Introduction 
 

          Forced sterilization has a long and unfortunate history, gaining significant prominence with the rise of eugenics in the early 1900s. From 1934 to 1976, the Swedish government forcibly sterilized between 20,000 and 33,000 Swedes in the name of racial biology. The victims were primarily young, poor women[1] During this same time, the Nazi regime forcibly sterilized between 300,000 and 450,000 people. Many were institutionalized minorities[2]. The United States introduced forced sterilization laws in 1907, targeting minorities for eugenics purposes[3]. These practices continued until 1983, when Oregon became the final state to repeal its eugenic sterilization law[4]. These practices disseminated into governments across the world, notably taking place in the 1990s within Latin America, and with the support of US agencies like USAID[5].

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          In July 2000, an immigrant woman with refugee status from Peru named “I.V.” was forcibly sterilized at the Women’s Hospital in La Paz, Bolivia. She was initially hospitalized due to pregnancy complications but received tubal ligation surgery without her prior informed consent[6]. A legal battle ensued, and I.V.’s case was heard before the Inter-American Court of Human Rights (the judicial institution of the Organization of American States that applies the American Convention on Human Rights) in November 2016. In a watershed moment, the Court found the State of Bolivia responsible for violating the rights of I.V., establishing a binding precedent within the jurisdiction of the Inter-American Court, which includes Mexico and much of Central/South America[7].  

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       Ramos Durand et al. v. Peru 
 

          The country from which I.V. had fled, Peru, soon saw its own case on forced sterilization in 2023 with Ramos Durand et al. v. Peru. From 1996 to 2000, the Fujimori Administration of Peru implemented a federal policy called “Programa Nacional de Salud Reproductiva y Planificación Familiar”[8]. The goal of this program was to reduce population growth in Peru.  

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          The government targeted rural and indigenous communities, primarily sterilizing women through tubal ligation or hysterectomy. From 1996 to 2001, an estimated 272,028 people were sterilized[9]. Many of these people, primarily women but some men, were indigenous and poor. Doctors were given quotas for sterilization and rewarded for meeting them. They were also punished if they failed. The Fujimori administration refused to acknowledge that these coercive sterilizations were taking place, instead choosing to describe them as always consensual and part of ‘family planning’. The stated goal of ‘family planning’ was to promote bodily autonomy for women, fight resource depletion, and combat poverty[10]. Ultimately, this was done through population control; it was the opposite of promoting bodily autonomy. Unfortunately, the impoverished in Peru were primarily indigenous and spoke Quechua, the native language of Peru, as their primary language. Doctors communicated almost exclusively in Spanish, but many of these communities had low Spanish literacy rates. In Quechua-speaking regions like Puno, illiteracy rates in 1993 were 22%, one of the highest illiteracy rates in Peru at the time[11]. Women did not understand what the doctors were telling them and more importantly, what the forms they were being handed said. Consequently, many were sterilized without informed consent. These women would not find out they had been sterilized until weeks, months, or even years later, often when complications associated with these procedures arose.  

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          In the process of these forced sterilizations, many people died. One of these women was Celia Edith Ramos Durand, who died on July 24, 1997, after being forcibly sterilized by medical providers. Mrs. Ramos Durand experienced severe medical complications during her sterilization procedure and died three weeks after her surgery. She had previously refused tubal ligation surgery[12]. She was a mother of three, and her story was one of over 3,000 victims that were presented before the Inter-American Court of Human Rights by non-governmental organizations Estudio para la Defensa de la Mujer, the Center for Justice and International Law, and the National Coordinator of Human Rights[13]. The complaint alleges that the Peruvian government violated the following articles of the American Convention on Human Rights: Article 1, Obligation to Respect Rights; Article 2, Duty to Adopt Domestic Legal Provisions; Article 25, Judicial Protection; Article 27, Protection of the Family; Article 4, Right to Life; Article 7, Right to Personal Liberty; Article 8, Judicial Guarantees[14]. The case was dismissed multiple times until the Inter American Commission on Human Rights admitted it in 2019. The case was sent to the Inter-American Court of Human Rights in 2023. On May 22, 2025, the IACHR held a public hearing on the case where Mrs. Ramos Durand’s daughter and two expert witnesses spoke before the court[15]. The IACHR will rule on whether the government of Peru failed to give Mrs. Ramos Durand informed consent on her tubal ligation procedure. If the court rules against Peru, then the ruling would be the first to find liability in the context of a state policy, which was not the case in the preceding I.V. v. Bolivia. This potential outcome raises the question: how should the outcome of Ramos Durand et al v. Peru inform governmental decision-making surrounding contraceptive care, and to what extent will the decision in Ramos Durand et al. lead to policymaking changes throughout Latin America? Understanding how systemic coercion complicates legal understandings of informed consent can provide a better path toward dismantling these systems and providing adequate reparations.  

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       Free, Prior, and Informed Consent 
 

          The IACHR’s standard for indigenous communities to accept medical care is freely given, prior, and informed consent (FPIC). This standard is derived from articles in the American Convention on Human Rights that Peru has allegedly violated in Ramos Durand et al.. For example, Article 7 dictates that “Every person has the right to personal liberty and security”, and Article 4 dictates that "Every person has the right to have his life respected”[16]. FPIC is based on the international human rights standard of self-determination: each person has a right to freely pursue economic, social, and cultural development. The ability for indigenous peoples to give or withhold their FPIC is predicated upon the standard of self-determination being met for these people. Thus, in the context of Peru’s forced sterilization, structurally coercive practices have evidently eliminated self-determination, fundamentally disintegrating the ability for indigenous peoples to provide FPIC[17].  

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          First, consent could not have been freely given. The government of Peru held (and still holds) an innate power over indigenous women, utilizing familial responsibility, education divides, social shaming, and language barriers to coerce consent. In the 1997 case of Magna Morales and Bernadina Alva, the Peruvian government offered food and clothing in exchange for tubal ligation. Mrs. Alva survived the surgery, while Mrs. Morales died. The gifts promised to Mrs. Morales were never delivered and because she had signed her consent, the government could not be sued[18]. She had provided consent, but because she was coerced by the promise of food and clothing, her consent was not freely given. Food is necessary for self-determination and thus a requirement for provision by the state, not a reward for consent. Furthermore, as a mother, Mrs. Morales had a social responsibility to her children to provide them with food. The Peruvian government was acutely aware of indigenous social structures and the role of mothers as providers for their children. By exploiting this duty, it knowingly corrupted the free nature of consent. Consent was also coerced and therefore not freely given because the government employed fear and shaming campaigns to convince women to be sterilized. Through ‘sterilization festivals,’ where food and water were given in exchange for signing sterilization papers, many women experienced both coercion to sign and shaming from nurses when they did not. Chaparro-Buitrago 2022 discusses the story of Luz, an Andean woman who was told in the 1990s by nurses, “You will not survive another pregnancy, and you will not have money to support all your children”[19]. Initially agreeing to sterilization as a result, Luz ultimately changed her mind, but the nurses “violently tied her hands and feet to the bed, and prepared her for the surgery”[20]. Chaparro-Buitrago 2022 writes that Luz’s story was not unique. These stories demonstrate a systematic shame and fear campaign. The government targeted women's fears of not being able to provide for their families to coerce consent, and it could not be revoked.  

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          Second, consent could not have been given prior to many of these operations. Prior consent must be “sought sufficiently in advance of any authorization or commencement of activities”[21]. While there is no exact bright-line for advance notice for prior consent to be valid, it is agreed that prior consent is not valid if a patient is under pressure and duress. Stories compiled by the Quipu Project discuss women who were forcibly sterilized while giving birth. Testimony 100 is the first-hand account of a woman who was coerced into sterilization when she went to the hospital to give birth. She could not have given consent because she was in duress—she visited the hospital because she was bleeding[22].  

Sometimes, prior consent was given through the signing of blank pieces of paper, and patients did not expect to receive a tubal ligation. These situations often took place because of language barriers. Investigative reports from the health ministry of Peru (MINSA) unearthed stories such as Gregoria Condori Riveros, who signed a blank paper under the pretense that it was for a uterine cleaning. However, doctors used the blank paper authorization as proof of consent for sterilization[23]. Public defense reports for women who were forcibly sterilized prove that women would sign without knowing what they were signing: “6 aseguraron que firmaron sin saber exactamente de lo que se trataba o firmaron bajo presión”[24]. For prior informed consent to be valid, the government would have had to provide translation for Quechua speaking people, and they needed to specify what signatures were actually authorizing.  

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          The government further undermined prior consent because it knew that translation services were not provided and utilized this knowledge to further advance forced sterilization[25].  

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          A lack of translation services also undermined informed consent. To consent to sterilization, participants would have needed to be aware of what it was. This was not the case during the Fujimori Administration’s sterilization campaign. Studies estimate that of women sterilized between 1995 and 1997, only 35% received complete information about sterilization and its side effects[26]. The large majority did not receive complete information. Indeed, not receiving complete information about sterilization increased the probability that a woman would be sterilized in 10 percentage points[27].  

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       Moving Forward 
 

          In the case of Peruvian sterilization, FPIC was demonstrably not provided. Peru’s legal structure also created (and still creates) limitations for the rights of indigenous peoples, removing their agency in judicial protection and representation, in violation of the American Convention on Human Rights. The IACHR has already recommended that Peru provide reparations to victims of forced sterilization, but the current structure for delivering reparations remains weak and practically nonexistent[28]. In 2015, Peru created the Registry of Victims of Forced Sterilizations (REVIESFO) to register victims. It has only registered 5,097 women, though over 200,000 victims are presumed to have undergone coerced sterilization[29]. Beyond registering victims, there are no structures put in place to provide reparations. Additionally, what reparations should be is not fully determined. There are two broad forms of reparations: monetary reparations and restorative reparations. The government of Peru needs to compensate women monetarily for the damages that it caused to their livelihood. Furthermore, the government needs to provide restorative reparations; it must provide psychological and medical care, acknowledge full wrongdoing, and publicly acknowledge its failures to raise public awareness for these injustices. To implement these reparations, the government must first make a more concerted effort to register more women in REVIESFO.  ​

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          Registering for REVIESFO requires travelling to one of Peru's 34 district level public defense offices (Direcciones Distritales de la Dirección General de la Defensa Pública), providing identification, and verifying sterilization. Victims also have to prove they did not consent to sterilization procedures, which involves further medical and legal collaboration[30]. Victims who cannot speak Spanish or are illiterate also need an interpreter, but these services are not guaranteed to be available at each district office. Furthermore, victims in rural areas have limited access to their district offices. Figure 1 highlights the locations of district offices, and Figure 2 depicts where sterilization primarily took place, indicated in red. Rural victims located within the Andean mountains or indigenous reserves have low accessibility to district offices, which are located in city centers and require travel to reach. The government must increase registration accessibility by coming to the victims. One way it can do this is by creating mobile registrars that travel into rural communities with translators who help victims register for REVIESFO. Upon increasing registration, the government must utilize gathered information to provide monetary reparations. Peru already has a framework for reparations through Law No. 28592, which enabled reparations for victims of mass political and terror violence between 1980 and 2000. This framework is not perfect and is still evolving, but it proves that Peru has the means to make meaningful policy regarding forced sterilization reparations.  

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          A comprehensive reparations program should include: 

1. Standard monetary compensation for forced sterilization. These practices destroyed the livelihood of many households by causing debilitating long-term consequences to people who were forcibly sterilized, including death. Women and men who were forcibly sterilized should receive monetary compensation in the amount determined by the IACHR. In 2012, the Peruvian reparation law entitled direct victims to at least 10,000 Peruvian soles, setting a clear precedent for present adaptation[31]. Additionally, the IACHR must determine that indirect victims (family members and dependents) are also monetarily compensated.  

2. The establishment of free psychological care. Forced sterilization imposes severe mental harm on victims, which requires intervention to combat the development of generational traumas. To indigenous communities in Peru, forced sterilization was essentially state-sponsored theft of childbearing abilities and the societal status of ‘mother.’ These deep psychological scars severely debilitate mental health, which harms later generations through the impacts of mental health disorders, such as suicide and substance dependency[32]. By providing psychological care, the reparations system can make progress with regards to cyclical impacts of forced sterilization, ensuring that future generations have destigmatized the impact sterilization had on society and how to properly heal from it.  

3. The establishment of free medical care. The Ministry of Public Health (MINSA) provides care to low-income citizens through Seguro Integral de Salud (SIS), but comprehensive benefits relating to complications from forced sterilization are not guaranteed. The government of Peru must provide a benefits package to victims who have been forcibly sterilized, allowing them free access to health assessments related to tubal ligation, and providing the necessary resulting care. Victims of forced sterilization can suffer from complications of neighboring organs, urinary tract infections, nerve artery and organ damage, blood clots, and deep vein thrombosis (DVT)[33]. A comprehensive benefits package would include continued treatment for any of these complications.  

4. Education programs and recognition. The history of Peru’s forced sterilization must not be repeated. Unfortunately, the government has failed to accept full responsibility for its implementation of the Programa Nacional de Salud Reproductiva y Planificación Familiar’s sterilization program and quotas. Accepting responsibility is a key step toward amelioration of the social stigma that exists today surrounding forced sterilization. Next, sharing information about the forced sterilization program is necessary to further take responsibility, but also to address systemic underpinnings that resulted in the initial policy. Education through the school system and public campaigns has the potential to decrease anti-Indigenous sentiment and is critical for ending cyclical violence against Peru’s indigenous population[34].  
    

          There are many more policy ideas that Peru can and should implement. If the IACHR finds that FPIC was not provided by the state at this systemic level, Peru will be responsible for these reparations programs. The precedent established will be necessary for justice in other areas under IACHR jurisdiction. First, it will characterize forced sterilization as structural reproductive violence, giving states less ability to defend against violations with claims of “valid” FPIC. Second, it will force Peru to establish its reparations framework for forced sterilization, which will prove to be an example for states like Bolivia and Puerto Rico, who are also under IACHR jurisdiction. A positive outcome of Ramos Durand et al. v. Peru will set up the global stage for a re-evaluation of structural reproductive violence, how to address its modern consequences, and how to deliver justice to victims who have yet to be reparated.