Friday June 16, 8:30 am session (breakout 4)
Joanne Woiak
“This Patient Asked for Sterilization”: Defining Disability, Consent, and Therapy in Washington
State Eugenics
DRAFT
On September 29, 1941, at the Northern State Hospital just outside Seattle, Washington,
a 31-year-old woman named Ruth was interviewed by the state’s Institutional Board of Health,
which was tasked with deciding if she qualified for sexual sterilization under state law. The
minutes of this Board meeting include what appears to be a transcript of Ruth’s hearing, and
there is also a one-page presentation summary describing her personal and medical history. Both
texts are preserved in the state archives in the hospital superintendent’s files. We know that Ruth
had been born in the Midwest, resided in Seattle, and was a married housewife with one child. In
March 1941, she was voluntarily admitted to Western State Hospital with behavior that her files
describe as “noisy, depressed, combative, negativistic.” In July, just a few weeks after a “rapid
recovery from [the] first attack,” she was again committed to a psychiatric ward, this time the
Northern State Hospital. She exhibited “emotional fluctuation—cried and laughed” and “made
contradictory statements.” She was diagnosed with dementia praecox (i.e. schizophrenia).
The purported transcript of Ruth’s sterilization hearing consists of just a single paragraph
of questions and answers, but it provides a far richer account of her life and interests than the
doctors’ clinical summary. She explains that the cause of her breakdown had likely been the
strain she felt over her mother’s recent illness and death. Asked if she might have any family
members with “mental trouble,” she answers no. But later in the interview, she wonders if indeed
she might risk passing on some “hereditary nervous tendencies,” and therefore she doesn’t “want
to take the chance” of another pregnancy. In response to the doctors’ query about her attitude
towards sterilization, Ruth states that both she and her husband are “in favor of it.” Why don’t
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they want to have any more children? Ordinary family planning considerations, she explains:
their daughter is already 12 years old and there would be too large a gap in ages if they had
another child. The members of the Board voted 4-1 in favor of sterilizing her. But the doctors’
opinions were mixed as to whether rendering her infertile was necessary for the eugenic good of
society, or for the therapeutic benefit of the patient herself. The transcript is prefaced by the
succinct comment: “This patient asked for sterilization.”
This patient asked for sterilization. What did this sentence mean to Ruth, her family, the
physicians at Northern State Hospital, and the superintendents on the Institutional Board of
Health? Why was this sentence included at all in the record of the Board’s business—why was it
deemed important to present this individual as a person with a disability who was a willing
participant in state-sanctioned eugenics? Should this document—and the process of the
hearing—be interpreted as merely the “illusion of consent,” or can we imagine that there was
some meaningful choice involved? Or both? This is the only document of its kind that I have
found so far in my archival research on the Washington state sterilization program. Its brief
narratives reveal clues about the lives of nine of the 685 documented victims of the compulsory
sterilization law. In this paper, I focus on excavating the possible meanings of this sentence, in
the light of other kinds of materials that I’ve found about Washington’s history of forced
sterilization, as well as scholarship based on sterilization records from other states.
The surviving records about the implementation of the Washington law are fragmentary.
It’s been a challenge to work with the state archivists to be able to locate and utilize materials
pertaining to patient medical histories from the 1930s and 40s, and I still need to do a lot more
digging. Nonetheless, I think it’s possible to begin using the available information not only to
construct an account of this neglected aspect of local history, but also to demonstrate the
contributions that a disability studies perspective can make to the historiography of eugenics.
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These records provide a window into interpreting the various and even conflicting meanings of
sterilization for the individuals involved—especially in terms of history from the patient’s
perspective. An analysis of individual cases is also important for informing wider questions
about the history and legacy of public policies and medical practices, and the ways that these
make meanings out of human differences.
This patient asked for sterilization. Read through the lens of mainstream understandings
of eugenics, the sentence makes little sense. As eugenics historian Molly Ladd-Taylor puts it, the
American history of compulsory sterilization is generally remembered and depicted as a “Nazilike scandal.” On this view, eugenics was mainly about antiquated biases against racial groups
deemed biologically inferior; about involuntary state-sponsored measures for preventing
procreation; and about sacrificing individual rights and well-being to the greater public good.
This fairly narrow interpretation of the eugenics movement has been revised by recent
historiography illustrating just how popular and heterogeneous the organized eugenics movement
actually was. Eugenics ideology and practices were flexible enough to advance a wide variety of
social interests. Eugenics was always more complicated and diversified than just the history of
sterilization laws, and as I hope to show here, compulsory sterilization itself was more complex
and ambiguous than what we know from the mainstream narratives.
This patient asked for sterilization. The statement implies that somehow eugenics could
have been perceived as bestowing some personal benefit on its victims, and that they were free to
make this reproductive choice. A number of historians have begun addressing the rhetoric of
therapeutic value and the appearance of patient agency in sterilization records in certain states
(North Carolina / Johanna Schoen, Oregon / Phil Ferguson, California / Alexandra Stern,
Minnesota / Molly Ladd-Taylor). They have shown that doctors sometimes argued that sexual
surgery would “cure” men of violent or deviant tendencies and “protect” women from the
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psychological perils of pregnancy, that families of people with intellectual disabilities might
have agreed to have the sterilization procedure done in order to secure their release from
institutions, and that in a few cases women may even have petitioned the authorities for their
own eugenic sterilization because they lacked any other reliable form of birth control. While
these scholars have vastly enriched our understandings of the methods and motives for deploying
sterilization legislation in specific locales, I contend that they have still not adequately addressed
one key question—who counted as a “patient”? Disability studies provides the critical tools
needed to fully explore this aspect of the sterilization movement. Talking explicitly about the
question “what was disability” raises new possibilities for understanding WHO was targeted for
institutionalization and sterilization, HOW sterilization decisions were made, and WHY sexual
surgery was recognized as an appropriate solution to social problems.
The state of Washington has always been on the “cutting edge” of advances in medical
interventions, biotechnologies, and laws that impact people with disabilities and other
marginalized groups. In 1909, we passed the second forced sterilization statute in the world. It
was a punitive measure directed at people labeled as habitual criminals or convicted of the
crimes or rape or child molestation. That law withstood a high court challenge and remains on
the books to this day, although evidently it has always been a dead letter. Washington was again
in the national forefront in 1921, when we ratified a second law that more broadly targeted
people with disabilities and included a formal appeals process, in response to the first wave of
constitutional challenges to forced sterilization. In the modern era, Washington continues to
operate several state institutions for people with mental disabilities, long after other states have
closed theirs, and our status as a medical and biotech center is seen as congruent with
controversial developments such as the Ashley X treatment and a physician assisted suicide law.
The history of eugenics and sterilization ought to be included in conversations about all of these
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disability rights and policy issues, yet little work has so far been done to uncover and interpret
our past and its legacies.
Under Washington’s 1921 sterilization statute, superintendents of the state hospitals and
custodial schools for individuals labeled with mental disabilities were directed to “report all
feebleminded, insane, epileptic, habitual criminals, moral degenerates and sexual perverts, who
are persons potential to producing offspring, who because of inheritance of inferior or anti-social
traits, would probably become a social menace or wards of the state.” The statute required that
patients or their guardians be informed of the sterilization order and that they had 15 days to
appeal. Also notable is that Washington’s 1921 law specified two legitimate purposes for
involuntarily sterilizing someone: eugenic and therapeutic. “For the betterment of the physical,
mental, neural, or psychic condition of the inmate, or to protect society from the menace of
procreation by said inmate.” The Institutional Board of Health was expected to meet 2 or 3 times
per year at each of the five state facilities, where as many as 50 inmates would be presented per
hearing. In the state archives, I have found documents from 12 of these meetings over a 6 year
span, as well as correspondence between superintendents and state officials regarding the
Board’s activities and legal duties.
According to the official tallies, a total of 403 “insane” people and 276 “mentally
deficient” people were legally sterilized, most between 1936 and 1942, when the state Supreme
Court overturned the law. 73% of the total number of victims were women, while a remarkable
88% of the so-called “feebleminded” cases were women. The files that I have located provide
limited information about 170 individuals at the mental hospitals and custodial schools who were
presented and either rejected for sterilization or whose fates were not recorded. The most
substantial and complete patient information comes from another 95 cases at Northern State
Hospital. All of the sterilization candidates are described as being of the “white race,” most as
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“Protestant,” and almost all as having an economic status of either “marginal” or “dependent.”
The youngest was a 15 year old woman, the oldest a 47 year old man. For each of those 95
patients, the Board generated 12 pages of standardized forms used to provide legal notification of
the order and to request that the patient and a family member indicate their consent for the
operation. 75% of the time the Board voted to approve sterilization and, according to handwritten notes at the top of 70 of those forms, the operation soon followed. In only a few cases
were the consent forms not signed, and sometimes those individuals were sterilized anyway.
Who qualified for sterilization? Most scholarship on eugenics in the US challenges the
eugenicists’ prejudiced ideas about biological inferiority regarding racial differences, gender
roles, class status, or sexuality, while implying that there was a distinct set of victims who were
actually “suffering” from mental disabilities. These historians thus take disability for granted as a
natural and objective condition. The “truly” disabled patients and inmates may be presumed to
be the “deserving” objects of eugenicists’ attention, and certainly would not be considered
capable of making their own reproductive choices. The story of Ruth, the patient at Northern
State Hospital who “asked for sterilization,” illustrates the value of integrating the vantage point
of disability studies into the interpretation of these patient records. Ruth was described as white,
economically “comfortable,” and seemingly a successful wife and mother. Some readers might
therefore identify her as one of the “truly disabled,” suffering from depression and
hallucinations, as her medical files indicated. But her own statement to the Board contextualizes
her own experience of disability—she experienced a traumatic event (her mother’s death) that
she thinks precipitated her breakdown. When the doctors committed her to Northern and voted to
sterilize her, they framed her psychological distress more simplistically as hereditary insanity.
They created disability as a fixed biological trait.
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The surviving documents from the Board meetings at Northern State Hospital reveal the
ways that traumatic experiences and deviance from social norms could be readily translated into
medical diagnoses. In particular, what was labeled as mental disease and disability was often
determined by normative assumptions around class, sexuality, and gender. My point is not that
these people were “misdiagnosed,” but rather that the category of disability was defined and
delineated in extremely broad fashion, thereby serving the interests of reinforcing professional
expertise and social control of problem groups and individuals.
A few examples from Northern: Genevieve, diagnosis manic depressive, precipitated by
pregnancies; 26 year old housewife with two children, husband’s whereabouts unknown; has a
“sensitive disposition” and is “frigid sexually;” “had two children and each time had a mental
attack;” has suicidal tendencies and requires restraint. Olga, psychosis with mental deficiency;
18 years old and in the hospital for 8 months; her mother was also a patient; nervous since birth,
excited over trifles, irritable, disagreeable, and ugly; “thought her brother and other relatives
were having sexual relations with her, showed memory defects and impairment of judgment.”
Marcene, psychosis with mental deficiency; 16 years old and IQ of 65; parents are from Sweden
and both have mental illness; failed at vocational schools, arrested for vagrancy, quarrelsome,
obscene, and promiscuous sexually. Lois, manic depressive; 25 years old, mother and brother
have been patients; left high school because of a pregnancy; husband was alcoholic and abusive;
upon divorce, her two younger children were given up for adoption; “became erratic and
quarrelsome, threatening, flighty, emotional.” Walter, dementia praecox, paranoid type; 22
years old, has been in the hospital 11 months; discharged from the Army due to disability, never
had an occupation, is unemployed. John, schizophrenic and homosexual; 27 years old, and
family supports him financially; has admitted “acts of perversion” since age 16; committed petty
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larceny;is “dull and seclusive, no initiative, has auditory hallucinations;” has shown no change
since receiving metrazol shock therapy.
A few patterns emerge from these stories of psychological distress and social nonconformity: women and men who were struggling financially; women who did not fit society’s
standards for femininity (i.e. they were not chaste girls, happy wives, and good mothers); men
who did not fit society’s standards for masculinity (i.e. they were not strictly heterosexual and
self-sufficient); women who were experiencing some kind of post-partum depression, stress in
their home lives, or even domestic violence; people with criminal histories; and people whose
families were recent immigrants. I think it’s important not to generalize too broadly from these
documents about the meanings of disability, gender, class, ethnicity, and the intersections
between them. But reading between the diagnostic lines we can learn a bit about the experiences
that likely brought these inmates to the Board’s attention in the social context of the late 1930s.
The few records I’ve found from the state custodial schools similarly suggest that
sexuality, gender roles, and economic dependency were main determinants of candidacy for
sterilization among people labeled with intellectual disabilities. In some cases, so-called mentally
deficient men were operated on and then paroled from the institution when their families
reported that a job was waiting for them at home. One set of forms from a 1940 Board meeting
emphasized the problem of sexual deviance in both the male and female inmates. Of the six
women, four were labeled “feebleminded of moron classification” with tendency to be “sexually
promiscuous” or “heterosexual.” The descriptions of the seven men included: “some homosexual
tendencies,” “stepmother complained of sexual advances,” “has molested small girls,” and
“homosexual tendencies and masturbation.” Of the 13 inmates presented that day, the Board
ordered that 11 of them be sterilized for “eugenic benefit,” and that one be sterilized for her own
“personal benefit.” Attaching a biomedical interpretation to undesirable deviancies from social
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norms justified the solution of sterilizing of people deemed “moral degenerates and sexual
perverts” under the law.
Previous scholarship has shown how the category “feeblemindedness” exploded in size
and social significance after the turn of the century, in response to anxieties among elites about
citizenship, immigration, economic crisis, and shifting gender roles. There has also been
substantial analysis of reproductive politics in the eugenics era, focusing on the intersections
between gender, class, and race. [Kline, Ladd-Taylor, Kluchin] Even though these scholars are
writing about “feeblemindedness,” critical analysis of the disability dimension of this history is
generally lacking. [Rembis, Carlson, Stubblefield, Carey] Recognizing the ableist attitudes that
underlay policies of sterilization and institutionalization can greatly enrich the critiques already
developed from a gender studies perspective. In particular, from the vantage point of disability as
a form of diversity, we can recognize that what the eugenicists’ biomedical approach framed as
traits of “incompetence” and “immorality” are better understood in terms of a disabling society
that did not provide people with impairments with supports or skills training they needed in areas
such as sex education, parenting, and independent living. Feminist writers have noted that the
public today is still generally unsympathetic towards demands for reproductive rights when these
are made by women who are poor or on welfare (welfare queens, etc.). When reproductive
politics are also viewed through a disability lens, we can see even harsher skepticism about the
rights and capacities of people with disabilities to have and support families of their own.
What can a disability lens tell us about the decision making processes under
Washington’s sterilization law? Evidence from the archival records, such as Ruth’s case in which
she allegedly wanted a contraceptive sterilization, suggest not just a blurring of the lines between
consent and coercion, but significant differences in what consent meant for different
stakeholders. If eugenics was about compulsory reproductive control, then how could inmates
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have volunteered for the sterilization procedure? If the Washington law did not require consent,
then why did the superintendents who implemented it insist that consent forms be signed by the
patient or guardian? And if people were committed to mental hospitals and custodial schools
because they were deemed “mentally unfit” to decide where and how they wanted to live, then
wasn’t it contradictory to ask them to make this choice about their reproductive lives? The
stories told by Ruth and other inmates about “voluntary” sterilization while in the institution
reveal patterns of power dynamics between patients, families, and medical authorities. We can
also see how some degree of agency was unexpectedly exercised by people who were otherwise
radically disempowered by their disability status. In short, disability studies provides a more
complete analysis, on the one hand, of why eugenic sterilization was oppressive, and on the
other, of how eugenic sterilization could have been welcomed by some of its putative victims.
The women at Northern State Hospital who were interviewed before the Board in 1941
had varying reactions when asked whether they wished to be sterilized. Edythe was “perfectly
willing to have this operation” because she couldn’t afford more children and feared another
breakdown. Whether she might need contraception after her release from the hospital seemed
uncertain: the transcript says that for the last several months she had been employed in the
superintendent’s home, but that her husband “doesn’t want me to come back to him.” According
to her medical file, she had had an illegitimate pregnancy and two abortions, and her mother had
also been a patient at Northern. Four years ago when admitted to the hospital (for her second
time), Edythe had experienced hallucinations and delusions, but was now “much improved,
pleasant and cooperative.” The vote to sterilize her was unanimous. Likewise, Alla says she had
already talked with the hospital physician about what a “very fine idea” sterilization is. She states
that although she is very knowledgeable about other means of contraception, her husband
“doesn’t like to use them.” The vote was 4-1 in favor of sterilization, “for her own good” rather
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than for eugenic reasons. For both of these women, a lack of other options in a patriarchal
society made the idea of sterilization seem like a desirable form of birth control.
Two of the women included in the Board meeting transcripts emphatically did not want
to be sterilized. Jean speaks in detail about her miscarriage, how lonely she was raising a baby in
a new city without any friends to support her, and traumas she suffered falling down a flight of
stairs and experiencing another death in the family. She is quite certain that her family history
contains no hereditary taint, and that she and her husband can take care of their own reproductive
decisions, even suggesting “we could resort to having separate rooms if necessary.” But in her
medical files, it states that Jean was admitted to the hospital because of delusions that “her
husband wanted to get rid of her.” Those ideas had since faded and she was “pleasant and
cooperative”—after metrazol shock therapy. The Board unanimously rejected her for
sterilization. In Marjorie’s case, she explains that she is in her second marriage, and would like
to start a family. By her account, she was committed to Northern because of a grave illness she
contracted while in Alaska, but she has no family history of mental illness and therefore sees no
reason she should be sterilized. The physician’s records note that she has been in the hospital for
a year with a diagnosis of schizophrenia, and describe her as having been “promiscuous before
marriage” and having had a miscarriage that may have been an abortion. The Board was
conflicted and voted 3-2 against sterilization. In both cases, the patient was able to resist.
Finally, in three of the interviews, the Board members ask the patient point blank whether
she is amenable to being sterilized only because she thinks that cooperation will secure an earlier
release from the hospital. Each woman denies such a motive. They state that they agree they
should not have any more pregnancies either because of their own health or that of their potential
children. But the fact that the Board even raised the issue of parole suggests that patients and
professionals alike knew that parole after sterilization was routine hospital practice. Hence
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patients may have had the opportunity to take advantage of the sterilization law not only to
secure reliable birth control, but also to return to their home lives. The superintendents might
then dismiss the “consent” as irrelevant or invalid: in two out of these three cases, the women
said yes to sterilization while the Board said no.
In other local contexts, including California, Minnesota, and Alberta, the laws mandated
“voluntary sterilization” that involved securing consent from the inmate’s guardian, spouse, or
kin. But in Washington, the Board’s practices went a step further and implied that there was
patient self-determination in some instances. Another notable comparison is with Johanna
Schoen’s work on the North Carolina sterilization program, where some economically
disadvantaged women were able to access birth control through the mechanism of the state
Eugenics Board. Through voluntary sterilization, these women were able to exert some measure
of control over their reproductive lives, but in the process they had to submit themselves to the
surveillance and stigmatization associated with the eugenics law. The archival records from
Washington offer an even more complex situation. Despite being disempowered by their
incarceration as well as by ableist assumptions about incompetence and dependency, women
such as Ruth seemingly succeeded in working the system to achieve their desired goals of
accessing birth control and perhaps even securing their parole. Through the transcripts, we hear
how active and resourceful these women were—contrary to both disability and gender
stereotypes. Ruth, for example, articulated her own interest in avoiding further pregnancies while
also enlisting the Board’s support by telling them what they wanted to hear about possible
hereditary defect in her family (“there are doubts…I don’t want to take the chance”). At the same
time, though, when the Board suspected that a patient was trying to exploit the law to get out of
the hospital before the experts thought she was medically qualified, they rejected her as a
sterilization candidate. This also raises the question of whether some individuals may have
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gotten themselves committed to the psychiatric hospitals for the express purpose of acquiring a
legal sterilization.
To conclude, as this project goes forward I want to try to use the Washington records to
tell a “history from below” that encompasses a social model perspective on the targets, methods,
and motives of the forced sterilization movement, and how it impacted the reproductive rights
and institutionalization of people with disabilities. Eugenicists claimed that disabled people were
“naturally” sexually deviant and incapable of being good parents, and they offered segregation
and sterilization as both a cure for these social ills and a cure for mental disability itself. Whether
their motives were eugenic or therapeutic was ultimately irrelevant, as the common outcome was
to reinforce medical power over how disability was defined and dealt with. Although the
implementation of the sterilization statute was only superficially and likely occasionally
voluntary, it at least offered some inmates the opportunity to advocate for and empower
themselves with respect to family planning and marital relations, in a time where few other
options were available to disadvantaged women. Their files can be read as counter-narratives to
disability stereotypes of weakness and defenselessness, while at the same time also illustrating
how vulnerable these individuals were in an institutional and social setting that offered them no
truly free choices.