Reframing Reproduction

Conceiving Gendered Experiences

M. Nash, M. Nash

• Publisher: Palgrave Macmillan
• Year: 2014
• ISBN:
  9781137267139
• Topic: Sciences sociales
• Subtopic: Sociologie

How do rapid social and technological changes shape reproductive realms today? This book considers the complex choices, anxieties and challenges that come alongside postmodern reproduction for women and men in the West. Topics include surrogacy, fatherhood, sperm banking, egg donation, contraception, breastfeeding, and postpartum body image.

Part I
Contested ‘Choices’ and Challenges

1

Towards a More Inclusive Framework for Understanding Fertility Barriers

Katherine M. Johnson, Julia McQuillan, Arthur L. Greil, and Karina M. Shreffler

Introduction

An important focus for North American feminists has been addressing and improving women’s reproductive autonomy (Lorber, 1989; Rapp, 2001; Roberts, 1997). Since the beginning of the second wave of feminist activism, there has been an ‘explosion’ of feminist research on reproduction (Feree and Hess, 2000; Ginsburg and Rapp, 1995). As feminist scholars and others have worked to bring human reproduction onto centre stage in the sociological enterprise, they have emphasised that reproduction is not simply a biological process but a socially constructed reality involving power relations over who controls women’s bodies (Rothman, 1989). Many feminist scholars have made use of intersectionality theory (e.g. Collins, 1990), which emphasises the ways in which gender, race/ethnicity, class, and sexual orientation – among other factors – interact to create social realities. Indeed, although (western) women in postmodern society are represented as having enhanced reproductive choices, feminist scholars have critiqued this as highly individualistic, ignoring the larger social context that such choices are embedded in (Bird and Rieker, 2008; Lublin, 1998; Nash, 2012a). In this vein, the concept ‘stratified reproduction’ (Colen, 1986) has helped to illuminate how reproduction is structured across social and cultural boundaries, empowering privileged women and disempowering less privileged women (Bell, 2010; Roberts, 1997).

Yet despite these important developments in feminist theorising about fertility and reproduction, barriers to conception have often been on the margins of the feminist sociology of reproduction (Rapp, 2001; Sandelowski and de Lacey, 2002). As van Balen and Inhorn (2002) have noted, there is a ‘scholarly lacuna’ of social scientific work on infertility and childlessness. Earle et al. (2008) have similarly observed social science’s emphasis on studying reproductive ‘success’ over reproductive ‘failures’, such as miscarriage, stillbirth, infant and maternal mortality, and disruptions to ‘normal’ reproduction more broadly. Two major exceptions to this generalisation are the significant bodies of work on assisted reproductive technologies (ARTs) (for a review, see Thompson, 2002) and on stratified reproduction in surgical sterilisation (Price, 2010).

In this chapter, we assert the importance of understanding the experience of infertility itself – and not just simply the use of reproductive technologies – as a sociological phenomenon. We argue that feminist theorising will benefit from thinking of infertility as one instance of ‘fertility barriers’, a term we employ to refer to a range of both biological and social factors that prevent women and men from having wanted children (Greil and McQuillan, 2010; Jacob et. al., 2007). A minority of women are infertile at any point in time, and a very small minority make use of ART; however, most women face obstacles to having the children they desire. Thus fertility barriers represent an important limitation to reproductive ‘choice’ in postmodern society. Our goal is to contribute to a more holistic picture of the factors that shape and constrain women’s and men’s reproductive lives in the contemporary US.

We employ a women-centred approach here because women’s bodies have historically been, and continue to be, the primary site for blame or responsibility and treatment, even in situations of male-only infertility (Becker, 2000; Greil, 1991; Lorber, 1989). In the sections below, we work toward articulating a more inclusive ‘fertility barriers’ framework. First, we briefly visit themes in feminist research addressing infertility. We then provide an overview and critique of both the medical definition of infertility and social science terminology of ‘involuntary childlessness’. We present our more inclusive typology of fertility barriers and illustrate its utility using data from the National Survey of Fertility Barriers (NSFB). We conclude by clarifying the linkages between the fertility barriers perspective and feminist concerns.

Theoretical and empirical background

Themes in feminist scholarship on infertility

Reflecting on earlier feminist thinking about reproductive technologies, Thompson (2002) distinguished between Phase One (early 1970s to the mid-1980s) and Phase Two (late 1980s and 1990s). During Phase One, most – but certainly not all – feminist writing criticised reproductive technology as reinforcing patriarchal control of women’s bodies and conflating motherhood with womanhood. Reproductive technology was also depicted as pitting privileged women, who had access to these technologies, against less privileged women, who did not. Little attention was paid to the suffering of infertile women; some of the women interviewed by Greil (1991) felt that they were being sent the message that if they were ‘true’ feminists they should not desire children so much. Although Phase Two was not a clear break from Phase One, Thompson (2002) suggests that feminists began to focus more on the experiences of infertile women and shifted from certainty to ambivalence about reproductive technology as inherently ‘good’ or ‘bad’ for women. This accompanied a move among many feminists to go beyond thinking that the desire for motherhood was necessarily in conflict with feminism. Phase Two saw further development of themes concerning stratified reproduction.

Recent feminist work on infertility and the new reproductive technologies has echoed broader themes in the scholarship on reproduction. These themes include: understanding the experience of infertility in terms of patriarchy and the motherhood mandate (Becker, 2000; Greil, 2002; Inhorn, 1996; Remennick, 2000; Ulrich and Weatherall, 2000); problematising ideologies of biological motherhood as ‘true motherhood’ (Letherby, 1999); documenting resistance to dominant images of infertile women (Letherby, 2002a, 2002b; Parry, 2005; Riessman, 2000; Todorova and Kotzeva, 2003); addressing the moral economy of infertility treatment in terms of who can (and should) have access to reproduction (Agigian, 2004; Becker, 2000; Bell, 2010; Steinberg, 1997); theorising women’s agency to make reproductive decisions in the midst of social and cultural constraints, such as the technological imperative (Beckman and Harvey, 2005); and addressing societal tensions between women’s childbearing, educational and career opportunities, and general life course timing (Earle and Letherby, 2007; Friese et al., 2006; Martin, 2010). There is also a large body of feminist work that analyses and critiques reproductive technologies (Franklin, 1997; Thompson, 2002), including surrogacy/gestational carriers (Markens, 2007; Rothman, 1989; Teman, 2010), in-vitro fertilisation (Gerrits, 2008; Throsby and Gill, 2004) and gamete donation (Almeling, 2007; Tong, 1996). Yet there has been a dearth of research that directly addresses, and potentially alters, the definition of infertility itself as a medicalised phenomenon. Indeed, much social science research on infertility appears to proceed with the assumption that it is an agreed-upon medical phenomenon (see Sandelowski and de Lacey, 2002 regarding the invention of infertility as a discursive category). Our goal is to move forward the sociological discussion of infertility itself, by focusing on the problem of its very definition.

Defining infertility and childlessness: problems and politics

The contemporary understanding of infertility is that it is a medical problem, subject to the definitional and treatment authority of physicians (Conrad, 2007). A common medical definition of infertility is no conception after a year of regular, unprotected sex (American Society for Reproductive Medicine, 2008). Feminist scholarship has critiqued this definition for reinforcing a heteronormative paradigm of sex and reproduction (Agigian, 2004; Johnson, 2012) for focusing on couples as a unit of analysis, thereby obscuring gender asymmetries in treatment and diagnosis (Sandelowski, 1993), and for ignoring the more subjective implications of lack of conception for women under different social and cultural conditions (Inhorn et al., 2009; Sundby, 2002). The definition further assumes that women are either trying to become pregnant (if they are not using contraception) or trying to avoid pregnancy (Greil and McQuillan, 2010).

The medical conceptualisation of infertility better captures the experiences of White affluent women who tend to see their pregnancies as events that can and should be planned (Bell, 2010; McQuillan et al., 2011) and who have relatively better access to medical services (Greil et al., 2011) than other women. Feminists therefore assert that the act of medically defining infertility implicitly defines the intended population of infertile patients as partnered, heterosexual, White women who are intending to conceive a pregnancy and who have socio-economic resources to seek medical treatments when problems arise (Greil and McQuillan, 2010). This definition has material implications for women’s lives because it is often used in creating legislation about infertility and in setting the terms of insurance coverage for treatment (Agigian, 2004; Johnson, 2012; King and Meyer, 1997).

Letherby (1999) recommends using the term ‘infertility’ to refer to the medically defined physical condition and using the term ‘involuntarily childlessness’ to describe the socially constructed experience that may accompany the medical condition. While this (re)asserts the social nature of the phenomenon, it ignores the experience of the roughly half of infertile women (who are not childless when they experience infertility) at the same time that it reifies distinctions between complex and potentially overlapping categories, such as involuntarily childless, childless by choice, or childfree (Abma and Martinez, 2006; Koropeckyj-Cox et al., 2007). The use of such categories implies that most adults are either parents, childfree, or involuntarily childless. Yet the line between ‘voluntary’ and ‘involuntary’ can be murky, hiding the reality that some women who have children face barriers to having additional children and obscuring the fact that many women have faced multiple barriers to fertility. Furthermore, the use of terms like voluntary and involuntary childlessness implies that women are either trying or not trying to become pregnant. However, many US women are uncertain about their fertility intentions (Hagewen and Morgan, 2005). Thus, the ‘voluntary’/‘involuntary’ dichotomy masks a continuum of intentionality and a complex history of experiences. What is needed is a way to talk about obstacles to having children without oversimplifying a complex reality more than is necessary and without arbitrarily excluding some women from consideration.

Towards a more inclusive framework: from infertility to fertility barriers

As a way forward, we offer and develop the notion of ‘fertility barriers’ to better understand the full diversity and complexity of issues involved when childbearing does not or cannot proceed ‘normally.’ Based on prior empirical work developed with the data described below (Greil and McQuillan, 2010; Jacob et al., 2007), we outline six potential types of barriers that women face in having children. This list is not necessarily exhaustive, but it hopefully begins the conversation about fertility barriers in a way that highlights the variety of ways that women may face obstacles to having desired children.

Intent status and infertility

As we argued above, there is much to critique about the medical definition of infertility. Nonetheless, we believe that it is still useful to incorporate the medical notion of infertility into our framework. First, it does capture some women’s experiences; second, the definition is firmly entrenched in medical literature and practice. In other work, we have split infertility into two categories: infertile with intent and infertile without intent (Greil et al., 2009). The former refers to women who were explicitly trying to get pregnant while meeting the medical definition of infertility. The latter refers to women who met the medical criteria, but did not express intention to conceive. We recognise that women often have difficulty with the idea of intended/unintended pregnancies (Moos et al., 1997) and therefore have employed measures which allow women to state that they were ‘ok either way’ rather than forcing them into the dichotomous categories of ‘intended’ and ‘unintended’.

Other biomedical barriers

Not all women who face biomedical barriers to having desired children are infertile by the medical definition. Some women might be advised by physicians that a health condition could make it dangerous for them to be pregnant (e.g. anaemia). Still others may be advised that their medication interferes with or increases health risks during pregnancy or affects the ability to have a healthy child. Some women decide that their own or their partner’s depression or disability will make raising a child too hard. All of these examples refer to health-related barriers to having desired children even though they do not clearly fit the medical definition of infertility.

Sterilisation regret

Sterilisation is neither inherently liberating nor oppressive; the meaning of sterilisation depends on its context (Schoen, 2005). Women’s surgical sterilisation has become increasingly popular since the mid-1960s and is now the second most frequently used method of contraception in the US, used by 45.3 per cent of contracepting women (Mosher and Jones, 2010). Sterilisation can offer women a sense of reproductive control and empowerment if freely chosen, but sterilisation can also be the result of overt or subtle coercion (Schoen, 2005). Given the history of eugenic sterilisation in the US, especially for women of colour and poor women (Roberts, 1997), it is crucial to recognise sterilisation in the context of both stratified reproduction and contemporary fertility barriers. Sterilisation may also be the consequence of treating a health condition that might make pregnancy or childbearing difficult or impossible. Because sterilisation is relatively permanent contraception, women who use this method may later wish that they could conceive and therefore see sterilisation as preventing childbearing. Other women may undergo sterilisation surgery for a medically necessary reason despite desiring more children. In such cases, women who do not fit the medical definition of infertility may still face barriers to having desired children.

Miscarriage and stillbirth

Approximately 14 per cent of all clinically recognised pregnancies in the US result in miscarriage, or a loss during the first 20 weeks of pregnancy, and another 0.5 per cent result in stillbirth, a loss after the 20th week (Saraiya et al., 1999). Saraiya et al. (1999) also observe that physicians consider recurrent miscarriages as a type of fertility problem, but even a single pregnancy loss can prevent women from realising their fertility goals and can be experienced as highly distressing (Shreffler et al., 2011).

Situational barriers

We consider life situations that prevent women from having (more) biological children as another form of fertility barrier (Jacob et al., 2007). In contrast to the previously described categories, this explicitly addresses social as opposed to medical factors. Women with situational barriers would like to have children at some point but perceive their current situation as not right. Several of these women may eventually become permanently childless due to continually postponing childbearing; others will have fewer children than they intended. Situational barriers can include: relationship status, sexual orientation, conflicting fertility ideals between partners, interference from education/career, financial constraints, and competing social obligations, such as caring for sick or elderly family members. Some women simply express that they are not yet emotionally and psychologically ‘ready’ for children. Thus many women who are biologically ‘fertile’ nonetheless face barriers that prevent them from h...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of Tables and Figures
• Acknowledgements
• Notes on Contributors
• Introduction: Conceiving of Postmodern Reproduction
• Part I Contested ‘Choices’ and Challenges
• Part II Reproductive Bodies and Identities
• Part III The (Global) Reproductive Marketplace
• Bibliography
• Index