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80 SUMMER 2013

Double Stigma: Forced Sterilization of Women Living with HIV in Kenya and Namibia
by Katelin Wilton
Editors note: Despite protective laws and international treaties, the abusive practice of involuntary sterilization continues. In this DifferenTakes, HIV advocate Katelin Wilton looks at how discrimination against women living with HIV in Kenya and Namibia makes them targets for unwanted sterilization and cash for contraception schemes. The author calls for recognition of this injustice and for supportive and comprehensive reproductive health services for women living with HIV. Betsy Hartmann and Anne Hendrixson

Double stigma is what Kenyan reproductive health activist Teresia Njoki Otieno calls the stigma faced by African women who are HIV positive and have been sterilized because of it. This is Africa and a woman is not able to give birthand again you are HIV positivethen you are no longer a woman, says Otieno.1 Otieno fights for the rights of HIV positive women in Kenya who have been coerced or forced into sterilization. She promotes

reproductive health and rights education for women living with HIV and psychosocial support services to counter this double stigma. AIDS medications make it possible for HIV positive women to give birth to HIV negative babies. Prevention of vertical transmission, or PVT, (also known as Prevention of Motherto-Child Transmission2) is possible by taking a course of antiretroviral medicine, which studies have shown prevents transmission of the HIV virus from a mother to her child over 95% of the time. 3 Women living with HIV can and do give birth to healthy, HIV negative children and live long, fulfilled lives. Despite this, women living with HIV are coerced or forced into sterilization through tubal ligationwithout informed consent and in some cases without their knowledgeoften in the name of preventing HIV transmission.

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For people, environment and justice.

A publication of the

Population and Development Program

CLPP Hampshire College Amherst, MA 01002 413.559.5506 http://popdev.hampshire.edu Opinions expressed in this publication are those of the individual authors unless otherwise specified.

Forced Sterilization of Women Living with HIV

According to the Open Society Foundations report, Against Her Will, forced sterilization occurs when a person is sterilized without

her knowledge or is not given an opportunity to provide consent.4 In 2011 the International Federation of Gynecology & Obstetrics (FIGO) reinforced the important point that sterilization is not an emergency procedure and therefore is subject to the laws of informed consent. The federation stated that a woman must be provided information about the procedure, its consequences and likely irreversibility, and that no one can give consent on her behalf.5 Forced or coercive sterilization is a violation of most countries constitutions (certainly Kenyas and Namibias). It is also a violation of numerous international laws and treaties, including the International Covenant on Civil and Political Rights (Article 7), the Convention on the Elimination of all forms of Discrimination Against Women (Articles 10h, 12, 16e, Gen. Rec. 19), Beijing Platform for Action (Women and Health par., 94), and the International Guidelines on HIV/AIDS and Human Rights.6 Yet forced sterilization continues in a number of locations around the world. Numerous countries have taken inadequate action against individuals who perform non-consensual sterilizations, and some have even sanctioned such procedures in national family planning initiatives with anti-natalist undertones based on racial or ethnic discrimination, says Anand Grover, the UN Special Rapporteur on the right to health.7 Namibia and Kenya are two countries where instances of forced and coercive sterilization of women living with HIV are well documented.

ICWs interviews with health care providers make it clear that HIV positive women, particularly women who become pregnant, are often viewed as irresponsible and incapable of managing their own health care needs and those of their families. Doctors felt they should make health care decisions for the women living with HIV in their care, as those patients did not know how best to care for their own bodies or did not understand the information that was given to them. In 2010, three women living with HIV brought the Ministry of Health and Social Services to court. They made two claims: first, that they had been sterilized against their will, and second, that they had been sterilized because of their HIV-positive status. Hundreds of women flooded the courtroom in support. The Namibian High Court heard the womens case and Judge Elton Hoff ruled that the three women had indeed been sterilized without their consent. However, the judge dismissed the second claim that they were sterilized because of their HIV status. Thus the case is described as a partial victory.10 However, it did receive media attention nationally and internationally, thereby succeeding in bringing awareness to the issue and prompting similar investigations around the world like the ones in Kenya.11

Kenya
The African Gender and Media Initiative (GEM), an organization dedicated to advancing the equality of women through research and advocacy, found that in Kenya forced sterilization is happening, and appears to be systemic in public health facilities. The groups 2012 report, Robbed of Choice, chronicles the stories of 40 women who were forcibly sterilized.12 One telling case is that of Alice (a pseudonym), who was sterilized during a cesarean section based on a consent form signed during overwhelming labor pain. She recalls, While I was groaning in pain, the doctor looked at my file and said to me, Woman you are still giving birth and you are HIV positive. She continued, When they insisted on tubal ligation, I signed the documents so that they could attend to me and relieve me of the pain I was going through. The interviewers found that Alice has not told her husband because she fears he would leave her and marry a woman able to bear children.13 Abandonment, at times by the same husband that signed the consent form for sterilization, is reported in other womens testimonies as well. This is indeed an example of double stigma.

Namibia
In 2008, the Namibia chapter of the International Community of Women living with HIV (ICW)a global network by and for women living with HIV conducted interviews with 230 HIV positive women. Most reported some form of discrimination in health services and 40 of them had been coerced or forced into becoming sterilized.8 Some women were told sterilization was necessary because of their HIV positive status. Others were given consent forms they could not read or understand. Some were never told that tubal ligation meant they could not bear children. One woman reported, Unfortunately there was one sterilization form that I was not aware of and I had already signed it. 9 Women were even asked to consent to the procedure in exchange for receiving medical attention during the duress of labor.

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In a video interview, another woman who had undergone sterilization in exchange for subsidized cesarean section delivery explained, Although I am happy my baby is HIV negative, I am sad that I cant have any more children.14 She and the other women are seeking justice and plan to sue the Kenyan government with the help of KELIN, a group of lawyers based in Kenya who are dedicated to the promotion and protection of HIV related rights. Allan Maleche, Executive Director of KELIN, stated, We will try our best to prove the link (in the Kenyan case) because out of all the women that we have so far, none of them is HIV negative.15 I recently spoke with Teresia Njoki Otieno about her ongoing advocacy around the sterilization of HIVpositive women and her work on Robbed of Choice. We are advocating for the review of the national family planning, counseling and HIV policies to address reproductive health and rights needs of women living with HIV and to include stronger language on informed consent, Otieno explained. Meanwhile, affected women also take part in monthly psychosocial support meetings which have created a safe space for women living with HIV to discuss their sexual, reproductive and health options. With GEM, Otieno has trained community champions on reproductive health and rights and worked to build the leadership and advocacy skills of women living with HIV. Forced sterilization is not the only strategy to stop Kenyan women living with HIV from having children. Project Prevention, a U.S.-based NGO operating in the country, offers financial incentives to women living with HIV to take long-acting birth control. Previously known as CRACK Children Requiring a Caring KommunityProject Prevention has achieved much notoriety in the U.S. for paying women who use drugs a cash incentive to be sterilized or to use a long-term birth control method.16 Recently exported to Kakamega and Mbita, both in Western Kenya, Project Prevention offers a payment of 40 U.S. dollars to women living with HIV in exchange for accepting an IUD.17 Program manager Willice Onyango figures cash incentives will work best in Kenya with women who have HIV, as a reward for choosing not to transmit the virus to an innocent child.18 In recent correspondence with me, Onyango confirmed that the project is still operating.19 Journalists claim that participating women most likely did not receive proper counseling and information about potential side effects, follow-up

medical attention, or the opportunity for psychosocial support.20 Fortunately, Project Preventions recent efforts to enter South Africa have not been successful. Professor Eddie Mhlanga, Director for Maternal, Child and Womens Health for the government of South Africa, stated, We cannot accept a situation where organizations come and exploit poor and defenseless people and we find it unethical that they are asking people to, for a certain fee, give up their reproductive rights.21

Conclusion
Sexual and reproductive health services should include a full range of safe and voluntary contraceptive options, including sterilization. Equally important, it is every womans right to become pregnant and to access medical care in order to ensure her own health and the health of her child. Women living with HIV should receive comprehensive counseling and HIV services based on WHO guidelines and information about all available health and contraceptive options. As Otieno told me, Through the media and different forums, the issues of forced and coerced sterilization have been moved from the side to the center of discussion within the communities, and nationally, by the experiences of women. 22 As proof of this, Juan E. Mndez, the UN Special Rapporteur on torture, recently declared, Forced sterilization is an act of violence, a form of social control, and a violation of the right to be free from torture and other cruel, inhuman, or degrading treatment or punishment.23 Research and advocacy on these issues are ongoing. For example, ICW and the Global Network of People living with HIV (GNP+) recently received support from UNFPA to conduct focus group discussions and key informant interviews on the quality of family planning services for women living with HIV. The research will take place in Zambia, Nigeria and Cameroon over the next three months. 24 No government, ministry of health or health care worker should go on believing that s/he knows whats best for a woman living with HIV. Violations of womens rights actually keep women from accessing healthcare, thereby further fueling the HIV pandemic. This is a situation where reproductive rights are key but also where reproductive justice is imperative.

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Katelin Wilton has worked with networks and association of people living with HIV across Africa and is committed
social justice issues related to health and human rights. She is an alumna of Hampshire College (F05) and holds a Masters degree in Medical Anthropology and Global Health from New York University.

Notes
1. Kenyan women sue against forced sterilisation, YouTube video, 2:27, from Al Jazeera with reporter Catherine Soi, posted by Al Jazeera English on October 8, 2012, http://www.youtube.com/watch?feature=player_embedded&v=q5a23GX549Q. 2. I use prevention of vertical transmission rather than prevention of mother-to-child transmission in solidarity with activists who are campaigning to eliminate the use of PMTCT as it adds to the stigma women face by placing the blame on her for the transmission of HIV to her child. 3. World Health Organization. Antiretroviral drugs for treating pregnant women and preventing HIV infections in infants: Recommendations for a public health approach, 2010 version. Geneva: World Health Organization, 2010, http://whqlibdoc.who.int/ publications/2010/9789241599818_eng.pdf 4. Open Society Foundations. Against Her Will: Forced and coerced sterilization of HIV positive women worldwide, New York: Open Society Foundations, October 4, 2011, 11. 5. International Federation of Gynecology and Obstetrics, FIGO Committee for the Study of Ethical Aspects of Human Reproduction and Womens Health. Ethical Issues in Obstetrics and Gynecology. London: FIGO, October 2012, http://www.figo.org/files/figo-corp/English%20 Ethical%20Issues%20in%20Obstetrics%20and%20Gynecology.pdf. 6. AWID, Violating Womens Rights: Forced Sterilization, Population Control And HIV/AIDS, commentary posted by Ani Colekessian, July 6, 2013, http://www.awid.org/News-Analysis/Friday-Files/Violating-Women-s-Rights-Forced-Sterilization-Population-Control-and-HIV-AIDS. 7. United Nations Human Rights, Office of the High Commissioner for Human Rights. Busting the myth that sterilization can end AIDS. OHCHR, August 28, 2012, http://www.ohchr.org/EN/NewsEvents/Pages/ForcedSterilization.aspx. 8. The International Community of Women Living with HIV/AIDS (ICW). The Forced and Coerced Sterilization of HIV Positive Women in Namibia, London: ICW, March 2009, http://www.icw.org/files/The%20forced%20and%20coerced%20sterilization%20of%20HIV%20 positive%20women%20in%20Namibia%2009.pdf. 9. Ibid. 10. BBC News Africa. Namibia HIV women sue over forced sterilization, June 1, 2010, http://www.bbc.co.uk/news/10202429. 11. Ibid. 12. African Gender and Media Initiative. Robbed of Choice: Forced and Coerced Sterilization Experiences of Women Living with HIV in Kenya, Faith Kasiva. Nairobi, Kenya: African Gender and Media Initiative, 2012, http://gem.or.ke/wp-content/uploads/2012/08/Robbed%20of%20 Choice.pdf. 13. Ibid. 14. Robbed of Choice, YouTube video, 9:50, from the GEM Initiative, posted by the GEM Initiative on July 31, 2012, http://www.youtube.com/ watch?v=TObwGI5xFfI. 15. Katy Migiro, HIV-positive Kenyan women plan to sue over sterilization, Thomas Reuters Foundation, September 13, 2012, http://www.trust. org/item/?map=hiv-positive-kenyan-women-plan-to-sue-over-sterilisation. For more information on the case, see http://kelinkenya.org/. 16. Judith M. Scully, Cracking open CRACK: Unethical sterilization movement gains momentum, DifferenTakes, No. 2, Spring 2000, http:// popdev.hampshire.edu/projects/dt/2-0. 17. For more on Project Prevention refer to: IRIN: humanitarian news and analysis, Kenya: Outrage over cash for contraception offer to HIV positive women, May 12, 2011, http://www.irinnews.org/report/92696/kenya-outrage-over-cash-for-contraception-offer-to-hiv-positivewomen; and Care2 make a difference, Poor or HIV +? Positive Prevention will pay you not to breed, commentary posted by Julie M. Rodriguez, May 13, 2012, http://www.care2.com/causes/poor-or-hiv-project-prevention-will-pay-you-not-to-breed.html. 18. Anna Clark, IUDs to Prevent HIV in Kenya? The Nation, http://www.thenation.com/article/160485/. iuds-prevent-hiv-kenya#axzz2WbZSf5yc. 19. Willice Onyago, Twitter message to author, June 19, 2013. 20. Anna Clark, IUDS to Prevent HIV in Kenya? The Nation, May 6, 2011, http://www.thenation.com/article/160485/ iuds-prevent-hiv-kenya#axzz2WbZSf5yc. 21. Anso Thom, U.S. project planning to sterilize HIV+ women in SA, health-e: The South African Health News Service, April 7, 2011, http://www.health-e.org.za/2011/04/07/us-project-planning-to-sterilise-hiv-women-in-sa/. 22. Teresia Njoki Otieno, email message to the author, June 7, 2013. 23. Juan E. Mndez, Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, New York: United Nations, February 2, 2013, http://www.ohchr.org/Documents/HRBodies/HRCouncil/RegularSession/Session22/A.HRC.22.53_ English.pdf. 24. Sonia Haerizadeh, email message to author, July 1, 2013.

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