[Brussels, 01 July 2011] Around the world evidence continues to exist that there is a disproportionate number of women in vulnerable situations to be threatened with non-consensual or forced sterilisation. Vulnerable women are women living with HIV, Romani women, women with mental health problems or intellectual disabilities, transgender persons, women who use drugs, and indigenous women. They are still threatened to be sterilised even without their own freely-given and informed consent. To prevent forced sterilisation the International Federation of Gynaecology and Obstetrics has adopted the following ethical guidelines and recommendations.

Ethical guidelines

1. Human rights include the right of individuals to control and decide on matters of their own sexuality and reproductive health, free from coercion, discrimination and violence. This includes the right to decide whether and when to have children, and the means to exercise this right.
2. Surgical sterilisation is a widely used method of contraception. An ethical requirement is that performance be preceded by the patient‘s informed and freely given consent, obtained in compliance with the Guidelines Regarding Informed Consent ( 2007) and on Confidentiality (2005). Information for consent includes, for instance, that sterilisation should be considered irreversible, that alternatives exist such as reversible forms of family planning, that life circumstances may change, causing a person later to regret consenting to sterilisation, and that procedures have a very low but significant failure rate.
3. Methods of sterilisation generally include tubal ligation or other methods of tubal occlusion. Hysterectomy is inappropriate solely for sterilisation, because of disproportionate risks and costs.
4. Once an informed choice has been freely made, barriers to surgical sterilisation should be minimised. In particular: a) sterilisation should be made available to any person of adult age; b) no minimum or maximum number of children may be used as a criterion for access; c) a partner‘s consent must not be required, although patients should be encouraged to include their partners in counselling; d) physicians whose beliefs oppose participation in sterilisation should comply with the Ethical Guidelines on Conscientious Objection (2005).
5. Evidence exists, including by governmental admission and apology, of a long history of forced and otherwise non-consensual sterilisations of women, including Roma women in Europe and women with disabilities. Reports have documented the coerced sterilisation of women living with HIV/AIDS in Africa and Latin America. Fears remain that ethnic and racial minority, HIV-positive, low-income and drug-using women, women with disabilities and other vulnerable women around the world, are still being sterilized without their own freely-given, adequately informed consent.
6. Medical practitioners must recognize that, under human rights provisions and their own professional codes of conduct, it is unethical and in violation of human rights for them to perform procedures for prevention of future pregnancy on women who have not freely requested such procedures, or who have not previously given their free and informed consent. This is so even if such procedures are recommended as being in the women‘s own health interests.
7. Only women themselves can give ethically valid consent to their own sterilisation. Family members including husbands, parents, legal guardians, medical practitioners and, for instance, government or other public officers, cannot consent on any woman‘s or girl‘s behalf.
8. Women‘s consent to sterilisation should not be made a condition of access to medical care, such as HIV/ AIDS treatment, natural or caesarean delivery, or abortion, or of any benefit such as medical insurance, social assistance, employment or release from an institution. In addition, consent to sterilisation should not be requested when women may be vulnerable, such as when requesting termination of pregnancy, going into labour or in the aftermath of delivery.
9. Sterilisation, it is unethical for medical practitioners to perform sterilisation procedures within a government program or strategy that does not include voluntary consent to sterilisation.
10. Sterilisation for prevention of future pregnancy cannot be ethically justified on grounds of medical emergency. Even if a future pregnancy may endanger a woman‘s life or health, she will not become pregnant immediately, and therefore must be given the time and support she needs to consider her choice. Her informed decision must be respected, even if it is considered liable to be harmful to her health.
11. As for all non-emergency medical procedures, women should be adequately informed of the risks and benefits of any proposed procedure and of its alternatives. It must be explained that sterilisation must be considered a permanent, irreversible procedure that prevents future pregnancy, and that non-permanent alternative treatments exist. It must also be emphasized that sterilisation does not provide protection from sexually transmitted infections. Women must be advised about and offered follow-up examinations and care after any procedure they accept.
12. All information must be provided in language, both spoken and written, that the women understand, and in an accessible format such as sign language, Braille and plain, non-technical language appropriate to the individual woman‘s needs. The physician performing sterilisation has the responsibility of ensuring that the patient has been properly counselled regarding the risks and benefits of the procedure and its alternatives.
13. The U.N. Convention on the Rights of Persons with Disabilities includes recognition ? that women and girls with disabilities are often at greater risk … of violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation?. Accordingly, Article 23(1) imposes the duty ? to eliminate discrimination against persons with disabilities in all matters relating to marriage, family, parenthood and relationships, on an equal basis with others, so as to ensure that:

• The right of all persons with disabilities who are of marriageable age to marry and to found a family … is recognized;
• The rights…to decide freely and responsibly on the number and spacing of their children …are recognized, and the means necessary to enable them to exercise these rights are provided;
• Persons with disabilities, including children, retain their fertility on an equal basis with others

Recommendations

1. No woman may be sterilized without her own, previously-given informed consent, with no coercion, pressure or undue inducement by healthcare providers or institutions.
2. Women considering sterilisation must be given information of their options in the language in which they communicate and understand, through translation if necessary, in an accessible format and plain, non-technical language appropriate to the individual woman‘s needs. Women should also be provided with information on non-permanent options for contraception. Misconceptions about prevention of sexually transmitted diseases (STDs) including HIV by sterilisation need to be addressed with appropriate counselling about STDs.
3. Sterilisation for prevention of future pregnancy is not an emergency procedure. It does not justify departure from the general principles of free and informed consent. Therefore, the needs of each woman must be accommodated, including being given the time and support she needs, while not under pressure, in pain, or dependent on medical care, to consider the explanation she has received of what permanent sterilisation entails and to make her choice known.
4. Consent to sterilisation must not be made a condition of receipt of any other medical care, such as HIV/AIDS treatment, assistance in natural or caesarean delivery, medical termination of pregnancy, or of any benefit such as employment, release from an institution, public or private medical insurance, or social assistance.
5. Forced sterilisation constitutes an act of violence, whether committed by individual practitioners or under institutional or governmental policies. Healthcare providers have an ethical response in accordance with the guideline on Violence against Women (2007).