TORONTO (AP) — Decades after many other rich countries stopped forcibly sterilizing Indigenous women, numerous activists, doctors, politicians and at least five class-action lawsuits say the practice has not ended in Canada.

A Senate report last year concluded “this horrific practice is not confined to the past, but clearly is continuing today.” In May, a doctor was penalized for forcibly sterilizing an Indigenous woman in 2019.

Indigenous leaders say the country has yet to fully reckon with its troubled colonial past — or put a stop to a decades-long practice that is considered a type of genocide.

There are no solid estimates on how many women are still being sterilized against their will or without their knowledge, but Indigenous experts say they regularly hear complaints about it. Sen. Yvonne Boyer, whose office is collecting the limited data available, says at least 12,000 women have been affected since the 1970s.

“Whenever I speak to an Indigenous community, I am swamped with women telling me that forced sterilization happened to them,” Boyer, who has Indigenous Metis heritage, told The Associated Press.

Medical authorities in Canada’s Northwest Territories issued a series of punishments in May in what may be the first time a doctor has been sanctioned for forcibly sterilizing an Indigenous woman, according to documents obtained by the AP.

The case involves Dr. Andrew Kotaska, who performed an operation to relieve an Indigenous woman's abdominal pain in November 2019. He had her written consent to remove her right fallopian tube, but the patient, an Inuit woman, had not agreed to the removal of her left tube; losing both would leave her sterile.

Despite objections from other medical staff during the surgery, Kotaska took out both fallopian tubes.

The investigation concluded there was no medical justification for the sterilization, and Kotaska was found to have engaged in unprofessional conduct. Kotaska's “severe error in surgical judgment” was unethical, cost the patient the chance to have more children and could undermine trust in the medical system, investigators said.

The case was likely not exceptional.

Thousands of Indigenous Canadian women over the past seven decades were coercively sterilized, in line with eugenics legislation that deemed them inferior. In the U.S., forced sterilizations of Native American women mostly ended in the 1970s after new regulations were adopted requiring informed consent.

The Geneva Conventions describe forced sterilization as a type of genocide and crime against humanity and the Canadian government has condemned reports of forced sterilization elsewhere, including among Uyghur women in China.

In 2018, the U.N. Committee Against Torture told Canada it was concerned about persistent reports of forced sterilization, saying all allegations should be investigated and those found responsible held accountable.

In 2019, Prime Minister Justin Trudeau acknowledged that the murders and disappearances of Indigenous women across Canada amounted to “genocide,” but activists say little has been done to address ingrained prejudices against the Indigenous, allowing forced sterilizations to continue.

In a statement, the Canadian government told the AP it was aware of allegations that Indigenous women were forcibly sterilized and the matter is before the courts.

“Sterilization of women without their informed consent constitutes an assault and is a criminal offense,” the government said.

“We recognize the pressing need to end this practice across Canada,” it said, adding that it is working with provincial and territorial authorities, health agencies and Indigenous groups to eliminate systemic racism in the country's health systems.

Boyer, the senator collecting data on the issue, recalled once being approached by a tearful Indigenous woman describing her forced sterilization.

“It made my knees buckle to hear her story and to realize how common it was,” Boyer said. "Nothing has changed legally or culturally in Canada to stop this.”

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Indigenous people comprise about 5% of Canada’s nearly 40 million people, with the biggest populations residing in the north: Nunavut, Yukon and the Northwest Territories.

The more than 600 Indigenous communities, known as First Nations, face significant health challenges compared to other Canadians. Suicide rates among Indigenous youth are six times higher than their counterparts and the life expectancy of First Nations people is about 14 years less than other Canadians.

Until the 1990s, Indigenous people were mostly treated in racially segregated hospitals, where there were reports of rampant abuse.

It’s difficult to say how common sterilization — with or without consent — happens. Canada's national health agency doesn't routinely collect sterilization data, including the ethnicity of patients or under what conditions it happens.

In 2019, Sylvia Tuckanow told the Senate committee investigating forced sterilizations about how she gave birth in a Saskatoon hospital in July 2001. She described being disoriented from medication and being tied to a bed as she cried.

“I could smell something burning,” she said. “When the (doctor) was finished, he said, ‘There: tied, cut and burnt. Nothing will get through that,’” Tuckanow said, referring to her singed fallopian tubes. She said she hadn’t consented to the procedure.

The Senate committee's work was prompted by a previous 2016 investigation led by Sen. Boyer into about a dozen forced sterilizations of Indigenous women at a Saskatchewan hospital.

In November, a report documented nearly two dozen forced sterilizations in Quebec from 1980 to 2019, including one woman who said her doctor told her after bladder surgery that he had removed her uterus at the same time — without her consent.

The report concluded that doctors and nurses “insistently questioning whether a First Nations or Inuit mother wants to (be sterilized) after the birth of her first child seems to be an existing practice in Quebec.”

Some women were not even aware they were sterilized.

Morningstar Mercredi, an Alberta-based Indigenous author, was sterilized as a 14-year-old, but didn’t find out until decades later when she sought help after being unable to conceive.

“I went into a catatonic stage and had a nervous breakdown,” Mercredi wrote in her 2021 book, “Sacred Bundles Unborn.”

She told the AP the cost to First Nations peoples of coerced sterilizations was “staggering,” noting the procedures were previously routine in Indigenous residential schools and hospitals.

“These many generations of Indigenous persons denied life is an effective genocide,” she said.

The Senate report on forced sterilization made 13 recommendations, including compensating victims, measures to address systemic racism in health care and a formal apology.

In response to questions from the AP, the Canadian government said it has taken steps to try to stop forced sterilization, including investing more than 87 million Canadian dollars ($65 million) to improve access to “culturally safe” health services, one-third of which supports Indigenous midwifery initiatives.

Last year, the government allocated 6.2 million Canadian dollars ($4.7 million) to help survivors of forced sterilization. It said the Senate report was “further evidence of a broader need to eliminate racism” and acknowledged that bias in the health system “continues to have catastrophic effects on First Nations, Inuit and Metis communities.”

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Dr. Alika Lafontaine, the first Indigenous president of the Canadian Medical Association, recalls times in his own training when it was unclear whether Indigenous women had agreed to sterilization.

“In my residency, there were situations where we would do C-sections on patients and someone would lean over and say, ‘So we’ll also clip her (fallopian) tubes,’” he said. “It never crossed my mind whether these patients had an informed conversation" about sterilization, he said, adding he assumed that had happened before patients were on the operating table.

One problem, Lafontaine said, is that many First Nations women must fly hundreds of miles south to deliver their babies. “That happens because we literally did not build any health facilities where Indigenous people live,” he said.

Gerri Sharpe, president of Pauktuutit Inuit Women of Canada, said health centers serving Inuit women often aren’t staffed by Indigenous people, resulting in translation problems. For example, in Inuit culture, people often communicate with facial expressions, like raising their eyebrows for “yes” or wrinkling their nose for “no.”

“Doctors will be speaking, and they look to the woman to acknowledge something. When she (raises her eyebrows), the doctor labels it as ‘non-responsive,’” Sharpe said.

Dr. Ewan Affleck, who made a 2021 film, “ The Unforgotten,” about the pervasive racism against Canada's Indigenous people, said the way forced sterilization happens now is more subtle than in the past. He noted an ongoing “power imbalance” in the country's health system. “If you have a white doctor saying to an Indigenous woman, ‘You should be sterilized,’ it may very likely happen,” he said.

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There are at least five class-action lawsuits against health, provincial and federal authorities involving forced sterilizations in Alberta, Saskatchewan, Quebec, British Columbia, Manitoba, Ontario and elsewhere.

May Sarah Cardinal, the representative plaintiff in the Alberta case, said she was pressured into having her tubes tied after having her second child in 1977, but the doctor never explained the procedure was irreversible.

“The doctor told me: ‘There are hard times ahead and how are you going to look after a bunch of kids? What if your husband leaves?’” Cardinal told the AP. “I was afraid if I didn’t go through with it, they would be angry with me, and I didn’t feel like I had a say.”

Cardinal only realized she had been a victim of forced sterilization when her daughter, Anita, pieced it together after watching a video in a university class about eugenics and forced sterilization.

“My mother had always told me she wanted more children but that she didn’t have a choice,” Anita Cardinal said.

May Sarah Cardinal said she recalled her doctor asking if she and her husband were “native” Canadians and wondered why that should make a difference.

“I would see mothers with their kids and my heart ached not to be able to have more,” she said.

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Kotaska, the ob-gyn who carried out the surgery that left an Indigenous woman sterile in 2019, was the president of the Northwest Territories’ medical association and held teaching positions at several Canadian universities.

Documents show an anesthetist and surgical nurse became alarmed when Kotaska said during the surgery to remove the woman's right fallopian tube: “Let’s see if I can find a reason to take the left tube as well."

Kotaska told investigators he was “voicing his thought process out loud” that removing both tubes would lessen the woman’s pelvic pain, the documents say.

Describing Kotaska’s actions as “a violation of his ethical obligations,” investigators suspended Kotaska’s medical license for five months, ordered him to take an ethics course and reimburse the cost of the inquiry. The Northwest Territories health department said it was the first time a “non-consensual medical procedure” had been referred for investigation.

The woman is suing Kotaska and hospital authorities for 6 million Canadian dollars ($4.38 million).

There was no suggestion in the documents that Kotaska was motivated by racism. Kotaska declined to comment to the AP.

The Canadian government would not comment on Kotaska's actions but said forced sterilization is illegal and prosecutable under Canadian criminal law. The Royal Canadian Mounted Police in the Northwest Territories said there is no criminal investigation into Kotaska.

“People don’t want to believe things like this are happening in Canada, but cases like this explain why entire First Nations populations still feel unsafe,” said Dr. Unjali Malhotra, chief medical officer of the First Nations Health Authority in British Columbia.

Despite Canada's reputation as a progressive society, its continued forced sterilization of Indigenous women puts it alongside countries like India and China, where the practice mostly affects women from ethnic minorities.

In Europe, forced sterilizations affected more than 90,000 Roma women in past decades in the Czech Republic, Slovakia, Hungary and Bulgaria. Court rulings, apologies from the governments, reparations programs and modified health policies have mostly stamped out the practice; the last known forced sterilization on the continent was in 2012.

In 1976, the U.S. found that forced sterilizations happened in at least one-third of the regions where the government provided health services to Native Americans. The U.S. government has never formally apologized or offered compensation.

Indigenous leaders in Canada say an official apology would be a critical step towards rebuilding the country's fractured relationship with First Nations people. Only the province of Alberta has apologized and offered some compensation to those affected before 1972.

Mercredi said she continues to endure the repercussions of being sterilized without her knowledge decades ago.

“Those who subject women to this must be held accountable,” she said. “No amount of therapy or healing can reconcile the fact that my human right to have children was taken from me.”

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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.