Introduction
While records of suction being used to remove uterine contents date back to the mid-nineteenth century, the techniques employing this mechanical principle have had various names depending on the time, place of use, and accompanying protocols.Footnote 1 Today, manual vacuum aspiration is the surgical method endorsed by the World Health Organization (WHO) for both voluntary pregnancy termination and the treatment of miscarriage. It is also the recommended method for removing hydatidiform moles- benign tumours with malignant potential that originate from placental cells.Footnote 2
The transnational circulation of vacuum aspiration accelerated during the mid-twentieth century and was embodied in cooperative sets of objects over the subsequent decades. These sets could be industrially manufactured, made to order, or partly improvised, and contain simple or sophisticated medical equipment, such as syringes, plastic or metal cannulas, dilators, and Pozzi forceps, as well as tweaked everyday items, including jars and inverted bicycle pumps. As this article will show, there could also be such accompanying substances as tea, coffee, or cava. With often quite different aspirations and not always the overarching aim of ending pregnancy, these objects were assembled in hospitals, clinics, or private homes by people with and without formal healthcare training. During the 1970s, as the historians Tanfer Emin Tunç, Michelle Murphy, Johanna Schoen, Branka Bogdan, Lucile Ruault, and Bibia Pavard have all shown, the technique translated into different technologies and protocols when practised by self-help groups in Los Angeles, in surgeries in Yugoslavia, by abortion activists in France, and to assist war rape victims in Bangladesh.Footnote 3 Bibia Pavard has argued that vacuum aspiration circulated across different ‘abortion worlds’: the activist and the medical. In this article, we will not only show how the technique travelled across the abortion worlds of Spain, but also across the non- or perhaps even anti-abortion worlds of elite academic gynaecology and obstetrics. By tracing the circulations of uterine vacuum aspiration in Spain during the decades preceding the partial decriminalisation of abortion in 1985, we develop a local but internationally connected biography of vacuum aspiration in Spain as an entangled, multi-meaning technology during a period of radical political change. Focusing on the final decades of the Francisco Franco dictatorship, the democratic transition, and early democracy, we construct genealogies of the healthcare practices that developed despite a total abortion ban. These preceded and continued during the political debates about abortion decriminalisation that have thus far monopolised most scholarly debates.
The importance of studying technology as a practice embedded in society, culture, and politics, with the power to shape the production of scientific knowledge, as well as bodies, has long been central to Science and Technology Studies (STS).Footnote 4 From this perspective, technology ceases to be a simple ‘application of science to practical problems’Footnote 5 and becomes a practice immersed in and constructed by social relations. Analysis of ‘operational chains’ – understood as ‘the series of operations involved in any transformation of matter (including our own bodies) by human beings’Footnote 6 – can illuminate the social representations of technologies. In the case of vacuum aspiration, these operational chains reveal very different ways of employing, understanding, conceptualising and applying the same mechanical principle. Distinct settings, users, and intentions have given rise to different techniques, which circulated through different, often independent routes under different names. The techniques derived from vacuum aspiration also gave rise to diverse relationships between, as well as a variety of self-representations among, both users and providers.
The fact that vacuum aspiration operates in the realm of reproduction further adds to these complexities. Historians of reproduction have a long-standing interest in the techniques and technologies that have operated on women’s reproductive bodies, and how these technologies have acquired or been inscribed with distinct meanings. For example, the possibility to prescribe the oral contraceptive pill for gynaecological disorders lessened social controversies and circumvented legal bans in many countries; its non-interference with coitus also raised ultimately futile hopes that the pill would be accepted by the Roman Catholic Church during the 1960s.Footnote 7 Other multi-meaning birth control technologies that have been explored include the morning-after pill, the intrauterine device (IUD), and Depo-Provera contraceptive shots.Footnote 8
Having analysed the history of the technique in Spain, we argue that vacuum aspiration was reincarnated within mainstream medical discourse as vacuum curettage: a diagnostic and therapeutic technique and a major medical innovation. At the end of the 1970s, clandestine abortion activists in Valencia, Barcelona, and Seville called the technique the ‘Karman method’ and emphasised its collective and political components. Doctors performing illegal abortions at this time also used vacuum aspiration, which they defined in terms of safety and medical innovation. As we will show, the technique embodied different, while sometimes overlapping, aspirations in Spain, aspirations linked to medical innovation, pro-women or feminist and leftist activism, and social justice.
While internationally connected, the Spanish history of vacuum aspiration is unique. Discussed in Spanish medical circles during the last few decades of a national Catholic dictatorship that had legislated a total abortion ban, the technique acquired new meanings during the democratic transition, through which abortion remained criminalised without exception. It is this unique situation that makes our historical analysis of vacuum aspiration in Spain a valuable case study for broader reflection, as the diverse discourses on vacuum aspiration we analyse here not only convey broader meanings of medicine, activism and democracy, they also contribute to the study of institutional and activist reproductive health cultures. Vacuum aspiration became widely used in abortion clinics following the decriminalisation of abortion in Spain in 1985, but failed to become standardised within gynaecological protocols outside the practice of pregnancy termination in specialised clinics. The 1993 care protocol of the Spanish Society of Gynaecology and Obstetrics, for instance, suggested the decision to use either vacuum or blunt curettage when treating miscarriage depended on ‘availability’ and the ‘special preference of the surgical team.’Footnote 9
This article is the first systematic and connected historical analysis of medical debates on vacuum aspiration in Spain. While the majority of histories of vacuum aspiration have focused on the meanings attached to the technique in either medical or pro-abortion activist circles, we address how vacuum aspiration was conceptualised by both abortion providers and the Spanish medical-intellectual elites, who, even if not entirely against the procedure itself, were certainly not in favour of women’s right to abortion. Local historiographies have explored clandestine abortion marketplaces and networks, and the existing scholarship has thus far focused on the early decades of Franco’s dictatorship (1940s–1950s) and largely ignored the roles played by medical professionals as abortion providers; with this article, we aim to begin to fill these gaps.Footnote 10
Our analysis is based on two main types of sources: medical publications and literature produced in Spain between the 1960s and the 2010s, consisting of thirteen scientific articles, four doctoral theses, and forty books, and oral history interviews with abortion providers. To analyse mainstream medical discourses on vacuum aspiration, María Mundi-López conducted a systematic review of articles and books on vacuum curettage published in Spain between 1965, when the technique was first reported in the country, to 2010, the year abortion on demand was legalised. This review revealed a peak in Spanish medical publications on vacuum curettage between the second half of the 1960s and the mid-1980s. Seventy oral history interviews with healthcare professionals and activists engaged in the provision of abortion services in various parts of Spain between the late 1970s and 2010 were conducted by Agata Ignaciuk and her research team between March 2022 and July 2024 within a research project overseen by the University of Granada’s Ethics Committee on Human Research.Footnote 11 All participants were given the opportunity to revise and update their interview transcripts and to be anonymised. At least thirteen had been engaged in the provision of abortion services before partial decriminalisation took effect in 1985, and twenty-four provided broadly defined surgical abortion, mainly through different forms of vacuum aspiration. In addition to these sources, we also utilise publications and unpublished documents from narrators’ personal archives as well as interviews with abortion activists conducted during earlier oral history projects on the history of family planning in Spain.Footnote 12
In what follows, we explore the transnational history of vacuum aspiration, then the political, social, and legal situation regarding abortion in Spain between the 1960s and 1980s. In the subsequent sections, we focus on the two embodiments of vacuum aspiration in Spain: vacuum curettage as a medical innovation, and vacuum aspiration abortion as a militant practice. We address the meanings of objects and protocols, and the relationships these promoted and enabled within the social and political changes of the late dictatorship and democratic transition.
Historicising vacuum aspiration
Physicians have used the mechanical principle of aspiration for gynaeco-obstetric processes since at least the mid-nineteenth century. As Tanfer Emin Tunç has shown, the US physician Frederick Hollick described the use of ‘dry cupping’ – the burning of alcohol in a cup placed against the skin to create a vacuum – on the ‘lower parts’ to ‘regulate the menses’ in 1849. This principle inspired the Scottish obstetrician James Young Simpson to attach an ‘exhausting syringe’ to a thin metal tube inserted into the uterine cavity and induce menstruation via a manually created vacuum. Over subsequent decades, physicians in various countries developed their own cannulas and manual or electrical suction systems, and a variety of suction devices were available on the North American market by the beginning of the twentieth century.Footnote 13
According to Tunç, the first explicit account of pregnancy termination via aspiration dates from the mid-1920s, when the Russian physician S. G. Bykov described the use of a narrow metal tube connected to a 100–200-centilitre syringe to irritate the uterine mucosa, with abortion taking place over the following days. There is no record of further research into or practice of this technique applied to the termination of pregnancy until the mid-twentieth century, when experiments with a negative-pressure bottle that did not require electricity and could therefore be used in rural areas were conducted as part of a birth control technology development program in China.Footnote 14 In a 1958 article in the Chinese Journal of Obstetrics and Gynecology, the physicians Y. T. Wu, H. C. Wu and K. T. Tsai described the use of electrical suction to initiate and complete an abortion.Footnote 15 This device inspired the Russian physician E. I. Melks and engineer L. V. Roze to design the ‘vacuum excochleator’. Using electrical suction and detachable mechanical crushers, the device could end pregnancies that had gone beyond twelve weeks. A subsequent version created in 1961 by the Russian A. V. Zubejev was presented at the 1963 11th All-Union Congress of Gynaecology in Moscow.Footnote 16 Gynaecologists in Yugoslavia played a key role in the further development of vacuum aspiration for abortion over the following decade, and the VE-2, an electric suction device based on the one presented in Moscow, was created by the physician Franc Novak and engineers from the Institute for Electronics and Automatics in Ljubljana. A film showing this model in use with a simplified paracervical block – a type of local anaesthesia – created by the Yugoslavian Berislav M. Berić was shown at the 1966 International Obstetrics and Gynaecology Conference in Copenhagen and the 1967 International Planned Parenthood Conference in Santiago de Chile. During the late 1960s, other films depicting pregnancy terminations via vacuum aspiration, including one featuring the British obstetrician and gynaecologist Dorothea Kerslake, were distributed and widely circulated in the United States.Footnote 17
This growing interest in vacuum aspiration led to two 1967 articles in Obstetrics and Gynaecology, the journal of the American College of Obstetricians and Gynaecologist, on the use of this technique in Czechoslovakia and Britain.Footnote 18 The 1973 federal decriminalisation of abortion in the United States, combined with the country’s political and economic rapprochement with Yugoslavia, enabled the creation of the Yugoslavian-American Medical Research Program. As Branka Bogdan has shown, part of this program, ‘The Ljubljana Abortion Study’ (1974) was the first to endorse the use of vacuum aspiration over the most widespread abortion technique of dilation and curettage (D&C), in which uterine contents were removed by scraping with a sharp, scooped or hooked metal instrument.Footnote 19 Although the historiography of abortion technologies in other parts of communist Europe is thus far limited, it can be affirmed that the circulation of surgical innovations in the realm of abortion was slow and unequal, despite an earlier (mid-1950s) and often more liberal legalisation of pregnancy termination in the region than in contemporary Western Europe. For instance, vacuum aspiration was only mainstreamed as a technique for pregnancy termination in Czechoslovakia during the 1980s. The technique never replaced D&C in Poland, where, despite being framed in public debate as a potentially harmful intervention, the ‘necessary evil’ of abortion was the main contraceptive method during most of the communist period.Footnote 20
In parallel with these developments, vacuum aspiration appeared in activist practices from at least the late 1960s. Although not systematically put into practice, as Michelle Murphy has shown, images of a vacuum aspiration bottle for performing abortions without electricity, originally published in a Chinese nursing journal, were circulated by such radical US feminist groups as the Redstockings during the late 1960s.Footnote 21 Recent research by Bibia Pavard has shown that Harvey Karman, a psychologist who had been imprisoned for performing abortions, filed a patent in the United States for a uterine vacuum aspiration device in 1973. In order to reduce the risk of perforation and infection, Karman designed a disposable cannula from flexible plastic (Figure 1). He also recommended psychological assistance to manage pain instead of using anaesthesia. Karman introduced his device to physicians, activists and lay providers and went on to co-write scientific papers with prominent doctors.Footnote 22 The device was eventually marketed in cannula kits and syringes for manual aspiration and promoted by international family planning organisations such as the International Planned Parenthood Federation (IPPF) and the United States Agency for International Development (USAID). As Murphy has demonstrated, IPPF sent Karman to Bangladesh in 1972 to terminate pregnancies resulting from rape during the war of independence.Footnote 23
Figure 1. Karman cannula and syringe. Image from Miguel López Valverde, José María Usandizaga Pombo, and José María Rivera Pomar, Legrado uterino por aspiración (Barcelona: Editorial Jims, 1978). Reproduced with permission.
That same year, Karman travelled to France to demonstrate his method to doctors and abortion activists. As Pavard and others have shown, vacuum aspiration began to circulate among activist groups in France, Italy and Germany under the name of the ‘Karman method’ from the mid-1970s.Footnote 24 Karman also promoted the practice among militant groups in the United States, and his device inspired the feminist activist Lorraine Rothman to design and patent the Del-Em, which included a collection jug between the syringe and cannula.Footnote 25 Framed as ‘Menstrual Extraction’, vacuum aspiration was promoted by Los Angeles feminist groups as a way for women to regain control over their reproductive lives: the process could take place in a feminist setting, and the aspiration of uterine contents before pregnancy could be confirmed, allowing abortion bans to be circumvented.Footnote 26
As both medical and militant circles in parts of Europe and the US were developing practices and eventually cultures of vacuum aspiration, Spain was beginning to transition towards democracy following the death of Francisco Franco in 1975. At the beginning of the dictatorship, contraception and ‘non-spontaneous’ abortion had been banned by enactment of the Ley para la protección de la natalidad, contra el aborto y la propaganda anticoncepcionista [Law for Natality Protection, against Abortion and Contraceptive Propaganda] in 1941. Both women who had undergone abortion and those carrying out the procedure were penalised, and medical professionals were required to report patients they suspected of having had abortions to the authorities.Footnote 27 Selling and marketing contraceptives became legal in 1978, prior to the constitutional referendum.Footnote 28 As Teresa Ortiz-Gómez and Agata Ignaciuk have shown, some members of the medical elites were in favour of providing contraceptive methods, especially the pill, to underprivileged patients from at least the early 1970s. Emerging collaborations between feminist activists and healthcare professionals materialised in bottom-up sexual and reproductive health projects after Franco’s death. The Federico Rubio women’s centre in Madrid offered advice on contraception, sexuality, and self-exploration, and provided referrals for abortions in other countries. This and similar initiatives involving various degrees of collaboration between healthcare professionals and activists without formal training mushroomed across Spain, swiftly normalising contraception use, especially for family planning purposes. From 1978 onwards, public healthcare began sponsoring and eventually absorbing most contraceptive services.Footnote 29 In 1985, abortion was decriminalised when pregnancy resulted from a previously reported rape, constituted a medically certified danger to a woman’s physical or mental health, and in cases of foetal malformation.Footnote 30 As Agata Ignaciuk has shown, most physicians linked with the family planning movement preferred to refer patients elsewhere rather than perform abortions themselves.Footnote 31 As we will discuss later, the vast majority of abortions carried out following decriminalisation took place in private clinics, some of which had developed from activist initiatives. These clinics mainly used vacuum aspiration and, by applying the WHO definition of health and thus taking physical, psychological, and social well-being into account, adopted a flexible interpretation of ‘risk to women’s health’.Footnote 32 Psychiatrists in some centres certified that the risk of depression and serious emotional stress from an unwanted pregnancy was justification for abortion.Footnote 33
Taking the technique as a lens to explore pre-1985 vacuum aspiration practices enables us to examine the complex nature of abortion practices and innovation. The technique could be interpreted as a method for diagnosis, treatment, or pregnancy termination: thus, as legal or illegal. Similarly, definitions of ‘health’ and the availability of professionals willing to embrace a broad interpretation continued to shape abortion access after the decriminalisation of 1985. This legal framework only changed with the Ley de salud sexual y reproductiva [Sexual and Reproductive Health Act] of 2010, which provided public funding for abortion services and legalised abortion on request up to fourteen weeks and up to twenty-two weeks for medical reasons.Footnote 34 The 2010 reform also initiated an important technological shift, as public healthcare services in some Spanish regions began to provide medication abortion.
Inventing vacuum curettage (1960s–1980s)
In this section, we analyse the introduction of vacuum aspiration to clinical practice in Spain. We show that the first references to the technique within Spanish medical literature were citations of publications on abortion from the Soviet sphere of influence. Given the illegality of abortion in Spain, doctors wrote about local adaptations of the technique for treatment and diagnosis in gynaecology and obstetrics. They used objects available in their clinics or designed their own devices with the help of local manufacturers and openly discussed the use of vacuum aspiration for abortion in other countries, while positioning themselves as international pioneers in the use of the technique in gynaecological treatment and diagnosis. In publications, they focused on the materials used, the procedure to be followed, and its advantages over other techniques, without consideration of, or reflection on, their female patients.
In 1965, Francisco Bonilla, Professor of Gynaecology at the University of Valencia, published an article on ‘vaciamiento uterino por aspiración’ [uterine evacuation by aspiration] in the Revista Española de Obstetricia y Ginecología [Spanish Journal of Obstetrics and Gynaecology], one of the leading Spanish gynaecological journals at that time. This was, to the best of our knowledge, the first mention of the technique in Spanish medical literature. In this article, which we discuss in more detail below, Bonilla claimed the technique had been developed in China in 1958 for pregnancy termination, and proposed adapting it for the treatment of gynaeco-obstetric ailments.Footnote 35 The Spanish professor located the origins of the technique in the 1950s socialist world, unaware of or ignoring US publications from the interwar period, such as those by gynaecologist John Rock, who adapted a 1920s Soviet technique to develop a surgical method of ‘diagnostic vacuum curettage’ for endometrial biopsies at that time.Footnote 36 The Spanish history is thus part of a longer transnational history of vacuum aspiration, as the technique circulated between various political and legal regimes, meanings and indications. Subsequent publications constructed Spanish genealogies of the therapeutic use of vacuum aspiration and employed a range of terms for the procedure, including ‘uterine aspiration’ [aspiración uterina], ‘endouterine aspiration’ [aspiración endouterina], ‘vacuum extraction’ [vacuextracción], and ‘vacuum aspiration’ [vacuoaspiración]. This terminology became increasingly homogenised from 1975 onwards, establishing ‘vacuum curettage’ [legrado por aspiración] as the standard term within Spanish medical circles.Footnote 37
In national medical discussions, vacuum curettage featured primarily in relation to the evacuation of incomplete spontaneous miscarriage, and to a lesser extent in the treatment of hydatidiform moles. Spanish physicians publishing on these applications claimed high levels of innovation in comparison to their foreign contemporaries, whose practices they depicted as largely restricted to pregnancy termination, without drawing on the aforementioned longer genealogies of therapeutic vacuum aspiration described in the US medical literature. The Professor of Gynaecology at the Hospital Virgen de la Macarena in Seville, José María Bedoya González, who would become closely involved with the family planning movement towards the end of the 1970s, made this point in 1971:
‘Tan et al. said that in 1969 there were only four papers on the use of aspiration in incomplete miscarriages…but they forgot, as is often the case, at least two Spaniards (Arbués, in 1967, and Bonilla in 1965)’Footnote 38
For Bedoya González, Spanish gynaecologists working on vacuum curettage were international pioneers and innovators, who had yet to receive the international recognition they deserved from others using the technique in gynaeco-obstetric treatment. This perceived lack of recognition illustrates the arbitrary nature of genealogical construction, both local and transnational, in relation to vacuum aspiration for therapy and abortion.
Spanish gynaecologists also complained of limited access to commercial devices that were adapted to the locally permitted indications. In his 1975 doctoral thesis on vacuum curettage at the University of Seville, supervised by Bedoya, gynaecologist José Luis Altamirano Serrano related the difficulties he faced finding equipment for the treatment of retained miscarriages and hydatidiform moles. These were often performed at later gestational stages than pregnancy termination and required cannulas of larger diameter and length:
‘I did not find any cannula with the dimensions presented here…practically impossible to aspirate, not only the uterine horns, but the fundus itself, in uteri [with pregnancies] older than 3.5 months…’Footnote 39
Physicians were therefore forced to creatively mobilise other objects, or even design and manufacture their own cannulas to suit specific indications with the help of local producers, including steel artisans (Figure 2).
Figure 2. Cannula designed by Miguel López Valverde, José María Usandizaga Pombo and José María Rivera Pomar, in López Valverde, Legrado uterino por aspiración (Barcelone: Editorial Jims, 1978). Reproduced with permission.
Reflecting on the practice of vacuum aspiration in the prologue of a 1978 monograph on vacuum curettage, Francisco Bonilla stated it ‘goes without saying’ that instruments had to be improvised ‘to some extent,’ as clinics were ‘not equipped for anything that was innovative’.Footnote 40 A set he had recommended during the mid-1960s consisted of a glass bottle for collecting aspirated material, a manometer, metal cannulas made from Hegar’s dilators – blunt metal rods of various sizes used to dilate the cervix for gynaecological procedures – and the vacuum equipment available in most clinics, usually an operating theatre aspirator or vacuum extractor delivery pump.
Despite local variations, metal cannulas and electrical aspiration feature in most reports of therapeutic vacuum aspiration in Spain (Figure 3). One exception was described in 1971 by José María Bedoya and C. Rivas, who claimed that the use of laryngeal intubation probes – thin hollow tubes of flexible plastic used for ventilating pulmonary airways – as cannulas made it ‘impossible to perforate the uterus’.Footnote 41 However, these tubes, similar to the flexible, plastic cannulas Karman would patent two years later, were subjected to no further published research, even by those receiving doctoral supervision from Bedoya, such as the aforementioned Altamirano Serrano.
Figure 3. Instruments and electric hoover described by Miguel López Valverde, José María Usandizaga Pombo and José María Rivera Pomar, in López Valverde, Legrado uterino por aspiración (Barcelone: Editorial Jims, 1978). Reproduced with permission.
The absence of the Karman cannula from Spanish scientific publications is probably due to the inadequacy of its small diameter for gynaeco-obstetric treatment and the genealogical recognition of vacuum curettage as originating from the Soviet side of the Iron Curtain, where circulation of this specific cannula was limited. In addition, links between the Karman cannula and pro-abortion activism in countries such as the United States and neighbouring France would have problematised its acceptance by institutionalised medicine in Spain, as it did in the United States.Footnote 42 Thus, the first mention of these cannulas we have been able to locate in medical publications is a description in the 1978 monograph by López Valverde, Usandizaga and Rivera:
‘Karman (1970) devised a flexible plastic cannula with a diameter of 3, 4, 5 mm…. Karman’s idea…has subsequently been modified by other authors, who, although they continue to use Karman’s cannula, it is of larger diameters…the diameters of 6, 8 and 10 mm should be referred to pregnancies of 8, 9-10 or 13 weeks, respectively…’Footnote 43
References to the Karman method in manuals increased following the advent of democracy, and again after the partial decriminalisation of abortion in 1985, but continued to occupy a more marginal position than other terminology and cannulas.
Pregnancy termination, the most internationally widespread use of vacuum aspiration, held a unique position in Spanish medical discourse. In his aforementioned 1965 article, Bonilla described Spanish doctors first learning about uterine aspiration from a 1964 article on its use in abortion from the East German journal Zentralblatt für Gynäkologie [Central Journal of Gynaecology]. The author of the original article, M. Chalupa, discussed abortion practice with vacuum aspiration in Czechoslovakia, where abortion had been legalised in 1958, cited a Chinese publication on the technique from that same year and described the apparatus created by Melks and Roze in 1960. Reporting the results of 100 vacuum aspirations using a metal curette alongside pictures of the apparatus and curettes, Chalupa concluded that this ‘gentlest’ abortion method reduced bleeding and other complications, and could be performed under local anaesthesia.Footnote 44
In the specific case of vacuum aspiration, physicians publishing in Spanish medical journals openly discussed the fact that abortion was the primary indication for this technique in other countries. In Bonilla’s 1965 publication, the Professor of Gynaecology clarified that this use of vacuum curettage could not be accepted in Spain.Footnote 45 Our interpretation is that such discussions of foreign uses in abortion provided the necessary background for positioning local uses as innovative and thereby justifying the introduction of this technique to the country. In other words, despite national legal and moral constraints, elite Spanish physicians demonstrated their familiarity with what was presented as an East Central European technique.
Thus, medical debates on abortion, like those on birth control, were not censored under the dictatorship, but rather used to legitimise ongoing and explicit references to Catholic morality and religion on the pages of medical journals and manuals. As Agata Ignaciuk, Teresa Ortiz-Gómez, Esteban Rodríguez-Ocaña and others have shown, the religious and scientific aspects of contraceptive technologies such as the oral contraceptive pill have been discussed together within the Spanish medical community since at least the late 1950s .Footnote 46 On the other hand, references to the use of vacuum aspiration for pregnancy termination in Spanish medical publications were not always charged with condemnation. Although many physicians stressed that this ‘unfortunately widely accepted indication’Footnote 47 should be ‘rejected because of our [Spanish physicians’] ideology’;Footnote 48 others limited themselves to the advantages of aspiration for abortion without making any moral or religious evaluation. This kind of framing, present in Spanish medical literature since the 1970s, is exemplified by the writings of the aforementioned José María Bedoya and some of his colleagues:Footnote 49
‘Everyone insists that this method is very useful in the first twelve weeks of pregnancy…in pregnancies of more than three months, use thicker cannulas…’Footnote 50
‘Although I have no experience in this type of curettage, I will say that 90% of authors are in favour of the technique, because of its extraordinary usefulness, especially before the 12th week of gestation…’Footnote 51
Such publications presented detailed descriptions of the exact method and materials required for safe and effective pregnancy termination: all the necessary ingredients that would enable a reader to carry out an abortion if they wished to do so.
Descriptions of uterine curettage by Spanish physicians were full of pride in the innovative nature of the technique and confidence in its future. All the authors whose works we analysed highlighted the superiority of vacuum curettage over pre-existing techniques, and Altamirano Serrano believed it would ‘replace conventional curettage in the very short term, due to the advantages it has, against so few disadvantages’.Footnote 52 Among the advantages listed were a low risk of haemorrhage and other complications, and the need for less dilation, benefits also referred to by Eastern European authors in articles on abortion. Any inconveniences were minimised: uterine perforations were the most frequent and dangerous of these, and encountered by Spanish authors more frequently than their foreign colleagues. This disparity was attributed to the inherent risks of different indications:
‘Pregnancy termination is the easiest and least risky side of all the applications that have been assigned to the method. While we only perform the difficult part because this intervention [pregnancy termination] is forbidden in Spain.’Footnote 53
Contrary to Chalupa’s recommendation in his pivotal 1964 article, anaesthesia was not protocolised for therapeutic vacuum aspiration in Spain, and a relative absence of pain was one of the main advantages pointed out by authors of gynaecological and obstetric manuals. Some even indicated that the procedure could be conducted without any anaesthesia; few supported such statements with any kind of data. While Bonilla indicated that he used thiopental as a general anaesthetic in 1965, later works referred to the use of local anaesthesia, analgesia and no pain relief at all. In 1975, Altamirano Serrano claimed that ‘once the phase of logical fear had been overcome’, all of the twenty per cent of patients on whom he did not use anaesthesia ‘coincided in the lack of painful sensation.’Footnote 54 Quoting foreign authors who linked pain to the specific neurological predisposition of some women, he disregarded cases in which women had described feeling pain: ‘only 10% of women feel pain, these being “neurovegetative labile” women who would need to be medicated’.Footnote 55 In fact, the only detailed description of pain assessment methodology we have located appears in the 1978 monograph by López Valverde, Usandizaga and Rivera:
‘Two pain assessment scales…one of the scales is self-applied, as it is given to the patient…and the other is administered by the operator…. In other words, the first scale, the self-administered scale, gives us a vivid image of the subjective assessment of pain, while the scale given by the operator is, therefore, an objective assessment of pain;…we are in a position to state the degree of pain or displeasure suffered by the women on a more scientific base…’Footnote 56
With the patient’s ‘subjective’ assessment of pain deemed unreliable and unscientific, the ‘objective’ opinion of the doctor bestows pain assessment with the character of ‘data’. In this case, the pain was deemed minimal and perfectly acceptable. Thus, in mainstream medical discourses on uterine aspiration in Spain, the technique, presented as a breakthrough and a national innovation, is at the centre: patients are entirely disregarded or, if they do appear, are replaced by such words as ‘uterus’. Similarly, their experiences are only included – and framed as subjective – to reflect the advantages of this ‘painless’ technique. The innovative instruments in use and the restriction of the technical gesture to the area of application constitute the focus of physician interest: women and their experiences are entirely absent.
Using vacuum aspiration for clandestine abortions (1970s–1980s)
At the nationwide feminist conference Jornadas Feministas Estatales, held in Llars Mundet, Barcelona, shortly after the enactment of the 1985 abortion law, a group of feminist activists with links to the pro-abortion commission in Barcelona participated in two collective vacuum aspiration abortions performed by a feminist physician. At a later press conference, the activists who accompanied the two women brandished the device that had been used (figure 4), along with two glass bottles of extracted material, and other objects that had been used in the procedure: Pozzi forceps and sanitary pads (figure 5). This action had a political aim: rather than embarking on a systematic provision of such services, the pro-abortion commissions were attempting to draw attention to how few abortions had been performed since the implementation of the law.Footnote 57 From the late 1970s onwards, many Spanish feminist groups had debated whether to provide abortions, but there was a significant lack of consensus around the issue, and few volunteers were willing to personally engage with abortion provision. The feminist movement’s public engagement with vacuum aspiration only materialised after decriminalisation and in the form of political protest.
Figure 4. Jar and pump used for vacuum aspiration abortion. Screenshots from a recording of the press conference during Jornadas Feministas Estatales Llars Mundet, Barcelona, November 1985. Grup de Lesbianes Feministes collection, Centre de Documentació de Ca la Dona, Barcelona. Reproduced with permission.
Figure 5. Other objects used in vacuum aspiration abortion. Screenshots from a recording of the press conference during Jornadas Feministas Estatales Llars Mundet, Barcelona, November 1985. Grup de Lesbianes Feministes collection, Centre de Documentació de Ca la Dona, Barcelona. Reproduced with permission.
In this section, we explore how the technique circulated within clandestine healthcare practices. As Bibia Pavard has shown, the ‘Karman method’, developed as a militant interpretation of manual vacuum aspiration and thus ‘halfway between a medical and a lay method,’ was deployed for a variety of objectives, including ‘helping women, changing the law, challenging the state and spreading revolt, transforming medicine or enabling women to reclaim their bodies’.Footnote 58 Using Pavard’s elaboration as inspiration, we examine the ways in which Spanish abortion groups deployed vacuum aspiration technology and argue that their practices entailed the mobilising of various medical and everyday objects, and diverse relationships. Abortions provided by these groups were often politically charged collective events, enabled by the left-wing sympathies of providers. Finally, we turn to physicians who provided clandestine abortions, who framed their applications of the technique in terms of safety and innovation. We interpret this medicalisation of abortion as a means of facilitating the subsequent creation of abortion clinics, where these services would be concentrated over the following decades. Vacuum aspiration activism in Spain emerged in radical left-wing circles during the late 1970s. In contrast to France and Italy, the geographic scope of the practice was mostly limited to three cities: Valencia, where forms of vacuum aspiration abortion continued throughout the first half of the 1980s and later became institutionalised into both radical and mainstream reproductive healthcare projects; Seville, where a group was active for several months during 1980 and later prosecuted; and Barcelona, where abortion groups were active during the late 1970s and the first half of the 1980s.
The key figure in the genealogy of clandestine vacuum aspiration abortion in Spain is Françoise, who may have been the first woman to perform manual vacuum aspiration in the country and has been described as ‘the mother of the technique in Spain’ (Figure 6).Footnote 59 Born in Poitiers, France, in 1941, Françoise, like many others in the militant abortion underground, used her first name as a mononym throughout her abortion provider career. In a 2017 interview, she described learning to perform vacuum aspirations in Marseille after a female friend invited her to accompany her to a commune where vacuum aspiration abortions were performed c. 1973.Footnote 60 As Bibia Pavard and others have shown, there were well over a hundred self-managed abortion groups in France using manual vacuum aspiration in group settings, often in private homes, at that time. This practice would challenge the repressive abortion legislation in place while constructing an alternative form of reproductive healthcare.Footnote 61
Figure 6. Françoise in the early 1980s. Reproduced with permission.
Having observed her first termination, Françoise volunteered to participate in the second and discovered a natural gift for the technique: merging the meanings of the Karman cannula with a somewhat fatalistic interpretation of destiny, she would later state that vacuum aspiration abortion became her ‘Karma’. With the service she provided in high demand, Françoise lived permanently on call and in motion: she and the people who worked with her, and the instruments they used, travelled between France, Italy and, later, Spain.Footnote 62 Following the legalisation of abortion in France in 1975, and the subsequent provision of abortion services within mainstream healthcare systems, Françoise and others in the commune began to provide abortion in Italy, travelling back and forth between Marseille and various cities in the north of the country, including Genova, Torino, Firenze and Milan. At a time of heightened political and social debates on abortion, they were afforded support against legal persecution by the Italian Partito Radicale. Footnote 63
During Easter of either 1977 or 1978, Françoise established an abortion group in Valencia, seeding and teaching the vacuum aspiration protocol – analysed below – that would shape the Spanish militant abortion underground throughout the subsequent decade. This loosely knit and constantly changing collective, composed of left-wing students, manual workers, and political activists, included young French and Italian people with previous experience of militant abortion practices. Despite their collective aim, the group was heterogenous in many ways, including both men and women, and those with and without prior healthcare or gynaecological training. Those with such experience learned vacuum aspiration from Françoise, not the mainstream medical channels discussed above. For example, a Valencian gynaecologist, Pere Enguix, who at that time – before the decriminalisation of contraception in 1978 – ran a family planning practice in Plaza Xunquer, learnt to perform vacuum aspiration abortions with Françoise and began to provide post-abortion checkups. Enguix was put in prison for practising abortion twice during the 1980s; alongside others, including the political activist and nurse Consuelo Catalá and the gynaecologist Enrique Lebrero, he founded the reproductive healthcare centre Acuario, which we will analyse later.Footnote 64
By the spring of 1979, four members of one of the three interconnected groups working in Valencia had decided to establish a group in Seville. On 9 January 1980, two men and two women who went under Colectivo de Salud [Health Collective] in their published work, opened the Los Naranjos centre in Mateos Gago street, central Seville, where they also initially resided. According to José Ángel Lozoya, who then went by Héctor and later wrote extensively about the experience, Los Naranjos project reproduced the technique and protocol first introduced by Françoise but sought a more explicitly political engagement with women and local communities. Collective pre-abortion sessions at the Los Naranjos centre included explanations of both the procedure and the group’s political position, in which sexuality, contraception and abortion were inextricably linked. Contacts with local trade unions, left-wing political parties and feminist organisations remained relatively distant until 21 October 1980, when, ten months after moving to Seville and having carried out over 400 abortions, Colectivo de Salud activists were arrested.Footnote 65 Despite the aforementioned arrest and legal prosecution of Pere Enguix, abortion activism continued. Françoise moved to Marseille during the early 1980s, from where she and others – known as ‘the French group’ – continued to cross the border to provide abortion services in Barcelona, following the collective protocol with local facilitators.Footnote 66 Some of the clinics in which she taught and worked alongside gynaecologists would become institutionalised following decriminalisation.Footnote 67
Unlike some of their French counterparts who openly advertised their services, Spanish groups relied on word-of-mouth and feminist, family planning and left-wing networks. In Seville, Colectivo de Salud provided information in the Los Naranjos centre and ‘the French group’ working in Barcelona during the early 1980s circulated a French telephone number. Women calling this number would be given a time and public meeting place, such as the Café Zurich in Plaza Cataluña, central Barcelona, where they would make themselves recognisable by holding a previously agreed newspaper or magazine, such as the popular tabloid ¡Hola!. Footnote 68
The militant Karman groups across Spain followed similar protocols. While their partners or friends waited in nearby bars, groups of four to six women would be taken to a flat, usually made available or organised by one of the women, but sometimes the home of one of the activists or their friends. The session would usually open with a group discussion, during which a Spanish group member would explain the procedure. This member would also be tasked with preparing the designated part of the flat, usually a bedroom or the kitchen, and talking to the woman undergoing an abortion, holding their hand while operating the pump. Others would examine the uterus to establish that gestation was not too advanced for successful termination, disinfect the genitals, dilate the cervix, and then insert the Karman cannula, rotating and moving back and forth to remove the uterine content. The procedure would usually take less than ten minutes, after which the extracted material was flushed down the toilet and the equipment returned to the bag. According to our interviewees, a generalised sense of relief or even celebration would follow, along with heartfelt goodbyes between people who knew they would never see each other again.Footnote 69 José Angel Lozoya has described how the initial stages of the protocol were conducted by Colectivo de Salud:
‘When [women] arrive, they are surprised to see that we are young, that we dress very informally and that we use entirely colloquial language.…we [first] form a group of women seeking abortion, that includes their partners or whoever accompanies them. We explain that we practice abortions, but are not doctors, however, we have plenty of experience. We tell them everything about the intervention, which is done through aspiration, the Karman method, the least traumatic known, and safest during the first weeks of pregnancy, infinitely safer than other clandestinely used methods as well as dilation and curettage used in hospitals to end a miscarriage, because it is easier, safer and certainly cheaper…’Footnote 70
Lozoya’s narrative illustrates how institutional medicine provided a frame of reference in the expectations of both women and abortion providers. The Karman method, conducted by ‘informally dressed’ and ‘colloquially speaking’ activists, was, in this narrative, safer than D&C, and the women are reassured that the collective has plenty of experience; Françoise has described the technical ability of activists sparking interest and gaining appreciation among some medical professionals.Footnote 71
This activist protocol combined intrinsically mobile objects with single-use spaces: a constantly changing location lessened the chance of discovery. In borrowed homes, a kitchen table or bed would be cleaned and lined with towels. Forceps, dilators and cannulas in disinfectant-filled boxes were transported in sports bags. The procedure entailed cleaning the vagina with an antiseptic solution, gripping the cervix with Pozzi forceps, dilating with blunt rubber dilators, and aspirating with the Karman cannula. Material travelled through the cannula to a large Nescafé jar connected to an inverted bicycle or motorcycle pump and a manometer.Footnote 72 As Cara Delay and others have explored, domestic places and objects have played a significant role in clandestine abortion practices;Footnote 73 given the need for constant mobility in Spain, a combination of recycled or repurposed household items and medical devices was entirely practical. Purchased in France, the Karman cannulas did not always cross the border without incident: on one occasion, Françoise affected broken Spanish to persuade customs officers that the cannulas were for use in a chemistry laboratory.Footnote 74
The protocol also included aftercare: drugs were provided or recommended, such as Methergine to prevent excessive uterine bleeding and antibiotics if the woman developed a fever, and the Barcelona groups provided an emergency telephone number.Footnote 75 The activists explained that, given the possibility of an adverse reaction to the anaesthetic, pharmacological pain relief was not included. Instead, other pain management strategies were implemented, including keeping operating time to a minimum, providing comprehensive information about the operation before and throughout, and creating a collective and compassionate space. These interventions were intended to help women overcome any fears they may have, which could potentially be exacerbated by the illegality of the situation, the unconventionality of the healthcare, and the distance from a traditional gynaecological practice and setting. Oral history interviews reveal the strategy worked. One interview partner told historian Laia Iturrizaga that despite the physical pain she felt during an abortion with the Valencia group in 1980, her experience was considerably more ‘comfortable and personal’ than a later legal abortion in a medical setting abroad.Footnote 76 Although not explicitly verbalised in activist narratives, the notion of managing fear to manage pain resonates with psychoprophylactic childbirth, developed in the Soviet Union in the 1950s, promoted in France by Ferdinand Lamaze during the mid-twentieth century, and adopted and adapted by Harvey Karman.Footnote 77 In this sense, the tea and coffee served before the operation as tranquilising and group-bonding objects, and the beer and cava consumed on occasion after the procedure, constituted integral parts of vacuum aspiration abortion protocols within an activist group.Footnote 78 As was the ‘shrimp feast’ that providers were invited to as an expression of gratitude for a successful abortion, noted by both Roseanna Webster in her analysis of urban working-class activism during the Spanish democratic transition and José Ángel Lozoya in his memoir.Footnote 79
This protocol also included payment, which varied between 5,000 and 15,000 pesetas, and, in the case of Los Naranjos at least, the signing of a personal declaration of consent to the abortion. The mean wage in Spain during 1983 was c. 1,400,000 pesetas, and the minimum wage was c. 32,000 pesetas. Footnote 80 During the late 1970s, as Agata Ignaciuk has shown, the fee for a clandestine abortion performed by a doctor could range between 30,000 and 100,000 pesetas, and the total cost of abortion travel to London was between 20,000 and 60,000 pesetas. Footnote 81 While the scale of these fees – significantly lower than local or overseas medical alternatives – could cast doubt on the non-profit status of these groups, the activists themselves conceptualised payment as a sign of commitment and a willingness to take responsibility, as well as a solidarity contribution to enable providers to continue the service. In addition, sliding scales and fee waivers were frequently applied.Footnote 82 Although not directly referenced by Spanish providers, this framing of abortion fees echoes the operational strategies of such militant abortion groups as The Service, later known as Jane, based in Chicago between 1969 and 1973, as well as groups operating in France.Footnote 83 The fee policy did attract criticism. In his memoir, José Ángel Lozoya described Colectivo de Salud adopting open accounting in order to enhance their credibility among local left-wing and feminist communities. As feminist activist Mireya Forel explained, this open accounting had been suggested by the local feminist movement:
‘The OLM [local feminist group] was concerned about the abortion business. And I proposed a typical workers’ movement solution, an open accounting. It was normal for them to charge, they were working on a rota basis, but this open accounting had to exist…. One cannot open a centre and have office hours without charging. But, in our mentality of the time, we were all idealistic volunteers, it was hard for us to understand these ideas [regarding payment for abortion services]. However, it was logical that means had to be controlled so that there was no speculation…’Footnote 84
It is clear that the payment element provoked debates in and beyond the collectives. José Ángel Lozoya has described the conflict that arose within Colectivo de Salud when, at a particularly busy time, part of the group decided to raise their salaries without raising fees.Footnote 85
The signed declarations of consent played a somewhat similar role to fees. According to Lozoya, these not only enhanced women’s accountability and guaranteed their discretion, but they could also serve as a safeguard in case of a police raid.Footnote 86 The personal data of women undergoing abortions could also be mobilised in court, as happened during the 1980s trial of Pere Enguix.Footnote 87 This collection of signatures dialogues with the ‘self-inculpation’ strategy adopted by the Spanish feminist movement as part of their pro-abortion rights campaign, in which they flooded the courts with declarations by those who had undergone or facilitated illegal abortions, bringing trials to a standstill and making the crime non-prosecutable. This mass signature collection strategy was mobilised by feminist activists during prosecutions of abortion providers in the late 1970s and early 1980s, including those of Pere Enguix, of Colectivo de Salud and of a working-class empirical provider and her clients in the Bilbao trials.Footnote 88
Just as objects were mobilised in the relational setting of a group to enable clandestine vacuum aspiration abortion to take place, the protocol brought three groups of people together: women seeking abortion services, the providers, including both those operating on the uterus and those providing support and company, and finally, a broader support network, which often included medical professionals employed in public hospitals willing to provide a safety net when complications arose. These three groups overlapped and gave form to a unique group at every collective abortion event.
From at least the late 1970s, some doctors began providing clandestine abortion services in hospitals and clinics. Rather than following the mainstream diagnostic framing of vacuum aspiration, the technique appears in the narratives of these doctors in relation to abortion. Isabel Serrano, a gynaecologist, family planning activist, and long-term president of the Spanish Family Planning Association, has genealogically linked the use of manual vacuum aspiration in Spanish family planning networks to Cuban practices rather than the militant use of the Karman method in France and Italy. With access to large syringes and Karman cannulas, doctors active in the family planning movement from the late 1970s onwards could perform aspirations in early-stage pregnancies, often for women in difficult psychological and social situations who were unable to undertake abortion travel. Inserting the cannula and aspirating would either end the pregnancy or initiate a miscarriage that could then be ‘finished’ in a hospital emergency ward.Footnote 89 At a time when attitudes were rapidly shifting, many hospital staff members would be unwilling to provide clandestine abortions themselves, but unlikely to deny care or denounce a woman in such a situation.Footnote 90 A male gynaecologist interviewed for this project recalled connections with left-wing networks enabling him to transport syringes and cannulas from southern France to a city in northern Spain. The family planning centre at which these devices were secretly sterilised and re-used had been established in 1978, following a local feminist campaign, and sponsored by municipal authorities to aid fellow politicians and colleagues, ‘because of friendship, at night and with malice aforethought’.Footnote 91 While all those who witnessed or engaged with clandestine abortions within the newly established family planning clinics noted their infrequency, it is difficult to evaluate whether such practices were as exceptional as they are now portrayed by family planning activists within the medical profession.
Certainly, some gynaecological or reproductive healthcare clinics did systematically provide clandestine vacuum aspirations. The Acuario centre in Valencia, one of the first healthcare centres in Spain to perform a legal abortion in 1986, had been providing the service for several years before decriminalisation. The abortion group that originally formed around Françosie had begun practising abortions at a reproductive health clinic around 1981, a strategy they had previously avoided in order to avoid endangering family planning services. The Acuario group also had birth homes in Valencia and Denia at this time. Gynaecologist Enrique Lebrero, who joined the Acuario group in 1982, learned both vacuum aspiration and natural childbirth techniques from Enguix, who in turn had learned vacuum aspiration from Francoişe. In the interview, he explained the difference between D&C and aspiration as targeted suction rather than complete removal of uterine wall material, ‘something which for a gynaecologist is very simple to learn’. Before 1985, Lebrero had travelled to the Netherlands to purchase cannulas; dilators and aspiration devices and engines could be purchased locally as they had legal uses, such as IUD insertion and assistance in childbirth and plastic surgery.Footnote 92 Lebrero described the mobilisation of a vacuum cup to assist childbirth and the use of urological dilators in clandestine abortion, but emphasised that the group’s key innovation was a symptom and consequence of their normalization of the abortion experience: ‘illegal vacuum aspirations and physiological, respected childbirth coexisted in Acuario in ways that coexist in many women’s biographies’.Footnote 93 Also referring to this normalisation, nurse and feminist activist Consuelo Catalá underlined the crucial role of maintaining close relations with women undergoing abortion both before and after decriminalisation.Footnote 94 For Raquel Novo, a gynaecologist whose provision of vacuum aspiration abortions from the mid-1980s onwards was later formalised in the Casanovas clinic, Barcelona, the experience of working with militant Karman providers and the local family planning movement situated their practice as multidisciplinary and reflexive.Footnote 95
Other physicians who practised vacuum aspiration in Valencia between the late 1970s and early 1980s interpreted their practices in terms of technical sophistication and safety-enhancing strategies. Doctor Josep Lluís Carbonell, who had engaged with militant providers in Valencia from the end of the 1970s, as well as an abortion practice in France where he underwent public health training, reflected on this time in a 2014 interview published in Interviú magazine:
‘I was bringing all the necessary material into the household operating room. It resembled a mobile ICU: a resuscitator for mechanical ventilation, oxygen, single-use plastic material. For the aspiration, we used a glass Nescafé jar with rubber lid, which we perforated and inserted a manometer to measure aspiration pressure, and an inverted bicycle pump to aspire instead of releasing air. All lasted 10 minutes.’Footnote 96
In this narrative, the do-it-yourself (DIY) elements of the militant Karman equipment – a glass Nescafé jar, a rubber lid perforated with three holes, and a household aspiration pump – were enhanced by medical devices and combined with the operator’s skill to equalise the domestic abortion with one performed in an operating room.Footnote 97 Carbonell would later found the Mediterránea clinic in Valencia and conduct research on and promote medication abortion.
A doctor who provided abortion in various Spanish cities prior to decriminalisation noted both the professionalisation of the services he and his colleagues provided, and their development of their own metal cannulas, preferred over plastic due to their visibility during ultrasound:
‘The first ones were from nickel-covered copper. You could see them perfectly, and this diminished the risks a lot. What’s more, from the very beginning the clinic had social workers and psychologists among staff…’
‘Karman existed them, but this was not what we did. We designed an operation that was safer, more efficient, faster and less violent for women. And we had lots of people [patients].… We medialized the service, we elevated it to another level. We did the interventions and we did it well. But we gave them a structure aligned with the law, so that there were no problems. And we set up advanced clinics…’Footnote 98
Professionalised protocols were established in this clandestine practice, not only in technique implementation, but also through specialised staff beyond the operating room: psychologists to provide support, and social workers to determine whether patient situations required intervention, such as a fee waiver or the facilitation of legal advice.
The gynaecologist Santiago Barambio, a pioneering abortion provider in Catalonia and Spain and at the time of the interview, medical director of the Tutor Médica clinic, Barcelona, viewed his mission as strengthening the presence of abortion in medical science at a time of flourishing social debate on abortion rights. Having qualified in gynaecology and obstetrics at the Hospital Clinic, Barcelona in 1975, Barambio established his first private practice, and, from 1977 onwards, focused on preventive reproductive medicine, including ultrasound. Diagnosing and certifying miscarriages enabled uteri to be emptied in a context that Barambio described as ‘relative clandestinity’, in contrast to the ‘absolute clandestinity’ of abortion provision under the dictatorship. As it was difficult to acquire plastic cannulas in Spain at that time, Barambio and other providers commissioned local manufacturers. Barambio described the cannulas he was using in 2023 as having evolved from the first of these, designed by Germán Sáenz de Santamaría, a gynaecologist who provided clandestine abortion services in Málaga from the late 1970s.Footnote 99 Depicting his early training in abortion services during the mid-1970s as self-driven and shaped by interaction with providers from Britain and the Netherlands, he referred to metal cannulas and the use of gentler, blunt dilators as part of a collective project to perfect the Karman method. Spanish abortion providers, according to Barambio, did not copy the Karman method; ‘we improved it.’Footnote 100
Conclusion
In this article, we have developed a Spanish biography of vacuum aspiration, a technology that was consolidating its position as the method of choice for voluntary pregnancy termination in Western Europe, parts of Eastern Europe and North America during the 1970s. The simplicity and reliability of the technique, together with the fact that it could be put into practice with empirical training and through the repurposing of medical objects and household items, facilitated its circulation between medical and later activist settings, all with strong links to transnational flows of knowledge and practices and claiming their place therein. This circulation began in the mid-1960s, under the sexual politics of a dictatorship that denied women reproductive rights, and continued as these rights were intensely debated and vocally reclaimed during the democratic transition. The diverse agents participating in debates surrounding vacuum aspiration and its practice had different aspirations for both the technique’s purpose and the concrete forms of its implementation. On the pages of medical journals and manuals, Spanish medical elites constructed vacuum curettage as an innovative form of gynaeco-obstetric diagnosis and treatment, for which they developed their own tools and protocols. Although the degree of implementation in daily clinical practice before the mid-1980s cannot be accurately assessed, even for therapeutic purposes, the detailed reconstructions of the technique could be read as a recipe for abortion, a practice that authors situated overseas but did not always condemn. However, they paid little attention to their patients’ perceptions or experiences of vacuum curettage. Physicians who provided clandestine abortions have also emphasised the innovative character of their tools, but do not refer to the body of knowledge on vacuum curettage created by other Spanish doctors. Instead, framing their work in terms of safety and medical standards constructed for the benefit of patients, they highlight protocols relating to pharmacological anaesthesia and nursing/social work care that would be key references in the implementation of legal abortion services following decriminalisation. While often interacting closely with physician providers, militant group members have emphasised their deployment of horizontal and experience-based teaching-learning processes. Their aspiration was linked to the transformative dimension of provision outside mainstream healthcare, in which women were active participants in the collective abortion experience. In the pursuit of these different aspirations, distinct interpretations and embodiments of vacuum aspiration were developed within a political and social transition. Militant illegal abortion practices deserve explicit recognition in the history of this transition, as forms of bodily and political resistance towards a decaying regime.
Acknowledgements
The authors thank the interview partners and the anonymous reviewers. We are grateful for José Luis Aguilar López-Barajas’ helpful comments on an earlier draft of this article, and for Joanna Baines’ copy-editing assistance. This article is a result of the research project ‘Aborto no punible en España: ciencia, asistencia y movimientos sociales (décadas de 1980 y 1990)’, ref. PID2020-113312GA-I00, funded by MCIN/AEI/10.13039/501100011033/. Funding for the open access charge was provided by the Universidad de Granada/CBUA.
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