Doctors under contract with the California Department of Corrections and Rehabilitation sterilized nearly 150 female inmates from 2006 to 2010 without required state approvals, the Center for Investigative Reporting has found.
At least 148 women received tubal ligations in violation of prison rules during those five years - and there were perhaps 100 more dating back to the late 1990s, according to state documents and interviews.
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.
The women were signed up for the surgery while they were pregnant and housed at either the California Institution for Women in Corona or Valley State Prison for Women in Chowchilla, which is now a men's prison.
Former inmates and prisoner advocates maintain that prison medical staff coerced the women, targeting those deemed likely to return to prison in the future.
Crystal Nguyen, a former Valley State Prison inmate who worked in the prison's infirmary during 2007, said she often overheard medical staff asking inmates who had served multiple prison terms to agree to be sterilized.
"I was like, 'Oh my God, that's not right,' " Nguyen, 28, said. "Do they think they're animals, and they don't want them to breed anymore?"
One former Valley State inmate who gave birth to a son in October 2006 said the institution's OB-GYN, Dr. James Heinrich, repeatedly pressured her to agree to a tubal ligation.
"As soon as he found out that I had five kids, he suggested that I look into getting it done. The closer I got to my due date, the more he talked about it," said Christina Cordero, 34, who spent two years in prison for auto theft. "He made me feel like a bad mother if I didn't do it."
Cordero, released in 2008 and now living in Upland, Calif., agreed, but she says, "today, I wish I would have never had it done."
The allegations echo those made nearly a half-century ago, when forced sterilizations of prisoners, the mentally ill and the poor were commonplace in California. State lawmakers officially banned such practices in 1979.
During an interview with CIR, Heinrich said he provided an important service to poor women who faced health risks in future pregnancies because of past cesarean sections. The 69-year-old Bay Area physician denied pressuring anyone and expressed surprise that local contract doctors had charged for the surgeries. He described the $147,460 total as minimal.
"Over a 10-year period, that isn't a huge amount of money," Heinrich said, "compared to what you save in welfare paying for these unwanted children - as they procreated more."
The top medical manager at Valley State Prison from 2005 to 2008 characterized the surgeries as an empowerment issue for female inmates, providing them the same options as women on the outside. Daun Martin, a licensed psychologist, also claimed that some pregnant women, particularly those on drugs or who were homeless, would commit crimes so they could return to prison for better health care.
"Do I criticize those women for manipulating the system because they're pregnant? Absolutely not," Martin, 73, said. "But I don't think it should happen. And I'd like to find ways to decrease that."
Martin denied approving the surgeries, but at least 60 tubal ligations were done at Valley State while Martin was in charge, according to the state contracts database.
Martin's counterpart at the California Institution for Women, Dr. Jacqueline Long, declined to discuss why inmates received unauthorized tubal ligations under her watch. But the Corona prison's former compliance officer, William Kelsey, said there was disagreement among staff members over the procedure.
During one meeting in late 2005, a few correctional officers differed with Long's medical team over adding tubal ligations to a local hospital's contract, Kelsey, 57, said. The officers viewed the surgeries as nonessential medical care and questioned whether the state should pay.
"They were just fed up," Kelsey said. "They didn't think criminals and inmates had a right to the care we were providing them and they let their personal opinions be heard."
The service was included, however, and Kelsey said the grumbling subsided.
Federal and state laws ban inmate sterilizations if federal funds are used, reflecting concerns that prisoners might feel pressured to comply. California used state funds instead, but since 1994, the procedure has required approval from top medical officials in Sacramento on a case-by-case basis.
Yet, no tubal ligation requests have come before the health care committee responsible for approving such restricted surgeries, said Dr. Ricki Barnett, who tracks medical services and costs for the California Prison Health Care Receivership Corp. Barnett, 65, has led the Health Care Review Committee since joining the prison receiver's office in 2008.
"When we heard about the tubal ligations, it made us all feel slightly queasy," Barnett said. "It wasn't so much that people were conspiratorial or coercive or sloppy. It concerns me that people never took a step back to project what they would feel if they were in the inmate's shoes and what the inmate's future might hold should they do this."
Jeffrey Callison, spokesman for the state corrections department, said the department couldn't comment because it no longer has access to inmate medical files.
"All medical care for inmates, and all medical files, past and present, are under the control of the Receiver's Office," Callison wrote in an email.
The receiver has overseen medical care in all 33 of the state's prisons since 2006, when U.S. District Judge Thelton Henderson of the Northern District of California ruled that the system's health care was so poor that it violated the constitutional ban on cruel and unusual punishment.
The receiver's office was aware that sterilizations were happening, records show.
In September 2008, the prisoner rights group Justice Now received a written response to questions about the treatment of pregnant inmates from Tim Rougeux, then the receiver's chief operating officer. The letter acknowledged that the two prisons offered sterilization surgery to women.
But nothing changed until 2010, after the Oakland-based organization filed a public records request and complained to the office of state Sen. Carol Liu, D-Glendale. Liu was the chairwoman of the Select Committee on Women and Children in the Criminal Justice System.
Prompted by a phone call from Liu's staff, Barnett said the receiver's top medical officer asked her to research the matter. After analyzing medical and cost records, Barnett met in 2010 with officials at both women's prisons and contract health professionals affiliated with nearby hospitals.
During those meetings, Barnett told them to halt inmate sterilizations. In response, she said, she got an earful.
The 16-year-old restriction on tubal ligations seemed to be news to prison health administrators, doctors, nurses and the contracting physicians, Barnett recalled. And, she said, none of the doctors thought they needed permission to perform the surgery on inmates.
"Everybody was operating on the fact that this was a perfectly reasonable thing to do," she said.
Martin, the Valley State Prison medical manager, said she and her staff had discovered the procedure was restricted five years earlier. Someone had complained about the sterilization of an inmate who had at least six children, Martin recalled. That prompted Martin to research the prison's medical rules.
After learning of the restrictions, Martin told CIR that she and Heinrich began to look for ways around them. Both believed the rules were unfair to women, she said.
"I'm sure that on a couple of occasions, (Heinrich) brought an issue to me saying, 'Mary Smith is having a medical emergency' kind of thing, 'and we ought to have a tubal ligation. She's got six kids. Can we do it?' " Martin said. "And I said, 'Well, if you document it as a medical emergency, perhaps.'"
Heinrich said he offered tubal ligations only to pregnant inmates with a history of at least three C-sections. Additional pregnancies would be dangerous for these women, Heinrich said, because scar tissue inside the uterus could tear, resulting in massive blood loss and possible death.
"It was a medical problem that we had to make them aware of," Heinrich said. "It's up to the doctor who's delivering (your baby) ... to make you aware of what's going on. We're at risk for not telling them."
Former inmates tell a different story.
Michelle Anderson, who gave birth in December 2006 while at Valley State, said she'd had one prior C-section. Anderson, 44, repeatedly was asked to agree to be sterilized, she said, and was not told what risk factors led to the requests. She refused.
Nikki Montano also had had one C-section before she landed at Valley State in 2008, pregnant and battling drug addiction.
Montano, 42, was serving time after pleading guilty to burglary, forgery and receiving stolen property. The mother of seven children, she said neither Heinrich nor the medical staff told her why she needed a tubal ligation.
"I figured that's just what happens in prison - that that's the best kind of doctor you're going get," Montano said. "He never told me nothing about nothing."
Montano eagerly agreed to the surgery and said she still considers it a positive in her life.
Dr. Carolyn Sufrin, an OB-GYN at San Francisco General Hospital who teaches at UC San Francisco, said it is not common practice to offer tubal ligations to women who've had one C-section. She confirmed that having multiple C-sections increases the risk of complications, but even then, she said, it's more appropriate to offer women reversible means of birth control, like intrauterine devices or implants.
"Every C-section, every situation is different," Sufrin said. "Some people with more prior C-sections have absolutely no problems and no risks."
History in eugenics
To be sure, tubal ligations represented a small portion of the medical care provided to pregnant inmates. Statistics and a report from the prison receiver's office show that from 2000 to 2010, 2,423 women gave birth while imprisoned in California, costing the state $2.7 million. Fewer than 1 in 10 were surgically sterilized.
But the numbers don't tell the full story. California still grapples with an ugly past: Under compulsory sterilization laws here and in 31 other states, minority groups, the poor, the disabled, the mentally ill and criminals were singled out as inferior and sterilized to prevent them from spreading their genes.
It was known as eugenics.
Between 1909 and 1964, about 20,000 women and men in California were stripped of the ability to reproduce - making the state the nation's most prolific sterilizer. Historians say Nazi Germany sought the advice of the state's eugenics leaders in the 1930s.
In 2003, the state Senate held two hearings to expose this history, featuring testimony from researchers, academics and state officials. In response, then-Attorney General Bill Lockyer and Gov. Gray Davis issued formal apologies.
"Our hearts are heavy for the pain caused by eugenics. It was a sad and regrettable chapter in the state's history, and it is one that must never be repeated again," Davis said in a statement.
Missing from the hearings was the perspective of state prison officials. Then-Corrections Director Edward Alameida Jr. had informed the Senate committee that the prison system lacked records about sterilizations.
"While obviously this was a dark chapter in our State's history, the CDC (California Department of Corrections and Rehabilitation) played a minuscule role," Alameida wrote in a June 2003 letter. "Thus our participation in your hearing would provide no substantial information on that role and I do not believe our presence would contribute in any way toward your objectives."
However, Alexandra Minna Stern, a professor at the University of Michigan and leading expert on California sterilization, cited state prison activity among the lingering questions from that era. Stern testified during the hearings that she found in private hands and university archives evidence of 600 sterilizations at San Quentin State Prison prior to 1941 that were not included in official numbers.
California sterilizers, Stern told the committee, consistently viewed their work as humane and cost saving.
"One of the goals ... and this is critical to understanding the history of eugenics in California - was to save money: how to limit welfare and relief," Stern told them, according to a transcript of her presentation. "And sterilization is very much tied up in this."
Seeking patient consent
Lawsuits, a U.S. Supreme Court ruling and public outrage over eugenics and similar sterilization abuses in Alabama and New York spawned new requirements in the 1970s for doctors to fully inform patients.
Since then, it's been illegal to pressure anyone to be sterilized or ask for consent during labor or childbirth.
Yet, Kimberly Jeffrey says she was pressured by a doctor while sedated and strapped to a surgical table for a C-section in 2010, during a stint at Valley State for a parole violation. Jeffrey, 43, was horrified, she said, and resisted.
"He said, 'So we're going to be doing this tubal ligation, right?' " Jeffrey said. "I'm like, 'Tubal ligation? What are you talking about? I don't want any procedure. I just want to have my baby.' I went into a straight panic."
Jeffrey provided copies of her official prison and hospital medical files to CIR. Those records show Jeffrey rejected a tubal ligation offer during a December 2009 prenatal checkup at Heinrich's office. A medical report from Jeffrey's C-section a month later noted that she again refused a tubal ligation request made after she arrived at Madera Community Hospital.
At no time did anyone explain to her any medical justifications for tubal ligation, Jeffrey said.
That experience still haunts Jeffrey, who lives in San Francisco with her 3-year-old son, Noel. She speaks to groups seeking to improve conditions for female prisoners and has lobbied legislators in Sacramento. Jeffrey recently completed her ACT college-entrance test and hopes to pursue a degree at San Francisco State University.
"Being treated like I was less than human produced in me a despair," she said.
State prison officials "are the real repeat offenders," Jeffrey added. "They repeatedly offended me by denying me my right to dignity and humanity."
Dorothy Roberts, a University of Pennsylvania law professor and expert on sterilization, said courts have concluded that soliciting approval for sterilization during labor is coercive because pain and discomfort can impair a woman's ability to weigh the decision.
"If this was happening in a federal prison, it would be illegal," Roberts said. "There are specific situations where you cannot say it's informed consent, and one of them is during childbirth or labor. No woman should give consent on the operating table."
Heinrich considers the questions raised about his medical care unfair and said he is suspicious about the women's motives. Heinrich insists he worked hard to give inmates high-quality medical treatment, adding that hundreds of appreciative prisoners could vouch for that.
"They all wanted it done," he said of the sterilizations. "If they come a year or two later saying, 'Somebody forced me to have this done,' that's a lie. That's somebody looking for the state to give them a handout.
"My guess is that the only reason you do that is not because you feel wronged, but that you want to stay on the state's dole somehow."
Barnett declined to say whether Heinrich's practices had been reviewed by the receiver's office, citing employee confidentially laws. Initially, she said she believed Heinrich had left the prison system. However, shortly after retiring in 2011, Heinrich returned in another role. He's currently listed as one of the prison's contract physicians.
Barnett stressed that she sought only to end prison sterilizations, not to investigate officials or interview inmates to discover whether abuses occurred.
"Did Dr. Heinrich say improper things? I can't say," she added. "Is our process sufficiently draconian enough to weed out bad actors? We have a lot of civil service processes. Is it 100 percent effective? Is it the best process we can come up with? No, of course not."