Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945

Nicole L. Novak University of Michigan, Department of Epidemiology

Kate E. O'Connor University of Michigan, Department of American Culture

Natalie Lira University of Illinois, Department of Latina/Latino Studies

Alexandra Minna Stern University of Michigan, Department of American Culture

University of Michigan Population Studies Center Research Report 16-866 June 2016

– Preliminary, not for quotation without the authors’ permission. –

Direct correspondence to: Nicole L. Novak, Doctoral Candidate, Department of Epidemiology, University of Michigan-Ann Arbor, 1415 Washington Heights, Ann Arbor, MI 48109. [email protected]

All sources and images used in compliance with University of Michigan Biomedical IRB HUM00084931 and the California Committee for the Protection of Human Subjects Approval 13-08-1310.

This working paper is part of a larger project, Eugenic Rubicon: California’s Sterilization Stories, a multidisciplinary collaboration among the University of Michigan, University of Illinois, and Arizona State University that includes historical demography and epidemiology, digital storytelling, data visualization, and the construction of interactive digital platforms. This project combines rigorous methods in public health and history and creative approaches to digital humanities, and foregrounds commitments to social and reproductive justice. Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 2

Abstract

Background: From 1907 to 1937, thirty-two US states authorized state institutions for the feebleminded and mentally ill to sterilize residents deemed unfit for reproduction. California carried out one third of sterilizations nationwide. Previous reports have documented the over-sterilization of Latino/Hispanic institution residents, and new individual-level data allows us to examine this ethnic bias at a granular level. Methods: We link data on 17,362 California state institution patients recommended for sterilization from 1920-1945 to U.S. Census microdata on total patient populations of each institution in 1920, 1930 and 1940. We estimate rates of sterilization by Latino/Hispanic ethnicity (Spanish surname) and compare ethnic bias in sterilization by gender, age, time, and justifications for sterilization (mental illness, “feeblemindedness”, or perceived social ills such as sexual delinquency or criminal tendency). Results: Latino/Hispanic institution residents were, on average, recommended for sterilization at 2.65 (95% CI: 2.52, 2.77) times the rate of non-Latino/Hispanic institution residents. Ethnic bias in sterilization varied significantly by sex, age group and institution, with the greatest ethnic bias in sterilization among females, among individuals younger than 15, and among individuals living in state homes for the feebleminded (relative to those living in mental hospitals). There were no consistent ethnic differences in reported degree of “feeblemindedness” or mental health diagnoses, but Latino/Hispanic sterilization recommendees were more frequently flagged for “criminal tendencies” than their non- Latino/Hispanic counterparts. Among females, Latina/Hispanic patients were more likely to be deemed “sexually delinquent”. Discussion: While eugenic sterilization laws did not explicitly encourage sterilization of racial/ethnic minorities, in practice these policies targeted patients stereotyped as over- fertile and criminally inclined.

Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 3

BACKGROUND

From 1907 to 1937, thirty-two U.S. states passed eugenic sterilization laws that were used to control the reproduction of vulnerable populations. These laws remained in force for more than six decades, during which time more than 60,000 sterilizations were officially recorded nationwide, principally in state homes and hospitals for the “feebleminded” and mentally ill. Sterilization rates were fairly steady in the 1910s and 1920s as eugenics gained currency, and increased markedly after 1927 when the U.S. Supreme Court upheld the constitutionality of the practice in Buck v. Bell, a case that tested Virginia’s 1924 law (Lombardo 2010). California passed the third eugenic sterilization law in the nation in 1909 and performed one third, or 20,000 of all documented sterilizations, the vast majority of these between the 1920s and 1950s (Braslow 1997; Kline 2001; Stern 2005; Wellerstein 2011). California’s eugenic sterilization laws authorized medical superintendents in nine state homes and hospitals (Figure 1) to perform sterilizations on patients classified as mentally ill, feebleminded, epileptic, syphilitic, or afflicted with other conditions “likely to be transmitted to descendants.” Eugenic sterilization programs across the U.S. tended to target racial and ethnic minorities (Begos et al 2012) and California’s program was no exception: previous reports have particularly highlighted the over-sterilization of individuals of Latino/Hispanic1 origin in California state institutions (Wellerstein 2011; Lira & Stern 2014). However, data has not been available to document the extent of this bias or the ways it varied by sex, age, over time or across institutions. A new source of individual-level data presents the opportunity to examine the workings of ethnic bias in detail. We quantify the degree of over-sterilization of individuals of Latino/Hispanic origin (as identified by Spanish surname), and evaluate the extent to which ethnic bias varies by sex, age, across institutions or over time. We also compare ethnic differences in the reported rationales for sterilization, such as mental health diagnosis, assessed degree of “feeblemindedness”, and perceived sexual delinquency or criminal tendencies.

1 Our preferred demonym is the term Latina/o (or ideally, Latinx, which does not impose gender binaries) rather than the term Hispanic. However, to adhere to disciplinary conventions we will use the term Hispanic in discussing our data and results, which use Spanish surname as a proxy for Latino/Hispanic ethnicity. Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 4

Figure 1. Map of California’s nine state homes and hospitals for the “mentally ill” and “mentally deficient” (adapted from Wellerstein 2011)

DATA

Sterilization records We use data from over 20,000 sterilization recommendation forms (see Figure 2), located in 2007 by PI Alexandra Stern in file cabinets in the main offices of the Department of Mental Health (now Department of State Hospitals) in Sacramento, California. With approval from the California Committee on Human Subjects Protections and the University of Michigan Biomedical IRB, these records, originally stored on 19 microfilm reels, were digitized and Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 5

separated into individual forms. These forms were abstracted to create a dataset with 212 unique variables per individual.

Figure 2. Data for this analysis were extracted from sterilization forms similar to this redacted one from Patton State Hospital in 1945 (Wellerstein 2011)

Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 6

The sterilization recommendations come from each of the nine state homes and hospitals located throughout California between 1919 and 1953. Although sterilization recommendation documents changed in format throughout the study period, a number of variables were collected consistently throughout the entire period from 1919 to 1953. For the present study, we restrict to individuals recommended for sterilization between 1920 and 1945 (n=17,852) and use the following information: institution, year of sterilization recommendation, age at sterilization recommendation (<15, five year age-groups from 15 to 50, and 50+) sex, and Latino/Hispanic ethnicity (identified by Spanish surname—see below). We exclude individuals missing data on institution of residence (n=24), sex (n=34), or age at sterilization recommendation (n=432), leaving 17,362 records in the analytic sample. We also include reported characteristics that were considered to be heritable and could be used to justify sterilization, including mental health diagnoses, “mental grade” (based on assessed intelligence quotient (IQ)), and other factors assumed to be heritable at the time such as “sexual delinquency” and “criminal tendencies”.

Census data In order to compare individuals recommended for sterilization to general institution populations, we use decennial U.S. Census microdata from 1920, 1930, and 1940. Each institution was a single census enumeration district. We extract data on individuals listed as living in the institution and identified as “patients” or “inmates” in the “Relationship to Head of Household” field (not institution employees or their family members).

Spanish surname classification The concept and definition of Latino/Hispanic ethnicity was in flux during this time period and was classified inconsistently, both within institution records and in U.S. Census data. To address this, we use the 1980 U.S. Census list of Spanish surnames to identify individuals of probable Latino/Hispanic origin in both institution and Census records (Winkleby & Rockhill 1992, Word & Perkins 1996). Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 7

METHODS

We conduct linear interpolation of Census data between decennial Census years in order

to estimate annual rates of sterilization for each institution and by age group, sex and ethnicity.

Interpolation slopes are created at the institution level using counts within each sex, age group,

and ethnicity group. Counts from 1940 were extended forward to 1945. Two institutions opened

during the study period, Pacific Colony in 1927 and Camarillo State Hospital in 1936. Counts

from the Census following the date of opening (1930 for Pacific Colony and 1940 for Camarillo)

was extended back to the year each institution opened.

Statistical analysis is conducted with Stata 13 (StataCorp, College Station, TX).

Significance is defined as a 2-tailed P< .05. The annual rate of sterilization (per 1000 patient-

years) in each institution is estimated by dividing the number of sterilization recommendations

by the number of institution residents in that year (in 1000s), according to sex, age group and

ethnic category from interpolated US Census data. We evaluate ethnic bias by using Stata’s

epitab function to estimate incidence rate ratios (sterilization rate ratios) and 95% confidence

intervals. We stratify sterilization rate ratios and use Mantel-Haenszel tests to compare levels of

ethnic bias by sex, institution, age group and time period.

It is not possible to formally compare ethnic bias in rates of sterilization by reported

justifications for sterilization (mental health diagnoses, “mental grade”, and perceived social ills)

because we do not know the distribution of these factors in the general institution population. We

report the results of chi-squared tests comparing the prevalence of these factors by ethnic group

among individuals recommended for sterilization.

RESULTS

Table 1 displays descriptive statistics of the 17,362 individuals recommended for

sterilization in California state homes and hospitals between 1920 and 1945. The two

institutions with the highest crude numbers of sterilizations are Sonoma State Home, a state Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 8

hospital for the feebleminded in Sonoma County in northern California, and Patton State

Hospital, a hospital for the mentally ill in San Bernardino County. The peak period of

sterilization was 1935-1939, with 4,391 sterilizations statewide. Slightly more males than

females were sterilized, with males comprising 50.8% of individuals recommended for

sterilization. The age group with the most sterilization recommendations was ages 15-19.

Table 1. Descriptive statistics, individuals recommended for sterilization (n=17,362) Non-Spanish Spanish surname Total (n=17,362) surname (n=15,379) (n=1,983) Institution Pacific Colony 1268 389 1657 Sonoma 3861 625 4486 Patton 3562 494 4056 Agnews 705 44 749 Norwalk 924 95 1019 Stockton 2841 212 3053 Napa 1674 79 1753 Mendocino 393 34 427 Camarillo 151 11 162 Year recommended for sterilization 1920-1924 1804 157 1961 1925-1929 3073 328 3401 1930-1934 3143 371 3514 1935-1939 3837 554 4391 1940-1945 3522 573 4095 Sex Male 7838 984 8822 Female 7541 999 8540 Age <15 639 161 800 15-19 3756 763 4519 20-24 2803 333 3136 25-29 2654 275 2929 30-34 2400 215 2615 35-39 1885 156 2041 40-44 824 57 881 45-49 301 13 314 50+ 117 10 127

Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 9

Table 2 illustrates the methods used to estimate ethnic bias in sterilization rates. The

number of patients recommended for sterilization (from the sterilization data) is divided by the

number of patient-years (summed from interpolated census data an all institution residents during

the study period) to estimate the sterilization rate, which is reported per 1000 patient-years.

Table 2. Sterilization rates, overall and by ethnicity

Number Patient-years Sterilization rate recommended per 1000 patient- for years sterilization All patients 17362 516336 33.6 Latino/Hispanic patients 1983 23986 82.7 Non-Latino/Hispanic 15379 492350 31.2 patients

Table 3 displays incidence rate ratios and 95% confidence intervals for Latino/Hispanic

institution residents relative to non-Latino/Hispanic institution residents. Latino/Hispanic

patients were sterilized at, on average, at 2.65 times the rate (95% CI: 2.52, 2.77) as non-

Latino/Hispanic patients. However, the rates of sterilization varied significantly by sex

(p<0.001), with Latina/Hispanic women and girls sterilized at 3.45 times the rate (95% CI: 3.23,

3.69) as non-Latina/Hispanic females, and Latino/Hispanic men and boys sterilized at 2.17 times

the rate (95% CI: 2.03, 2.32) as non-Latino/Hispanic males. Because ethnic bias in sterilization

rates varies so much by sex we continued to examine ethnic bias stratified on sex for the rest of

the analyses in this paper.

Table 3. Ethnic bias in sterilization (incidence rate ratios), overall and by sex

IRR (95% CI), IRR (95% CI), IRR (95% CI) Males only Females only Mantel- (n=17,362) (n=8822) (n=8540) Haenszel p

2.65 (2.52, 2.77) 2.17 (2.03, 2.32) 3.45 (3.23, 3.69) <0.001

Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 10

Ethnic bias by year Figure 3 displays annual rates of sterilization by ethnicity and sex from 1920-1945. Latino/Hispanic patients of both sexes were at the highest risk of sterilization for the entire period. In the first six years of the period under study (1920-1926) men and boys of both ethnicities were recommended for sterilization at higher rates relative to female co-ethnics. This gender bias reversed for the remainder of the study period, with female patients of both ethnicities at highest risk of sterilization than their male counterparts.

Figure 3. Sterilization rates by ethnicity and sex, 1920-1945

Sterilization Rates by Ethnicity, Sex and Time California State Hospitals, 1920-1945 200 150 100 50 Rate per 1000 patient-years 0

1920 1925 1930 1935 1940 1945 Year

Non-Hispanic Male Non-Hispanic Female Hispanic Male Hispanic Female

Table 4 displays the results of statistical tests comparing the degree of ethnic bias across different time periods. Latino/Hispanic patients were at higher risk of sterilization than non- Latino/Hispanic patients during the entire study period, but in the general study population there was no significant change in the degree of ethnic bias across time periods (Mantel-Haenszel p=0.121). However, the degree of ethnic bias did increase over time among female patients, with ethnic bias ranging from 2.69 times the risk of sterilization (95% CI: 1.96, 3.63) in 1920- 1925 to 3.96 times the risk of sterilization (95% CI: 3.47, 4.50) in 1940-1944. Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 11

Table 4. Ethnic bias in sterilization (sterilization rate ratios) over time, overall and by sex IRR (95% CI), IRR (95% CI), IRR (95% CI) Males only Females only Year (n=17,362) (n=8822) (n=8540)

<1925 2.51 (2.12, 2.96) 2.33 (1.90, 2.83) 2.69 (1.96, 3.63) 1925-1929 2.54 (2.26, 2.85) 2.30 (1.97, 2.68) 2.94 (2.45, 3.50) 1930-1934 2.48 (2.22, 2.76) 1.89 (1.59, 2.23) 3.39 (2.92, 3.92) 1935-1939 2.73 (2.49, 2.98) 2.24 (1.96, 2.54) 3.57 (3.14, 4.05) 1940-1944 2.96 (2.69, 3.26) 2.37 (2.05, 2.73) 3.96 (3.47, 4.50) 1945-1949 3.01 (2.32, 3.87) 3.21 (2.10, 4.75) 3.37 (2.38, 4.66) Mantel- Haenszel p 0.1207 0.1374 0.0562

Ethnic bias by age category Figure 4 displays rates of sterilization by age group, ethnicity and sex from 1920-1945. For all groups the highest rate of sterilization was in age group 15-19. Latina/Hispanic women and girls have the highest rate of sterilization (and non-Latino/Hispanic males have the lowest rate of sterilization) for every age group under 40.

Figure 4. Sterilization rates by ethnicity, sex and age group

Sterilization rate by ethnicity, sex & age California State Hospitals, 1920-1945 400

350

300 years - 250

200

150

100 Rate Rate per patient 1000 50

0 <15 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ Age Category

Non-Hispanic Male Non-Hispanic Female Hispanic Male Hispanic Female

Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 12

Table 5 displays the results of statistical tests comparing the degree of ethnic bias across age groups. Ethnic bias was strongly patterned by age group and was most extreme at the youngest ages (individuals less than 15 years of age). Patterning of ethnic bias by age was consistent for both male and female patients.

Table 5. Ethnic bias in sterilization (sterilization rate ratios) by age group, overall and by sex IRR (95% CI), IRR (95% CI), IRR (95% CI) Males only Females only Age category (n=17,362) (n=8822) (n=8540)

<15 2.39 (1.86, 3.05) 2.54 (2.12, 3.03) 2.96 (2.28, 3.80) 15-19 1.26 (1.12, 1.41) 1.38 (1.28, 1.49) 1.56 (1.39, 1.74) 20-24 1.51 (1.28, 1.78) 1.46 (1.30, 1.64) 1.44 (1.21, 1.69) 25-29 1.35 (1.12, 1.62) 1.47 (1.29, 1.66) 1.68 (1.41, 2.00) 30-34 1.24 (1.00, 1.52) 1.37 (1.19, 1.58) 1.58 (1.30, 1.91) 35-39 1.01 (0.78, 1.28) 1.38 (1.17, 1.63) 2.09 (1.64, 2.62) 40-44 1.02 (0.72, 1.41) 1.33 (1.00, 1.75) 2.06 (1.20, 3.34) 45-49 0.72 (0.36, 1.31) 0.99 (0.52, 1.73) 2.58 (0.30, 10.36) 50+ 2.74 (1.22, 5.41) 3.34 (1.56, 6.37) 4.02 (0.09, 26.75) Mantel- Haenszel p <0.0001 <0.0001 0.0001

Ethnic bias by institution Figure 5 displays rates of sterilization, by sex and ethnicity, across the nine state institutions under study. Rates of sterilization were highest in the two institutions for the “feebleminded”, Pacific Colony and Sonoma State Home, relative to the rates of sterilization in homes for the mentally ill. Table 6 displays the results of statistical tests comparing the degree of ethnic bias across institutions. Ethnic bias varied widely across institutions (p<0.0001), ranging from little evidence of ethnic bias (Camarillo State Hospital) to a sterilization rate ratio of 1.66 (Norwalk State Hospital) to a rate ratio of 3.09 (Pacific Colony). Variation in ethnic bias across institutions was observed for both male and female patients. We observed slightly higher ethnic bias in sterilization in the state homes for the feebleminded, Sonoma State Hospital and Pacific Colony (pooled IRR [95% CI]= 2.45 [2.29, 2.64]) relative to the state hospital for the mentally ill (pooled IRR [95% CI]=2.19 (2.05, 2.34). Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 13

Figure 5. Sterilization rates by ethnicity, sex and institution

Sterilization rate by ethnicity, sex and institution California State Hospitals, 1920-1945 400

350 years - 300 250 200 150 100 50 Rate Rate per patient 1000 0

Feebleminded homes Homes for the Mentally Ill Institution Non-Hispanic Male Non-Hispanic Female Hispanic Male Hispanic Female

Table 6. Ethnic bias in sterilization (sterilization rate ratios) by institution, overall and by sex

IRR (95% CI), IRR (95% CI), IRR (95% CI) Males only Females only Institution (n=17,362) (n=8822) (n=8540) Sonoma 2.13 (1.95, 2.32) 2.21 (1.95, 2.49) 2.13 (1.89, 2.40) Pacific Colony 3.09 (2.75, 3.47) 2.43 (2.02, 2.91) 3.68 (3.15, 4.27) Patton 2.26 (2.05, 2.48) 1.86 (1.64, 2.11) 2.98 (2.57, 3.43) Agnews 2.01 (1.45, 2.73) 1.53 (0.92, 2.40) 3.20 (2.03, 4.84) Norwalk 1.66 (1.33, 2.06) 1.13 (0.73, 1.68) 2.11 (1.62, 2.71) Stockton 1.99 (1.72, 2.29) 1.58 (1.32, 1.88) 2.89 (2.26, 3.65) Napa 2.19 (1.73, 2.75) 1.66 (1.16, 2.32) 3.05 (2.19, 4.15) Mendocino 1.91 (1.30, 2.71) 2.31 (1.50, 3.43) 1.12 (0.41, 2.50) Camarillo 1.10 (0.54, 2.03) 1.03 (0.32, 2.55) 1.42 (0.51, 3.21) Mantel- Haenszel p <0.0001 0.0005 <0.0001

Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 14

Ethnicity and justification for sterilization

The available data do not permit us to estimate rates of sterilization by justification for sterilization because we do not know the distribution of these factors (“mental grade” or IQ, mental health diagnoses, perceived social ills such as “sexual delinquency” and “criminal tendency”) in the overall institution populations. However, we can compare the prevalence of these factors by ethnicity to lend some insight into the logics used to process and classify institution residents as they were recommended for sterilization. It is important to note that all of these classification schemes were highly problematic and reflected social biases of the time. We do not report them with any confidence that they were accurate reflections of the individuals in question; rather, we report them to lend some insight into the strategies medical and public health professionals used to justify sterilizing residents in their care.

IQ and mental grade: Individuals in institutions for the feebleminded (Pacific Colony and Sonoma State Hospital) were assessed for IQ, which was classified into “Mental Grade”: Idiot, Imbecile, Moron, Borderline and Normal. Among the 5,433 individuals living in institutions for the feebleminded, there was virtually no ethnic difference in assessed IQ. The average IQ among Latino/Hispanic patients recommended for sterilization was 1 point lower than the average IQ among non-Latino/Hispanic patients, and this difference did not reach statistical significance (57.4 vs. 58.4, p=0.08).

Mental health diagnoses: A range of mental health diagnoses was recorded for patients in state hospitals for the mentally ill (Agnews State Hospital, Camarillo State Hospital, Mendocino State Hospital, Napa State Hospital, Norwalk State Hospital, Stockton State Hospital, Patton State Hospital). The diagnoses used during the time period under study do not map cleanly on to contemporary categories of psychiatric diagnoses, and no obvious pattern emerges in terms of ethnic differences is diagnosis. Latino/Hispanic patients were more likely to be diagnosed with “psychosis” (21.7% of Latino/Hispanic patients vs. 18.4% of non-Latino/Hispanic patients, Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 15

p=0.01), but less likely to be diagnosed with “paranoia” (10.9% vs. 15.0%, p<0.01). There was no significant difference in diagnoses of the other common conditions: “dementia praecox” (42.6% vs. 45.7%, p=0.06), “hebephrenia” (14.1% vs. 12.3%, p=0.10, or “manic depressive” (17.8% vs. 18.9%, p=0.37).

Sexual delinquency: Sterilization recommendation records documented patterns of “sexual delinquency” among patients, including: “promiscuity”, “immorality”, having children out of wedlock, “homosexuality”, being a victim or perpetrator of rape, and being “overdeveloped”. A slightly higher proportion of female Latina/Hispanic sterilization recommendees were flagged for some sort of sexual delinquency relative to female non-Latina/Hispanic sterilization recommendees (11.4% of recomendees vs. 9.4%, p=0.04). There was no significant ethnic difference in being labeled “sexually delinquent” among males (8.0% among Latino/Hispanic males vs. 8.7% among non-Latino/Hispanic males, p=0.56).

Crime: Sterilization recommendation records also flagged patients for “criminal tendencies”, documenting patterns of “petty” and “violent” crime. A slightly higher proportion of Latino/Hispanic sterilization recommendees were flagged for “petty crime” relative to non- Latino/Hispanic sterilization recommendees (3.8% vs. 3.0%, p=0.04), but there was no difference in the proportion flagged for violent crime (0.6% vs. 0.5%, p=0.62).

DISCUSSION A new source of data has allowed us to document the magnitude and dynamics of the over-sterilization of Hispanic and Latina/o residents of state hospitals under a state eugenics program. We find evidence of widespread ethnic bias across sex, age, institutions, and over time, with Latino/Hispanic institution residents typically being recommended for sterilization at two to three times the rate of non-Latino/Hispanic residents. Ethnic bias was greater among women and girls, especially those at young ages. There is evidence of slightly greater ethnic bias sterilization in state homes for the feebleminded relative to state hospitals for the mentally ill. Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 16

Among males, ethnic bias was relatively constant throughout the period under study (1920- 1945), but the magnitude of ethnic bias in recommending females for sterilization increased over time. There were not clear ethnic differences in the documented diagnosis of institution residents. Assessed IQ, which was likely underestimated among Latino/Hispanic institution residents, was nearly equal among Latino/Hispanic and non-Latino/Hispanic institution residents. While certain mental health diagnoses varied across ethnic groups, there was not a clear pattern to suggest that Latino/Hispanic patients were recommended for sterilization at higher rates due to a higher burden of “feeblemindedness” or mental illness. That a higher proportion of Latino/Hispanic patients were labeled “sexually delinquent” or “petty criminals” suggests that other social biases and stereotypes affected definition and classification of the “unfit,” as Lira (2015) has examined in-depth in the case of Pacific Colony. However, the magnitude of these differences is small relative to the observed magnitude of ethnic bias in sterilization; future work will examine whether these biases were stronger in particular institutions or age groups. These findings are the first in a larger project that will link these quantitative findings to qualitative information found in tens of thousands of patient records as well as other historical documents. For instance, Norma Sánchez (psuedonym) was fifteen years old when she was recommended for sterilization at the Sonoma State Hospital in 1934. Details on her sterilization recommendation form indicate that she was born in Mexico, that her mother had died of tuberculosis, and that she had been transferred to the Sonoma State Hospital after running away from Pacific Colony, the home for the feebleminded in Los Angeles County. Norma’s record classifies her as a “Moron” (the highest-functioning category of feeblemindedness), and her sterilization form indicated that she had “Mental disease which may have been inherited and is likely to be passed on to descendants.” Norma’s husband signed the consent form for the procedure, which was approved in May of 1934. Norma is just one of over 360 Latina adolescents under 18 years of age whose sterilization recommendation forms are included in the present study.

Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 17

Limitations

Spanish surname criteria: We used a standard list of Spanish surnames to identify patients of probable Latino/Hispanic origin because sterilization records and US Census data did not consistently identify Latino/Hispanic ethnicity during the time period under study: for example, the 1920 Census collected data on individuals’ place of birth and their parents’ place of birth, which was sometimes used to identify individuals of “Mexican” nationality or descent, whereas the 1930 Census defined ”Mexican” as a racial group, not a nationality. The 1940 Census instructions specified that all who were previously classified as “Mexican” should henceforth be classified as “White” (Hayes-Bautista & Chapa, 1987). Sterilization forms, on the other hand, would occasionally mention a nationality, city of origin, or ethnoracial identifier (e.g. “Guatemalan”, “San Salvador”, “Mexican-Indian”), but there was no systematic collection of data on nationality or race/ethnicity. Given these challenges of determining ethnicity in our data sources, using Spanish surname lists is the best available, albeit imperfect, method for consistently identifying individuals of probable Latino/Hispanic origin in both datasets. (Our efforts to document and quantify ethnic bias are further complicated by the fact that neither the term “Latino” [which denotes individuals with Latin American heritage, including Brazil] nor the term “Hispanic” [which denotes individuals with heritage in Spanish-speaking countries, including Spain and excluding Brazil] were in widespread use during the time period under study, although the institutional, racialized and historical biases against people of both Latin American and Southern European [including Spanish] origin were solidly in place.) Spanish surname may be most appropriate for identifying individuals who would be considered “Hispanic” by today’s definition as Spanish surname would identify individuals of Spanish (non-Latino origin), including recent immigrants from Spain as well as California’s long-established population of Spanish and mestizo heritage (“Californios”, see Benavides 2006). Spanish surname may exclude some individuals who would be identified as “Latino” by contemporary definition, including those of Latin American descent whose surname is indigenous or of other non-Spanish origin, and those who are from Brazil and have Portuguese surnames. Spanish surname may also Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 18

lead to “false positive” or “false negative” identification of individuals who are multi-ethnic or multi-racial or whose surnames have changed due to marriage. Numerous research studies have used Spanish surname in the absence of data on self- identified Latino/Hispanic ethnicity (Williams, Binkin & Clingman 1986; Hazuda et al 1986; Pérez-Stable, Hiatt, Sabogal & Otero-Sabogal 1995; Wei, Virnig, John & Morgan 2006; Sweeney et al 2007; Grofman & Garcia 2014). The effectiveness of Spanish surname in correctly identifying individuals of actual Hispanic origin (sensitivity) and correctly excluding individuals who are not of Hispanic origin (specificity) varies according to sex (Spanish surname is more sensitive and specific in identifying ethnicity of men: Perez-Stable, Hiatt, Sabogal & Otero-Sabogal 1995; Wei, Virnig, John & Morgan 2006), social class (individuals of higher socioeconomic status are more likely to be misclassified by Spanish surname criteria: Hayes- Bautista 1980, Wei, Virnig, John & Morgan 2006), ethnic composition of the local population (for example, high concentrations of Filipino, Italian, or Portuguese individuals can lead to more false positives; Hayes-Bautista 1980; Perez-Stable, Hiatt, Sabogal & Otero-Sabogal 1995; Grofman & Garcia 2014), and the methods used to define Spanish surnames in the first place (Grofman & Garcia 2014; Winkleby & Rockhill 1992, Word & Perkins 1996). Given the population and time period of this study, we have reason to believe that Spanish surname is relatively more effective for identifying individuals of Hispanic origin than it has been in more recent studies. For example, intermarriage between Latinos/Hispanics and other ethnic groups (which could lead to misclassification of Latinos using Spanish surname criteria) was relatively low during this time period. A study of marriage records in Los Angeles from 1924-1933 found that 91% of Mexican Americans seeking marriage licenses married other individuals of Mexican origin (Panunzio 1942). A study using Census data found that rates of in-marriage for Mexican-origin women nationwide in were 87.4% in 1910 and 90.7% in 1920. Rates of in-marriage for Mexican-origin men nationwide were 74.9% in 1910 and 90.5% in 1920 (Wildsmith, Gutmann & Gratton 2003). This degree of “in-marriage” is much higher than rates of in-marriage observed among individuals of Mexican origin later in the twentieth century in California (around 66% in 1970; Schoen, Nelson & Collins 1978) and nationwide (around 66% in 1970, 84% in 1980, and 82% in 1990; Wildsmith, Gutmann & Gratton 2003). This suggests Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 19

that Spanish surname would be a better approximation of Latino/Hispanic identity in the time period we study than in more recent studies. (It is also worth noting that anti-miscegenation laws in California prohibited some individuals of Mexican origin from marrying Asian or Black individuals until the 1948; Menchaca 2008). In order to ensure that we minimize misclassification of Latino/Hispanic identity, future work will evaluate: 1) the extent to which Filipino Californians are identified using the Spanish surname criteria 2) whether differences in the age distribution of the population recommended for sterilization relative to the Census population lead to differential misclassification of Latino/Hispanic identity due to different histories of intermarriage according to age. Potential bias introduced by sterilized individuals being counted in Census data: Because census data includes all patients living in an institution, the denominator used in estimating sterilization rates includes institution residents who had already been sterilized, i.e. individuals who were no longer at risk of the outcome. This would bias our estimation of sterilization rates downward. If the magnitude of this downward bias is equal among both Latino/Hispanic and non-Latino/Hispanic patients we would not expect this to affect incident rate ratios, our measure of ethnic bias. However, if Latino/Hispanic residents were more or less likely to continue living in institutions after sterilization, our incident rate ratios comparing Latino/Hispanic and non-Latino/Hispanic sterilization rates could be biased in either direction. Sterilization was often a condition for release from institutions, so many sterilized patients were discharged from the institution soon after undergoing the procedure. Future work with these records will try to evaluate whether using sterilization as a condition for release was more or less common among Latino/Hispanic residents relative to non-Latino/Hispanic residents.

Future directions This analysis evaluates ethnic bias in rates of sterilization among institution residents by comparing the group sterilized to the overall institution populations. However, with census data it will also be possible to estimate ethnic bias in institutionalization and ethnic bias in sterilization relative to total state population. Future work can compare the group sterilized to the overall California population to estimate and compare sterilization rates in the total Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 20

population. We also will examine length of time between admission to an institution and request for sterilization and sending county in order to further analyze temporal and spatial dimensions of California’s sterilization program. Eugenic thinking that led to ethnic bias in sterilization was closely linked to anti- immigrant and nationalist sentiment. This included biases against not only Latinos, but also immigrants of Asian origin and immigrants from southern and eastern Europe. Future work can also evaluate anti-immigrant bias in sterilization practice and whether this anti-immigrant bias varies by region of origin. Some particularly zealous eugenicists, including the superintendent of Sonoma State Home, sought to institutionalize individuals, particularly young women, primarily for the purposes of sterilization. This is evident in the sterilization files in cases when a sterilization request date precedes the patient’s admittance date. We plan to use survival analysis to model time-to-sterilization and compare the speed with which individuals were deemed “unfit for reproduction,” which we hypothesize will vary by ethnicity, gender, and institutional setting.

Ethnic Bias in California’s Eugenic Sterilization Program, 1920-1945 21

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