It happened in 2001 when she was 29, after her sixth child, about an hour from where we sat in Regina, the capital of Canada's agricultural province, Saskatchewan. The pregnancy and the delivery at Saskatoon Hospital had been routine. S.A.T., who is Cree, had been placed in a hospital room with another Indigenous woman.

It was the second time she'd ever spoken about her experience with anybody outside her family, friends and lawyer—the first was with an Indigenous reporter. And she wanted her oldest daughter to hear about what it meant to be forcibly sterilized.

And then, she said, her son was whisked away and she was wheeled into an operating room. Scared they were going to cut into her, she kept saying, “What are you doing?” and “Please don’t do this.” She was ignored and transferred into another bed by a brusque man—probably the physician—and a team of nurses.

Sterilization is described as a “permanent method of birth control” by the American College of Obstetricians and Gynecologists. For women, this is usually carried out through a tubal ligation—a procedure that closes off the fallopian tube, where fertilization occurs—but can also happen through hysterectomies, induced abortions, and other procedures. When sterilization is forced, however, it becomes a human rights violation, and a tactic of genocide designed to control or eliminate a population.

“The doctor, I remember, he looked at me when it was done and said, “Okay, you’re tied, cut and burned, nothing will get through that.”

The nurses angled her in a strange position. A sheet dropped between her upper and lower half so she couldn’t see the procedure. They gave her another epidural, and as the numbness crept up into her body, she found herself unable to breathe. She continued to say No, she continued to be ignored. And then, a burning smell, a few minutes of metal clinking.

Telling this part of her story, S.A.T. became nervous. She glanced at her daughter, a 20-something young mother with rainbow-dyed hair and a supportive smile. S.A.T. drew a breath. “I didn’t know this would be so hard,” she said before she continued.

But most importantly, perhaps, they are calling for a recognition of colonization and genocidal practices that never ended.

Now more than 100 Indigenous women from various First Nations in the region have come forward to say they were coerced or forced into a sterilization procedure as recently as 2018. Many are part of a class-action lawsuit led by Indigenous rights attorney Alisa Lombard, which has been developing since 2017. The women are calling for sweeping reform to the health system, and $7 million (CAD) each in damages.

Then, four years ago, Indigenous women in the Canadian province of Saskatchewan began to come forward to say that this was still happening in Canada. Brenda Pelletier and Tracy Bannab were the first two women who told the Saskatoon Star Phoenix that they were pressured by staff to sign consent forms for tubal ligations while in the hospital delivering babies.

In the 1970s, both the U.S. and Canada stopped promoting pro-sterilization policies. But they didn’t outlaw them either.

In North America, forced and coerced sterilization of Indigenous women is usually described as something of the past, a dark blemish in American history and a symptom of colonization and the 20th century eugenics movement. The data is sparse but significant: Anywhere from 25 to 50 percent of the Indigenous women of reproductive age in the U.S. were sterilized between 1970 and 1976. In Canada, 1,200 Indigenous women were sterilized between 1970 and 1975, according to Karen Stote, researcher and author of An Act of Genocide, one of the only books on the history of forced sterilization in Canada.

Canada’s implementation of the Indian Act, which heavily restricted First Nations communities from traveling and practicing their culture, pushed Indigenous children to go to residential schools, away from their parents, where they were forced to learn Christian ideology. “If you don’t understand the context of systemic racism, and how colonization shaped these interactions, it amounts to individual bad people doing bad things,” Stote said.

At the time, Indigenous people were often subjected to IQ testing to establish mental deficiency as a diagnosis for sterilization. IQ tests are widely known to be problematic —ill equipped at measuring the acumen of people raised outside of a traditional Western education system. This meant a disproportionate number of Indigenous people were diagnosed as mentally defective and subsequently sterilized.

Hitler himself applauded this movement. “What he did to the Jews, they were already doing to the Indians here—the forced removal of people,” said Juana Majel Dixon, a California-based Indigenous law scholar and secretary of the National Congress of American Indians, who herself was sterilized by the Indian Health Services when she was 16 years old.

At the turn of the 20th century, the eugenics movement was at its height in the U.S. and Canada. As part of the movement, both governments were looking to promote the Anglo-Saxon way of life, and to control the Indigenous population, which had been sovereign and out of reach of mainstream law and culture. Two provinces in Canada—Alberta and British Columbia—created the Sexual Sterilization Act to promote the procedures, and targeted Indigenous women.

Throughout this era, both Canada and the U.S. created and expanded health systems specific to the Indigenous populations in the early 20th century. Both of these systems were largely run and operated by non-Indigenous physicians and government officials, and historically delivered discriminatory and inadequate healthcare .

Emily Murphy, the first woman Magistrate Court Judge in Canada, was hailed as a suffragette when she was appointed in 1916, but she also embodied the government's view of Indigenous people at the time: “One hardly knows whether to take the Indian as a problem, a nuisance or a possibility,” she once said. “Regarding his [sic] future we may give ourselves little uneasiness. This question is solving itself. A few years hence there will be no Indians. They will exist for posterity only in waxwork figures and in a few scant pages of history.”

Morningstar Mercredi, who is from Alberta, one of the first provinces to enact sterilization laws, knows this firsthand. The Dené woman, now in her early 50s, said she lived a difficult, tumultuous life, subject to sexual abuse in her family, and moving between schools and towns in her childhood before she became pregnant at 13. Midway through her pregnancy, Mecrerdi had moved into the baby’s father’s house in Saskatoon, 300 miles from home, when she started spotting blood.

“Some people will say, Well, it was used to prevent the poverty but it’s all connected to the marginalization, the discrimination, the racism,” said Michele Audette, a Quebec-based politician and one of the commissioners on the renown Missing and Murdered Indigenous women report. “The genocide for us, it wasn't just one form....this one was very slow and hypocritical over the long term.”

Their methods had lasting impact on the size of Indigenous families, along with health conditions and economic deprivation. In the U.S., the size of the average Navajo family dropped from 3.72 children to 2.52 between 1970 and 1980. The Apache tribe saw families shrink from an average of 4 children to 1.78 in the same time period. In Canada, the aboriginal birth rate was 47 per 1,000 people in the 1960s and fell to 28 per 1,000 people by 1980.

These systems espoused the Anglo-Saxon idea of a nuclear family unit, a departure from the collectivist societies and large families that many tribal communities had built over centuries. Health providers were told to encourage and carry out “family planning” practices like sterilization and forced abortions on Indigenous populations. Many of these physicians believed they were helping poor Indigenous communities by shrinking family units, and lessening the burden of more mouths to feed, Stote writes.

She left the hospital and called a social worker from her hometown in Alberta. They drove to another clinic across the province—Mercredi depressed and listless—where another physician examined her body, and the small incision in her abdomen. “He had tears in his eyes,” she said. “He said ‘Why did they do this to you?’”

When she went to the hospital, the doctors, without explaining anything to her or receiving consent from her parents, sedated her. When she woke up, her life had been permanently altered. “I was in a lot of pain. I no longer had a baby. And the only thing the doctor told me was your chances of becoming pregnant will be less than that of an average woman,” she said.

“As of September 1975,” wrote U.S. comptroller James G. Abourezk in an official report, “the Aberdeen, Albuquerque, Oklahoma City and Phoenix areas were generally not in compliance with the Indian Health Service regulations.”

It wasn’t until the 1970s, when pro-sterilization laws began to be repealed in both the U.S. and Canada, and after thousands of women like Mercredi had been forcibly sterilized in their childbearing years, that both governments started to look closely at whether or not sterilization procedures were legal and consensual.

Mercredi was later able to have one child—a healthy son—with her first husband, and then would never be able to deliver another baby. Eventually she would see an ultrasound of her pelvic region and find that the doctors in Saskatoon had removed her left ovary and fallopian tube, a procedure called a salpingectomy.

But this wasn’t enough. More women across the region were recognizing themselves in the story, and both the provincial and federal government had yet to offer more than an apology.

“The common denominator was they were told, they were threatened or they did not give consent or they broke their consent or they felt there was no other choice for them,” Boyer said. “So there was no real valid consent at all.” The health region, meanwhile, provided a cursory update of its sterilization manual, guiding health providers to obtain “full, free and informed” consent, recognizing some of its faults.

Senator Yvonne Boyer, who is of Métis descent, and Judith Bartlett, a health administrator and researcher, began an independent review at the request of the Saskatoon Health Region (now the Saskatoon Health Authority), the agency that governs health in the area—eventually publishing a report in 2017 that called for comprehensive and culturally appropriate consent for sterilization procedures, especially as they related to Indigenous women.

“They made it pretty clear they didn’t want me discharged until my tubes were tied,” Brenda Pelletier had told the media about her sterilization procedure at Royal University Hospital in 2010.

But just because sterilization procedures are not completely done in secret doesn’t mean they’re performed ethically. The procedures are never meant to happen by coercion—pressuring weary and exhausted women in the hospital, asking them to do it while they have a cesarian section, or giving out money. In fact, even during the eugenics movement the Department of Indian Affairs in Canada required consent. But this is one of the most pernicious ways that women have been made to sacrifice their reproductive rights in recent decades.

Today, physicians are not told in any official way to shrink or decimate Indigenous families in the U.S. or Canada. Their promotion of sterilization procedures, invasive birth control methods, and other reproductive services, instead, are rooted in a combination of financial incentive and racial violence, the same kind that has led to missing and murdered Indigenous women in recent years.

But as the women in Saskatchewan have confirmed, there is no outright law that bans forced sterilization in Canada.

Morningstar Mercredi was listening to news on the radio as she drove. A report on the lawsuit prompted her to pull over to the side of the road as memories of her own procedure flooded her mind.

S.A.T. found out about the sterilization lawsuit in the way many people get their news these days: Facebook. She was reading articles online one day in 2017 when she saw that other Indigenous women were speaking out about being subjected to tubal ligation procedures and hysterectomies without their consent. She remembered, with a heavy darkness, the doctor from 15 years ago, and sent a message to Pelletier.

Last year, the stakes got even higher. Lombard approached the United Nations Committee Against Torture in Geneva with her case during a hearing about Canada’s human rights record. The committee responded with a series of recommendations for Canada, and called for the criminalization of anybody involved with involuntary sterilization.

“We’ve spoken to women all the way over to Nova Scotia,” Lombard said. “I get the sense the women are feeling emboldened. They didn’t think what the doctor had done was anything they could do anything about.”

Two years later, both women number among the 100-plus plaintiffs waiting for the government to respond. Alisa Lombard, the attorney representing the women in Saskatchewan, has led her clients through numerous hearings, fighting for the right to retain their privacy in the process. And there are other lawsuits coming to fruition in other provinces like Manitoba and Ottawa.

But the racism is not just in the attitude, Lombard said, it’s in the structure of how health services are administered and paid for. Within Canada’s universal health system, the federal government pays for specific First Nations benefits, including birth control. But it’s the province that pays for surgery and procedures—which means that when physicians perform a sterilization procedure, they make more money for something like a tubal ligation, and the federal government gets to pay less for years of birth control. [Neither the federal nor the provincial governments responded to requests for comment.]

“I’ve been through lots of racism, especially in the health system,” said S.A.T.. “Like if I take my kids to the clinics, all the white people would be called in first.” Other times she’s been chastised for the number of kids she had, or her family’s financial status. “Maybe it’s wrong to say, but it’s normal.”

It would require the government, first, to recognize its own racism. In Canada, where the Saskatchewan-based lawsuit is taking place, this is hardly a secret. Indigenous people in Saskatchewan have an R on their government health cards, signifying their status as soon as they walk into the office.

Arresting physicians who have carried out forced sterilization procedures, however, is difficult. For one, Canada tends to protect its physicians, since they often leave to the U.S. where they have higher salaries. But there is also no easy fix to how colonization has influenced health systems, and who should be held accountable.

In the U.S., twice as many Indigenous women receive sterilizations compared to their white counterparts, which most experts say is not simply a matter of demand and supply. One study by Oklahoma State University researchers found that doctors are more likely to suggest sterilization to Indigenous women than white women because they believe them to be less compliant with birth control, or more likely to have bigger families.

“I'm not suggesting they're all sitting in a room like this having a conversation about how they're financially incentivized to sterilize Indigenous women,” Lombard said. “What I'm saying is that the system operates in such a way that the feds don't have to pay this exorbitant amount of money for birth control.”

A map commissioned by the Swedish royal commission showed where sterilization had been implemented in the U.S. by 1929. Image: Wikimedia Commons

For S.A.T., her procedure weighed heavily on her marriage. Her husband blamed her for what had happened—at times convinced she had secretly consented to avoid having more children with him. And she spent decades after avoiding the health system altogether, refusing to face doctors she couldn’t trust, even as her body went into early menopause as a side effect of the procedure.

The more than 100 women suing the government in Saskatchewan are asking not only for an accountable system, but for the damages caused by the trauma that occurs after a forced or coerced sterilization.

In some cases, health providers tell women that they need a sterilization procedure to prevent a reproductive health problem, or lose a future child. But the Oklahoma researchers found that this was often done even if there was no medical reason.

When she went to University of California, Los Angeles, for college, she remembers talking to other Indigenous women for the first time—students from other tribes and reservations that she had never interacted with in Pauma. For the first time, she said, women talked about their sterilization procedures—realizing that this had been happening across the country. “We realized we had a common enemy,” she said.

Majel Dixon herself was sterilized when she was a teenager. Her mother had taken her to an Indian Health Service—i.e. government run—clinic in the nearby town of Escondido for pain in her abdomen. The doctor had her mother sign a paper with no explanation. Then Majel Dixon remembers a quick, painful cauterization procedure—she thought her appendix was taken out—and a note that she could sit out her next volleyball game.

Across the border, at her family’s home on the Pauma Indian Reservation in southern California, Juana Majel Dixon said the long-term trauma of sterilization is not just about the woman, or her family, but about entire communities coping with the absence of a whole and healthy next generation. “We know each other, we see each other,” she said of the women who have been sterilized. “We were dying quicker than we were living.”

For Mercredi, the confusing circumstances of what happened to her as a teenager made it difficult to maintain romantic relationships, and navigate numerous episodes of depression and suicidal ideation. Even after she came forward, the Saskatchewan government send her a letter claiming they had no record of what had happened.

But Majel Dixon didn’t know that it had happened to her until years later, when she tried to become pregnant in her relationship. After she found out, she said, every moon cycle was a reminder that she wouldn’t have children. Every relationship she had required a painful conversation. One time, at a conference of spiritual healers, she said, a traditional practitioner approached her. “Do you know you have spiritual children following you around?” she recalled the practitioner saying. “And I felt the spirit of these children.”

Of women who receive sterilization procedures in general, an estimated 10 percent regret the choice, and wish they had the ability to have more children. Compounded with the coercion and forced procedures, the trauma is far worse for the victims in the lawsuit.

“The women that have undergone this horrendous traumatization are so damaged by the sterilization that the only the plea for help I’ve gotten is that ‘I wanna have children’,” said Boyer.

Now, Majel Dixon said she is concerned by the conversation around reproductive health and how it impacts young women. She doesn’t approve of the medicalization of childbirth—requiring women to only deliver their children from Western physicians in hospitals, far from the midwives and healers that were involved before. And she doesn’t support the emphasis on birth control in her community as the only way to have a sexual relationship, especially given the dwindling population, and her cultural views on children. “For us, every child is a gift,” she said.

It’s clear that in many ways, Indigenous women have been left out of mainstream reproductive health conversations around contraception and abortion, building on a history in which they were left out of suffrage movements in the 20th century. “In both countries [the U.S. and Canada], the conversation has been focused on these specific rights because of the centering of white middle class women,” said Holly McKenzie, a researcher in Interdisciplinary Studies at the University of British Columbia, who studies reproductive rights and the Musqueam Nation.

While the Indian Health Service and the First Nations Health Authority continue to remain chronically underfunded, medical providers still push invasive forms of birth control on this community, McKenzie said. Doctors tell women to get long-acting IUDs and implants, while they tell white women to get birth control pills. [The Indian Health Services did not respond to requests for comment.]

This push remains in stark comparison to the services that Indigenous women have access to, and health systems in which they are chronically lacking in prenatal support, birthing facilities, and healthy birth outcomes.

These days S.A.T. avoids Facebook—there are too many harsh comments from outsiders who don’t understand what Indigenous women are going through. She tries to have a normal life, and to explain to her family about what she’s going through. “I feel like a weight has been lifted off my shoulders, it was something I had blocked out of my mind for so many years.”

Recently, she even went to the doctor for the first time, after a friend who is a nurse convinced her that it would be okay.

But the support of her family and the other women in the lawsuit, she said, doesn’t abate her anger. S.A.T. said the lawsuit will only be successful when Canada changes its national sterilization policy to overtly reject and ban coerced sterilization, and has more restrictions and regulations to protect people like her, and the next generation.

“I don’t want my daughters to ever go through what I went through,” she said. “I don’t want something to be taken away from them.”

Martha Troian contributed to the reporting of this story.

This story was made possible through a grant from the International Women's Media Foundation.