From Forced Sterilization to Fertility Technology: Addressing Medical Mistrust in Puerto Rico

Isabella Long

Assisted Reproductive Technology (ART) aided in 2% (74,926) of births in the United States in 2018, but in Puerto Rico (a territory of the United States) it assisted in only 0.4% (84) of births. At the same time, according to the Centers for Disease Control and Prevention (CDC), approximately two thirds of pregnancies in Puerto Rico are unplanned, due to a lack of access to and use of contraception, compared to 41.6% in the United States. This disparity reflects a long history of systemic reproductive neglect and coercion.

Puerto Rico has the lowest birth rate of any US state or territory (6.1 per 1,000 people), yet one of the highest cesarean section rates at 50.5%, far above the US average of 32.2%, and continues to report disproportionately high rates of preterm birth, low birth weight, and infant mortality. These challenges are compounded by decades of underfunded care and the ongoing consequences of natural disasters and emerging infectious diseases, and a history of medical abuse.

A legacy of coercion: Sterilization and contraceptive trials

Puerto Rico’s history of reproductive health policies dates back to the early 20th century, when coercive sterilization programs were implemented under the guise of economic and public health reform. In 1937, Law 116 legalized free sterilization, leading to Dr. Clarence Gamble opening sterilization clinics throughout the territory. Fueled by eugenics and the economic interests of American corporations seeking a larger labor force, this initiative resulted in nearly one-third of childbearing women being sterilized by the 1950s, the highest rate in the world. Many women were coerced, misled, or unknowingly sterilized. Resistance to these abuses came from leaders such as Dr. Helen Rodríguez-Trías and organizations including the Committee to End Sterilization Abuse (CESA), which documented widespread violations of informed consent and fought to protect reproductive rights. However, sterilization was not the only form of reproductive exploitation Puerto Rican women endured.

In 1956, Margaret Sanger and Gregory Pincus launched clinical trials for an experimental contraceptive pill in Puerto Rico, circumventing stricter US regulations. Over 200 women in Rio Piédras were enrolled, most of whom were poor and lacked access to formal education. These participants received little to no information about the drug’s safety, reflecting the medical standards of the time which did not prioritize informed consent. Women who later reported serious side effects such as nausea, dizziness, and blood clots were dismissed as “unreliable historians.” These trials echoed broader eugenicist ideologies and disproportionately targeted marginalized communities. Sanger, a central figure in these trials, later founded Planned Parenthood, an organization now advocating for reproductive autonomy, yet built upon a legacy of exploiting Black and Brown women. Without these ethically compromised experiments on Puerto Rican women, much of the groundwork for ART would not exist.

Rebuilding trust and expanding reproductive rights

The history of coerced sterilization and unethical contraceptive trials is not just a chapter of the past, it continues to shape reproductive healthcare decisions today. The expansion of ART in Puerto Rico must be understood within a broader demographic context. According to the World Bank, Puerto Rico’s total fertility rate has dropped to just 0.9 births per woman, far below the replacement rate. This dramatic decline has prompted government and medical institutions to view ART as a solution to what some frame as a population crisis. Yet this perspective presents a troubling ethical reversal from suppressing reproduction to encouraging it. While ART has the potential to offer reproductive autonomy, its rollout risks repeating past injustices if it is used as a demographic tool rather than a human rights-based intervention.

International human rights frameworks, such as the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), offer pathways toward restorative justice. These frameworks recognize reproductive autonomy as a fundamental right and provide a foundation for redressing historical harm. They necessitate acknowledging past violations, repairing damaged trust, and ensuring full and informed consent in all aspects of reproductive healthcare. The UN Special Rapporteur on Torture’s classification of forced sterilization as an act of violence calls for more than just prevention, it demands accountability, truth-telling, and a justice process that acknowledges the gendered nature of these offenses.

However, systemic failures persist. The aftermath of Hurricane Maria (September 2017) exposed the fragility of Puerto Rico’s healthcare system, disproportionately impacting maternal and reproductive health services. Clinics struggled with power outages and supply shortages, leading to life-threatening situations for pregnant individuals. The availability of abortion services was severely limited, with only one clinic remaining open immediately after the storm.

Against this backdrop, any expansion of ART in Puerto Rico raises critical concerns. ART could reinforce disparities if it primarily serves affluent individuals while lower-income communities, particularly those still grappling with the consequences of past medical exploitation, remain excluded. The high cost of fertility treatments (with a single round of IVF costing upward of $30,000 in the United States) combined with the lingering mistrust stemming from sterilization programs and unethical trials creates a system where reproductive autonomy is preserved for some but remains out of reach for others. In its earliest attempts to regulate ART, Puerto Rico’s legislature overlooked critical issues of consent, equity, and ethical oversight. The draft regulations failed to address pressing concerns such as posthumous reproduction limits, embryo use consent, and access for marginalized communities. Without integrating ethical frameworks and community-informed safeguards, ART risks replicating reproductive injustices.

Equitable access to ART in Puerto Rico requires a human rights-centered approach to expand availability and actively work to rebuild trust in reproductive healthcare. This means implementing transparent, community-informed policies, integrating ethical oversight into ART services, and addressing the economic barriers that currently limit access. To stop ART becoming yet another technology that deepens existing inequalities, future strategies may include:

Implementing robust informed consent procedures: Collaborate with Puerto Rican healthcare advocates, ethicists, and community members to develop consent procedures for that acknowledge historical trauma, integrate cultural values, and ensure accessible, community-centered information.
Strengthening oversight and accountability mechanisms: Pass legislation establishing a Puerto Rico Reproductive Ethics Board with binding regulatory authority. Require transparent annual public reporting on ART practices and outcomes.
Centering the voices of Puerto Rican women: Establishing intergenerational healing initiatives that address trauma resulting from past reproductive abuses, connecting elders who experienced historical violations with younger generations to foster healing and inform ethical approaches to reproductive care.

By addressing the root causes of medical mistrust and ensuring equitable access, ART can be a tool for empowerment rather than a perpetuation of historical injustices.

Isabella Long is a senior at American University in Washington, DC, United States.