Quiet Eugenics: sterilization in North Carolina's institutions for the mentally retarded, 1945-1965.

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 and highly revealing practice of characterizing patients as "inmates," who were released from the institution on "parole," and who might sometimes "escape" and need to be recaptured. (14)

Like other institutions throughout the United States and in North Carolina, Caswell administrators retained an absolute right to determine when and if their "inmates" would be released, regardless of the wishes of both the individuals concerned and the nearest kin. Such decisions involved a great deal of class-based discrimination; while respectable middle-class families might wield considerable control over their institutionalized relatives' fates, "bad" families were likely to find themselves permanently separated. As the Caswell psychologist put it, requests to send a resident home were generally honored as long as it was "ascertained that the home is a suitable place for the parolee." (15) This assumption of control over the residents' futures continued unchanged into the 1960s (and quite possibly longer). In one 1962 sterilization case, for example, the patient's next of kin provided a handwritten letter of consent that documented her understanding that the operation would facilitate the patient's release into her care:

   I think it is best for Annie to have the sterilization operation[.] I have
   done decided it my self and I really do think she needs to be sterilized
   and when it is done I want her to come home from down there[.]

The patient was also described as "unwilling to undergo [the] operation unless this will increase her chances of release and return to full community living." Nevertheless, the social history in the case file indicated that even temporary home visits were inadvisable. The sterilization petition described a "home situation which has but few economic advantages and is in many ways asocial," stressing the sexual misbehavior of both the patient and her extended family. (16)

Like much of the institutional routine--including, of course, sterilization itself--such assumption of control over patients' lives combined simple professional arrogance with a tradition of penal practices and, somewhat paradoxically, a paternalistic attitude toward patients that was often genuinely benevolent, if always condescending. During the postwar decades mental retardation was frequently interpreted using what critics later termed the "eternal child" model. Individuals with retardation, whatever their chronological age, were regarded as children who needed adult protection and supervision and who could not be considered responsible for their own behavior. At Caswell, as else where, patients were invariably referred to as "boys," "girls," or "children," regardless of their age, and they were encouraged to call staff members "Momma" and "Daddy." As the school newsletter put it,

   These youngsters are just like other children, other big boys and girls.
   They have the same longing for companionship, a desire to be appreciated, a
   love of beautiful things, and a sincere reverence for the Heavenly Father.
   (17)

From this point of view, adult sexuality and reproduction were simply dangers from which these innocent children required protection. Thus, the clearly sexual behavior of many adult residents, and the expressed desire of some women with mild retardation to become mothers, did not need to be taken seriously when institutional authorities made decisions on their behalf.

During the years immediately following World War II, staff shortages and lack of resources made any consistent or thorough eugenic sterilization program impossible at Caswell. With no social workers on staff and no organized case management, the institution had no way of collecting information about residents' background or family history. Case files contained only whatever information the referring agency chose to provide on the admission forms, and there was generally little contact between the Caswell staff and family members. Obviously, this situation made it difficult to select prospects for sterilization based on family histories of feeble-mindedness. (18)

There is evidence that at least some staff members would have preferred a more comprehensive and more eugenic program of sterilization. A 1940 issue of the school newsletter included a vehement plea on the necessity of eugenics:

   In the whole discussion of marriage and the family should one think of the
   good of the individual or of the good of the race? ... While we do not know
   as much about heredity as we should like, and while we are in no position
   to apply very definitely what we do know, it is time that we began to use
   what knowledge we have. There is nothing but grief in the propagation of
   people who are definitely compromised by heredity. (19)

In 1947 Moya Woodside, a researcher funded by eugenics enthusiast Clarence Gamble, visited Caswell and interviewed staff members on their attitudes toward sterilization. From her 1950 report, it appears that the direct-care staff were most concerned with the immediate prevention of sexual problems; they may have shared the common misconception that sterilization would eliminate sexual desire as well as reproduction. Perhaps indicating an interest among Caswell administrators in the eugenic ramifications of the procedure, school psychologist Elizabeth Brown expressed the hope of sterilizing all residents before they were released from the institution on parole. This was the general practice in states such as California or Oregon, where the eugenics movement had been particularly influential. Budgetary constraints, however, limited the number of sterilizations performed at Caswell during this period to twenty per year, and there is no indication in the Eugenics Board records that sterilization was ever successfully linked to parole. (20)

Interestingly, Woodside's interview with Caswell superintendent William T. Parrott revealed significant differences of opinion between the medical professionals who headed the institution and the rest of the mental health staff. The superintendent, a psychiatrist, did not condemn sterilization altogether, but he emphasized that the practice was of limited eugenic value. He also asserted that sterilization would never lead to a significant wholesale reduction in mental handicaps. Though not shared by all institutional psychiatrists in the United States, his view did conform to the widely accepted medical opinion laid out in an influential 1936 study sponsored by the American Neurological Association, known as the Myerson report. The disparity in enthusiasm for eugenics between Caswell's psychiatric superintendents and its professional staff would emerge as a significant factor shaping the institution's sterilization program. It should be noted, though, that it was the psychologist and her coworkers, not the superintendent, who had primary responsibility for choosing candidates for sterilization. (21)

Thus, although eugenics played a prominent role in the thinking of at least some mental health professionals, more practical considerations dictated the sterilization program at Caswell in the years immediately following World War II. According to the case summaries presented at Eugenics Board meetings, the primary criterion for sterilization at Caswell in the late 1940s was being a "sex problem at the school." Although Caswell, like other public institutions, enforced a rigorous segregation of the sexes, it is clear that a variety of covert sexual encounters, both homosexual and heterosexual, took place between the more active and capable members of Caswell's population. Indeed, according to one later report, residents had evolved an elaborate system of dating and "going steady," despite the fact that school regulations strictly forbade them even to hold hands. Sterilization thus provided one means of controlling this unruly population, compensating for the imperfections of institutional discipline. (22)

No doubt other factors contributed to the choice of a particular individual for sterilization in the late 1940s and early 1950s. Whatever those factors were, however, they were not made explicit in the petitions submitted to the Eugenics Board. These documents clearly reflected the lack of time and resources of Caswell's staff, as well as an apparent perception that petitions from Caswell did not require much justification. They generally included little information about the patient's social or family background and no details about the offending behavior that had inspired the request for sterilization. They did include a brief IQ test report, sometimes the notation "sex problem at the school," and consent forms signed by the patient's next of kin or a court-appointed guardian. Provided that the necessary paperwork was in order, the board made few demands on Caswell's staff, rubberstamping its approval despite the minimal information about the individual in question. Although North Carolina's statute established a hearings procedure by which the next of kin could challenge a sterilization petition, this rarely occurred. The board preferred to avoid controversy and emphasized that the approved sterilizations were overwhelmingly voluntary. It did not distinguish between the consent of a guardian and the consent of the patient. (23)

By its own standards, the Eugenics Board was quite rigorous in its consent procedure, sending sterilization petitions back to Caswell's staff if the appropriate forms were missing, or if there were any question about whether the consenting person was in fact the legal guardian. Petitions signed by mothers but not fathers, for example, were likely to be returned, unless there was some specific explanation of the father's absence. It is not very clear, though, what means were used to elicit relatives' consent. According to staff members interviewed in 1947 for Woodside's study, parents of Caswell residents were often reluctant to agree to their children's sterilization, feeling that "there is a stigma attached." In some cases, Caswell staff were able to convince the parents of the need for the operation. In most cases, though, the parents were too far away for direct consultation by Caswell staff members, and the task of obtaining consent was left to the local welfare department. (24) It is impossible to know what welfare officials told the parents; as in Annie's case described above, parents and guardians may have been left with the impression, correctly or incorrectly, that the operation was a prerequisite to secure a relative's release from the institution. The residents themselves were not consulted, but they were informed that they would be undergoing an operation and that they would not be able to have children. (25) Under such circumstances, with family members making decisions on residents' behalf and with officials employing such leverage, it is difficult to know exactly where the line between voluntary and compulsory sterilization should be drawn.

In the early 1950s several related factors began to transform the context of institutional sterilization. For the first time in decades, institutional superintendents found some sympathy in the state legislature for their perpetual pleas for more funds. This development was closely related to the growth of advocacy groups such as the North Carolina Association for Retarded Children (NCARC), led by middle-class parents of children with retardation; institutional superintendents finally had political allies. Caswell Training School benefited from the improved funding climate directly and immediately, most notably from a bond issue authorized by the state legislature in 1953. (26) At the same time, NCARC and other advocates for the disabled worked to transform the public's perception of mental retardation. After decades of publicity linking the "feeble-minded" with delinquency, promiscuity, and all varieties of social threat--including, of course, genetic taint--these groups focused instead on "mentally retarded children," sweet and innocent creatures from normal, middle-class families. Needless to say, parent advocates strongly de-emphasized hereditary explanations for the condition and stressed that any parent might give birth to a child with retardation, "regardless of economic status, race, color or religion." (27) This construction of mental retardation could not have been more at odds with traditional eugenic conceptions. Caswell endorsed these new views in its newsletter, and Caswell's superintendent maintained close relations with NCARC in its early years. (28)

Yet in the 1950s, even as the long-term institutional crisis was diminishing and public sympathy for the mentally retarded was on the rise, Caswell's sterilization program became most explicitly and methodically eugenic in its justifications. As budgetary constraints relaxed somewhat, the number of sterilizations performed at Caswell rose to approximately thirty per year, and then to between forty and fifty per year in the mid-1950s. (29) In 1954 and 1955 Caswell began to include reports on its residents' families and social histories with Eugenics Board petitions, most likely as a consequence of an expanding staff of social workers. As formal social histories were added to the sterilization petitions, the case summaries presented to the Eugenics Board increasingly emphasized the most negative aspects of the patient's background and family history. By 1955 approximately half of Caswell's case summaries highlighted family problems: parents or siblings with histories of mental illness, retardation, crime, welfare dependency, or promiscuity. In 1956 an official council on sterilization was established at Caswell to review cases and choose those most suitable for the operation. (30)

Of course, these family-based justifications for sterilization cannot be termed eugenic in the strictest sense; many of the undesirable behaviors and traits listed in the social histories were clearly not hereditary, and poor social conditions seemed to figure at least as prominently as poor biology in the thinking of Caswell social workers. Caswell's petitions to the Eugenics Board during the mid-1950s conform to what Molly Ladd-Taylor has described as the social welfare version of sterilization, reflecting the priorities and principles of social work rather than biology or psychiatry, and emphasizing the importance of a stable family background and responsible social behavior as necessary prerequisites for motherhood. (31) Yet at the same time, Caswell's social workers and psychologists clearly thought of sterilization in hereditarian terms, however loosely defined. In the social histories submitted to the Eugenics Board, information about family members was typically placed under the headings of "Paternal Heredity" and "Maternal Heredity." In one 1958 sterilization case the psychological report on file claimed, "This kind of response indicates inherited brain structure of a meager sort. The family history bears this out as her mother made an IQ 43, and her forebears were illiterate and immoral." Interestingly, the secretary of the Eugenics Board chose to omit entirely the issue of heredity from the case summary presented at the board meeting, noting instead that "[t]his girl will need supervision and guidance all her life and it is thought sterilization will be a protection to her." Apparently, by 1958 the Eugenics Board itself was no longer entirely comfortable with the traditional harsh rhetoric of eugenics. (32)

Thus, Caswell's initial moves toward regularity and increased professional review in its sterilization proceedings, made possible by the improved climate for mental retardation funding and services, actually distanced its program even further from the newer, more sympathetic attitudes toward mental retardation. This discrepancy points to the isolation and marginality of the institution, its residents, and its staff during this period. There was simply no real connection between internal institutional practices and public discourse about retardation. Neither NCARC nor any other outside group made efforts to reform Caswell's internal policies or critiqued institutional conditions. There were no public scandals or media investigations, such as those that occasionally occurred elsewhere. Even the state's homegrown eugenics organization, the Human Betterment League of North Carolina, expressed virtually no interest in Caswell or its sterilization program. (33) Similarly, the well-known eugenicist Clarence Gamble, who funded sterilization and birth control programs in North Carolina and elsewhere, focused his efforts on sterilization in the community and did nothing to encourage eugenics in North Carolina' s institutions for mental retardation. (34) Sterilizations in the institution were free to decline, increase, or continue unchanged, according to the wishes of a few key staff members.

Thus far, this article has primarily looked at sterilization from the vantage point of the professionals involved to examine how they viewed mental retardation and how they managed Caswell's sterilization program. Still to be considered is the larger question of who actually underwent sterilization at Caswell and at other North Carolina state institutions. The demographics of sterilization recipients suggest a great deal both about the persistence of older eugenic models and about the emergence of new links between sterilization, race, and welfare.

One issue that has never been satisfactorily addressed in the historiography of eugenic sterilization is whether and how the older eugenics movement was tied to the upsurge of sterilization abuses in the late 1960s and 1970s. In the early 1970s a series of scandals and lawsuits brought to public attention the fact that some federally funded hospitals and clinics were sterilizing impoverished women, often women on welfare, without their consent. Well-publicized cases such as the Relf sisters, two African American adolescents sterilized in a clinic in Alabama without their or their mother's knowledge, eventually led to stricter federal guidelines governing valid consent to sterilization and the public financing of the procedure. (35)

Commentators were quick to point out the racial dimension of these abuses and to connect the predominance of African American, Hispanic, and Native American women targeted for involuntary sterilization with the earlier racism of the eugenics movement. (36) Yet more recent studies have demonstrated that the eugenic statutes of the 1920s and 1930s were invoked mainly to sterilize poor whites. Because these statutes, with a few exceptions, limited sterilization to residents of institutions, the exclusion of African Americans from southern institutions for the mentally retarded led to their exclusion from many sterilization programs. There were cases of clearly racist sterilization practices, most notably at South Carolina's state mental hospital, but in general, eugenic sterilization in the 1930s and 1940s seemed to reflect more class-based biases. As Edward J. Larson has argued, eugenics advocates viewed sterilization primarily as a means to improve the genetic stock of the white race by eliminating reproduction of the white "unfit"; they had little interest in improving the genetic quality of other, presumably inferior races. Thus, there appears to have been a significant gap between eugenic sterilization and the more recent cases of racially based, compulsory sterilization. (37)

North Carolina's sterilization program, unlike others, did legalize sterilization on eugenic grounds outside as well as inside the state institutions. As Johanna Schoen has documented, welfare officials in the 1950s made extensive use of the 1933 statute to authorize state-funded sterilizations for women on the welfare rolls. (38) Although this study focuses on institutions, broad comparisons between community-based and institutional sterilization can illuminate both. By examining a period in which institutional eugenic sterilization and the sterilization of women on welfare coexisted in the same state bureaucracy, it is possible to see both the discontinuities and the interconnections between the two practices.

For various reasons, the group originally perceived as the greatest eugenic threat to mainstream white America was young, lower-class whites, especially women, diagnosed as "morons" or "high-grade feeble-minded." As these individuals were higher-functioning and apparently almost normal, they seemed most likely to marry and have children. It therefore seemed necessary to single them out for sterilization at an early age, before they could reproduce. And the female half of this population, presumably both prone to promiscuity and vulnerable to sexual predation from more intelligent males, was considered most likely of all to produce offspring. (39)

In the immediate postwar years North Carolina's sterilization program conformed closely to this model. The vast majority of sterilizations were performed on women, and in the late 1940s these women were primarily white teenagers diagnosed as mentally ill or mentally deficient. During the 1950s, however, an interesting divergence appeared between sterilizations in institutions for the mentally retarded and other Eugenics Board-endorsed sterilizations. The board gradually began to receive more extra-institutional petitions for women in their twenties and thirties, many of whom already had several children. The state mental hospitals, both white and black, also began to sterilize some older women. At the same time, the number of sterilizations performed in mental hospitals began to decrease, while the number of extra-institutional operations grew quite rapidly. As more and more black families appeared on the welfare rolls in the 1950s, and as the proportion of extra-institutional sterilizations rose, the proportion of black women sterilized increased dramatically. Some of these women, nearing the end of their childbearing years and raising a number of children already, were probably happy to have the state finance a tubal ligation. Others were certainly pressured into the operation. (40)

At Caswell Training School, meanwhile, the demographic profile of patients sterilized remained remarkably stable between the late 1940s and the early 1960s. Caswell residents were sterilized young; the median age of sterilization subjects held steady at seventeen to eighteen. Three-quarters of those sterilized were age twenty or below; this age group accounted for only about 35 percent of North Carolina's institutional population in the mid-1940s and slightly over 50 percent by 1959. (41) Only one person was ever listed as having previously married or given birth. When the sterilization program was reorganized and regularized in the mid-1950s, this pattern of operating on adolescents was made explicit. According to the staff psychologist, patients were normally retested for IQ "when they have reached maturity--or at age 16 or 17," and this was considered an appropriate time to also screen candidates for sterilization. (42)

Until 1960, the average IQ score of those sterilized at Caswell hovered around 40. Caswell's candidates for sterilization were most often diagnosed as "middle-grade," "trainable," or (when the terminology changed in the late 1950s) "moderately retarded." (43) This IQ average was lower than the intellectual level targeted by older eugenics advocates, but it was representative of Caswell's population as a whole. Given the overwhelming demands on institutional space, Caswell admitted a relatively small proportion of people diagnosed as "educable," leaving higher-functioning individuals in the care of local welfare departments when at all possible. (44)

Fifty-six percent of sterilizations at Caswell between mid-1946 and 1960 were performed on women. This is far below the proportion of women in other sections of North Carolina's sterilization program; the percentage of women among all sterilization cases reached 87 percent in the 1950s and 1960s. (45) Since extra-institutional sterilizations were targeted at welfare recipients, who were overwhelmingly female, this contrast is not surprising. However, the relatively even sex ratio of Caswell sterilizations complicates the task of those historians who analyze eugenic sterilization primarily in terms of its function in controlling female sexuality and reproduction. Sterilization at Caswell was indeed aimed partly at controlling those residents who were considered "sex problems." But both male and female sexuality were treated as threatening, for somewhat different reasons. In certain respects, men with mental retardation were at risk for even harsher disciplinary practices; in the 1930s and 1940s twelve Caswell residents were actually castrated. (46)

Yet in the 1960s, when the grounds for sterilization were narrowed considerably and eugenic justifications were explicitly abandoned at Caswell, only two operations out of a total of twenty-seven were performed on men. The decline of male sterilizations at Caswell was a particularly dramatic example of a similar decline across the United States. Between 1954 and 1958, 45 percent of sterilizations in the United States were performed on men; between 1958 and 1961, the proportion fell to 22 percent. (47) It appears that the new attempt to focus exclusively on the interests of the residents--to protect the vulnerable from the responsibilities of parenthood--led directly to the rejection of male, but not female, sterilization. A draft of a 1972 Eugenics Board policy statement made this rejection explicit. It stated that most cases of male sterilization were proposed either on the basis of "the heredity theory" or out of fear that the man would become sexually violent; in neither case would the operation be justified. It seems never to have occurred to either the Eugenics Board or Caswell staff members that parenthood might create unmanageable responsibilities or pose personal problems for men as well as women. (48)

The most fascinating area of contrast between extra-institutional sterilization and sterilizations in North Carolina's institutions for the mentally retarded was the racial composition of the sterilized population. Like most southern states, North Carolina had no formal facilities for black residents with mental retardation until well after World War II. A section of the black mental hospital at Goldsboro was given over to the care of patients with mental retardation, primarily severely disabled people with nowhere else to go; there were three hundred such patients in 1953. (49) As part of the larger expansion in mental retardation services, a separate training school for African Americans with mental retardation, O'Berry School, was established in Goldsboro in 1957. No sterilizations were authorized for O'Berry residents during the 1950s; the school performed twelve operations between 1960 and 1965, slightly less than Caswell's total for the same period, and conducted no more sterilizations through 1968, the last year of the Eugenics Board reports. (50) For the most part, then, institutional sterilization of the mentally, retarded remained a white phenomenon, while extra-institutional sterilization was increasingly prescribed for black women.

A closer look at the Goldsboro state mental hospital's sterilization program, however, reveals a somewhat more complicated process at work. As at Caswell, the number of sterilizations performed at Goldsboro rose during the early 1950s as financial pressures eased. A small but significant number of these operations were performed on patients diagnosed as mentally retarded, often in conjunction with a diagnosis of mental illness. In the fiscal year 1951-52, for example, twelve out of the thirty-seven sterilization petitions from Goldsboro had listed a diagnosis of mental deficiency. In contrast to Caswell, all but two of the thirty-seven petitions were for female patients. Interestingly, the median age for sterilization candidates diagnosed as retarded was only eighteen, while the median age for other patients was twenty-seven. While mentally ill women, like women in the welfare system, were seen as candidates for sterilization only after marriage or childbirth, the older model of sterilization inherited from the eugenics movement remained intact for those perceived as mentally retarded; they were to be sterilized as adolescents and prevented from reproducing altogether. Although African Americans were by no means singled out for this type of sterilization, they were also not exempt from it. (51)

The Goldsboro petitions provide a useful means of tracing the development of these two models of sterilization. The reasons for sterilization provided in the Goldsboro petitions of the early 1950s were a mixed lot, with little difference between the mentally deficient and the mentally ill cases. Some case summaries focused on family strains of mental defect, while others emphasized patients' violent or disorderly behavior; some asserted that the women could not emotionally handle more children, and others lacked justification altogether. By the late 1950s, however, the rationale behind the sterilization of black women at Goldsboro was extremely consistent and probably resembled that for the sterilization of women on welfare. After the opening of O'Berry School, which provided an institution for African Americans with mental retardation, mental deficiency was rarely proffered as a reason to sterilize Goldsboro patients. In 1958, for example, only three of the twenty petitions contained a diagnosis of retardation. In only one case, that of a sixteen-year-old boy with mental retardation, was the sterilization candidate under twenty years old; in only three cases did the candidate have no children. Instead, with few exceptions, case summaries emphasized the large numbers of children that the women had already borne, the birth of illegitimate children, and the women's inadequacy as mothers. Motherhood, almost unknown at Caswell, had become a virtual prerequisite for sterilization at Goldsboro. (52)

In some cases, the women in question probably welcomed the help in ending their childbearing; in other cases, they almost certainly did not. Either way, sterilizations at Goldsboro had become inextricably linked to women's status as mothers dependent on the state and to the board's interest in limiting their ability to reproduce further. Meanwhile, by the late 1950s the pattern of sterilizations at Caswell Training School was not really comparable to anything else in the Eugenics Board's program, with the possible exception of sterilizations among the mentally retarded contingent of the other state institutions. Caswell's near-exclusive focus on adolescents, its inclusion of males, and its persistent hereditarian tendencies made it highly unusual, if not unique, in North Carolina. Somehow, philosophies and practices that no longer seemed entirely applicable to the mentally ill, those on welfare, or the population at large still went more or less unquestioned in the context of mental retardation.

While the sterilization program continued with little alteration, changes did come to Caswell during the late 1950s. The growth of advocacy groups such as NCARC, the greater political sympathy for the needs of "retarded children," and the improved funding for mental retardation services had little direct effect on institutional policies. Nonetheless, such developments made it possible for Caswell's professional staff to redefine their mission, in theory at least, in increasingly optimistic terms. Staff members could see themselves as taking part in a truly progressive and beneficial treatment program, drawing contrasts between the hope-filled present and the penal and custodial practices of the past. (53) Gareth Thorne, a psychologist who headed Caswell's education program, wrote in the mid-1950s:

   The protection of the rights of each student is now a factor of major
   concern and has at present even been acknowledged by those staff members
   who had forecast failure on the part of the student to adjust to additional
   liberties.... Harsh restrictions and disciplinary measures formerly used
   have now vanished from the scene....

Superintendent Frederick E. Kratter predicted that Caswell could "become one of the most outstanding and respected schools in the United States," characterized by its progressive and scientific treatment. Although the institution did not entirely succeed in this goal, its growing emphasis on progressive treatment did eventually have consequences for institutional policies such as sterilization. (54)

In spite of real improvements in Caswell's staffing and facilities, there were few immediate changes in institutional routine. Rhetoric and attitudes were much easier to modernize. By the late 1950s the medicalized terminology of mental health treatment had largely replaced the older institutional vocabulary more appropriate to a prison than a hospital. Caswell's "inmates" became patients or pupils, "parole" became outplacement or rehabilitation, "morons" became mildly retarded individuals, and the monthly count of escapees disappeared from reports to the North Carolina Hospitals Board of Control. The new terminology did not mean, of course, that escape ceased to be a issue, or that institutional discipline became any less of a priority. For example, the barred and cagelike punishment cell described disapprovingly by inspectors in 1952 was removed only in 1959. (55) The persistence of such practices and institutional realities existed in sharp tension with Caswell's attempts to construct a more benevolent self-image.

In Caswell's petitions to the Eugenics Board during the late 1950s, paternalistic benevolence meshed uneasily with a continuing interest in sterilization as a eugenic measure. Although the submitted psychological reports and social histories continued to express a hereditarian understanding of mental retardation, now the documents also stressed the benefits of sterilization for the patient as well as for society. An adolescent with an "inherited brain structure of a meager sort," for instance, was simultaneously described as "incapable of realizing the consequences of her acts" and requiring "supervision and guidance all her life." Sterilization, the petition argued, would protect her from things that she could not understand. Protection, supervision, and the patients' inability to understand the consequences of sexuality were constant themes in the board's case summaries during this period. Eugenic ideology had not been abandoned, but it fit awkwardly into a medically based, theoretically nonpunitive treatment program. (56)

An experimental sex education program in 1956 and 1957 dramatized the growing tension between the practice of compulsory sterilization and the ideal of helping patients in a context of mutual trust. The program taught higher-functioning Caswell residents about puberty, dating, and heterosexual social codes in the hope of curbing institutional problems with homosexuality and other sexual behaviors considered inappropriate by the Caswell staff. It focused on etiquette and self-control, not direct sex education. Yet, in spite of the program's conservative and disciplinary intent, teachers ran into trouble immediately. Since the institution still maintained strict regulations governing heterosexual contact, teachers found themselves trying to explain that dating and limited physical intimacy were normal parts of adolescence, but that such things were nonetheless forbidden to Caswell residents. A class discussion of sterilization produced even greater difficulties, as a number of female students insisted on their desire for children, resisting all attempts to convince them that they would be better off childless. Unfortunately, many of these women had already been sterilized. (57)

These tensions finally reached the breaking point in 1959, when Caswell's sterilization program underwent a major reevaluation. The debates and conflicts over sterilization at Caswell that occurred during this transitional period are highly revealing. The reappraisal of the program brought to the surface a clear split between the medical professionals of North Carolina's mental health system, who had come to see sterilization as backward and probably useless, and social welfare professionals, who continued to see sterilization as an essential tool for care. The precipitating factor was the appointment of psychiatrist Eugene A. Hargrove, the head of the North Carolina Hospitals Board of Control, to the Eugenics Board. According to the board's executive secretary, Hargrove immediately expressed an interest in developing uniform sterilization policies for North Carolina's institutions "from a medical view point," employing medical and psychiatric expertise. It appears that the Eugenics Board representatives from the State Board of Public Welfare initially hoped that the attention, under Hargrove's influence, would result in the expansion of institutional sterilization programs. For some time, certain welfare workers had been frustrated by the declining numbers of sterilizations at state mental hospitals and by the failure of state institutions to sterilize cases referred to them by local welfare departments. They believed that this situation might be remedied through better communication between Hargrove and the Eugenics Board at the state level, and through codification of formal sterilization policies for state institutions. (58)

Welfare professionals, however, were sorely disappointed by Hargrove's actions. Hargrove summarily rejected a proposed policy statement, written by the board secretary after discussions with Caswell's psychologist and one other staff member, that essentially codified existing practices. The policy statement emphasized the protective functions of sterilization for the individual involved, called for patients to be considered for sterilization beginning at age fifteen, and gave social workers the task of selecting cases to be considered by Caswell's council on sterilization. (59) Instead, after consulting the heads of the medical departments at Caswell and other state institutions, Hargrove concluded that sterilization "is generally unnecessary for persons as long as they have the protected environment of the institution." Sterilizations at Caswell came to a halt immediately. No operations were performed between July 1959 and July 1961. When the program resumed in late 1961, it was on a much smaller scale, with only two to six operations per year. (60)

Clearly, Hargrove had decided not only to offer a medical point of view but to place psychiatrists in charge of a process that had previously been dominated by social workers and psychologists. Psychiatrists and other doctors tended to define eugenics in relatively narrow terms, as the attempt to prevent the transmission of undesirable hereditary traits. From this perspective, they were probably more conscious of the questionable scientific basis for eugenic sterilization. As early as 1947, Caswell's medical superintendent had expressed ambivalence about the sterilization program, arguing that sterilization would never lead to the elimination of mental deficiency (as eugenicists had once hoped). (61) Furthermore, many doctors during the 1950s were wary of tubal ligation under any circumstances, even when a woman actively sought out the operation. An unsigned note in Hargrove's Eugenics Board file asks, "What does the sterilization do to the emotional life--will it lead to behavior disorders, regression, psychosis, emphasize the `I'm different'?" These were typical concerns for psychiatrists, who viewed women's emotional health as intimately connected with their childbearing abilities. (62)

Social welfare officials, on the other hand, often paid little attention to distinctions between eugenic, psychiatric, and social justifications for sterilization. Trained in the casework approach, they focused not on the elimination of mental defect in global terms, but on the prevention of undesirable reproduction, as they perceived it, in particular cases. Furthermore, county welfare departments actually had to deal with children born to women who might not be able to care for them. Consequently, these agencies were eager to avoid the problem altogether. Although there had been little communication between welfare officials and Caswell staff during the late 1940s, by 1959 welfare departments sometimes played a crucial role in pushing for the sterilization of Caswell residents from their counties. (63) In 1960, to the confusion of the board, two petitions were submitted from Caswell without the endorsement of the medical department or (in one case) the superintendent, apparently at the insistence of county welfare workers. The board rejected both of these petitions. (64)

One of these two petitions, for a sixteen-year-old gift with Down syndrome, was submitted at the request of the girl's parents as well as the welfare department. This fact points to an interesting transition in the role played by parents and relatives in decisions about sterilization. In 1947 Caswell staff reported that it was extremely rare for parents to request the sterilization procedure. By the late 1950s, on the other hand, there was a small but steady trickle of cases said to have been initiated on behalf of the parents. While there was a great deal of variation in the attitudes taken by patients' families, parents who strongly supported sterilization were no longer so exceptional. (65)

In part, the spread of the paternalistic "eternal child" model of retardation had prepared some parents to support policies aimed at protecting their child from adult responsibilities. Perhaps families had also become less likely to perceive the operation as a direct judgment on their own genetic stock, as the popular eugenics movement faded further into the past. Probably the largest factor, however, was simply the increasing involvement of many parents in the lives of their institutionalized children. In the early 1950s residents at Caswell were almost completely cut off from their families, if they had families at all. The institution was an inconvenient distance from most homes, visiting hours were extremely short, and parents were generally not even allowed to see their children's living quarters, meeting them only in the public areas of the central building. The North Carolina parents' association rarely criticized institutional policies in the 1950s, but it did push for expanded visiting hours and a simpler procedure for home visits. (66) In several cases in the late 1950s, parents requested their children's sterilization after observing their behavior during home visits. As parents had more direct contact with their offspring and became more involved in their care, they encountered for themselves the same problems that Caswell staff had always faced in regulating and controlling sexual behavior. (67)

It is noteworthy that none of the actors involved--parents, psychiatrists, Caswell staff, county welfare workers--expressed concern for Caswell residents' autonomy or right to self-determination. Eugenics was finally on its way out, but paternalism remained intact. By the beginning of the 1960s, considerations of protecting the patient and acting in his or her best interest decisively outweighed the need to protect society from the patient and his or her potential offspring. Opponents and advocates of sterilization both claimed to have the best interests of Caswell residents in mind. All sides stressed the need for careful, case-by-case evaluation of whether the operation would be beneficial to a particular individual. But neither opponents nor advocates questioned their own ability to determine what was best on the patient's behalf. (68)

In the early 1960s new protocols for Eugenics Board petitions required information about the patient's attitude toward sterilization. Moreover, by this time, Caswell residents were at least consulted about the operation and made to understand its nature. In one case the patient was even asked to sign a consent form. (69) But these early moves toward informed consent did not go far. Caswell staff members still had no compunction about requesting the operation in the face of determined resistance from the individual involved. In fact, in one case a young woman's strong desire to become pregnant and have children was presented as a major factor necessitating the operation. (70) The idea that a woman with mental retardation might have as much right as other women to choose to have children had not yet entered the discourse.

The resumption of occasional sterilizations at Caswell in 1961, after a two-year hiatus, is some indication of the pressures for sterilization that emanated from both inside and outside the institution. (71) Hargrove's belief that the structured environment of the institution made sterilization unnecessary was, of course, unrealistic. The Caswell staff continued to use sterilization in the early 1960s partly to compensate for the inadequacies of institutional control. However, the majority of sterilizations in the early 1960s were performed for extra-institutional reasons, especially in cases where sexually active women were about to be released into the community. Caswell had finally linked sterilization with parole, if only on an occasional basis. In addition, staff members acceded to at least one parental request for sterilization (one of only two Caswell cases of male sterilization in the 1960s). (72)

From the 1960s cases it appears that the welfare departments and their successors had won the day in the battle over sterilization. A number of the Caswell petitions noted that "community agencies will find it easier to work with her," or that "social agencies in this girl's community ... will be more willing to assist and work with her," if sterilizations were performed. (73) Unlike earlier sterilization cases, most petitions in the 1960s were for women with mild or borderline retardation--the women most likely to be released. For the eight patients submitted to the board in 1961 and 1962, the average IQ score was 64, in the upper ranges of mild retardation. (74)

Ironically, the trend toward sterilizing the higher-functioning individuals at Caswell seems to have been closely linked to the institution's attempts to develop more progressive and enlightened treatment programs. In the 1960s Caswell staff were increasingly aware that not all residents belonged in an institution, and community placement became a growing priority. If community agencies demanded sterilization as a precursor, they were likely to have their requirements met. Six of the eight petitions submitted in 1961 and 1962 were for women involved in the new Caswell Rehabilitation Center. This program, initiated in 1960, was a great source of pride for the institution, endlessly profiled and applauded in Caswell's newsletter. With rehabilitation, people with mental retardation would finally have their "chance for equal rights" and their "chance at life, liberty, and the pursuit of happiness." (75) Nonetheless, many obstacles to successful community adjustment, including local resistance to accepting the mentally retarded person back into the community and problems created by an individual's own behavior, had to be overcome. The failure rate was high, especially for women, but sterilization was one possible means of improving a woman's chances for reintegration and economic independence. The praiseworthy goal of deinstitutionalization, combined with continuing community fears of reproduction by women with mental retardation, led caseworkers to resort repeatedly to the old Eugenics Board process for their clients. (76)

It thus seems clear that the decline of sterilization at Caswell was largely due to the efforts of a small group of psychiatrists and high-ranking professionals, rather than either public pressure or any wholesale abandonment of eugenic thinking by Caswell's staff. Indeed, loosely hereditarian beliefs about the nature of mental "defect" were strikingly persistent among some social workers and state welfare officials both inside and outside the institution. Yet with psychiatrists determined to oversee a scientifically sound and medically managed program (by their own definition of the terms), the possibilities for putting such beliefs into practice were increasingly limited.

As a result, by 1965 explicitly eugenic sterilization was a thing of the past in North Carolina's institutions for the mentally retarded. Sterilization as a means of dealing with sexual behavior within the institution was also in decline, though not altogether eliminated. (77) Consultation with the client and careful case review had replaced the brief and uninformative petitions of the 1940s. On the whole, sterilization had become the exception rather than the rule for institutionalized adolescents with mild to moderate mental retardation. Yet persistent paternalism, community pressure, and the continuing need for institutional control combined to ensure that involuntary sterilization would survive at Caswell, just as it continued to survive elsewhere in North Carolina's social welfare system. The confidence of both medical and social welfare professionals in their own ability to make choices on their clients' behalf was still largely intact.

It is impossible to be sure when involuntary sterilization actually ended at what is now known as Caswell Center. Petitions to the Eugenics Board continued through at least 1968, when the board ceased publication of its biennial reports. Even if figures were available for the post-1968 period, it would be very difficult to pinpoint the boundary between voluntary and involuntary sterilizations. Questions of what might constitute informed consent for people with mental disabilities, and who should properly make the decision to sterilize someone who is truly incapable of understanding the operation, have never been satisfactorily answered. Since the mid-1960s, the continued use of old sterilization laws has produced a long series of court cases and lawsuits, and court after court has been called to determine when the sterilization of an individual with mental retardation is justified. Different courts have arrived at different conclusions, and the legal issues surrounding the sterilization of legally incompetent persons remain murky. (78)

The stubborn persistence of involuntary sterilizations in state institutions for the mentally retarded with so little public concern or protest demonstrates both the vigor and the lingering impact of the eugenics movement in North Carolina. It also may suggest something of the importance attached to intelligence in mainstream American culture and the enormous stigma attached to mental retardation. But, at the core, sterilization programs such as Caswell's were driven by social marginality and poverty--both on the part of individuals subjected to involuntary sterilization and on the part of neglected public institutions struggling to survive with inadequate resources. With few outsiders interested in what happened inside a place like Caswell, and with overwhelming immediate problems with which to contend, it is not surprising that new standards of professional conduct and modern treatment were slow to have much impact. Sterilizations continued quietly, with little public notice and less public protest, until they fell prey to professional divisions within the state bureaucracy itself.

(1) Case ID 284, Sterilized Cases, Eugenics Commission Record Group (North Carolina State Archives, Raleigh, N.C.); hereinafter cited as Eugenics Records. This study is based in large part on the summaries of potential sterilization cases that were prepared for consideration at Eugenics Board meetings. The corresponding summary to the case quoted above can be found in Case 11, Consent Cases, February 23, 1957, in Minutes and Agendas, Eugenics Records; hereinafter cited as Eugenics Board Agendas. In addition, I reviewed a small sample (sixteen files) of full case records between 1950 and 1962; the case quoted above is from this sample. The sample was selected after reviewing the case summaries. Case files generally included brief medical histories, psychological reports with IQ test results, Eugenics Board forms, and in later cases a social history of some sort. To maintain confidentiality, the full case records are always cited by reference to the corresponding case summary, and with a case ID number assigned by me. Case numbers for case summaries follow the unofficial numbering on the Eugenics Board agendas. All patient names have been changed.

I am very grateful for the extensive work of Ed Morris and other staff members at the North Carolina State Archives in preparing the Eugenics Board case records for my use. I would also like to thank Margaret Humphreys for her assistance with the original version of this paper. The present article benefited greatly from the comments of Matthew Twining, Elaine Castles, and three anonymous reviewers for the Journal of Southern History.

(2) Case ID 345, Sterilized Cases, Eugenics Records (corresponding case summary in Case 24, Consent Cases, August 26, 1958, Eugenics Board Agendas) (quotations); Nicole Hahn Rafter, ed., White Trash: The Eugenic Family Studies, 1877-1919 (Boston, 1988); Henry Herbert Goddard, The Kallikak Family: A Study in the Heredity of Feeble-Mindedness (New York, 1912; reprint, New York, 1973).

(3) Human Betterment Association of America, Sterilizations Reported in the United States to January 1, 1961 (New York, 1961). On the eugenics movement see Daniel J. Kevles, In the Name of Eugenics: Genetics and the Uses of Human Heredity (New York, 1985); Carl N. Degler, In Search of Human Nature: The Decline and Revival of Darwinism in American Social Thought (New York and Oxford, 1991); Martin S. Pernick, The Black Stork: Eugenics and the Death of "Defective" Babies in American Medicine and Motion Pictures Since 1915 (New York and Oxford, 1996); and Ian Robert Dowbiggin, Keeping America Sane: Psychiatry and Eugenics in the United States and Canada, 1880-1940 (Ithaca, N.Y., and London, 1997).

(4) Roberta Cepko, "Involuntary Sterilization of Mentally Disabled Women," Berkeley Women's Law Journal, 8 (1993), 122-65.

(5) On the history of eugenic sterilization legislation and practices in the United States see Edward J. Larson, Sex, Race, and Science: Eugenics in the Deep South (Baltimore and London, 1995); Philip R. Reilly, The Surgical Solution: A History of Involuntary Sterilization in the United States (Baltimore and London, 1991); James W. Trent Jr., Inventing the Feeble Mind.' A History of Mental Retardation in the United States (Berkeley, Los Angeles, and London, 1994); Steven Noll, Feeble-Minded in Our Midst: Institutions for the Mentally Retarded in the South, 1900-1940 (Chapel Hill and London, 1995). Both Reilly and Larson include information on sterilization trends during and after World War II, in some cases tracing the rise and fall of specific institutional programs through evidence in annual reports and surveys from national eugenics organizations. However, the amount of detail that can be gained from such sources is limited.

(6) Larson, Sex, Race, and Science, 84, 120, 124-39, 157.

(7) Biennial Report of the Eugenics Board of North Carolina, July 1, 1956-June 30, 1958 (Raleigh, N.C., 1958), table 1, p. 14; Biennial Report of the Eugenics Board of North Carolina, July 1, 1958-June 30, 1960 (Raleigh, N.C., 1960), table 1, p. 14; Biennial Report of the Eugenics Board of North Carolina, July 1, 1954-June 30, 1956 (Raleigh, N.C., 1956), table 4, p. 15. Hereinafter, citations to these reports will appear as Biennial Report, with the two-year period appended. On extra-institutional sterilizations in North Carolina see Johanna Schoen, "`A Great Thing for Poor Folks': Birth Control, Sterilization, and Abortion in Public Health and Welfare in the Twentieth Century" (Ph.D. dissertation, University of North Carolina at Chapel Hill, 1995).

(8) Although the number of sterilizations decreased in most states during the 1950s, the majority of states with sterilization laws continued to perform at least a few operations into the 1960s or later. Thus, for the years 1956-57, all but four of twenty-seven states with valid sterilization statutes reported some sterilizations to the Human Betterment Association, which collected these figures. In 1960-61 twenty-one out of the twenty-seven states reported operations. In many cases, the number of operations performed was very small, much like Caswell's sterilization program after 1959. Human Betterment Association, Sterilizations Reported in the United States to January 1, 1954 (New York, 1954), 2; Human Betterment Association, Sterilizations Reported in the United States to January. 1, 1958 (New York, 1958), n.p.; Human Betterment Association, Sterilizations Reported in the United States to January 1, 1961, p. 2.

(9) Eugenics Board of North Carolina, Manual of the Eugenics Board of North Carolina (Raleigh, N.C., 1948), esp. 7-9; Schoen, "`A Great Thing for Poor Folks,'" 152-56.

(10) Until 1958 Caswell Training School was not only the oldest but also the only institution for mental retardation in North Carolina. Thus, this article focuses primarily on Caswell's sterilization program. Two new facilities, one for white and one for black North Carolinians, opened in 1958. As will be discussed, these newer institutions made very little use of the Eugenics Board procedures.

(11) Bureau of Educational Research and Service of the University of North Carolina, A Survey of the Program for the Mentally Deficient in North Carolina (Chapel Hill, 1952), 14; North Carolina State Board of Public Welfare, Division of Psychiatric and Psychological Services, "Inspection Report of Caswell Training School, December 14, 1950," Monthly Reports File, 1945-1960, Administration Section, Mental Health, Mental Retardation, and Substance Abuse Record Group (North Carolina State Archives, Raleigh, N.C.), hereinafter cited as MH-MR-SA Records; "Book Population, July 1955-July 1956," Population Statistics (unprocessed records, Caswell Center, Kinston, N.C.; hereinafter cited as Caswell Records); Elizabeth Brown, untitled paper, n.d., and "Report of the Department of Psychology, June 30, 1944, to June 30, 1946," both in Folder on "Department of Psychological Service," Caswell Records.

(12) "Caswell Training School, Kinston, North Carolina," 1953, Folder on "The History of Caswell and Mental Retardation," Caswell Records; "Report of the General Superintendent to the Hospitals Board of Control, Sept. 23, 1952," and "Report of the General Superintendent to the Hospitals Board of Control, June 7-8, 1955," both in Monthly Reports File, 1945-1960, Administration Section, MH-MR-SA Records.

(13) Bureau of Educational Research, Survey of the Program for the Mentally Deficient in North Carolina, esp. pp. 3 (quotations), 15-23, 25-26, 29-33, 42-51, 55-56.

(14) "Hospital Report Given Governor," 1952, Scrapbook on "News clippings, 1936-1961," Caswell Records (first quotation); "Let's Have Prompt Action on This One," Children Limited, 4 (March 1955), 1; "Boys Kept in Caged Cells," Children Limited, 5 (February 1956), 7. For examples of penal language see Eugenics Board, Manual of the Eugenics Board of North Carolina, 10; "Jottings from the Dormitories," Caswell News, 17 (October 1953), 5; and "The Academic Department," Caswell News, 17 (March 1953), 3-4.

(15) Elizabeth M. Brown, "Community Adjustment of the Moron," American Journal of Mental Deficiency, 50 (January 1946), 434-36 (quotation on p. 434).

(16) Case ID 359, Sterilized Cases, Eugenics Records (corresponding case summary in Case 11, Consent Cases, March 27, 1962, Eugenics Board Agendas).

(17) Elizabeth M. Brown and Sarah Shaw Genheimer, Haven on the Neuse: A History of Caswell Center, Kinston, North Carolina, 1911-1964 (New York and other cities, 1969), 64; Joe Lassiter, Kinston, N.C., personal communication to author, May 13, 1999; "What Is Caswell Training School?" Caswell News, 17 (March 1953), 2. For a general debate over the terminology used in referring to institutional residents, and an effort to find a replacement for both "boy" and "girl" as well as for the more stigmatizing "inmate," see The Exceptional Child Faces Adulthood: Proceedings of the 1955 Spring Conference of the Child Research Clinic of the Woods Schools (Langhorne, Pa., 1955), 111. On the history of the eternal child model of mental retardation see Janice A. Brockley, "Rearing the Child Who Never Grew: Parents, Professionals, and Children with Intellectual Disabilities, 1910-1965" (Ph.D. dissertation, Rutgers University, 2001), esp. 9-11.

(18) Bureau of Educational Research, Survey of the Program for the Mentally Deficient in North Carolina, 37.

(19) "The Marriage," Caswell News, 5 (May 1940), 3.

(20) Moya Woodside, Sterilization in North Carolina: A Sociological and Psychological Study (Chapel Hill, 1950), 33-35; Woodside, manuscript of "Sterilization in North Carolina," General File, Eugenics Records; Elizabeth M. Brown to R. Eugene Brown, February 20, 1942, General File, Eugenics Records. On the practice in California and Oregon see, for example, Larson, Sex, Race, and Science, 32-39, esp. 36-37; and Irvin B. Hill, "Sterilizations in Oregon," American Journal of Mental Deficiency, 54 (January 1950), 399-403.

(21) Woodside, manuscript of "Sterilization in North Carolina"; Abraham Myerson et al., Committee of the American Neurological Association for the Investigation of Eugenical Sterilization, Eugenical Sterilization: A Reorientation of the Problem (New York, 1936), esp. 183; "Negative and Positive Eugenics Programs," n.d., Folder on "Papers of Kratter, Frederick E.," Caswell Records.

(22) Woodside, Sterilization in North Carolina, 34; Frederick Edward Kratter and Gareth David Thome, "Sex Education of Retarded Children," American Journal of Mental Deficiency, 62 (July 1957), 44-48 (quotation on p. 45). For examples of cases described as "sex problem at the school" see Case 3, Consent Cases, February 23, 1949, and Case 20, Consent Cases, May 27, 1953, Eugenics Board Agendas. For an analysis of the relationship between sterilization and institutional control in the 1920s and 1930s see Trent, Inventing the Feeble Mind, 192-224.

(23) Biennial, Report, 1944-46, p. 7; Biennial Report, 1946-48, pp. 11-12; Eugenics Board, Manual of the Eugenics Board of North Carolina, 16. I am aware of only five cases from Caswell in which the hearings procedure was used, all in 1954 and 1955. The patient and relatives were not present at the hearings in any of these cases. See Case 1, Hearing Cases, April 28, 1954; Case 3, Hearing Cases, October 27, 1954; Case 2, Hearing Cases, February 22, 1955; Case 2 and Case 3, Hearing Cases, March 22, 1955; all in Eugenics Board Agendas.

(24) Woodside, Sterilization in North Carolina, 34 (quotation); "Report of the Department of Psychology for the Month of February, 1956," Folder on "The Department of Psychological Service," Caswell Records.

(25) Woodside, Sterilization in North Carolina, 34-35; Annie's case is cited at n. 16. An earlier draft of Woodside's study, however, does not include the claim that patients were informed they would not have children. Woodside, manuscript of "Sterilization in North Carolina."

(26) Taylor R. Kennerly, History of the North Carolina Association for Retarded Children, Inc.: The First Fifteen Years (n.p., 1968), 1-8.

(27) National Association for Retarded Children, The Child Nobody Knows (New York, 1955), n.p.

(28) See, for example, "Talk It Up!" Caswell News, 17 (October 1953), 2; and Kennedy, History of the North Carolina Association for Retarded Children, 10-49.

(29) Biennial Report, 1950-52, table 8A, p. 21; Biennial Report, 1952-54, table 8A, p. 21; Biennial Report, 1954-56, table 4, p. 15.

(30) Caswell case summaries, Consent Cases, 1954-1955, Eugenics Board Agendas. On the growth of Caswell's social welfare department see Brown and Genheimer, Haven on the Neuse, 162. On the formation of Caswell's council on sterilization see "Reports of the Superintendents of State Hospitals and Training Schools, August 1956," Monthly Reports File, 1945-1960, MH-MR-SA Records; and "Progress Report, July 1, 1956-June 30, 1957," General File, Eugenics Records.

(31) Molly Ladd-Taylor, "Saving Babies and Sterilizing Mothers: Eugenics and Welfare Politics in the Interwar United States," Social Politics, 4 (Spring 1997), 136-53.

(32) Case ID 346, Sterilized Cases, Eugenics Records (corresponding case summary in Case 4, Consent Cases, September 23, 1958, Eugenics Board Agendas).

(33) Human Betterment League of North Carolina Records #4519 (Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill); Trent, Inventing the Feeble Mind, 226-27.

(34) William Van Essendelft, "A History of the Association for Voluntary Sterilization, 1935 1964" (Ph.D. dissertation, University of Minnesota, 1978), 82-122; Reilly, Surgical Solution, 133-34.

(35) Thomas M. Shapiro, Population Control Politics: Women, Sterilization, and Reproductive Choice (Philadelphia, 1985), 87-94; Reilly, Surgical Solution, 150-51; Larson, Sex, Race, and Science, 162-63.

(36) Jack Slater, "Sterilization: Newest Threat to the Poor," Ebony, 28 (October 1973), 150-56; Angela Y. Davis, Women, Race and Class (New York, 1981), 213-21.

(37) Larson, Sex, Race, and Science, 153-57; Noll, Feeble-Minded in Our Midst, 89-103; Reilly, Surgical Solution, 138.

(38) Schoen, "`A Great Thing for Poor Folks,'" chap. 4.

(39) See, for example, Stanley Powell Davies, Social Control of the Mentally Deficient (New York, 1930; reprint, New York, 1976), 117; Howard W. Potter and Crystal L. McCollister, "A Resume of Parole Work at Letchworth Village," in Marvin Rosen, Gerald R. Clark, and Marvin S. Kivitz, eds., The History of Mental Retardation: Collected Papers (2 vols.; Baltimore and other cities, 1976), II, 127-43, esp. 136-37.

(40) Schoen, "`A Great Thing for Poor Folks,'" 122-23, 236; Biennial Report, 1946-48, table 1, p. 17, table 7A, p. 22; Biennial Report, 1948-50, table 7A, p. 23; Biennial Report, 1950-52, table 7A, p. 19, table 14, p. 29; Biennial Report, 1952-54, table 7A, p. 19, table 13, p. 28; Biennial Report, 1954-56, table 8, p. 20, table 10, p. 21; Biennial Report, 1956-58, table 8, p. 20, table 10, p. 21; Biennial Report, 1958-60, p. 10, table 8, p. 20, table 10, p. 21.

(41) Caswell case summaries, 1947-1962, Eugenics Board Agendas. For age distributions at Caswell see "Report of the Department of Psychology, June 30, 1944, to June 30, 1946," Folder on "Department of Psychological Service," Caswell Records; and "Caswell's Progress Since 1954," n.d., Folder on "Papers of Kratter, Frederick E.," Caswell Records; and National Institute of Mental Health, Patients in Mental Institutions, 1959. Part One: Public Institutions for Mental Defectives and Epileptics (Washington, D.C., 1961), table 8, p. 1-34.

(42) Case 14, Consent Cases, June 27, 1961, Eugenics Board Agendas; "Report of the Department of Psychological Service of Caswell for the Month of February, 1955," and "Report of the Department of Psychological Service of Caswell for the Month of March, 1955" (quotation), both in Folder on "Department of Psychological Service," Caswell Records.

(43) Based on Caswell case summaries, 1947-1960, Eugenics Board Agendas.

(44) "Purposes and Aims," Caswell News, 22 (July 1957), 2-4. It is likely that states whose institutions held large numbers of court-referred "defective delinquents" would have had a much higher proportion of people with mild or borderline retardation. North Carolina's institutions for the mentally retarded accepted patients on the referral of county welfare workers, but they did not generally accept referrals from the juvenile or criminal courts.

(45) Biennial Report, 1946-48, table 8A, p. 25; Biennial Report, 1948-50, table 8A, p. 25; Biennial Report, 1950-52, table 8A, p. 21; Biennial Report, 1952-54, table 8A, p. 21; Biennial Report, 1954-56, table 4, p. 15; Biennial Report, 1956-58, table 4, p. 15; Biennial Report, 1958-60, table 4, p. 15; Biennial Report, 1960-62, table 4, p. 15; Schoen, "`A Great Thing for Poor Folks,'" 122.

(46) Twenty-four men at the Goldsboro mental institution for African Americans were also castrated during this period. Biennial Report, 1948-50, table 8A, p. 25. On castration as an institutional practice see C. C. Hawke, "Castration and Sex Crimes," American Journal of Mental Deficiency, 55 (October 1950), 220-26. On eugenic sterilization and female sexuality see Nicole H. Rafter, "Claims-Making and Socio-Cultural Context in the First U.S. Eugenics Campaign," Social Problems, 39 (February 1992), 17-34; and Wendy Kline, Building a Better Race: Gender, Sexuality, and Eugenics from the Turn of the Century to the Baby Boom (Berkeley, Los Angeles, and London, 2001), esp. 32-60. Kline discusses the approximately even sex ratio in California's early sterilization program but emphasizes the tendency of prominent eugenicists to focus on women in their rhetoric. Sterilization in the United States became increasingly targeted at women over time. By the mid-1950s, according to the Human Betterment Association's cumulative statistics, 65 percent of people with mental retardation ever sterilized in the United States were female. In this, as in other things, Caswell seems to have lagged behind the rest of the country. Reilly, Surgical Solution, 98; Human Betterment Association, Sterilizations Reported in the United States (New York, 1954), n.p.

(47) Human Betterment Association, Sterilizations Reported in the United States to January 1, 1954, p. 2; Human Betterment Association, Sterilizations Reported in the United States to January 1, 1958, n.p.; Human Betterment Association, Sterilizations Reported in the United States to January 1, 1961, p. 2.

(48) Biennial Report, 1960-62, table 4, p. 15; Biennial Report, 1962-64, table 4, p. 15; Biennial Report, 1964-66, table 4, p. 15; Biennial Report, 1966-68, table 4, p. 15; Bob Rollins, M.D., to Eugenics Board members, "Proposed Eugenics Board Policy," April 18, 1972, General File, Eugenics Records.

(49) Kennerly, History of the North Carolina Association for Retarded Children, following p. 9.

(50) Biennial Report, 1958-60, table 15, p. 29; Biennial Report, 1960-62, table 4, p. 15; Biennial Report, 1962-64, table 4, p. 15; Biennial Report, 1964-66, table 4, p. 15; Biennial Report, 1966-68, table 4, p. 15. Fourteen sterilizations were also performed during this period at Murdoch Center, a white institution that opened at approximately the same time as O'Berry School.

(51) Goldsboro case summaries, 1951-1952, Eugenics Board Agendas.

(52) Goldsboro case summaries, 1958, Eugenics Board Agendas.

(53) "Purposes and Aims," 2-4; F. E. Kratter, "A Modern Approach to Mental Deficiency," North Carolina Medical Journal, 19 (July 1958), 268-71.

(54) Gareth Thorne, "Historical Review of the Department of Training," ca. 1956, Folder on "Papers of Thorne, Garrett [sic]," Caswell Records; Frederick E. Kratter, "A Message," Caswell News, 22 (January 1957), 2.

(55) "Report of Superintendents of State Hospitals and Training Schools, July 1959," Monthly Reports File, 1945-1960, Administration Section, MH-MR-SA Records. For the modernized terminology see Case ID 331, Sterilized Cases, Eugenics Records (corresponding case summary in Case 18, Consent Cases, March 22, 1958, Eugenics Board Agendas); "Student Council," Caswell News, 23 (July 1958), 6; and "Spring," Caswell News, 25 (April 1960), 1. On escapes see "Reports of the Superintendents of State Hospitals and Training Schools," 1952-1955, Monthly Reports File, 1945-1960, Administration Section, MH-MR-SA Records.

(56) Case ID 346, Sterilized Cases, Eugenics Records (quotations; corresponding case summary in Case 4, Consent Cases, September 23, 1958, Eugenics Board Agendas); Biennial Report, 1958-60, pp. 7-8.

(57) Kratter and Thorne, "Sex Education of Retarded Children," 45-48; Gareth D. Thorne, "Sex Education of Mentally Retarded Girls," American Journal of Mental Deficiency, 62 (November 1957), 460-63.

(58) Ethel Speas to Ellen Winston, May 22, 1959, Folder on "General Correspondence from 1970," General File, Eugenics Records (quotation). See also "Progress Report, July 1, 1957-June 30, 1958," General File, Eugenics Records.

(59) Ethel Speas to Eugene A. Hargrove, "Policies and Procedures Relating to Sterilization at the Training Schools for the Mentally Retarded," January 19, 1959, and Hargrove to Speas, February 19, 1959, both in Folder on "Eugenics Board Sterilization," Central Files: Miscellaneous Records, MH-MR-SA Records.

(60) "Progress Report, July 1, 1959-June 30, 1960," General File, Eugenics Records (quotation); Biennial Report, 1958-60, table 4, p. 15; Biennial Report, 1960-62, table 4, p. 15; Biennial Report, 1962-64, table 4, p. 15.

(61) Woodside, manuscript of "Sterilization in North Carolina."

(62) Folder on "Eugenics Board Sterilization," Central Files: Miscellaneous Records, MH-MR-SA Records. On medical experts' belief that women's mental health was tied to their reproductive capacity see Elaine Tyler May, Barren in the Promised Land: Childless Americans and the Pursuit of Happiness (New York, 1995), 153-59, 170-77; on more recent medical resistance to women seeking sterilization see Annily Campbell, Childfree and Sterilized: Women's Decisions and Medical Responses (London and New York, 1999), 130-36.

(63) See, for example, the multiple petitions for Caswell residents from Guilford County in Consent Cases on the November 26, 1957, agenda, Eugenics Board Agendas.

(64) Case 9 and Case 10, September 27, 1960, Eugenics Board agenda, in Folder on "Eugenics Board Sterilization," Central Files: Miscellaneous Records, MH-MR-SA Records. See also Ethel Speas to Frank Badrock, July 27, 1960, in ibid.

(65) Case 9 cited in n. 64; Woodside, Sterilization in North Carolina, 34-35. For other cases of parental involvement in the sterilization petition see Case ID 309, Sterilized Cases, Eugenics Records (corresponding case summary in Case 17, Consent Cases, October 22, 1957, Eugenics Board Agendas); Case 24, Consent Cases, October 28, 1958, and Case 7, Consent Cases, November 28, 1961, Eugenics Board Agendas.

(66) Bureau of Educational Research, Survey of the Program for the Mentally Deficient in North Carolina, 8, 55; Kennerly, History of the North Carolina Association for Retarded Children, 4-5, 50, 126; "New Horizons," Caswell News, 24 (January 1959), 5.

(67) See, for example, Case 17, Consent Cases, October 22, 1957, and Case 18, Consent Cases, April 22, 1958, both in Eugenics Board Agendas.

(68) Based on Caswell case summaries, Consent Cases, 1961-1962, Eugenics Board Agendas.

(69) Case 14, Consent Cases, June 27, 1961, Eugenics Board Agendas.

(70) Case 27, Consent Cases, February 28, 1961, Eugenics Board Agendas.

(71) Biennial Report, 1958-60, table 4, p. 15; Biennial Report, 1960-62, table 4, p. 15. Interestingly, Philip Reilly found a similar pattern of sterilization, ending, then eventually resuming on a limited scale, at Faribault State Hospital in Minnesota. Sterilization officially ended there in 1961 and did not resume until 1970. In Minnesota, as in North Carolina, the decision to end the practice of sterilization was made at the state level by the psychiatrist in charge of the institutional system. He was eventually convinced that a policy of no sterilizations at all was "too strict." Reilly, Surgical Solution, 140-43 (quotation on p. 143).

(72) Case 7, Consent Cases, November 28, 1961, Eugenics Board Agendas; and Biennial Reports cited at n. 48. See, generally, Caswell case summaries, Consent Cases, 1961-1962, Eugenics Board Agendas.

(73) Case 11, Consent Cases, March 27, 1962, Eugenics Board Agendas (first quotation); Case ID 356, Sterilized Cases, Eugenics Records (second quotation; corresponding case summary in Case 14, Consent Cases, June 27, 1961, Eugenics Board Agendas).

(74) Caswell case summaries, Consent Cases, 1961-1962, Eugenics Board Agendas; Herbert J. Grossman, ed., Classification in Mental Retardation (Washington, D.C., 1983), 13.

(75) Caswell case summaries, Consent Cases, 1961-1962, Eugenics Board Agendas; "Rehabilitation," Caswell News, 25 (October 1960), 1; "Rehabilitation," Caswell News, 26 (January 1961), 7-8; Charity Holland, "A Study," Caswell News, 27 (October 1962), 2, 8; W. A. Dunne, "Give Me a Chance," Caswell News, 27 (October 1962), 3 (quotations).

(76) On women's "lack of social and emotional adjustment" as a barrier to successful rehabilitation see Holland, "A Study," 2 (quotation), 8.

(77) The development of alternative forms of birth control provided an alternative to sterilization in regulating institutional behavior. I have not determined when oral contraceptives or other forms of birth control were introduced at Caswell. However, Eugenics Board reports from the mid-1960s assume that the possibility of oral contraceptives was only a factor in extra-institutional cases, and that the decline in institutional sterilizations was due to other factors. "Eugenics Board Publishes Its Biennial Report," ca. 1966, Folder on "Publicity--Eugenics Board," General File, Eugenics Records.

(78) Reilly, Surgical Solution, 148-60; Cepko, "Involuntary Sterilization of Mentally Disabled Women," 122-65.

MS. CASTLES is a Ph.D. candidate in history at Duke University.