Forced Sterilizations on Trial

On May 22, 2025, the Inter-American Court of Human Rights (IACHR) held a hearing in Ramos Durand et al. v. Peru, a case that could redefine state responsibility for forced sterilizations and strengthen standards on reproductive autonomy. This is only the second forced sterilization case before the Court (after I.V. v. Bolivia) and the first addressing a widespread, state-led policy of coercion like Peru’s.

A central issue in the hearing was whether Celia gave free and informed consent to her sterilization, and how to assess it within a broader context of structural coercion. The victims’ expert described the procedure as part of a systematic and bureaucratized policy targeting vulnerable women. In contrast, the State’s expert argued that Celia had given valid consent according to Peruvian civil law, framing sterilization as a public health measure.

As the Court weighs these opposing positions, this commentary situates Celia Ramos’s case within the broader historical and structural context of Peru’s sterilization policies. It outlines international human rights standards that should guide the Court’s analysis and argues that understanding the full scope of violations requires addressing the underlying inequalities and institutional violence that enabled them.

A Systemic Policy of Reproductive Violence in Peru

Between 1980 and 2000, Peru experienced an internal armed conflict that, according to the Truth and Reconciliation Commission (“Truth Commission”), constituted “the most intense, extensive, and prolonged episode of violence in the country’s republican history.” The Truth Commission documented a strong link between poverty, social exclusion, and the likelihood of victimization, noting that most victims were rural subsistence farmers.

This context of structural violence and marginalization laid the foundation for public policies that deepened inequalities, particularly in reproductive health. In 1996, President Alberto Fujimori launched the National Reproductive Health and Family Planning Program (1996–2000) (NRHFPP). Official records report at least 265,824 sterilizations, while other experts estimate the number exceeds 300,000. While no definitive count exists, the program led in practice to the mass sterilization of hundreds of thousands of women.

The program aimed to expand contraceptive coverage to between 50% and 70% of women of reproductive age, and to ensure that all patients receiving institutional care for childbirth or abortion were discharged using a contraceptive method after counseling. A key strategy to achieve these objectives was the promotion of surgical sterilization, particularly tubal ligation.

Though national in scope, the program prioritized women of reproductive age, pregnant women, and those at risk of unintended pregnancy, predominantly low-income populations. Amid post-conflict inequality, the program framed its objectives within a discourse of a “war on poverty”, marginalization, and lack of family planning information. It justified the policy by pointing out that low-income women had higher fertility rates and less access to contraceptive methods. Rooted in neo-Malthusian logic, the policy was presented as a means to reduce poverty.

Human rights organizations began documenting abuses as early as 1996. The Ombudsperson’s Office received its first formal complaints in 1997 and published a 1998 report highlighting the absence of safeguards to guarantee free and informed choice. Researchers and civil society groups uncovered systemic violations, including mandatory quotas for surgical contraception in health centers and among medical personnel.

A system of incentives and sanctions reinforced the policy: healthcare providers received cash or in-kind payments for each sterilized woman, while promotions, demotions, and the allocation of medical equipment were tied to the fulfillment of sterilization targets and quotas. The program was also implemented through mass campaigns. DEMUS reported large-scale operations aimed at recruiting women for tubal ligation, including so-called “ligation festivals,” which promoted sterilization as a path to happiness and often offered food or money as incentives.

Deceptive practices were widespread. Many women were misinformed about the nature of the procedure or told it was minor. In other cases, they were offered debt forgiveness related to childbirth or abortion in exchange for agreeing to be sterilized. Within a broader context of poverty and exclusion, sterilization often became a transactional means of accessing healthcare or food, services the state was already obligated to provide.

The program operated in an authoritarian and militarized environment. In certain areas, military doctors participated in procedures, and soldiers were stationed outside operating rooms, reinforcing the coercive and state-driven character of the interventions.

Celia Ramos Durand’s Case

Within this broader pattern, the case of Celia Ramos is paradigmatic. A 34-year-old mother of three from a rural village in Piura, Celia fit the target profile of the program. A local nurse repeatedly pressured her to undergo tubal ligation. Her daughter testified that women were told the procedure was “as simple as pulling a tooth” and were not fully informed of the risks. On July 3, 1997, Celia underwent surgery and died from complications, as the health center lacked the equipment and medication to perform it safely.

In this case, the Inter-American Commission argues that the sterilization was rooted in gender stereotypes and structural discrimination, violating Celia’s rights to health and reproductive autonomy. The procedure, carried out without her informed consent, amounted to arbitrary interference with her private life.

Her death was never properly investigated, and the persistent impunity has caused deep harm to her family.

Forced Sterilizations in the Inter-American System

Although this is not the first forced sterilization case brought before the Inter-American system, it will be the first time the Court rules on the Peruvian case and a massive, state-sponsored policy of this kind. In 1999, the Inter-American Commission received the case of María Mamérita Mestanza, a Peruvian woman who, like Celia, was forcibly sterilized under the NRHFPP (Peru’s National Reproductive Health and Family Planning Program) and died from complications. That case concluded in 2003 with a friendly settlement, in which Peru acknowledged international responsibility and agreed to provide reparations.

Years later, in I.V. v. Bolivia, the Court addressed forced sterilization and developed key standards on informed consent. I.V., a Peruvian woman living in Bolivia, was sterilized without her knowledge during childbirth, learning only the next day of her permanent loss of reproductive capacity. The Court affirmed that informed consent before a medical intervention with permanent consequences on reproductive capacity is part of the rights to autonomy and private life (para. 162). It emphasized that every person must be able to make free decisions about their life plan, including whether to have children, how many, and when (para. 162).

The Court held that informed consent must be prior, free, full, and informed, interrelated elements that require a cumulative process, not a one-time acceptance (para. 166). Consent must be given without threats, coercion, inducement, or improper incentives, and only after receiving adequate, complete, reliable, and accessible information (para. 165). That information must be effectively understood, enabling an autonomous and informed decision. Health providers must explain the diagnosis, procedure, associated risks and benefits, alternatives, side effects, and the consequences of the treatment (para. 189). The IACHR also recognized that gender stereotypes and inequality deepen power imbalances in medical settings (paras. 186-7).

However, in I.V., the Court found that the facts did not reflect a state policy or a context of systematic violence (para. 297). This makes Ramos Durand a unique opportunity for the Court to rule on a state’s international responsibility for implementing a widespread, structural, and coercive policy of forced sterilization.

International Standards on Forced Sterilization

Within the UN system, the CEDAW Committee (CEDAW), the Special Rapporteur on Violence Against Women, and the Committee on the Elimination of Racial Discrimination (CERD) have classified forced sterilization as a form of gender-based violence that violates women’s physical integrity and security. The Special Rapporteur has noted that the practice disproportionately affects women due to entrenched stereotypes about their reproductive role (see Report, para. 21). Non-consensual sterilizations are often justified by assumptions that women are incapable of making responsible decisions about their reproductive health, are unworthy of contraception, unfit to be “good mothers,” or that their children are undesirable.

The CERD, CEDAW, and the Special Rapporteurs on Torture and Violence Against Women have also underscored that such practices often target ethnic and racial minorities, constituting intersectional discrimination. Depending on the circumstances, these practices may also constitute torture or cruel, inhuman, or degrading treatment. The Special Rapporteur on Torture and the CEDAW Committee have both stressed that forced sterilization is a form of violence and social control, violating the right to be free from ill-treatment. The mandate on torture specifically notes that coercive sterilizations under state-run family planning policies may amount to torture.

As UN bodies have emphasized, individuals must have the right to choose or refuse sterilization. Respecting autonomy means that any counseling or information provided by healthcare workers must be non-directive, empowering individuals to make the best decisions for themselves. It also requires that patients be fully aware that sterilization is a permanent procedure and of reversible alternatives. Consent must always come from the patient herself and can never be overridden by arguments of medical necessity or emergency if consent is still possible.

This issue has also been addressed in the Peruvian context. In October 2024, the CEDAW Committee ruled on a complaint by five victims of forced sterilizations under Peru’s national program. It concluded that the violations constituted gender-based and intersectional discrimination based on sex, gender, rural origin, and socioeconomic status (para. 8.6). The Committee recommended reparations, continued investigation, and broader reparative measures (para. 9).

Finally, under the Rome Statute, enforced sterilization is classified as a crime against humanity when committed as part of a widespread or systematic attack against civilians. The IACHR has previously qualified acts under its jurisdiction as crimes against humanity, such as in Almonacid Arellano et al. v. Chile (para. 104). Given the widespread, and large-scale nature of Peru’s sterilization program, the Court could also address this in its ruling and whether it will include references to the principle of non-applicability of statutory limitations.

Conclusion

The upcoming Ramos Durand judgment represents a critical opportunity to address a long-standing chapter of impunity in Peru. It could also redefine regional legal standards on structural reproductive violence and set a powerful precedent for Latin American women subjected to such practices. For the first time, the IACHR may explicitly characterize forced sterilizations as reproductive violence and thus as a form of gender-based violence, contributing to a broader and more inclusive understanding of reproductive rights violations within the regional human rights framework.

Central to this analysis is the question of how structural conditions affect autonomy and undermine informed consent. How does decision-making unfold in militarized and coercive environments? In what ways do state-run campaigns distort or suppress individual agency? What are the implications of transactional dynamics in contexts of poverty and exclusion? The Court’s reasoning on how factors such as militarization, institutional coercion, poverty, and gendered stereotypes converge to erode autonomy will be essential for understanding how reproductive injustice operates, and for defining the legal contours of state responsibility in preventing and remedying such violations.