Why is the burden of sterilisation on women in India? The answer lies in the Emergency era

In 1976, men across India were drastically changing their behaviour. Some were abandoning the beds inside their homes to sleep in fields, others were skipping major festivals and public gatherings. Those who in the past had taken the train freely, without a ticket, were finding alternate routes. They were all trying to avoid government officials. On trains, inspectors were suddenly cracking down on ticketless passengers with heavy fines, but they would give fare dodgers a break on one condition: that they agreed to be sterilised.

Government workers, from train inspectors up to the top brass, were working to sterilise as many men as possible. Some even had monthly quotas for how many men they had to convince to get vasectomies. In turn, poor men in rural villages were doing everything they could to avoid government officials, because any such encounter might end with the villager on a dingy operating table where his genitals would be cut  – whether or not he wanted the operation, whether or not he already had children.

Dr Arvind Bhopalkar recalls losing count of the number of procedures he performed during this period. In 2015, the surgeon told the Indian Express, “We were told to do the operation on as many men as possible...a revenue department official, in his zeal for rounding up men, even brought a doctor’s father to us.” Bhopalkar would let unmarried men, and those who were married but childless, slip out without undergoing the procedure. “Doctors have hearts too,” he told the paper.

The mass sterilisation drive of 1976 was one of the most infamous incidents of the 21-month period known as the “Emergency,” which Prime Minister Indira Gandhi had declared the year prior, suspending the Indian constitution. Gandhi justified her decision to dissolve human rights protections by citing internal security disturbances and a need to uplift the underprivileged. She implemented welfare-style programmes, gave land to those without property, and artificially lowered the price of some basic goods to make them more affordable. But these policies, ostensibly meant to help poor people, often included a coercive element. In some parts of the country, poor men and women were offered plots of land in exchange for getting sterilised, or for “motivating” others to do so.

In 1976 alone, the Indian government sterilised 6.2 million men. Permanent methods of birth control remain very popular in India, but today women bear almost the entire sterilisation burden  – 93% of it, according to the most recent government statistics. The Indian government has switched its gender focus, but many of the methods used in recent years to recruit women for tubal ligations were pioneered during these early male sterilisation drives.

India’s sterilisation campaigns for both men and women have been part of international campaign intended to control the nation’s population: long after Indian independence, these measures were  – and continue to be  – rooted in imperialist ideas, and in long-held Western attitudes about Indian manhood and womanhood. Nearly half a century after the aggressive campaigns of the 1970s, women are still dying in sterilisation camps, undergoing procedures that they understand to be the only option, without fully knowing the risks or the alternatives.

Colonial legacy

Western conceptions of both Indian men and women were cemented during British colonial rule in the 18th and 19th centuries. Indian men, Europeans said, were emasculated and weak, whereas women were the hapless victims of Indian society  –  yet also the symbol of its woes.

In the 20th century, American visitors furthered this rhetoric  – and the writings of two very different American women typified Western attitudes toward Indian reproductive politics. The first was Katherine Mayo. When she traveled to India in 1925, she was already well-known for her polemic The Isles of Fear: The Truth About the Philippines, in which she argued that Filipinos owed the Spanish an enormous debt for introducing Christianity and “forms of European law” to the islands.

Mother India, the wildly popular treatise Mayo would write about her travels in the country, similarly argued that India’s only hope was in British colonisers and in Christian missionaries  – but, as the title indicates, she made this argument through the figure of the mother. As Asha Nadkarni writes in Eugenic Feminism, the title invokes “the idealised figure of the nation celebrated by Indian nationalists, rewriting it as the pathologised reproductive figure of a diseased body politic.” Mayo painted Indian mothers as pathetically impoverished and diseased, unable to take care of their children, and depicted Indian sexuality as depraved.

A decade later, Margaret Sanger, the founder of the birth control movement, traveled to India with her own mission: promoting contraception. In essays and speeches, she was emphatic that birth control was something that Indian women actually wanted  – badly. In a 1936 radio address, she said:

“I turned to the social worker, ‘Ask this mother how many children she has’” and I pointed to a woman in a ragged sari squatting on the street and holding a baby in her arms.

‘Six,’ was the answer.

‘And how many dead?’ I asked.

‘Five,’ she answered.

‘And how many more do you want,’ I pursued.

She threw out her hands in a pathetic gesture. A look of fear came into her tired, lined face.

‘Please God, no more!’”

Sanger’s descriptions of Indian women were often clichéd  –  she described them as “tired” and “pathetic,” as well as gentle and childish. Though far less explicitly racist and contemptuous, this picture of India was not entirely different from Mayo’s. Both writers painted India as a place beset by an uncontrollable fertility that threatened disease, destruction, and war.

By 1952, Sanger had moved away from fighting for “birth control” for individual Indian women and had begun to emphasise “population control” for the masses. She gave an address in Bombay arguing for government-led family planning policies, linking large family sizes with national instability. “The cry for babies is the cry for armament, the cry for war,” Sanger said. “There is also the tremendous expense of care of defective mentalities and the army of delinquents.” The solution, in her view, would need to come from the top down:

“It should be [health officials’] duty to the State, to the public and to our future civilization to see that those who do not have the individual initiative and intelligence to plan and control the size of their families should be assisted, guided, and directed in every way to eliminate the undesirable offspring, who usually contribute nothing to our civilization but use up the energy and resources of the world.”

The same year she gave this address, Sanger founded the International Planned Parenthood Federation, which funded Indian organisations that would have an influence on population policy. It was also in 1952 that the Indian government launched its first population control efforts, which were geared toward women.

Pressure from the US

Years before the Emergency, the US government began to put pressure on Indira Gandhi to pursue a more aggressive policy on population control. The Lyndon B Johnson administration was concerned that population growth was a threat to trade and national security, a view that was largely due to a powerful lobbying campaign backed by corporate funders, including the Rockefeller Foundation, the Shell Corporation, and the Ford Foundation.

Hugh Moore, president of the Dixie Cup Company, funded the publication of a pamphlet called “The Population Bomb.” A decade and a half later, it would lend its title to Stanford University professor Paul R Ehrlich’s best-selling book. In the 1950s, hundreds of thousands of copies of Moore’s pamphlet were distributed, and it was translated into newspaper and televisions advertisements. One warned Americans that overpopulation would lead to “a world of chaos, riots and war. And a perfect breeding ground for communism.” The ad continued, “We cannot afford a half dozen Vietnams.”

This type of thinking was echoed in a now declassified National Security Council memorandum that identified India as a country whose population size was of strategic concern for the US. The authors warned that, in order to avoid “charges of an imperialist motivation,” Westerners should emphasise the “right of the individual couple to determine freely and responsibly their number and spacing of children” when justifying their population control activities.

When President Johnson spoke publicly about population control, he framed it as a development issue. In a 1966 United Nations address, he echoed a RAND Corporation report he’d read, advising his audience to “act on the fact that less than five dollars invested in population control is worth a hundred dollars invested in economic growth.” This was the same year that Prime Minister Gandhi would visit Washington, and Johnson began placing some of this pressure on her. When an adviser asked the president if he wanted to promise Gandhi more food aid during her visit, he exploded: “Are you out of your fucking mind?... I’m not going to piss away foreign aid in nations where they refuse to deal with their own population problems.”

India’s government was already the first in the world to attempt to control its citizens’ fertility on a large scale, and early efforts focused on women, in sync with the international birth control movement. By the 1960s, however, the government had already started to redirect its family planning efforts toward men. The Emergency would accelerate this shift to the breaking point.

Male focus

As Professor Savina Balasubramanian outlines in “Motivating Men: Social Science and the Regulation of Men’s Reproduction in Postwar India,” after India’s family planning efforts got off to a slow start, American communications scientists began suggesting a new strategy that regarded men as the ideal targets for contraceptive intervention.

In 1962, J Mayone Stycos argued that the Indian government had “middle class” and “feminist” biases, and that officials prioritised female-oriented contraceptive methods for couples who had the time and money to access clinics and continuous care. Stycos argued that the Indian government should instead focus more on sterilisation, a method available to poor couples with limited health care access, and should make men the target of these efforts.

Vasectomy was a safer procedure than tubectomy, especially at the time, and it required less recovery time and follow-up. But Indian men were also seen as easier to target and reach than women were. Dudley Kirk, the director the Population Council’s demographic division, wrote that, “particularly in Asian countries,” men were “the logical channels of information and communication [who] regard themselves as the initiators responsible for family destiny.” Thus, Kirk concluded, “a program to motivate men would be more successful than efforts to motivate women.”

Balasubramanian notes that this approach was peculiar to India, and not evident in other postcolonial countries where the US had an interest in controlling the population. She theorises that this may be because scientists inherited colonial concepts about Indian masculinity, framing Indian men as less “hyper-sexualised and hyper-procreative” than Latin American men, for example.

State governments across India began holding “mass vasectomy camps.” These were intended to not only sterilise men but also to promote fertility control through “festival-like productions,” which included poster exhibitions and dance routines. Balasubramanian argues that these camps were the Indian government’s attempt to answer sociologist and demographer Donald J Bogue’s call for “an ambitious supplementary program of communication and motivation” to shift attitudes and beliefs about contraception.

During the Emergency, the idea of “motivation” took on a whole new meaning. Karan Singh, India’s minister of health and family planning, wrote in a 1976 statement, “In addition to individual compensation, Government is of the view that group incentives should now be introduced in a bold and imaginative manner so as to make family planning a mass movement with greater community involvement.”

The term “motivation” was applied to a variety of incentives and disincentives intended to convince citizens to get sterilised or bring others to do so, from offering plots of land in return for sterilization to threatening fare fines or the loss of a government job for those who refused the procedure. While both men and women could be “motivated,” the medical system was equipped to do many more vasectomies than tubectomies (though neither procedure was performed in the safest of conditions). Men were also easier targets for threats like job loss or fines, since they were were more likely to be employed outside the home, to take public transportation, and to go out and pick up government food rations.

The campaign to sterilise men involved many levels of harassment. As Mohan Rao notes in From Population Control to Reproductive Health: Malthusian Arithmetic, “population control during the Emergency was not just about compulsion. It was an experiment in ‘integration,’ in which every branch of government would take part.” A new national policy, for example, froze the number of representatives each state was allotted in the Lok Sabha, India’s lower parliamentary body, so that states would not have political incentive to grow their populations. And the government wasn’t acting in isolation: USAID, the World Bank, and the UN were all pressuring Indian officials to incentivise sterilisation.

Records show that wealthier Indians were able to buy their way out of this system. After spending time with upper class Indians, a Washington Post reporter found that, while some approved of the aggressive family planning policy, none of them had had to experience it themselves. And a 1980 Guttmacher Institute survey noted that Indians with some level of higher education were more likely to support compulsory sterilisation  –  an indication that it was likely easier for those less affected by the sterilization drive to applaud its effectiveness.

Of course, during the Emergency, the Indian government used methods far more extreme than cash incentives. The results were bloody. In addition to the approximately 2,000 men who died in botched procedures, some particularly aggressive government officials were killed by protesting villagers  – and even more civilians died during police retaliations.

Indira Gandhi and her Congress Party were voted out of power in a landslide in 1977. The opposition had focused on the emergency sterilisation drives during the campaign. “The skinny, ill-fed, semi-clothed, so-called illiterate villager of India refused to be seduced by promises of food and fuel in exchange for their basic human rights,” said Soli Sorabjee, the additional solicitor general for the government of India. “To the spurious question of whether the poor man would rather have food or freedom, the resounding answer which he gave was: ‘We will have both.’”

Back to women

After the Emergency, the Indian government began to turn its family planning policy 180 degrees  –  back toward women. In 1980, the government’s working group on population policy issued a report declaring women to be the “best votaries” of fertility control. Although the authors of the report acknowledged that men would eventually become a part of the programme  –  after being reeducated “to remove misconception about vasectomy” – they concluded that, presumably because of the political climate, women should be their focus “in the short run.”

But instead of slowly reenlisting men, the Indian government came to rely on them less and less. As TK Sundari Ravindran notes in Reproductive Health Matters, “female sterilisations, which accounted for 46 percent of all sterilisations in 1975-’76, and fell to only 25% in ’76–’77, rose to 80% in 1977–’78. Throughout the 1980s they accounted for about 85% of all sterilisations, and in 1989–’90, 91.8%.” That ratio has only become more uneven over the last three decades, and female sterilization is by far the most popular method of contraception in India, despite continued risks. In 2014, 13 women died at a Chhattisgarh sterilisation camp, in an incident that brought back memories of the Emergency.

More than four decades after the Emergency, the shift away from men during the backlash has never rebalanced. Today, conventional wisdom among health workers in India suggests that men simply aren’t interested in family planning. But some experts think the blame doesn’t rest entirely on disinterested men: health care workers, too, generally focus only on women. The Indian government’s 2017 statistics showed significantly more female than male community health care workers in every state and district surveyed, with especially drastic differences in some areas. A recent study suggests that reproductive health care would improve for both men and women if more male workers were employed in community health care.

After the 2014 sterilisation tragedy, the Indian government began to signal it might change course, although there isn’t much momentum behind this shift. Still, sterilisation camps have been banned, and while the number of female sterilisations still outstrips that of male sterilisations, the overall numbers have been declining. The health ministry has outlined plans to shift its focus back to male sterilisation, although it has yet to take action. RISUG, a reversible male contraceptive in injectable form, is in development and has successfully completed human clinical trials, though it has yet to receive funding to move toward production.

The Indian government has yet to make any real strides to bring men back into the reproductive conversation. If it does begin to actively recruit men to take on part of the contraceptive burden, it will have to work to do so in a way that isn’t grounded in reductive ideas of gender, nor bound by an international agenda to control the population. Otherwise, though perhaps in subtler forms than the extreme policies of the mid-1970s, history will continue to repeat itself.

This is the first of a three-part series called Breaking the Cycle on How We Get To Next. Reporting and research was supported by the Pulitzer Center on Crisis Reporting. Breaking the Cycle will examine the past, present, and future of reproductive health in India, from early ideas about population control to on-the-ground interventions happening now, to a potential future where men and women share contraceptive responsibility.

This article first appeared on How We Get To Next.