LAST MONTH, the Karnataka High Court permitted full abdominal hysterectomy of a 23-year-old woman with severe intellectual disabilities. The judgment in response to a prayer made by her parents, has reignited a fraught and deeply uncomfortable debate about reproductive rights of women living with disabilities in India. The case, which appears otherwise straightforward, involved a multidisciplinary medical board that confirmed the woman’s incapacity to provide informed consent, documented her inability to manage menstrual hygiene, and unanimously recommended the procedure in her ‘best interests.’ The Court, exercising its parens patriae jurisdiction, granted permission.
Yet beneath this seemingly benign judicial intervention lies a troubling historical continuum. The Court’s order, while careful and circumspect in its language, sits uneasily within a broader context where women with disabilities have been systematically subjected to medical procedures that permanently curtail their reproductive capacity, often without their knowledge or consent. The judgment demands scrutiny not for its individual merits, but for what it reveals about the persistent gaps in India’s legal and policy framework regarding reproductive autonomy for persons with disabilities.
The Karnataka case is the latest instance of courts being compelled to adjudicate matters that should ideally be governed by clear legislative guidance and robust medical protocols. The fundamental question of how one obtains informed consent from a person who cannot, by definition, provide it, remains unresolved in Indian law, leaving families, medical professionals, and ultimately the judiciary to navigate an ethical minefield.
How the law evolved
Historically, women with intellectual disabilities have been highly vulnerable to forced sterilisation and non-consensual medical procedures. The most infamous instance remains of the Shirur home in Pune in 1994, where eleven women with psychosocial disabilities were subjected to hysterectomies. Ten others escaped the procedure only after women’s organisations raised an outcry, and a delegation led by former CPI(M) MP and All India Democratic Women’s Association (‘AIDWA’) leader late Ahilya Rangnekar met the then Maharashtra Chief Minister Sharad Pawar to halt the exercise. The incident exposed the chilling ease with which institutions could disregard the bodily integrity of disabled women in the name of convenience or misguided protection.
Two decades later, the legal framework ostensibly evolved. Section 10 (2) of the Rights of Persons with Disabilities Act, 2016 (‘RPD Act’) explicitly prohibits medical procedures leading to infertility without the free and informed consent of the person concerned. Yet the practical implementation of these protections remains deeply flawed.
Even before the 2016 legislation, the Supreme Court, in the landmark Suchita Srivastava v. Chandigarh Administration (2009) judgement, affirmed that reproductive choice is a fundamental dimension of personal liberty under Article 21. The Court had also relied on various international legal instruments including the United Nations’ Convention on the Rights of Persons with Disabilities.
Capacity to consent and the ‘best interests’ standard
The central dilemma that confronts our courts is when a woman’s intellectual disability is so severe that she lacks the cognitive capacity to understand the nature, risks, and consequences of a procedure, how then can ‘informed consent’ be obtained? The law prohibits non-consensual sterilisation, but also recognises that ‘some individuals’ cannot provide consent. Caregivers and doctors cannot unilaterally make such decisions; they must approach a court. The judiciary then invokes the parens patriae doctrine, stepping into the shoes of a guardian for individuals “unable to care for themselves.”
The Karnataka High Court, however, did not rely merely on parental request; it constituted a multidisciplinary Medical Board that included specialists in psychology, psychiatry, neurology, obstetrics and gynaecology, radiology, and anaesthesiology. The Board’s unanimous recommendation, based on comprehensive assessment, concluded that the patient’s social age was approximately five years and four months, her IQ was 36, and she had Global Developmental Delay with moderate permanent intellectual and developmental disability, alongside cerebral palsy and a seizure disorder. The Board’s consensus was that she was incapable of independently managing menstrual hygiene and that the procedure would serve her welfare.
Yet the judgment reveals uncomfortable truths about how the ‘best interests’ standard operates in practice. The Court, while acknowledging the irreversible nature of hysterectomy, repeatedly emphasised that its decision was based on “medical necessity” rather than disability per se. It distinguished the case from forced sterilisation for eugenic purposes, population control, or caregiver convenience. The petitioners were parents advancing in age, concerned about their daughter’s recurring infections and their declining ability to provide lifelong care.
But is the ‘best interests’ standard sufficient protection? The National Platform for the Rights of the Disabled (‘NPRD’) has long argued that the law’s provisions are dangerously vague. In its 2014 memorandum to the Parliamentary Standing Committee examining the Rights of Persons with Disabilities Bill, the NPRD specifically addressed the reproductive rights of women with disabilities. Amongst others, it proposed that hysterectomy should never be performed on girls and women with disabilities “unless a team of medical practitioners including a gynaecologist and a psychiatrist considers that preservation of uterus is not advisable due to dysfunctional uterine conditions which are not curable by medicine or any therapy.”
The NPRD also sought amendments to Section 105(f) (now Section 92 of the RPD Act) of the Bill to remove the broad exception that allowed medical procedures to be performed on women with disabilities with guardian consent and the opinion of a single registered medical practitioner. These recommendations were not accepted.
The RPD Act, as passed, contains a troubling exception in Section 92(f). While it criminalises performing any medical procedure on a woman with disability that leads to or is likely to lead to termination of pregnancy without her express consent, it includes a proviso: except in cases where medical procedure for termination of pregnancy is done in severe cases of disability and with the opinion of a registered medical practitioner and also with the consent of the guardian of the woman with disability. This exception, drafted in broad terms, effectively undermines the protective force of the main provision. It is precisely such loopholes that enable the continued vulnerability of disabled women to non-consensual medical interventions.
A systematic review published in Epidemiologic Reviews in 2026 examined hysterectomy risk among women with and without disabilities. The findings, based on studies from the United States, Canada, and South Korea, suggest that women with disabilities have a higher likelihood of undergoing hysterectomy compared with their non-disabled peers. The frequency of hysterectomy in women with disabilities ranged from 6.1 percent to 22.8 percent, whereas for women without disabilities, it ranged from 2.2 percent to 18.6 percent. Adjusted estimates indicated that women with disabilities were 1.12 to 2.18 times more likely to have a hysterectomy.
The study also raised concerns that hysterectomy may be recommended for reasons that are not strictly medically indicated, including concerns about menstrual hygiene, behavioural fluctuations, or caregiver anxiety about sexual abuse and unintended pregnancy. Women with disabilities, the review noted, often face barriers to advocating for alternative, less invasive treatments. Healthcare providers receive minimal training on disability – a 2016 survey of 322 obstetricians and gynaecologists in the United States found that only 17.2 percent reported receiving any disability-specific training. Communication barriers, time constraints, and implicit biases may influence clinical decision-making in ways that reduce the threshold for surgical intervention.
The asymmetry between sterilisation and abortion law
The inconsistencies in Indian law become even more apparent when examining the abortion provisions. Under the Medical Termination of Pregnancy Act, 1971, if a pregnant woman has a mental illness, a pregnancy can be terminated with the written consent of her guardian. However, the law does not extend this guardian-consent provision to women with intellectual disabilities. For them, their own consent remains an absolute legal requirement for an abortion, a requirement that, by definition, cannot be met if they lack the capacity to consent.
This distinction was central to the Supreme Court’s ruling in Suchita Srivastava, where a woman with intellectual disability, who was raped while residing in a State-run welfare home, expressed a desire to keep her child. The Court, noting that she had “mental retardation” (the term in vogue then) and not mental illness, held that the State could not force an abortion without her consent. The ruling was celebrated as a victory for reproductive autonomy. Yet it left unanswered the question of what happens when a woman’s disability is so profound that she cannot express any preference whatsoever.
In Z v. State of Bihar (2017), a destitute woman with mild intellectual disability, who was living with HIV, was raped and sought to terminate her pregnancy. Despite her willingness, the government hospital delayed the procedure, insisting on obtaining consent from her estranged husband or her father. By the time the Supreme Court intervened, the pregnancy had crossed the legal limit for abortion, forcing her to carry to term. The Court criticised the “retardant attitude and laxness” of State authorities and awarded compensation, but the damage was done.
The contrast between the Karnataka hysterectomy case and the abortion cases holds interesting insights. In the former, while the Court permitted an irreversible procedure that permanently removes reproductive capacity, it refused to allow procedures that would terminate pregnancies in the latter. The inconsistency reflects deeper uncertainties about how the law treats women with disabilities — as autonomous agents whose choices must be respected, or as dependents whose ‘best interests’ must be determined by others.
What reform would require
The Karnataka hysterectomy case, underscores the urgent need for systemic reform. The current legal framework is riddled with contradictions. The RPD Act prohibits non-consensual sterilisation but includes a broad exception that allows precisely such procedures with guardian consent. The Medical Termination of Pregnancy Act distinguishes between mental illness and intellectual disability – the rationale is left unexplained. The courts, left to fill the gaps, have produced inconsistent precedents that offer limited guidance for future cases.
What is required is a comprehensive policy that addresses the reproductive rights of persons with disabilities in all their complexity. Such a policy should be developed through a participatory process involving disabled persons’ organisations and other representative bodies. It must include clear protocols for obtaining consent; or, where consent is impossible, for determining ‘best interests’ in a manner that does not reduce disabled women to passive objects of medical intervention. It must ensure that non-invasive and reversible alternatives are exhausted before any irreversible procedure is considered. It must mandate ongoing training for healthcare providers on the rights and needs of persons with disabilities. It must also address the broader social determinants of health, including access to education, employment, and social support for persons with disabilities and their caregivers.
The NPRD’s recommendations, made over a decade ago, demand that hysterectomy be permitted only where preservation of the uterus is not medically advisable due to incurable conditions (that too, only with the concurrence of a multi-disciplinary medical team), strikes an appropriate balance between protecting the bodily integrity of disabled women and enabling necessary medical care. The insistence that the reproductive rights of women with disabilities be explicitly protected is a recognition that vulnerability to exploitation is a structural feature of existing institutional arrangements.
The Karnataka High Court’s judgment cannot be dismissed as a mere violation of rights. The Court demonstrably engaged with the medical evidence, balanced competing considerations, and sought to ensure procedural safeguards. Yet the very necessity of the case, the fact that parents had to approach a court to seek permission for a medical procedure that, in other contexts, would be a matter between doctor and patient, speaks to the impoverished state of India’s legal and policy framework on disability rights.
The broader question that this case forces us to confront is how society should treat persons whose capacity for autonomous decision-making is significantly impaired. The answer cannot be simple paternalism, which reduces disabled women to perpetual children requiring others to determine their ‘best interests’. Nor can it be a rigid autonomy that leaves such women without meaningful access to necessary medical care. The challenge is to develop institutional mechanisms that respect the personhood of disabled women while acknowledging the practical realities of their conditions.
The law should be clear that procedures be subject to rigorous safeguards, that medical decisions be made by multi-disciplinary teams rather than individual practitioners and would also include rehabilitation professionals, and that the voices of disabled persons themselves be central to policymaking. These demands are not radical; they are the minimum requirements of a society that claims to respect the dignity and rights of all its members.
Three decades since the Shirur home horrors, the Karnataka case serves as a reminder of how far we still have to go. What is needed today is legislation that closes the loopholes, policies that provide clear guidance and institutional mechanisms that protect the rights of the most vulnerable. Judicial discretion however well-intentioned is not the alternative.
