Similarly, a conversation between two residents at Boston City Hospital proceeded as follows:

Resident: "...if you can talk her into it (hysterectomy), get the papers and have me sign them...If she won't agree to a hysterectomy, get me and I'll talk her into it."

Student: "Are the fibroids?"

Resident: "We don't know. The guy that sent her in thought there might be, but we don't believe that unless we can find them ourselves. She's 42 and doesn't need a uterus."

A Los Angeles County Hospital staff doctor reportedly said, "Let's face it, we've all talked women into hysterectomies who didn't need them during residency training."

The report, which quotes numerous other phsycians, cites this type of "sterilization sell" as the cause of the significant rise in sterilizations, particularly hysterectomies, performed. Edelin said, however that in the last few years he has seen a marked decrease in sterilization abuse and sterilization by hysterectomy at the Boston City Hospital.

In addition, the group in a 1979 report pinpointed teaching hospitals as widespread violators of Federal sterilization regulations. The report found that in that year 70 per cent of the more than 80 hospitals surveyed violated 1974 sterilization consent regulations even though they had been in effect for five years. Dr. Sidney Wolfe, chairman of the Health Research group, says these hospitals, which primarily service the poor, serve as training grounds for sterilization abuse practices, which then spread elsewhere.

"Doctors learn their bad habits on the poor, but they don't forget their bad habits, they take them to the private sector. In private practice, there are far fewer regulations that a doctor has to contend with," Wolfe adds that there is no method which exists to monitor the extent of private sector abuse.

Last July, the Health Research Group released a report which stated that many states--especially California, Colorado, Connecticut, the District of Columbia, Georgia, Illinois, Kansas, Maine, Michigan, North Carolina, Oregon, Pennsylvania, Virginia, and West Virginia--persist in violating Federal regulations concerning sterilization of low-income Medicaid patients.

Although Massachusetts was not mentioned in the group's report, a Medicaid specialist working with the Massachusetts program, who asked not to be identified, said that the state has not been complying with Federal regulations. The specialist added that the greatest percentage of errors occurred with hysterectomies where, among other things, a consent form and certification that the operation has been completely explained to the patient are required. During the period from July 1980 to March 1981, some 60 per cent of these were improperly handled. "The state has made some effort to clean up, but we won't see any improvement until the quarter beginning with last April," says the specialist.

Still, most activists and medical practitioners agree that the poor bear a large share of the sterilization abuse problem. Both Horner and Wolfe cite educational barriers as a main obstacle to communication between doctors and patients.

"Some doctors don't explain what is going on," Horner says. "Doctors don't use lingo: they don't talk the patient's language. A woman will ask a doctor if she has her uterus out, can she have children. Harvard (which used to be affiliated with Boston City Hospital) has not been able to communicate to poor people, like using the word 'womb' instead of 'uterus' to explain," she adds.

THE PUSH for Federal sterilization regulations and public awareness of the problem began when the parents of Minnie Lee Relf, age 12 and her sister Mary Alice, just two years older, charged an Alabama clinic with sterilizing their daughters without their consent in 1973. In that year, the HEW implemented regulations stressing the need for consent forms to govern sterilizations performed with Federal funds. Under pressure from activist groups, the department amended its regulations in 1974, and again in 1979. These new laws extended the waiting period between time of consent and the operation from 72 hours to 30 days, prohibited hysterectomy for primarily sterilization purposes, and forbade doctors from obtaining consent during childbirth labor, a common practice among sterilization abusers.

In the Boston area, the activist groups against sterilization abuse, such as CESA, which recently disbanded, and the Massachusetts Childbearing Alliance, have sought to familiarize the public with the special plight of poor and Third World women.

"Groups like CESA started around the country because of the realization in the women's health movement that working for certain health care rights for women was a problem for Third World women. While women, primarily white women, were saying that they had a right to be sterilized, sterilization was being pushed on poor women and women of color," Kim DeAndrade, a former member of the Boston chapter of CESA, said.