By: Maeher Khosla
Volume X – Issue II – Spring 2025
I. INTRODUCTION
In 2022, Wendy Williams, a prominent media figure and renowned talk show host, was publicly placed under financial guardianship following a court determination that she was “permanently disabled and legally incapacitated.” [1] Control over her assets and key decisions was subsequently transferred to a court-appointed guardian. The case immediately sparked widespread concern, as it revealed how swiftly and comprehensively legal agency can be revoked, even from individuals with substantial professional success and public visibility. While Williams has not been subjected to sterilization, her case highlights the far-reaching consequences of guardianship statutes and the extent to which autonomy can be legally curtailed under the guise of protection. These concerns become even more acute when such authority extends to decisions about reproductive health and capacity.
As such, this paper examines the extent to which guardianship laws and “best interest” standards enable the non-consensual sterilization of individuals with mental disabilities. I argue that state statutes, predicated on vague and subjective assessments of capability, perpetuate the legacy of eugenics by authorizing sterilization without meaningful consent from the affected individuals. This legal permissiveness ultimately disproportionately targets women with mental disabilities and effectively undermines their reproductive autonomy. Through an analysis of legal precedent, statutory language, and the operation of guardianship frameworks in relation to “best interest” standards, I advocate for the adoption of a disability justice-inclusive reproductive justice framework that affirms and safeguards the fundamental right to bodily autonomy.
II. HISTORICAL CONTEXT OF THE FORCED STERILIZATION MOVEMENT IN THE UNITED STATES
The forced sterilization movement in the United States emerged in the early twentieth century, shaped by the rise of the eugenics movement and widespread anxieties about immigration, labor unrest, and shifting gender norms. [2] Eugenics refers to the “ideology and practice of selective breeding [that assesses] reproductive fitness according to economic status, race, ethnicity, criminality, illegitimacy, intelligence, and sexual deviance.” [3] With respect to forced sterilization practices, this paper will focus on the implications of negative eugenics. Unlike positive eugenics which promotes the reproduction of those deemed “fit,” negative eugenics aims to restrict the procreation of people deemed “unfit” or “socially inadequate.” [4] This movement was largely predicated on the notion that those belonging to marginalized communities would disproportionately produce offspring that are “dangerous and burdensome to society.” [5] To deter the reproduction of individuals deemed a threat, states imposed mandatory sterilization procedures, with Indiana, in 1907 becoming the first state to pass eugenical legislation permitting the compulsory sterilization of “confirmed criminals, idiots, imbeciles, and rapists.” [6]
Between 1907 and 1937, thirty-two states enacted eugenical sterilization laws that granted physicians in state institutions the authority to operate on patients without their consent. [7] By 1963, over 60,000 women were forcibly sterilized, “purportedly ‘for the health of the individual … and the welfare of society.’” [8,9]
The Supreme Court's landmark ruling in Buck v. Bell (274 U.S. 200 (1927)) solidified the constitutional foundation for these practices. At six-years old, Carrie Buck was separated from her mother when authorities decisively determined that her mother could not provide “adequate care” for her due to her mental disability.[10] Carrie was subsequently adopted by the Dobbs family, and over a decade later, sexually assaulted by the nephew of her adoptive mother, leading to pregnancy. [11] After learning of her pregnancy, “‘[the Dobbs family] petitioned to have her institutionalized because she was ‘feebleminded.’” [12] The Court affirmed this determination and subjected Carrie Buck to a salpingectomy, a procedure which cauterized her fallopian tubes, effectively stripping her of her reproductive ability on the basis that she was “the probable potential parent of socially inadequate offspring … and that her welfare and that of society will be promoted by her sterilization.” [13] Writing for the majority, Justice Oliver Wendell Holmes argued: “It is better for all the world, if instead of waiting to execute degenerate offspring for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind [...] Three generations of imbeciles are enough.” [14] This decision entrenched the legitimacy of eugenics-driven sterilization and remained binding precedent for decades, effectively legalizing the practice across the country. In the decade following the ruling, the number of physician-performed sterilizations of institutionalized individuals doubled. [15]
Fifteen years after Buck v. Bell, the Supreme Court considered Skinner v. Oklahoma (Skinner v. Oklahoma 316 U.S. 535, 1942), which challenged Oklahoma’s Habitual Criminal Sterilization Act of 1935. The statute authorized the sterilization of individuals classified as “habitual criminals,” defined as those convicted of three or more felonies. [16] The Court ultimately struck down the law on the grounds of the Equal Protection Clause, finding that its selective application (targeting certain offenses while excluding others) rendered it constitutionally invalid. [17] While the decision marked a critical step in limiting punitive sterilization, it notably avoided confronting the broader constitutionality of involuntary sterilization itself. As a result, Skinner left Buck v. Bell intact and failed to address the forced sterilization of individuals with disabilities, thereby allowing such practices to continue under new legal rationales. [18] Over time, overtly eugenic language gave way to public health justifications, but the underlying premise that certain populations should not reproduce remained embedded in law and policy well into the latter half of the twentieth century.
Specifically, during the 1960s and 1970s, federal family planning initiatives such as the Office of Economic Opportunity and the Family Planning Services and Population Research Act of 1970 expanded access to sterilization, particularly for women experiencing poverty and women of color. [19] Although often framed as efforts to promote reproductive choice, these programs frequently served as mechanisms for coercive population control masked as voluntary contraception. In a salient example, the Relf sisters, aged twelve and fourteen, were sterilized at a federally funded clinic in Alabama in 1973 under the false pretense of receiving birth control injections. [20] Their case underscored the systemic disregard for informed consent, especially among disabled women and minorities.
Though formal sterilization programs have largely ended, their legacy persists in the legal mechanisms that continue to authorize such procedures, often targeting individuals with disabilities under guardianship. These legal and institutional realities have ultimately facilitated the forced sterilization of over 100,000 women across the twentieth and twenty-first centuries, reflecting the enduring scale and reach of these practices. [21]
III. EXAMINATION OF EXTANT STATE STATUTES AND ARGUMENTATIVE ANALYSIS OF JUSTIFICATIONS AND DEFENSES
i. Guardianship Law
Guardianship is a legal mechanism through which a court appoints a substitute decision-maker for an individual deemed legally incapacitated. [22] While often framed as a protective measure, guardianship frequently operates as a broad and permanent transfer of authority that deprives individuals, specifically those with intellectual and developmental disabilities, of their legal rights. [23] Full, or plenary, guardianships are sweeping, granting guardians decision-making power over nearly all aspects of a person's life, including financial matters, healthcare, living arrangements, and reproductive choices. [24]
The determination of incapacity is typically predicated on cognitive or psychological evaluations and tends to prioritize diagnostic labels over functional assessments. [25] In many states, capacity is treated as binary and static—either wholly present or entirely absent—without sufficient consideration of an individual’s ability to exercise autonomy with appropriate, flexible modes of external support. Once imposed, guardianships often lack built-in mechanisms for periodic reassessment or rights restoration. [26] As a result, individuals may remain under guardianship indefinitely, regardless of their evolving needs or capacities.
Under these statutory guidelines, guardians are frequently granted authority to make healthcare decisions on behalf of the person under guardianship, including decisions related to sterilization. [27] In a number of states, the power to consent to sterilization is explicitly addressed within guardianship statutes, which typically impose procedural requirements, such as court approval, evidentiary hearings, and the appointment of legal representation. Authorization in these statutes is also generally contingent on the procedure serving the individual’s best interest. [28] In others, sterilization may not be explicitly addressed in guardianship statutes but may still be permitted under broader medical consent laws or through judicial discretion. [29] In practice, however, the guardianship structure itself often enables and legitimizes such decisions. Notably, some states permit petitions for sterilization without requiring the individual’s presence in court or their direct participation in the proceedings. [30]
Furthermore, procedural protections designed to safeguard against abuse, such as the requirement to consider “less restrictive alternatives,” are inconsistently enforced. Concomitantly, supported decisionmaking models, which allow individuals to make their own choices with the assistance of trusted supporters, are rarely integrated into formal guardianship structures. [31] Even where legal representation is guaranteed, attorneys assigned to guardianship cases may default to what they believe is in the individual’s best interest, rather than advocating for their client’s expressed preferences. [32] The result is a legal structure in which key decisions concerning bodily autonomy can be made without the affected individual’s meaningful consent.
These instances are not isolated oversights, but rather systemic features of a guardianship structure that presumes incapacity and prioritizes risk aversion at the expense of preserving individual autonomy. With over 1.3 million disabled individuals currently under guardianship in the United States, the implications of this system are significant. [33] Guardianship law not only legally authorizes substitute decision-making on personal concerns, but also entrenches a system in which disability is treated as a justification for reduced autonomy. When applied to reproductive decisions, the consequences are especially far-reaching, as they implicate fundamental rights to privacy, personhood, and bodily integrity.
While it is important to recognize that some individuals may lack the capacity to provide fully informed consent to reproductive decisions, this limitation does not necessitate removing them entirely from the decision-making process. Capacity should be assessed on a functional and individualized basis, rather than inferred solely from diagnostic labels. For individuals with limited or variable capacity, supported decision-making offers a structured approach that facilitates participation and promotes autonomy. In situations where independent consent is not possible, any substituted judgment should be narrowly applied, subjected to clear procedural safeguards, and guided by the least restrictive means possible. Without mechanisms for reassessment or alternative models, the default to plenary guardianship risks extending beyond protection and into ongoing restriction.
ii. The “Best Interest” Standard
Within guardianship frameworks, the “best interest” standard is the prevailing legal doctrine used to justify medical and personal decisions on behalf of individuals with disabilities. Though framed as a tool to promote welfare, the standard lacks consistent definition and is vulnerable to subjective, and often biased, interpretations. [34] In reproductive contexts, it is frequently invoked to authorize sterilization on the grounds that the individual is presumed unable to parent, at risk of unintended pregnancy, or likely to burden caregivers and public resources. [35]
The principal concern with the “best interest” standard lies in its failure to require meaningful consideration of the individual’s personal values, expressed preferences, or life objectives. In many states, judges and guardians are permitted to impose decisions based on generalized assumptions about what constitutes a good or acceptable life, often shaped by ableist beliefs that equate autonomy with independence, productivity with worth, and normative family roles with societal value. [36] These beliefs presume that individuals with disabilities are inherently less capable of making informed choices, forming families, or contributing meaningfully to society. As a result, determinations are rarely grounded in the lived experiences of the individuals they affect and often proceed without their direct involvement.
iii. Extant State Statutes
As of 2022, thirty-one states and Washington, D.C., permitted the sterilization of individuals with disabilities through guardianship or judicial proceedings, with seventeen of these jurisdictions explicitly authorizing non-consensual sterilization. [37] In contrast, eleven states and Washington, D.C., lack any statutory safeguards or remedies addressing forced sterilization. [38] Only Alaska and North Carolina have formally banned the practice. [39] Yet even these prohibitions can inadvertently restrict autonomy, as they often prevent individuals under guardianship from accessing sterilization when they affirmatively seek it. In doing so, such laws risk substituting blanket protectionism for nuanced, supported decision-making. The principle of procreative liberty includes not only the right to refuse sterilization, but also the right to affirm it, meaning that categorical bans, while protective in intent, can function as another form of reproductive constraint.
Recent legislative developments serve to further illustrate how sterilization laws continue to evolve. In 2019, Iowa enacted a statute allowing guardians, with court approval, to authorize the sterilization of a protected person in addition to other significant healthcare decisions, such as abortion or the withdrawal of life-sustaining treatment. [40] Nevada passed a similar law the same year, requiring a full evidentiary hearing, the appointment of counsel, and a finding by clear and convincing evidence that sterilization is in the individual’s “best interest.” [41] These requirements are intended to provide a layer of legal protection and ensure that sterilization is not authorized without judicial scrutiny. However, even with such safeguards, the statutes reaffirm a broader legal structure in which courts and guardians, rather than the individuals themselves, retain authority over reproductive decisions.
The statutory language used to support this framework, however, varies widely across the U.S. In Georgia, for example, a court may authorize sterilization if an individual is found to be permanently unable to care for a child in a way that would cause serious harm, regardless of the availability of external support. [42] In Arkansas, sterilization may be ordered for individuals found incapable of self-care who also exhibit “sexual inclinations,” language that echoes long standing eugenic assumptions about deviance and social risk. [43] While some states, such as Nevada and California, impose procedural prerequisites, such as evidentiary hearings, expert evaluations, or the appointment of counsel, these protections are inconsistently enforced and provide limited constraint on judicial discretion. [44,45] Comparatively, in states without explicit statutory authorization, like New York, courts may still intervene in reproductive decisions involving individuals with disabilities, often subjecting them to heightened scrutiny, psychological evaluations, or judicial oversight even when they seek care voluntarily. [46] These legal regimes collectively demonstrate that judicial interpretation, rather than individual autonomy, continues to determine outcomes under the “best interest” standard.
In the absence of a federal standard, and given the wide variation in statutory language and enforcement, reproductive autonomy for individuals under guardianship remains contingent, inconsistently protected, and structurally precarious. The “best interest” framework thus operates as both a justification and a shield, enabling deeply invasive interventions while preserving a veneer of protective intent.
IV. APPLICATION OF A DISABILITY JUSTICE-INCLUSIVE REPRODUCTIVE JUSTICE FRAMEWORK
Autonomy, particularly in the context of reproductive decision-making, is a central legal and ethical principle. In cases where individuals face significant limitations in capacity, the law must seek to balance protection with participation. Supported decision-making, periodic reassessment, and a commitment to the least restrictive alternative offer mechanisms to involve individuals meaningfully while concomitantly mitigating the risk of irreversible interventions. These approaches provide a foundation for rethinking current practices and moving toward a more inclusive, rights-respecting model of reproductive decision-making.
To scrutinize the legal foundations of non-consensual sterilization, this paper draws on the principles of disability justice and reproductive justice. These frameworks critique the structural inequities embedded in existing legal structures and advocate for a more inclusive and respectful approach to autonomy.
Disability justice, articulated by activist groups such as Sins Invalid, centers the lived experiences of those most marginalized within the disability community, including individuals of color, queer and trans individuals, and those with limited access to legal recourse. [47] It rejects the idea that autonomy must be earned through displays of competence, instead affirming bodily autonomy as a fundamental and inalienable right. [48]
Reproductive justice, a framework pioneered by Black feminist thinkers, expands traditional understandings of reproductive rights to encompass the right to have children, the right not to have children, and the right to raise children in safe and supportive environments.49 It emphasizes the need to dismantle systemic barriers that inhibit these rights, including those posed by poverty, racism, and ableism. [50]
Together, these frameworks expose how the law’s invocation of “best interest” often disguises coercion as care and reinforces institutional biases. They call for a shift from paternalistic models of guardianship to relational and supportive models of decision-making that recognize the agency of disabled individuals. By reframing capacity as the capability to change over time and autonomy as contextual, these approaches challenge the foundational assumptions of guardianship law.
This theoretical lens reveals the need to reconsider how legal systems construct and evaluate reproductive decision-making. Rather than asking whether a person is fit to reproduce, these frameworks question the state’s authority to make that determination on their behalf. Disability and reproductive justice, as such, demand that reproductive autonomy be treated not as conditional, but as a protected right for all individuals.
To meaningfully integrate these principles into law existing doctrines governing guardianship and reproductive healthcare must be restructured to prioritize individual agency and reduce judicial discretion in irreversible decisions like sterilization. First, supported decision-making should be codified as a formal legal alternative to guardianship, with clear procedures for assessing and accommodating an individual’s decision-making capacity through accessible and individualized support. Second, statutes authorizing sterilization under the “best interest” standard must be revised to include a presumption against sterilization unless the individual provides informed consent with sufficient assistance, or the procedure is proven to be medically necessary and supported by strict, individualized review. Third, courts should be required to consider the individual’s history, expressed wishes, and social context, not just diagnostic categories, in any reproductive decision-making process. Finally, periodic reassessment of capacity should be mandated in all guardianship regimes to ensure that individuals are not permanently stripped of rights based on outdated or overly broad findings of incapacity.
These legal reforms reflect the core tenets of disability and reproductive justice: that autonomy is contextual, capacity can evolve, and all individuals, irrespective of disability, are entitled to make decisions about their own bodies. Implementing these frameworks within law does not merely protect against abuse; it reorients legal systems toward equity, accountability, and respect for the personhood of disabled individuals.
V. CONCLUSION
The continued use of forced sterilization under the auspices of legal protection ultimately represents a failure of justice. While the rhetoric of eugenics may have receded, its ideological underpinnings persist in the statutes and judicial decisions that authorize the sterilization of individuals deemed incapable.
Guardianship laws and the best interest standard, when left unchecked, function as mechanisms of reproductive control, disproportionately targeting disabled women and other marginalized groups. They substitute paternalism for consent and institutional judgment for individual voice.
To move toward a more equitable and humane legal framework, a justice-oriented approach that affirms autonomy, challenges ableism, and centers the experiences of those most affected must be adopted. The case of Wendy Williams serves as a reminder that legal capacity can be easily revoked— even from individuals with substantial social and economic capital. For those without such privileges, the threat of reproductive disenfranchisement is even more acute.
As such, safeguarding reproductive autonomy requires dismantling the structural conditions that enable coercive practices and reworking guardianship in a manner consistent with human dignity and fundamental rights.
Endnotes
[1] Derrick Bryson Taylor, “Wendy Williams Declares She's Alcohol Free: What to Know About Her Guardianship,” The New York Times, last modified March 14, 2025, https://www.nytimes.com/article/wendy-williamsguardianship.html.
[2] Rebecca M. Kluchin, Fit to Be Tied: Sterilization and Reproductive Rights in America, 1950-1980, Critical Issues in Health and Medicine (Rutgers University Press, 2009), 12.
[3] Kluchin, Fit to Be Tied, 11.
[4] Robyn M. Powell, “Confronting Eugenics Means Finally Confronting Its Ableist Roots,” William and Mary Journal of Race, Gender, and Social Justice 27, no. 3 (2021): 612-613.
[5] Powell, “Confronting Eugenics,” 613.
[6] Linda Villarosa, “The Long Shadow of Eugenics in America,” The New York Times, last modified June 8, 2022, https://www.nytimes.com/2022/06/08/magazine/eugenics-movement-america.html.
[7] Paul A. Lombardo, "Republicans, Democrats, & Doctors: The Lawmakers Who Wrote Sterilization Laws," The Journal of Law, Medicine, and Ethics 51, no. 1 (2023): 123.
[8] Lombardo, “Republicans, Democrats, & Doctors,” 123.
[9] Hoangmai H. Pham and Barron H. Lerner, "In the Patient's Best Interest? Revisiting Sexual Autonomy and Sterilization of the Developmentally Disabled," The Western Journal of Medicine, o.s., 175, no. 4 (2001): 281.
[10] Buck v. Bell, 274 U.S. 200 (1927). https://supreme.justia.com/cases/federal/us/274/200/.
[11] Buck, 274 U.S. 200.
[12] Cori Brosnahan, “Finding Carrie Buck,” PBS, last modified November 2, 2018, https://www.pbs.org/wgbh/americanexperience/features/eugenics-finding-carrie-buck/.
[13] Buck, 274 U.S. 200.
[14] Buck, 274 U.S. 200.
[15] Pham and Lerner, “In the Patient’s Best Interest,” 281.
[16] Skinner v. Oklahoma, 316 U.S. 535 (1942). https://supreme.justia.com/cases/federal/us/316/535/.
[17] Powell, “Confronting Eugenics,” 614.
[18] Powell, “Confronting Eugenics,” 614.
[19] Villarosa, “The Long Shadow.”
[20] Villarosa, “The Long Shadow.”
[21] Villarosa, “The Long Shadow.”
[22] Emily DiMatteo, Vilissa Thompson, and Osub Ahmed, "Rethinking Guardianship to Protect Disabled People's Reproductive Rights," Center for American Progress, 2022, https://www.americanprogress.org/article/rethinkingguardianship-to-protect-disabled-peoples-reproductive-rights/.
[23] DiMatteo, Thompson, and Ahmed, “Rethinking Guardianship.”
[24] DiMatteo, Thompson, and Ahmed, “Rethinking Guardianship.”
[25] DiMatteo, Thompson, and Ahmed, “Rethinking Guardianship.”
[26] National Council on Disability, Turning Rights into Reality: How Guardianship and Alternatives Impact the Autonomy of People with Intellectual and Developmental Disabilities, 2019, https://www.ncd.gov/assets/uploads/docs/ncd-turning-rights-into-reality-508-0.pdf, 24.
[27] DiMatteo, Thompson, and Ahmed, “Rethinking Guardianship.”
[28] DiMatteo, Thompson, and Ahmed, “Rethinking Guardianship.”
[29] DiMatteo, Thompson, and Ahmed, “Rethinking Guardianship.”
[30] DiMatteo, Thompson, and Ahmed, “Rethinking Guardianship.”
[31] DiMatteo, Thompson, and Ahmed, “Rethinking Guardianship.”
[32] DiMatteo, Thompson, and Ahmed, “Rethinking Guardianship.”
[33] DiMatteo, Thompson, and Ahmed, “Rethinking Guardianship.”
[34] DiMatteo, Thompson, and Ahmed, “Rethinking Guardianship.”
[35] DiMatteo, Thompson, and Ahmed, “Rethinking Guardianship.”
[36] DiMatteo, Thompson, and Ahmed, “Rethinking Guardianship.”
[37] “Forced Sterilization of Disabled People in the United States,” National Women's Law Center, 2021, https://nwlc.org/resource/forced-sterilization-of-disabled-people-in-the-unitedstates/?gad_source=1&gad_campaignid=22045111430&gbraid=0AAAAAD7mv1OS2BnTWx5l_uttaX0v3GAJA& gclid=CjwKCAjwq7fABhB2EiwAwk-YbOeezm6OrsJEMJvN51Camm_-8ImPxx8- Yfmp9EVcnUhZCFOCN81axhoCv6wQAvD_BwE.
[38] National Women’s Law Center, “Forced Sterilization.”
[39] National Women’s Law Center, “Forced Sterilization.”
[40] Iowa Code § 633.635 (2023).
[41] Nev. Rev. Stat. § 159.0806 (2019).
[42] Ga. Code §§ 31-20-3 (2010).
[43] Ark. Code §§ 20-49-204 (2018).
[44] Nev. Rev. Stat. § 159.0806 (2019).
[45] Cal. Prob. Code § 1952 (2023).
[46] National Council on Disability, “Turning Rights into Reality.”
[47] “What is Disability Justice?,” Sins Invalid, last modified June 16, 2020, https://www.sinsinvalid.org/news1/2020/6/16/what-is-disability-justice.
[48] Sins Invalid, “What is Disability Justice.”
[49] Kimala Price, "What is Reproductive Justice? How Women of Color Activists Are Redefining the Pro-Choice Paradigm," Meridians 10, no. 2 (2010): 43.
[50] Price, “What is Reproductive Justice?,” 42-65.