FOR A READER ACCUSTOMED TO THE CONTEMPORARY LANGUAGE OF disability fights and to modern social welfare discourse, older professional writings about people with mental illness or mental retardation can be more than a little jarring. Consider, for instance, the following excerpt from the 1957 case history of a resident at Caswell Training School, in Kinston, North Carolina, the state's first facility for those diagnosed with mental retardation:
Robert was the fifth in a sibling group of eleven.... A younger brother, James, has also been committed to Caswell. Their oldest brother was described as a habitual drunkard.... He [Robert] came from a broken home as his father was serving a term in the pententary [sic] for assault with a deadly weapon. He [the father] was found guilty on incest charge[s] with his step daughters. The parents suffered from asthma, and were considered feeble-minded. He [Robert] also was infected with venereal disease. (1)
This case history reads much like the eugenic family studies of the early twentieth century: it shares with those studies vague accounts of relatives "considered feeble-minded" or "said to be mentally retarded," along with an emphasis on the large number of children and elaborations of every possible negative trait in the extended family. (2) It is well documented that eugenic beliefs about the hereditary nature of mental handicaps were widespread in the United States during the first decades of the twentieth century, when eugenic ideology was also popular in Germany and elsewhere. Eugenicists typically tried to link mental handicap to any number of undesirable traits--anything from criminality to epileptic seizures--as evidence of a broader hereditary "unfitness"; and they sought legal measures to prevent the reproduction of those deemed "unfit," most often through forced sterilization. Between the 1910s and the 1930s twenty-nine states enacted and put into practice laws permitting the involuntary sterilization of the "feebleminded," as well as the mentally ill, the epileptic, and sometimes the criminal. (3)
Yet Robert's case history does not date from the 1920s or 1930s, at the height of the eugenics movement in the United States. It appears in a 1957 petition to the North Carolina Eugenics Board requesting permission to sterilize this Caswell resident. The Eugenics Board, established in 1933, remained operative in North Carolina until the early 1970s. Even as late as 1980, a North Carolina court authorized the involuntary sterilization of a woman diagnosed with mild retardation. (4)
Clearly, the effects of the eugenics movement persisted long after eugenics lost most of its public popularity following World War II. Yet previous studies have primarily examined how eugenic theories and legislation were accepted by medical and political authorities before 1940. (5) The process by which eugenic mandates were still carried out decades later remains to be explained. In North Carolina and elsewhere, authorities at a lower level, operating within the state bureaucracy and inside state institutions, continued to implement eugenic policies well after the enabling legislation had been enacted and forgotten by state legislatures. The study of eugenics from this perspective allows us to see eugenic sterilization not as a political goal or an abstraction of operations performed per year, but as a complex social process unfolding within the context of a beleaguered state mental health system.
By the 1950s eugenics was to some degree a southern phenomenon. However, the region had initially lagged behind the rest of the nation in embracing sterilization legislation. South Carolina in 1935 and Georgia in 1937 were the last states in the nation to pass sterilization statutes; moreover, the funding crises of the Great Depression meant that, in these states and across the South, very few operations were actually performed during the 1930s. After World War II, however, while the numbers of sterilizations performed elsewhere in the country were slowly decreasing, the numbers rose substantially in Virginia, Georgia, North Carolina, and to a lesser extent, South Carolina. During the late 1950s sterilizations in Virginia, Georgia, and North Carolina together comprised about three-fourths of the operations performed under eugenic statutes in the United States. (6) These figures are distorted somewhat by the fact that North Carolina, unlike other states, authorized large numbers of sterilizations outside state institutions. County welfare boards in North Carolina sterilized around two hundred people each year in the late 1950s. Caswell Training School, in contrast, performed slightly fewer than fifty operations per year during the mid-1950s, at the height of its sterilization program. (7) Still, the fact remains that sterilization came into its own at Caswell, as in many other state institutions in the South, just as it was carried out more selectively (though seldom abandoned altogether) in the rest of the United States. (8)
North Carolina had one of the best documented, as well as one of the most vigorous, sterilization programs of the 1950s. Under the provisions of its 1933 eugenics law, which authorized sterilization on the basis of mental disease, "feeble-mindedness," or epilepsy, a centralized Eugenics Board approved or rejected all eugenic sterilization petitions. By law, the board was composed of five state officials: the commissioner of public welfare, the secretary of the state board of health, the attorney general, the chief medical officer of Dorothea Dix State Hospital in Raleigh, and a rotating fifth member from other state institutions. According to Johanna Schoen, during the 1940s and 1950s most board members showed little interest in the board's work, attending meetings irregularly or sending substitutes to take their places. Board members did not even review the full case files, relying instead on the brief case summaries prepared by the executive secretary. Petitions were rarely turned down. The board was effectively dominated by the executive secretaries and by two successive commissioners of public welfare who actively supported the sterilization program. The records of the board's work, together with administrative records from Caswell Training School and from state-level mental health administrators, are an invaluable resource for understanding the human reality behind the abstract statistics of operations performed. (9)
Two different factors, one involving the atmosphere and practical demands of institutional life and the second involving eugenics as an ideology, must be considered in tracing the history of sterilization in North Carolina's institutions. These factors varied over time in their importance and their visibility. First, no account of sterilization would be complete without acknowledging how smoothly the practice fit into the larger context of the institution. The normal institutional regime in facilities for persons with mental retardation was both remarkably penal in nature and enormously condescending and paternalistic toward the clientele. As a disciplinary practice of sorts, sterilization complemented other harsh measures taken to control the behavior and the lives of the institution's residents. As a so-called protective measure, it ensured the childlessness of individuals thought to be incapable of handling the burdens of parenthood, and it continued a long tradition of treating those with mental retardation as helpless children themselves. There was simply no conception within the institutional framework that individuals with mental retardation had a right to self-determination, especially in major life choices such as whether to have children.
In this context, Eugenics Board procedures that were originally intended to license sterilization on hereditarian grounds were used to meet other, more pragmatic institutional needs. Immediate pressures from both within and without the institution were always crucial in keeping the sterilization program at Caswell going, regardless of support from eugenic ideology; in the 1960s, when eugenic justifications had been officially abandoned, these pressures ensured that sterilization remained fin accepted practice: The need to prevent pregnancy among residents within the institution was, of course, a strong incentive to perform sterilizations. In addition, the institution faced demands from local officials to prevent residents on vacation or newly released into the community from reproducing and creating new problems. Underfunding, overcrowding, and inadequate personnel--universal issues in mental health care that were particularly acute in the South--made sterilization all the more attractive as a quick and easy way to alleviate strain on the institution.
At the same time, though, it is important not to underestimate the role of eugenics per se in shaping and maintaining institutional sterilization programs in North Carolina. The ideology of eugenics proved remarkably adaptable and resilient among institutional personnel. To a surprising degree, explicitly eugenic judgments of patients' unfitness for parenthood informed decisions about sterilization at least into the late 1950s. Scientific developments that demonstrated the limitations of hereditarian explanations for mental retardation were slow to penetrate obscure and marginalized places like Caswell, and they were especially irrelevant for the on-the-ground work of social workers and psychologists who collected social histories and selected candidates for sterilization. Furthermore, the eugenic component of the rationale behind sterilization at Caswell Training School actually became more pronounced during a period in the mid-1950s when institutional personnel first began to think seriously about modernizing and regularizing their medical practices.
The heightening of civil rights consciousness in the 1960s nudged mental health workers toward a greater appreciation of their clients' individual rights, but change at Caswell was slow and erratic. The physical and social isolation of the institution, together with the general stigmatization of and indifference to mental retardation, meant that public pressure for reform was nonexistent. Only the determination of a few state-level administrators to bring the Eugenics Board into line with modern medical practice, and to assert their own authority as psychiatric professionals over the social welfare establishment, led to the sharply decreased use of sterilization in the 1960s.
In many ways, the history of eugenic sterilization in public institutions such as Caswell is a history of long-term institutional crisis. This was particularly true in the early years--between 1945 and the early 1950s--of Caswell's sterilization program. (10) In theory, Caswell was a school, accepting only white North Carolinians above the age of six with IQs below 70. In reality, it was a custodial institution, with eleven teachers for a resident population that reached 1,800 in 1955. According to its chief (and, for many years, only) psychologist, Caswell residents frequently stayed at the institution for their entire lives; in 1946 only 34 percent of residents were below age twenty and thus of school age, while 13 percent were age forty or above. (11) Institutions for the feeble-minded, especially in the South, had already experienced funding difficulties during and after the Great Depression. The sharp rise in institutional populations after 1945 strained an already overburdened system even further. At Caswell the number of residents doubled between 1945 and 1955. Faced with perpetually long waiting lists for admission, the institution gave precedence to those without families able to care for them and those considered in direst need by local welfare departments. As a result, Caswell's residents were largely drawn from the most impoverished and socially isolated sections of North Carolina's white population. (12)
Not surprisingly, funding for this type of institution was not the state's highest priority, even when the school's basic needs went unmet. An outside evaluation in 1952 found that nearly every aspect of North Carolina's mental retardation program was entirely unsatisfactory. In comparison with other states, the amount of institutional space available was much too small: while the average state could provide facilities for an estimated 10 percent of the "mentally deficient" population, North Carolina had space for only 5 percent. Persons in dire need of care were occasionally committed to jail in order to obtain the status of "urgent" cases who could be moved to the head of Caswell's waiting list. Institutional services were also seriously inadequate: residents' diet, medical care, physical living conditions, education, and case management were marginal at best. Yet Caswell residents were well off in comparison to their African American counterparts, who occupied a section of the state mental hospital for African Americans at Goldsboro, which had no specialized services available for the mentally retarded. (13)
The 1952 investigators accused Caswell of being more like a penal institution than a mental health facility; they described the training school as essentially a "detention home," citing such details as a barred room used as a punishment cell. This complaint was commonly levied against such institutions, and for good reason. In a number of states, juvenile delinquents were regularly committed to facilities for the mentally retarded, and some superintendents defended practices such as solitary confinement as the only way to control their more violent charges. Although North Carolina's institutions did not accept referrals from the juvenile courts, they followed the customary …