At the heart of systemic racism

You would think that gynecological and obstetrical violence in Quebec belonged to another century. However, the last known case of forced sterilization occurred in 2019 on an Indigenous woman1. This exemplifies that this harmful problem is still occurring, despite the evolution of sexual and reproductive rights in recent years.

Obstetric and gynecological violence is defined as any medical act carried out using pressure and fear tactics that prevent patients from providing consent1. These acts can occur in the context of:

• Pregnancy and birth (obstetrical): This may include cesarean section, forced sterilization or hysterectomy - removal of the uterus, forced abortion, etc.
• Any other gynecological care provided to people with a uterus: This may occur during an STI screening test, pap test, IUD insertion, tubal ligation, etc.

These acts may be carried out deliberately or unconsciously by healthcare professionals1^, 2^, 3^, 4^, 5. Gynecological and obstetrical violence perpetrated specifically against Indigenous women is poorly documented and rarely discussed in Quebec1.However, Indigenous women are more likely to experience these forms of violence1.

In history

The phenomenon of obstetric and gynecological violence is part of a movement to discourage reproduction in black and Indigenous populations2^, 4^, 8. In Canada, until about fifty years ago, forced sterilization was permitted in Alberta and British Columbia2. These regulations made it possible to recommend tubal ligation (getting tubes tied) on a woman considered by the medical profession to be mentally unfit to become a mother2^, 7. Those considered less intelligent, or those who did not fit in with social expectations (for example, a woman with multiple sexual partners), could have been deemed unfit to reproduce7. Although these laws have been abolished, the practices continue, putting Indigenous women in particular at an increased risk of being victims of this type of violence.

A difficult picture to paint in Quebec

In Quebec, the last known case of forced sterilization occurred in 20191^, 6. A survey of Indigenous women's testimonies revealed that over half of them (60%) had been subjected to obstetric violence and forced sterilization1. Due to all the violence they experience, Indigenous women distrust police and the Quebec justice system, which poses a serious barrier to reporting obstetrical and gynecological violence. Collecting data remains difficult and obtaining testimonies is challenging.

Testimonials of those who have spoken out

Forced sterilization often takes place in conjunction with other types of obstetric and gynecological violence3. Survivors of obstetrical and gynecological violence who testified reported several experiences:

• Pain is not taken seriously or into account at all. For example, women can be accused of exaggerating the levels of pain they feel1^,3.
• Violence can be experienced through inaction or omission on the part of healthcare professionals1. This can manifest itself in not believing patients, not assessing all the problems reported by them, not clearly answering their questions, or not offering them all possible contraceptive options. It also translates into a lack of consent to provide care, as when consent forms are not provided in languages spoken by those receiving care.
• Physical violence is committed through abrupt gestures, such as closing the patient's legs when she is about to give birth, or non-consensual touching during genital examinations1^,3^, 6.
• Psychological violence is expressed through non-verbal language that conveys exasperation (e.g., sighs), anger, condescension, or annoyance. It can also take the form of pressure to consent to procedures, as in the case of patients who reported accepting tubal ligation under duress and fear1^,3​​​​​​​^, 6​​​​​​​.
• Verbal abuse is reflected in judgmental, sexist, contemptuous, and racist remarks and comments, such as those made by Joliette hospital staff to Joyce Echaquan. Verbal abuse can also take the form of criticism, for example of a person's parenting skills, choice of number of children, or lifestyle. Finally, it can be expressed through the dissemination of stereotypes about aboriginal origins, such as the one suggesting that people get pregnant repeatedly to receive financial benefits1^,3​​​​​​​^, 6​​​​​​​. 

The experiences reported violate the rights of Indigenous women in many ways. Also, these acts of violence have long-term consequences for the survivors:

• On a physical level, hysterectomy that causes hormonal imbalance, or pain following abrupt surgery1.
• On a psychological level, the lack of understanding of symptoms and the impact of physical consequences contribute to the deterioration of psychological well-being1.
• On an interpersonal level, the impossibility of starting a family or procreating again leads to a profound sense of guilt, regret, or shame, and impacts relationships1. It also leads to a loss of trust in medical institutions and healthcare personnel1^, 2^, 3. This, in turn, can be detrimental to the health of Indigenous people, as they become more reluctant to seek help.

Recommendations

To improve the health and rights of Indigenous women in Quebec, certain recommendations can be put in place to foster the necessary changes:  

• It is important to recognize the presence of gynecological and obstetrical violence among Indigenous women1. It is suggested to put in action awareness-raising campaigns on gynecological and obstetrical violence. This could have the effect of making healthcare professionals more aware and better equipped to intervene. Patients could be made more aware of their rights when it comes to obstetric and gynecological care, which could help prevent slippage.
• It is important for healthcare professionals to become familiar with the realities of Indigenous women receiving care. To achieve this, the government must hire more professionals from Indigenous communities3. It is also recommended to adopt a stance that encourages Indigenous people to regain power over decisions concerning their sexual and reproductive health3. This requires free and informed consent and the cultural safety of care spaces, for example by allowing access to spiritual guides, providing consent forms in the language spoken by the patient, or ensuring that interpreters are provided if necessary1.
• Denouncing injustice and putting concrete measures in place seems to be the approach of choice for repairing patients' trust in the medical profession. This represents an important first step towards access to more equitable care2.

Despite advances in sexual and reproductive rights, it is disturbing to note that gynecological and obstetrical violence persists in Quebec, particularly among Indigenous women. We must recognize this reality and act collectively to put an end to these unacceptable practices. The courage of the survivors who testify to the profound impact of this violence on their lives can inspire us to work together toward a more equitable obstetrical and gynecological care system, respectful and attentive to the rights of everyone.

This blog post was originally written as part of the Sexual and interpersonal victimization course taught by our member Marianne Girard, at UQAM's sexology department in Fall 2022. The publication of this article was made possible thanks to our partner, the Interdisciplinary Research Centre on Intimate Relationship Problems and Sexual Abuse (CRIPCAS), and the Fonds de recherche du Québec. 

• 1a1b1c1d1e1f1g1h1i1j1k1l1m1n1o1p1q1rBasile, S., & Bouchard, P. (2022). Consentement libre et éclairé et stérilisations imposées de femmes des Premières Nations et Inuit au Québec. [Rapport de recherche]. Commission de la santé et des services sociaux des Premières Nations du Québec et du Labrador. https://files.cssspnql.com/s/oPVHFaKIp8uw5oF
• 2a2b2c2d2e2fClarke, E. (2021). Indigenous women and the risk of reproductive healthcare: Forced sterilization, genocide, and contemporary population control. Journal of Human Rights and Social Work, 6(2), 144–147. https://doi.org/10.1007/s41134-020-00139-9
• 3a3b3c3d3e3f3g3h3iDavis, D.-A. (2019). Obstetric racism: The racial politics of pregnancy, labor, and birthing. Medical Anthropology, 38(7), 560–573. https://doi.org/10.1080/01459740.2018 .154 9389
• 4a4bEl Kotni, M., & Quagliariello, C. (2021). L’injustice obstétricale: Une approche intersectionnelle des violences obstétricales. Cahiers du genre, 71, 107-128. https://doi-org.proxy.bibliotheques.uqam.ca/10.3917/cdge.071.0107
• 5Lausberg, S. (2020). Violences obstétricales, un enjeu de la lutte contre les violences envers les femmes. Périnatalité, 12(4), 157–164. https://doi.org/10.3166/rmp-2020-0097.
• 8Stote, K. (2022). From eugenics to family planning: The coerced sterilization of Indigenous women in post-1970 Saskatchewan. Native American and Indigenous Studies, 9(1), 102-132. http://doi.org/10.1353/nai.2022.0013
• 7a7bStote, K. (2019). Sterilization of Indigenous women in Canada. Dans The Canadian Encyclopedia. https://www.thecanadianencyclopedia.ca/en/article/sterilization-of-indigenous -women-in-canada
• 6a6b6c6dNovello-Vautour, K. (2021). Discriminer le miracle de la vie : La violence obstétricale chez les personnes noires et autochtones dans les institutions de santé au Canada. [Mémoire de maîtrise]. Université d’Ottawa. http://hdl.handle.net/10393/42722