Infertility: Invisible Disability

This book begins with a lengthy prologue, a verbatim transcript of an interview conducted by Marcia Inhorn with Rahina, who relates her story of marital infertility and her quest for conception. The individual stories in this book are situated within larger cultural contexts that both inform and enlighten. Rahina and her husband live a middle class life in the UK having left their East African cultures of origin, but not the pressures from their cultures of origin to have (many) children. As it is for most of the couples we meet here, reproduction is socially mandated and very much entangled with concepts of womanhood, manhood and patriarchy. A wife who does not or cannot birth several children to her husband’s patriline is considered a less than fully competent adult woman who can be (and often is) set aside, divorced or made to endure a polygamous marriage if her husband marries a second, hopefully fertile wife. As Inhorn notes, infertile women endure “many forms of harm, including medical mistreatment, verbal abuse, social ostracism, divorce, economic abandonment, domestic violence, and even torture” (p. 151). Rahina’s inability to conceive is due to chlamydia, a sexually transmitted infection (STI) that leaves fallopian tubes obstructed by scar tissue. She considers herself to be “invisibly disabled.” While causally invisible, her infertility is entirely too visible to kin and clan whose “bullying” pressure on her and her husband to reproduce is a constant source of ongoing despair and desperation.

Marcia Inhorn has spent decades studying and writing about infertility and assisted reproduction, much of her work focused in North Africa and countries of the Middle East. Grounded in that long term research, this current study is based on six months of intense fieldwork in 2007 (plus several follow-ups to 2013), during which she interviewed 125 married couples from some 50 different countries, whose quest brings them into the caring hands of Dr. Pankaj and his staff at Conceive, an internationally renowned fertility clinic in the United Arab Republic (UAE), near the border of Sharjah and Dubai. Stories are the core of ethnographic research and these stories of the quest for conception are exceptionally intimate glimpses into the marital relationships these couples have created and the sacrifices they are willing make in order to have children.

The analysis is organized around five “key tropes:” reprotravel stories, global assemblages, reproscapes, reproflows, and reproductive constraints. The married couples we meet are reproductive travellers or “reprotravellers,” a descriptor preferred by all respondents adamant that what they are going through is not reproductive “tourism,” not fun in the sun, not a holiday. Respondents have accumulated huge debt, spending thousands on travel, accommodation, medical treatments, and ‘cycles’ in the hope that they can become one of the lucky “18-25 per cent” (p. 224) who “take home” a baby.

Reprotravellers are decidedly “cosmopolitan” as they travel the globe, crossing and recrossing international borders searching for facilities practicing cosmopolitan medicine—western, urban, scientific, biotechnological medicine—that offers hope to overcome infertility. Citing Collier and Ong, Inhorn discusses this cosmopolitanism as comprising a global assemblage, a multiplicity of phenomena, such as “technoscience, circuits of licit and illicit exchange, systems of administration or governance, and regimes of ethics or values” (p. 22), which coalesce, assemble, disassemble in particular places, spaces and time to become a “global assemblage.” Inhorn then expands Appadurai’s theory of “scapes” to include a medical or bioscape “of moving biological substances … and body parts” in those global assemblages that, in this instance, become part of a reproscape “combining globalization and global flows” (p. 20) of people, technology, bodies. This swirl of movements, bodies, technologies, commercialism, and border crossings fueled by despair and hope conjures up quite a surreal images. Mobile biological substances and bodies constitute reproflows, that is, “flows of reproductive actors, reproductive technologies, and reproductive substances,” including of course, those reproductive bodies “required for the processes of assisted conception” (p. 24).

But reproflows are not without reproductive constraints, which can be “structural, sociocultural, ideological, and practical obstacles and apprehensions” (p. 25) that impede the quest for conception. Inhorn groups these reproductive constraints include resource categories include such things as finances and travellers’ lost wages, the high cost of treatments, which may or may not “take,” availability of specific treatments, access to clinics, waiting lists. Many countries have legal and religious prohibitions on certain procedures and on categories of persons eligible for procedures. Hindu, Muslim and Christian religions have a variety of prohibitions, not least on surrogacy, adoption, donor gametes, and pregnancy reductions; some countries have age constraints such that women (but not men) “age out” of ART eligibility. The “medical horror stories” and too frequent iatrogenic harm (p. 255) emphasise the importance of choosing a clinic that provides safe, quality care and good success rates. Sociocultural issues are always paramount as clinic staff and clinic clientele come from many cultural and linguistic backgrounds, a cosmopolitan fact than can lead to social barriers and miscommunication on many levels. Issues of privacy, even secrecy, are critical to reprotravelers, whose immediate families and extended kin have no idea they are undergoing these treatments, and because some couples travel for procedures that contravene legal and religious constraints of their home countries.

This culturally complex and detailed ethnography is only possible because of Inhorn’s long term study of infertility in the Middle East and contiguous countries. Her awareness of the cultural and religious complexities enveloping her respondents meant she was able to approach this extremely intimate topic with compassion and sensitivity to elicit a rich story of married couples’ desires and needs for a biologically related child. Marcia Inhorn has gifted us with a very challenging book that is impossible to condense to a few words here. This ethnography challenges what we thought we knew about human fertility, the causes and consequences of marital infertility, and how women and men each come to grips with their “invisible disability” within their cultural construction of gendered reproduction. The global number of infertile persons and of women experiencing secondary infertility (inability to conceive a second child) is probably incalculable. But there are “many millions” of infertile persons, with “estimates ranging widely” from about 49-186 million; with infertile males contributing to more than half of “all cases of childlessness” (p. 107). She has also challenged the way in which much gendered research is undertaken in separate spheres, particularly when researching topics of sex, sexuality and marital relations, with women interviewing women and men interviewing men. Inhorn rejects that practice, which often results in one-sided analyses, to engage in “marital ethnography,” that is, interviewing couples together.

Finally, when I think about what I have read, it occurred to me that feminism, writ large, has failed infertile women. Feminism is about choices. Many cosmopolitan women choose childlessness; many women in noncosmopolitan countries have no such choices and have more children than they want. The majority of women in the global south have no options for careers or alternate lifestyles; without children they have nothing and they are nobody, particularly in patriarchal, patrilineal societies where they are not members of a lineage. Feminist analyses of assisted reproduction technologies (ARTs) have long decried the “highly gendered” bioscape, whereby reproductive technologies are “enacted on women’s and men’s bodies in highly differentiated ways” (p. 24). And there are the structural inequalities of who can and cannot access ARTs and the potential for exploitation of poor women as surrogates or gamete donors. While fighting for women’s rights to make reproductive choices, for contraception and abortion, and to not have children, feminists have not engaged equally strongly with a woman’s right to have children and to access ARTs in order to overcome their own or their husband’s infertility in order to have biological children. There is often an unacknowledged whiff of eugenics by default when talking about infertility in so-called less developed countries that are deemed overpopulated by cosmopolitan countries. Hence, there is little sympathy for or resources allocated to reproductive assistance for infertile women who bear the social and cultural brunt of infertility and whose lives are made a living hell because they are childless. Inhorn closes with a plea for “reproductive justice.” There needs to be more work and thought put into the prevention of infertility by treating sexually transmitted infections that “play havoc with male and female reproductive organs” (p. 302). There needs to be more “support of the infertile” starting with destigmatizing fertility and offering more support to infertile women and men, especially in “societies where parenthood is socially mandated” and not a matter of choice (p. 303). This could entail increasing education and career opportunities and providing choice; albeit changing cultural concepts of appropriate gender roles is easier said than done. And finally, infertility treatments need to be less costly. No surprise that Inhorn’s activist passion is vested in the movement for low-cost IVF (LCIVF) to “make safe, affordable, effective IVF accessible to everyone who needs it, but primarily to people in the global South” (p. 303).

This book truly does take the reader into the “womb” of a cosmopolitan IVF clinic and the reprotravelers who are its clientele. It is a must read for students of anthropology, medicine, women’s history, whether or not they are involved in research on human reproduction. This is a must read for NGOs, ministries of health, medical practitioners, and others who are deeply committed, particularly in noncosmopolitan states, to working for the improvement of women’s maternal and reproductive health. I highly recommend this enlightening, ethnographically rich and deeply compassionate book.

Naomi M. McPherson is a cultural anthropologist and Associate Professor Emeritus at the University of British Columbia. She has returned six times between 1980 and 2009 to Bariai, West New Britain, Papua New Guinea where, among other topics, she has studied concepts of gender and gender relations, gendered violence, ethno-obstetrics, and women’s maternal and reproductive health. Selected publications include: Modern Obstetrics in a Rural Setting: Women and Reproduction in Northwest New Britain (1994); Women, Childbirth and Change in West New Britain, Papua New Guinea, P. Liamputtong, ed. (2007); Sik AIDS: Deconstructing the Awareness Campaign in Rural West New Britain, PNG. R. Eves and L. Butt, eds. (2008); Anthropology of Mothering. M. Walks and N. McPherson, eds. (2011); Black and Blue: Shades of Gendered Violence in West New Britain, PNG. C. Stewart, ed. (2012); Missing the Mark? Women and the Millennium Development Goals in Africa and Oceania. Naomi McPherson, ed. Demeter Press, February 2016.

© 2016 Naomi M. McPherson
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