In June, Britney Spears spoke publicly for the first time about her conservatorship. In a harrowing 24-minute testimony, Spears laid out the ways in which having almost no decision-making power has curtailed her ability to live her own life over the past 13 years. She told a Los Angeles judge she has been forced to perform, forced to take medication she did not want, and, perhaps most shocking to the general public, forced to use contraception. Spears told a Los Angeles judge, “I have an [IUD] inside of myself right now, so I don’t get pregnant. I wanted to take the [IUD] out, so I could start trying to have another baby, but this so-called team won’t let me go to the doctor to take it out, because they don’t want me to have children—any more children.” Last night, Spears reiterated many of the claims she made in June, adding that in addition to major abuses like being forced into a residential psychiatric facility, she was subjected to a number of petty ones. Her hair vitamins, coffee, and driver’s license were all taken away. “Ma’am, that’s not abuse, that’s just cruelty,” she told the judge.

No one with knowledge of conservatorship interviewed for this piece was surprised by any of Spears’s allegations, including the ones around reproductive choice. Advocates say forced birth control and sterilization are still routine in the United States for women under conservatorship. Tom Stenson—the deputy legal director of Disability Rights Oregon, a federally funded protection agency—said he has never seen a case involving a man’s family seeking birth control or sterilization of a son. “I’m sure somewhere out there, there’s somebody trying to get their son or brother with a disability sterilized. But I’ve had a number of these cases arise, and they are, in my experience and so far, all women.”

There are no national statistics for how many people under conservatorship are sterilized each year in the United States. There aren’t even exact records of how many people are under conservatorship in this country. A 2013 report from AARP estimates 1.5 million Americans, but they note, “data are scant and varying in quality.” There are no federal regulations for record keeping on conservatorship. In a recent letter asking for more federal oversight of conservatorship, sometimes called guardianship, Senators Elizabeth Warren and Bob Casey wrote, “comprehensive data regarding guardianship (referred to as conservatorship in some states) in the United States are substantially lacking—hindering policymakers and advocates’ efforts to understand gaps and abuses in the system and find ways to address them.”

It isn’t hard to have someone under conservatorship, called guardianship in Oregon, sterilized. Disability Rights Oregon says a guardian is supposed to inform the organization of every sterilization request. “Oregon has a law on the books that requires a process,” Stenson said. The reality, however, does not match the legislation. Concerned bystanders sometimes notify Disability Rights Oregon after sterilization has taken place, but the group often receives no word at all. Stenson says a guardian hasn’t alerted him to any cases in the last six years, but he is certain people are still being sterilized. “So many providers just treat [sterilization] like any other medical procedure, which a guardian would be permitted to determine under Oregon law,” he told me. According to a report in The Daily Beast, more than half of states currently allow conservators to compel the permanent sterilization of someone under their care.

Stenson hasn’t seen any cases involving less-permanent forms of birth control like Spears’s IUD. Because pills or implants can be temporary, they are unlikely to make it to his office. Instead, he highlighted the basic lack of sexual autonomy many disabled people face under guardianship. “One of the most common things that arises is, ‘I have a boyfriend’ or ‘I have a girlfriend,’ and ‘my parents don’t want me to spend time with or see them,’” Stetson said. He was careful to note that many guardians are understanding, but he said, “There are definitely some guardians that are really freaked out by the concept that people with disabilities have autonomy, including choosing who they want to be romantically and sexually involved with.”

When we discuss sterilization of disabled people, it is often as a relic of the past. Forced sterilization became especially popular in early-20th-century America as eugenics became a dominant scientific theory. At the time, many medical professionals thought humanity could be improved by reducing the reproduction of those considered “unfit”—disabled people, people of color, and women who were thought to engage in immoral behavior. The state carried out sterilizations at a fever pace, and eventually the practice was legally challenged. In 1927, the Supreme Court ruled that it was constitutional for the state of Virginia to sterilize 17-year-old Carrie Buck. Buck had a daughter after allegedly being raped, and this was interpreted as evidence of her “social inadequacy.” In an 8-1 ruling, the judges determined that forced sterilization was not only constitutional but desirable. “Three generations of imbeciles are enough,” wrote Justice Oliver Wendell Holmes in the majority decision. The ruling was never overturned. California’s eugenics program, which sterilized an estimated 20,000 people, helped inspire the Holocaust. In the South, forced sterilization was primarily deployed against Black women, and was so widespread that it became known as a “Mississippi appendectomy.” A third of the sterilizations were performed on girls under the age of 18. Despite horror at Nazi crimes during the Holocaust, the practice survived for decades. Between the 1930s and the 1970s, publicly funded hospitals sterilized about a third of the women in Puerto Rico.

In California, where Spears lives, it is technically illegal to permanently sterilize people under conservatorship “solely for the reason of developmental disability,” according to Shannon Cogan, an attorney working for Disability Rights California. The process is slightly more difficult than it is in Oregon. The law is a direct response to the state’s leading role in American eugenic sterilization between 1909 and 1979. Yet the practice has proceeded largely unquestioned and uninterrupted for people with certain kinds of disabilities. What has changed is the reason given for sterilization. It is presented as being for the disabled individual’s own good, rather than being for the benefit of the country or the quality of the (usually) white race. “A conservator can petition the court for permission to [sterilize], and it’s not because she’s disabled. It’s for a medical reason,” Cogan explained. But these medical reasons can be and often are specious, and the law seems to be more of a suggestion than a hard-and-fast rule.

This is evident in the 2013 case of Denise B. v. Maria B. in California’s Court of Appeal for the Fourth District. In the case, Maria B., the mother and conservator of Denise B., petitioned the court to authorize the sterilization of her daughter. Denise B. has a developmental disability, but the reason given for the request is “severe menstrual bleeding and migraines.” Astonishingly, the judge determined that the argument made “misses the mark” but allowed the sterilization to proceed. “Maria’s counsel failed to explain how the result would have been any different if the trial court applied the clear and convincing evidence standard of proof,” but “we affirm the trial court’s ruling granting Denise’s petition despite the court’s application of the incorrect standard of proof.” Cogan summarized the decision for me: “[The court] disagrees with how you got there, but we agree with the result. You can go ahead and sterilize her.”

Like Stenson, Cogan hasn’t encountered a conservatorship case involving an unwanted IUD, or the desire to stop birth control in order to have a baby. Most forms of birth control don’t require the same legal scrutiny permanent sterilization does. Cogan gave an example of a disabled client who didn’t want to take birth control pills, because she “didn’t like the way they made her feel,” so the woman contacted Disability Rights California. “We had conversations with her parents and with the doctor, and the doctor said, ‘I think maybe we can find a medication that would make her feel differently.’” The case was resolved because the woman and her doctor found a birth control method that was more tolerable. She just needed someone to advocate for her comfort and autonomy. But that isn’t always possible. There isn’t always legal ground to advocate. While people under conservatorship technically retain the right to refuse medication and medical treatment, the desired end can and often is simply achieved through completely legal coercion. Conservators can punish people; they have legal power to pressure them to accept medication and medical treatment. Cogan gave an example: “You like the home you live in now? Well, I’ll move you and put you somewhere else you like less.” Conservators can also legally limit access to friends, family, and the outside world. Cogan recounted the case of an institutionalized client who wanted to stop receiving contraceptive Depo Provera injections: “Her parents told her she has to keep having it. So she kept having it.… She had so little power in that situation.”

Unlike most cases, Spears’s struggle is public, and she has been able to speak about injustices usually carried out in secret.

Last night, Spears had a breakthrough: She was granted the ability to select her own legal representation. This is unusual. While people under conservatorship have an “absolute right to council,” they do not normally select that council themselves. According to Cogan, the court normally assigns lawyers to people under conservatorship in California. Usually they’re massively overworked public defenders, who often have little time to devote to individual clients. “[Public defenders] have a huge caseload, and it’s a barrier to justice,” Cogan explained. By selecting her own representation, former federal prosecutor Mathew Rosengart, Spears will finally have an advocate who can spend significant time and resources to end the conservatorship. Soon, Spears may be able to choose where she lives, what she does every day, and what she can do with her own body. After the decision, Spears tweeted last night, “Pssss this is me celebrating by horseback riding and doing cartwheels today,” followed by a series of emojis, and for the first time, #FreeBritney.