Celia Ramos Durand was one of thousands of Peruvian women forcibly sterilised in the late 1990s under the notorious National Reproductive Health and Family Planning Programme (PNSRPF) implemented by the regime of then-president Alberto Fujimori.
Three weeks later, Ramos, a 34-year-old mother of three young children, was dead.
Nearly 30 years later, the Peruvian state is finally being tried for her death, returning the spotlight to a programme that saw almost 300,000 Peruvians sterilised – the vast majority of them women from poor, rural backgrounds who spoke Quechua, an Indigenous language.
The programme was the capstone of a regime marked by extrajudicial killings, enforced disappearances, abductions and corruption. In his ten years in power, President Fujimori led a coup that dissolved Congress, intervened in the judiciary and all oversight bodies, and militarised the main media outlets before being deposed in 2000.
The Peruvian state has since acknowledged its responsibility for crimes committed under the sterilisation programme, even signing a settlement agreement with the family of another victim in the early 2000s and launching a Registry of Victims of Forced Sterilisation in 2015.
But at a hearing on 22 May this year over Ramos’ tubal ligation and subsequent death in 1997, legal representatives for Peru’s current government told the Inter-American Court of Human Rights that her sterilisation was part of “a public health policy dedicated to protecting sexual and reproductive rights and not a harmful practice”.
It is unusual for a government to defend, decades later, discredited practices implemented by an authoritarian regime, particularly when the state has already apologised for its actions. But, the Peruvian government’s U-turn signals democracy in the country is under threat once more.
In recent years, Congress and president Dina Boularte have introduced reforms that have co-opted high courts and other supervisory bodies, passed laws to grant amnesty to war crimes and crimes against humanity and crack down independent journalism and silence civil society, violently repressed social protests and echoed global far-right narratives against feminism, LGBTIQ rights and sexual education. Fujimori died in 2024, but not before political and judicial dysfunction meant that he was pardoned of all his crimes.
Given this political context, the whitewashing of Fujimori-era crimes is “not surprising”, Florencia Reggiardo, a lawyer from the Centre for Justice and International Law (CEJIL), one of the legal groups representing the Ramos family, told openDemocracy.
Explaining the state’s decision to defend the sterilisations, Reggiardo told openDemocracy: “It’s the denialism that the three branches of government have been showing for a year and a half now and which is becoming increasingly entrenched.
“This is not at all a democratic and respectful defence of human rights in line with the pillars of the Organisation of American States and the treaties that the state voluntarily signed. But, coming from Peru, it's not surprising,” she added.
openDemocracy attended the online eight-hour court hearing in full, translated much of the evidence into English, read historical records and the case’s key documents, and spoke to lawyers representing Ramos’s family to uncover how the Peruvian government’s rejection of this 28-year fight for justice is linked to its efforts to erode the country’s democracy.
Ramos’s case is a reminder of how regimes around the world – in countries as varied as the United States, Australia (where the women with disabilities continue to face forced sterilisations), Denmark, and India – have used reproductive violence as a tool to oppress and control vulnerable communities. The social contexts have often been very different, but the outcomes have been eerily similar: the denial of the personal and bodily autonomy of women and gender minorities.
In Peru, more than 272,000 women and 22,000 men were sterilised between 1996 and 2000. It is not known how many were subjected to the procedure against their will, through coercion, duress or deception. Almost 7,000 people have reported their cases in the Registry of Victims of Forced Sterilisation, though the actual number of victims is likely to be much higher.
Ramos’s three daughters, who were aged ten, eight and five when she died, managed to take her case to the Inter-American human rights system in 2010, after many years of impunity. They succeeded in getting the court to open the first international trial for forced sterilisations in Peru in 2023.
Those who attended the hearing listened in astonishment as the government representative, deputy procurator Carlos Llaja Villena, said that “the main purpose of the PNSRPF was to optimise the sexual and reproductive health of men and women”.
Llaja Villena added that the scheme also aimed “to comply with international obligations arising from the Beijing Declaration and Platform”, the 1995 UN summit on women's rights.
“The PNSRPF made it mandatory to provide accurate and adequate information; its manual included counselling guidelines and scenarios for subsequent repentance,” Llaja Villena said. It had a “neutral approach” and sought “the general welfare”.
The procurator argued that the health authorities had had adequate oversight of the programme, concluding that “the state requests that the legitimacy and reasonableness of the PNSRPF be recognised” since it “has proved that it acted in accordance with the principle of equality and that there was no violence against women”.
The procurator’s claims are not only contradicted by numerous investigations by Peruvian public bodies – including the Ombudsman's Office, Congress and various prosecutors' offices – and national and international organisations, but are at odds with the state’s previous stance.
In 2003, the state acknowledged its responsibility for crimes committed under the PNSRPF in a settlement agreement with the family of another victim, Mamérita Mestanza, a 33-year-old mother of seven who died from an infection due to poor medical care following a forced sterilisation in 1998. The agreement, which was signed under the supervision of the Inter-American Commission on Human Rights (IACHR), allowed the state to avoid an international trial such as the one it faces now.
Last year, after analysing the cases of five victims, the United Nations Committee on the Elimination of Discrimination against Women ruled that the sterilisation policy was “a form of gender-based violence and intersectional discrimination against indigenous, rural and economically disadvantaged women”.
Celia Ramos Durand’s last days
Ramos’s eldest daughter, Marisela del Carmen Monzón Ramos, told the hearing how her mother was a strong, cheerful and loving woman, who was the backbone of their family.
Ramos was born in the village of La Legua, in the north-west Peruvian department of Piura, and lived there until she died aged 34. Describing the conditions her mother lived in, Monzón Ramos said: “Families [in La Legua], most of whom were living in poverty, had running water and electricity [for] a few hours per day. The only health service was a health post that treated minor cases.
“There was no sewerage system or drainage. The houses are built of reeds and mud. Some were made of bricks.”
Ramos attended primary and secondary school before marrying Jaime Monzón and having three daughters. “We lived with my mother's extended family, my maternal grandparents and uncles,” Monzón Ramos told the hearing.
In the weeks leading up to her sterilisation in July 1997, Ramos received at least five visits from health workers trying to convince her to agree to the procedure, which they told her was “as simple as having a tooth pulled”, Monzón Ramos said. Ramos repeatedly told the health workers, as well as her friends and family, that she did not want the sterilisation, but she eventually gave in.
There were 15 sterilisations planned for 3 July at the local health post, which had running water for only a few hours a day. Ramos was number 14. Number 15 was never carried out.
According to testimony from an assistant doctor and a stretcher bearer included in the original police investigation, the doctors performing the sterilisation had asked the nurses for more anaesthetic and oxygen, but were told there was none left. “And this was in front of Mrs Celia's desperate cries,” said CEJIL lawyer Gisela de León, reading the police report at the hearing.
The nurses were ordered to go to the pharmacy to buy supplies. Ramos was eventually given diazepam, a medication usually used to treat anxiety, seizures or muscle spasms, which caused her to have an allergic reaction and cardiorespiratory arrest. At 4pm, she was rushed to a private clinic an hour and a half away in Piura city. By the time she arrived, she had brain damage due to a lack of oxygen, according to the report of the doctor who received her.
Meanwhile, when Ramos did not return home from her sterilisation, some relatives went to the health post to ask about her. They were told that she had been rushed to the city after having a tumour removed. “My aunt arrived very shocked, with a bag they had given her containing a liquid and something that looked like a tumour,” her daughter recounted at the hearing. It was later confirmed that it belonged to someone else.
Ramos spent the next three weeks in a coma. She died on 24 July 1997.
No justice
Three days after Ramos died, her husband reported the doctors who operated on her for causing “serious injuries followed by death”. The public prosecutor's office closed the investigation in December 1997, describing the incident as “fortuitous”.
The state has spent the three decades since repeatedly opening and closing probes into both Ramos’s death and the cases of thousands of other victims. The most recent such investigation was launched in 2018, Stuardo Ralón, a commissioner from the IACHR, told the hearing. “The investigation still remains in the preliminary stage,” he said, “with no clarification of the facts or punishment of those responsible.”
In 2010, Ramos’s daughters reported their mother’s sterilisation and death and the state’s denial of justice to the IACHR, which monitors member states’ compliance with the American Convention on Human Rights but is not a court of justice. It found Peru responsible for violating the rights to life, integrity, judicial guarantees, equality before the law and judicial protection, as well as Ramos’s sexual and reproductive rights. The commission recommended the state provide reparations to her family, investigate and punish those responsible. In 2023, in light of the Peruvian authorities’ inaction, the IACHR referred the case to the Inter-American Court of Human Rights.
Fujimori, who was imprisoned in 2009 for other crimes against humanity committed during his presidency, died free last year after the Constitutional Court ordered his release, upholding a presidential pardon granted to him back in 2017. A Peruvian law passed last August that prevents the prosecution of all war crimes and crimes against humanity committed before 2002 now looms as a new threat to the sterilisation trials.
‘Sterilise yourself and be happy’
The PNSRPF and its flagship component, voluntary surgical contraception (VSC), were launched in 1996, one year after Fujimori won re-election. At that point, he was already presiding over an authoritarian regime, having led a coup that dissolved Congress, intervened in the judiciary and all oversight bodies, and militarised the main media outlets in 1992.
Fujimori had blamed Congress for obstructing his policies, particularly the fight against the leftist guerrilla groups Shining Path and the Túpac Amaru Revolutionary Movement, a conflict that left nearly 70,000 dead and missing between 1980 and 2000, according to the Truth and Reconciliation Commission. Most of the victims were Quechua speakers.
As a result of the conflict, nearly 900,000 people were displaced between 1990 and 1995. Widespread poverty and a lack of healthcare meant that by 1996, Peru had the second-highest maternal mortality rate in South America and one of the highest in the world, at 265 deaths per 100,000 live births.
Under the guise of fighting poverty, in 1991, the Fujimori government set a goal of “reducing the natural population growth rate to no more than 2% per year by 1995” with an overall fertility rate that “should not exceed 3.3 children per woman”. Sterilisations were carried out throughout the decade, but skyrocketed in the first two years of the PNSRPF, from 1996 to 1998.
Giving her expert opinion to the court hearing last month, Kimberly Theidon, a medical anthropologist with a PhD from the University of California, linked the sterilisations to the logic of Peru's internal war. “From military doctors to soldiers standing guard at the doors of makeshift operating rooms, from military cots to surgical equipment, it was a combined operation that blurred the lines of war, deployed in a highly militarised context due to years of armed conflict,” she said.
As Peru was preparing for the widespread sterilisations, many world leaders were agreeing to place sexual and reproductive health within the framework of human rights, rather than demographic and birth control policies, while recognising the right of individuals, especially women, to decide on their fertility autonomously. This was a milestone of the UN population conference in Cairo in 1994, and was reinforced a year later at a conference in Beijing.
Feminist activists from CLADEM (Latin American Centre for the Defence of Women's Rights) first received reports of abuses by the PNSRPF in Huancabamba, a mountainous province in Piura, the department where Ramos lived, in November 1996, when they visited the area for different work. The following year, the first complaints were received by the Ombudsman's Office.
A CLADEM report published in 1999 and entitled “Nada personal” (Nothing personal) documented the early years of the PNSRPF, recording 243 cases of forced sterilisation in 19 of the country's 24 departments up to November 1998 and revealing that local authorities were being issued with incremental targets for VSC and quotas for the number of sterilisation patients needing to be recruited by each health centre.
The report also found that medical workers were being offered cash payments (of between $4 and $8, according to statements made at the hearing) for each woman “effectively recruited” for the sterilisations, and documented the pressure, incentives and threats that were used to get medical staff to increase the number of surgeries.
Some women were sterilised immediately after giving birth or while undergoing a caesarean section without having been informed beforehand. Others reported being taken away by force and threatened with themselves or their children being denied health care, or even being reported to the police. Sometimes, health workers made the woman's husband or partner sign a consent form without her knowledge.
“Gender stereotypes, colonial legacies, ethnic discrimination and macho norms were imposed, which considered that poor, indigenous, illiterate women were incapable and did not have the right to make decisions about their fertility,” Theidon told the court.
Although the programme also included vasectomies, quotas were set only for the number of women who should be sterilised. They were recruited through massive promotional campaigns exclusively run by the VSC, such as fairs and festivals, and repeated visits to women, just as those made to Ramos.
Bands and sporting activities were common at these events, according to the CLADEM report. At one such festival in San Lorenzo, in the Peruvian Amazon, a poster read: “We decided to have only two children. That's why we chose tubal ligation and we are happy!”
Theidon observed: “The messages linked sterilisation with happiness, promises of monetary compensation and food.” She explained how, in the context of high chronic child malnutrition, which she estimated to affect 45% of children in rural areas, “hungry children were used as a weapon to convince mothers to be sterilised”.
The campaigns also featured misleading offers of healthcare for the whole family, ranging from screenings for tuberculosis, dengue and malaria to dental care and cancer checks, which were then not delivered.
The Ombudsman's Office conducted several investigations, the first in 1998 involving nine victims. Its recommendations included urging authorities to investigate reports of deaths, forced sterilisations and medical complications; to replace VSC campaigns with campaigns about contraceptive options and family planning; to change the quotas system and many others.
These recommendations were not followed, and the ombudsman’s second investigation, conducted the following year, examined 157 complaints. The situation became so serious that the Ombudsman's Office created a special system to monitor the sterilisation programme, with an emphasis on rural areas. Its third report, which examined 773 cases, was published between mid-1999 and September 2002.
The number of sterilisations carried out dropped drastically after Fujimori fled to Japan in 2000, and the programme was closed in 2001.
What consent?
Since Ramos’s case reached the inter-American system in 2010, no evidence has been presented that she consented to the sterilisation.
In its initial written response to the court, the government suggested that Ramos’s medical records had been destroyed during the catastrophic flooding that hit Peru in 1997 and 1998 as a result of the El Niño weather phenomenon. This, it wrote, “makes it impossible for the Peruvian State to present the signed consent form”.
But at the May hearing, one of the state’s expert witnesses, civil rights lawyer Eduardo Buendía de los Santos, showed a photograph of what he said was Ramos’s “informed consent” form. He told the court that he had received it from government representatives “three or four weeks” earlier, and that he had never seen the original document.
Dated 1 July 1997 and entitled ‘Request and authorisation for surgical prevention of reproductive risk’, the photographed document states that the signatory was “informed of the contraceptive methods available and the reasons why my health would be seriously compromised in the event of pregnancy”.
But, when questioned by the judges, Buendía admitted that the document does not mention Ramos having any illness or condition that would justify sterilisation, nor her being told the risks associated with the surgery or its irreversible nature – essential elements of informed consent.
Reggiardo from CEJIL has cast doubt on the photograph’s authenticity. “The form is quite different from the model used at the time, and the victim's signature does not match hers,” she told openDemocracy.
Legal representatives of the plaintiffs, Ramos’s daughters and her mother, considered the move to be “bad faith” by the government, as the photograph was presented only three days before the hearing – long after the end of the extensive evidence-gathering phase – meaning they were unable to obtain an expert opinion on its authenticity and content.
Government lawyer Domingo Rojas replied that they had found the document “a couple of months ago” and that it was a photocopy of a photocopy, as the original document had been destroyed in a flood.
The court noted that the photograph is not yet formally included in the case file, and it must decide whether to admit it or not. “This document was first in the possession of the expert witness, not the court, four weeks before he carried out his assessment, and you brought photographs of this document to the hearing,” judge Ricardo Pérez Manrique reprimanded the government.
In its closing argument, the government denied that there was impunity in Ramos’s case, given that a “serious and diligent investigation” is underway in Peru. It also rejected the allegations against the PNSRPF.
“We do not wish to ignore legitimate claims that are pending at national courts,” said deputy procurator Llaja Villena. “But we do wish to point out that the programme, in terms of its goals and guidelines, was correct and is correct.”
The parties have until 23 June to submit their final written arguments.
