Helena Ragoné & Sharla K Willis. Handbook of Social Studies in Health and Medicine. Editor: Gary L Albrecht, Ray Fitzpatrick, Susan C Scrimshaw. Sage Publications, 2000.
During this century the world has become rapidly more technological. Technology is generally viewed as a positive and vital force in our lives, allowing us to become more developed as a society and live a higher quality of life. Nowhere is this view more apparent than in the field of health and medicine. Rapid advances in medical knowledge and technology call into question commonly held and accepted beliefs concerning the body, illness, and disease. This is especially true in the area of reproductive technology, where advances over the past decades have changed the biological and social meaning of reproduction. Fertility and infertility have moved into the realm of the controllable, raising questions of rights, responsibility, and ethics.
This chapter examines the impact of medical knowledge and medical technology on reproduction, particularly as it affects women. It begins with a review of the theory of medicalization and its relationship with reproduction to provide the context for further discussion. An increasing body of literature has documented and addressed the move from unassisted to medicalized ways of dealing with once ‘natural’ processes across a woman’s reproductive life cycle, such as menses, conception, pregnancy, childbirth, and menopause. Specific examples are given in this chapter from the perinatal period and the menstrual cycle. Childbirth is discussed first because the medicalization of reproduction began with the birth process. The process of medicalization has now moved to encompass the prenatal period as well, which is discussed in the next section. The medicalization of the menstrual cycle, specifically the development of the concept of premenstrual syndrome and menopause as diseases, is reviewed in the next two sections. The newest area of reproduction and reproductive technology is discussed next and in more depth. Assisted reproductive technologies have redefined concepts of family and motherhood by increasing the number of players involved in conception. The impact on those who participate is discussed in this section, as well as issues of secrecy and kinship. The chapter concludes by moving from what we have learned to a discussion of the implications of reproductive technology and the medicalization of reproduction on individuals and society, and the direction that social scientists should take from here.
Increasingly, human experiences have come under medical care, leading to what Mich called the ‘medicalization of life’ (Mich 1976). The process of medicalization occurs on at least three different levels, conceptually, institutionally, and within the doctor-patient interaction (Conrad and Schneider 1980). Conceptually, medicalization occurs when a process or condition is defined as a medical problem. Institutionally, it occurs when medical professionals legitimize the problem at hand as a medical issue. Within the doctor-patient relationship, medicalization occurs when an individual is diagnosed and treated for a problem.
Medicalizing an issue requires that the subject under consideration be defined as deviating from the norm. Once a condition is recognized as departing from the norm it then becomes obligatory for the illness to be addressed. It is important to consider that science, as well as illness, is ultimately a social construction that helps to reinforce social norms (Riessman 1983). Women and women’s bodies have been particularly vulnerable to the process of medicalization due in part to Western gender-biased ideologies that view women primarily as reproductive beings (King 1992; Martin 1987). The male body, on the other hand, has been held up as the standard for the proper function of the human body from which women deviate, having obvious physical and hormonal differences (Gurevich 1995). Medicalization of the female reproductive process has led to the female body being viewed ‘as a medical problem from the cradle to the grave’ (Gijsbers van Wijk et al. 1996: 708).
Medicalization has occurred over time within the context of cultural, political, and social changes. While differences of opinion on the cause of medicalization abound, the majority of authors have focused on the expansion of the medical profession and medicine’s influence on lay people, specifically their reliance on medical practitioner’s ‘expertise’ (Riessman 1983; Williams and Calnan 1996). In the case of reproduction, this reliance has given physicians a power and mastery over women’s reproductive experiences, often questioning or even replacing a woman’s own knowledge and understanding of her experience. Jordan and other researchers have developed this idea in the area of pregnancy and childbirth specifically as it pertains to ‘authoritative knowledge’ (see Davis-Floyd and Sargent 1997a). Jordan explains authoritative knowledge in the following way: ‘for any particular domain, several knowledge systems exist, some of which, by consensus, come to carry more weight than others, either because they explain the state of the world better for the purposes at hand (efficacy) or because they are associated with a stronger power base (structural superiority), and usually both’ (Jordan 1997: 56).
In part, the medicalization of reproduction has occurred because of the Western reliance on technology. Data produced by technological devices are seen as being more accurate than subjective signs and symptoms (King 1992), and the increasing technical complexity of society has augmented society’s reliance on the expertise of medical professionals (Zola 1972, 1975). Like science, technology is not value-free. Medical technology reflects the values and beliefs of its creators and is influenced by politics as well as science, generating power and social control by accepting physicians and medical care institutions as the brokers of knowledge (King 1992). Banta (1983) defines medical technology as ‘the drugs, devices and medical and surgical procedures used in medical care and the organisational and support systems within which such care is provided.’ As will be discussed below, technology has played a critical role in the medicalization of reproduction from early developments such as the use of forceps in delivering infants to more recent developments in assisted reproductive technologies.
The Perinatal Period
In America, and to a lesser degree in England, the historical shift of childbirth from a social event to a medical process has been well documented (Arms 1975; Leavitt 1986; Oakley 1984; Shaw 1974; Wertz and Wertz 1989). Researchers have discussed the roles that the medical profession as well as women have played in facilitating this shift. Physicians sought to strengthen their new claim as a profession, while women sought to be relieved from the fear and discomfort that accompanied the childbirth process. What was once carried out at home with the assistance of a female support group, and occasionally a midwife, evolved into a medical model of labor and delivery as a potentially pathological occurrence requiring the supervision of trained medical professionals in a hospital equipped with all of the latest technologies.
‘Childbirth is a culturally defined act set within the universals of a common human evolutionary heritage’ (Michaelson 1988: 8). The Western birth process is defined within the culture of technology, a type of ‘technomedicine’ that characterizes the way birth is viewed (Davis-Floyd and Sargent 1997b). In the obstetrical literature (Barker 1998; Wertz and Wertz 1989) women and childbirth have been likened to ships that must be piloted and cars that must be fixed by skilled mechanics (obstetricians). Most women generally assume that some form of technology will play a part in their birth experience, which requires them to depend on the physicians, or ‘technicians’, who possess the authoritative knowledge to interpret this technology (Davis-Floyd 1988; Davis-Floyd and Sargent 1997b).
Reproductive technologies, such as forceps, anesthesia, fetal monitoring, episiotomies, and cesarean sections, have been instrumental in the medicalization process. Medicalization should be viewed as having both positive and negative consequences for childbirth. It has reduced the risks of birth by providing the technology to deal more effectively with high-risk births and complications. Unfortunately, the use of many of these technologies has become routine, with little evidence that they improve birth outcomes in general. They have become part of the American ‘birth ritual,’ and can serve to distance women from their health-care providers if the technology becomes the focal point during labor rather than the women (Davis-Floyd 1988). The knowledge that these technologies provide can be used to negate women’s own understanding of their bodies and birth experience, and may blind both patient and provider to the possibility of nontechno-logical interventions (Michaelson 1988). While more women are exploring ‘natural childbirth’ with limited medical intervention, the majority of women in the United States and many other countries still are dependent primarily upon the knowledge and expertise of the medical professional (Wertz and Wertz 1989).
Since prenatal care is still primarily viewed as relatively low technology, women feel more free to choose which prenatal advice to accept depending on how well it fits within their own knowledge of pregnancy and the reality of their lives (Browner and Press 1996). As prenatal technology, such as ultrasounds, amniocentesis and other diagnostic tests, become more utilized, however, pregnancy becomes more medicalized. An example is the alpha feta protein (AFP) prenatal diagnostic blood test for neural tube defects, now required to be offered in California. Even those women who had the test were uncertain of what it is, but they nonetheless wanted the test, the most common reasons cited being to be reassured, to be prepared, or to comply with doctor’s instructions (Browner and Press 1995).
Until as recently as the mid-1980s, ultrasounds were only used in high-risk pregnancies. Since that time, they have become more prevalent and a standard part of prenatal care in much of the world. In Greece, three ultrasounds are done, on average, per pregnancy (Georges 1996). While women often want and request these ultrasounds, the information learned from this technology can also be used to reinforce medical authority and the superiority of technological knowledge. Georges (1996) provides several examples of how women’s knowledge of their pregnancy is denied in favor of the ‘reality’ of pregnancy dates available to physicians through ultrasounds.
All technology requires individuals to choose whether they will utilize the technology. One is forced, however, to ask whether this choice is always free, or can be coerced. In Western society, great value is placed on making informed and conscious decisions (Rothman 1988). As Browner and Press point out, ‘Once a prenatal diagnostic technology becomes widely available it cannot be refused neutrally because refusal can be construed as a lack of responsibility on the part of the pregnant woman’ (Browner and Press 1996: 153). There is ‘no right not to know’ (Michaelson 1988: 16), and many women accept new technologies because they do not want to risk ‘blame for the failures that result from the inefficiencies of natural reproduction’ (King 1992). In her study of women’s decisions to have or not to have amniocentesis, Rothman (1988) found that when women were at risk and chose the unexpected, not to have the test, they were more prepared to defend their actions and explain.
Prenatal diagnostic testing is an area in which a dialogue must be opened allowing women to share their experiences. Unlike other aspects of pregnancy, it is deeply personal and there is a silence surrounding this medical event that separates it from the common maternal experience (Rapp 1988). There is a unique pressure on women not only to avail themselves of the technology, but to then face the question of what they are to do with the information provided (Browner and Press 1995; Rapp 1988; Rothman 1988).
Premenstrual syndrome (PMS) was first defined as a medical problem in 1931 and since has been the subject of considerable research, although the etiology and appropriate treatment still remain unresolved. Gurevich (1995) points to the cultural nature of this ‘disease’ in her discussion of comparative research, which has shown that PMS is much more prevalent in the US and other Western societies than in other cultures. Martin (1987) illustrates the role of social construction in the science of PMS research in the US throughout the period from the 1930s to the 1970s. Research on the menstrual cycle was originally concerned with the impact on women as employees. The pattern of findings on menstruation related to social changes, such as wars and the feminist movement, and the need for women in the workforce or the need for them to relinquish their jobs to men. If men needed the jobs, research findings tended toward the conclusion that PMS was detrimental to a woman’s ability to work. If women were needed, such as during the war, researchers tended to find that women should not be allowed to use their menstrual cycles as an excuse as it had no bearing on their functionality as employees.
Once PMS was medicalized it led not only to the need for diagnosis, but for treatment as well, as it does for all diseases. Riessman (1983) suggests that market forces have played a role in the increase of PMS. She proposes that physicians, specifically obstetrician/gynecologists, need new problems to treat as their numbers increase and birth rates decline. Pharmaceutical companies have also played a pivotal role, since numerous drug therapies have been developed to treat premenstrual symptoms, with treatments ranging from over-the-counter medications and self-help books to progesterone therapy and PMS clinics (Gurevich 1995).
Just as with the medicalization of childbirth, this process has not been devoid of the participation of women or completely without benefit to women. Women have been actively involved in searching for answers to premenstrual syndrome as they seek out relief from menstrual discomfort (Riessman 1983). Gurevich (1995) suggests that PMS affords women an opportunity of maintaining culturally defined femininity, generally seen as passive, while allowing them a medically sanctioned release for emotionality. Unfortunately, it also reinforces the belief that women are controlled by their reproductive systems, or their ‘raging hormones,’ and redefines hormonal changes during the menstrual cycles as pathological rather than natural (Riessman 1983). Riessman points to several problems arising from this redefinition: medical treatments may become the norm, previously asymptomatic women may perceive symptoms simply because a medical explanation exists, and it reduces attention to women’s complaints by explaining them away as ‘simply PMS.,’
Conceptually, the medicalization of menopause began in the 1930s and 1940s when it was labeled a deficiency disease caused by a lack of estrogen (Bell 1987). In the 1960s, synthetic estrogen became widely available, increasing the focus on menopause and the need for it to be treated (McCrea 1983). Much of the focus on menopause in the 1960s, though, was, interestingly enough, on the impact of menopause on the woman’s husband and others around her rather than on the woman herself. Some practitioners advised that women be treated whether they realized they needed to be or not, emphasizing the point that the knowledge that counted was not with the women, but with the physicians. Gynecologist Robert A. Wilson, prominent advocate of estrogen, even suggested that women be given estrogen from ‘puberty to grave’ (Wilson and Wilson 1963).
Menopause, like all ‘diseases,’ is culturally dependent, as women from different cultures, ethnic groups, and class backgrounds experience symptoms differently (Flint and Samil 1990; Kaiser 1990). There is a pressing need to understand how women perceive menopause and to understand why women present certain symptoms. The biomedical model of menopause needs to encompass a biopsychocultural model and multidisciplinary research that includes both biomedical and social/behavioral inquiry (Flint and Samil 1990), as does research on all aspects of reproduction.
As with PMS and other areas of reproduction, the medicalization of menopause has had mixed effects. While it has legitimized women’s menopausal complaints, it has also reinforced traditional stereotypes of aging women. Ironically, Bell (1987) points out that the disease orientation of menopause was introduced to reassure women that most often menopause was a normal and natural physiological event, but it has instead served to increase the cultural authority of medicine by overriding the importance of women’s experiences. ‘By individualizing the problems of menopause, the physician turns attention away from any social structural interpretation of women’s conditions. The focus of the solution then becomes the doctor-patient interaction in which the physician is active, instrumental, and authoritative, while the patient is passive and dependent’ (McCrea 1983: 113).
In recent years a plethora of studies exploring assisted reproduction technologies and infertility has emerged in the field of anthropology (Cannell 1990; Franklin and Ragoné 1998; Ginsburg and Rapp 1995; Inhorn 1994, 1996; Modell 1989; Ragoné 1994, 1996, 1998; Sandelowski 1993; Strathern 1991, 1992). In 1995, 6.2 million women aged 15-44 in the United States alone reported impaired fecundity; 44 per cent of these women had sought medical help for fertility problems (Chandra and Stephen 1998). There are a number of treatment options available to those who are diagnosed with fertility problems, ranging from hormonal to more invasive techniques (Hamberger and Janson 1997). Of course the act of defining infertility as a medical problem and the development of assisted reproductive technologies (ARTs) has helped lead to its medicalization. Once infertility is medically designated as a disease, both patients and practitioners pursue a “cure” through a well-delineated pattern of medical treatment, despite any risks such treatment may entail (Becker and Nachtigall 1994: 516).
The existence of a technology to address infertility places pressure on infertile patients to seek out treatment. As Donchin (1996), in her review of feminist studies of the topic, points out, what was once accepted with resignation, the inability to conceive, is now viewed as a surmountable obstacle. Infertile patients cannot stop trying, because with today’s technological options there is no problem that cannot be solved (Sheth and Malpani 1997). Treatment for infertility is generally a process of 3 years or more in length, often involving a progression of treatments. There are risks involved, but women take these risks because treatment is viewed as a socially responsible behavior for those who wish to conceive and to fulfil the cultural norm of motherhood (Becker and Nachtigall 1994).
With the introduction of assisted reproductive technologies (ARTs), seemingly simple yet nonetheless culturally bound assessments concerning what constitutes a ‘family,’ ‘motherhood,’ and ‘fatherhood’ can no longer be taken for granted. Reproductive technologies have served to defamiliarize what was once understood to be the ‘natural’ basis of human procreation and relatedness. In essence, ARTs have served, as the Comaroffs so eloquently said of ethnography, ‘to make the familiar strange and the strange familiar, all the better to understand them both’ (Comaroff and Comaroff 1992). Perhaps no other area of study in contemporary EuroAmerican culture is so charged with meaning, emotion, and contestation at this time as that of assisted reproduction.
In recent history, there have been three profound shifts in the Western conceptualization of the categories of conception, reproduction, and parenthood. The first occurred in response to the separation of intercourse from reproduction through birth control methods (Snowden et al. 1983). A second shift occurred in response to the emergence of assisted reproductive technologies and the subsequent fragmentation of the unity of reproduction, when it became possible for pregnancy to occur without necessarily having been ‘preceded by sexual intercourse’ (Snowden et al. 1983: 5). The third shift occurred in response to further advances in reproductive medicine that called into question the Organic unity of fetus and mother’ (Martin 1987: 20).
It was not until the emergence of reproductive medicine that this fragmentation of motherhood became a reality. With that historical change, what was once the ‘single figure of the mother is dispersed among several potential figures, as the functions of maternal procreation—aspects of her physical parenthood—become dispersed,’ (Strathern 1991: 32). It has called into question the EuroAmerican definitions of kinship and family, which are based primarily on biological relationships. Assisted reproduction effectively disperses kinship as well as conception, including not only those who produce a child with assistance, but those who assist (Strathern 1995). With the development of new fertility technologies, the social pressure to produce biologically related children intensifies (Donchin 1996). The issue of relatedness is of paramount importance in assisted reproductive technology research, since individuals who avail themselves of these technologies are often engaged in a desperate search for a genetic link.
This has ramifications not only for the relationships between those involved in the new forms of procreation, but also for the option of adoption. Adoption may increasingly be viewed as a last resort by couples after efforts to reproduce themselves genetically (Donchin 1996; Strathern 1995). The inherent problems individuals and couples face in the adoption process has been discussed elsewhere, including age-based criteria, religion, shortages of healthy EuroAmerican children, and cost (Ragoné 1994, 1996). Other controversial aspects of adoption include transnational and transracial adoption, both of which have caused a growing number of individuals and couples to turn to assisted reproduction.
Assisted reproduction encompasses a wide spectrum that ranges from a couple using their own sperm and ova carried to term in the woman’s uterus, to the extreme end of the spectrum where a couple provides neither sperm nor ova and contracts with another woman to carry the child in her uterus. Each situation has varying degrees of acceptability for practitioners and for those involved, as will be discussed below (Dans 1992). The following section addresses the issues of kinship and relatedness at the end of the spectrum which is most problematic genetically—gamete donation and surrogacy.
Gamete donation refers to the process whereby men donate semen and/or women donate ova in order to assist infertile couples/individuals in their quest for children. Sperm donation has a long and checkered history in the annals of Western medicine. The first recorded case of donor insemination (DI) occurred in 1884 when a physician inseminated an unconscious and uninformed patient, a procedure clearly at odds with contemporary perspectives on donation.
Although sperm donation is now positively valued and somewhat commonplace, in the 1940s and 1950s it was considered a deviant practice calling into question both the donor’s and mother’s motivations. Britain’s Feversham Committee, for example, considered that it ‘might be expected to attract more than the usual proportion of psychopaths’ (Report of the Departmental Committee on Human Artificial Insemination 1960: 58). The Archbishop of Canterbury’s Commission viewed the motivations of the woman who desired to enter motherhood through ‘the seed of a man not her husband’ as a pathological desire for motherhood (1948: 25). As late as 1948, the Archbishop of Canterbury’s Commission recommended that a donor’s semen be ‘collected from the donor’s wife’s vagina’ to remove the troublesome act of masturbation, and to include the ‘donor’s wife’ so that ‘she too was contributing to donation,’ (Haimes 1993a: 87). Over time, many of the beliefs and attitudes that equated sperm donation with social deviance have receded. In contemporary EuroAmerican culture, sperm donation is seen as a straightforward process of collection and insemination. The process has been predicated consistently on anonymity and, with a few notable exceptions, has remained devoid of cultural interpretation.
While sperm donation was the first successful attempt to extract gametes from the human body for the treatment of infertility, advances in reproductive medicine, specifically in vitro fertilization (IVF), now allow women the option of donating ova. The first recorded case of ova donation was in Australia in 1983, and since then there has been a meteoric rise in the rates of ovum donation. Ovum donation provides both agonadal women and women who fear passing on sex-linked diseases to their potential offspring with an opportunity to experience pregnancy and birth. Although ovum donation is certainly a great deal more medically complicated, risky, and intrusive than sperm donation, ovum donation also remains largely bereft of cultural analysis.
Gamete Donors and Surrogates
Gender is a crucial if understudied variable in any assessment of gamete donation. Studies on sperm donation have revealed that donors are primarily motivated by remuneration, but have found other motivations including altruism and assessing their own fertility (Daniels 1989; Handelsman et al. 1985; Mahlstedt and Probasco 1991; Purdie et al. 1994; Schover et al. 1992). While sperm donors report a feeling of ‘specialness’ while donating, they may come to reconsider their donor status (Baran and Pannor 1989). As one former sperm donor in a study examining the long-term impact of targeting students as donors expressed, ‘he wished he had had the foresight to know that one day, twenty-five years later, he would regret that period in his life’ (Baran and Pannor 1989: 90). Such reassessments appear to be influenced by the experience of becoming a father and realizing that they may have unknown offspring (Myers 1990) and ‘a role devoid of any responsibility to the children they produce,’ (Baran and Pannor 1989: 96). In contrast to prevailing American views, France and Sweden encourage donation from older, married men, who are already fathers (Haimes 1993a).
Most surrogates and ovum donors deny the importance of remuneration in their decision-making process, but the fact remains that many of these women acknowledge that they find the financial incentive attractive. The issue of remuneration/altruism is a complicated one; women who choose to participate in surrogacy do so for a host of compelling reasons (Ragoné 1994, 1996, 1998). Surrogates continually assert that the importance of remuneration decreases as the process progresses, and this pattern may be repeated with ovum donors and sperm donors. Of all the surrogates’ stated motivations, remuneration is the most problematic. On a symbolic level, of course, remuneration detracts from the idealized cultural image of women/mothers as selfless, nurturing, and altruistic, an image that surrogates and, quite likely, ovum donors do not wish to lose.
In one study of an oocyte donation program, the screening process for prospective ovum donors insists that the ‘primary reason for participation … [be] a desire to help an infertile woman have a baby’ (Sauer and Paulson 1992b: 727). In spite of this policy which does not permit women who express financial incentive to serve as ovum donors, 76 per cent of the ‘women who had gone through at least one aspiration stated that compensation was important for their continued participation’ (Sauer and Paulson 1992b: 727). Although the authors conclude that oocyte donors differ from men donating sperm, who routinely state the importance of remuneration (Sauer and Paulson 1992a), their conclusion seems odd when the majority of their ovum donors appear to value compensation. Such assessments conflate commonly accepted yet engendered and essentialist ideas about women and men.
The increasing demand for ova coupled with the routinization and naturalization of the procedure has created amongst infertility clinics the practice of targeting reproductively inexperienced young women as ovum donors (using the model of sperm donation in which college-aged men and medical students are the target audience). Acting on the questionable assumption that women in college have ‘smarter’ ova, clinics seek ova from these young women using financial incentives (the woman earns a fee of $10000 for four ovulatory cycles). Competition among infertility clinics is increasing, and the prospect of making enormous profits coupled with weak regulatory policies (Reame 1998) is creating a volatile environment. Although a great deal has been written about infertility clinics’ practice of inflating their ‘success rates,’ little has been written on the practice of advertising for ova donors in college newspapers. In contrast, the largest ovum donation program in the United States requires prospective donors to have had at least one child in order to be accepted into the program (also the policy in French programs).
Extensive research on gestational surrogates revealed that they routinely report feeling ‘unprepared’ for the rigors and discomfort of self-administering shots during the course of their pregnancies (Ragoné 1998). Surrogates, however, commonly reformulate their expectations to include the near sacrifice of their lives and ‘readily embrace the idea of meaningful suffering, heroisim, or sacrifice,’ even when their experiences of surrogacy are at odds with their expectations (Ragoné 1996: 354). Perhaps this will also prove true for ovum donors.
An additional issue, aside from the reported physical discomfort ovum donors feel during the period surrounding retrieval (Rosenberg and Epstein 1995), is the risk of cervical cancer associated with ovulating-induction drugs (Rosen et al. 1997). While studies have consistently demonstrated the willingness of infertile women to accept the risks associated with infertility treatments (Modell 1989; Sandelowski 1993), they are making an informed decision, whereas when a young, fertile woman agrees to subject herself to the same risks it is not a comparable situation. Statistically we know that a percentage of ovum donors will join the ranks of the infertile, and they may come to regret deeply their decision to donate ova, a decision made at a time when they had minimal or no reproductive experience or knowledge. Do infertility clinics provide their prospective ovum donors with adequate information concerning drug protocols, and do these young women process this information in a meaningful and informed way?
Although sexual mores have changed since the 1940s and 1950s, contemporary studies on male infertility have yet to explore fully the emotional and/or psychological issues faced by infertile men and sperm donors (Pedersen et al. 1994). One of the most significant problems facing infertile men is the association between male infertility and impotence, although the two are not necessarily linked. Gender stereotyping, which assigns to males the role of ‘initiators,’ defines infertile men as ‘powerless’ or passive, unable to undertake successfully that which is considered ‘appropriate masculine behavior’ (Snowden et al. 1983: 121), further complicating the issue of infertility. A lack of medical knowledge and effective treatment programs (Snowden et al. 1983) also contributes to the stigma attaching to male infertility. The fact that 40 per cent of infertility is male (30 per cent female and 30 per cent unknown and/or shared) makes the lack of male infertility research puzzling. Furthermore, research on the exact number of children born through donor insemination (estimated at 30000 births per year in the United States) (Barratt et al. 1990) has been impeded because records are routinely destroyed, information denied, and secrecy widely practiced by physicians (Baran and Pannor 1989: 5).
In the 1950s, physicians were known to permit a husband to inseminate his wife with the ‘actual syringe containing the donated semen so that he could say, “I impregnated my wife”’ (Fletcher 1955: 125). Physicians routinely mixed donor semen with the semen of the intending father well into the mid-1980s in an attempt to intentionally obscure the issue of paternity, and some continue to recommend to couples who request such mixed semen to engage in sexual intercourse prior to insemination (thus mixing semen on their own). Although the practice of mixing semen has been discontinued, it nonetheless reveals the highly engendered beliefs surrounding male infertility. Of profound interest is the current unreflective practice of mixing ova and embryos in a newfound attempt to confuse the issue of maternity and/or parenthood, respectively.
Women in committed relationships with infertile men/husbands are, through donor insemination (DI), able to sustain a pregnancy which further contributes to the secrecy model, because many individuals agree that no one else needs to know about the husband’s sterility. Although gender-role stereotyping may heighten the stigma associated with male infertility, it may conversely lessen the stigma associated with female infertility in that the characteristics associated with infertility, such as powerlessness, are more readily considered part of the spectrum of ‘appropriate feminine behavior’ (Snowden et al. 1983: 142). This theory is supported in part by the fact that many women with infertile husbands who participate in DI allow others to believe that they, rather than their husbands, are infertile (Snowden et al. 1983).
This strategy has been viewed as a means to shield men from potential shame or ridicule. In addition, when a DI wife feigns infertility, she is aware that any stigma associated with her infertility will be removed once she becomes pregnant, and that her infertility can thus be understood as a transient form of infertility, whereas his would not be so understood (Ragoné 1994). Perhaps even more important it is also a means by which the wife compensates for the fact that the resultant child will be biologically related to her and not to her husband. As Baran and Pannor’s research (based upon an admittedly small sample) has revealed, some men whose wives have conceived through DI have reported a lifelong struggle to come to terms with their infertility and the fact that they lack a genetic tie to their children (Baran and Pannor 1989). With traditional surrogacy, in which a surrogate donates an ovum as well as the use of her womb, the intending mother must grapple with her lack of a genetic tie to the child which also requires that all the individuals negotiate their relationship to the child and to one another (Ragoné 1994, 1996, 1998).
In spite of attempts to cast sperm/ovum donation as equivalents, Haimes has argued that there are notable differences in sperm donation and egg donation and the issue of secrecy (1993). In general, anonymity appears to be preferred (especially for sperm donation), because a ‘sense of danger’ is attached to semen donation/donors that is not attached to egg donors (Haimes 1993a: 87). The fact that treatment with donor eggs ‘was more acceptable than donor spermatozoa to both men and women in the fertile as well as the infertile population,’ (Kazem et al. 1995: 1547) seems to reinforce this position. As Lessor et al. (1990) has suggested, perhaps paternity may be viewed as more important in cultures with patrilineal systems of inheritance. Additionally, with ovum donation both wives and husbands feel that ‘they have contributed to the birth of the child’ (Kazem et al. 1995: 1547).
Fragmentation and Reunification of the Body
The fragmentation of motherhood and the negotiation of relationships within this novel experience of assisted reproduction require a redefining of motherhood for those involved. Not surprisingly, this differs according to the role the participants choose to play. For example, with traditional surrogacy in which a surrogate donates an ovum, the overwhelming majority of surrogates devalue their own genetic/physical contribution. They do this while highlighting the ‘pseudopregnancy’ of the adoptive mother and the importance of the tetter’s role as nurturer. In this way, motherhood is reinterpreted as primarily a social role in order to avert problematic aspects of the surrogate’s genetic relationship to the child and the adoptive mother’s lack of a genetic link. A 39-year-old surrogate reflects this focus upon intention and nurture by both surrogates and adoptive mothers in the following statement:
Parents are the ones who raise the child. I got that from my parents who adopted children. My siblings were curious and my parents gave them the information they had and they never wanted to track down their biological parents. I don’t think of the baby as mine; it is the parents, the ones who raise the child that are important.
In the process of emphasizing the value of nurture, surrogates describe motherhood as a role that one can either adopt or refuse, and this concept of nurture as choice is for them the single most important defining aspect of motherhood. Traditional surrogates believe that motherhood is comprised of two separable aspects: first, the biological process (insemination, pregnancy, and delivery), and second, the social process (nurture). They reason that a woman can choose to nurture, that is, to accept the role of social mother, or choose not to nurture, thereby rejecting the role of social mother. A traditional surrogate explains her perception of surrogacy in the following way, ‘It was an egg I wasn’t going to be using.’
Ovum donors also embrace this position. On the other hand, they find it more difficult to contemplate serving in the capacity of surrogate, citing their belief that their husband would have difficulty accepting surrogacy, a history of problem pregnancies, and/or the fear that they might bond with the child they were gestating for the couple. Interestingly, they are, however, able to part with their ova and potentially their genetic child.
At odds with these perspectives is the gestational surrogate’s view of the relationship. As a whole, women who elect to become gestational surrogates tend to articulate the belief that traditional surrogacy, even though less medically complicated, is not an acceptable option for them because they are uncomfortable with the prospect of contributing their own ovum (or ova) to the creation of a child. They also cannot readily accept the idea that someone else would raise a child who is genetically related to them. In other words, they explicitly articulate the opinion that in traditional surrogacy (where the surrogate contributes an ovum) the surrogate is the mother of the child, whereas in gestational surrogacy (where she does not contribute an ovum) she is not.
Couples are attracted to ovum donation for different reasons: husbands for the genetic link, wives for the experience of pregnancy, and both wives and husbands are able to gain prenatal control. Prenatal control is also important to couples who pursue gestational surrogacy whether it is the couples’ embryos or embryos produced through ovum donation. Couples who choose gestational surrogacy using donor eggs/husband’s semen/gestational surrogate are still ending up with the same degree of relatedness to the child as they would with traditional surrogacy, i.e., a child who is genetically related only to the husband. It appears, though, that some couples chose this arrangement for its ability to sever the surrogate’s genetic tie to the child (Ragoné 1996, 1998). Adding to the complexity of these arrangements is the couple who will use donated eggs and, in some cases, donor semen, and the intending mother gestates the embryo(s). The intending mother, through the process of gestation, forms her bond to the child, a bond that, as we have seen, the gestational surrogate intentionally de-emphasizes.
In a study of the experiences of recipient couples in the context of ovum donation, 90 percent of couples in the program used anonymous donation and 9.7 percent used known, i.e., sister, donation (Applegarth et al. 1995). The authors concluded that only a ‘small percentage,’ 10 percent of husbands and 26 percent of wives, ‘expressed the desire to meet their ovum donor’ (Applegarth et al. 1995: 577). The fact that over one-quarter want to meet their donors seems highly significant.
Individuals typically attest to their satisfaction with ovum donation by thanking ‘God,’ ‘the wonders of modern medical miracles,’ ‘medical science,’ and ‘fantastic technology.’ In only one case does a recipient state that she is ‘thankful for my donor’ (Applegarth et al. 1995: 580). The acceptance and subsequent implementation of anonymity in both ovum donation programs and sperm banks contributes not only to the further fragmentation of reproduction and the body but, as the above quotes aptly demonstrate, to the fact that in practice gamete donation involves disembodied gametes (rather than persons). The ovum donor coordinator at the largest ovum donation program stated that they often interview couples who are seeking total anonymity. As she said, ‘Some couples don’t want any contact, they want to see her [ovum donor] as genetic material!’
The complexity of these relationships and the difficulty of reinterpreting our definitions of motherhood are evident in the questions raised by the courts as they attempt to clarify the roles of the players. Current legal opinion in both Britain and Australia is that ‘when a child is born to a woman following the donation of another’s egg the women giving birth should, for all purposes, be regarded in law as the mother of that child’ (Shalev 1989: 117). Does this apply equally to a woman who receives a donor egg that she gestates herself and a woman who contracts another to be a gestational surrogate through in vitro fertilization? It is interesting to note that this opinion contradicts the views expressed by gestational surrogates who choose gestational surrogacy precisely because it eliminates the issue of genetic relatedness for them. This effort to expand our definition of relatedness runs contrary to the EuroAmerican emphasis on genetic relatedness, in which genetic parents are legally and socially considered the ‘real’ parents. The fragmentation or dispersal of parenthood, a byproduct of reproductive technologies, has resulted in the ‘claims of one kind of biological mother against other kinds of biological and nonbiological mothers’ (Strathern 1991: 32) and biological and nonbiological fathers.
In the precedent-setting case in California, Anna Johnson v. Mark and Crispina Calvert, Case #S023721, a gestational surrogate and a couple both filed custody suits. Under California law, both of the women could claim maternal rights: Johnson by virtue of being the woman who gave birth to the child, and Calvert, who donated the ovum, because she is the child’s genetic mother. In rendering its decision, however, the court in a sense circumvented the issue of relatedness and focused instead on the ‘intent’ of the parties as the ultimate and decisive factor in determining parenthood. Specifically, Justice Edward Penelli wrote: ‘It is not the role of the judiciary to inhibit the use of reproductive technology when the legislature has not seen fit to do so. Any such effort would raise serious questions in light of the fundamental nature of the rights of procreation and privacy.’ In addition, the court concluded that compensation to the surrogate is understood not as the New Jersey Supreme Court ruled—as baby selling or selling the rights to her child—but rather as payment for her services of gestation and labor. The court ruled that surrogacy contracts are enforceable and consistent with prevailing public policy. To date, no egg donor has attempted to claim maternal rights.
Constructing Family—Secrecy and Anonymity
Psychological directives that reiterate the importance of informing children of their birth origins and the deleterious consequences of secrecy continue to be ignored for the most part, just as the importance of the genetic basis of relatedness in EuroAmerican kinship ideology is ignored. In EuroAmerican culture the ‘blood relationship cannot be lost’ (Schneider 1968: 24) nor can one have an ex-blood relative (Schneider 1968). The literature on gamete donation suggests tacitly that the acceptance of anonymity is predicated on the belief that the family must be protected from the potential disruption posed by known donors. With ovum donation (unlike with sperm donation), however, there is some precedent for known donors, namely sisters, but its impact on the overall practice of ovum donation appears at this point to be somewhat negligible.
Purdie et al. recommend that DI ‘move away from the animal husbandry model (with the selection of highly fertile donors to service many recipients) to a social model where a donor (and his family) “adopt” one or a few infertile couples’ (Purdie et al. 1994: 1358), a recommendation that seems to be a radical departure from gamete donation policies in the United States. Implementation of a disclosure policy would require a rethinking of the issues of secrecy and privacy, and a reeducation of recipients (and donors) which would require programs to encourage individuals to accept their infertility and also their worst fear, namely that the donor, the only person that can ameliorate their childlessness, is also the person who may want to take back the child (also a common fear with surrogacy). It should be noted that anonymous donation not only requires a significantly less developed infrastructure, but it also does not place demands on the paying client.
The Glover Report, in a radical departure from anonymous models of donation, has advocated an experimental approach in which children produced through DI would be given information and access to their donors upon reaching 18 years of age (Haimes 1993a: 88). However, despite the growing body of literature on adoptees and their often frustrating attempts to locate their biological parents (a search that is often confined exclusively to mothers), they continue to be denied access to the identity of their biological parents and, most importantly, to their own sense of identity. Using a small sample of adults who were conceived through sperm donation, Baran and Pannor (1989) concluded that many of these individuals are ‘angry’ about the secrecy surrounding their birth origins and their biological father’s identity, and they are joining traditional adoptees in searching for their biological parents. While Sweden and Australia have passed legislation to permit DI children access to identifying information about their donors when they have reached 18 years of age (Weil 1997), and Austria and The Netherlands are ‘moving in this direction’ (Haimes 1993b), the issue of disclosure remains controversial in the United States. At the largest sperm bank in the United States, though, there is now a policy that the bank will contact the donor to ask him if he would be willing to relinquish his anonymity if a DI child requests information. They have found that donors are more likely to agree to the request after they have had their own children.
The policy at the largest and most well-established surrogate program is predicated on disclosure and openness. Having entered ovum donation, they too now permit anonymous donation. It is not, however, anonymous in the strictest sense in which donors know little if anything about their couples. For example, one 28-year-old ovum donor whose first donation was completely anonymous (facilitated by a physician) described her negative experience: ‘It made me feel like a prostitute. It was disgusting. I left there crying. In the end, I said, “I will never do this again”; it was a horrible experience.’ Interestingly, she donated two additional times in a program that encourages openness. One of the psychologists at the largest program explained her decision to donate again as an action that was ‘helping her to heal.’ Her ability to participate a second and third time was because in an open program the ovum donor and prospective couple meet and are free to accept or reject one another, which accords agency to both commissioning couples and donors.
It seems likely that individuals who have gestational surrogates may be tempted not to inform the child of her origin. This appears to be especially true for couples who engage in gestational surrogacy contracts independent of programs. Research on gestational surrogacy reveals that many couples view their surrogates as ‘carriers,’ and emphasize the remunerative aspect of their relationship as the defining factor. This view stands in stark contrast to couples enrolled in open programs who have ready access to guidelines and counselors who continually advocate openness and disclosure.
In the open surrogacy programs, which require surrogates and commissioning couples to meet and interact with one another throughout the process, couples are strongly encouraged to inform their child of his birth origins, and it appears that most couples take this admonition seriously. However, as Hilary Hanafin, the psychologist at The Center for Surrogate Parenting and Egg Donation, reasoned, IVF surrogacy (when it is the couple’s embryos) can be reduced to a reproductive act since the couple ends up with the same child they would have had through traditional reproduction. As a consequence, the motivation for couples to inform their children about their gestational surrogate is lessened.
Information on children produced through gamete donation (whether by ovum or sperm donation) is sparse. In the handful of studies that have examined third-party reproduction, the pattern has been that when children were informed of their birth origins it was usually because ‘the system … had broken down and the practice of secrecy had failed’ (Baran and Pannor 1989: 71). Researchers have concluded that children conceived by third-party reproduction and not informed of their birth origins appear to be well adjusted; parenting in these families also appears to be superior (Golombek et al. 1993). The psychosocial development of these children appears to be the same as that of children conceived through traditional means and adoptees (Kovacs et al. 1993). Based upon the only longitudinal study on DI, which points to the ongoing secrecy of these arrangements and the continued resistance of parents to the idea of informing their children about their birth origins (Snowden et al. 1983), we have little reason to expect disclosure with ovum donation. At present, there are no available data on the long-term effects of either anonymous or open ovum donation.
In preliminary interviews with ovum donors who were in semi-anonymous relationships, all five interviewees expressed similar sentiments when questioned about not being able to meet their couples. They all reported that they felt the need to ‘respect their couple’s wishes,’ a position not at all dissimilar to that of surrogates who were enrolled in anonymous or ‘closed’ relationships (Ragoné 1994). One component of the constellation of altruistic motives expressed by surrogates, which may also apply to gamete donors, is the courteousness of donors toward recipients.
With surrogate motherhood, as greater numbers of prospective surrogates learned of surrogate mother programs that encouraged interaction between surrogates and commissioning couples, it became increasingly more difficult for programs to enlist the services of surrogates who would agree to anonymous arrangements. At the largest ovum donation program, some of their ovum donors insist upon meeting their recipient couples, and those donors are matched with couples who want to meet their donors. The donor coordinator also said that ‘All donors are told of a birth; it creates closure for them. We believe they are entitled to that.’
Franklin (1995) points out that there has been a shift in the cultural meaning and organization of reproduction. Reproductive technologies, however routinized and naturalized, are culturally constructed. The ability to separate gametes from their Owners’ has yet to be sufficiently unproblematized, although it has met with a plethora of complex litigation.Advances in reproductive medicine have far-reaching implications and consequences not only for individuals who avail themselves of the procedures, but also for the donors and the children born via them. Continued failure to consider the ways in which individuals must grapple with their decisions to partake in reproductive technologies and beliefs about what constitutes family and relatedness in EuroAmerican kinship ideology (an ideology that bespeaks to the centrality of blood tie) will continue to produce studies, policies, and positions that neglect to take full account of technology’s complicated intersections with culture and social values.
The control of reproduction has led to a need for a greater understanding of the impacts of this control, not only on the individuals involved, but also on society. The emotional, social, and economic consequences of choices leading to the use of reproductive technology must be calculated. Questions arise that must be addressed. For example, Does everyone have the right to choose to give birth when and under the circumstances that they want? How do reproductive technologies impact a woman’s and couple’s right and responsibility to produce a healthy child and member of society? Does society have a say in these decisions? Are women being led to feel that they are somehow responsible for ‘quality control’ through reproductive technology as Rapp (1988) suggests? Questions related to the economic costs should include the following: Who should pay for reproductive technology and its consequences? Should only those individuals who can afford to pay be given the opportunity to conceive through ARTs? Should society bear the cost of the technology needed to ensure a successful pregnancy for those whose personal choices place them at greater risk to require more technological interventions?
This raises the issue of balancing personal freedom in choices with accountability for those decisions. Cultural values and norms, which can vary between generations, interplay with biological processes to influence fertility. For example, childbearing later in life due to a desire to focus on establishing one’s career or to a desire to have additional children in a second marriage can result in decreased fertility, making the need for technological intervention more likely. The desire to ensure a healthy pregnancy when one does get pregnant can lead toward overutilization of technology and the need to address the decisions necessitated by the information provided. The choices made earlier in life, including the use of reproductive technologies such as contraceptives or fertility drugs, can have repercussions throughout the reproductive cycle and beyond. As the postmenopausal population continues to grow, more attention must be focused on the health needs of this cohort, as is being done with the Women’s Health Initiative (WHI), a large, US clinical trial assessing the health consequences of nutritional and hormonal interventions for postmenopausal women (Rossouw et al. 1995; WHI Study Group 1998).
Advances in reproductive technology have further contributed to the process of medicalization and continue to influence interactions between women and health-care providers. In all areas of reproduction, the tendency has been a move toward ‘technomedicine,’ and the knowledge most valued increasingly has become that of the physician trained to interpret the technology. As Jordan (1997: 58) explains, ‘the power of authoritative knowledge is not that it is correct, but that it counts.’ Because health-care providers often act as arbiters of the knowledge provided by reproductive technology, it is important to study their experiences with, and perceptions of, technology as well as their interactions with patients. While this has been somewhat accomplished in the area of childbirth, there remains a need for more studies of health-care interactions in other domains of reproduction. For example, the acknowledgment that clinicians are ‘highly influential’ in ‘creating the overall atmosphere … in which donors and recipients experience gamete donation’ (Hamies 1993b: 1518). The role of infertility clinics in the acceptance of anonymity and the structuring of donors and recipients’ perceptions, expectations, and experiences deserves further study, as does the influence of health-care providers on women’s decisions to undergo prenatal diagnostic testing and their understanding of, and reactions to, those tests.
As discussed, women have been far from passive in the various processes involved in the medicalization of reproduction. Additional studies on whether women are satisfied with the prices and results of medicalization, or if in fact other models could be developed to deal more effectively with women’s concerns about their reproductive health. Women must be given a voice in the discourse of reproduction and reproductive technology because they are the ones whose lives are impacted, both positively and negatively, by the use of reproductive technologies. Their individual perspectives and understandings of the issues surrounding specific areas such as prenatal diagnosis and assisted reproduction are necessary, as is an understanding of the social context within which they live. As seen in the examples provided in this chapter, cultural and medical views about women must also be taken into account when studying reproduction and reproductive technology. As Reissman (1983) illustrates in her analysis of PMS, it is important that the conceptual medicalization of an issue, i.e., naming it a disease, does not hinder an examination of the social etiology. How does medicalizing an issue, such as menopause or infertility, affect the women who are diagnosed with the ‘disease’?
The importance of examining differences in women’s reproductive experiences based upon such variables as socioeconomic class and ethnicity cannot be overstated. For example, Gabe and Calnan (1989) found that lower-class women were less accepting of medical technology than were middle-class women. Ethnicity also affects the availability of ovum donors and surrogates: specifically, Asian American and Jewish women will participate with great frequency in ovum donation, but it is extremely difficult to find women from these ethnic groups who are willing to serve as surrogates (Ragoné 1998). Further studies are needed to determine how race, culture, and religion influence reproduction in its technological atmosphere.
The sociocultural aspects of reproduction and reproductive technology must be taken into consideration, as well as biomedical aspects. There is a need to work in multidisciplinary teams employing a variety of data collection and analysis methods. The perspective of a broad range of scholars, anthropologists, sociologists, feminists, and cultural historians, as well as clinicians and epidemiologists, is necessary if we are to fully appreciate the complexities of reproduction and reproductive technologies.