The simplest form of male sterilization, castration, is an old practice and probably began with animals. Because most domestic animals tend to flock together and produce roughly the same number of male and female offspring, and one male was all that was actually needed to service dozens of females, castration to early herders served to be the ideal solution to the fighting and competition that resulted from male animals seeking to mate with as many females as possible. Some individuals even became specialists at castrating, and in the early Vedic record of India, the term vadhyrsava (literally “he who castrated horses”) appears.
There are many methods for castrating animals but it is safest to do so shortly after the testicles descend in the newborn male. The mortality rate is not particularly high if castration is carried out on the young. It is higher when adult animals are castrated. If a string or horse hair is tied tightly around the scrotum, the testicles turn black and drop off in about three weeks. Among the many other methods is biting of the testicles with one’s teeth (as was often done with lambs by sheepherders).Some species of animals were castrated so frequently that they developed special names such as gelding or ox.
In humans, the castration process originally was probably quite brutal with a slash of a sword cutting off the penis and testicles. Because this is such a vascular area, the mortality was extremely high and such drastic methods were also regarded as painful and symbolic ways of killing an enemy. When males were first castrated for religious purposes or to become the neutered servants or bureaucrats of the powerful has been lost to history but it was done in many ancient civilizations. Many of the imperial servants in China were castrated, having not only their testicles removed but their penis as well. One of the religious groups that emphasized male castration was the hijras of India. Renunciation of sex desires was held by the believers in the cult to emphasize their commitment to the gods.The emasculation operation itself is called nirvan, a term for the state of mind in which the individual is liberated from the finite human consciousness and approaches the dawn of a higher consciousness. Many of the slaves in ancient Rome were castrated, and the practice continued in the Byzantine and Islamic empires. In the Byzantine Empire many of the key court officials, even generals, were castrated, because only a man with testicles could be installed as ruler. In the Islamic harems, the servants in the harems were eunuchs, and some units of the military were comprised of eunuchs. Few of those in the Byzantine or Islamic world underwent total castration but simply had their testicles removed or crushed. Some forms of castration were more painful than others. A tortuous form of castration involving splitting the penis is discussed in the Hindu Arthavaveda.
As far as females are concerned, female sterilization is mentioned as occurring among the ancient Lydians but what this implied is unclear. Although there was early recognition of the female “testicles” (ovaries), there is little record of them being removed. Female circumcision, however, which involves in its more drastic form not only the removal of the clitoris but of the labia minora and majora and the sewing up of the vaginal entrance to allow only the expelling of urine and menses, was and is common in parts of Africa and the Middle East. The earliest mention of a human ovariectomy dates only from the end of the seventeenth century, when a Dutch sow gelder reportedly had successfully effected the removal of both ovaries from his own daughter to prevent her from “gadding” about at night. Whether this is medical folklore or reality is unclear, but it is evidence that female ovariectomies were being done on animals. It is not clear when such procedures began. It was not until the end of the eighteenth century that the first successful ovariectomy is recorded by a surgeon who did so to remove a tumor.
Even in the Western world, however, castration and genital mutilation took place at the end of the nineteenth century in countries such as the United States in order in extreme cases to “avoid the dangers of masturbation.” It was also widely used in the twentieth century as a punishment for sex crimes and under much of the eugenic legislation for sterilizing both the mentally retarded and handicapped. It was not, however, until the end of the nineteenth century, with the recognition of the importance of asepsis and the use of anesthesia that surgeons were at all willing or able to deal with any invasion of the body cavities with any chance of success, that the incidence of female sterilization increased.
It was only in the twentieth century that the voluntary sterilization movement developed, and at the present time it is the most effective method of birth control known. It is also the most widely used method of contraception not only in the United States but in the world and it has become the method of choice for couples who decide that they have completed their family and do not want any more children. The major problem with sterilization is that it is difficult although not impossible to reverse, something those contemplating the surgery should keep in mind.
The standard method for sterilizing males is the vasectomy. It is one of the safest, simplest, and most effective methods of contraception. Interestingly, many of the techniques associated with it in the early twentieth century were perfected by Eugen Steinach (1861-1944), who originally advocated it as a method of sexual rejuvenation. He believed, like the ancient Chinese, that the secretions associated with ejaculation would flow back into the body if he cut and ligated (tied) the vas deferens. Though his idea was discredited when it was pointed out that the secretion simply flowed back into the urine, his method was adopted as a way of sterilizing males. Vasectomy is widely used in China and elsewhere. It is sponsored by Planned Parenthood, and in the United States it is endorsed and encouraged by the Association for Voluntary Sterilization.
Vasectomy is a simple, minor surgical procedure, usually performed under local anesthesia, that takes from ten to fifteen minutes to perform. The surgeon makes a small opening in the scrotum and severs the vas deferens either by tying it, blocking it, or cutting out a small piece. He or she then repeats the operation on the other side because there are two vas deferens, one for each testicle. Some surgeons prefer to make only one incision. Some seal the ends of the vas by ligation (tying it); others, by coagulating it with electricity; and still other, by using clips.
Regardless of the method, the incision is then closed, usually with an absorbable suture such as catgut, although some surgeons make such small incisions that no suturing is required. Postoperative care is relatively simple and involves the patient resting for one or two hours in the clinic and then at home for several more hours. The man should avoid hard work or strenuous exercise for two or three days after surgery and wear a scrotal support for seven or eight days. Sometimes there is mild discomfort, which can be relieved by taking aspirin or other mild painkillers. Usually the incision heals in about a week. Sexual intercourse can be resumed at any time during or after the healing process but contraceptives should continue to be used because infertility is not immediate. In fact, it may take ten weeks or more before the male is infertile. This is because sperm have been stored in the reproductive tract on the urethral side of the obstruction and these must be expelled before it is safe to have intercourse without using some other method of contraception. Part of the usual procedure is to have the semen checked for sperm six to eight weeks after the vasectomy; if they are still present another check is called for within a few weeks, and if they are still present, another surgical procedure might be necessary.
The major obstacle in male sterilization seems to be psychological, which is why careful and accurate counseling is essential before the surgery is performed. Some men, however, should not have a vasectomy or should have it delayed for physical reasons, for instance, if there are local skin infections, a varicocele (enlarged veins in the spermatic cord), a large hydrocele (accumulated fluids in the testes), inguinal hernia (protrusion of the hernial sac containing the intestine through the inguinal opening of the scrotum), filariasis (a chronic disease caused by the existence of thread worms), or the presence of scar tissue from previous surgery. Some systemic disorders such as diabetes also suggest caution, as does a recent heart attack.The failure rate is low, about .15 per 100 person years for those who have an active sex life. This means that there are 15 pregnancies every year for every 10,000 operations. Usually these were a result of surgical errors.
The number of requests for reversals is low, probably not more than two in every 1,000 cases; still this adds up to a significant number. Success with the reversal depends on both the condition of the tissue and the skill of the surgeon, with success being determined by the patient’s ability to impregnate his partner. Even though the vas can be restored, pregnancy is often not guaranteed because a vasectomy leads to decreased sperm count. The longer the vas has been ligated, the less the chance of success.
Other methods of occluding the vas that make the procedure more reversible are being experimented with. The Chinese, for example, inject into the vas a liquid polyurethane or silicone, which provides a solid plug to block the passage when the injected substance hardens. In the United States the silicone plug is being used because the polyurethane apparently releases a chemical that causes cancer in rats. Contraceptive plugs can also be surgically inserted in the vas. Something called the Vassoclude uses one or two medical clips in each vas. As experiments continue, new methods will appear and the would-be candidate should investigate the method best suited for him.
One of the standard methods of female sterilization in the middle of the twentieth century was a hysterectomy, the removal of the uterus and ovaries. The nominal reason for this was a prolapsed uterus or some other kind of uterine difficulty, but in retrospect it seems that many were done as a means of preventing pregnancy. Although hysterectomies are still performed, usually now for reasons other than sterilization, almost all methods of voluntary female sterilization in some way or another block the fallopian tubes, which transmit the ova from the ovaries into the uterus.
Tying the tubes (tubal ligation) is one of the oldest forms of tubal occlusion. Traditionally, it was performed by making a 3- to 4-inch (10-cm) incision (a laparotomy) in the abdomen and tying, dividing, resecting (removing), or crushing the tubes or burying the stumps in the muscular wall of the uterus. Simple ligation (tying off), which dates from 1880, is seldom performed today because of the high failure rate (up to 20 percent). The most widely used procedures are those involving removal of a segment of the tube and ligation of the end. A number of variations to this method are of interest to the specialist, but the most widely used technique is one developed by Ralph Pomeroy, who used it early in the twentieth century, although no description of it was published until after his death. It is the technique recommended by the International Planned Parenthood Federation Panel of Experts. The procedure involves picking up the tube near the mid-portion to form a loop, tying (ligating) the base of the loop with an absorbable suture, and cutting off (resecting) the top of the loop. As the suture material is absorbed, the ends of the tube pull apart. The failure rate is low (0-0.4 percent), although the rate is higher if the procedure is performed at the same time as a cesarean section because the tissues are traumatized.
Since 1960, the procedure has been simplified with the development of the minilaparotomy and laparoscopy. The minilaparotomy, sometimes called the “minilap,” can be performed under local anesthesia. A small insertion of about 2 cm (approximately l inch) is made. Each fallopian tube is then pulled up into the incision in order to be cut and tied, blocked with rings or clips, and allowed to slip back into place. Laparoscopy involves inserting a laparoscope into the abdomen. The laparoscope is a long tube, somewhat like a telescope, through which the surgeon locates the tubes, severs them, and closes the end by cautery, clips, or rings. The incision is smaller than for a minilaparotomy and can be made close to the umbilicus (navel), normally leaving no scar visible. It is easier, however, to make the incision at a spot somewhat lower in the abdomen because this brings the scope closer to the target organs.
It is also possible for the surgeon to enter the abdomen through the vagina (a colpotomy), with or without the scope, to carry out the procedure. This approach has been used extensively in India but is less popular in the Untied States. All of the procedures can be carried out on an outpatient basis under local anesthetic and can be completed in about ten to twenty minutes. If a general anesthetic is used, hospitalization is required and the risk of such surgery is increased substantially because of the inherent risk of anesthesia.
The Chinese developed a method of sterilization in the 1960s through chemical occlusion, that is, obstructing the tubes by chemical burning. This method can be done without surgery and without anesthetic. It involves the insertion of a cannula (a tube) through the cervix and uterus up into the fallopian tubes where phenol (carbolic acid) solution is injected.This results in a scarring of the tubes, which ultimately closes the opening. One of the side effects is mild to moderate pain. The phenol preparation can also cause minor fever, dizziness, nausea, pelvic inflammation, and vaginal discharge. An occasional perforation of the uterus or peritonitis (an infection of the serous membrane that lines the abdominal wall) can occur as well. Chemical occlusion is a very low cost method of sterilization but it is not reversible.
Experiments have been conducted on other chemical compounds: quinacrine, a hardening and thickening agent that damages the tissues of the tubal lining, and methyl cyanoacrylate, a tissue adhesive that turns from a liquid to a solid when it comes in contact with fluid in the tubes, and thus blocks them. New kinds of clips are also being developed that can be inserted either through a minilaparotomy or through various vaginal approaches. The tubal ring can also be installed in the same way. Once the ring is installed, it expands, blocking the tubal opening. Restoring fertility has a higher probability when rings have been used. Like the vasectomy in men, the method of female sterilization is a subject that the woman should discuss with her physician before deciding on the method.
One of the dangers of any kind of tubal sterilization is ectopic pregnancy, that is, the implantation of fertilized ovum outside the uterine cavity. Though the statistical incidence of this is very low, a substantial percentage of those pregnancies that do occur in sterilized women are ectopic ones, and they require surgical removal.
Women with a vaginal or pelvic infection should not undergo sterilization but can proceed when the infection has cleared up. Some kinds of procedures also cannot be used where there are adhesions or scars from previous surgery or infections. Few women in today’s world should undergo any major surgery such as hysterectomy or bilateral oophorectomy (removal of the ovaries) to become sterile, although there might be other reasons, such as cancer, which would justify such drastic surgery.
Some forms of tubal ligation are more reversible than others, and this is something the individual needs to take into consideration if sterilization seems to be the most desirable means of birth control. Sterilization is increasingly the method of choice for those persons who have decided that they have completed their families and, as indicated, is the most widely used family planning method in the world. Female sterilizations, however, far outnumber male sterilizations, even though males can be more easily sterilized than females can. As with so many other forms of contraception, the answer as to why such differences exist lies more in the sphere of human psychology than in techniques or in knowledge.
This article deals with voluntary sterilization. Unfortunately, for a good part of the twentieth century, there was also involuntary sterilization of both sexes. This was part of the eugenic movement discussed elsewhere in this topic. In most of the fifty American states, and in many European countries, individuals who were diagnosed as mentally deficient or socially maladjusted were sterilized. Involuntary sterilization was conceived as a therapeutic method of improving the quality of the “race” and the health of the individual. Involuntary sterilization was first legalized in Indiana in 1907 and by the 1930s, some 27 states had such laws on their books. The Supreme Court affirmed the constitutionality of Virginia’s law on the subject in 1927 in Buck v. Bell.
Decisions about who was to be sterilized varied by jurisdiction and mostly affected disenfranchised people in the United States. Under such programs, a disproportionate number of African Americans, Native Americans, welfare mothers, prison inmates being discharged, people with mental illnesses or physical handicaps, and others who did not conform to middle-class values and standards were sterilized.While there was some opposition to such practices, the real opposition to them was set off by the excesses of Nazi Germany in World War II. The practice then began to decline, although in California the practice was not officially ended until the 1960s.
It should be emphasized that voluntary sterilization means the individual has chosen to terminate his or her reproductive capacity; it is not to be confused with sterilization imposed on others by government or administrative edict.
