been implemented in the 1935 Nuremberg racial hygiene laws.[89] In 1936, Laughlin was invited to an award ceremony at Heidelberg University in Germany (scheduled on the anniversary of Hitler’s 1934 purge of Jews from the Heidelberg faculty), to receive an honorary doctorate for his work on the “science of racial cleansing”. Due to financial limitations, Laughlin was unable to attend the ceremony and had to pick it up from the Rockefeller Institute. Afterwards, he proudly shared the award with his colleagues, remarking that he felt that it symbolized the “common understanding of German and American scientists of the nature of eugenics.”[90]

Henry Friedlander wrote that although the German and American eugenics movements were similar, the United States did not follow the same slippery slope as Nazi eugenics because American “federalism and political heterogeneity encouraged diversity even with a single movement.” In contrast, the German eugenics movement was more centralized and did not contain as many diverse ideas as the American movement.[91] Unlike the American movement, one publication and one society, the German Society for Racial Hygiene, represented all German eugenicists in the early 20th century.[91][92]

After 1945, however, historians began to attempt to portray the US eugenics movement as distinct and distant from Nazi eugenics.[93] Jon Entine wrote that eugenics simply means “good genes” and using it as synonym for genocide is an “all-too-common distortion of the social history of genetics policy in the United States.” According to Entine, eugenics developed out of the Progressive Era and not “Hitler’s twisted Final Solution.”[94]

The 1978 Federal Sterilization Regulations, created by the United States Department of Health, Education and Welfare or HEW, (now the United States Department of Health and Human Services) outline a variety of prohibited sterilization practices that were often used previously to coerce or force women into sterilization.[95] These were intended to prevent such eugenics and neo-eugenics as resulted in the involuntary sterilization of large groups of poor and minority women. Such practices include: not conveying to patients that sterilization is permanent and irreversible, in their own language (including the option to end the process or procedure at any time without conceding any future medical attention or federal benefits, the ability to ask any and all questions about the procedure and its ramifications, the requirement that the consent seeker describes the procedure fully including any and all possible discomforts and/or side-effects and any and all benefits of sterilization); failing to provide alternative information about methods of contraception, family planning, or pregnancy termination that are nonpermanent and/or irreversible (this includes abortion); conditioning receiving welfare and/or Medicaid benefits by the individual or his/her children on the individuals “consenting” to permanent sterilization; tying elected abortion to compulsory sterilization (cannot receive a sought out abortion without “consenting” to sterilization; using hysterectomy as sterilization; and subjecting minors and the mentally incompetent to sterilization.[95][65][96] The regulations also include an extension of the informed consent waiting period from 72 hours to 30 days (with a maximum of 180 days between informed consent and the sterilization procedure).[65][95][96]

However, several studies have indicated that the forms are often dense and complex and beyond the literacy aptitude of the average American, and those seeking publicly funded sterilization are more likely to possess below-average literacy skills.[97] High levels of misinformation concerning sterilization still exist among individuals who have already undergone sterilization procedures, with permanence being one of the most common gray factors.[97][98] Additionally, federal enforcement of the requirements of the 1978 Federal Sterilization Regulation is inconsistent and some of the prohibited abuses continue to be pervasive, particularly in underfunded hospitals and lower income patient hospitals and care centers.[65][96]

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