The Long Shadow of Eugenics in America - The New York Times

I keep a sepia-tone photograph of the Relf sisters folded up and tucked in my wallet. It’s from a 1973 issue of Ebony magazine. The older of the two sisters, Minnie Lee, stares hard at the camera, her gaze direct and unsmiling but pleasant, almost quizzical. Her hair is freshly pressed, hot-curled and brushed into place, making her look older than 14. In a clean white dress with lacy zigzags, she seems ready for Sunday school. Her left arm is draped around her baby sister, Mary Alice, age 12, anchoring her in place. The younger Relf sister cracks a big, playful smile, her hair in braids — and not the usual three unruly braids from other pictures of the sisters during this time. Instead they are pinned down, neat and tidy for the Ebony shoot. The bottom of Mary Alice’s schoolgirl dress is hiked up as she reaches up to rest her right arm, the one that’s not fully formed, a disability she was born with, on her sister’s shoulder.

That same picture lay on the passenger seat of my rental car in February 2020 as I turned into the Westport Apartments, a cluster of brick homes situated behind a strip mall near the Mobile Highway in south Montgomery, Ala. When I knocked on the door of the Relfs’ home — a cramped single-story apartment that looks like all the others in the public-housing complex — Mary Alice yanked it open with a big smile, the same one in that picture from 49 years ago. She pulled me into the house and said something I didn’t quite understand, though after spending time with her, I would come to better comprehend what on that day was a raspy collection of sounds, resulting from a speech impediment and an intellectual disability that make communication difficult for her.

On that afternoon, Minnie Lee sat resting her elbows on their dining-room table, which was covered with glass to keep it from getting scratched. “I’m sorry, ma’am, I can’t stand up for you,” she said politely, pointing down to her right foot. It was in a bulky gray cast. While reaching for a can of string beans in her kitchen cabinet the week before, she lost her balance and fractured it in three places.

Mary Alice pulled a chair close to her sister, so they were nestled next to each other as in the Ebony photo and nearly every other photo of the Relf sisters. They are now 61 and 63; looking at them pressed together as though attached, I could still see the faces of the two young girls forever memorialized a half century ago beneath the headlines “Suit Says Girls Were Sterilized” in The New York Times; “Sterilized, Why?” in Time magazine; and, in Ebony, “Sterilization: Newest Threat to the Poor.”

In the summer of 1973, Minnie Lee and Mary Alice were taken from their home in Montgomery, cut open and sterilized against their will and without the informed consent of their parents by a physician working in a federally funded clinic. The Relf case would change the course of history: A lawsuit filed on their behalf, Relf v. Weinberger, helped reveal that more than 100,000 mostly Black, Latina and Indigenous women were sterilized under U.S. government programs over decades. It also officially ended this practice and forced doctors to obtain informed consent before performing sterilization procedures — though as it would turn out, forced sterilizations by state governments would continue into the 21st century.

From 1907 to 1932, 32 states passed explicit eugenics laws that allowed for the government to sterilize the “insane,” the “feebleminded,” the “dependent” and the “diseased” — all of whom were deemed incapable of making their own decisions about reproduction. Nearly all of these laws have been repealed (in Washington State, a version of the law still remains on the books). Indiana, Virginia and North Carolina have created historical markers to commemorate those who were sterilized through government-sanctioned programs. Eight states have issued official apologies.

“While eugenics practices and policies are no longer in existence, the impact and the legacy deeply remains today,” Jill Krowinski, speaker of Vermont’s House of Representatives, said on the Statehouse floor in Montpelier last October. Vermont state legislators apologized for using forced sterilizations and other practices to reduce populations deemed unfit to have children — including Indigenous and mixed-race people, people with disabilities and low-income families. “For those that were directly impacted, for their descendants, and for all of the communities involved, we cannot undo the trauma that this moment has caused, but we can start by formally acknowledging this dark period in our state’s history. Today, we publicly apologize for the Legislature’s role in ever allowing this to occur.”

Some states have begun to go beyond apologies. Three so far, Virginia, North Carolina and California, have established programs to compensate victims of forced sterilization. But Alabama, where the Relf sisters were forcibly sterilized and which has been their home all their lives, is not one of those states, and the federal government has made no such moves. The Relf sisters subsist in obscurity on meager Social Security checks.

“I can show you what they did to me,” Minnie Lee said. She lifted up her T-shirt and revealed a jagged horizontal scar that rips across her abdomen. “That’s where they cut me.” As she lowered her shirt — which had the word “courage” printed three times on the front — she dropped her head. Mary Alice, sitting on a floral-patterned chair next to her, with a poster of the Last Supper displayed in an ornate plastic frame on a nearby wall, watched intently, her glasses pushed up on her face. Her half arm rested lightly on her thigh as she leaned in to listen to her sister. “It might have happened a long time ago, but it still brings back memories,” Minnie Lee said, looking at Mary Alice. “We’re still thinking about it.”

The history of legalized forced sterilization by the government begins in 1907, when Indiana became the first state to pass a eugenics law providing for the involuntary sterilization of “confirmed criminals, idiots, imbeciles and rapists.” Those affected early on were mainly men viewed as criminalistic, including those whose “defect” was supposedly excessive masturbation or homosexuality.

“That first law focused on vasectomizing poor white men who were identified as being sexually deviant,” says Dr. Alexandra Minna Stern, a professor of American history and culture at the University of Michigan and co-director of the Sterilization and Social Justice Lab. Her research team studies the history of eugenic sterilization in the United States and has collected the records of more than 60,000 survivors in California, Iowa, Michigan, North Carolina and Utah. “We’re talking about sterilizing populations that are being seen as hypersexualized or as sexually inappropriate, as promiscuous, as not having middle-class sexual respectability.”

By the 1930s, women became a majority of the victims, sterilized in mental hospitals and prisons and under court orders. This shifting gender pattern resulted from a rising concern about the fitness to parent, with a focus on mothering, as well as the development of a safer, standardized tubal-ligation procedure for sterilizing women. The movement was codified in 1927, when the Supreme Court upheld the right of the state of Virginia to sterilize Carrie Buck, a 20-year-old white woman. Born in 1906 to a mother living in poverty in Virginia, Buck was sent to a working-class foster home, where at age 16 she was raped by an extended-family member. Her foster parents took custody of Buck’s daughter and successfully petitioned a local court to confine Buck at the Virginia State Colony for Epileptics and Feeble-Minded — though she was neither epileptic nor intellectually disabled. There she was sterilized without her consent. Writing for the majority in the landmark Supreme Court case Buck v. Bell, Justice Oliver Wendell Holmes Jr. stated, “It is better for all the world, if instead of waiting to execute degenerate offspring for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind.” He added, “Three generations of imbeciles are enough.”

More than 60,000 men, women and children would be sterilized under these state laws, which would also inform Nazi Germany: The Third Reich sterilized approximately 400,000 children and adults, mostly Jews and other “undesirables,” using a 1933 law modeled after legislation in the United States. Germany’s Law for the Prevention of Offspring and Hereditary Diseases focused on people with a high probability of having a child with a serious “defect,” including blindness, deafness and manic depression. The last eugenics legislation in the United States was passed in Georgia in 1937, and eventually the laws would be rolled back in a series of repeals. But that didn’t stop local governments from sterilizing many more people, mostly women of color. The voting rights activist Fannie Lou Hamer was given a hysterectomy without her consent in 1961 when undergoing removal of a uterine tumor by a white physician. The practice of being sterilized, including during unrelated surgery, grew so common among poor Black women in the South that it came to be known as a “Mississippi appendectomy.”

“You start seeing people sterilized in the ’40s, ’50s, ’60s and beyond as a population-control measure, as a means of decreasing the dependent population, which was the same idea the eugenicists had, but now without the laws,” says Paul A. Lombardo, a professor at the Georgia State University College of Law in Atlanta, author of “Three Generations, No Imbeciles: Eugenics, the Supreme Court and Buck v. Bell” and editor of “A Century of Eugenics in America: From the Indiana Experiment to the Human Genome Era.”

“It generally came down to sex and money, which means, ‘Who’s having babies that I don’t want my tax dollars to go to?’” Lombardo says. “So then you start identifying people like the Relfs.” He continues, “Those young girls represented the perfect storm of race, poverty and alleged disability.”

Jessie Bly, a 30-year-old Black social worker, was working in Montgomery when she received a call from a local city councilman in 1972. Her employer, the City of St. Jude Catholic Church, was founded by a progressive Catholic priest in the 1930s to serve as a “center for the religious, charitable, educational and industrial advancement of the Negro people.” Bly was born and raised in Montgomery; her mother was a housekeeper and her father a gravedigger. They understood early that their seventh child was bright and engaged, and they sent her to private school. She was the only one of eight siblings to finish college. Her work at City of St. Jude included checking on the condition of the elderly and the poor to make sure they had necessities and basic services.

Now the councilman was asking her to take a ride with him to a poor Black community in Montgomery called Flatwood to go see a family. When she asked, “What kind of family?” she recalled that he replied, “Trust me, in the day that we’re living, I never thought that we would see anything like this in the United States of America.”

In Flatwood, Bly was shocked by what she witnessed. “I was waiting to see a house,” she said, “but I never saw one.” The Relfs, a husband, wife and six children, were living as squatters in a field, sheltered in a shanty built from cardboard boxes. “They had no running water, no electricity,” Bly, now 80, said, closing her eyes and shaking her head. “I was really taken aback, because I just couldn’t believe that anybody would be living in those conditions. But they were.”

Bly, a mother, grandmother, great-grandmother and ordained minister who still lives in Montgomery, said what crushed her heart most were the girls, teenage Katie and her two younger adolescent sisters, Minnie Lee and Mary Alice. Bly couldn’t shake the image of the youngest girl, who was physically and intellectually disabled. “She was born with an automatic amputation, with the umbilical cord wrapped around her right arm,” Bly said. “She had no hand, and the arm was just a little stub.”

Like many Black families at the tail end of the Great Migration in the 1950s and 1960s, the children’s parents, Lonnie and Minnie Relf, both illiterate, were forced out of rural Macon County, Ala., where mechanization had caused jobs in the fields to dry up. Some former field workers went North, but others crowded into Southern cities like Montgomery, the state capital. Census data shows that in 1960, for the first time, Alabama’s urban population exceeded the rural population, in a state that was nearly one-third Black. This influx of rural Black residents, most unskilled and lacking education, increased poverty in the Black communities in a number of Southern cities. But even if Lonnie Relf had been able to find a job in Montgomery, he was disabled in an accident and was unable to work.

Bly arranged with the director of the Montgomery Housing Authority for the Relfs to live in a three-bedroom apartment in Smiley Court, a public-housing project on the west side of the city. Once the family moved into their new home, Bly took them to the Salvation Army and Goodwill to buy used furniture and put out a call for donations of linens, cooking utensils and other household items to the people in her church and network. She taught Minnie, who was used to preparing meals on a rudimentary oil burner in old burned pots, the basics of keeping house and how to use a stove. “They didn’t know how people really lived,” Bly says. “Life had passed them by.”

The girls had no idea about hygiene, so Bly showed them how to wash and care for their bodies and got the two older daughters enrolled in public school. She took Mary Alice to a pediatrician who specialized in developmental disabilities for evaluation. He declared her “mentally incompetent,” not teachable but trainable, and recommended the McInnis School for Retarded Children. Bly worries, years later, that visiting the government-funded diagnostic facility put the Relf girls on the radar of the family-planning clinic that would eventually arrange the sterilizations. More likely, they were flagged by the government services they were receiving: food stamps, a $156 monthly check from the Alabama Department of Pensions and Security, medical benefits and a subsidized apartment in public housing.

These services were administered through the Office of Economic Opportunity, the federal agency established in 1964 as part of the U.S. government’s proclaimed war on poverty. That year, President Lyndon Johnson initiated his ambitious multibillion-dollar Great Society agenda, which would lead to Medicare, Medicaid, Head Start, the distribution of food stamps and other programs in an effort to end poverty and hunger, reduce crime, abolish inequality and racial barriers and improve the environment. Also under the auspices of the O.E.O., in 1967 the U.S. government created its family-planning program, which was intended to help poor people prevent unwanted births through contraception and other reproductive-health services.

After Richard Nixon was elected president in 1968, his Republican administration set out to dismantle Great Society programs, while also increasing funding for family-planning services in an effort to target the so-called population bomb. This term, popularized by the Stanford University professor Paul Ehrlich — and the title of his 1968 best-selling book — referred to an exaggerated population explosion that he incorrectly predicted would lead to global famine in the 1970s and 1980s. Nixon championed the Family Planning Services and Population Research Act of 1970, also known as the Birth Curb Bill, a $382 million federal program to control population growth, which had ballooned into a national obsession.

Efforts like this took particular aim at poor women, arguing that poverty bred more poverty, so keeping the poor from having babies — particularly “illegitimate” children born out of wedlock — offered a solution. Though the initial O.E.O. regulations of 1967 stated that “no project funds shall be expended for any surgical procedures intended to result in sterilization or to cause abortions,” the prohibition on funding voluntary sterilization ended in 1971. “The ’70s and ’80s were this kind of interesting moment where at the same time state sterilization laws were being repealed, America was creating the conditions for the sterilization of the Relf sisters,” says Dr. Stern of the University of Michigan Sterilization and Social Justice Lab. “The federal government funneled money into county family-planning programs, especially in the South,” she continues. “These facilities were twisted by racial and eugenic logics and pre-existing, longstanding racism and disempowerment of Black mothers and Black girls. Yet there were no checks on anything.”

According to the Relf v. Weinberger lawsuit, not long after the family moved into public housing, the Relf sisters were directed to the family-planning clinic of the Montgomery Community Action Committee, which was funded and controlled by the federal O.E.O. The process began with Katie, the oldest of the three girls, who was about 16 when she was first injected with the contraceptive Depo-Provera. At that time, the drug was still in the investigational phase and not yet approved by the F.D.A. for administration to adult women, let alone minor teenagers. Between 1967 and 1978, during a clinical trial of Depo-Provera, the Grady Memorial Hospital Family Planning Clinic in Atlanta administered the drug to 11,400 mostly poor Black women despite serious side effects, including heavy or interrupted menstrual bleeding and near suicidal depression.

The staff at the family-planning clinic in Montgomery never obtained permission to perform the injections or adequately explained the shots to Katie or her mother. Sometime later, Minnie Lee and Mary Alice were also injected with Depo-Provera. Bly remembers that a member of the staff would later explain the decision by saying that she was worried that “boys are hanging around the house, and we don’t want no more of their kind,” though there was no evidence that any of the girls were sexually active. The Relf sisters were judged to be intellectually inferior, though only Mary Alice would be diagnosed with an actual disability. The other two girls lacked formal education and were struggling to catch up to their peers. In March 1973, Katie, then 17, was again taken to the family-planning clinic, this time for insertion of an IUD, after the Food and Drug Administration denied approval of Depo-Provera because of its link to cancer in animals. Though Katie was under the age of consent, her parents would later insist that they were not consulted about the IUD.

On June 13, 1973, at least one nurse employed by the family-planning clinic came to the Relfs’ apartment and informed Minnie that her daughters would need to see a doctor for what she understood to be more shots. Minnie’s two younger girls, then 14 and 12, were driven first to a doctor’s office and then to the Professional Center Hospital in downtown Montgomery. Later, when she met them at the hospital, health care providers told Minnie she needed to sign a paper. It is unclear what Minnie Relf understood, but she trusted her daughters in the hands of the staff at this clinic, sponsored by the same government that had given her family a home, food, money and an education for her children. Still, it is very clear from her later Senate testimony that she had no idea that signing the piece of paper would mean that her daughters would never be able to bear children. Because she could not read or write, Minnie signed what turned out to be a surgical consent form with an X and was then escorted out to be driven home while the younger girls remained alone in the ward.

Before Minnie got back home, one of the same family-planning nurses returned to the Relfs’ apartment to pick up Katie and take her to the hospital. Katie refused to go, locking herself in her room. The following day, when Jessie Bly stopped by, a frantic Katie told her what had happened. “Where are your sisters?” Bly asked. “I can show you, Miss Bly,” Katie told her, and they got in Bly’s car and drove to the Professional Center Hospital.

Nearly half a century later, Bly has no trouble recalling the younger Relf girls in the hospital, huddled together, looking small and scared in cotton surgical gowns. The second they saw the social worker, they both began to cry. Clinging to Minnie Lee, Mary Alice sobbed and repeated over and over: “I just hurt so bad. I just hurt so bad, Miss Bly, help me. Help me, Miss Bly.”

Bly was shaken. She recalls being unable to sleep, haunted by the image of the young girls crying and calling her name as they stood in the hospital ward. She also feared she was somehow at fault, though she had not been informed about the contraceptive shots or the sterilizations. “I knew I wouldn’t be able to rest, knowing that this kind of an injustice had been perpetrated upon these young ladies and nobody was speaking for them,” she says. “It happened because of where I am, so I felt like God wanted me to be the mouthpiece for them. I was going to do what I had to do.”

Jessie Bly found her way to a law office in a small, old house on Washington Avenue in Montgomery, where the Southern Poverty Law Center was founded two years earlier by two young civil rights lawyers, Morris Dees and Joe Levin, with the civil rights leader Julian Bond as its first president. Bly shared the Relfs’ story with Levin and Dees, who decided to take the case.

In early summer 1973, they filed a case in Federal District Court in Montgomery, and then weeks later refiled the case as Relf v. Weinberger in D.C. District Court, claiming that government officials “have failed to promulgate constitutionally acceptable guidelines by which federally funded and directed agencies can determine who should or should not be sterilized. Further, there are no constitutionally acceptable guidelines to determine what persons are capable of giving knowledgeable, informed consent to the administration upon them of any birth control measures.” Caspar Weinberger, the director of the U.S. Department of Health, Education and Welfare, now the Department of Health and Human Services, from 1973 to 1975, who would later become Ronald Reagan’s defense secretary, was named as a respondent in the suit. The case also named two former Nixon White House aides, John W. Dean III and John D. Ehrlichman.

Just before the official filing, Levin called Bond to brief him on the Relf case. Bond immediately saw it as “a horrendous attack on privacy, innocence and the right of motherhood,” he would tell The New York Times in an article published on July 2, 1973. He encouraged Levin and Dees to contact the news media, and soon articles in The Times and Time magazine and a report on NBC News revealed the plight of the Relfs and the issue of forced sterilization to a national audience. “The suit all of a sudden attracted a great deal of attention,” Levin, now 79, remembers. “And it’s not that we hadn’t had attention, but this was actually at a scale that we hadn’t seen before.”

After Bly was interviewed by reporters from The Washington Post and Jet magazine, she says, the media attention became too intense for her. “I couldn’t go home; I couldn’t go to work,” she says. “Newspaper, magazine people were following me around to get information, and I had to take my kids, and we had to go stay at my mom’s for a while.”

As publicity about the case increased, Orelia Dixon, the director of the family-planning clinic in Montgomery, defended the actions of her facility. In the July 2 Times article, Dixon insisted that her nurses clearly explained to Minnie Relf that the injections for her daughters were no longer authorized and suggested sterilization as an alternative. Dixon also claimed that she and her staff believed sterilization was a proper alternative because the girls were not “disciplined” enough to take daily birth-control pills. “There’s no doubt in my mind that they all knew what that meant,” Dixon told The Times, adding, “We explain everything, and we don’t use words that people can’t understand.”

Levin and Dees, the Relfs’ lawyers, would tell the court that the girls had been targeted for sterilization because they were Black. (Dixon was white, as was the physician who performed the operation, though clinic employees emphasized in interviews for news articles that the nurses who took the girls from their home were Black.) The lawyers also tried to demonstrate that the sisters did not comprehend that they had been sterilized, and still dreamed of bearing children someday. A Times article on July 8, 1973, included an exchange between Morris Dees and young Minnie Lee:

Q. Are you ever going to get married?
A. Yes.
Q. Are you going to have any children?
A. Yes.
Q. How many?
A. One.
Q. A boy or a girl?
A. A little girl.

The news stories caught the eye of Senator Edward Kennedy, Democrat of Massachusetts, then chairman of the Senate Subcommittee on Health of the Committee on Labor and Public Welfare, and he asked Levin and the Relfs to appear at a congressional hearing and tell their story. Levin accompanied Lonnie, Minnie, Katie, Minnie Lee and Mary Alice to Washington — the Relfs’ first and only time on an airplane — to testify. Levin and the Relf parents agreed that it would be too difficult for the girls to speak in an open hearing, so on the morning of July 10, 1973, Katie, Minnie Lee and Mary Alice met with Kennedy behind closed doors.

Levin recalls that the senator showed them pictures of his children, spoke to them gently and listened closely, moved by what he heard. During the Senate subcommittee hearing on sterilization abuse, Kennedy challenged Henry Simmons, H.E.W.’s deputy assistant secretary for health and scientific affairs, and other administrators about why the federal government was involved in coercive, nonconsensual sterilizations of Black and poor women. Then it was Lonnie and Minnie’s turn. Speaking in the gentle tone he used earlier when meeting with the younger Relfs, Kennedy thanked the parents for appearing and asked them to describe in their own words what happened to their daughters. They told their story haltingly, Minnie explaining how she signed an X on the form given to her by the public-health-service workers. “I did not want it done,” Lonnie insisted. “I am still upset about it.”

“What was your feeling then that they had operated on your children?” Kennedy asked Minnie.

“I felt very bad about it,” she said. “I got mad.”

“Would you have permitted it if you had known about it?” Kennedy asked.

“No,” she said. “I would not have let them do that. They said that they was going to give them shots.”

Kennedy again thanked the Relf family for their testimony, complimenting their three daughters and acknowledging their courage. “We have seen too many incidents, mothers and fathers that have been saddened by the kinds of things that have happened to their children,” Kennedy said. “We are going to do our very best to make sure that it does not happen again.”

Levin says that the Senate testimony and Kennedy’s support for the case and the issue had an enormous effect. Though the Relfs’ case would take years to resolve, it helped uncover a pattern of sterilization abuse, financed by the U.S. government and practiced for decades. At the family-planning clinic that executed the sterilizations of the Relf children, 11 adolescent girls had been sterilized, 10 of them Black. But the practice turned out to be much more widespread.

In July 1973, the same month Levin and Dees filed the Relfs’ case in D.C. District Court, a Black woman from North Carolina, Nial Ruth Cox, also filed a suit against a number of people, including the doctor who had surgically sterilized her after telling her, she claimed, that the results would “wear off.” At the time of the sterilization in 1965, Cox was 18, unmarried and the mother of a baby girl. Cox lived with her mother, who was a recipient of government benefits. A county caseworker threatened to strike the family from the welfare rolls unless the mother agreed to have her daughter’s tubes temporarily tied. Five years later, Cox would learn that the sterilization was permanent. Though Cox — who was represented by several lawyers, including the future Supreme Court justice Ruth Bader Ginsburg — lost in court, her suit revealed that her sterilization was part of a eugenics program, created under state law, that began decades earlier.

In North Carolina, doctors performed some 7,600 sterilizations between 1929 and 1974, justified as a way to keep welfare rolls low, reduce poverty and improve the gene pool by preventing the “mentally deficient” from reproducing; the victims were disproportionately Black women and Native American women. In California, more than 17,000 were sterilized between 1920 and 1945 under a state eugenics law used to prevent reproduction of those deemed “unfit”; a disproportionate number were women of Mexican descent. In 1976, a study by the U.S. General Accounting Office found that between 1973 and 1976, four of the 12 Indian Health Service regions sterilized 3,406 Native American women without their permission, including three dozen who were under 21. Also in 1976, H.E.W. reported that over 37 percent of Puerto Rican women of childbearing age, most in their 20s, were sterilized between the 1930s and the 1970s. The U.S. government had taken an active role in population control beginning in 1898, when it assumed governance of Puerto Rico, on the supposed grounds that overpopulation would increase poverty and other social and economic conditions.

Eventually, because of the Relfs’ case and others, the congressional investigations and journalists reporting on them found that thousands of poor, mostly Black women were sterilized each year in the United States under federally funded programs. Many others were coerced into sterilization when health care providers threatened to cut off their benefits unless they agreed to give up their fertility. The Relfs’ suit ended these practices, and H.E.W. was forced to withdraw regulations under which the government funded forced sterilizations. The federal government also instituted a requirement that health care providers obtain informed consent before performing sterilization procedures — more than the X Minnie Relf had signed.

The Relf case happened almost 50 years ago, in another century, and many people would prefer to see it as a dark moment in history that could never happen now. But coerced contraception, including sterilization, has continued into the 21st century. In 2013, the Center for Investigative Reporting found that physicians under contract with the California Department of Corrections and Rehabilitation sterilized nearly 150 female inmates from 2006 to 2010 without required state approvals for the tubal ligations the women received. According to the reporting, prison staff coerced or pressured women they believed likely to return to prison. State documents and interviews pointed to some 100 more procedures dating back to the late 1990s: “From 1997 to 2010, the state paid doctors $147,460 to perform the procedure, according to a database of contracted medical services for state prisoners,” C.I.R. reported.

In 2017, Judge Sam Benningfield of White County, Tenn., was reprimanded for promising 30-day sentence reductions to incarcerated men and women who agreed to receive vasectomies or birth-control implants. Benningfield claimed he was trying to encourage personal responsibility and prevent incarcerated people from being burdened with children when they were released. The A.C.L.U. chapter in Tennessee said in a statement at the time that “offering a so-called ‘choice’ between jail time and coerced contraception or sterilization is unconstitutional.” In the fall of 2020, a nurse at a for-profit Immigration and Customs Enforcement detention center in Georgia reported that unnecessary gynecological procedures — including hysterectomies — had been performed on undocumented migrant women. The women said that they had undergone the operations without fully understanding or consenting to them. The Times reported that Dr. Ada Rivera, medical director of the ICE Health Service Corps, said that the whistle-blower’s claims “raise some very serious concerns that deserve to be investigated quickly and thoroughly.”

These cases demonstrate the persistent vulnerability of incarcerated and detained women in the criminal-justice and immigration systems. But even after the Relf case led to changes in laws, regulations and guidelines regarding forced or coerced sterilization, the question of compensation for the victims has remained. The federal lawsuit was not the only one filed on behalf of the Relfs themselves: Levin and Dees recruited Melvin Belli, nicknamed the King of Torts — and Melvin Bellicose by insurance companies — to file a damages suit to compensate the family. Loud and outrageous, Belli was best known for his celebrity clients: Errol Flynn, Mae West, Lana Turner, Lenny Bruce, Zsa Zsa Gabor, Muhammad Ali and the Rolling Stones. In February 1974, Belli’s firm filed a $5 million damages suit on behalf of the Relfs against the former White House aides Dean and Ehrlichman and other federal officials for blocking the distribution in 1972 of federal guidelines that would have prevented the Relf sterilizations. After that suit was dismissed, Belli followed with another suit for $15 million that July.

After two and a half more years of motions, reversals, reconsiderations and transfers, the Relfs’ last suit was dismissed in September 1977; Levin says it was because an appropriate defendant could not be identified under the Federal Tort Claims Act. The family was left still penniless. “I felt sorry for them,” Levin says now. “The issue was brought to light but had no beneficial consequences for the kids and the Relf family. It felt very bad.”

In 2013, North Carolina — where Nial Ruth Cox’s 1973 lawsuit revealed the state’s eugenics program — agreed to compensate victims of forced or coerced sterilization. Three years earlier, the North Carolina Justice for Sterilization Victims Foundation was started to identify survivors of the state’s program. The organization estimated that between 1,500 and 2,000 survivors might be alive and recommended paying $50,000 to each. In 2013, the State Legislature set aside $10 million. According to Lombardo, the Georgia State University College of Law professor, nearly 800 North Carolinians filed claims, with 220 qualifying for financial restitution. (To be eligible, the operations had to have occurred under the state’s Eugenics Board, but some of the sterilizations occurred outside the auspices of the state, for example at county-run facilities.)

In 2015, the Virginia General Assembly set aside $400,000 for compensation, later adding more, and 30 survivors received $25,000 each. In 2003, California issued a formal apology to the victims of its eugenics program; last year, the state budgeted $4.5 million as compensation for its survivors. From 1909 through 1979, under state eugenics laws, thousands of people who lived in California state-run hospitals, homes and institutions were sterilized. Even after those laws were repealed in 1979, forced or coerced sterilizations continued to be performed on people in custody at state prisons or other correctional facilities. More than 20,000 people were sterilized in California, more than in any other state, and about 600 survivors are still alive today and eligible for compensation. Each will receive an equal share of the funds in two installments.

“Even as everyone recognizes that receiving a check, even for $25,000, is never going to undo the reproductive violence that was done to these people, at least it’s something,” Stern says. “The state is making amends in some way, and it’s an important material and symbolic gesture. I really hope that everyone who can receive compensation is able to find their pathway to the victim’s compensation board and request it.”

The concept of reparations has long been contentious, debated in Congress and elsewhere as a question of what is owed to U.S. citizens who are descendants of those who were enslaved centuries ago. But the steps to compensate the living victims of forced sterilization can also be understood as reparations, and with three states having done so, new pressure has been placed on the remaining 29 states and the federal government itself.

In North Carolina, the first state to compensate survivors, the process began in late 2002, when The Winston-Salem Journal ran “Against Their Will,” a five-part series on North Carolina’s eugenics program. Immediately afterward, Gov. Mike Easley issued a public apology. In April 2003, the North Carolina Senate voted to overturn the sterilization law that had been on the books since 1919. In 2009, the state placed a historical marker in Raleigh to commemorate the 7,600 victims sterilized under the state’s eugenics laws between 1929 and 1974, and the media covered survivors’ sharing memories of the trauma the surgery caused. In 2010, the North Carolina Justice for Sterilization Victims Foundation was started to find survivors; the following year, Gov. Bev Perdue appointed a task force to study a potential compensation package and its cost. Finally, in 2013, North Carolina’s Republican-controlled Legislature voted to spend $10 million to compensate the survivors of the state’s eugenics program.

“There’s a huge movement all across the country to look at historical wrongs, including forced sterilization, and to consider what needs to be done now in order to redress them,” explains Margaret Burnham, founder and co-director of the Civil Rights and Restorative Justice Project at Northeastern University School of Law. “I think this is really the question of the 21st century.”

Minnie Lee Relf never finished high school, dropping out in 11th grade. Keeping up with classwork was difficult for her, given the absence of formal learning in her early childhood and the limitations of her parents. “I was a slow reader in school,” she says now. “I can read, but I’m just slow. I was just slow.” She also recalls her classmates mocking her after learning of the case through media coverage. “People was just picking at me at school, always saying: ‘You can’t have no children. You can’t do this and you can’t ... ,’” she says, her voice trailing off. “It hurt me. I felt so sad.”

Mary Alice was placed in McInnis, the special-needs school that Jessie Bly sought out for her. But she didn’t graduate, either. Their mother died in 1980, just as they reached adulthood, and their father in 2009. Katie, their older sister, lives in an apartment in the same complex. They are still bound tightly together, walking to the store for groceries, attending church, sitting side by side watching TV. “Some days I feel sad, but other times just tired,” says Minnie Lee, who explains that she and her sister struggle with hypertension and asthma, and that Mary Alice also suffers from seizures. “Not long ago, I was crying and felt like doing something to myself, like I wanted to go with my mom and dad,” Minnie Lee adds, looking over at her sister, who doesn’t seem to understand.

Minnie Lee says she recalls the lawsuit; Levin, Dees and of course Miss Jessie Bly; the airplane trip to Washington and Senator Kennedy. But when I describe the impact of their case, how their story stopped the government from harming more girls and women like them, Minnie Lee looks confused. It is too much to comprehend. Mary Alice holds on to my arm and smiles.

I met Katie in April. Now 66, she never finished high school. She and her husband, Michael, had one child, Jerome, who died shortly after he was born. Katie says she can barely remember anything about what happened to her and her sisters 50 years ago; she doesn’t understand why her family didn’t receive any compensation for what was done to them. “But I think about it every day, really,” she said.

As I described the way her family’s case made history, she moved closer to listen. I then explained that apologies have been made to survivors in other places. An apology, she said, “would mean the world to us, and I would forgive them.” She looked away and began to weep.

“Sterilization involves two forms of harm, the physical harm to one’s reproductive autonomy and the moral stigma associated with sterilization, including the suggestion that you are unworthy to reproduce, in the Relfs’ case because they are Black women,” Burnham says. “These women bear a mark of being deemed less than a full person. That moral harm has to be addressed by an apology, and it must come from the state. But they are also owed material redress, some sort of financial repair. That’s what is clearly acknowledged in the Virginia, North Carolina and California initiatives: that practices of truth telling, repair and reparation must come into play when formal law fails.”

Minnie Lee may not understand what the nation gained because of her case. But it is hauntingly, painfully clear that she understands what she and Mary Alice lost. When I visited, I saw that each woman slept with a brown baby doll, Mary Alice’s nestled in a tangle of sheets, Minnie Lee’s laid across her pillow. “I know I can’t have kids, and it gets to me sometimes,” Minnie Lee says. “Every time I see somebody like my cousin or my niece Debbie with their child, I think about it. Seeing these little pretty babies, I wish that was me.”

Linda Villarosa is a contributing writer for the magazine, focusing on race and health. She is an associate professor at the Craig Newmark Graduate School of Journalism at CUNY and also teaches at the City College of New York in Harlem. Hannah Price is a photographic artist and filmmaker based in Philadelphia, with a focus on documenting relationships, race politics and misperception.

This article is adapted from “Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation,” published this month by Doubleday.