Assisting Reproduction, Testing Genes : Global Encounters with the New Biotechnologies [1 ed.] 9781845459413, 9781845456252

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ASSISTING REPRODUCTION, TESTING GENES

Assisting Reproduction, Testing Genes : Global Encounters with the New Biotechnologies, edited by Daphna Birenbaum-Carmeli,

Fertility, Reproduction and Sexuality GENERAL EDITORS: David Parkin, Fellow of All Souls College, University of Oxford Soraya Tremayne, Co-ordinating Director of the Fertility and Reproduction Studies Group and Research Associate at the Institute of Social and Cultural Anthropology, University of Oxford, and a Vice-President of the Royal Anthropological Institute Marcia Inhorn, William K. Lanman Jr. Professor of Anthropology and International Affairs, and Chair of the Council on Middle East Studies, Yale University Volume 1 Managing Reproductive Life: CrossCultural Themes in Fertility & Sexuality Edited by Soraya Tremayne

Volume 10 Where There is No Midwife: Birth & Loss in Rural India Sarah Pinto

Volume 2 Modern Babylon? Prostituting Children in Thailand Heather Montgomery

Volume 11 Reproductive Disruptions: Gender, Technology, & Biopolitics in the New Millennium Edited by Marcia C. Inhorn

Volume 3 Reproductive Agency, Medicine & the State: Cultural Transformations in Childbearing Edited by Maya Unnithan-Kumar Volume 4 A New Look at Thai AIDS: Perspectives from the Margin Graham Fordham

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Volume 5 Breast Feeding & Sexuality: Behaviour, Beliefs & Taboos among the Gogo Mothers in Tanzania Mara Mabilia Volume 6 Ageing without Children: European & Asian Perspectives on Elderly Access to Support Networks Philip Kreager & Elisabeth Schröder-Butterfill Volume 7 Nameless Relations: Anonymity, Melanesia and Reproductive Gift Exchange between British Ova Donors and Recipients Monica Konrad Volume 8 Population, Reproduction & Fertility in Melanesia Edited by Stanley J. Ulijaszek Volume 9 Conceiving Kinship: Assisted Conception, Procreation & Family in South Europe Monica M. E. Bonaccorso

Volume 12 Reconceiving the Second Sex: Men, Masculinity, and Reproduction Edited by Marcia C. Inhorn, Tine TjørnhøjThomsen, Helene Goldberg & Maruska la Cour Mosegaard Volume 13 Transgressive Sex: Subversion & Control in Erotic Encounters Edited by Hastings Donnan & Fiona Magowan Volume 14 European Kinship in the Age of Biotechnology Edited by Jeanette Edwards & Carles Salazar Volume 15 Kinship and Beyond: The Genealogical Model Reconsidered Edited by Sandra Bamford & James Leach Volume 16 Islam and New Kinship: Reproductive Technology & the Shariah in Lebanon Morgan Clarke Volume 17 Midwifery & Concepts of Time Edited by Chris McCourt Volume 18 Assisting Reproduction, Testing Genes: Global Encounters with the New Biotechnologies Edited by Daphna Birenbaum-Carmeli & Marcia C. Inhorn

Assisting Reproduction, Testing Genes : Global Encounters with the New Biotechnologies, edited by Daphna Birenbaum-Carmeli,

ASSISTING REPRODUCTION, TESTING GENES GLOBAL ENCOUNTERS WITH NEW BIOTECHNOLOGIES

Edited by Daphna Birenbaum-Carmeli and

Copyright © 2009. Berghahn Books, Incorporated. All rights reserved.

Marcia C. Inhorn

Berghahn Books New York • Oxford

Assisting Reproduction, Testing Genes : Global Encounters with the New Biotechnologies, edited by Daphna Birenbaum-Carmeli,

First published in 2009 by

Berghahn Books www.BerghahnBooks.com © 2009 Daphna Birenbaum-Carmeli and Marcia C. Inhorn All rights reserved. Except for the quotation of short passages for the purposes of criticism and review, no part of this book may be reproduced in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system now known or to be invented, without written permission of the publisher.

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Library of Congress Cataloging-in-Publication Data Assisting reproduction, testing genes : global encounters with new biotechnologies / edited by Daphna Birenbaum-Carmeli and Marcia C. Inhorn p. cm. — (Fertility, reproduction and sexuality ; v.18) Includes bibliographical references and index. ISBN 978-1-84545-625-2 (alk. paper) 1. Human reproductive technology. 2. Biotechnology. 3. Human genetics. 4. Fertilization in vitro, Human. 5. Human embro— Transplantation. 6. Surrogate motherhood. I. Birenbaum-Carmeli, Daphna. II. Inhorn, Marcia Claire, 1957– RG133.5.A788 2009 618.1'7806—dc22 20090 13507 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library. Printed in the United States on acid-free paper ISBN 978-1-84545-625-2 (hardback)

Assisting Reproduction, Testing Genes : Global Encounters with the New Biotechnologies, edited by Daphna Birenbaum-Carmeli,

CONTENTS

Introduction: Assisting Reproduction, Testing Genes: Global Encounters with New Biotechnologies Daphna Birenbaum-Carmeli Marcia C. Inhorn

1

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PART I Families and Beyond: Reproductive Technologies and New Social Orders 1. East in West? Turkish Migrants and the Conception of the Ethnic Other in Germany Lisa K. Vanderlinden

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2. Cultural Meanings of Assisted Reproductive Technologies: Women’s Voices from Bulgaria Yulia Panayotova and Irina L. G. Todorova

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3. Middle Eastern Masculinities in the Age of Assisted Reproductive Technologies Marcia C. Inhorn

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PART II Couples and Others: Assisting Reproduction with Third Parties 4. The Traffic Between Women: Female Alliance and Familial Egg Donation in Ecuador Elizabeth F. S. Roberts 5. Law, Ethics, and Donor Technologies in Shia Iran Soraya Tremayne

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Contents

6. Inappropriate Relations: The Ban on Surrogacy with In Vitro Fertilization and the Limits of State Renovation in Contemporary Vietnam Melissa J. Pashigian 7. Contested Surrogacy and the Gender Order: An Israeli Case Study Daphna Birenbaum-Carmeli

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PART III Testing Genes and Using Cells: Encounters with Advanced Genetic Technologies 8. The Genesis of Embryos and Ethics In Vitro: Practicing Preimplantation Genetic Diagnosis in Argentina Kelly Raspberry

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9. Assisted Life: The Neoliberal Moral Economy of Embryonic Stem Cells in India Aditya Bharadwaj

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258

Contributors

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Index

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10. Doubt is the Mother of All Inventions: DNA and Paternity in a Brazilian Setting Claudia Fonseca

Assisting Reproduction, Testing Genes : Global Encounters with the New Biotechnologies, edited by Daphna Birenbaum-Carmeli,

Introduction

ASSISTING REPRODUCTION, TESTING GENES GLOBAL ENCOUNTERS

WITH

NEW BIOTECHNOLOGIES

Daphna Birenbaum-Carmeli and Marcia C. Inhorn

Introducing Technologies

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S

ince the 1978 birth of Louise Brown, the world’s first “test-tube” baby, assisted reproductive technologies (ARTs) have proliferated in number and in kind. Beginning with the development of in vitro fertilization (IVF)—a technique in which sperm and eggs are retrieved, fertilized in a petri dish, and transferred as fertilized embryos to a woman’s womb—the past thirty years have seen the rapid and largely unregulated development of many ARTs. Some of these technologies are simple variants of IVF, whereas others have bridged the fields of reproductive science and human genomics. In addition to IVF, the host of reproductive biotechnologies now includes: • intracytoplasmic sperm injection (ICSI) to overcome male infertility, sometimes with the accompanying techniques of electroejaculation for spinal-cord-injured males, and testicular biopsy and aspiration for men with no sperm in the ejaculate; • ooplasmic transfer from a younger to an older woman’s oocytes, to improve oocyte quality;

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• cryopreservation, or long-term freezing of sperm, oocytes, and embryos; • third-party donation (and sale) of sperm, oocytes, and embryos to individuals and couples; • the use of surrogates to gestate the fetuses of heterosexual and gay individuals and couples, and to gestate the fetuses of those individuals not wishing to be pregnant (so-called “vanity” surrogacy); • “gay” insemination and IVF; • microsorting of sperm for the purposes of sex selection; • preimplantation genetic diagnosis, to screen IVF embryos for genetic defects or to select embryos of a certain sex and, potentially, certain “designer” traits; • IVF-assisted induction of pregnancy in postmenopausal women; • multifetal pregnancy reduction (so-called selective abortion) in high-order IVF pregnancies; • removal and freezing of human ovaries for later use in cancer patients and postmenopausal women; • embryo research and manipulation for the production of human stem cells;

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• DNA-based paternity testing of children produced through either “natural” or “assisted” conception; and • cloning genetic material for the production of animals (e.g., Dolly the sheep) and, potentially, humans. As a group, these current developments implicate not only new groups of potential patients, but also new groups of assistors, especially those who see gamete and embryo donation or surrogacy as a form of work (Thompson 2005). In this fin de siècle moment, ARTs have diversified, globalized, and denaturalized the taken-for-granted divisions between, inter alia, sex–procreation, nature–culture, gift– commodity, informal–formal labor, biology–sociality, heterosexuality– homosexuality, local–global, secular–sacred, and human–nonhuman. Thus, there is much to contemplate in thinking through what is “new” about the so-called new reproductive technologies. In this volume, we explore the practice of such technologies in settings beyond Euro-America. Our interest is in the cultural signifi-

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Global Encounters with New Biotechnologies

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cance and political impact of the technologies as they travel along multiple pathways and trajectories. Examining such global encounters with new biotechnologies tests taken-for-granted assumptions about biotechnological Eurocentrism, namely, as reproductive and genetic technologies are widely embraced in diverse non-Western settings, these technologies undergo sometimes profound forms of invention and innovation, occasionally leading to surprising and unprecedented legal outcomes and sociocultural transformations. In this volume, we stress the importance of examining local encounters with new biotechnologies, given that these technologies are not “immune” to culture as they make their way around the globe (Inhorn 2003a). Local considerations, such as support or deterrence on the part of local religious authorities, the provision of public funding for ARTs, inclusive versus restrictive admission criteria in IVF clinics, and favorable or distrustful media coverage, all impact the gendered and kinship relations within which local consumers seek out and deploy these reproductive and genetic technologies. Examination of the culturally and historically salient aspects of locality bespeaks a process of technological indigenization—namely, those who actually use new reproductive and genetic technologies imbue their practice with particular local sensibilities. As a result, the assumption on the part of global producer nations (e.g., the United States, the United Kingdom, Australia) that these biotechnologies are value free, inherently beneficial, and thus easily transferred elsewhere is subject to challenge once local formulations, perceptions, and actual consumption are taken into consideration. As we will show in this volume, new reproductive and genetic biotechnologies may translate into a collective symbol of the technological knowhow shared by the advanced, wealthy nations of the world, highlighting new notions of local modernity. On the other hand, the local encounter with new biotechnologies is fraught with tensions, constraints, and inequalities, suggesting that such technological encounters both reflect and contribute to the construction of new global power relations.

A Brief History of Assisted Reproductive Technologies and Preimplantation Genetic Diagnosis Before examining this globalization process, it is important to trace, at least briefly, the development of ARTs in the West. In the 1950s, scientists and commercial companies began devoting substantial

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Daphna Birenbaum-Carmeli and Marcia C. Inhorn

resources to the development of increasingly potent treatments, mostly ovulation-inducing hormonal medications, to facilitate conception. These drugs, which were all made for women’s use, were in line with the view that reproduction was in the female domain. It took much longer for male infertility to be recognized and researched, and treatment options remain today fewer and less effective (Birenbaum-Carmeli, Carmeli, and Capser 1995; Inhorn 2007). Following the 1978 conception of the first test-tube baby, procreative medicine was “upscaled” to encompass treatments of unprecedented technological sophistication, requiring a greater investment of women’s time, money, and bodily invasiveness. In the two subsequent decades, IVF would become increasingly popular, with clinics mushrooming throughout the industrialized world. Although originally offered to women with blocked fallopian tubes, the treatment gradually became standard care for so-called unexplained and male infertility. However, with the 1992 introduction of ICSI—in which “weak” sperm are “micromanipulated” under a high-powered microscope, thereby forcing them to fertilize ova—male infertility came under the domain of ARTs, creating a powerful technological solution to an otherwise intractable male reproductive problem (Devroey et al. 1998; Kamischke and Neischlag 1998). By the early 1990s, ARTs were available in the West to assist in overcoming the most common forms of both female and male infertility. At the same time, genetic tests were being developed to detect hereditary diseases present in the ART-generated human embryo. Preimplantation genetic diagnosis (PGD) can detect genetic abnormalities in IVF- or ICSI-created embryos. Used in concert with these ARTs, PGD allows clinicians to select mutation-free embryos to implant into the mother’s uterus. PGD may be used as a substitute for other prenatal genetic screening procedures—including chorionic villus sampling, performed in the first trimester of pregnancy, or amniocentesis, performed in the second trimester—thus saving prospective parents the dilemma of pregnancy termination (Franklin and Roberts 2006). Developed as a screening test for couples with family histories of life-threatening genetic illnesses, such as cystic fibrosis or Tay-Sachs disease, the uses of PGD have significantly broadened in the past decade, including sex selection—that is, selecting only male or female embryos for subsequent embryo transfer, either to guarantee that offspring will be male or female or as a means to ensure “family balance” for couples with existing children (Van Balen and Inhorn 2003). In some IVF clinics in the West, PGD is now used as a routine screening measure for men with severe

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male factor infertility (of a potential hereditary origin) and for women with advanced maternal age and concerns about age-related embryo abnormalities. Indeed, PGD has initiated a new era in genetic testing. Whereas the purpose of earlier forms of genetic testing was to diagnose genetic disease in the tested person or human fetus, PGD allows for the identification of future health risks in the eight-celled human embryo. Those embryos deemed to be carriers of genetic disease generally are not transferred nor are embryos of the “wrong” sex when PGD is used for sex selection. Thus, the practice of PGD poses various ethical questions about foundational notions of kinship and gender, the rights of the genetically disabled, and the sanctity of life in its very early stages (van Balen and Inhorn 2003). Furthermore, the costs of such testing—along with the ARTs themselves—vary widely but usually range in the thousands of dollars. These costs are especially significant since ARTs and PGD are generally not covered by public health care systems. Using PGD to identify genetic disorders is hailed by some (e.g., Peyvandi 2005; Peyvandi et al. 2006) and questioned by others, on religious and cultural grounds (Al-Aqeel 2005). The so-called disposition of embryos (including disposal) opens up debates about abortion and the beginning of life, which take different shapes in different cultural contexts (Morgan and Michaels 1999; Nachtigall et al. 2005). Furthermore, the gender concerns and severe criticism once voiced by feminists in regard to IVF when it was first introduced into the industrialized world (e.g., Corea 1985; Raymond 1993; Spallone 1988) can now be applied to PGD as a sex-selective technology. Indeed, alongside the recognition of the authentic choice that such technologies may offer to some women (and men), feminists’ concerns regarding the contribution of ARTs and PGD to gender, class, racial, and global inequalities are growing (Deech 2003; Spar 2006).

Global Inequalities One of the major concerns about ARTs and genetic technologies is that their use will not be evenly distributed within societies and across the globe. The notion of “stratified reproduction” (Colen 1995; Ginsburg and Rapp 1995), or the ways in which reproduction is privileged among elite members of society but devalued and even despised among subalterns, is extremely relevant to the subject of

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ARTs. Indeed, numerous “arenas of constraint,” or various structural, ideological, and practical obstacles and apprehensions (Inhorn 2003a), may serve to limit access to these technologies for those at highest risk of infertility or genetic disorders. With regard to infertility, this condition affects more than 15 percent of all reproductive-age couples worldwide (Bentley and MascieTaylor 2000; Vayena, Rowe, and Griffin 2002). However, its scope and gravity is much more severe in the non-Western world, a fact now widely recognized (Inhorn 2003b). Owing largely to the problem of untreated reproductive tract infections—those that are sexually transmitted and those that are the result of unsafe abortions, postpartum infections, and genital tuberculosis (Chavhan et al. 2004; Gonzales et al. 2004; Hoffman et al. 2005; Leonard 2002)—infertility affects millions of women and men in the non-Western world. The exact magnitude of the problem is difficult to measure. International agencies, for example, count only married women, excluding those women who have divorced or been divorced on grounds of infertility (Leonard 2002). In central and southern Africa, the presence of an “infertility belt” has been repeatedly affirmed in cross-national studies (Van Balen and Inhorn 2002), with places like Cameroon showing a national infertility average of 43.9 percent among reproductive-age couples (Feldman-Savelsberg 2002). Effective infertility treatments and ARTs unfortunately are generally inaccessible in these poor and mostly rural nations, leading to a grim scenario of untreated and intractable infertility in large portions of sub-Saharan Africa as well as other resource-poor nations (Hassa et al. 2005; Sundby 2002; Van Balen and Gerrits 2001). The lack of effective treatment options, including the nonexistence of IVF and other ARTs in some developing countries, is often legitimized in terms of population control, scarcity of health care resources, and the heavy burden of life-threatening diseases such as HIV/AIDS (Kumar 2001; Okonofua 1996). An additional concern touches upon the encounter between poorly trained health care practitioners and an uninformed clientele (Macklin 1995; Sundby 2002). Although these concerns raise major questions about the prioritization of infertility as a global reproductive health problem (Inhorn 2003b), the silence surrounding infertility in the non-Western world may also reflect a tacit eugenic view that the infertile poor are unworthy of treatment and that overcoming their infertility problems contradicts Western interests in global population control (Greenhalgh 1995; Inhorn 2003b; Lane 1994). However, infertility in non-Western countries often leads to profound human suffering, in particular on the

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part of women. Strong pronatalist norms frequently translate into blaming women for reproductive failure, sometimes to the point of divorce and social ostracism (Inhorn 1994, 1996). Lifelong childlessness also implies severe difficulties in achieving old-age security in societies without strong social safety nets (Inhorn and van Balen 2002). Even in the Western world, access to ARTs reflects pronounced class- and race-based inequalities (Becker et al. 2006; Ceballo 1999; Inhorn and Fakih 2006; Quiroga 2007), as the costs often fall on consumers. With the exception of Israel, where treatment for IVF is almost completely state funded (Birenbaum-Carmeli 2003; Kahn 2000), all health care systems—both public and private—set restrictive eligibility criteria that limit consumer access. The financial burden is even heavier in non-Western countries, where state-subsidized ARTs are rare, and infertile couples are most likely to be quite poor. Owing to this economic reality, ARTs in the non-Western world tend to be restricted to the middle and upper classes, and even they may face numerous arenas of constraint in accessing successful ARTs (Inhorn 2003a). In addition, ARTs introduce even more problematic global and local divisions of labor along racial and national lines, threatening to augment domestic and transnational divisions of labor and perpetuate various forms of disparity and social injustice (Deech 2003). Multiple sets of inequalities surface in the practice of ARTs, reflecting intersecting oppressions based on gender, race, class, caste, religion, age, sexual orientation, and disability (Quiroga 2007). For example, poor minority women in some countries are being recruited as gestational surrogates, similar in some ways to their domestic servitude as low-paid maids and nannies (Ragone 2000). Meanwhile, racially “preferential” white women from the economically dislocated postSoviet societies are being trafficked as egg donors for affluent Western European couples, a form of reproductive transnationalism within the European Union that is being compared to sex tourism (Storrow 2006). Such global disparities between rich and poor countries are clearly reflected in the transnational trade in human gametes and the donors who produce them. These disparities are also reflected in the global trafficking of stem cells, the byproduct of excess embryos produced in IVF laboratories around the world. As will be shown in this volume, the global “outsourcing” of stem cell production has resulted from current American abortion politics, politics not necessarily shared in poor countries such as India, where the vast majority of the population will never benefit from any of these technologies.

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Yet, this volume provides proof that ARTs are reaching poorer subpopulations in some non-Western nations. ARTs are being offered to individuals and couples in countries ranging from Ecuador to Vietnam, opening opportunities to local residents of multiple class and ethnic backgrounds. Such globalization of ART services through a largely private, fee-for-service industry has manifold social impacts on the local level. Indeed, the globalization of ARTs provides an excellent example of “the local in the global” as local populations in the non-Western world come to accept, transform, and in some cases resist the uses of these reproductive and genetic technologies according to local social and religious norms (Inhorn 2003a).

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Local Moralities The aforementioned realities encourage us to reflect upon the moral economy of ARTs and genetic technologies, as these biotechnologies invoke numerous ethical and legal debates, which are often deeply embedded within particular “local moral worlds” of religion and culture (Kleinman 1997). Even though ARTs may be scientifically deployed and somatically experienced in similar ways across cultural settings, they tend to produce differing moral responses, which may include enthusiastic accommodation, cultural reconfiguration and hybridization, or resistance and rejection based on local sentiments of moral repugnance. Depending upon the cultural setting, these technologies have ramifications for personhood, kinship, and family life that can be viewed as deeply unsettling, profoundly liberating, or, more commonly, some patchwork of both. In the Western countries, religion–science rifts are normally addressed in plurivocal public debates, leaving a moral vacuum to be filled by ethicists and lawyers. In the United Kingdom, for example, a government-commissioned ethics committee has been charged with tackling the thorny ethical issues surrounding ARTs in ways that have been very influential throughout Europe (Franklin 1997). In the United States, on the other hand, the landscape of ARTs is often described as the “Wild West,” with little if any regulation and a profession that is largely free-market regulated and profit driven (Spar 2006). In such a setting, cases of negligence and abuse are handled by a legal system and courts, which are forced to chart new legal terrain. In other societies around the globe, however, religion may impact the practices of ARTs more directly. For example, in the Muslim

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world, gamete donation and surrogacy have been strictly prohibited, although minority Shia fatwas (religious decrees) have opened the door to both in Shia-dominant Iran and Lebanon (Abbasi-Shavazi et al. 2008; Clarke 2008; Inhorn 2006a, 2006b; Tremayne 2006). Furthermore, although the Vatican continues to denounce all forms of ARTs, IVF and its related technologies are widely practiced in Catholic countries around the world (Bonaccorso 2008), including most of the nations of Latin America (with the exception of Costa Rica, where IVF was banned by the nation’s supreme court). The ways religions have attempted to impose regulation through religious bans on IVF, gamete donation, and surrogacy in multiple societies around the globe provides one of the most prominent examples of local moralities. Yet, in the world of ARTs, other examples include: how PGD is being promoted as a sex-selective technology in societies practicing son preference–daughter discrimination; contested parenthood and custody cases that follow IVF laboratory “mix ups” as well as post-hoc DNA paternity-testing cases; legal battles over the disposition of frozen embryos; and whether the state should be expected to subsidize cycles of IVF as part of national health care plans. The moral economy of ARTs can also be found in the complex regulatory environment surrounding a multibillion-dollar IVF industry that prefers to regulate itself through data collection and self-policing rather than by international policy or law (Spar 2006). Numerous thorny ethical and legal questions are raised by ARTs and genetic technologies: Who has the right to reproduce through “assisted” means? How is fair and equal access to these technologies to be promoted and protected? How can assistors, namely, donors and surrogates, be protected from family-based, class-based, racebased, or other forms of discrimination or coercion? When does life begin—is an embryo a human life? Are all embryos created equally, or can/should some be culled before implantation for research or disposal? Who should decide which technologies are ethically and socially acceptable—physicians, theologians, lawyers, patients, local communities, national governments, or international regulatory bodies? Who should pay for ARTs? Are ARTs ultimately helpful or harmful to women? To men? How and by whom should the IVF industry be regulated? What impact do specific legal decisions have on the technologies and their use? What role should be played by patient support groups or religious sects in lobbying for or against these technologies? Should the Internet be encouraged as a form of patient education or regulated because of its potential to encourage human commodification and exploitation? What data should be

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collected about these technologies and by whom? What is the role of these technologies in changing national and global economies? How do these technologies impact relations between science and society—for example, are they perpetuating the so-called biomedicalization of human bodies? To what extent are these technologies changing our definitions of the family? Finally, should the use of these technologies by gay individuals and couples be encouraged as part of the national and international debate on the legitimacy of gay-family forms, including marriage?

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Technology and Society Such disputes and ethical conundrums, most of which are far from being resolved, vividly illustrate the cultural embeddedness of biomedical technologies. Our broad theoretical assumption in this volume is that technologies are sociotechnical products, which are shaped by human and nonhuman factors, including the technical features of the technologies as well as the economic, political, cultural, and moral environments in which they unfold (Wajcman 2002). This assumption implies that technologies are intimately linked with power relations and only eventually accepted by professionals and lay audiences when perceived as being reasonable in the context of existing social relations and knowledge systems (Webster 2002). Within this general perspective, social-technological relationships become both pivotal and mutually constitutive, with each being a source and consequence of the other (Ong and Collier 2005). This general perspective links up with two related theoretical frameworks: actor-network theory within sociology and anthropological holism. Actor-network theory suggests that advanced biomedical technologies must be examined within the midst of the practicing professionals applying them, the consumers using them, the policy makers and religious authorities legislating them, and the media commentators writing about them for popular audiences. By situating technologies within these human networks, as well as the surrounding culture and social order, we can begin to unpack the multifaceted repercussions of advanced biomedical technologies within a given society. In order to do this, case studies of biomedical technologies must be geographically anchored and ethnographically situated but must also simultaneously illustrate broader cultural and political processes.

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Anthropological holism and the ethnographic method allow for abstract cultural and political processes to be instantiated through deeply local, socially relevant case studies. Anthropologists are trained to identify and describe ethnographically local social phenomena, such as the uses of ARTs in particular community settings. At the same time, anthropologists embed these often-rich local descriptions within larger macroeconomic and political contexts, thereby demonstrating the relationship between local forms of agency and more comprehensive macrolevel structures. From within these theoretical vantage points, we set out in this volume to explore the practice and significance of ARTs and genetic technologies in settings beyond Euro-America. Our interest is in the diverse ties between various local biomedical and technological discourses and practices, and the workings of structure and power at a more global level of analysis. We specifically ask in this volume how local–global intersections are being produced, reproduced, modified, and resisted through the application of these biotechnologies to the bodies of individual women and men outside the usual Western sites of investigation. By interrogating the reception and practice of these technologies in diverse non-Western settings, we hope to foster understanding of both the technologies and the settings themselves, highlighting cross-cultural similarities as well as the differences that arise when technology travels across global landscapes. Through the purposeful cross-cultural framework of this volume, we ultimately address the challenges globalization presents to local orders and power structures and to communities that become connected, wittingly or unwittingly, across space and through time (Zsuzsa and Riain 2002). At a more foundational level, the nature–culture intersection signified by ARTs has come to occupy a particularly important role in many non-Western countries (Birenbaum-Carmeli and Carmeli 2002a, 2002b; Franklin and Lock 2003; Thompson 2001; Strathern 1992). Owing to the centrality of kinship in some of these contexts, ARTs may accelerate the erosion of traditional nature–culture dichotomies in the realm of reproduction, effecting far-reaching consequences, such as the blurring of boundaries between nuclear and extended families or the breaching of couples’ intimacy. For example, DNA paternity tests in Brazil (chapter 10) and ova donation in Ecuador (chapter 4) call kinship into question by contesting the place of biology in its construction. Whereas some of these changes may contribute to greater gender equality, others—such as the search for

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“young” eggs—may undermine, even disrupt, women’s sense of security, their marriages, and kinship systems. Analyses of ARTs that unveil the social and the political in the construction of the “natural” thus describe the potentially shattering impact of these technologies in more traditional contexts. Whatever the diverse outcomes, these technologies tend to bring much more than simple “progress” or “medical miracles” to local cultural contexts. On the whole, ARTs reveal late-modern responses to biotechnology-prompted destabilizations. Redefining foundational notions of nature and culture, family and kinship, time and space, and practitioner and consumer relations, these technologies provide a convenient lens through which to examine twenty-first-century social relations during a very fluid, complex epoch. In this respect, ARTs are a key symbol of our times, representing the growing prominence of biotechnologies as central to the configuration of individual, familial, and collective identities.

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Gendered Subjectivities One of the most prominent identities affected by these technologies is gender. Not only are gender identities deeply implicated in the process of ART utilization, but also as socially and culturally shaped technologies, ARTs are deeply gendered. These technologies are usually applied in a fairly standardized fashion across biomedical contexts—with female and male bodies scrutinized and disciplined through now-regularized biomedical protocols. Yet, ARTs are applied more invasively to women’s bodies, thus facilitating the traditional view that women bear the responsibility for reproductive problems (Ettore 2002; Inhorn 2003a; Van Balen 2002). As a consequence, ART practices and discourses often render men invisible even though more than half of all infertility cases around the world involve a male factor (Inhorn, this volume). In some contexts and circumstances, ARTs may entirely marginalize men in the reproductive process, configuring an exclusively female fertility domain wherein problems are not only detected but also resolved within a female network, supported by female relationships and resources (Goldberg forthcoming). As the technologies themselves are highly gendered—being carried out on men’s and women’s bodies in highly specific ways—ARTs inevitably affect gendered identities and have the potential to destabilize a given society’s gender order. It is only through a detailed look at ARTs that the nuances of technology and

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gender will be revealed and that the concrete production, reproduction, and transformation of gender relations will unfold. Indeed, the chapters in this volume show that when ARTs enter various patriarchal societies, gender stereotypes are reworked in complex ways. For example, Marcia Inhorn’s study of infertile men in Egypt and Lebanon (chapter 3) brings to life the destabilizing effect of ARTs on prevailing gender perceptions and power relations. Although treatment is generally concentrated on women’s bodies, men diagnosed as infertile are deeply affected not only by their medical condition, but also by the love and loyalty publicly displayed by their committed wives. This picture of companionate marriage among infertile couples, which does not correspond with Western views of gender in the Arab-Muslim world, challenges stereotypes and suggests that the massive growth of the IVF industry in the Middle East is being fueled by infertile couples’ love and commitment. Ethnographic inquiry in the Middle East also reveals the destigmatization of male infertility as the condition becomes effectively medicalized through men’s access to ICSI. Whereas the fecundity of older men can be facilitated through ICSI, women’s fertility is age sensitive, often requiring a donor egg at later stages of the reproductive life cycle. This asymmetry, when coinciding with the license to polygamy, which is practiced in many countries beyond the Euro-American setting, leads to a gendered privileging of men, including infertile men who can marry a younger woman in order to try ICSI. Thus, ART-induced time may become a powerful gendered problematic in some non-Western societies, giving new powers to men, even those otherwise emasculated by their infertility. In short, ARTs powerfully impact foundational notions of time, further problematizing the “time sensitivity” of women’s fertility as compared to men’s (Friese, Becker, and Nachtigall 2006, 2008). This brings us to the experiential world of those who “consume” ARTs. In general, ART users are infertile women and men who have experienced years, even decades, of painful childlessness. The chapters in this volume will reflect on the subjective experiences of infertility and the “emotional rollercoaster” of often-repeated but unsuccessful IVF trials. How individuals “embody progress” (Franklin 1997) in the pursuit of ARTs has been well described by numerous anthropologists and sociologists working in diverse settings around the world. However, this volume examines some of the newer dimensions of the subjective experience of ARTs, such as the panic associated with “advanced maternal age,” the stigma of azoospermia

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in infertile men who, for reasons of masculinity and religion, are unable to accept the use of donor sperm, and the altruism of infertile couples willing to donate excess embryos to embryonic stem cell (ESC) research. Subjectivities are inflected by culture, gender, education, and nationality, as well as the subtleties of physician–patient interaction, access to social support (including local support groups), and the “discourses of hope” (Becker 2000) perpetuated within clinics and the mainstream media. Many of the elements of what might best be termed the “ART encounter” will be addressed in the ethnographically oriented chapters in this volume, with serious attention paid to the ways local culture leads to a variety of gendered subjectivities and responses.

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The Volume Against this global backdrop, the chapters in this volume explore the particular processes that converge in local understandings of ARTs and genetic technologies. The volume begins with the foundational technologies of IVF and ICSI as practiced in a variety of “Eastern” settings. The volume then moves on to the generational, gender, and class relations implicated in ARTs with third-party donors, and concludes with advanced genetic technologies and the stem cell “encounter” in the global South. In this respect, the volume unites women and men, rich and poor, young and old, science and culture, the personal and the collective, the North and the South, and the local and the global, thus enabling readers to glimpse the rapidly evolving social and political contexts within which these technologies are becoming embedded. The volume is divided into three sections. Part I Families and Futures: Investing in IVF and ICSI The first section examines the dramatic spread of ARTs around the globe and how they affect and are being affected by local familial and gender relations. In the past decade, new variants of IVF have promised to overcome both male and female infertility. The new millennium has seen a rapid spatial expansion in the global scope of these reproductive biotechnologies. This section examines how men and women around the world have received IVF and ICSI, including as embodied subjects. ARTs exact a toll on the body, especially

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for women as ART recipients and as ova donors and surrogates, but also for men in the era of ICSI. The section also examines the “local moral worlds” in which these ARTs are accommodated, in disparate cultural settings, including Muslim populations living in the Middle East or as marginalized ethnic minorities. Although ARTs may be greeted with hope and anticipation in diverse pronatalist settings, this section reveals the numerous arenas of constraint facing ART recipients as they attempt to create normative families and achieve parenthood. In chapter 1, Lisa Vanderlinden examines German Turkish experiences of infertility, providing an important window on the complexities of migrant and immigrant life in multicultural Germany. As simultaneous insiders and outsiders in both contemporary Germany and Turkey, German Turks occupy a complicated transnational space between cultures. Nothing reflects this more than German Turks’ narratives about their quests for parenthood, which throw into relief their multicultural identities and peripheral social positionalities. Like infertility sufferers across the globe, German Turks’ involuntarily childless status causes them great personal and social distress. Yet, unlike many mainstream sufferers of infertility, they cope not only with reproductive disruptions, but also with a broad array of the social, cultural, political, and economic disruptions associated with their outsider status in contemporary Germany. This ethnographic chapter examines the meaning of infertility for German Turks in the context of migration, and the broader symbolic and pragmatic significance of reproduction for them as Eastern “Others” in the West. The chapter shows how German Turks’ decisions to use ARTs resist antinatalist pressures and anti-immigrant sentiments in German society, which often cast German Turks as overpopulators who strain the social welfare system and create social problems. At the same time, German Turks’ reliance on ARTs to resolve their childlessness often places them in precarious positions that contribute to their receiving more invasive medical procedures and greater stigma. In chapter 2, Yulia Panayotova and Irina L. G. Todorova describe the social context of ARTs in post-Soviet Bulgaria. As part of Eastern Europe, Bulgaria is in the midst of dramatic social and economic changes that accompany the transition to a democratic society and market economy. These changes include important implications for health, as the medical system is undergoing profound restructuring in its transformation from social to private medical care. Within this fluid context, the patriarchal and hierarchical organization of fam-

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ily relations has essentially been sustained, and the act of giving birth has remained a moral issue and a sacred duty to one’s family and country. Within this context, ARTs, which have been available and expanding for over a decade, are in great demand. However, due to the gradual decline of social medicine, many couples face escalating difficulties in affording these health services. This chapter presents an overview of the history and current use of ARTs in Bulgaria based on two ethnographic studies carried out since 2000 in a private IVF clinic in the capital, Sofia. It focuses on women’s attitudes toward ARTs and experiences of psychosocial and institutional barriers to their use, providing a specific illustration of the interplay between technoscience, gender, and local cultures. The view of ARTs in Bulgaria as benevolent and the virtual absence of any critique of their implementation, as well as the prevailing optimism, are explained by the high trust placed in science and technology, the construction of doctors (particularly IVF specialists) as being trustworthy, and women’s great personal desire to become mothers, which is enhanced by strong social expectations for motherhood. The introduction of ARTs in Bulgaria thus exemplifies an encounter in a cultural space that views science and technology through predominantly positive lenses. In the final chapter of this section, Marcia C. Inhorn explores the little-understood domain of male infertility in the era of ICSI. As noted earlier, male infertility is the major contributing factor to more than half of all cases of childlessness. Yet, male infertility remains deeply hidden in most societies because of its conflation with impotency and emasculation. This chapter reflects on the “coming out” of male infertility in the era of ICSI. Developed in Belgium in 1992, ICSI is designed to overcome male infertility through injection of “weak” spermatozoa directly into ova under a high-powered microscope in IVF laboratories. “Forcing” fertilization in this way has produced biological offspring for men who otherwise never would have fathered biogenetically related children. Furthermore, the invention of ICSI has led to recognition of male infertility as an important reproductive health problem in its own right and has repaired masculinity in men who were once silently suffering from their infertility. However, ICSI has other important gender effects, not always beneficial. This chapter, based on ethnographic research in Cairo, Egypt, and Beirut, Lebanon, examines the impact of ICSI on male infertility and gender in the Muslim world. There, prohibitions on both adoption and gamete donation necessitate ICSI to overcome male infertility but also imperil older women who cannot produce

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viable ova for the ICSI procedure. Like their Bulgarian and German Turkish counterparts, Egyptian and Lebanese infertile couples cope with the repercussions of these new, imported technologies that have come to dominate the most private spheres of their lives. At the same time, these new users redefine the very significance of these Western-originated innovations, suggesting that non-Western infertile couples are not passive recipients of technology transfer. Part II

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Donors and Surrogates: Assisting Reproduction with Third Parties In virtually all of the ART procedures, sperm and eggs are retrieved from bodies, embryos are returned to bodies, and sometimes these reproductive materials are donated to other bodies or used for medical research. Despite the existence of national and international statements opposing the commercialization of ART services, significant commodification has occurred as gametes and embryos are increasingly being sold on the open market, through Internet websites and college newspapers (with advertisements such as “Sperm Donors Needed—We Will Pay!”). This section examines the burgeoning global phenomena of third-party gamete donation and surrogacy as they are embedded within local moral, ethical, religious, market, and kinship systems. Donation and surrogacy both reflect and affect all of these domains, challenging deeply held notions of kinship, morality, and modernity. As this section will show, the use of third parties has served to solidify kinship ties, transform local market systems, and showcase the modernity of a nation. In so doing, these new reproductive practices have led to profound social-moral transformations, which in some cases may lead to social dissent and legal reckonings. Whereas the previous section focuses on technology and gender, this section highlights the disparate ways ARTs are ramifying throughout familial, moral, and legal systems around the globe, with outcomes that are sometimes unprecedented. In chapter 4, Elizabeth F. S. Roberts explores Ecuadorian women’s decisions about ova donation. When IVF patients in Ecuador are told they need an egg donor, many prefer to use female relatives (e.g., sisters, nieces, goddaughters, sisters-in-law, and grown daughters) rather than the anonymous donors provided by the clinics. In these cases, relatedness is not produced by the “elementary structures of kinship,” which, as proposed by Levi-Strauss, always involves the exchange of women between men. Instead, the exchange of eggs

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between working- and middle-class female relatives in Ecuador promotes continued relationships between them, reinforcing formalized ties of affection and commerce that do not necessarily participate in bourgeois distinctions between love and money. This chapter highlights the kinship effects of third-party egg donation based on ethnographic research carried out in Quito, Ecuador, where familial egg donation is not just indicative of “diffuse enduring solidarity,” as in North America, but is instead an exchange for past economic aid and support. Contrary to many practitioners’ predictions—that using a known donor may threaten the nuclear family—kinswomen view their strengthened connection as a concomitant benefit, and the parentage of these children is not in doubt. Although the donor is seen as having an enhanced relationship with a child born through her donation, the care and cultivation of a child inside the recipient’s body becomes the primary marker of maternity. The recipient is understood as the mother of a child whose existence is predicated on the strengthened alliance between kinswomen. In chapter 5, Soraya Tremayne examines religious attitudes regarding gamete donation in Shia Iran, where religious leaders have shown remarkable open-mindedness and flexibility in embracing innovations in science and technology, including the use of ARTs, which require Islamic legitimizing interpretations to make their use possible. These are being provided by new fatwas and laws that are being decreed to license the use of technology and to accommodate the changes within an Islamic framework. As a consequence, ARTs are flourishing in Iran. This chapter examines the interaction between Shia law as applied to fertility treatment, the treatment of infertility as practiced in various clinics, and the resourcefulness and interpretations of patients as they make sense of the laws and use of the facilities. The combination of these three components—religious authority, practitioners, and patients—ultimately determines the process and outcome of fertility treatments in general and of gamete donation (sperm, egg, embryo) and surrogacy in particular. The chapter suggests that the Iranian drive to have children is so strong and the religious law as the ultimate authoritative body of knowledge is so all encompassing that it has not been deemed necessary to develop separate ethical, moral, and legal frameworks for gamete donation beyond their Islamic interpretations or immediate impact. The potential problems of this moral-ethical-legal void will only arise when the “new babies” born of ART and gamete donation come of age.

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In chapter 6, Melissa Pashigian explores Vietnam’s relatively recent introduction to IVF, gamete donation, and surrogacy. Intertwining related and unrelated human bodies and biogenetic entities such as gametes in IVF, techno-reproduction has challenged the Vietnamese state and its citizens to contemplate the appropriate ways to engage in new forms of reproduction. This chapter investigates the range of personal and political relationships surrounding the introduction of IVF into Vietnam, including discourses on appropriate and inappropriate sources for donor gametes based on gender and relatedness; political-legal choices intended to protect infertile women and fertile would-be surrogates from exploitation (thereby further stratifying infertile women); and the repositioning of infertile women within national endeavors to enter a global marketplace of fertility services. In this chapter, Pashigian argues that once-ignored infertile women are being remade to enhance a national and international reputation for low-cost, effective IVF treatment, transforming IVF-attenuated infertile bodies into paragons of Vietnam’s new market economy. The final chapter of this section examines some of the situations and dilemmas that have been invoked through the use of ARTs in Israel and that challenge accepted modes of sense making and moral judgment. Daphna Birenbaum-Carmeli examines the public debate that surrounded one such case in Israel, a legal dispute between estranged partners over the right to have their fertilized embryos implanted in a surrogate mother. This chapter explores how, in the course of the debate, existing ideas were reinforced through being selected as frames of reference for the complex case. At the same time, some prevailing notions were challenged and modified when applied to the new situation. The general suggestion is that even when grappling with a dilemma that is constituted and accepted as groundbreaking, social response appears to be of an evolutionary, rather than a revolutionary, character. In other words, the political ramifications of ARTs, even when conceptualized as unprecedented, may still be largely contained within accepted notions and understandings rather than constituted as carriers of social change. As such, public debates regarding reproductive disruptions may become a vehicle for both patriarchal gender relations and social transformations. This general argument is contextualized within the Israeli setting to show how local particularities—primarily powerful pronatalist ideologies and policies—encourage and at the same time are being enhanced through the discourse and practice of ARTs.

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Part III

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Embryos and DNA: Encountering Advanced Genetic Technologies The final section of this volume examines the new global intersection of reproductive and genetic medicine. New genetic technologies are being accessed in contemporary IVF clinics around the globe, thereby “sorting out” defective from nondefective embryos (including “defects” based on gender). Like earlier ultrasound and prenatal screening technologies, new genetic technologies such as PGD challenge local notions of personhood, including when human life begins, the status of the embryo as a human being, which lives are valued, and whether the disabled have a right to life. The social responses to genetic screening take particular local-moral forms. Furthermore, embryos created in IVF laboratories are being used for a variety of purposes, one of which is the globalizing industry of human embryonic stem cell (hESC) research. This section raises numerous thorny ethical questions about the “newest” of the new ARTs, including PGD, hESC, and DNA paternity tests. Like the earlier sections of the book, this final section explores the potentially disruptive social and ethical scenarios engendered by the intersection of reproductive and genetic technologies in multiple sites around the globe. In chapter 8, Kelly Raspberry examines the moment in 2001 when private ART clinics in Argentina began offering PGD to the public, becoming one of the only countries in Latin America to do so. Although medical referrals for the technique increase yearly, legitimizing PGD as a valuable and recommended service has been a complicated and as-yet-unresolved process for Argentine infertility experts. Current debate focuses on the moral status of the in vitro human embryo, as, even more than other ARTs, the practice of PGD calls into question both scientific definitions of when life begins and the ethical “right to life” of a human embryo. Without legal guidelines or a medical consensus on what is permissible, reproductive medicine practitioners are left to sort out the thorny issues of the viability and personhood of a human embryo and the value of human life. Raspberry examines this current PGD debate and the slew of competing interests and ethics involved, including conservative Catholic values, claims to modernity and legitimacy, desperate hopes, and economic incentives. Using ethnographic data, Raspberry argues that Argentine fertility clinics are producing babies as well as particular ideologies of modernity, motherhood, health, and morality. In chapter 9, Aditya Bharadwaj examines the burgeoning growth of hESC research in India, where the hESC industry reflects how both

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the state and private research interests are capitalizing on the restrictions on, and shortage of, hESC materials in the Euro-American countries. India currently provides the West with generous supplies of hESC materials from its many IVF clinics. This chapter shows the extent to which global advances in biotechnology shape and become shaped by global power relations and ethical hierarchies, and how the emergent transnational collaborations unfold within local cultures and prevailing notions of life, reciprocity, altruism, and compassion. Drawing upon ethnographic research from IVF clinics, hESC research laboratories, and interviews with infertile embryo donors, clinicians, and bioscientists in New Delhi and Mumbai, this chapter provides an account of the journey taken by “spare” human embryos from the point of conception, in IVF clinics, to public and private research laboratories engaged in isolating hESCs for potential future local and global consumption. By exploring these potential “biotech futures,” this chapter scrutinizes the involvement of various stakeholders ranging from the Indian state as promoter of this biotechnology to the status of women as sites for “embryo harvesting.” In doing so, the nature of local and global market-led developments in biotech research is reflected upon, as well as the potential for gender-based human exploitation in the absence of governance and ethical frameworks regulating the research and development of biotechnology in India. In the volume’s final chapter, Claudia Fonseca interrogates the implication of DNA paternity testing in both private and public laboratories in Brazil. These tests, applied to existing and sometimes older children, have become popular throughout Brazil, raising interesting questions about the mutual shaping of the legal and medical spheres in family issues. The chapter examines these questions through an ethnographic study of the people involved in paternity disputes as they present their claims in the different judicial settings of Porto Alegre, Rio Grande do Sul, Brazil, as well as how the different actors involved in this scenario interact with recent Brazilian paternity legislation. Far from inspiring greater tranquility or promoting women’s rights, the very existence of a paternity test stirs up doubts and has profound repercussions on how paternal identity is constructed and is made “known.” The reactions to the DNA tests described in this chapter also raise questions relevant to the anthropology of knowledge centered on Western beliefs about science and kinship. Taken together, these ten chapters look into the future, at both the potentialities and pitfalls of ARTs in the twenty-first century.

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Some sentinel questions are encapsulated within this volume. How are ARTs implicated in social and cultural transformations? How will future ethical dilemmas be approached and resolved? Will the global turn toward religious “fundamentalisms” affect the practice of ARTs in societies around the world? How will national and international ideas of reproductive rights shape the future uses of ARTs around the globe? Although the volume does not pose ready answers, we hope that this state-of-the-art anthology will provide readers with an exceptional lens for viewing some of the pressing social, moral, and legal issues facing individuals and societies in their twenty-first-century “global encounter” with new reproductive and genetic technologies.

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Tine Tjørnhøj-Thomsen, Helene Goldberg, and Maruska la Cour Mosegaard. New York: Berghahn Books. Gonzales, G. F., G. Muñoz, R. Sánchez, R. Henkel, G. Gallegos-Avila, O. DíazGutierrez, P. Vigil, F. Vásquez, G. Kortebani, A. Mazzolli, E. BustosObregón. 2004. “Update on the Impact of Chlamydia Trachomatis Infection on Male Fertility.” Andrologia 36, no. 1: 1–23. Greenhalgh, S., ed. 1995. Situating Fertility: Anthropology and Demographic Inquiry. Cambridge: Cambridge University Press. Hassa, Hikmet, Unal Ayranci, Ilhami Unluoglu, Selma Metintas, and Alaeddin Selma. 2005. “Attitudes to and Management of Fertility among Primary Health Care Physicians in Turkey: An Epidemiological Study.” BMC Public Health 5, no. 1: 33. Hoffman, L., K. Chan, B. Smith, and S. Okolo. 2005. “The Value of Saline Salpingosonography as a Surrogate Test of Tubal Patency in Low-Resource Settings.” International Journal of Fertility and Women’s Medicine 50, no. 3: 135–39. Inhorn, Marcia C. 1994. Quest for Conception: Gender, Infertility, and Egyptian Medical Traditions. Philadelphia: University of Pennsylvania Press. ———. 1996. Infertility and Patriarchy: The Cultural Politics of Gender and Family Life in Egypt. Philadelphia: University of Pennsylvania Press. ———. 2003a. Local Babies, Global Science: Gender, Religion, and In Vitro Fertilization in Egypt. New York: Routledge. ———. 2003b. “Global Infertility and the Globalization of New Reproductive Technologies: Illustrations from Egypt.” Social Science & Medicine 56: 1837–51. ______. 2006a. “Making Muslim Babies: IVF and Gamete Donation in Sunni Versus Shi’a Islam.” Culture, Medicine, & Psychiatry 30: 427–50. ______. “‘He Won’t Be My Son’: Middle Eastern Muslim Men’s Discourses of Adoption and Gamete Donation.” Medical Anthropology Quarterly 20: 94–120. ———. 2007. “Masculinity, Reproduction, and Male Infertility Surgeries in Egypt and Lebanon.” Journal of Middle East Women’s Studies 3, no. 3: 1–20. Inhorn, Marcia C., and M. H. Fakih. 2006. “Arab Americans, African Americans, and Infertility: Barriers to Reproduction and Medical Care.” Fertility and Sterility 85, no. 4: 844–52. Inhorn Marcia C., and Frank Van Balen, eds. 2002. Infertility Around the Globe: New Thinking on Childlessness, Gender, and Reproductive Technologies. Berkeley: University of California Press. Kahn, Susan Martha. 2000. Reproducing Jews: A Cultural Account of Assisted Conception in Israel. Durham, NC: Duke University Press. Kamischke A., and E. Nieschlag. 1998. “Conventional Treatments of Male Infertility in the Age of Evidence-based Andrology.” Human Reproduction 13, Suppl 1: 62–75. Kleinman, Arthur. 1997. Writing at the Margin: Discourse between Anthropology and Medicine. Berkeley: University of California Press.

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Kumar, Sanjay. 2001. “Developing Countries Tackle Reproductive Health.” The Lancet 357, no. 9273: 2029. Lane, S. D. 1994. “From Population Control to Reproductive Health: An Emerging Policy Agenda.” Social Science and Medicine 39: 1303–14. Leonard, L. 2002. “Problematizing Fertility: ‘Scientific’ Accounts and Chadian Women’s Narratives.” In Infertility Around the Globe: New Thinking on Childlessness, Gender, and Reproductive Technologies, ed. Marcia C. Inhorn and Frank Van Balen. Berkeley: University of California Press. Macklin, R. B. 1995. “Reproductive Technologies in Developing Countries.” Bioethics 9, nos. 3–4: 276–82. Morgan, Lynn M., and Meredith Wilson Michaels, eds. 1999. Fetal Subjects, Feminist Positions. Philadelphia: University of Pennsylvania Press. Nachtigall, R. D., Becker, G., Friese, C., Butler, A., and K. MacDougall. 2005. “Parents’ Conceptualization of Their Frozen Embryos Complicates the Disposition Decision.” Fertility & Sterility 84: 431–34. Okonofua, F. E. 1996. “The Case Against New Reproductive Technologies in Developing Countries.” British Journal of Obstetrics and Gynaecology 103: 957–62. Ong, Aihwa, and Stephen J. Collier. 2005. Global Assemblages: Technology, Politics, and Ethics as Anthropological Problems. Oxford: Blackwell. Peyvandi, Flora. 2005. “Carrier Detection and Prenatal Diagnosis of Hemophilia in Developing Countries.” Seminars in Thrombosis and Homeostasis 31, no. 5: 544–54. Peyvandi, F., G. Jayandharan, M. Chandy, A. Srivastava, S. M. Nakaya, M. J. Johnson, A. R. Thompson, A. Goodeve, I. Garagiola, S. Lavoretano et al. 2006. “Genetic Diagnosis of Haemophilia and Other Inherited Bleeding Disorders.” Haemophilia: The Official Journal of the World Federation of Hemophilia 12, Suppl 3: 82–89. Quiroga, Seline Szkupinski. 2007. “Blood is Thicker than Water: Policing Donor Insemination and the Reproduction of Whiteness.” Hypatia 22, no. 2: 143–61. Ragone, Helene. 2000. “Of Likeness and Difference: How Race is Being Transfigured by Gestational Surrogacy.” In Ideologies and Technologies of Motherhood, ed. Helene Ragone and Frances Winddance Twine. New York: Routledge. Raymond, J. 1993. Women as Wombs: Reproductive Technologies and the Battle Over Women’s Freedom. New York: HarperCollins. Spallone, Patricia. 1988. Beyond Conception: The New Politics of Reproduction. New York: Bergin and Garvey. Spar, Deborah. 2006. The Baby Business: How Money, Science, and Politics Drive the Commerce of Conception. Cambridge, MA: The Harvard Business School Press. Storrow, Richard. 2006. “Quests for Conception: Fertility Tourists, Globalization and Feminist Legal Theory.” Hastings Law Journal 57: 295. Strathern, Marilyn. 1992. After Nature: English Kinship in the Late Twentieth Century. Cambridge: Cambridge University Press.

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Sundby, Johanne. 2002. “Infertility and Health Care in Countries with Less Resources: Case Studies from Sub-Saharan Africa.” In Infertility Around the Globe: New Thinking on Childlessness, Gender, and Reproductive Technologies, ed. Marcia C. Inhorn and Frank Van Balen. Berkeley: University of California Press. Thompson, Charis. 2001. “When Elephants Stand for Competing Models of Nature.” In Complexity in Science, Technology, and Medicine, ed. A. Mol and J. Law. Durham, NC: Duke University Press. ———. 2005. Making Parents: The Ontological Choreography of Reproductive Technologies. London: MIT Press. Tremayne, Soraya. 2006. “Not All Muslims are Luddites.” Anthropology Today 22: 1–22. van Balen, Frank. 2002. “The Psychologization of Infertility.” In Infertility Around the Globe: New Thinking on Childlessness, Gender, and Reproductive Technologies, ed. Marcia C. Inhorn and Frank Van Balen. Berkeley: University of California Press. van Balen, Frank, and T. Gerrits. 2001. “Quality of Infertility Care in PoorResource Areas and the Introduction of New Reproductive Technologies.” Human Reproduction 16, no. 2: 215–19. van Balen, Frank, and Marcia C. Inhorn, eds. 2002. “Introduction. Interpreting Infertility: A View from the Social Sciences.” In Infertility Around the Globe: New Thinking on Childlessness, Gender, and Reproductive Technologies. Berkeley: University of California Press. ———. 2003. “Son Preference, Sex Selection, and the ‘New’ New Reproductive Technologies.” International Journal of Health Services 33: 235–52. Vayena, E., P. J. Rowe, and P. D. Griffin, eds. 2002. Current Practices and Controversies in Assisted Reproduction. Geneva: World Health Organization. Verma, I. C. 2000. “Burden of Genetic Disorders in India.” Indian Journal of Pediatrics 67, no. 12: 893–98. Wajcman, Judy. 2002. “Addressing Technological Change: The Challenge to Social Theory.” Current Sociology 50, no. 3: 347–63. Webster, Andrew. 2002. “Innovative Health Technologies and the Social: Redefining Health, Medicine and the Body.” Current Sociology 50, no. 3: 443–57. Zsuzsa, Gille, and Sean O. Riain. 2002. “Global Ethnography.” Annual Review of Sociology 28: 271–95.

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Part I

FAMILIES

AND

BEYOND: AND

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REPRODUCTIVE TECHNOLOGIES NEW SOCIAL ORDERS

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Chapter 1

EAST

IN

WEST?

TURKISH MIGRANTS AND THE CONCEPTION OF THE ETHNIC OTHER IN GERMANY Lisa K. Vanderlinden

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G

lobalization, both as a world process and an area of theoretical investigation, has gripped the anthropological imagination in recent decades and fueled much analysis and debate (Hannerz 1989; Kearney 1995; Malkki 1995; Appadurai 1996; Gupta and Ferguson 1997; Ong 1999; Tsing 2000).1 Although they acknowledge the value of the global as a tool for ethnographic investigation, some anthropologists are wary of the totalizing and reductionist tendencies of globalization theories. Anna Tsing, for example, cautions against “assuming a single global trajectory” and urges anthropologists instead to attend to “varied globalist claims and perspectives” in order to mark global projects and dreams while examining the heterogeneous complexities and uneven dynamics of global flows (2000: 343). Modern Germany presents a compelling case of a nation in the throes of multiple global transformations: cultural, spatial, political, and symbolic. During the second half of the twentieth century, Germany admitted the largest numbers of foreign laborers and refugees/ asylum seekers in Europe, markedly increasing the ethnic diversity of its multicultural social landscape (Bade 1997).2 Whereas Germany has embraced migration policies, primarily to recruit non-German laborers for agricultural, industrial, and service work, its naturalization policies have remained highly selective. This has contributed to the formation of communities of German Turks and other minorities

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Lisa K. Vanderlinden

who are long-term permanent residents without citizenship rights. In addition to their political marginalization, German Turks suffer from stark economic and social inequalities when compared to “ethnic” German nationals. As Easterners in the West, German Turks, like other resident non-Germans, live in a paradoxical space between exclusion and inclusion, and hostility and acceptance (Kolinsky 1996: 88). As resident outsiders, they are simultaneously bicultural and between cultures. Kristin Koptiuch argues that such transnationalized labor flows have resulted in the “third worlding” of the West (1997). Global divisions based upon “exploitative incorporation and hegemonic domination—and its fierce contestation by subjugated peoples” have become part of the landscape of the West, which pragmatically means that “the third world can no longer be geographically mapped off as a space separate from a seigniorial first world” (236). In the German context, this third worlding at home has created a complex interweaving of East in West. Following Tsing (2000), in this chapter I take a critical ethnographic approach to globalization through an examination of the reproductive politics of infertility among German Turks living in Berlin. With an eye to cultural specificity and situatedness, I examine the highly personalized interface between German Turks’ migration experiences and their use of biomedical fertility technologies to resolve issues of infertility. I argue that the challenges German Turks encounter with infertility reflect larger German societal tensions surrounding issues of social reproduction, ideologies of inclusion, and the politics of difference. In order to gain entry into these cultural arenas, I analyze German Turks’ illness narratives as an important means through which they give meaning to their life experiences.3 Created in conjunction with larger sociocultural ideologies, illness talk is both a reflection of culture and an engagement with the world outside the body. In this chapter, I address how German Turks use “cultural idioms” (Crapanzano 1977), especially “idioms of distress” (Nichter 1981), to construct narratives that give meaning to their profound experiences of suffering, mark the centrality of biomedical infertility technologies as a means to resolve their reproductive disruptions, and convey messages of social distress related to their often-marginalized status in German society. Unlike many mainstream sufferers of infertility, German Turks cope not only with reproductive disruptions, but also with a broad array of the social, cultural, political, and economic disruptions associated with their outsider status. I argue that German-

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The Conception of the Ethnic Other in Germany

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Turkish narratives of infertility highlight this overlay of their peripheral positionalities as migrants on to their lived experiences of involuntary childlessness.

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Methodology The research for this paper comes from a larger anthropological study of the experience of infertility, ethnic difference, and the cultural politics of involuntary childlessness in modern Germany (Vanderlinden 2003). Central to the research project was a comparative analysis of the biomedical journeys through fertility treatment of ethnic Germans and German Turks, Germany’s largest ethnic minority. The qualitative data were drawn from eighteen months of ethnographic fieldwork in Berlin (1998–2000), the newly recrowned capital of Germany and an ethnically diverse metropolis of 3.5 million. These data were centrally derived from participant observation in three reproductive health centers, one fertility clinic, and two hospitals, as well as formal interviews conducted with seventy-four infertility patients, nine practitioners, and five social experts on infertility in Germany. The sample of couples selected for the formal, semistructured, open-ended interviews had undergone in vitro fertilization (IVF) or the related procedure, intracytoplasmic sperm injection (ICSI) at least once in their varied infertility regimes. In addition to my formal interviews, I conducted forty informal interviews and observed over two hundred clinical encounters between infertility patients and their physicians. Most of my participant observation was conducted in a fertility clinic affiliated with a major university hospital. Unique to the German medical landscape, this clinic fostered a culturally sensitive model of treatment and a medical research agenda dedicated to a greater understanding of the needs and perspectives of minority patients, particularly German Turks. To these ends, bicultural and bilingual German-Turkish nurses were available, one female German-Turkish obstetrician/gynecologist was on staff, and brochures and informational meetings were provided in Turkish. Couples were foregrounded in the research design, both because gender was a primary research variable and because the couple, not the individual, is the standard unit characterizing infertility problems in German society and the German biomedical system.4 The rich literature on the anthropology of reproduction focuses mostly on the experiences of women, whereas men’s subjectivities have largely

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gone unrecorded in the ethnographic record (Dudgeon and Inhorn 2003, 2004). In addition, the reproductive lives of couples are an underexplored area of anthropological inquiry. In light of these empirical gaps, I wanted to focus on the experiences of involuntarily childless couples as agents in family formation and to examine the dynamic interactions of men and women as partners coping with infertility and resolving their parenting desires. As such, most of the formal interviews (90 percent) were conducted with couples. Due to biomedical therapeutic conventions, however, I encountered female patients much more frequently than males in the context of the fertility clinic, as, regardless of the infertility diagnosis (male factor vs. female factor), the majority of therapies are enacted on female bodies. This uneven access to males and females at my primary research site contributed to informal interviews being conducted more frequently with female informants at the clinic without their male partners. The research methodologies employed in this study emerge from critical ethnographies in the context of heightened transnational cultural flows, and from anthropology in the context of displacement and intense cultural change (Gupta and Ferguson 1997; Marcus and Fisher 1986; Said 1979). They build upon the ethnographic studies of Inhorn (1994, 1996, 2003), Martin (1994), and Rapp (1999), all of which focus on a group of individuals coping with a shared medical condition and the biomedical clinics in which they are enmeshed.

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Reproduction and the German Cultural Context Reproductive technologies used for the biomedical treatment of infertility, such as IVF and ICSI, have become routine components of Germany’s social medical system and the German social imaginary. One in every eighty children born in Germany comes by way of the petri dish and some advanced reproductive technology (Blech, Lakotta, and Noack 2002). The widespread social acceptance and broad availability of these therapies have radically altered the landscape of reproduction and the prospect of biological parenthood in Germany. In comparison to places like the United States and Egypt, where access to fertility technologies is highly stratified (Greil 1991; Sandelowski 1993; Inhorn 1994, 1996, 2002), infertility therapies in Germany are economically and socially easier to access, as most are covered by national health insurance. However, health care coverage of

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fertility therapies remains uneven in several respects. It applies only to married couples who are legal residents of Germany and thus economically excludes those in alternative family structures, including unmarried long-term heterosexual partners, homosexual couples, polygamous unions, and prospective single parents. It also excludes asylum seekers and illegal aliens. In addition, national health insurance no longer covers ICSI, the most common advanced treatment for male-factor infertility.5 This therapeutic option is therefore inaccessible to many minorities and those of lower socioeconomic status who depend upon the public health system. There are also many differences in the treatments covered by private, as opposed to public, insurance policies insofar as private insurance policies are much more comprehensive, pay physicians higher rates for medical services rendered, and cover more rounds of therapies. The pragmatic effect of these inequities is that private insurance holders, who are usually middle and upper class, are more highly sought-after patients. In addition to these economic restrictions to infertility therapy, fertility specialists also deny certain prospective patients access to therapy. As the final arbiters of physiological and psychological fitness for fertility treatment—and thus biological parenthood— physicians are put in the position of medical gatekeepers. Insofar as these specialists judge prospective patients with nontraditional family structures to be morally unsuitable for parenthood, these individuals are socially excluded from therapy.6 Despite the relatively generous provisions of Germany’s social medical system, German Turks suffer health disparities regarding infertility and its treatment. Although as legal residents of Germany, Turks receive the same social benefits, including medial care and unemployment rights, as German nationals, German Turks seeking access to advanced fertility therapies encounter the fraught social politics of German reproductive policies and practices. Turks and German Turks, groups traditionally marked in the German imaginary as “overpopulaters” in need of contraceptive treatments, are among the most frequent users of infertility technologies in Germany. Whereas German Turks comprise about 2.5 percent of the total population of Germany and 8 percent of the population of Berlin, they represent 20 percent of the patients seeking infertility treatment (Kentenich and Yüksel 1997). Yet, infertility problems and technologies are widely identified with “ethnic” (white) Germans of high socioeconomic status who postpone childbirth for the sake of careers (Vanderlinden 2003). However, when compared to their “eth-

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nic” German counterparts and other resident minority groups, German Turks suffer persistent deficits in economic, cultural, social, and symbolic capital (Çaglar 1995).7 Ethnic minorities, commonly designated as foreigners or “foreign co-citizens” (ausländishe Mitbürger), are erased from mainstream images and discourses of involuntary childlessness. This discrepancy is particularly problematic given that minority and lower-status persons are demographically at greater risk for infertility complications, due in part to their relative lack of access to medical care. For instance, nearly twice as many Turkish (28 percent) as German couples (16 percent) at the infertility clinic were diagnosed with tubal-factor infertility, which is correlated with inadequate gynecological care (Kentenich and Yüksel 1997). Germany’s open medical policies exist alongside their historically exclusionary citizenship laws. German nationality has long been conceptualized as a community of descent linked by blood and German statehood perceived as “ethnocultural” (Bade 1997; Linke 1999). Migrants have been excluded historically from the German body politic and imagined as distinct from the German nation (Brubaker 1992; Horrocks and Kolinsky 1996; Linke 1999). Despite the passage of a more open citizenship law in 1999, the German nation remains primarily determined by genealogy rather than territory, which means that “non-German” residents continue to face resistance to their inclusion as members of the body politic. Depicted as ethnic “Others” in many media and political discourses, resident foreigners are frequently viewed as outsiders with strange cultural ways and as aliens who threaten German societal norms and practices (White 1997; Vanderlinden 2003; Ewing 2006). The coexistence of open discrimination against and the acceptance of foreigners alongside intensely pro- and anti-immigration sentiments indicate Germans’ enduring ambivalence toward foreigners.8

Cultural Idioms: Family as Life Continuity, Infertility as Disruption German Turks situate themselves in their complexly shifting, merging, and nuanced cultural contexts through their narratives of infertility and concomitant articulation of “cultural idioms.” Infertility is one of the most powerful cultural idioms in German-Turkish lifeworlds, encapsulating, as Vincent Crapanzano argues, systems of values, interpretation vectors, patterns of association, ontological presupposi-

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tions, spatiotemporal orientations, and etymological horizons (1977: 11). The infertility idiom reveals basic ontological assumptions about German-Turkish culture as it simultaneously structures human experience and conditions people’s interactions. A highly stigmatized condition among Turks, infertility fundamentally signifies loss, life disruption, and social pathology. In describing rural Turkish village society, the social environment from which the majority of German Turks have emigrated, Carol Delaney argues that much of traditional Turkish male power and authority derives from a man’s ability to generate life, and a great part of a woman’s value derives from her fertility (1991: 38–40).9 For men, the siring of children signifies their power, brings them greater legitimacy in public life, and increases their social status in village hierarchy. Women are characterized as having “indiscriminate fecundity,” which is viewed as so powerful as to necessitate modesty norms such as conservative dress, virginity, and fidelity (1991: 38– 40). Both men and women are assumed to be fertile and expected to procreate. Therefore, married men and women who suffer from infertility are considered socially deviant, their masculinity and femininity are questioned, and other members of their communities often view them with suspicion. Even for most second- and thirdgeneration German Turks, the cultural idiom of infertility powerfully punctuates their lifeworlds. Infertility operates as an antithesis to the potent cultural idiom of family, a central orienting concept and core symbolic frame of interpretation. Family literally and figuratively signifies the continuity of life—a powerful statement of robustness, survival, and success, especially for Turks in migration. Having children ensures a more secure future, as they are seen as bringing happiness and increasing social status. Most important, children, in particular males, are considered essential components of life, as they continue the patrilineage and provide economic and social support for their aging parents. As many scholars have argued, the meaning of a couple’s desire for a child and the challenges associated with their failure to conceive a child are socially and culturally contingent (Inhorn 1994; Becker 2000; Franklin 1997; Feldman-Savelsberg 1999). Although most couples in Germany experience strong cultural obligations to have children, my research suggests that German Turks feel more social pressure than ethnic Germans in this regard and have a comparatively stronger desire to parent. Whereas both ethnic Germans and German Turks endure frustration, grief, anxiety, suffering, and stigma as a result of being infertile, there simply is more at stake for German-

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Lisa K. Vanderlinden

Turkish couples to conceive their own child. This clearly emerges from German-Turkish narratives of involuntary childlessness. Among all of the German-Turkish couples I interviewed, biological progeny was not seen as a social option or a lifestyle choice but as a taken-for-granted desire. A German-Turkish obstetrician/gynecologist most clearly captured this strong position regarding parenthood in her unequivocal statement that there is no such thing as a voluntarily childless Turkish couple—every married couple wants a child. When I first heard this assertion, early in my fieldwork, it seemed too extreme to be valid. Yet, after eighteen months in Germany, I encountered only one married German-Turkish couple who explicitly expressed a desire to live childfree. My research findings corroborate the conclusions of other anthropologists who have studied Turkish culture. In her research on cosmology in rural Turkey, Delaney states that “part of the [marriage] contract, albeit unwritten, is the production of a child within the first year of marriage”; Jenny White’s work on Turks in migration similarly reveals “a continued emphasis among German Turks on marriage and family as primary sources of identification and reciprocal support, even among the second generation” (Delaney 1991: 146; White 1997: 759). Although German-Turkish couples regard economic resources, nice apartments, and secure jobs as important components of a good quality of life in Germany, none is considered as essential as children. Progeny are seen as completing the life of married couples and rendering women and men fully adult. As further evidence that voluntary childlessness is considered socially aberrant for German Turks, many of my informants were confused by my interview question regarding their central motivations for having children (kinderwunsch), since they did not regard parenthood as a matter of choice or preference but as a predetermined path. Having children was considered a self-evident necessity for a fully actualized marriage and a complete adult life. According to Hasan, a twenty-nine-year-old German-Turkish man, “A Turkish marriage is not a real marriage without children. Turkish life is focused on a family and children.” Upon hearing the question, another informant, a thirty-five-year-old German-Turkish male, Seki, initially looked confused and then carefully stated, “We don’t ask ourselves this type of question, since it simply goes without saying that everyone wants children. Children are happiness. Children are life. We do not just want children, we need children.” For my informants, having children was an elemental component of life and a universal need. Many of my informants made this

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point by contrasting a positively construed Turkish cultural view of family with a negatively construed German cultural view of family. In the words of Mustafa, a thirty-five-year-old German-Turkish man, “The Germans don’t desire children as much as Turks do. We need children in our lives to be happy. Germans kick their children out of their homes when they grow up. They just throw them away. Turks never do that. We always want our children near us. Our children are our future, since they take care of us when we are old. They will give us grandchildren to make us laugh. That is why [infertility] is more difficult for Turks than for Germans.” Germans were frequently viewed as not valuing and loving their children with the same integrity and passion as Turks. Instead, Germans were depicted as being unappreciative of their children, casting them out of their homes when they finish their schooling and not putting them at the center of their lives. Ayse, a twenty-four-yearold Turkish woman, stated:

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I always wanted to be a nursery school teacher, because I love children. We Turks love children—they are the center of our lives. They are life’s happiness. When you have children, you can get together with other mothers, watch the children play, and talk about your life. You can bring the children to the relatives to visit and everyone is happy to see them. You have someone to care for and look after. Once you have children, you are finally a woman.

The cultural idioms of infertility and fertility marked in GermanTurkish narratives convey much about the foundational role of kinship ties in structuring and perpetuating German-Turkish society. In their illness talk, German Turks highlight sociocultural reasons for desiring children, citing that children would enrich their lives by broadening their social networks and solidifying family connections, improve their social status in the German-Turkish community, and fulfill expected Turkish social roles. Children allow for the continuation of Turkish culture and life. Each of the narratives I collected from German Turks spoke of the normalcy of parenthood and the ensuing disruption and trauma of infertility. When confronted with the disorienting realizations and conflicting understandings that characterize infertility problems, German Turks often struggle to find a narrative framework that accounts for and reduces the incongruity between their fertility struggle and their idealized life trajectory. As van Balen and Inhorn state, “A childless life in the West tends to be much more accepted, and the social, psychological, and economic repercussions of involuntary childlessness

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are generally less severe” (2002: 8). As people straddling East and West, German Turks occupy a fraught transnational space: socioeconomically, they enjoy access to most biomedical technologies for the treatment of infertility; culturally, their passage into adulthood is still strongly marked by biological progeny; and politically, they are depicted in mainstream German discourses as outsiders who strain the social welfare system by having too many children. While their parenting desires continue to be more synonymous with those of nonWesterners, their treatment options and choices are decidedly Western. Although the birth of a child is generally viewed as a blessing and a joy in the German-Turkish imaginary, the birth of a GermanTurkish child is viewed more skeptically in the German imaginary. German-Turkish narratives of infertility attempt to give meaning and a degree of cohesion to this conflicted cultural space.

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Embodied Distress: German-Turkish Experiences of Assisted Reproduction Technologies Woven into German-Turkish narratives of their experiences with assisted reproductive technologies (ARTs) are the threads of both interpersonal and intersubjective dimensions of illness. Their accounts of infertility reveal “illness-identity talk,” conveying not only their illness experiences, but also their associated identity challenges and personal adaptations to infertility (Estroff 1991: 337). Following Gay Becker’s work on illness and marginality, I further see these illness accounts revealing “the juxtaposition of disruption, and embodied distress in particular, against cultural discourses on normalcy” and highlighting “specific kinds of disruption,” which “throws cultural phenomena into relief so that disparities become more visible” (1999: 16). The moving narratives are a tangle of explanations of the self in relation to sickness and socially situated expressions of larger cultural illness knowledges, as well as discourses of normalcy and disruption. In addition, these accounts of infertility reveal painful experiences of cultural difference, struggles to resolve disruption, and resistance to the status quo. Given the nuance of each account and the unique positionality of each infertility sufferer, I was struck by my informants’ near-universal embrace of modern German medical treatment as a means to achieve a biologically related baby. Whereas German-Turkish patients struggle with the process of IVF itself—such as the disturbing side effects of treatment, the physical pain, the wrenching emotions,

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the challenges of navigating the German medical culture, the relationship stress, and the stigma of being labeled as infertile—they remain committed to the perceived opportunities and hope that biomedicine affords them. Although encounters with biomedical therapies and practitioners are simultaneously repressing and enabling for German Turks, they are generally grateful to have the opportunity to access such health care services and are eager to use the array of the therapies available in Germany. This is partially reflected in German Turks’ extremely high usage rate of ARTs, as previously discussed. Their openness to biomedical therapies is greatly conditioned by the dominant German-Turkish ideology that a fully adult life requires marriage and parenthood. Reflecting the demographics of Turkey, most of my informants were Sunni Muslims, who have few sanctioned religious alternatives to biological parenthood. According to the Koran, adoption is considered haram, morally illicit, as it threatens the sanctity of the family; foster parenting is socially taboo, given the moral imperative of only blood relations living together in the home. Given the importance of biological descent and inheritance in the Islamic world, social parenthood, achieved through such Western conventions as adoption, fostering, and gamete donation, is not regarded as a viable way to resolve infertility for most Muslims (Inhorn 2003, 2006). As such, social parenthood remains socially stigmatized among German Turks, and medical therapies to achieve biological parenthood, such as IVF and ICSI, are highly desired. Strikingly, a few of my informants stated that if IVF or ICSI failed them, they would consider adopting a newborn or secretly using gamete or embryo donation to achieve a pregnancy. With infertility so highly stigmatized in the German-Turkish community, I had expected most of my informants to keep their involuntary childlessness a secret from friends and family. Yet, many openly shared their conditions with family and friends. Murat, a thirty-threeyear-old German-Turkish man living in Germany since childhood, stated: You feel the societal pressure after you have been married a while and don’t have any children. Parents always want their kids married off and starting families of their own. … Even though this situation [infertility] is not our fault, it is really stressful. In the Turkish community, there is intense social pressure to have a child after you have been married for a while. When you are married and don’t have a child, you are seen as infertile and you are stigmatized. It is a very lonely experience. But our families are open and not as traditional,

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so we decided just to directly tell them that we want children, but we cannot get pregnant. I mean, why not? It should be just like with any other illness, right? Both of our families simply said that we should undergo [medical] therapy. They really understood—I mean, they want grandchildren—and they tried to support us and to accept the situation.

Whereas German-Turks’ feelings about the illness experience were usually fraught and ambivalent, their desire to use infertility treatment remained strong. Most of my informants viewed access to ARTs as a welcome way to resolve the inherently disruptive experience of infertility. Most couples felt that access to ARTs as a means to pregnancy gave them “reproductive self-determination” (Petchesky 1998) and were pleased by the possibilities provided by the biomedical procedures. According to Meral, a twenty-five-year-old German-Turkish woman who works as a pharmacist’s assistant, The therapies give us hope. There is at least a chance for us. I know what they say the odds are, but why shouldn’t we be the ones? I feel very positive about the experience thus far. You can actually see the process working this time. They counted fourteen eggs this week, which means fourteen chances for me to be a mother. That is more than I would have had twenty years ago [when she still lived in Turkey]. I just hope that I can keep my energy and emotional strength, because I became depressed during the last IVF, which really affected the outcome.

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Meral’s husband, Ferhat, a twenty-eight-year-old carpenter, added: These therapies are very stressful for the relationship. All of your thoughts and actions are directed toward this one goal, making a baby, and it utterly consumes you. The emotional swings are very extreme. We were thrilled when therapies were successful—and hope begins to build and grow as you imagine what it would mean to have a child, like normal people. Then something goes terribly wrong, and suddenly all of your hope is shattered. It is devastating. You start to doubt everything, because life seems so random. But we keep trying. All things considered, we feel more positive than negative about the fertility therapies, because despite all of the doubts and the stress and the sadness, they give us a chance.

Meral and Ferhat’s illness narratives mark common tropes among German-Turks’ accounts of infertility. Biomedical fertility treatment is one of the few options to potentially alter their state of difference and resolve their struggle with involuntary childlessness. They avail

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themselves of fertility therapies as a means to achieve the foundational German-Turkish life goal of parenthood. At the same time, they struggle with the IVF experience, which has caused them further emotional anguish and suffering. Diagnosed with clinical depression, Meral is certain that her depression has contributed to her failure to achieve a pregnancy. Gülüzar, a twenty-nine-year-old German-Turkish woman, had a similar perspective. Like many German Turks, she was grateful to be able to access the therapies but ambivalent about the experience of treatment:

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The good thing about being in Germany is that the therapies are free. We are so lucky! No one would give you free medicine for infertility in Turkey—that is for sure. But here the doctors are [pause]—they don’t understand us, so that is a problem. But here we can choose. We can decide what we want, but then there is the questioning about the future. What will happen? And the past … Did I do enough? … But I would rather have the option to go to the IVF clinic and have the therapies, because in Turkey, we would never have the chance for a family together, for a baby. That is what is good about Germany.

With the reproductive autonomy that allows Gülüzar to “choose” how to deal with her infertility and be an active agent in family formation comes great patient responsibility. Her account highlights a rhetoric of free choice and empowerment overlaid with a sense of accountability for potential medical failings. Like many German Turks, she is willing to try any of the available biomedical infertility therapies in her attempt to achieve biological parenthood. Indeed, Gülüzar and her husband had been through six intrauterine inseminations (IUI) and four rounds of IVF. German Turks undergoing fertility therapy in Germany are much more likely than ethnic Germans to have one of the more invasive forms of treatment, such as IVF or ICSI. Gülüzar and her husband’s avid use of fertility technologies perpetuates Turkish pronatalist ideologies in addition to enabling them to pursue their very personal goals of becoming parents. In this sense, the use of ARTs reinforces traditional societal norms that compel procreation and simultaneously allows couples to be active agents in family formation. Most German-Turkish narratives characterized ARTs as a way to enhance the natural process of conception. Only rarely did German Turks comment that these therapies seemed unnatural or that the use of technology was a disturbing interruption of the reproductive process. The counternarrative of one informant, Emine, marks an

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important departure from this dominant trope. It is significant that Emine, a thirty-three-year-old teacher’s aide who has spent most of her life in Germany, raised concerns that parallel many ethnically German infertility sufferers:

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The therapies are very unnatural, which has negatively influenced my ability to become pregnant and carry a baby to term. My babies [zygotes] did not like the technology and they did not want to stay in my body [after IVF and implantation]. How would you like to be frozen and then thawed? Of course, they did not want to grow and see the world after such a traumatic experience as that. The IVF fertilization process is so unnatural, so cold, that it takes the life out of the eggs. My body and my babies just don’t like such artificial therapy.

Emine’s narrative is a powerful statement of resistance to the status quo. Despite her apprehensions regarding the use of fertility technologies, she and her husband had undergone multiple courses of IUI and IVF and were immersed in yet another cycle. Their reproductive disruption had thrust them into a liminal state where they had been living for years with the hope for a baby, the hope of restoring “normalcy.” As was the case with many German Turks, Emine believed that medical persistence would ultimately improve their situation. Although she actively resisted normalizing ideologies of technology as enhancing the natural process of conception and struggled with the powerful social conditioning that motherhood was inherent to adulthood, she still could not give up her dream of having a baby. Emine was vividly aware of the tensions among German-Turkish procreative imperatives, ARTs as a responsible means to infertility resolution, and her own embodied experience of rejecting conceptive therapies. All of the German Turks I interviewed lived with such disparity, albeit in varied forms. Gülüzar’s encounter with biomedical infertility therapies embodied another form of disparity and disruption. Marking other departures from normalizing ideologies, her narrative illustrates how the experience of infertility is both repressing and enabling. The ability to access biomedical therapies is seen as a privilege by many German Turks, as in Turkey they would not have the economic or cultural capital to avail themselves of such biomedical therapies. Significantly, the experience of reproductive technologies comes to symbolize both the comparatively higher socioeconomic status of German Turks relative to many Turks and the lower socioeconomic status of German Turks relative to most ethnic Germans. The use of such medical treatments by German Turks is a marker of the in-

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creased economic capital achieved through migration, yet the experience of inequality in some clinical encounters marks their diminished cultural and symbolic capital as marginalized permanent residents in German society. Gülüzar desires more cultural sensitivity in the delivery of infertility treatment and wishes to be seen by her physicians in a less pejorative light. Ferhat, a thirty-three-year-old German-Turkish computer graphics specialist, further elucidates this fraught power dynamic:

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Our first experience with Dr. Schmidt [a fertility specialist] was such a bitter disappointment. With the first doctor, my wife had many problems undergoing the [gynecological] exams, because she felt exposed and ashamed, since he was male. This was really difficult for her, and yet he had no patience or understanding. He actually asked, “How do you have sex with your husband if you cannot go through such an exam?” He treated the encounter like an assembly-line production in a factory, totally without emotion or understanding. I was so shocked by what he said that I couldn’t react. I still regret that I did not do something. Even though my wife’s German wasn’t very good, she just burst out and told him off. She said, “I am from Turkey. Our culture is different than German culture. These exams are not easy for Turkish women.” I hated that my wife had to go through that. The most difficult thing about these treatments is watching my wife undergo this kind of pain. There is so little understanding for Turkish customs. German doctors need to provide more support for Turkish patients with different ways.

German health care organizations have generally been slow to respond to the disproportionate health deficits of minority populations (Jundt 2003; Borde, David, and Kentenich 2002). Despite German medical professionals’ emerging interest in cultural competency in health care delivery, the German medical system is currently not equipped to provide adequately for resident foreigners’ and minority citizens’ varied health needs. While it is increasingly acknowledged that developing interventions that are “culturally appropriate” would help to reduce health care disparities in the German context, few cultural competency programs have been implemented. Unlike other reproductive health centers, the main fertility clinic where I conducted my research already provided cultural-competency training to its medical personnel and culturally sensitive services to its migrant and minority clients in the late 1990s. In their narratives of illness, many German-Turkish infertility patients marked disconcerting clinical encounters with ethnically German physicians. These fraught doctor–patient interactions high-

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lighted a lack of practitioner and institutional knowledge of differing German-Turkish disease etiologies and health-seeking practices. Significantly, only one German Turk mentioned such a difficult medical interaction in association with the fertility clinic with the culturalcompetency program. Most minority infertility patients were more satisfied with the therapies they received in the clinical context of increased cultural sensitivity. German-Turkish women and their husbands often felt uncomfortable receiving gynecological care from male physicians and with standard biomedical procedures, such as vaginal examinations, which violate cultural norms of shame and modesty. This response was especially prevalent among women who had migrated from rural areas of Turkey. This is strongly correlated to the fact that the majority of German Turks, particularly those from agrarian backgrounds, lack biomedical understandings of the body and its reproductive functioning (Borde, David, and Kentenich 1999), which results in differing interpretations of the need for gynecological procedures. As the research record has documented, negative doctor–patient interactions contribute to doctor–patient misunderstanding and distrust, decreased patient compliance with medical recommendations, and lower patient satisfaction with care (Good 1994; Santiago-Irizarry 2001). German-Turkish illness accounts reveal the societal constraints under which German Turks are operating, the uneven power dynamics in the fertility clinic, and practitioners’ cultural deficits regarding Turkish norms. Still, use of ARTs allows these cultural outsiders to powerfully shape the course of their fertility desires.

Idioms of Distress: Infertility as Trauma, Migration as Trauma The fertility clinic is a place of social and cultural dissonance for almost all infertility sufferers. It is a space in which one’s procreative expectations and self-identity are frequently challenged by biomedical knowledge systems and where one’s reified cultural perceptions are often abruptly called into question by medical ideologies. The cultural collisions between German biomedical healing modalities and German-Turkish disease etiologies are emblematic not only of divergent understandings of reproduction, but also of larger German societal tensions and implosions regarding the composition of the German nation. Questions about infertility and procreation are intimately tied to attitudes concerning the right to reproduce and

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the constitution of the body politic. The dynamics embedded in personal experiences of infertility reveal patterns of ethnic stratification as well as sociopolitical pressure points regarding migration. German-Turkish narratives often reveal “illness-identity statements” (Estroff 1991) that go beyond sufferers’ self-representations and categorizations of infertility to mark associations of involuntary childlessness with political powerlessness, social distress, and lack of cultural belonging. Following Nichter (1981), I view these as “idioms of distress” that highlight the symbolic and affective associations of infertility with the social inequalities that German Turks experience as resident outsiders. “Idioms of distress” refers to “ethnopsychiatric phenomena underscoring symbolic and affective associations, which take on contextual meaning in relation to particular stressors, the availability and social ramifications of engaging alternative expressive modes, and the communicative power of these modes given intervening variables and the responsiveness of concerned others” (Nichter 1981: 379). These stressors take on contentious significance when viewed in conjunction with the highly disorienting experience of infertility. When many German Turks discuss their illness, they speak of a condition brought on or exacerbated by cultural displacement, migration stress, and sociopolitical marginalization. Many of my informants associated their inability to conceive with their geographical and cultural distance from Turkey. Their illness narratives contain vivid descriptions of “home” that are strongly associated with their longings for support from and interaction with their extended families, the warmth of the Turkish sun, flavorful Turkish foods, the rich smells of the countryside, and the physical geography of Turkey’s rural and urban landscapes. As articulated by Banu, a twenty-five-year-old German-Turkish woman who recently had relocated to Germany, I feel disconnected from my family, nature, and life in Germany. My family is so far away, and I sometimes feel lonely, so alone here, even though I have my husband and his parents. I am still homesick for the tastes and smells and sights of Turkey. In Turkey you can taste and feel life, and it gives me energy. The fruits and vegetables here are so dull—they have no flavor—and the sun does not shine with the same intensity. Germany is gray, and the environment is gray, and the life tastes gray. It makes me feel gray; I think that is why I am so sad and depressed. There is no spark of life here. In Turkey I could have conceived a child, but not here. … Maybe if my husband and I have a long vacation in Turkey—I think we could make a baby. But not in Germany.

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As was my experience in most interviews with German Turks, Banu’s biomedical disease etiology never surfaced in her illness narrative as a viable explanation of infertility causation. Her childlessness was rather seen as geocultural, caused by being uprooted from her home, a place colored in rich metaphors of germination and sustenance. Banu’s account foregrounds her discomfort in German society and her feelings of alienation from her family and the Turkish environment. Living in Germany, far from family and home, she sees her body as lifeless and therefore unable to produce new life. As many German-Turkish illness narratives reveal, the inability to make a baby is often perceived as the result of cultural estrangement, distance from family, and geographic displacement. Although Turkey is seen as creating optimal conditions to support conception, Germany is not, despite the greater availability and financial accessibility of biomedical fertility therapies. According to a twenty-seven-year-old German-Turkish woman, Semra,

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My mother in-law and other friends in Turkey tell us that if [in vitro fertilization] does not work here in Germany, we should try to undergo therapies in Turkey. People say that in Turkey, at home, it is easier to get pregnant and have a child. … There is no understanding for Turkish customs here, so it could be easier in Turkey, where we feel more comfortable and can express ourselves freely. Of course, in Turkey at the private hospitals we would have to pay for everything ourselves. It is difficult. The medicine here is very good, but I wonder if it really works for Turks?

In remarking that having a child might be easier in Turkey, Semra’s account also links infertility disease etiology to geocultural displacement. Unlike Banu, she invokes biomedicine as a concrete means of resolving her infertility but only insofar as biomedical therapies are delivered in a culturally sensitive mode and preferably in Turkey. Although marking the power of advanced Western fertility technologies to resolve infertility, her narrative emphasizes it would nonetheless be easier to have a child “at home,” where one is a cultural insider. This was a sentiment frequently expressed by my informants, many of whom had a preference for undergoing ARTs in Turkey but were hindered by the prohibitive economic costs of therapy, travel, and lost wages. Like Semra, many longed for the familiarity of Turkish practitioners who could provide medical explanations in their native tongue, as well as a more nuanced cultural understanding of their infertility experiences. Significantly, despite their expressed de-

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sires for receiving biomedical fertility therapies in Turkey, few German Turks actually sought such health care options. Only three of the couples I interviewed elected to have ARTs in Turkey: two underwent intrauterine insemination, and the third received one cycle of IVF. None of these therapies resulted in a pregnancy. Although the couples were disappointed with the outcomes, they found the therapeutic process much easier in Turkey than in Germany. It is interesting that many felt the act of simply being in Turkey could help achieve conception, as the land, weather, people, and food were regarded as better able to nurture the body and spirit and create the optimal conditions to achieve a pregnancy. For this reason, many German Turks tried to save vacation time to allow for long stays in Turkey. It is significant that such technologies would be unavailable and inaccessible to most German Turks if they were still living in Turkey.10 Barriers to infertility treatment have been classified in terms of accessibility, economic cost, and sociocultural factors (Lunenfeld and Van Stireteghm 2004), all of which are simultaneously present in the Turkish context. Comparatively fewer biomedical resources are available to Turks to help resolve infertility issues. In 2001, there were 32 IVF centers in Turkey, which is equivalent to 0.5 centers per one million people—this is four times lower than the rest of Europe, which on average has 2 centers per one million (Collins 2002). The lack of IVF centers is correlated with low patient-utilization rates. The optimal demand for IVF and ICSI is estimated to be 1,500 cycles per million people per annum, while only 37 treatment cycles per million were given in Turkey in 2001, compared to 412 in the rest of Europe (Collins 2002). In regard to cost and ability to pay, Turkey’s Gross Domestic Product per capita in 2001 was $8,178 (OECD 2008), but according to estimates from three prominent Turkish IVF clinics,11 one cycle of IVF or ICSI costs between $3,500 and $4,000. This means that the cost of a single IVF cycle was equivalent to almost 50 percent of the average Turk’s income in 2001.12 Even for German Turks earning German marks and receiving therapies in Turkey, the cost of one cycle of IVF or ICSI was equivalent to nearly 20 percent of annual household expenditures.13 As most couples require multiple IVF or ICSI cycles to achieve a pregnancy and give birth to a baby, these costs are prohibitively expensive for most Turkish and German-Turkish couples. In addition, Turks’ access to biomedical conception technologies is further impeded by sociocultural factors, including lack of knowledge regarding procedures, poor infrastructure, and proximity to the nearest medical facility.

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Migration stress was another common interview trope associated with the onset of infertility. Many German Turks saw the stress and unhappiness of the migration experience as contributing to the embodied distress of involuntary childlessness. This was an interesting departure from ethnic Germans, who more frequently perceived the inability to achieve a pregnancy as primarily a physiological problem that sometimes led to (but was in no way caused by) intense sadness and depression. Notions of disease causation, especially when expressed as “idioms of distress,” reveal illness as embedded in the symbolic structures and cultural ideologies of sufferers’ lifeworlds. As such, German-Turkish accounts of infertility describe not only their profound loss of biological parenthood, but also losses in other cultural domains. As a thirty-two-year-old German-Turkish woman, Nesrin, who emigrated at age sixteen, stated,

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It has been difficult to acclimate to life in Germany for my family. There are so many cultural and environmental changes. Daily life seemed so strange and different at first and it was really hard on everyone. And now we are both jobless. That is difficult. … Sometimes I wonder if I would have experienced the same difficulties in Turkey that I have here—with having a baby, I mean. Would life have been easier? Would there have been less stress? When we go back to visit, there are many things that I know I would not like about life [in Turkey] now that I have lived in Germany. … My mother thinks that [my husband and I] need a break from Germany. Then she says the baby will come. I don’t know what to think anymore. (pause) Maybe my womb just does not like this stress! (laughs)

As they spoke of the stress and worry concerning infertility, my informants often simultaneously detailed the stress and worry associated with common migratory problems such as unemployment, inadequate housing, linguistic competence, family reunification, and ethnic stigmatization. In some instances the two sets of stressors fused together almost seamlessly and became one thread, describing and conceptualizing loss. As Guarnaccia, Lewis-Fernandez, and Marano (2003) articulate in regard to ataques de nervios, illness can provide the means of expressing social distress associated with the inequalities experienced by marginalized groups, particularly in the context of migration. In German-Turkish illness narratives, the overwhelming challenges associated with migration become synonymous with the overwhelming challenges associated with fertility resolution. Another narrative theme that emerged in my interviews with German Turks was the confluence of infertility with sociopolitical margin-

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alization. German Turks carry a stigmatizing yoke with their foreign identity. Viewed as backward, uneducated, uncultivated, illiterate, and misogynistic, German Turks are socially and symbolically excluded from many aspects of German culture (Adelson 2000). Even though immigration and the presence of minorities are long-standing characteristics of the German republic, ethnocentric and xenophobic attitudes remain commonplace in German society (Thränhardt 1995; Linke 1999). Even more worrisome for minorities living in Germany is the persistent threat of extremist violence and xenophobic prejudice (German Federal Ministry of the Interior 2000). Although incidents of extreme violence declined in the late 1990s, the continued presence of hate crime and antiforeigner rhetoric leaves many German Turks apprehensive about being victimized and insecure in their new German homes (Panayi 2000: 258). In the words of Gülüzar,

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For me to wear a headscarf makes me feel proud. I feel like a woman when I wear it. I feel like I am Turkish when so much around me is not. But many Germans do not like our headscarves. They call out on the street and insult me: Dirty foreigner! Fat pig! Go home—we don’t want you here! The Germans try to make me feel shame because I wear a headscarf. … If we have a child here, I wonder how life will be for him.

Gülüzar’s experiences of cultural marginalization are infused into her illness talk, revealing idioms of distress about her position in German society. Her concerns about her own embodied fertility struggles are fluidly linked to her feelings of social exclusion, her worries about hate crimes, and her fears about what the future might bring for a minority child growing up in Germany. For Filiz, a thirty-one-year-old German-Turkish woman, the stigmatization she feels as a cultural outsider is even more directly linked to her experience of infertility and the fertility treatments she receives: Germans often have bad impressions of Turks. I feel uncomfortable about this. They don’t like our headscarves, they don’t like our children, and they say that we stink, like garlic. They think I am stupid, and they speak very slowly, and they laugh. Then I feel bad. Some Germans, they do this, but some are very kind and interesting. The doctors are like that too. Some are friendly, but some are upset and not patient. They are too busy for a Turkish woman like me. When they look at me, sometimes I feel like they just see my headscarf. Only that and not me—beneath. They speak to my husband, and then they ask slowly and very loudly, “Do you understand, Frau Sacli?” They think I can’t understand how the baby is make [sic]. I

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just want the doctor to be nice and to explain everything to me. They should take time with us. They should talk to us. They should know me more than my headscarf.

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Filiz connects the hostility and symbolic violence14 she endures on the street with the prejudice she has experienced from some of her physicians. Her experience in Germany, like Gülüzar’s, highlights the ways in which she is marked as Other and rendered unacceptable. Many German Turks resist conforming to the cultural norms and conventions of German society. German Turks often interpret the assimilation process as a mandate to renounce Islam, to discard traditional dress and headscarves, exclusively use the German language, and take up German mannerisms and attitudes (Adelson 2000: 93). Instead, many German Turks are looking for cultural openness, tolerance, and mutual respect. Filiz clearly desires this in her medical encounters with her physicians. German-Turkish infertility narratives reveal human agency at work in everyday life. As much as illness talk among migrant groups is a reflection of their structural marginality, it is also a form of everyday resistance. It is a space in which reproductive politics are shaped, cultural themes amended, and predominant ideologies challenged. In making sense of their disjointed experiences of infertility and migration, German Turks often resist hegemonic German discourses. Meral asserts: Germans want us to stop being Turkish and act German. They don’t want any more women wearing headscarves. They don’t want us to pray in public. They want us to eat pork. They don’t want us to have large families. But they don’t want us to be German, you understand? That would be too much. That would take things too far. I mean, even if you have a German passport and speak perfect German and eat Schnitzel and wear jeans, they don’t think that you’re German. But if we act like Germans, then life is easier for them.

Such contestations are highly political in that they mark constellations of power in German society. Meral is overtly resisting reductionist labels and homogenizing discourses that flatten the complexly nuanced identities of German Turks. She is also contesting the normalizing ideologies of German identity. Numerous theorists have cautioned against the over- or underascription of political consciousness and agency to ethnographic subjects (see Abu Lughod 1990). Yet I would argue, following Sherry Ortner, that “[resistance] highlights the presence and play of power in most forms of relationships

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and activities” (1995: 175). For many German-Turkish infertility sufferers, resistance opens up a space for regaining control. The stories they tell about their infertility experiences are creative ways of resisting the biomedical physicians who wield so much control over their reproductive destinies, the stigmatizing social labels (such as “infertile”) that threaten to diminish their cultural capital within the German-Turkish community, and the national-ethnic discourses that position and devalue them as outsiders in German society. Further, many German Turks feel marginalized in Turkish society as well, where social and economic ties continue to be nurtured through connections with family, arranged marriages, and annual return trips (izin). Dubbed “Germaners” (Almancilar) in Turkey, and “guest workers” (Gastarbeiter), “foreign laborers” (ausländische Arbeitnehmer), “native foreigners” (einheimische Ausländer), and “foreign co-citizens” (ausländische Mitbürger) in Germany, German Turks are given what Jenny White calls a “stigmatizing badge of difference” in both Germany and Turkey (1997: 755). German Turks are often denied cultural legitimacy by middle-class Turks, who regard them as yokels from the countryside lacking the embodied trappings of middleclass culture, such as manners and polished Turkish-language skills (Çaglar 1995: 317). In many ways, German Turks are caught in a space of cultural liminality, chastised in both Germany and Turkey for being too foreign. Nowhere is German-Turkish marginalization more apparent than in the context of fertility treatment. German Turks seeking medical assistance for infertility endure a double cultural stigma. In the German imaginary, they are castigated for using the German medical system to reproduce more foreigners, already viewed as burdens on German society. In the German-Turkish imaginary, they are stigmatized for not fulfilling adult gender norms. As many of my informants conveyed, this outsider status has pronounced effects on their perceptions of self and creates ambivalent relationships to the German nation. As one thirty-five-year-old German-Turkish male, Halil, relayed, I like living in Germany. In some ways the opportunities for advancement are greater here and there are certainly more social benefits, but I am so conscious of the fact that many Germans perceive me as an outsider, which has a psychological effect on me. I am always conscious of my status as a foreigner, and that won’t improve once I have a German passport. I came here as a boy at age seven; I went to school here—primary school, high school [Gymnasium], university; I under-

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stand German culture; I deliver lectures in German. And yet, the question is always the same, “Where are you from?” Sometimes I wonder if this damages not only the mind and emotions, but also health.

Evoking metaphors of exclusion, Halil’s account suggests that his experiences of sociopolitical marginalization are part of disease etiology. Numerous critics have persuasively illustrated that “there is a link between imagining disease and imagining foreignness” (Sontag 1988: 48). However, this has classically occurred in pernicious social discourses that devalue and demonize foreigners by casting them as disease-bearing “germs” invading an otherwise healthy body politic. In the case of my informants, the link between foreignness and disease has a different quality; it is a sociopolitical sense of disenfranchisement, a quality associated with the lived experience of foreignness, which is seen to cause illness or, in this case, infertility. Halil’s narrative suggests that a lack of social recognition and political acceptance can contribute to emotional and physiological stress, which may in turn produce illness. Many other social critics would agree with him. According to Gay Becker, “[w]hen people cannot live out ideal representations of the body and the normalizing ideologies that are reflected in them, their bodily distress may be profound” (1997: 83). As empirical evidence has shown, disenfranchised groups suffer differential disease rates, as “the adverse health impact of contemporary social health inequalities exacerbates those very inequalities, resulting in a spiral from which it is difficult to emerge” (Nguyen and Peschard 2003). Involuntarily childless German Turks are unable to actualize the embodied cultural ideologies of procreation within either German-Turkish or German societies. As a result of their stigma, they experience social exclusion and difference. Such social inequality, independent of income, has itself been found to contribute to poor health in numerous cultural contexts (see Marmot 1986, 2004; Kawachi et al. 1997; Donohoe 2003). In the case of many German Turks, the embodied distress associated with infertility becomes virtually inextricable from the embodied distress of social exclusion. Indeed, the discord experienced by displaced populations, such as German Turks, in their postmigration environments may only worsen health conditions such as infertility (Silove, Steel, and Watters 2000). In a very real sense, the complex overlay of social, psychological, and physiological stressors associated with German-Turkish marginalization is a likely determinant of their increased levels of affliction and worsened health outcomes in Germany.

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Conclusion Narratives of infertility are fundamentally about disruption and difference (Inhorn 1994; Becker 2000; Franklin 1997; Feldman-Savelsberg 1999). When German-Turkish men and women cannot enact societal gender roles and meet the cultural expectations of parenthood, they are thrown into a space of disjuncture. They challenge Turkish constructions of normalcy and ideologies of biological parenthood. These couples’ struggles with infertility and embodied experiences of reproductive disruption defy the German-Turkish social order. As such, German Turks coping with infertility are marked as inherently deviant and deficient and bear the weight of social stigma in their Turkish communities. These German-Turkish couples thus endure disruptions of their individual bodies and of the Turkish social bodies that construct their lifeworlds. As Scheper-Hughes and Lock poignantly illustrate, the individual body, the social body, and the body politic are thoroughly interconnected (1987). German-Turkish infertility narratives powerfully link German Turks’ embodied distress, their anxiety about not conforming to the German-Turkish social body, and their stress regarding their exclusion from the German body politic. German Turks’ profound distress at not conforming to Turkish procreation ideologies and being marginalized due to their social differences compounds their distress as cultural outsiders in Germany who are further marginalized by their exclusion from German nationalist ideologies. It is not surprising that these multiple disruptions are intimately interwoven in German-Turkish illness talk, where the mutually constitutive relationship between biological and social reproduction is so movingly articulated. Reproduction is a politicized cultural space, and reproductive practices are highly symbolic acts that both literally and figuratively construct the nation. In the words of Donna Haraway, “[r]eproductive politics are at the heart of questions about citizenship, liberty, family, and the nation” (1997: 189). German Turks must cope with multiple conflicting ideologies in the transnational, intercultural space that is modern Germany. German-Turkish narratives of infertility provide windows to embodied distress and life disruption resulting from their experiences of infertility, migration, and sociopolitical marginalization. Their individual plights with involuntary childlessness are inseparable from the larger traumas they endure as cultural and political outsiders. In studying the cultural idioms and idioms of distress that are embedded in migrants’ infertility narratives, we may

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enrich our understanding of the complex links between the disruptions and trauma that simultaneously shape the individual body, the social body, and the body politic (Scheper-Hughes and Lock 1987).

Acknowledgments The research on which this chapter is based was supported by grants from the Social Science Research Council, Berlin Program (1998– 1999), the Rutgers University Bevier Fellowship (1999–2000), and the Woodrow Wilson Foundation (2000–2001). I am very thankful for the support these institutions have provided. I am also grateful to the physicians, biologists, nurses, nursing assistants, and administrative assistants at the fertility center for their willingness to show me their clinical lifeworlds. Finally, I am indebted to the women and couples who generously shared their stories of infertility and narratives of migration. The statements, conclusions, and any shortcomings in this analysis are entirely my own.

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Notes 1. Jonathan Xavier Inda and Renato Resaldo define globalization as “the intensification of global interconnectedness,” which is characterized by “radical accelerations in the flows of capital, people, goods, images and ideologies” such that there is a “fundamental reordering of time and space” (2002: 5). Central to this process is the deterritorialization of culture (Gupta and Ferguson 1997) due to transnational migrant circuits (Rouse 2002) and other global cultural flows in our late capitalist, postcolonial world (Appadurai 1996). 2. As scholars such as Klaus Bade (1997) and Christof Kleßman (1992) argue, migration has been an enduring characteristic of German history, even long before Germany’s unification as a nation state in 1871. 3. For a broader discussion of the significance of illness narratives, see Kleinman (1988), Kleinman and Kleinman (1991), Estroff (1991), Lock (1993), Good (1994), Becker (1997), Mattingly and Garro (2000), Inhorn (1994), and Rapp (1999). 4. Although I had initially hoped to include homosexual couples and prospective single parents in my sample, I did not have the opportunity to access any such informants at the fertility clinic, as they did not present themselves for therapy during my fieldwork. Physicians and fertility experts suggest that Germany’s restrictive laws compel many nontraditional prospective parents to pose as mainstream heterosexual

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5.

6.

7. 8.

9.

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10.

11.

12.

13.

14.

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couples in order to gain unencumbered access to therapies or simply to leave the country for fertility treatment. After I completed my ethnographic research, in 2001, access to ARTs was further eroded. The implementation of a new state insurance policy in January 2004 radically reduced the number of German Turks and other economically disadvantaged infertility sufferers able to access fertility technologies. Although most biomedical infertility therapies were formerly included in standard national health-insurance coverage, access to all therapies apart from the initial diagnostic procedures are now severely restricted. Patients currently must pay for half of treatments like IVF and ICSI, rendering these expensive therapies economically inaccessible to many of Germany’s most marginalized residents. According to Germany’s IVF Registry, 10,000 fewer ART births occurred in 2004, ostensibly as a result of this policy change. For example, a study of the screening practices of ART programs found that only 59 percent of ART program directors agreed that everyone has the right to have a child, with only 44 percent agreeing that fertility doctors do not have the right to decide who is a fit potential parent (Gurmankin, Caplan, and Braverman 2005). For further elaboration on these forms of capital, see Pierre Bourdieu (1986). One comprehensive survey indicated that 52 percent of German citizens feel that “[t]here are too many foreigners in Germany” (Der Spiegel 48 [23 November 1988]: 27). Delaney argues that a woman’s social value is determined by her fertility and her modesty, particularly her sexual purity. Although socioeconomic, religious, and ethnic differences among Turkish immigrants in Germany are varied and complex, the vast majority of first-generation German Turks emigrated from rural areas, and had little formal education and very little earning power in Turkey. With ARTs being so cost prohibitive, most German Turks would not have had the ability to pay for these therapies. This information was relayed to me by a German-Turkish obstetriciangynecologist practicing in Germany and was substantiated by information I solicited from Turkish fertility clinics. These data provide a window to the macropolitics of reproductive health inequalities. However, they reflect only average income and not the distribution of income, thus occluding economic variations in the population. This calculation is based upon the OECD estimate for German Gross Domestic Product per capita in 2001 of $26,862, adjusted for Turkish earning capacity (Statistisches Bundesamt 2000) to $20,147. Uli Linke suggests that “symbolic violence” is a social marker of the overarching anxiety that Germans have regarding the ethnic Other. For further elaboration see Linke (1999).

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References Abu Lughod, Lila. 1990. “The Romance of Resistance: Tracing Transformations of Power through Bedouin Society.” American Ethnologist 17: 41–55. Adelson, Leslie. 2000. “Coordinates of Orientation: An Introduction.” In Atlas of a Tropical Germany: Essays on Politics and Culture, 1990–1998, ed. Z. Senocak. Lincoln: University of Nebraska Press. Appadurai, Ajrun. 1996. Modernity at Large: Cultural Dimensions of Globalization. Minneapolis: University of Minnesota Press. Bade, Klaus. 1997. “From Emigration to Immigration: The German Experience in the Nineteenth and Twentieth Century.” In Migration Past, Migration Future: Germany and the United States, ed. Klaus J. Bade and Myron Weiner. Providence, RI: Berghahn Books. Becker, Gay. 1997. Disrupted Lives: How People Create Meaning in a Chaotic World. Berkeley: University of California Press. ———. 2000. The Elusive Embryo: How Women and Men Approach New Reproductive Technologies. Berkeley: University of California Press. Blech, Jörg, Beate Lakotta, and Hans-Joachim Noack. 2002. “Babys auf Rezept.” Der Spiegel 4: 70–80. Borde, Thea, Matthias David, and Heribert Kentenich. 1999. “Wissen über den weiblichen Körper von deutschen und türkischen Patientinnen einer Frauenklinik.” Forum 2: 12–21. ———. 2002. “What Turkish-speaking Women Expect in a German Hospital and How Satisfied They Are with Health Care during Their Stay in a Gynecological Hospital in Berlin.” Gesundheitswesen 64: 476–85. Bourdieu, Pierre. 1986. “The Forms of Capital.” In Handbook of Theory and Research for the Sociology of Education, ed. J. Richardson. New York: Greenwood Press. Brubaker, Rogers. 1992. Citizenship and Nationhood in France and Germany. Cambridge, MA: Harvard University Press. Çaglar, Ayse. 1995. “German Turks in Berlin: Social Exclusion and Strategies for Social Mobility.” New Community 21, no. 3: 309–23. Collins, John A. 2002. “An International Survey of the Health Economics of IVF and ICSI.” Human Reproduction Update 8, no. 3: 265–77. Crapanzano, Vincent. 1977. “Introduction.” In Case Studies in Spirit Possession, ed. Vincent Crapanzano and Vivian Garrison. New York: John Wiley and Sons. Delaney, Carol. 1991. The Seed and the Soil: Gender and Cosmology in Turkish Village Society. Berkeley: University of California Press. Donohoe, Martin. 2003. “Causes and Health Consequences of Environmental Degradation and Social Injustice.” Social Science and Medicine 56: 573–87. Dudgeon, Matthew R., and Marcia C. Inhorn. 2003. “Masculinity and Reproduction: Anthropological Perspectives.” International Journal of Men’s Health 2: 31–56.

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———. 2004. “Men’s Influences on Women’s Reproductive Health: Medical Anthropological Perspectives.” Social Science and Medicine 59: 1379– 95. Estroff, Sue. 1991. “Everybody’s Got a Little Mental Illness: Accounts of Illness and Self among People with Severe, Persistent Mental Illness.” Medical Anthropology Quarterly 5, no. 4: 331–69. Ewing, Katherine P. 2006. “Between Cinema and Social Work: Diasporic Turkish Women and the (Dis)Pleasures of Hybridity.” Cultural Anthropology 21, no. 2: 265–94. Feldman-Savelsberg, Pamela. 1999. Plundered Kitchens, Empty Wombs: Threatened Reproduction and Identity in the Cameroon Grassfields. Ann Arbor: University of Michigan Press. Franklin, Sarah. 1997. Embodied Progress: A Cultural Account of Assisted Reproduction. New York: Routledge. German Federal Ministry of the Interior. 2000. Datenreport 1999. Bundeszentrale für politische Bildung. ———. 2000. Policy and Law Concerning Foreigners in Germany. Berlin. Good, Byron J. 1994. Medicine, Rationality, and Experience: An Anthropological Perspective. Cambridge: Cambridge University Press. Greil, Arthur L. 1991. Not Yet Pregnant: Infertile Couples in Contemporary America. New Piscataway, NJ: Rutgers University Press. Guarnaccia, Peter J., Roberto Lewis-Fernandez, and Melissa Rivers Marano. 2003. “Toward a Puerto Rican Popular Nosology: Nervios and Ataques De Nervios.” Culture, Medicine and Psychiatry 27: 339–66. Gupta, Akhil, and James Ferguson. 1997. “Culture, Power, Place: Ethnology at the End of an Era.” In Culture, Power, Place, ed. Akhil Gupta and James Ferguson. Durham, NC: Duke University Press. Gurmankin A. D., A. L. Caplan, and A. M. Braverman. 2005. “Screening Practices and Beliefs of Assisted Reproductive Technology Programs.” Fertility and Sterility 83, no. 1: 61–67. Hannerz, Ulf. 1989. “Notes on the Global Ecumene.” Public Culture 1, no. 2: 66–75. Haraway, Donna. 1997. Modest_Witness@Second_Millennium.FemaleMan_Meets _OncoMouse: Feminism and Technoscience. New York: Routledge. Horrocks, David, and Eva Kolinsky. 1996. “Introduction: Migrants or Citizens? Turks in Germany between Exclusion and Acceptance.” In Turkish Culture in German Society Today, ed. D. Horrocks and E. Kolinsky. New York: Berghahn Books. Inda, Jonathan Xavier, and Renato Resaldo. 2002. “Introduction: A World in Motion.” In The Anthropology of Globalization: A Reader, ed. J. Inda and R. Rosaldo. Malden, MA: Blackwell Publishers. Inhorn, Marcia C. 1994. Quest for Conception: Gender, Infertility, and Egyptian Medical Traditions. Philadelphia: University of Pennsylvania Press. ———. 1996. Infertility and Patriarchy: The Cultural Politics of Gender and Family Life in Egypt. Philadelphia: University of Pennsylvania Press.

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———. 2003. Local Babies, Global Science: Gender, Religion, and In Vitro Fertilization in Egypt. New York: Routledge. ———. 2006. “Middle Eastern Muslim Men’s Discourses of Adoption and Gamete Donation.” Medical Anthropology Quarterly 20, no. 1: 94–120. Jundt, K. 2003. “Special Considerations Involved in Treating Foreign Patients in Gynecology.” Gynakologe 36, no. 11: 1005–10. Kawachi, I., B. Kennedy, K. Lochner, and D. Prothrow-Smith. 1997. “Social Capital, Income Inequality, and Mortality.” American Journal of Public Health 87: 1491–98. Kearney, Michael. 1995. “The Local and the Global: The Anthropology of Globalization and Transnationalism.” Annual Review of Anthropology 24: 547–65. Kentenich, Heribert, and Emine Yüksel. 1997. Psychosomatisches Betreuungskonzept steriler türkischer Paare in der Migration. Berlin: Virchow-Klinikum and Frauen-und Kinderklinik DRK-Kliniken Westend. Kleinman, Arthur. 1988. The Illness Narratives: Suffering, Healing and the Human Condition. New York: Basic Books. Kleinman, Arthur, and Joan Kleinman. 1991. “Suffering and its Professional Transformation: Toward an Ethnography of Experience.” Culture, Medicine and Psychiatry 15: 275–301. Kleßman, Christoph. 1992. “Einwanderungsprobleme im Auswanderungsland: Das Beispiel der ‘Ruhrpolen.’” In Deutsche im Ausland. Fremde in Deutschland—Migration in Geschichte und Gegenwart, ed. Klaus J. Bade. Munich: Beck Verlag. Kolinsky, Eva. 1996. “Non-German Minorities in Contemporary German Society.” In Turkish Culture in German Society Today, ed. David Horrocks and Eva Kolinsky. New York: Berghahn Books. Koptiuch, Kristin. 1997. “Third-Worlding at Home.” In Culture, Power, Place: Explorations in Critical Anthropology, ed. A. Gupta and J. Ferguson. Durham, NC: Duke University Press. Linke, Uli. 1999. German Bodies: Race and Representation After Hitler. New York: Routledge. Lock, Margaret. 1993. Encounters with Aging: Mythologies of Menopause in Japan and North America. Berkeley: University of California Press. Lunenfeld, B., and A. Van Stireteghem. 2004. “Infertility in the Third Millennium: Implications for the Individual, Family, and Society: Condensed Meeting Report from the Bertarelli Foundation’s Second Global Conference.” Human Reproductive Update 10, no. 4: 317–26. Malkki, Liisa. 1995. “Refugees and Exile: From ‘Refugee Studies’ to the National Order of Things.” Annual Review of Anthropology 24: 495–523. Mandel, Ruth. 1996. “A Place of Their Own: Contesting Spaces and Defining Places in Berlin’s Migrant Community.” In Making Muslim Space in North America and Europe, ed. Barbara D. Metcalf. Berkeley and Los Angeles: University of California Press. Marcus, George E., and Michael M. J. Fischer. 1986. Anthropology as Cultural

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Critique: An Experimental Moment in the Human Sciences. Chicago: University of Chicago Press. Marmot, Michael G. 1986. “Social Inequalities in Mortality.” In Class and Health: Research and Longitudinal Data, ed. R. G. Wilkinson. London: Tavistock. ———. 2004. The Status Syndrome: How Social Standing Affects our Health and Longevity. New York: Times Books. Martin, Emily. 1994. Flexible Bodies: The Role of Immunity in American Culture. Boston: Beacon Press. Mattingly, Cheryl, and Linda C. Garro. 2000. Narrative and the Cultural Construction of Illness and Healing. Berkeley: University of California Press. Nguyen, Vinh-Kim, and Karine Peschard. 2003. “Anthropology, Inequality, and Disease: A Review.” Annual Review of Anthropology 32: 447–74. Nichter, Mark. 1981. “Idioms of Distress: Alternatives in the Expression of Psychosocial Distress. A Case Study from South India.” Culture, Medicine, and Psychiatry 5, no. 4: 379–408. Ong, Aihwa. 1999. Flexible Citizenship: The Cultural Logics of Transnationality. Durham, NC: Duke University Press. Organization for Economic Co-operation and Development. 2008. http:// stats.oecd.org/wbos/Index.aspx?datasetcode=SNA_TABLE1. Ortner, Sherry. 1995. “Resistance and the Problem of Ethnographic Refusal.” Comparative Studies in Society and History 37: 173–93. Panayi, Panikos. 2000. Ethnic Minorities in Nineteenth and Twentieth Century Germany: Jews, Gypsies, Poles, Turks, and Others. London: Longman. Petchesky, Rosalind Pollack. 1998. “Introduction.” In Negotiating Reproductive Rights: Women’s Perspectives across Countries and Cultures, ed. R. P. Petchesky and K. Judd. London: Zed Books. Rapp, Rayna. 1999. Testing Women, Testing the Fetus: The Social Impact of Amniocentesis in America. New York: Routledge. Rouse, Roger. 2002. “Mexican Migration and the Social Space of Postmodernism.” In The Anthropology of Globalization: A Reader, ed. J. Inda and R. Rosaldo. Malden, MA: Blackwell Publishers. Said, Edward W. 1979. Orientalism. New York: Vintage Books. Sandelowski, Margarete. 1993. With Child in Mind: Studies of the Personal Encounter with Infertility. Philadelphia: University of Pennsylvania Press. Santiago-Irizarry, Vilma. 2001. Medicalizing Ethnicity: The Construction of Latino Identity in a Psychiatric Setting. Ithaca, NY: Cornell University Press. Scheper-Hughes, Nancy, and Margaret Lock. 1987. “The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology.” Medical Anthropology Quarterly 1: 6–41. Silove, Derrick, Zachary Steel, and Charles Watters. 2000. “Policies of Deterrence and the Mental Health of Asylum Seekers.” The Journal of the American Medical Association 284, no. 5: 604–27. Sontag, Susan. 1988. AIDS and Its Metaphors. New York: Farrar, Strauss, and Giroux.

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Thränhardt, D. 1995. “Germany: An Undeclared Immigration Country.” New Community 21: 19–36. Tsing, Anna. 2000. “The Global Situation.” Cultural Anthropology 15, no. 3: 327–60. van Balen, Frank, and Marcia C. Inhorn. 2002. “Introduction: Interpreting Infertility.” In Infertility around the Globe: New Thinking on Childlessness, Gender, and Reproductive Technologies, ed. M. C. Inhorn and F. van Balen. Berkeley: University of California Press. Vanderlinden, Lisa K. 2003. “Conceiving Fertility: Ethnic Difference, Reproductive Politics, and the Experience of Infertility in Berlin.” PhD dissertation, Department of Anthropology, Rutgers University. White, Jenny. 1997. “Turks in the New Germany.” American Anthropologist 99, no. 4: 754–69.

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Chapter 2

CULTURAL MEANINGS OF ASSISTED REPRODUCTIVE TECHNOLOGIES WOMEN’S VOICES

FROM

BULGARIA

Yulia Panayotova and Irina L. G. Todorova

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F

or most Bulgarians, the ability to be a parent is taken for granted. The importance of having a child is underscored when the biological processes of conception are disrupted through infertility, often described as one of the most dramatic events for both men and women (Becker 2000; Greil 1991; Throsby and Gill 2004; Webb and Daniluk 1999). Provided they have the information, access, and financial means, more and more Bulgarian infertile couples are choosing assisted reproductive technologies (ARTs), including in vitro fertilization (IVF), to overcome infertility. In the last two decades, a large body of literature has addressed how ARTs have affected the lives of those experiencing “reproductive disruptions” (Becker 2000; Franklin 1997; Inhorn 2002; Inhorn and van Balen 2002; Kahn 2002; Riessman 2000; Riessman 2002; Thompson 2005; Throsby and Gill 2004). New legal, ethical, and social considerations are constantly emerging. The negative consequences of the use of ARTs are frequently explicated within feminist analyses of the social, political, and ethical implications (Franklin and McNeil 1988; Rapp 1987; Raymond 1993; Franklin 1995; Thompson 2005), beginning with their radical rejection as technologies of patriarchal control and surveillance. These address iatrogenic con-

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sequences and claim that ARTs violate the sacredness of human life, commodify the human body, and medicalize reproduction (Rowland 1992; Pfeffer 1987; Wajcman 1991). However, a more nuanced interpretation acknowledges that the complexity of ARTs “embrac[es] both sides of the feminist tension” (Thompson 2002: 53). Despite this large body of literature, in Eastern Europe and in Bulgaria in particular, the topic of ARTs is rarely part of the public discourse. Even though this is a region of dramatic socioeconomic changes, many of which have obvious implications for reproductive health, Bulgarian social scientists have rarely directed their attention to the topic of childlessness and ARTs. In traditional Bulgarian culture, the patriarchal and hierarchical organization of family relations has constructed the act of giving birth as a sacred duty to family and nation (Gavrilova 1999; Kotzeva and Todorova 1994; Marinov 1994). Meanwhile, the transition from a socialist to a democratic society has introduced new models and practices to family formation, such as a slight increase in maternal age at first birth, a decline in the number of births, and an increase in cohabitation and children born to single mothers (Buhler and Philipov 2005; Philipov 2001). Nevertheless, motherhood is a takenfor-granted part of a woman’s life. Whether married or living in cohabitation, “the aspect of almost universal parenthood remained,” being directly associated with having at least one child. Having a child is closely associated with a stable partnership and “a socially accepted way of living together, either in a marriage or cohabitation” (Buhler 2006: 14). Bulgaria’s total fertility rate has fallen from 2.9 percent in 1950, to 1.2 percent in 1995 (Philipov 2001). According to national surveys, most women would prefer to have two children, but economic realities usually set the limit to one (Mirchev 1996). Only 3 percent of women surveyed would prefer not to have children (Philipov 2001). As abortions are a frequent method of birth control, Bulgaria has one of the highest elective-abortion rates in Europe, exceeding the number of births in a given year (Mirchev 1996; UNDP 1995). This high rate is often used in arguments claiming that abortions cause infertility and thus contribute to Bulgaria’s demographic crisis (Bulgarian Association for Sterility and ART 2001). Yet, according to available European data, the rate of infertility (10 percent) is lower in Bulgaria as well as in Hungary, the Czech Republic, and the former Yugoslavia, in comparison to the European countries of Ireland, Switzerland, Austria, and Belgium (Prioux 1993). Other data show an even lower rate of infertility, 6.1 percent, among Bulgar-

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ian women of childbearing age.1 However, the pronatalist discourse in Bulgaria consistently associates infertility with discouraging demographic tendencies, which are seen as “threatening the Bulgarian nation” (Todorova and Kotzeva 2005: 222). One of the goals of the National Program for the Treatment of Infertility, developed in 1998, is to increase the number of births and ameliorate this demographic crisis. Health care providers and their patients are consonant on the point that infertile couples are an important demographic resource, and using similar rhetoric and arguments, they attempt to persuade policy makers of the urgent need for government decisions and measures to expand ARTs. This pronatalist language and the motivations behind it are willingly adopted by reproductive health activists, such as the nonprofit Zachatie (Conception), which provides information on family planning, reproductive health, and infertility treatment and prevention, and works to improve regulations and health care for infertile couples.2 Moral or religious considerations rarely enter into decisions about infertility treatment. Although in 1990, 31.8 percent of Bulgarians considered themselves religious and by 1999, that percentage had risen to 46.7 percent, religion still plays a limited role in shaping worldviews and moral frameworks. In a 1999 World Values Survey, 33.7 percent of the respondents stated that the church gives answers to moral problems, including ARTs (Yanakiev 2005). Even though the Bulgarian Orthodox Church is not vocal in its beliefs about reproduction, its position is in favor of the “integrity of the person and marital relations” and therefore rejects the use of donor insemination and surrogates. It does not reject contraceptives or prenatal testing (except when leading to abortions) but does reject sex selection. In general, though, the church views ARTs as positive to the extent that they can “reduce human suffering” and that, most important, such decisions are personal and should be made with a priest rather than through general doctrines (Yanakiev 2005). Attitudes toward ARTs are further embedded in the broader, generally positive cultural discourse on science and technology, as shown in a study conducted in Bulgaria and the United Kingdom in the mid-1990s (Boyadjieva, Tchalakov, and Petkova 1994). Bulgarians expressed very high levels of trust in science and scientists, whereas respondents in the United Kingdom were more skeptical of new technology. This contrast between Bulgaria and the United Kingdom can be seen as indicative of a more general East–West difference in beliefs about science and technology. We can assume that these will be similar in regard to beliefs about ARTs.

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Transitions in Bulgarian Health Care Although its problems had become evident by the 1980s, the Soviet model of state-supported health care that existed in Bulgaria during the communist era can be credited with providing free health care, controlling disease, and increasing life expectancy. This model was generally preserved in the years following the 1989 collapse (Balabanova and McKee 2002a); in 1991, private health care services were legalized for the first time since 1972 (Koulaksazov et al. 2003) and have expanded significantly. Its shortcomings, due to insufficient state expenditures, were obvious, but past studies show public support for a strong state role, and many respondents felt the most appropriate financial form of health care was tax based, as it was believed to offer universal coverage and, thus, equity (Balabanova and McKee 2004). In 1998, the Health Insurance Act introduced a compulsory insurance system, regulated by the National Health Insurance Fund (NHIF), in which health care is paid by the employee and the employer; the unemployed are covered by the state. This insurance covers outpatient services, and since 2001, hospitals have been contracting with the NHIF. All current outpatient care “can be considered privately provided, though publicly funded” through the NHIF (Koulaksazov et al. 2003: 19). Insured patients using these services pay either nothing or small copayments. However, facilities in the private sector that do not have contracts with the NHIF require full out-of-pocket payments and are used relatively infrequently (Balabanova and McKee 2004), as few citizens can afford them. Since 1989, informal payments given directly to providers have been standard and have expanded. In addition, cost sharing became official in 1997 (European Observatory on Health Care Systems 2003), and formal price lists for copayments were developed. However, under-the-table payments still exist, and the distinction between the two is never quite clear (Balabanova and McKee 2002b; Rivkin-Fish 2005). These informal payments ensure that the patient will be treated by highly skilled specialists and have access to the best health care. The previous understanding that health care is the state’s responsibility has now shifted to one in which individuals are responsible for their own health, stressing the need for personal initiative in preventive health behaviors (Todorova et al. 2006), accessing information, identifying appropriate clinics and providers, and complying with treatment protocols, although the individual’s role in medical decision making is rarely considered (Rivkin-Fish 2005).

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In summary, large-scale health care reform in Bulgaria is still under way. As this reform requires a major transformation of the public health care system in regard to decentralization and privatization, it has not been able to adequately cover population needs. Even though universal medical care is a constitutional right, the state’s insufficient resources, its municipalities, and the NHIF have made it impossible to always ensure this right, which has led to deepening health care disparities (Walters and Suhrcke 2005). Thus, the public’s attitude toward health care reform in Bulgaria reveals the coexistence of strong collectivistic values that support equity and free access to health care, with a valorization of paid services as ensuring high-quality provider expertise, the best care, and the most modern facilities and technologies. However, even though Bulgarians continue to expect free care, they also have a basic mistrust of the health care system, with its insufficient funding and perceived corruption, and as a result, they avoid the system until the last possible moment (Avramova et al. 2005; Balabanova and McKee 2002a).

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Assisted Reproductive Technologies in Bulgaria In the collective rhetoric of the former regimes, reproduction, like other areas of health care, was presented as a responsibility of the state. However, following the collapse of communism, the many aspects of reproduction, such as abortion rights, sexual education, and contraception, have been reconceptualized as services provided within a market economy. The Health Insurance Act identified the services to be covered by or excluded from insurance. As many of the ARTs are not covered, infertility treatments are only available through the private sector, where they are paid for in full, which has important implications for access to treatment and how ARTs are constructed in the public imagination. The cost of IVF and intracytoplasmic sperm injection (ICSI) ranges from 3,000 to 5,000 Leva, equal to or higher than the average yearly salary in Bulgaria.3 ARTs have been available in Bulgaria for over fifteen years but were not regulated until 2005, when the health law took effect. The first baby born as a result of IVF was born in January 1988, in the Maichin Dom Hospital, the maternal hospital of the medical university.4 There are now fifteen infertility clinics in Bulgaria, all of which offer services also available in the West, including IVF, ICSI, testicular sperm aspiration, zygote intrafallopian transfer, and gamete intrafallopian transfer, as well as any these clinics have developed on

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their own. These clinics have launched effective advertising campaigns and professional websites with detailed information about the causes of and treatments for infertility. All are in the largest cities, hold a permit from the Ministry of Health, and are funded privately. They are located in completely independent facilities or in larger hospitals; some contract with hospitals for facilities for surgery and rooms for those patients requiring more complicated interventions. Bulgaria lacks clear state regulations and control over these ART clinics. Until 2005, providers worked under a 1968 health law in which the word “gametes” appears only once. According to the provisions of the 2005 law, ARTs are employed when the natural method of conception is hampered and with the written consent of both partners. The law prohibits the use of ARTs for sex selection (excluding genetic-disease prevention), cloning, and “every form of discrimination of human genome” (Bulgarian Health Law 2004, Article 135, 1–4). Any eggs, sperm, and embryos not used for fertilization can be donated to research, with the informed consent of the donor(s) (Article 134). Although the law was approved in 2004 and enacted in January 2005, the additional decrees informing its practical implementation have yet to be developed. In fact, medical-practice standards and a code of ethics do not exist. Instead, ART clinics are guided by their own rules of practice, which differ significantly (Panayotova and Todorova 2006). In 2005, the NHIF initiated a program in which women would be reimbursed for the cost of their IVF medications. A limited number of women were to benefit from this support: the initial number was 1,000, but at the end of the year the NHIF reported that 1,232 women had participated. The program was presented as supporting several ART attempts, and women were invited to apply for funding once a year. In order to apply for the program, women had to be referred by a medical specialist, making it easier for ART patients to gain access to this funding. However, women receiving the subsidy in the first year were not allowed to apply again, thus making multiple attempts less possible and reducing the chances for conception. In addition, women and clinics were not required to report the outcome of treatment. In the last few years, several studies have been published on women’s experiences of infertility in Bulgaria (Todorova and Kotzeva 2003, 2005, 2006). Using qualitative methodology, these studies focus on how social and cultural contexts are entwined in women’s meanings of their infertility experience, and how women construct and reconstruct their identities and resist the stigma of infertility.

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These works indicate that the experiences of infertility are intimately connected to questions of acceptance and use of ARTs within the Bulgarian cultural and social contexts. This chapter is focused on women’s reflections on ARTs in Bulgaria. Our analysis is informed by the idea that these technologies are permeated and shaped with local meanings (Inhorn 2003). We will identify some of the “local constraints” that limit the availability and use of ARTs (Inhorn 2003) but will predominantly reflect on the striking attractiveness of ARTs and the reasons for their high demand and relatively uncritical acceptance in Bulgaria. We argue that in the context of the strong values of fertility and childbearing, a vocal discourse of a demographic crisis, and an absence of religious barriers, ARTs are perceived as predominantly empowering, benevolent, and trustworthy. In this specific cultural context, science and technology are viewed positively, and infertility specialists are seen as possessing a unique expertise. To the extent that critiques of ARTs do exist, they are not directed toward ARTs but to the ways they are practiced, financed, and legislated in Bulgaria.

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Voices Semistructured interviews with seventeen women were conducted at two different times. The first twelve interviews were held in 2003, at one of the most widely known private ART clinics, which is located in the Bulgarian capital, Sofia. The additional five interviews were held in 2006, with one of those interviews conducted in Varna, the second largest Bulgarian city. For the first round of interviews, women were recruited through personal invitation and with the assistance of clinic administrators. In the case of the latter, a clinic physician invited the women to participate; therefore, the women considered the interviewer as being closely related to the clinic and an “insider.” For the second round of interviews, participants were recruited through the Zachatie website. All participants were between twenty-five and forty-five years of age and lived in different parts of the country. Of the participants, half had secondary infertility (infertility following a previous pregnancy), and half had primary infertility (no pregnancies)—of these primary cases, four were identified as male factor. The number of years in infertility treatments was between three and twelve. One to five cycles had been attempted, but most women had undergone only one. Additional data were obtained by interviews with clinic directors, physicians,

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embryologists, psychologists, and policy makers (see Panayotova and Todorova 2006). Each interview lasted from forty to eighty-five minutes and was transcribed verbatim. Analyses were informed by the method of constructivist grounded theory (Charmaz 1990, 1995), which uses the techniques of grounded theory but with an explicit social constructionist orientation. Charmaz defines constructions as “people’s creation of taken-for-granted interactions, emotions, definitions, ideas and knowledge, about illness and about self,” which shape people’s realities and are given form in social interactions. The text was also approached with an understanding of language as generative of social reality, paying close attention to participants’ use of language when constructing their experiences. We proceeded through a very close reading of the text, identifying and selecting passages, words, and phrases relevant to ARTs. These passages were then coded with initial open codes and in-vivo codes, and subsequently organized into broader categories.

Images of Assisted Reproductive Technologies

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The Long Search The ART procedures the participants were undergoing during our study were the end result of a long, frustrating, and determined search for treatment. Although fifteen ART clinics now exist in Bulgaria, many of them were established in the last few years and only became more visible through clinic websites and Internet advertisements. In most of these narratives, a major focus was the time lost searching for treatment. According to thirty-two-year-old Raya, So even for me, even though I live in Sofia, I’m not from the woods, right. When I faced this problem, I had no idea who to turn to, I just didn’t know where to find these specialists, and it hadn’t even occurred to me that there are specialized infertility clinics. … So in practice it is clear that we lose six months to a year, even, in hanging around in the office of the neighborhood gynecologist who does not want to admit that he is not competent on the topic and does all kinds of crazy things, including things that can be dangerous for the patient’s health. Until finally the person is fed up and a light bulb turns on, and she realizes this is probably not the place where she should be.

As thirty-nine-year-old Milena stated,

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But in my case, you know, the disappointment comes from the fact that I didn’t have any information, and I was being treated by physicians who I can say with a clear conscience shouldn’t be working the way they work and just didn’t want to lose another [paying] customer. So I needed two years to find people who really treat infertility. Because obstetrics is one thing, gynecology another, and infertility is something specific.

Meanwhile, participants were grateful for physicians who did not “experiment” on them and referred them to infertility clinics, as it is not unusual for primary-care gynecologists to treat women for infertility even if they are not specifically trained to do so. This occurs not only in some remote areas, but also in larger cities. This observation was confirmed by our interviews with infertility-treatment providers who complained about the cases that had been “neglected” and pitied the women who had wandered before stumbling upon their clinics. Stories of treatment were long narratives of multiple examinations, various treatments, and surgeries. Participants expressed frustration with having undergone unnecessary tests and inappropriate treatments and receiving incorrect diagnoses. Yet, they often blamed themselves for some of these negative outcomes—for failing to gather enough information beforehand and not choosing the best clinic. Most were convinced they had finally found the right clinic and felt it offered the best possible care. Almost all narratives compared disappointing experiences to their current high-quality treatment. As Stela said, “[At the previous clinic] some of my water leaked out, I went for an exam. The doctor said definitely that’s not the water, just some discharge. Of course I had a very long exam, a very painful one, at the end I couldn’t stand it. Here [at the current clinic] with all the manipulations I go through, they have not caused me the kind of pain I had there.” Women expressed their great disappointment with inadequate treatments and providers and constructed a positive and hopeful, almost idealized, image of the clinics in which they were currently receiving treatment. Some of the interviews were conducted at the clinic by the first author, who was introduced to the participants by the medical staff, which could have influenced the women’s responses. However, based on other interviews and observations over several years, we feel that our conclusions about the positive attitudes toward current specialists are generally valid. Yet, even when the women fully trusted the staff, the procedures required great effort and dedication. Most of the clinics in Bulgaria

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are still in their infancy, and therefore all services cannot be provided in one location. Thus, the patients must navigate several different environments while under treatment. As Galya commented,

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Yes, the way they treat us and their attitude [I am very satisfied]. But it is somewhat inconvenient. … We are inpatients at the hospital, and we come to the [private] clinic every evening for exams. And every morning we go to [the laboratory] near the train station, for the labs. And it is very inconvenient. And all this travel, especially at night … well, not every night but every once in a while, we have to wait for the exams until very late. … If you are alone, you have to get back to the hospital at 10 or 10:30 PM. It is very inconvenient.

The inaccessibility of ARTs was embodied not only in the confusion of locating an infertility clinic and navigating treatment, but also in the financial burden. Considering the extremely high price of IVF and ICSI cycles relative to the average Bulgarian’s monthly salary, financial planning was sometimes necessary, including saving money over a long period of time, borrowing money from parents, or selling property. As most of the participants constructed their hope for success around the statistics that several IVF attempts are necessary in order to achieve a higher probability of conception, they were making plans to fund three or more attempts. Thus, many of the women wished for government intervention and longed for the days of socialized medicine. They invoked public rhetoric about the demographic crisis in Bulgaria, using the logic that if the government were genuine about stimulating the birth rate, the introduction of subsidies for infertility treatments would be a very effective way to positively influence the Bulgarian population. As Stela commented, If my husband and I had had to come here [for IVF treatment] just on our salaries, it would have been impossible. My father funded our first attempt, and now he’s funding our second IVF, but not everyone has parents who can help. … I think this is a medical issue, like diabetes or heart disease, and the National Health Insurance Fund has funds for those. … [They should cover] at least part of the expenses. Something can be done; I even think that people with diabetes are not as unhappy as some women [with infertility]. If it were possible for the NHIF to cover at least the medications for ovulation stimulation, many more women would do it. Many women have said, “If only I had the funds, nothing else matters, if only I could find the money.”

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Unique Expertise In the last decade, several authors have addressed the level of satisfaction or dissatisfaction of those undergoing infertility treatment, showing that women and men have been generally satisfied with the medical aspects of the treatment offered but less satisfied with how the emotional aspects were addressed (Malin et al. 2001; Souter et al. 1988; Schmidt 1998; Boivin, Scanlan, and Walker 1999). On the basis of our research, we can state that Bulgarian women have become more sensitive to how treatment is conducted and more selective about the quality of the technologies offered. While they wander through the health system, they become more informed about their own situations and the types of treatment available, and their expectations and criticism increase. As in other studies, the women in our study expressed their opinions on the quality of care in terms of their access to and outcome of treatment. Assessing satisfaction with treatment is complicated when the patient has met a variety of doctors, nursing personnel, and procedures in different clinics over a long period of time (Sandelowski 1993; Greil 1997). From the interviews we conducted during the first phase of our study, we can conclude that each participant placed great trust in her clinic’s medical staff. At the time of our study, the clinic at which we conducted the first round of interviews was the most famous in Bulgaria and was led by the specialist recognized publicly as the person who had introduced ARTs to Bulgaria. The women’s positive attitudes were additionally informed by their belief that the staff provided realistic success rates. Some participants recalled the very high and therefore unrealistic success rates other clinics had given them, thus raising women’s doubts about their efficacy. The risk and relatively low success rates given at the current clinic were not seen as discouraging, as long as the staff openly addressed them. As Stela commented, “They are confident that sooner or later I will have [a child]. And since I’ve started coming to this clinic, I am also convinced that I will have a positive result.” One of our participants’ greatest concerns was the lack of competent Bulgarian infertility specialists. Infertility treatment was viewed as a very specific field requiring professionals with a high level of skill and knowledge about emerging technologies. The lack of knowledge held by primary-care gynecologists was seen as a serious obstacle to proper care. As Raya stated, “[They sent me] back to my primary-care gynecologist, who might be good as a physician, but I claim that she doesn’t understand infertility, because she worked on

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the basis of trial and error. … She gives these explanations, which, if you have read anything, they don’t stick. They don’t sound serious.”

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Technologies of Hope Although participants expressed some ambivalence about ARTs, they overwhelmingly endorsed their use and saw them as technologies of hope and empowerment (Franklin 1997). Furthermore, some of the women felt ARTs had the potential to give them back their real lives, which they felt they had lost to infertility. Mira, who was pregnant after one IVF/ISCI treatment, said, “I always felt upset when hearing that a close friend had had a child or that she was pregnant. Not because I’m envious. Everyone has their own life and you can’t … I don’t want their husband, I don’t want their life, I want[ed] my own life [back].” Participants believed that ARTs were helpful and should be available to all infertile women. They generally did not perceive ARTs as forcing nature or as a magical and miraculous instrument but as a tool that empowers women through their physicians. ARTs were seen as giving hope to and an opportunity for women to follow their “normal” path to motherhood. The decision to undergo IVF treatment was not a difficult one, considering each woman’s long history of testing and previous treatment. Rather, the decision to undergo ARTs was framed as the natural next step and often as “the only hope.” As Poli stated, “We do not have many possible choices, because his [husband’s] results do not give us a range of opportunities. Our only opportunity was the one that the doctors proposed: a combination of IVF and ICSI, and I fully trust them. At this point there is no sense in doing artificial inseminations and waiting to see if it will happen or not.” Few of the women expressed any fears about the negative consequences of ARTs, and those who did utilized different strategies to minimize the risks and pain involved in the procedures. Although the public discourse does not provide much information about the negative aspects of treatment, many of the women were well informed in general, either by providers or through books and Internet sites. However, this knowledge about IVF and its risks did not translate into substantial fears or any possible future health issues, perhaps because of their concentration on the ongoing treatment and their unwillingness to allow any negative thoughts. The need for a positive, though “realistic,” attitude is part of the culture of the clinics, and the women saw remaining optimistic as one of their responsibilities. As Nadya said,

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So believing is very important, I think. You have to be confident, to be relaxed, because if you worry and keep thinking about it, the doctors said, you can get contractions, which can expel the fetus. And I think you have to have a very positive attitude in the sense that even if it doesn’t work, you shouldn’t be angry, you shouldn’t have a negative attitude.

In the face of great social pressure and an absence of a negative discourse on ARTs, each participant was willing to do anything to become a biological mother. Even when pain was acknowledged, it was presented as insignificant compared to the pain of childlessness. After two tubal surgeries, Stela was surprised that the egg retrieval was “nothing, just nothing,” and participants who had undergone egg retrieval reported that it was not painful at all and felt that the clinic staff had exaggerated. The main concern was whether the procedure would be successful. As Gayla said, “So we do worry. There is worry during the ten days of stimulation. Then [we worry about] the retrieval. Then we worry about the transfer. Then the biggest worry is about the result of the transfer.” Women in this study experienced varying degrees of anxiety about the upcoming procedures. Women who had already been treated in the same clinic were less anxious, because they were familiar with the procedures and staff. Stela, who was undergoing a second IVF attempt, had been fearful before her first procedure. As a result of her vivid memories of the pain associated with her previous ectopic pregnancies, she collapsed after her first hormone injection. At the time of the interview, however, she was relaxed and smiling, full of optimism about the outcome. “The first time I came with a lot of fear. But now it is radically different, I came relaxed, I feel as if … as if I’m going on a vacation, on a vacation in another city. The first time it was very, very difficult.” A confusing experience for some women was how ARTs redefine bodily boundaries, particularly during the fertilization procedure. According to a doctor in the clinic, the staff tries to steer women away from thinking about their fertilized eggs as “babies” in case the procedure is unsuccessful. As one doctor said, “It is better to convince them that these are cells. It’s less traumatic to think of cells that have not been implanted than of [the loss of] a baby.” Regardless, according to Nadya, When I had the retrieval done, I felt like they were there, that they needed me. Yes, it was a feeling like that. … And then, when they do the transfer, it is as if you feel them. I think it is like a psychosis, I

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know you can’t really feel them, but … And then when you get a negative test, of course it’s not the doctors’ fault, so you start [blaming yourself]—I didn’t do this, I didn’t do that, a feeling of both guilt and loss. Because you sort of felt them within you, but then they’re not there. Exactly a feeling of loss.

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Believing ARTs During our interviews, participants strongly expressed their belief in their own perseverance, the expertise of the physicians, and the potential of the technologies. However, these statements were entwined with an acceptance of past or potential failures as revealing a predetermined “fate.” Although accepting unsuccessful ART outcomes through the logic of fate was quite common, ARTs were not seen as interfering with one’s fate. Most women were convinced that their own life paths had to include motherhood (Todorova and Kotzeva 2003) and that the technologies would help them back on to the path. The concept that one’s predetermined fate may not include children would be an unusual one—the proof of this only could be reached after multiple unsuccessful treatments. Accepting this fate was the only source of relief from the frustration and discouragement of shattered hopes. As Nadya commented, “Our little paths are predetermined, and one can’t change one’s fate and one shouldn’t regret the past.” Although “fate” was usually not understood in explicitly religious terms, some participants framed it as an illustration of “God’s will.” In these cases, scientific intervention was not seen as displacing God’s will but rather as an investigation of what this will is, testing the limits of what God might want or allow. The technologies could be used to their full potential, but if a pregnancy was not in the divine plans, the technology could not change these plans, even if attempts were made to force them. As one participant commented, For one woman, the sperm were running away from the egg. Under the microscope they could see that. And in spite of everything, they fertilized [the egg], and in spite of everything she miscarried the fetus two weeks later. So, we are in God’s hands. Whatever depends on me I will try to do it. … And from then on what will be the outcome is not under our control nor in our abilities to predict it. We can only believe, to hope and to fight according to our abilities.

Science was not seen as contradicting religious beliefs, or as Lie points out, “Science and religion often function as one belief system, and not as contrasting forms of knowledge” (2002: 394). Neverthe-

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less, religious considerations rarely entered the participants’ decisions, and even when they did, the use of technology for facilitating conception was not seen as opposing their religious beliefs. Redefining Partnerships IVF treatment can redefine the male partner’s position. Participants usually presented their male partners as supportive and caring. However, partners were minimally represented in the narratives, creating an impression of a “missing” partner or one who has a secondary role in the drama of IVF. As Stela said,

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My husband is a very good man and he never allowed me to worry if we have no children. … We almost don’t talk about this at home— not that we’re trying to avoid it. He just says, “For me, it is not important [if we have children or not].” Even for the IVF he told me, “It’s up to you, I can’t [make a decision].” Now for the second in vitro he said, “I don’t want you to go.” To him it seems much scarier than it does to me … not for him personally, but he is afraid because I will experience pain.

Although participants spoke of ARTs in terms of empowerment, they felt their partners were much more skeptical.5 These different levels of trust in the ARTs can be a source of tension—whereas the women saw ARTs as their hope for motherhood, the men saw them as creating uncertainty about fatherhood, as they did not feel secure about the technology (and by extension, the clinical staff) in safeguarding their biological paternity. One woman recalled her husband’s doubts about whether they were going to use his sperm for fertilization, which, according to a clinic biologist, is a common concern for male partners. Confirming their biological fatherhood through genetic testing is an expensive procedure and is not seen as a real option. In addition, partners worried about the treatment’s potential negative side effects, even more than the women did. Male partners’ uncertainty about ARTs, insistence of proof of biological fatherhood, and their general invisibility in the lengthy and complicated treatment process are all closely tied to cultural discourses of masculinity in relation to men’s bodies and health (Courtenay 2000a, 2000b). Their distrust of ARTs has been observed in another study on the experiences of infertility in Bulgaria (Todorova and Kotzeva 2003). Although fatherhood is an expected role and is associated with constructions of masculinity in Bulgaria, male infertility is even more stigmatized than women’s, to the extent that many men avoid infertility treatments.

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In addition to reinforcing the construction of masculinity as associated with emotional inexpressiveness (Throsby and Gill 2004), the women portrayed themselves as the main actor in the decisionmaking process and independent of their partners. Although this can be seen as ARTs offering empowerment and choice, it also places a great burden on women. Participants actively sought information, and were generally better informed than their partners about the procedures, clinics, and treatments. Ema, for example, said, “My husband, yes, I only give him the facts. He sounds like he is doing mathematical calculations and then says ‘yes’ or ‘no’ about something, but he generally agrees with me. He doesn’t contradict me and doesn’t discuss every step of mine, doesn’t look at my actions under a microscope.” Thus, in the context of ART treatment we can identify a symbolic redefinition of the family and parental roles, which was evident in participants’ narratives, as well as in each clinic’s culture and promotional discourses (Todorova and Kotzeva 2005). Infertility specialists were often endowed with a metaphoric paternal role, a role further endorsed through the marginalization of the male partner. Male partners often became outside observers of the activities surrounding treatment—their most desired role was one of nonintervention.

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Women’s Voices from Bulgaria: Analyzing the Discourse Marcia C. Inhorn (2003) identifies the eight “arenas of constraint” relevant to ARTs in Egypt. Some of these constraints can also be identified in the Bulgarian context, the most powerful of which is the financial burden. ARTs are offered exclusively through the private sector, with the exception of a recent government program that reimburses a limited number of women for the cost of the medications. Thus, the expanding use of ARTs allows some people to reproduce but not others (Ginsburg and Rapp 1995). Yet, the overwhelming attitude of the Bulgarian women we interviewed and their providers is that, ultimately, financial constraints do not truly impede access to ARTs—the assumption is that anyone, no matter how limited their economic resources, can find a way to finance the treatments, because the possibility of having a biological child is priceless. An additional constraint in accessing ARTs was the absence of information about specialized clinics and infertility experts, as well as inappropriate referrals, unnecessary tests and procedures, and sim-

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ilar frustrations, all of which resulted in lengthy periods of searching and losing valuable time. The complicated logistics of following the treatment protocols and the inconvenience of and fatigue from traveling from the clinics to the laboratories to the hospitals (problems that are being reduced as more well-equipped clinics are established) contributed to the difficulties of treatment. However, participants saw these constraints as barriers that had to and could be overcome through stoic efforts and determination at almost any cost. Some of the constraints identified in other contexts were not observed in Bulgaria. Unlike the constraints discussed by Inhorn (2003) and Kahn (2002), the women we interviewed rarely invoked personal, religious, or moral dilemmas about whether to utilize ARTs. These discussions were framed predominantly within a secular understanding of reproduction and medical interventions. In the rare times when religious beliefs were invoked, they were not seen as being in conflict with science and technology. If the treatment had been unsuccessful, it was seen as “God’s will.” The few indirect references to moral dilemmas about the use of ARTs regarded male partners’ feelings about these procedures. Male partners were much more critical about their use, and were particularly apprehensive about the iatrogenic consequences to their partners’ health and thus were torn about allowing treatment to continue. Although the women did not voice any concerns about the possible mix-up of gametes, their male partners frequently asked about their sperm, questioning the certainty of their paternity. Male partners had a more passive role in the dynamics of ARTs but also expressed greater skepticism and moral questioning about repeated procedures. When the Bulgarian media introduces new reproductive technologies, it tends to focus on the positive effects for women and society but contains little about the risks and negative aspects of treatment. Although this initially was also true of the medical profession, providers and clinics are now much more forthcoming about the possible risks and relatively low efficacy rates. Such information is available at the clinics’ websites, but rather than discouraging women, this information contributes to positive construals of the clinics and their procedures. Thus, the medical risks associated with hormonal stimulation, egg retrieval, and other stages of the procedures are well known. Yet, the women we interviewed minimized these risks and reported that procedures, including the egg extraction, were relatively painless and uncomplicated. The pain and inconvenience of IVF and ICSI were felt to be incomparable to the pain experienced

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during other procedures and, in particular, to the pain of living without a child. Though the possible iatrogenic consequence of ARTs were acknowledged by both the clinical staff and the women, there is virtually no critique or discussion of their implementation from feminist or ethical points of view. For example, there is minimal questioning of these technologies from a bioethical perspective. The fear that such technological interventions will shift from “giving nature a helping hand” (Throsby 2002: 51) to meddling with nature has not emerged in relation to conceptive technologies in the highly pronatalistic Bulgarian context. However, it is certainly evident in popular and personal discussions about genetic interventions, stem cell research, and cloning. “A distinction between helping nature and tampering with nature is crucial to the construction of IVF as fundamentally natural, with IVF functioning within this discourse as low rather than high tech; mechanical rather than technological” (Throsby 2002: 51). In Throsby’s terms, IVF and ICSI are seen in Bulgaria as a relatively low-tech intervention, as tools for “helping” nature rather than “tampering” with it—that is, when considering potential risks. However, ARTs were relocated to a high-tech status when participants emphasized the importance of the high level of physician expertise, which encouraged their optimism and hope that such highly advanced tools would make their dreams of conception come true. Thus, a positive image of ARTs was constructed through the great respect for the specialists implementing them. Women created a vivid contrast in the images of their current clinics and physicians, as compared to previous ones. The current infertility specialists were valorized in terms of skill and expertise and were cast in a parental role, generally independent of gender. The according of power, high expertise, and a paternalistic role of physicians can undoubtedly be part of the legacy of the previous medical system, in which the hierarchical relationships between physicians and patients were emphasized (Rivkin-Fish 2005). RivkinFish (2005) also draws attention, however, to the unique manifestation of these hierarchical relations in the socialist medical system, in which physician dominance in the doctor–patient relationship takes place in the context of relative organizational and political disempowerment of the medical profession. In the current period of transformation of health care structures, privatization, and the role of new technologies, elements of the paternalistic image of physicians are being preserved yet transformed. The ART clinics in particular offer a unique example of coexistence of elements of a

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paternalistic model as well as a more co-active model of physician– patient interaction. In general, most of the women expressed trust and were grateful for the care they received, independent of the outcome of their current treatment. We must underline, however, that similar to Franklin (1997), the “glowing” terms women use when describing the clinics and doctors are usually reserved for those who use ARTs and can be in stark contrast to how they present their experiences in other reproductive health care contexts. Our own previous research suggests that this idealization of the physicians is restricted to infertility specialists in their roles of “making babies” through the new technological interventions. In other areas of health care, such as cervical cancer prevention (Avramova et al. 2005) and more low-tech forms of treating infertility (Todorova and Kotzeva 2006), women’s attitudes can be much more ambivalent or explicitly critical, and technologies are not seen as benevolent (Rivkin-Fish 2005). As described in the beginning of this chapter, the development of ARTs is in a cultural space, which historically exemplifies a positive public understanding of science and technology. In addition, technologies in the area of reproductive medicine carry specific historical meanings from the times of socialized medicine, elements of which might be carrying over to the current period. As Rivkin-Fish (2005) illustrates, medicalization through high reliance on technology ensures care and control of care in the context of limited economic resources. Participants’ meanings resonated with these broader cultural meanings of science as progress. The role of science and technology as a catalyst of national progress takes on additional importance in the current context of the Bulgarian demographic crisis. Lie points out that “science has extended its influence over the reproductive process from the periods of pregnancy and birth to the moment of conception and can symbolically appear as the creator, or the new father” (2002: 394). In our interviews, science was seen as positive; however, it was not abstractly powerful and paternal but anchored as a tool in the parental hands of the highly skilled physicians. The full trust with which participants endowed their physicians seamlessly diffuses into the technological tools. Specifics of health care reform in Bulgaria contribute to shaping the local conceptualizations of ARTs. Rivkin-Fish (2005: 9) identifies three key “strategies for social change” relevant to the transformation of the health care system in Russia after the collapse of the Soviet Union: individualizing, personalizing, and privatizing strategies. Of central significance to the expansion of ARTs in Bulgaria is

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the privatization of infertility treatment. On the one hand, privatization does not allow for state and insurance funding, thus introducing the most substantial barrier to the use of ARTs: financial. On the other hand, the fact that ARTs are offered only in costly and fully privatized clinics, which have flourished in the last decade, imbues these procedures with quality, expertise, and desirability. This also supports the image that highly qualified physicians work in these clinics, as they are among the few who have been able to build successful private practices at a time when practitioners who contract with the NHIF provide most other health needs.6 Although these images of privatization are associated with well-equipped facilities and luxurious environments for the procedures, this was of secondary importance to participants when determining clinic reputation. That infertility clinics function completely on a fee-for-service basis additionally underscored the centrality of economic and professional relations between clients and staff, and minimized the relevance of personalization strategies, which play a major role in most other spheres of health care in Bulgaria.7 Individualizing strategies are somewhat more ambiguous in the context of ARTs in Bulgaria. It was obvious that participants saw themselves as determined individual agents in the search for information and clinics and in their perseverance during treatments. This self-reliance is reinforced by discourses that have shifted responsibility to the individual in the new realities of health care reform (Rivkin-Fish 2005; Todorova et al. 2006), as well as through those that locate the primary responsibility for infertility in the woman’s body (Inhorn 1994) and construct the absence and passivity of the male partner (Todorova and Kotzeva 2006). During our interviews, however, the women addressed forms of collective agency and searched for others facing similar issues, which was clearly illustrated by the formation and growing success of Zachatie. This organization and the women in this study and in others (Todorova and Kotzeva 2003) advocated for social, systemic, and legislative changes. Most of their formal and informal appeals were requests for government subsidies or insurance coverage of infertility treatment. These were most probably motivated by their personal wishes for children, as well as by the strong societal value for collective responsibility and equity in health care (Balabanova and McKee 2004). However, a broader political agenda includes the need for the government to play a part in regulating infertility treatment and elucidating patients’ rights and clinic responsibilities, such as criteria for licensing of infertility clinics and regulating third-party

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donation and embryo preservation. Although our informants rarely expressed resistance about the conflation of womanhood and motherhood, they appealed for the destigmatization of infertility in society and reflected on possible approaches.

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Conclusion In Bulgaria, motherhood is generally essential to the social construction of womanhood. Thus, not having children is rarely a realistic option. In this struggle for motherhood, the women we interviewed strongly endorsed ARTs. When motherhood was denied through difficulties with conception and in a pronatalist context, the women we interviewed used all possible means to overcome financial, emotional, and logistical difficulties. In addition, infertility in Bulgaria is imbued with animated concerns about the “dying out of the nation” due to low fertility rates and large-scale emigration. The women we interviewed internalized these concerns and perceived the act of giving birth as their contribution to preserving the nation (Alsop and Hockey 2001; Todorova and Kotzeva 2003). Although they did express ambivalence about ARTs, they saw them as an empowering and optimistic alternative. Women’s ambivalences about ARTs mostly concerned the potential negative side effects of hormonal hyperstimulation and physical pain of the procedures, as well as with the high cost and absence of legislative regulation of their implementation. In conclusion, ARTs in Bulgaria are generally perceived as benevolent and responsible. A critique of their implementation can be identified but is mainly limited to their potential negative side effects and costs. The main explanations for this optimism are the specifics of health care reform in Bulgaria; the construction of doctors (particularly IVF specialists in the private sector) as highly skilled, trustworthy, and expert; the high trust in science and technology; the demographic context and the strong societal and personal expectations for motherhood.

Notes 1. From 2000–2004, the United Nations Population Fund financially supported Project BUL/00/P01, titled “Strengthening the National Reproductive Health Programme.” Implemented by the Bulgarian Ministry of Health, the Bulgarian Association of Sterility and Reproductive Health

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2. 3.

4. 5. 6. 7.

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and the Bulgarian Society of Obstetrics and Gynecology conducted a survey on the prevalence and causes of infertility in Bulgaria in 2002. The results are published in Reproduktivno zdrave 2004, no. 7: 7–12. http://www.zachatie.org According to the Bulgarian National Statistical Institute, the average monthly salary in 2005 was 330 Leva (http://www.nssi.bg/content/ publikacii/metodica.html). http://www.zachatie.org/modules.php?name=News&file=print&sid =141 Male partners’ negative and skeptical attitudes were inferred from women’s accounts as well as our ethnographic observations. Private infertility clinics contract very minimally with the NHIF for some of the more standard laboratory testing. Through these personalization strategies of change, the official rules and expectations are circumvented, and personal relations, such as connections and friendships in the health sector, are sought in order to ensure adequate care (Rivkin-Fish 2005: 10).

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References Alsop, R., and J. Hockey. 2001. “Women’s Reproductive Rights as Symbolic Resources in Central and Eastern Europe.” European Journal of Women’s Studies 8, no. 4: 454–71. Avramova, L., D. Balabanova, J. Bradley, Y. Panayotova, and I. Todorova. 2005. Psychosocial and Health System Dimensions of Cervical Cancer Screening in Bulgaria. Sofia, Bulgaria: Health Psychology Research Centre and EngenderHealth. Balabanova, D., and M. McKee. 2002a. “Access to Health Care in a System of Transition: The Case of Bulgaria.” International Journal of Health Planning and Management 17: 377–95. ———. 2002b. “Understanding Informal Payments for Health Care: The Example of Bulgaria.” Health Policy 62: 243–73. ———. 2004. “Reforming Health Care Financing in Bulgaria: The Population Perspective.” Social Science and Medicine 58: 753–65. Becker, G. 2000. The Elusive Embryo: How Women and Men Approach New Reproductive Technologies. Berkeley: University of California Press. Boivin, J., L. C. Scanlan, and S. M. Walker. 1999. “Why are Infertile Patients not Using Psychosocial Counselling?” Human Reproduction 14, no. 5: 1384–91. Boyadjieva, P., I. Tchalakov, and K. Petkova. 1994. Naukata–jivot izvn laboratoriyata (Science: Life Outside the Laboratory). Sofia, Bulgaria: Bulgarian Academy of Sciences Press. Bühler, Christoph. 2006. “On the Structural Value of Children and its Implication on Intended Fertility in Bulgaria.” Max Planck Institute for De-

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mographic Research, Rostock, Germany, in its series MPIDR Working Papers. Number WP–2006–003. Bühler, Christoph, and D. Philipov. 2005. “Social Capital Related to Fertility: Theoretical Foundations and Empirical Evidence from Bulgaria.” Vienna Yearbook for Population Research 53–81. Bulgarian Association for Sterility and ART. 2001. http://www.basrh.org. Bulgarian Health Law. 2004. Article 135, 1–4. Charmaz, K. 1990. ‘‘‘Discovering’ Chronic Illness: Using Grounded Theory.” Social Science and Medicine 30, no. 11: 1161–72. ———. 1995. “Grounded Theory.” In Rethinking Methods in Psychology, ed. J. Smith, R. Harre, and L. Van Langenhove. London: Sage. Courtenay, W. 2000a. “Constructions of Masculinity and their Influence on Men’s Well-Being: A Theory of Gender and Health.” Social Science and Medicine 50: 1385–401. ———. 2000b. “Engendering Health: A Social Constructionist Examination of Men’s Health Beliefs and Behaviours.” Psychology of Men and Masculinity 1, no. 1: 4–15. European Observatory on Health Care Systems. 2003. Health Care Systems in Transition: Bulgaria. World Health Organization, Regional Office for Europe. Franklin, S. 1995. “Postmodern Procreation: A Cultural Account of Assisted Reproduction.” In Conceiving the New World Order: The Global Politics of Reproduction, ed. F. Ginsburg and R. Rapp. Berkeley: University of California Press. ———. 1997. Embodied Progress: A Cultural Account of Assisted Conception. London: Routledge. Franklin, S., and M. McNeil. 1988. “Reproductive Futures: Recent Literature and Current Feminist Debates on Reproductive Technologies.” Feminist Studies 14, no. 3: 545–74. Gavrilova, R. 1999. Koleloto na jivota (The Wheel of Life). Sofia, Bulgaria: Sofia University Press. Ginsburg, F., and R. Rapp, eds. 1995. “Introduction: Conceiving the New World Order.” In Conceiving the New World Order: The Global Politics of Reproduction. Berkeley: University of California Press. Greil, A. 1991. Not Yet Pregnant: Infertile Couples in Contemporary America. New Brunswick, NJ: Rutgers University Press. ———. 1997. “Infertility and Psychological Distress: A Critical Review of the Literature.” Social Science and Medicine 45, no. 11: 1679–704. Halman, L. J., A. Abbey, and F. M. Andrews. 1993. “Why Are Couples Satisfied with Infertility Treatment?” Fertility and Sterility 59: 1046–54. Inhorn, M. 1994. “Interpreting Infertility: Medical Anthropological Perspectives.” Social Science and Medicine 39, no. 4: 459–61. ———. 2002. “The ‘Local’ Constructs the ‘Global’: Infertile Bodies and New Reproductive Technologies in Egypt.” In Infertility Around the Globe: New Thinking on Childlessness, Gender and Reproductive Technologies, ed. M. C. Inhorn and F. van Balen. Berkeley: University of California Press.

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———. 2003. Local Babies, Global Science: Gender, Religion and In Vitro Fertilization in Egypt. New York: Routledge. Inhorn, M. C., and F. van Balen, eds. 2002. Infertility Around the Globe: New Thinking on Childlessness, Gender and Reproductive Technologies. Berkeley: University of California Press. Kahn, S. M. 2002. “Rabbis and Reproduction: The Uses of New Reproductive Technologies Among Ultraorthodox Jews in Israel.” In Infertility Around the Globe: New Thinking on Childlessness, Gender and Reproductive Technologies, ed. M. C. Inhorn and F. van Balen. Berkeley: University of California Press. Kotzeva, T., and I. Todorova. 1994. The Bulgarian Woman: Traditional Images and Changing Realities. Pernik, Bulgaria: Krakra Press. Koulaksazov, S., S. Todorova, E. Tragakes, and S. Hristova. 2003. “Health Care Systems in Transition: Bulgaria.” European Observatory on Health Care Systems 5, no. 2: 46–47. Lie, M. 2002. “Science as Father? Sex and Gender in the Age of Reproductive Technologies.” The European Journal of Women’s Studies 9, no. 4: 381–99. Malin, M., E. Hemminki, O. Raikkonen, S. Sihvo, and M.-L. Perala. 2001. “What Do Women Want? Women’s Experiences of Infertility Treatment.” Social Science and Medicine 53: 123–33. Marinov, Dimitar. 1994. Narodna vyara i narodni religiozni obichai (Beliefs and Religious Rituals of the Bulgarian People). Sofia, Bulgaria: Bulgarian Academy of Sciences Press. Mirchev, M. 1996. Reproductive Behavior, Family Planning, Use of Contraceptives. Sofia, Bulgaria: Agency for Social Surveys and Analysis. Panayotova, Y., and I. Todorova. 2006. “The Politics of Reproductive Rights and Reproductive Technologies in Bulgaria.” Paper presented at the IUSSP Seminar of Ethical Issues in Reproductive Health. Wassenaar, The Netherlands. Pfeffer, N. 1987. “Artificial Insemination, In-vitro Fertilization and the Stigma of Infertility.” In Reproductive Technologies: Gender, Motherhood and Medicine, ed. M. Stanworth. Minneapolis: University of Minnesota Press. Philipov, D. 2001. Fertility and Family Surveys in Countries of the ECE Region. United Nations: New York, Geneva. Prioux, F. 1993. “L’infecondite en Europe.” In Demographie Europeenne, ed. A. Blum and J. L. Rallu. Paris: John Libbey Eurotext/INED. Rapp, R. 1987. “Moral Pioneers: Women, Men and Fetuses on a Frontier of Reproductive Technologies.” Women and Health 13: 101–16. Raymond, J. 1993. Women as Wombs: Reproductive Technologies and the Battle Over Women’s Freedom. San Francisco: Harper Collins. Riessman, C. 2000. “Stigma and Everyday Resistance Practices: Childless Women in South India.” Gender and Society 14, no. 1: 111–35. ———. 2002. “Positioning Gender Identity in Narratives of Infertility: South Indian Women’s Lives in Context.” In Infertility Around the Globe: New

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Thinking on Childlessness, Gender and Reproductive Technologies, ed. M. C. Inhorn and F. van Balen. Berkeley: University of California Press. Rivkin-Fish, M. 2005. Women’s Health in Post–Soviet Russia. Bloomington: Indiana University Press. Rowland, R. 1992. Living Laboratories: Women and Reproductive Technologies. Bloomington: Indiana University Press. Sandelowski, M. 1993. With Child in Mind: Studies of the Personal Encounter with Infertility. Philadelphia: University of Pennsylvania Press. Schmidt, L. 1998. “Infertile Couples’ Assessment of Infertility Treatment.” Acta Obstetricia et Gynecologica Scandinavica 77, no. 6: 649. Souter, V. L., G. Penney, J. L. Hopton, and A. A. Templeton. 1988. “Patient Satisfaction with the Management of Infertility.” Human Reproduction 13, no. 7: 1831–36. Thompson, Charis. 2002. “Fertile Grounds: Feminists Theorize Infertility.” In Infertility Around the Globe: New Thinking on Childlessness, Gender and Reproductive Technologies, ed. M. C. Inhorn and F. van Balen. Berkeley: University of California Press. ———. 2005. Making Parents: The Ontological Choreography of Reproductive Technologies. Cambridge, MA: MIT Press. Throsby, K. 2002. “Negotiating ‘Normality’ When IVF Fails.” Narrative Inquiry 12(1): 43–65. Throsby, K., and R. Gill. 2004. “‘It’s different for men’: Masculinity and IVF.” Men and Masculinities 6, no. 4: 330–48. Todorova, I., A. Baban, D. Balabanova, Y. Panayotova, and J. Bradley. 2006. “Providers’ Constructions of the Role of Women in Cervical Cancer Screening in Bulgaria and Romania.” Social Science and Medicine 63: 776– 87. Todorova, I., and T. Kotzeva. 2003. “Social Discourses, Women’s Resistive Voices: Facing Involuntary Childlessness in Bulgaria.” Women’s Studies International Forum 26, no. 2: 139–51. ———. 2005. “The Social Construction of Infertility in Bulgarian Society.” Sotsioogicheski problemi 3–4: 215–43. ———. 2006. “Contextual Shifts in Bulgarian Women’s Identities in the Face of Infertility.” Psychology and Health 21, no. 1: 123–41. UNDP. 1995. The Situation of Women in Bulgaria. Sofia, Bulgaria: United Nations. Wajcman, J. 1991. Feminism Confronts Technology. Cambridge: Polity Press. Walters, S., and M. Suhrcke. 2005. Socioeconomic Inequalities in Health and Healthcare Access in Central and Eastern Europe and CIS: A Review of the Recent Literature. Working Paper 2005/1. Geneva, Switzerland: World Health Organization European Office for Investment for Health and Development. Webb, R., and J. Daniluk. 1999. “The End of the Line: Infertile Men’s Experiences of Being Unable to Produce a Child.” Men and Masculinities 2, no. 1: 6–25. Yanakiev, K. 2005. “The Church and Contemporary Biotechnologies.” Altera 9: 22–23.

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Chapter 3

MIDDLE EASTERN MASCULINITIES IN THE AGE OF ASSISTED REPRODUCTIVE TECHNOLOGIES Marcia C. Inhorn

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I

nfertility, classically defined as the inability to conceive after a year or more of trying and resulting in involuntary childlessness, affects more than 15 percent of all couples worldwide (Bentley and MascieTaylor 2000; Vayena, Rowe, and Griffin 2002). Among infertile couples, male factors, involving primarily low sperm count (oligospermia), poor sperm motility (asthenospermia), defects of sperm morphology (teratozoospermia), and total absence of sperm in the ejaculate (azoospermia), contribute to more than half of all cases (Irvine 1998). Yet, male infertility is a health and social problem that remains deeply “hidden,” including in the West. Studies have shown male infertility to be among the most stigmatizing of all male health conditions (Becker 2000, 2002; Greil 1991). Such stigmatization is clearly related to issues of sexuality. Male infertility is popularly, although usually mistakenly, conflated with impotency, as both disrupt a man’s ability to impregnate a woman and to “prove” one’s virility, paternity, and manhood (Goldberg 2009; Webb and Daniluk 1999). Over the past two decades, the study of infertility and the new assisted reproductive technologies (ARTs), primarily in vitro fertilization (IVF), has emerged as a major area of scholarship in the West,

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including in medical anthropology (Becker 1997, 2000; FeldmanSavelsberg 1999; Franklin 1996; Inhorn 1994, 1996, 2003a; Inhorn and van Balen 2002; Kahn 2000). Yet, male infertility has received relatively scant attention, despite the fact that millions of reproductiveaged men worldwide are estimated to be infertile (Irvine 1998). Lloyd (1996, 1997), one of the few ethnographers to study the lived experiences of male infertility directly, has suggested that Western researchers interpret infertile men’s nonresponse to their survey questions as an indication of the “sensitivity” of this emasculating reproductive health condition. However, little is known about the “truth of infertility” in men’s lives (1996: 452). This chapter seeks to explore the “truth of infertility” in Middle Eastern men’s lives by describing the possible causes and gendered consequences of male infertility and its evolving treatment for Middle Eastern men in Cairo, Egypt, and Beirut, Lebanon.1 As will be shown in this chapter, male infertility may be a particularly vexing health and social problem among Middle Eastern Muslim men, for whom ARTs to overcome male infertility are simultaneously promising and problematic. As will be suggested here, not only is male infertility a stigmatizing and potentially emasculating condition for Middle Eastern men, but also the very technologies designed to overcome it add additional layers of stigma and cultural complexity. In the case of male infertility, the ARTs that are being rapidly transferred to the Middle Eastern region in order to solve this once-intractable medical condition are leading simultaneously to hope and increased suffering, with major social consequences for marriage and family life (Inhorn 2003a). This chapter seeks to reveal the tortured relationship between male infertility, stigma, masculinity, and issues of disclosure among Middle Eastern men, particularly as “high-tech” ARTs to purportedly overcome male infertility become increasingly available to Middle Eastern populations. Following a brief overview of the ethnographic setting and methods, the first half of this chapter examines the male infertility problem in the Middle East from both epidemiological and masculinities perspectives. I argue that Middle Eastern men are unwittingly at greater epidemiological risk of a stigmatizing health condition that may be emasculating for both social and cultural reasons. The second half of the chapter describes how the “newest” ART to arrive in the Middle East—intracytoplasmic sperm injection (ICSI)—is now producing biological offspring for once hopelessly infertile Middle Eastern men. However, as the chapter will show, this technology may also produce paradoxical

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effects, including increased stigmatization, moral quandaries, and highly gendered suffering.

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Methods The findings presented in this chapter are based on ethnographic research carried out in four IVF clinics in two urban Middle Eastern locales, namely, Cairo, Egypt, and Beirut, Lebanon. In Egypt, I spent the summer of 1996 studying infertile couples attending IVF clinics in two elite suburbs of Cairo. Seventy percent of the sixty-six couples in my study suffered from male factor infertility, and in most of these cases, the husband’s infertility was the sole cause of the couple’s childlessness. Among 40 percent of the couples in the study, both husbands and wives participated in the interviews, agreeing to speak with me about a wide variety of issues pertaining to IVF in Egypt (Inhorn 2003a). Thus, despite my previous focus on female infertility and IVF in Egypt (1994, 1996), my study in Cairo in 1996 was my first formal introduction to infertile male informants, who proved to be animated and loquacious in their own right. Through this study, I obtained rich interview data on male infertility and its treatment (2002, 2003b), even though I had not originally been seeking it. Before I began my Egyptian IVF study, I had been highly skeptical that I would be able to conduct research with infertile Middle Eastern men, given the sensitivity of the subject as well as general cultural barriers surrounding intergender communication. However, my position as a foreign female duktura—that is, as a knowledgeable, empathic listener ethically committed to confidentiality—seemed to put infertile Egyptian men at ease (Inhorn 2004). Furthermore, Middle Eastern-born male colleagues subsequently convinced me that my gender status might, in fact, be advantageous. In their view, Middle Eastern men may be much less likely to reveal their reproductive vulnerabilities to another man, given that virility and fertility are areas of intense masculine competition. Thus, despite the impending U.S.-led war on Iraq (Inhorn 2004), I decided to return to the Middle East for eight months in 2003—in this case to Beirut, Lebanon—to study male infertility specifically.2 As in my Egyptian study, I was fortunate to gain ethnographic access to two of the busiest and most successful IVF clinics in central Beirut. One was located in a large, private university-based teaching hospital and catered to a religiously mixed patient population

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of both Sunni and Shia Muslims, Christians of a variety of sects, Druze (a minority Muslim subsect), and various immigrant and refugee populations. The other was a private stand-alone IVF clinic catering primarily to Southern Lebanese Shia patients but with occasional Christian and Sunni Muslim patients from both Lebanon and neighboring Syria. Between these two clinics, I was able to recruit 220 Lebanese, Syrian, and Lebanese-Palestinian men into my study; 120 of them were infertile cases (i.e., based on spermogram results and World Health Organization definitions of male infertility), and 100 were infertile controls (i.e., the husbands of infertile women whose spermogram results showed them to have normal sperm parameters). This epidemiological “case-control” design also served important ethnographic purposes; it allowed me to understand the experiences and perspectives of infertile men as well as men who were not infertile but who were experiencing childless marriages. As in my Egyptian study, about half of my interviews were conducted in Arabic and half in English, depending on the preference and ability of informants (many of whom spoke excellent English). Although I tape-recorded some interviews in Egypt, most of my interviews in both countries were not taped because of considerable discomfort on the part of most infertile informants, particularly men.3 In most cases, I conducted the interviews alone, but a research assistant was present during some of the Arabic interviews, especially in the initial stages of research, when I was refamiliarizing myself with two very distinct colloquial dialects of Arabic (Egyptian versus Levantine). A large amount of data was collected during the eight-month study period in Beirut. This included: 220 completed eight-page reproductive history/epidemiological questionnaires, which I administered verbally to each man in the study; 1,200 pages of qualitative interview transcripts, generated from open-ended interviews with all of the men in the study, some of their wives, and a variety of physicians, nurses, and embryologists at the two clinics; 550 pages of field notes based on participant observation as well as informal interviews and conversations with staff and patients at the two IVF clinics; and more than 200 blood samples, which were frozen in the Beirut IVF laboratories and then hand carried by me via airplane to the United States for the purposes of later toxic-metal analysis.4 This chapter is based primarily on qualitative interview data collected in both countries. Yet, as will be seen in the following section, I asked men in their reproductive history interviews to reflect on

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the perceived causes of their infertility and their potential exposures to known epidemiological risk factors for male infertility. In addition, in open-ended interviews that I conducted with most men in the study, I asked questions revolving around what I characterized as the “four M’s”: masculinity, marriage, morality, and medical treatment seeking. Although the Lebanese data from 2003 suggest that male infertility no longer “troubles” Middle Eastern masculinity as it once did in an earlier period in Egypt, masculinity issues in male infertility are still significant, shrouding this subject in relative secrecy in both countries. Moreover, in the age of ARTs, male infertility and its treatment lead to significant marital and moral conundrums in this predominantly Muslim region of the world, for reasons to be made clear in this chapter.

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Male Infertility in the Middle East Infertility prevalence rates, including male infertility rates, are lacking for the Middle Eastern region, although such rates are available throughout much of sub-Saharan Africa (Larsen and Raggers 2001). In Egypt, a World Health Organization-sponsored study carried out in the early 1990s placed the total infertility prevalence rate in that country at 12 percent (Egyptian Fertility Care Society 1995). There are no available data on infertility prevalence rates from Lebanon (a country that still lacks an official census because of multisectarian political rivalries), but there are enough cases of infertility to support a thriving infertility treatment industry. Although the country has only about 3.5 million Lebanese citizens, there are approximately fifteen IVF centers in operation (some more successful than others), mostly located in greater Beirut. In Egypt, with its population of more than 70 million people, there were approximately fifty IVF centers in operation by 2003, mostly located in greater Cairo. Thus, in both countries, which have long historical traditions of colonially imposed Western biomedicine, the Western-developed and manufactured ARTs to overcome infertility have spread rapidly and are now firmly entrenched in urban settings, where they are offered in private hospitals and IVF clinics (Inhorn 2003a, 2004). Part of the reason why IVF flourishes in both Egypt and Lebanon has to do with the purportedly high rates of male infertility in this region. Although so-called “male factors” (low count, low motility, sperm deformities, absence of sperm) are thought to contribute to about half of all cases in the United States and Western Europe,

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male infertility cases are even more common—and often more severe—in the Middle East. In the clinics in this study, male infertility cases make up at least 60–70 percent of the patient load. Furthermore, IVF physicians in these clinics, virtually all of whom have had comparative Western training in infertility, note that male infertility rates appear to be higher in IVF clinics in the Middle East than in Western settings. This is partly due to the fact that lower rates of sexually transmitted diseases (STDs) lead to fewer cases of primary tubal factor infertility in women. However, even in cases where Middle Eastern women suffer from a female factor, such as polycystic ovary syndrome, husbands often also present with persistent male infertility problems. Many of these cases, furthermore, are severe, involving such problems as azoospermia and arrested spermatogenesis (i.e., no sperm whatsoever being produced in the testicles). As one doctor explained, reiterating a theme found in virtually every physician interview I conducted in Lebanon:

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I think [the prevalence of male infertility] is higher here. Most of the studies that have been done show that it’s definitely greater than fifty percent, more than half of all cases. Most of the literature from the West says forty to fifty percent. But here, male infertility by itself is fifty percent—at least half of all cases—in addition to those cases where it’s both male and female factor. Plus we see very severe cases. Severe oligo[spermia], severe asthenospermia. In the States, you see obstructive azoospermia following vasectomies. But here, it’s definitely non-obstructive azoospermia cases, which are also high in Arabic populations in the [United] States.

When I asked this physician, “Why so much male infertility?” his explanation was genetic. Namely, as shown in recent studies (Bittles and Matson 2000), Y-chromosome microdeletions and other genetic anomalies are clearly linked to some—maybe many—cases of male infertility, and such genetic conditions may be magnified through consanguineous marriage. Because interfamilial marriage, including with first cousins, is the preferred form in many parts of the Middle East (Inhorn 1996), including in some Muslim regions of Lebanon, consanguineous marriage may put a significant percentage of Middle Eastern males at unwitting risk of male infertility (Inhorn et al. 2009; Thomas and Jamal 1995). In addition, Middle Eastern men, particularly those living in increasingly polluted urban centers such as Cairo and Beirut (Hopkins, Mehanna, and el-Haggar 2001), may be at increased risk of low sperm count and poor sperm motility due to environmental toxins. For

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example, lead is becoming a highly prevalent ambient air pollutant in urban areas of the Middle East where gasoline is still leaded, and lead is a well-known cause of spermatotoxicity (Schettler et al. 1999). Other sources of toxin exposure, particularly to pesticides and heavy metals, are occupational in nature (Schettler et al. 1999) and may be linked to the lack of environmental and worker protections found in most industries in the Middle East. In addition, under periods of long-term warfare in some Middle Eastern countries, including Lebanon, men may have been exposed to other environmental toxins, including heavy metals, such as depleted uranium used in American-made and Israeli-deployed bombs and artillery.5 In addition to environmental toxins, significant amounts of caffeine and tobacco are ingested by many men (both in cigarettes and through waterpipes) in the contemporary Middle East. Both of these substances have been shown to exert negative effects on male fertility (Curtis, Savitz, and Arbuckle 1997; Inhorn and Buss 1994). Finally, histories of infections that impair male reproductive function, such as adult-onset mumps orchitis, schistosomiasis, or various STDs, are a potential cause of obstructive azoospermia and have been reported as a major cause of male infertility in parts of sub-Saharan Africa (World Health Organization 1987; Yeboah, Wadhwani, and Wilson 1992). For their part, many infertile Middle Eastern men wonder why they are among the “unlucky” ones to suffer from this serious reproductive impairment. Relatively few men in my studies attributed their own lifestyle factors, such as heavy smoking, to male infertility. Instead, men who deemed themselves to be “religious” said that they accepted the fact that infertility is a condition “from God,” while others said that they were probably infertile from factors beyond their individual control. These included, inter alia, infections and other health conditions that were undiagnosed or mistreated; food and water contaminated with hormones and pesticides; lack of nutritious food during critical periods of adolescent development; “shocks” and stresses suffered as a result of economic uncertainties and other misfortunes; and, in the case of Lebanon, being forced to live (and even fight) through the fifteen-year civil war. In Lebanon, the most commonly cited reason for male infertility among men in my study was il harb, that is, “the war.” Many men believed that their infertility somehow stemmed from the civil war, and the causes they cited were varied. These included the stresses and fears caused by war, physical relocation, and economic disruption; the use of toxic chemicals in bombs and weapons; the uncon-

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trolled dumping of toxic wastes during that period; the use of saltpeter-like substances to quash sexual desire among young militia men; or genital and other forms of physical and psychological torture that some men endured during and after this period (which continued until the year 2000, with the Israeli occupation of most of Southern Lebanon and the imprisonment of thousands of Lebanese men) (Fisk 2002; Khalaf 2002; O’Ballance 1998). As was clear from the demographic data I collected from each informant, my study population represented a generation of reproductive-aged men (twenty-five to fifty-five years) whose lives, including education, marriage, and physical health, were significantly disrupted by years of warfare. Many men in the study had experienced injuries from bombs, artillery, or shrapnel (Inhorn et al. 2008). Those who were “lucky” were sent out of the country, usually by concerned parents, during the war period, either to escape the ravages of war or to find work and schooling opportunities that would benefit the extended family back in Lebanon. Periods of residence outside of the country affected men’s abilities to marry in a timely fashion and also led some of them to contract potentially sterilizing infectious diseases. At least some of the men in this study blamed themselves for “ruining their reproductive organs” or “using up all their sperm” through premarital sexual activity, STDs, or excessive masturbation, for which they felt excessive remorse. To take but one example, Ali,6 a Southern Lebanese Shia man who fled to West Africa in 1977 to escape the ravages of war in his home community, described in an interview—while literally hanging and hiding his head in shame—that he and eleven other Lebanese refugee men had had serial group intercourse with a West African prostitute. Following this episode, he contracted an STD, which was quickly resolved with an antibiotic. Nonetheless, both Ali and his close hometown friend who had also participated in the “group sex” had gone on to suffer from long-term infertility in their subsequent marriages, of fifteen- and twenty-year durations respectively. In Ali’s view, it was this illicit sex act that caused his infertility, not his two-pack-aday smoking habit for thirty-five years, which he did not associate with his low sperm count and poor sperm motility.7

Imagining Middle Eastern Masculinities For infertile men like Ali, one of the major reasons that reproductive failure may be problematic is that men in the Middle East (and

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beyond) may deem paternity an important achievement and a major source of their masculine identity. According to the first definition in The New Shorter Oxford English Dictionary (Brown 1993: 1675), “male” means “of, pertaining to, or designating the sex which can beget offspring; in organisms which undergo sexual reproduction, designating, pertaining to, or producing gametes (as spermatozoa) that can fertilize female gametes (ova).” If biological “maleness” is, in fact, constituted by begetting offspring through the production of spermatozoa, then male infertility, or the inability to produce fecundating sperm, may come as a striking blow to men’s social identities, with far-reaching implications for the construction of masculinity. The relatively small but growing body of social scientific literature on male infertility in the West suggests that male infertility can have these kinds of emasculating effects. For example, in an article provocatively titled “The End of the Line: Infertile Men’s Experiences of Being Unable to Produce a Child,” Webb and Daniluk note that American men’s sense of personal inadequacy constituted a major theme during interviews about their infertility. According to the authors, “[t]he participants used words and phrases like failure, useless, a dud, inadequate, not a real man, garbage, loser, and defective in reference to their self-perceptions as infertile men—men who were unable to ‘give their wife a child’” (1999: 15). Some men, furthermore, attempted to compensate for their feelings of inadequacy by acting like “super jocks,” having affairs with other women, or throwing themselves into their work. In another study, men reported that their male physicians attempted to “smooth troubled waters” by referring to their infertility as “shooting blanks”—language that left men feeling separate and estranged from their somatic experiences (Moynihan 1998). Both infertility and its treatment have been reported in the West as resulting for some men in impaired sexual functioning and dissatisfaction, marital communication and adjustment problems, interpersonal relationship difficulties, and emotional and psychological distress (Abbey, Andrews, and Halman 1991; Daniluk 1988; Greil 1991, 1997; Greil, Porter, and Leitko 1990; Nachtigall, Becker, and Wozny 1992). It is very much an empirical question whether the effects of male infertility on men’s sense of masculinity are culturally invariant; the topic has been even less researched in non-Western sites. The few comparative studies tend to come from Israel, more “Western” than “Middle Eastern” in some ways, where a handful of scholars have examined the impact of infertility treatment and especially donor insemination on masculinity (Carmeli and Birenbaum-Carmeli 1994,

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.

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2000; Goldberg forthcoming). In Israel, infertile men were found to experience a profound sense of embarrassment and “anomie” in clinical treatment settings. There, poor semen-analysis results were usually taken as indications of personal failure. Furthermore, infertile men felt as if they were expected to “compete” with another man, the sperm donor, who could easily substitute for them as a biological progenitor. Thus, the authors of one Israeli study suggest that infertility may have a “diffuse, total impact” on men, who may become a “target of ridicule” if their infertility becomes known to family and friends (Carmeli and Birenbaum-Carmeli 1994: 674). Another author suggests that a conceptual link between dysfunctional sperm, failed masculinity, and impotence in sexual intercourse clearly exists in Israeli male infertility-treatment settings (Goldberg 2009). Little if any social scientific research has explicitly focused on the subject of male infertility and masculinity among Middle Eastern Muslim men. Yet, Middle Eastern Muslim men may also suffer over their infertility, for a number of important reasons. First, on the social structural level, men living in pronatalist Middle Eastern communities are expected to have children, as reflected in the relatively high marriage and fertility rates across the region (Population Reference Bureau 2001). Middle Eastern men achieve social power in the patriarchal, patrilineal, patrilocal, and endogamous extended family through the birth of children, especially sons, who will perpetuate patrilineal structures into the future (Inhorn 1996; Obermeyer 1999; Ouzgane 1997). “Intimate selving” in Arab families involves expectations of “patriarchal connectivity” (Joseph 1999), whereby men assume patriarchal power in the family not only with advancing age and authority, but also through the explicit production of offspring, whom they love and nurture but also dominate and control. Thus, in this region of the world, which “with some truth, is still regarded as one of the seats of patriarchy” (Ghoussoub and SinclairWebb 2000: 8), men who do not become family “patriarchs” through physical and social reproduction may be deemed “weak” and ineffective (Lindisfarne 1994), and may be encouraged to take additional wives in order to contribute to the patrilineage and to “prove” their masculine virility (Inhorn 1996). In addition, a repeating theme in the small but growing literature on Middle Eastern masculinities is one of homosocial competition between men in the realms of virility and fertility, which are typically conflated (Ali 2000; Lindisfarne 1994; Ouzgane 1997). According to Ouzgane, an expert on contemporary Arabic literature, virility

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emerges as the “essence of Arab masculinity” in the novels of some of the region’s most eminent writers (1997: 3), with men in these stories both distinguishing themselves and being distinguished from other men through the fathering of children, especially sons. If this is in fact the case, as much of the literature from this region suggests, then the experience of male infertility for a Middle Eastern man can only be “imagined” as an extremely threatening and emasculating condition (Ghoussoub and Sinclair-Webb 2000), particularly in a region of the world where “hegemonic masculinities” (Connell 1995) are homosocially competitive and men work hard to sustain their public images as “powerful, virile” patriarchs (Ouzgane 1997: 4). My own studies, particularly in Egypt, suggest that this may in fact be the case. In Egypt, for example, few men in my study were willing to tell anyone, including their closest family members, that they suffered from male infertility. Male infertility was described variously as an “embarrassing,” “sensitive,” and “private” subject for the “Egyptian male,” who would necessarily feel ana mish raagil—“I am not a man”—if others were to know that he was the cause of a given infertility problem. Because of the association between male infertility and manhood, men’s wives were generally expected to participate in a two-person “cult of silence” regarding the male infertility, which usually meant that women “shouldered the blame” for the infertility in public. When women were questioned (as is often the case in Egypt) about the source of their childlessness, most told others that there was “nothing wrong” with either partner and that the matter was “up to God.” Sometimes, women suggested to their acquaintances that they themselves were seeking treatment for the infertility. Women often explained that they “covered” for their husbands out of love and loyalty. However, some women also said that they feared the potential familial and marital consequences of “exposing” their husbands’ “secret” (Inhorn 2003a). In my more recent study in Lebanon, this conspiracy of silence surrounding male infertility was not as readily apparent. Why? For one, there seems to have been a “normalization” process occurring over time, particularly in the decade since IVF and ICSI have arrived in the Middle East. Lebanese men acknowledged that there is increasing “openness” about male infertility these days, particularly in light of the modern ARTs being provided and advertised widely in Lebanon. Furthermore, once inside treatment centers, Lebanese men seemed to begin accepting the fact that male infertility is a medical problem “like any other medical condition.” Thus, they typically stated in interviews that male infertility “has nothing to do with man-

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hood.” Indeed, this was one of my most surprising findings. Although I was fully expecting infertile Lebanese men to lament their impaired manhood in interviews—much as Egyptian men and their wives did in my earlier studies—most of the Lebanese men I asked insisted they had never equated their infertility with emasculation. In other words, male infertility was not the major “crisis of masculinity” I had found in Egypt or had expected from reading the literature cited previously. For these men, male infertility wasn’t necessarily a “big secret.” Many men in the study had consulted friends and family members about male infertility, in order to obtain treatment advice and the names of good infertility physicians. Furthermore, families—at least close relatives on both husbands’ and wives’ sides—were often heavily invested in infertile men’s treatment quests; in many cases, family members, especially parents and siblings, had donated considerable money to offset the high costs of ARTs. Nonetheless, this family investment in treatment seeking may be based on familial pressure to produce progeny “for the family.” In some cases, infertile men lamented the fact that they were seeking ART treatment more to satisfy the demands of their wives and families and particularly to “keep the family name going” than out of their own innate desire to have children or become fathers. In other words, becoming a father—and hence a family patriarch—was not necessarily an ardent desire. Having said all this, some additional information must be considered when assessing the links between male infertility and masculinity in Lebanon. First, Lebanon has generally higher educational and literacy rates than most other Middle Eastern societies, including Egypt. Thus, many Lebanese men in my study were highly educated—with at least a high school diploma and many with advanced degrees—and virtually all were literate. Many of these men had educated, working wives and thus presented to IVF clinics as “career couples.” Presumably higher levels of education and satisfaction with professional careers may have offset the potential effects of emasculation and contributed to men’s acceptance of a “medical model” of male infertility cited previously. In addition, it is widely recognized within Lebanon that the country is in the midst of a postwar economic crisis. Men in particular feel the stress of societal expectations to support both nuclear and extended family members (especially aging parents). Thus, male infertility may seem like a relatively trivial concern, especially given a current economic climate seen by most Lebanese as not conducive to raising a family.

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Further, the psychologically exhausting fifteen-year civil war, at least seven years of postwar economic crisis, and the 2006 “summer war” between Israel and Lebanon seem to have generated high levels of poor mental health in Lebanon. Many men in my study openly admitted to feelings of stress, depression, and anxiety, for which some were taking medications. In general, the Lebanese men in my study did not seem “happy,” an impression seconded by some of the physicians I also interviewed. Lebanese men rarely laughed, were somewhat morose and reserved during interviews, and generally looked much older than their reported ages (presumably from a weathering effect attributable to the war, too much sun, and heavy smoking). Although I enjoyed my interviews with many men in this study, particularly after some of them started “opening up” as the interviews progressed, I found Lebanese men to be much less forthcoming and animated than Egyptians, the latter of whom are known within the region for their sometimes excessive loquaciousness and good humor. Perhaps this tendency toward reserve made it more difficult for Lebanese men to admit deeply personal and potentially humiliating feelings of masculine inadequacy. Indeed, I will never know for certain whether pervasive bad mood or feelings of diminished masculinity were the ultimate sources of the high nonresponse rate in my study. Namely, in Lebanon, a significant (although undetermined) percentage of men who were asked by their IVF physicians, clinic staff members, or by me directly to participate in my study refused outright to become my informants. On any given day, one, two, or even more men who were asked to participate in my study declined to be interviewed, even after careful description of the benefits of the study and its guarantees of confidentiality. Reasons for refusal, if given, were of three general types: “not in the mood to talk,” “not enough time” (even though most men spent hours in the clinic waiting for their wives to complete IVF procedures), and “this is something confidential” (i.e., a secret not to be shared even in a confidential interview). This issue of male nonresponse, first noted by Lloyd (1996) among men in Western infertility studies, may mean many things in Lebanon. On the one hand, it could relate to the general mood problems described previously, leading to a lack of enthusiasm on the part of some men to participate as research subjects. However, most of the Lebanese IVF physicians and clinic staff members attributed nonresponse to masculinity issues—namely, the “sensitivity” and “shyness” of most Lebanese men to reveal their reproductive problems to anyone, including a Western researcher.8 Like the physicians, I

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suspect that at least some of this nonresponse reflects the fact that male infertility is, on some level for some Lebanese men, deeply humiliating—something to be hidden rather than revealed. In fact, when I first arrived at one of the Lebanese IVF centers and explained my study to the clinic staff members, a nurse predicted bluntly that my study would never succeed because of the stigma and secrecy surrounding this topic. She described how couples with an infertile husband tried to “hide from each other” in the recovery rooms and would sometimes stay there for hours if they saw an acquaintance who might expose their secret to the outside world. Although her prediction about my study’s inherent failure did not come to pass, her point was well taken. At least some men in Lebanese IVF clinics probably refused to speak to me out of feelings of stigma and emasculation. Those who did agree to participate were probably the ones who felt least diminished by their infertility, for reasons of education, supportive wives and family members, and idiosyncrasies of personality and resilience. As George, a Christian oil executive, explained to me, there are two views of male infertility in Lebanon, an “insider’s” point of view and an “outsider’s” perspective: In Lebanon, yes, male infertility does affect manhood. Men don’t want to admit they can’t have children. They’re not men any more. But this is not the view of people inside treatment. People who are “in” know it is a medical problem. So we don’t feel this problem of manhood or womanhood. In our company [where he works], four to five people have IVF babies. One guy was married for fifteen years, and he went to Singapore [for IVF]. Then another one went there. So, in my company, people talk about it. I tell everybody about it. I don’t mind. Because it’s easier to tell everyone what you’re doing. Even at work, it’s easier to tell them so that they just stop asking. My boss said, “You’ve been married for more than two years and you didn’t get your wife pregnant yet?” I said, “I’m trying, but I couldn’t get my wife pregnant yet.” Two days ago, I told him I’m coming for IVF. But this is very uncharacteristic of Lebanese people. People think like, “Manhood. He can’t have children.” So a lot of people blame the woman, even when it’s male infertility. This is because people are secretive. They don’t know the problem is male infertility, and so they say [it’s from] the woman.

Ahmed, an infertile, American-trained Lebanese physician who was attempting with his wife to make a third IVF baby (perhaps a son after the birth of two daughters), described the relationship between masculinity and male infertility:

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Manhood. It’s really an important factor in society. I know this as a pediatrician. The first thing people ask for at the first baby visit is to check the [male] baby’s reproductive organs. They’re worried from the first moment of life if [the child has] normal reproductive organs. If they will have a normal sexual life. It’s about his future manhood. It’s a strong feeling. And it’s a deficiency if you can’t have children. I do think people feel this. I would assume they do, because it’s a secret kind of thing, male infertility. In my own case, who knows about this [his male infertility problem, involving abnormal sperm morphology]? My wife doesn’t want anyone to know. So we come here [to the IVF clinic] in secrecy.

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The Age of Assisted Reproductive Technologies Infertile men such as George and Ahmed are essentially required to seek treatment at an IVF clinic if they hope to overcome their infertility. Why? Traditional medical therapies to overcome male infertility, including surgeries for varicoceles (varicose-type dilations of the veins in the testicles) and estrogen-containing hormonal drugs, are widely prescribed by medical andrologists and urologists in the Middle East (Inhorn 2003b). However, these therapies have been heavily criticized in the West for being largely unproven, ineffective, and rife with unpleasant side effects, including exacerbation of male infertility problems (Devroey et al. 1998; Kamischke and Nieschlag 1998). In short, male infertility is intransigent to the standard therapies that are generally tried by most Middle Eastern men but that fail to turn them into fathers. However, the newest ART, ICSI (pronounced “ik-see”), has promised to change all of this. First developed in Belgium in the early 1990s, ICSI has allowed thousands of severely infertile men to father children with their own gametes. As long as even one viable spermatozoan can be retrieved from an infertile man’s body—including through painful testicular aspirations and biopsies—this spermatozoan can be injected directly into the ovum with the aid of a “micromanipulator” on a high-powered microscope, thereby effectively forcing fertilization to occur. Over the past decade, ICSI has become widely available in assisted reproduction centers in the West, where it has now helped thousands of severely infertile men to father their own “biological” children. Although ICSI is an expensive technique only easily accessed by elites in most Middle Eastern countries (Inhorn 2003a), it may rep-

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resent the only hope for Middle Eastern Muslim men to overcome their infertility. Why? In the Sunni Islamic world, contemporary Muslim religious scholars, following mandates originally set forth in the Islamic scriptures, have effectively disallowed alternative modes of family formation for infertile couples, including third-party donation of sperm, eggs, embryos, or surrogate uteruses (Inhorn 2003a; Meirow and Schenker 1997; Serour 1996). For this reason, third-party donation is illegal in most Sunni-dominated Middle Eastern countries, including Egypt, where it is simply not practiced in IVF clinics (Inhorn 2003a). Similarly, because alternative modes of family formation are not allowed, legal adoption of an orphan as practiced in the West is prohibited in Islam. Although the Islamic scriptures encourage kindness and care in the upbringing of orphans, legal adoption—whereby a child acquires the name of, and can inherit from, its adoptive parents—is clearly prohibited within the Islamic scriptures (Inhorn 1996; Serour 1996; Sonbol 1995). Thus, unlike infertile men in the West, who may agree to donor insemination or adoption to overcome their childlessness (Becker 2000, 2002), infertile men living in the “local moral worlds” (Kleinman 1992) of the Sunni Muslim Middle East have literally no other way of becoming fathers— within their own countries at least—except through resort to expensive trials of ICSI using their own sperm. Yet, it is important to point out the exception to the rule, which has affected the practice of IVF and ICSI in two Middle Eastern countries, namely, Iran and Lebanon. At the end of the 1990s, Shaikh Ali Khamenei, Iran’s Shia Muslim spiritual leader, issued a religious proclamation approving of both egg and sperm donation for infertile Shia couples. Although egg-donor programs have subsequently been initiated in Iran and in some of the clinics in Lebanon that cater to large Shia populations (including one of the clinics in this study), the notion of third-party donation—and of sperm donation in particular—still does not meet with social acceptance among the vast majority of infertile Muslims, be they Shia or Sunni.9 Clearly, the strong social prohibitions against sperm donation, which I found in both Egypt and Lebanon among Sunni and Shia men alike, can be traced to patrilineal kinship ideologies and Islamic scriptural beliefs, which privilege patrilineal continuity and the importance of men’s biological paternity. Or, to put it in the words of Egyptian and Lebanese male informants, a child produced from donor sperm “will not be my son.” The “questionable” nature of such a child is reflected in Ayatollah Khamenei’s own ruling: namely, a donor-insemination

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child can be raised by, but not inherit from, its infertile “social” (as opposed to biological) father. Given these religious understandings and strong cultural prohibitions against the uses of donor sperm, ICSI remains the only hope for most infertile men in Egypt, Lebanon, and the rest of the Middle East. Yet, ICSI itself engenders a range of moral anxieties among Middle Eastern men, who may fear (un)intentional sperm “mixing”—including with racialized “black bizri” (literally, black seeds)— in Middle Eastern IVF laboratories (Inhorn 2003b). For example, in one of the IVF clinics in my study, a recurrent fear among the infertile Lebanese men was that their semen would somehow become tainted with the semen of the black West African janitor whose job was to accompany men to the semen-collection room and carry their “fresh” semen samples back to the IVF laboratory. Such fears of racial miscegenation were prominent in my Egyptian IVF study as well (Inhorn 2003a). In addition, infertile men also worried about the stigma that might surround their child if its “test-tube origins” were revealed, due to the popular societal assumption that an IVF baby might be the product of donor gametes. Thus, the stigma and secrecy surrounding male infertility, particularly in Egypt, were compounded by the “technological stigma” of IVF/ICSI itself, which continues to be morally questionable because of lingering assumptions that something haram, or “sinful,” is going on through the mixing of donor gametes in IVF laboratories. Although this technological stigma was much less pronounced in Lebanon in 2003 than it was in Egypt in 1996 (Inhorn 2003a), I found that “IVF is haram” views still circulated in my 2003 study, particularly among Syrian men, who had essentially “secreted” themselves and their wives from Syria to Lebanon, in order to undertake IVF without the knowledge of either family or friends.10 Finally, it is important to note that ICSI also poses particular marital dilemmas in the Middle East, with consequences for women that are potentially profound (Inhorn 2003a). Generally speaking, wives of infertile Middle Eastern men tend to accommodate their husbands’ treatment desires, not only to avoid conjugal disputes, but also to achieve their own reproductive aims and to overcome their “courtesy stigmatization” (Lorber 1989). However, for men, the advent of ICSI has also brought new possibilities. Middle-aged infertile men are generally married to middle-aged women, the latter of whom were once fertile but may no longer be able to produce viable ova for the ICSI procedure. When these men

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are informed that a wife’s age may be a major limitation to the success of the procedure, some men may decide to divorce their oncefertile but now “reproductively elderly” wives, to test their reproductive futures with younger, potentially more fertile women. By the time of my 1996 study in Egypt, such cases were beginning to occur, particularly given the Sunni Islamic mandate disallowing egg donation. In Lebanon, I also interviewed several middle-aged men with “forty-something” wives who were in the midst of such marital crises. In one memorable case, where the husband wept openly during his interview about the “dying out” of his family name, the couple became pregnant through ICSI but then lost the fetus in an unfortunate, maternal-age-related, second-trimester miscarriage. By the time I was readying myself to leave Lebanon, this Shia couple was on the verge of divorce, and the wife was clearly desperate, for her husband would not accept the idea of egg donation. Having said this, most of the infertile marriages I encountered in both Egypt and Lebanon were remarkably stable for reasons that I have described in my earlier publications (Inhorn 1996, 2003a). Furthermore, in Lebanon, where donor-egg programs are “quietly” in place in some IVF clinics, including one of the clinics in my study, new marital scenarios are beginning to emerge as infertile husbands, particularly those of the Shia faith, are beginning to accept the idea of eggs from other women. Because Islam allows polygyny, or the taking of more than one wife, egg donation is being conceptually conflated with polygyny, whereby the egg donor becomes like a second wife to the husband. Those Shia shaikhs who accept the premise of egg donation may recommend that egg donation be accompanied by a mut’a, or temporary marriage, during the period ranging from retrieval of the eggs to transfer of the fertilized embryos back to the wife’s uterus.11 Thus, in the complicated, multisectarian religious landscape of Lebanon, the growing acceptance of third-party donation in IVF has brought the possibility of new marital imaginaries still unthinkable in the more homogeneous Sunni Islamic environment of Egypt. Indeed, ICSI and the practices of third-party donation have brought with them moral and marital scenarios that are rapidly evolving in the Middle East and that have major implications for women’s wellbeing and marital security. Clearly, such scenarios speak to the importance of understanding the local cultural context and particularly the local moral worlds in which new health technologies such as ICSI are being rapidly deployed.

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Conclusion Exploring Middle Eastern men’s experiences of male infertility and ARTs—including, among other things, their understandings of infertility etiology, their feelings about their masculinity, their embodiment of new reproductive technologies, their interpretations of local religious moralities, and their sometimes conflicting feelings of marital loyalty versus desires for fatherhood—presents itself as a fruitful area of medical anthropological research. Furthermore, investigation of this topic is timely, given the relative recency of the “new” ART, ICSI, which is rapidly making its way to the Middle East. There, gender studies are also shifting from an almost exclusive focus on women to a new interest in Middle Eastern men as men, whose masculinity is molded in particular, culturally regnant ways (Ghoussoub and Sinclair-Webb 2000; Ouzgane 2006). Thus, the study of male infertility in the era of ICSI can contribute in a unique and powerful way to the emerging field of masculinity studies in the Middle East, where fatherhood has traditionally been synonymous with manhood (Ouzgane 1997). As suggested by this study of male infertility in Egypt and Lebanon, male infertility is an emasculating condition for some men, perhaps the majority of them. In both countries, infertile men’s secretive behavior, including their high rates of nonresponse to my recent IVF-clinic-based study, likely reflects the degree of stigmatization still surrounding this condition. Although the emergence of ICSI may eventually help bring this once-intractable and still-hidden condition from behind its veil of secrecy, as is clearly beginning to take place in Lebanon, ICSI itself has created new marital and moral dilemmas. As shown in this chapter, these dilemmas, in and of themselves, are accompanied by additional layers of stigma and secrecy. Thus, for the Middle East at least, interrogating ARTs from the vantage point of men’s own reproductive lives seems to be a worthwhile endeavor, one that, ideally, should be repeated in many sites around the globe.

Acknowledgments I want to express my gratitude to the numerous men and women in both Egypt and Lebanon who spoke to me about their infertility and reproductive lives. The IVF physicians, nurses, and staff mem-

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bers who helped me to recruit male patients into this study deserve great credit; they include (in alphabetical order) Antoine Abu Musa, Johnny Awwad, Abbass Fakih, Michael Hasan Fakih, Walid Ghutmi, Najwa Hammoud, Antoine Hannoun, Azhar Ismail, Da’ad Lakkis, Zaher Nassar, Khaled Sakhel, Gamal Serour, Hanady Sharara, Mohamed Yehia, Salah Zaki, and Tony Zreik. I also want to thank my primary research assistants, Mary Ghanem and Tayseer Salem, as well as Huda Zurayk and Rima Afifi, who cordially provided me with institutional affiliations in Lebanon. This research was generously supported by the National Science Foundation and the U.S. Department of Education Fulbright-Hays Program. Finally, I owe a major debt of gratitude to my professor and mentor, Joan Ablon, for forging the intellectual path down which she led me and for her unflagging support of my career.

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Notes An earlier version of this chapter was published in the Journal of Middle East Women’s Studies 3(3): 1–20. 1. This chapter is based on the article “Middle Eastern Masculinities in the Age of New Reproductive Technologies: Male Infertility and Stigma in Egypt and Lebanon,” published in Medical Anthropology Quarterly 18 (2004): 34–54. Reprinted with permission of University of California Press. 2. Originally, I was supposed to return to Egypt to conduct this study, but I did not receive research permission from the Egyptian government. Thus, I relocated my study to Beirut, with the assistance of a number of Lebanese colleagues. 3. The option to be tape-recorded was presented to each informant, on the written informed consent form. Most informants asked about this, and when I told them it was not necessary to tape-record the interview, they uniformly declined, usually with visible relief. This “taperecordless” strategy, which I have used in most of my interviews in both Egypt and Lebanon, requires me to take almost-verbatim shorthand notes, which I learned through a previous career as a medical journalist. 4. All of these blood samples were tested for nine heavy metals in the environmental health laboratory of my study’s co-principal investigator, Dr. Jerome Nriagu, of the University of Michigan School of Public Health (Inhorn et al. 2008). 5. Depleted uranium (DU), which is used in the manufacture of some U.S. weapons, including those sold to Israel, is a source of scientific

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6. 7.

8.

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9.

10.

11.

Marcia C. Inhorn

controversy in the environmental-health community, which is currently assessing the long-term health risks of this substance. DU was used by U.S. forces in the Gulf War (when some U.S. military personnel were affected). Thus, there is public concern in Lebanon, raised in the popular media, that DU was used by Israeli forces in Southern Lebanon. For this reason, we decided to search for DU in the blood samples of men in this study. No DU was found in 2003. However, the specter of DU contamination in Lebanon emerged again with the war between Lebanon and Israel in summer 2006, when U.S. “bunker buster” armaments with DU were used by the Israeli military in Southern Lebanon. All names in this chapter are pseudonyms. Because Ali was clearly distraught by this admission of sexual “immorality,” I attempted to assuage his anxieties by telling him it was unlikely that an STD had led to his infertility. STDs can lead to infertility through obstructive scar tissue in the epididymis (so-called obstructive azoospermia). However, Ali did not suffer from azoospermia; he suffered from guilt, which my medical explanation probably did not and could not remedy. It is important to note that I was also conducting my study during a period of heightened political tension, due to the U.S.-led war in Iraq. In one clinic, which catered to many members of the Shia political party Hizbullah, I clearly was not welcome during the period of the war, when virtually every Lebanese and Syrian man who was asked refused to participate in my study. Once the war officially ended and bad feelings toward the United States had ebbed somewhat, my interviews at this clinic resumed. I have written about this elsewhere (Inhorn 2004). Because of widespread disapproval of sperm donation in Lebanon, it was rarely practiced. However, I did meet several men in my study, including one uneducated Shia laborer and two highly educated Christian men who were resorting to sperm donation because of intractable azoospermia. The rest of the men using donor sperm during the time of my study refused to participate (Inhorn 2006a, 2006b). Although Syria borders Lebanon, its historical ties to the West are much weaker and its standards of living much lower. Thus, IVF clinics are few and far between in Syria when compared to Lebanon. Furthermore, the views of male infertility reported to me by Syrian men were much closer to what I found in Egypt in my earlier studies. Thus, Syrian men who agreed to participate in my study were generally “sharing a secret” they had discussed only with their wives and IVF physicians. Mut’a marriages were, in fact, being undertaken between some husbands and egg donors in the predominantly Shia clinic in which I worked.

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References Abbey, Antonia, Frank M. Andrews, and L. Jill Halman. 1991. “Gender’s Role in Responses to Infertility.” Psychology of Women Quarterly 15: 295– 316. Ali, Kamran Asdar. 2000. “Making ‘Responsible’ Men: Planning the Family in Egypt.” In Fertility and the Male Life-cycle in the Era of Fertility Decline, ed. Caroline Bledsoe, Susana Lerner, and Jane I. Guyer. Oxford: Oxford University Press. Becker, Gay. 1997. Healing the Infertile Family: Strengthening Your Relationship in the Search for Parenthood. Berkeley: University of California Press. ———. 2000. The Elusive Embryo: How Women and Men Approach New Reproductive Technologies. Berkeley: University of California Press. ———. 2002. “Deciding Whether to Tell Children About Donor Insemination: An Unresolved Question in the United States.” In Infertility around the Globe: New Thinking on Childlessness, Gender, and Reproductive Technologies, ed. Marcia C. Inhorn and Frank van Balen. Berkeley: University of California Press. Bentley, Gillian R., and Nicholas Mascie-Taylor, eds. 2000. Infertility in the Modern World: Present and Future Prospects. Cambridge: Cambridge University Press. Bittles, A. H., and P. L. Matson. 2000. “Genetic Influences on Human Infertility.” In Infertility in the Modern World: Present and Future Prospects, ed. Gillian R. Bentley and C. G. Nicholas Mascie-Taylor. Cambridge: Cambridge University Press. Brown, Lesley, ed. 1993. The New Shorter Oxford English Dictionary. Vol. 1. Oxford: Clarendon Press. Carmeli, Yoram S., and Daphna Birenbaum-Carmeli. 1994. “The Predicament of Masculinity: Towards Understanding the Male’s Experience of Infertility Treatments.” Sex Roles 30: 663–77. ———. 2000. “Ritualizing the ‘Natural Family’: Secrecy in Israeli Donor Insemination.” Science as Culture 9: 301–24. Connell, R. W. 1995. Masculinities. Berkeley: University of California Press. Curtis, K. M., D. A. Savitz, and T. E. Arbuckle. 1997. “Effects of Cigarette Smoking, Caffeine Consumption, and Alcohol Intake on Fecundability.” American Journal of Epidemiology 146: 32–41. Daniluk, Judith C. 1988. “Infertility: Intrapersonal and Interpersonal Impact.” Fertility and Sterility 49: 982–90. Devroey, P., M. Vandervorst, P. Nagy, and A. Van Steirteghem. 1998. “Do We Treat the Male or His Gamete?” Human Reproduction 13 (Suppl 1): 178–85. Egyptian Fertility Care Society. 1995. “Community-based Study of the Prevalence of Infertility and its Etiological Factors in Egypt: (1) The Populationbased Study.” Cairo: The Egyptian Fertility Care Society.

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Feldman-Savelsberg, Pamela. 1999. Plundered Kitchens, Empty Wombs: Threatened Reproduction and Identity in the Cameroon Grassfields. Ann Arbor: University of Michigan Press. Fisk, Robert. 2002. Pity the Nation: The Abduction of Lebanon. New York: Thunder’s Mouth Press. Franklin, Sarah. 1996. Embodied Progress: A Cultural Account of Assisted Conception. London: Routledge. Ghoussoub, Mai, and Emma Sinclair-Webb, eds. 2000. Imagined Masculinities: Male Identity and Culture in the Modern Middle East. London: Saqi Books. Goldberg, Helene. 2009. “The Sex in the Sperm: Male Infertility and its Challenges to Masculinity in an Israeli-Jewish Context.” In Reconceiving the Second Sex: Men, Masculinity, and Reproduction, ed. Marcia C. Inhorn, Tine Tjørnhøj-Thomsen, Helene Goldberg, and Maruska la Cour Mosegaard. New York: Berghahn Books. Greil, Arthur L. 1991. Not Yet Pregnant: Infertile Couples in Contemporary America. New Brunswick, NJ: Rutgers University Press. ———. 1997. “Infertility and Psychological Distress: A Critical Review of the Literature.” Social Science and Medicine 45: 1679–704. Greil, Arthur L., Karen L. Porter, and Thomas A. Leitko. 1990. “Sex and Intimacy among Infertile Couples.” Journal of Psychology and Human Sexuality 2: 117–38. Hopkins, Nicholas S., Sohair R. Mehanna, and Salah el-Haggar. 2001. People and Pollution: Cultural Constructions and Social Action in Egypt. Cairo: The American University in Cairo Press. Inhorn, Marcia C. 1994. Quest for Conception: Gender, Infertility, and Egyptian Medical Traditions. Philadelphia: University of Pennsylvania Press. ———. 1996. Infertility and Patriarchy: The Cultural Politics of Gender and Family Life in Egypt. Philadelphia: University of Pennsylvania Press. ———. 2002. “Sexuality, Masculinity, and Infertility in Egypt: Potent Troubles in the Marital and Medical Encounters.” The Journal of Men’s Studies 10: 343–59. ———. 2003a. Local Babies, Global Science: Gender, Religion, and In Vitro Fertilization in Egypt. New York: Routledge. ———. 2003b. “‘The worms are weak’: Male Infertility and Patriarchal Paradoxes in Egypt.” Men and Masculinities 5: 236–56. ———. 2004. “Privacy, Privatization, and the Politics of Patronage: Ethnographic Challenges to Penetrating the Secret World of Middle Eastern, Hospital-Based In Vitro Fertilization.” Social Science & Medicine 59: 2095– 108. ———. 2006a. “Middle Eastern Men’s Discourses of Adoption and Gamete Donation.” Medical Anthropology Quarterly 20, no. 1: 94–120. ———. 2006b. “Making Muslim Babies: IVF and Gamete Donation in Sunni Versus Shi’a Islam.” Culture, Medicine and Psychiatry 30: 427–50. ———. 2008. “Medical Anthropology Against War.” Medical Anthropology Quarterly 22, no. 4: 416–24.

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Inhorn, Marcia C., and Kimberly A. Buss. 1994. “Ethnography, Epidemiology, and Infertility in Egypt.” Social Science & Medicine 39: 671–86. Inhorn, Marcia C., Luke King, Jerome O. Nriagu, Loulou Kobeissi, Najwa Hammoud, Johnny Awwad, Antoine A. Abu-Masa, Antoine B. Hannoun. 2008. “Occupational and Environmental Exposures to Heavy Metals: Risk Factors for Male Infertility in Lebanon?” Reproductive Toxicology 25: 203–12. Inhorn, Marcia C., Loulou Kobeissi, Zaher Nassar, Da’ad Lakkis, and Michael H. Fakih. 2009. “Consanguinity and Family Clustering of Male Factor Infertility in Lebanon.” Fertility and Sterility 91, no. 4: 1104–109. Inhorn, Marcia C., and Frank van Balen, eds. 2002. Infertility around the Globe: New Thinking on Childlessness, Gender, and Reproductive Technologies. Berkeley: University of California Press. Irvine, D. S. 1998. “Epidemiology and Aetiology of Male Infertility.” Human Reproduction 13 (Suppl 1): 33–44. Joseph, Suad, ed. 1999. Intimate Selving in Arab Families: Gender, Self, and Identity. Syracuse, NY: Syracuse University Press. Kahn, Susan Martha. 2000. Reproducing Jews: A Cultural Account of Assisted Conception in Israel. Durham, NC: Duke University Press. Kamischke, A., and E. Nieschlag. 1998. “Conventional Treatments of Male Infertility in the Age of Evidence-based Andrology.” Human Reproduction 13 (Suppl 1): 62–75. Khalaf, Samir. 2002. Civil and Uncivil Violence in Lebanon. New York: Columbia University Press. Kleinman, Arthur M. 1992. “Local Worlds of Suffering: An Interpersonal Focus for Ethnographies of Illness Experience.” Qualitative Health Research 2: 127–34. Larsen, Ulla, and Han Raggers. 2001. “Levels and Trends in Infertility in Sub-Saharan Africa.” In Women and Infertility in Sub-Saharan Africa: A Multi-Disciplinary Perspective, ed. J. Ties Boerma and Zaida Mgalla. The Netherlands: Royal Tropical Institute. Lindisfarne, Nancy. 1994. “Variant Masculinities, Variant Virginities: Rethinking ‘Honour and Shame.’” In Disclocating Masculinity: Comparative Ethnographies, ed. Andrea Cornwall and Nancy Lindisfarne. London: Routledge. Lloyd, Mike. 1996. “Condemned to be Meaningful: Non-response in Studies of Men and Infertility.” Sociology of Health and Illness 18: 433–54. ———. 1997. “The Language of Reproduction: Is It Doctored?” Qualitative Health Research 7: 184–201. Lorber, Judith. 1989. “Choice, Gift, or Patriarchal Bargain? Women’s Consent to In Vitro Fertilization in Male Infertility.” Hypatia 4: 23–36. Meirow, D., and J. G. Schenker. 1997. “The Current Status of Sperm Donation in Assisted Reproduction Technology: Ethical and Legal Considerations.” Journal of Assisted Reproduction and Genetics 14: 133–38. Moynihan, Clare. 1998. “Theories of Masculinity.” British Medical Journal 317: 1072–75.

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Nachtigall, Robert D., Gay Becker, and Mark Wozny. 1992. “Effects of GenderSpecific Diagnosis on Men’s and Women’s Response to Infertility.” Fertility and Sterility 54: 113–21. O’Ballance, Edgar. 1998. Civil War in Lebanon, 1975–92. London: Macmillan. Obermeyer, Carla Makhlouf. 1999. “Fairness and Fertility: The Meaning of Son Preference in Morocco.” In Dynamics of Values in Fertility Change, ed. Richard Leete. Oxford: Oxford University Press. Ouzgane, Lahoucine. 1997. “Masculinity as Virility in Tahar Ben Jelloun’s Fiction.” Contagion: Journal of Violence, Mimesis, and Culture 4: 1–13. ———, ed. 2006. Islamic Masculinities (Global Masculinities). London: Zed. Population Reference Bureau. 2001. World Population Data Sheet. Washington, DC: Population Reference Bureau. Schettler, Ted, Gina Soloma, Maria Valenti, and Annette Huddle. 1999. Generations at Risk: Reproductive Health and the Environment. Cambridge: MIT Press. Serour, Gamal I. 1996. “Bioethics in Reproductive Health: A Muslim’s Perspective.” Middle East Fertility Society Journal 1: 30–35. Sonbol, Amira el Azhary. 1995. “Adoption in Islamic Society: A Historical Survey.” In Children in the Muslim Middle East, ed. Elizabeth Warnock Fernea. Austin: University of Texas Press. Thomas, J. O., and A. Jamal. 1995. “Primary Testicular Causes of Infertility.” Tropical and Geographical Medicine 47: 203–205. Vayena, E., P. J. Rowe, and P. D. Griffin. 2002. Current Practices and Controversies in Assisted Reproduction: Report of a WHO Meeting on “Medical, Ethical and Social Aspects of Assisted Reproduction.” Geneva: World Health Organization. Webb, Russell E., and Judith C. Daniluk. 1999. “The End of the Line: Infertile Men’s Experiences of Being Unable to Produce a Child.” Men and Masculinities 2: 6–25. World Health Organization. 1987. “Infections, Pregnancies, and Infertility: Perspectives on Prevention.” Fertility and Sterility 47: 964–68. Yeboah, E. D., J. M. Wadhwani, and J. B. Wilson. 1992. “Etiological Factors of Male Infertility in Africa.” International Journal of Fertility 37: 300–307.

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Part II

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COUPLES AND OTHERS: ASSISTING REPRODUCTION WITH THIRD PARTIES

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Chapter 4

THE TRAFFIC BETWEEN WOMEN FEMALE ALLIANCE

AND FAMILIAL IN ECUADOR

EGG DONATION

Elizabeth F. S. Roberts

Preface: Her Nephew’s Wife

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I

n the summer of 2003, Frida, a businesswoman living in Queens, New York, made one of her bimonthly trips to Ecuador, the country of her birth. Frida imports inexpensive clothing to Quito, but this particular trip included a transaction of another sort. Frida and her husband, a limousine driver, had wanted to have a child since marrying ten years before. After two years of trying to conceive, they consulted an infertility clinic in Quito, where they were living at the time, and Frida was diagnosed with blocked fallopian tubes. As Frida did not have enough money to undergo the recommended treatment of in vitro fertilization (IVF), she “dedicated” herself to work in order to save for the procedure. Working harder eventually meant moving to the United States, but Frida planned to undergo IVF at the same clinic in Quito, which was much cheaper than in the United States. Lower costs were not the only thing drawing Frida to Ecuador. At the age of forty-six, her eggs had been deemed “too old,” and she needed younger ones. The eggs were to come from twenty-five-yearold Anabela, Frida’s nephew’s wife. Anabela and Frida had been close for years; when Frida left for the United States, she bequeathed Ana-

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bela her clothing stall in one of Quito’s open-air markets. With Frida’s continued support and advice, Anabela’s business had done very well, and she had expanded to two stalls, which in turn allowed her to ex-pand her family to two children. Anabela saw egg donation as a means of giving Frida something in return for her past support. Characterizing herself as “owing” her aunt, Anabela said, “I have so much gratitude for her. I said, ‘I have two children. For me there is no problem.’ For me it makes me feel good. My aunt is like my mother. I have nothing without her. I will help her in all that is humanly possible.” In fact, Anabela had been willing to do more. When Anabela first learned about Frida’s problem, she assumed she would need to act as a surrogate mother, an arrangement she had seen on a telenovela (soap opera). Anabela was happy when she was informed she only needed to donate eggs, a practice she had never heard of. After Anabela’s fertilized eggs were transferred to Frida, Anabela was worried she had gotten something she had not anticipated. She and her husband had had unprotected intercourse while she was in the ovarian-stimulation phase of her cycle. The clinic doctors had warned her to abstain from sexual relations during this time, but as she had an IUD, she thought she was protected. At her post-retrieval ultrasound, the doctors thought they might have seen a gestational sac. Although Anabela thought she might eventually want a third child, her youngest child was only nine months old, and she was busy with her clothing business. The last thing she wanted at that point was to be pregnant again.

Introduction This chapter examines the exchange of eggs as material resources between Ecuadorian kinswomen. Since 2000, I have conducted research in Ecuador’s IVF clinics, mainly in Ecuador’s nine private IVF clinics, located in Quito, the capital, and Guayaquil, the country’s largest and most commercial city. I observed and spoke with practitioners and their patients in laboratories and operating, waiting, and recovery rooms. I conducted over 130 formal interviews, the majority of which were with female infertility patients, although some interviews were with their male partners. I was privy to twenty-eight cases of egg donation in Ecuador, eleven of which involved known donors and seventeen of which involved anonymous donors. I also conducted interviews with IVF practitioners, physicians, technicians,

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laboratory biologists, or staff at IVF clinics, as well as sperm donors, surrogate mothers, priests, lawyers, and bioethicists. I have changed the names of all my informants to preserve anonymity (for an extended discussion of my findings, see Roberts 2006a). When IVF patients in Ecuador are told they need an egg donor, many prefer to use female relatives—sisters, nieces, goddaughters, sisters-in-law, and grown daughters—rather than anonymous, paid donors recruited by their clinics. Although egg transfer is a novel sociotechnical practice, the movement of women’s eggs to their kinswomen has been easily integrated into preexisting reciprocal relationships. Frida and Anabela were but one of the several known egg-donation cases I followed in Ecuador. However, even among kinswomen not directly “in business” with each other, egg donation between sisters, nieces and aunts, mothers and daughters, etc., not only served to make new children, but also provided occasions to reflect on and maintain pathways of inheritance and property transfer. In these cases, relatedness is not produced through the elementary structures of kinship proposed by Lévi-Strauss (1969), always the exchange of women between men. Instead, the movement of eggs between female relatives in Ecuador promotes continued relationships between them, reinforcing formalized ties of affection and commerce that do not participate in bourgeois category distinctions of public and private, kinship, and economy. In other words, the antipathy to paid anonymous donation is not the fact of payment but the fact that anonymity does not foster continued alliance. My aims in this chapter are twofold. First, I demonstrate the anxieties that surface (or do not) in Ecuador over new life-making technologies, in order to compare them with the more globally dominant scientific and ethical norms that surround these technologies elsewhere, and I concentrate on the norms that shape the boundaries of family and finance. Second, I demonstrate empirically how a practice such as egg donation is employed to reproduce long-standing forms of connection between women in Ecuador. These practices are especially meaningful when revisiting the anthropological literatures on kinship and economy, including arguments about the traffic in women. My claim that egg donation in Ecuador exemplifies traffic between women in no way diminishes the fact that the sociotechnical “assemblages” (Ong and Collier 2005) that constitute the ever-expanding assisted reproduction technology industry is not a traffic in women, as well as human gametes and other tissues, pharmaceuticals, medical equipment, and hope and fear, nor does it diminish the fact that this traffic is primarily made between men. However,

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I conclude that although these technologies are not inherently libratory, to say the least, they are being used by some Ecuadorian women to produce female economic alliances central to their families’ economic fates.

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Origin Stories of Kinship, Sociality, and Exchange Familial egg donation in Ecuador speaks to the mutually constituted anthropological literatures on kinship and exchange (Strathern 1985). Susan McKinnon points out that “the analogy that focuses on the power of paternity (and fraternity) to mobilize more ‘natural’ female resources through the enterprising spirit of the market is not ‘just’ a metaphor but an analogy central to anthropological understandings of what kinship and the creation of culture are all about” (2001: 297). In this passage McKinnon refers to Claude Lévi-Strauss’s ofttold origin tale of social life, in which kinship, produced through the incest taboo and exogamy, worked to bind nonbiologically related groups through the exchange of women between men. Women were “the most precious possession” (Lévi-Strauss 1969: 62) that men as fathers and brothers “naturally” wanted to keep for themselves. The incest taboo functioned to compel these men to exchange sexual and reproductive access to their women with other groups. This act of exchange ultimately turned “fear to friendship,” diminishing intergroup hostility and providing the basis for a vast series of interconnected, ongoing, and cascading series of reciprocal exchanges, constituting social life—always between men (68).1 This “traffic in women” and its analysis were revisited and revitalized by Gayle Rubin in her now-classic 1975 critique and expansion of Lévi-Strauss’s argument, in which she grapples with the implications of a productive–reproductive economic kinship system where women’s labor is always converted into male wealth. Rubin argues that “the traffic in women” is shorthand for expressing the social relations of a kinship system in which men have certain rights to their female kin. As women are the basis for all exchange, they are not in the position to give themselves away and are less able to engage in exchange relationships, excluding them from much of social life itself. This “asymmetry of gender equals the difference between exchanger and exchanged—and entails the constraint of female sexuality” (183). Using Marxist language, Rubin calls for a “revolution in kinship” (199) made possible by Lévi-Strauss’s “profound perception of a system in which women do not have full

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rights to themselves” (177), where sexuality and marriage must be incorporated in the analysis of sex oppression, and where “obligatory sexualities and sex roles” are eliminated (204). Although Rubin’s reading of Lévi-Strauss inspires my analysis, my material on egg donation between kinswomen in Ecuador should not be understood as emancipatory or revolutionary in Rubin’s sense, that the obligatory nature of sexuality and sex roles might be overcome. My argument intersects with Rubin and other feminist anthropologists when taking note of how the material and gendered basis of political power and social adulthood is linked to the ability to exchange. In another provocation of structuralism, Luce Irigaray asks what happens “when the good get together” (1980). For Irigaray, “getting together” is a sexual challenge to the elementary structures of kinship. What if the goods, women, had sex with each other? Less excitingly, but more generally, we can ask what happens to the traffic in women when we explore any type of traffic between them. How does this traffic affect our understanding of social life when, for example, the Ghanaian food-distribution system is organized through the efforts of market women, who make up over 70 percent of the vendors (Clark 1994)? Feminist anthropologists have also noted that the structures of gender put strictures on trade. For example, exchanging women often become structural men, in at least some parts of their lives. Lovedu women, in southern Africa, who give and receive cattle can marry women and become husbands (Sacks 1975), and Devadasis, in southern India, who never marry mortal men, often perform the financial/kinship duties of sons in their natal families (Ramberg 2006). These are certainly not revolutions in kinship and instead might be better read as signs of just how entrenched the traffic in women is when, in certain circumstances, a woman can only obtain rights to herself by exchanging as a man and avoiding the role of wife. However, these ethnographic examples guide us toward the variety of ways women have structured their productive/reproductive lives to exercise rights in themselves and others in both structure and practice. Another of Lévi-Strauss’s interlocutors, Pierre Bourdieu, provides an alternate frame in which to complicate Lévi-Strauss’s origin tale of social life. Bourdieu uses the negotiations and exchanges involved in marriage arrangements to distinguish his “theory of practice” from structuralist accounts of kinship: Marriage provides a good opportunity for observing what in practice separates official kinship, single and immutable, defined once and for

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all by the norms of genealogical protocol, from practical kinship, whose boundaries and definitions are as many and as varied as its users and the occasion on which it is used. It is practical kin who make marriages; it is official kin who celebrate them (1977: 34).

According to Bourdieu, women, who are constantly exchanging between themselves, are the practical kin who make marriages, precisely because women, at least in Kabylia, Algeria, are “the persons least qualified to represent the group and to speak for it” (34). In other words, women begin the bulk of most marriage negotiations because their actions and intentions are easily disowned if things go awry and are easy to omit from the official kinship of a group’s selfrepresentation. Bourdieu’s argument with Lévi-Strauss is not that he was wrong about the exchange of women between men, but in delineating the overarching structures of kinship, he left out the daily myriad practices that shape these structures, making official kinship appear seamless to the ethnographer. Practice, then, is crucial to my understanding of the traffic in eggs between Ecuadorian kinswomen. However, unlike the practices of Kabylian women, the practice of these Ecuadorian women is not hidden to make way for the overarching structure of official kinship; instead, these arrangements are presented as crucial to the official production and continuity of familial, economic, and social life.

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Public Value and Private Dignity Lévi-Strauss drew heavily on the work of Marcel Mauss for his theory of kinship and exchange in “archaic” societies where economy and kinship (and everything else) had not been divided into separate domains (Mauss 1990). Mauss argues that the gift exchange is still a part of our own economic life, but like the social theorists who came before him, he laments that buying and selling in a moneyed economy contributes to the deadening of social relations, extinguishes reciprocal responsibility between employer and employee, and hides the workers’ labor, embedded within commodities (Durkheim 1997; Marx 1976; Mauss 1990). Although social scientists have demonstrated that these distinctions between a gift and a moneyed economy are not very clear and the exchange of money can be productive of sociality as well (Simmel 1990; Zelizer and Rotman 1994), these divides are powerful rhetorical tools expressing how moderns imagine themselves as carving up the world (Latour 1993).

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Economy and kinship are two domains that intersect only problematically within discourses of modern bourgeois respectability.2 To maintain this respectability, it is ideal for love, home, and the family never to mingle with the corrupting power of money, commerce, and the market. Much of the philosophical rationale for the separation of the realms of love and money is articulated by Kant’s discussion of value and dignity. “Whatever has value can be replaced by something else which is equivalent; whatever on the other hand is above value and therefore admits of no equivalent, has a dignity” (cited in Rabinow 1999: 102). When economic production left the home, reproduction and women’s labor became increasingly domesticated and privatized and removed from the taint of money, as home and family became the repository of dignity and the market became the maker of value. This separation between the realms of home– market, public–private, value–dignity, subject–object has gone global, now heard in universalistic human rights discourses against human trafficking and often painfully knocking up against more local understandings of dowry, bride wealth, and death payments (Adams and Pigg 2005; Keane 2002; Strathern 2005).3 These sets of modern divides currently fuel some of the preeminent anxieties about the social arrangements entailed in new reproductive technologies. The possibility that a person, especially a woman, could harness what should remain her private reproductive potential in the business of surrogate motherhood or selling eggs collapses the two realms of kinship and economy (Blakely 1983; Gimenez 1991; Ragoné 1994; Roberts 1998). It is no surprise, then, that paid egg donation has been banned in a number of countries and is debated in others (Steinbrook 2006). However, this has not been the case in Ecuador, where these realms often combine unproblematically. The work of many Andean ethnographers has demonstrated that exchange relationships and gender, especially among indigenous and working-class women and men, stand somewhat outside bourgeois distinctions between value/dignity and public/private. One of the central figures in this literature is the Andean market woman, a troubling figure for the bourgeois order, which is surely why a sexspecific label exists for her (Allen 1988; Buechler and Buechler 1996; Cadena 2000; Weismantel 2001).4 Market women are suspect for committing a variety of category mistakes. Their relationships to other women, children, and men are not defined solely by private nurturance but instead involve commodity and gift exchange. Their lives cannot be easily separated into the domains of private consumption and public transaction. Weismantel found that in the Andes,

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interactions between siblings, spouses, parents, and children revolve around more formalized exchange relations. Euro-American family life is governed by generalized reciprocity, an ideology of “boundless love, which creates ill-defined exchanges filled with unresolved guilt and resentment. The movement of material goods within indigenous families in contrast was marked by a mannered courtesy at once more distant and more generous than the casual intimacies of middle-class life in North America” (2001: 140). We can see this mannered courtesy in Frida and Anabela’s relationship, which consists of ties of affection and shared business interests. Anabela’s act of donating eggs to Frida is not part of a generalized reciprocity, or what David Schneider calls “diffuse enduring solidarity” (1980), but rather works to reciprocate for past economic aid and support. Weismantel warns, however, that the superficial appearance of the Andean marketplace as an independent “city of women” can be misleading, as “relationships with men and with masculine institutions set invisible boundaries everywhere” (2001: 60). However, she also describes how market women engage with men in a variety of relationships that do not necessarily involve dependence and inequality. Although Rubin argues that compulsory heterosexuality in the context of gender inequality forces intercourse—sexual and social—to become an unequal exchange, Weismantel describes a different heterosexuality and structure of production/reproduction in the Andes. Despite the encroachment of a wage-labor economy, among working class and rural indigenous people, she finds evidence of heterosexual sex as “rough and playful,” a “pleasurable fight between equally matched opponents in which both parties’ capacity and desire for sexual gratification is taken for granted” (2001: 161). Likewise, these market women are baffled by the idea that they should have a father for their children or that they should want a permanent male partner. For them, ideal relationships consist of a form of mutually enriching gifts that are often hierarchical and often move between women. In fact, trading partners are often the children they care for. Unlike bourgeois women, market mothers expect their charges to contribute rather then expend household wealth. In this world, children are wanted as much for their labor as for their love—neither can be separated. The ability for these market women to maintain at least some economic and sexual rights to themselves, even if outside of feminine respectability, forms the backdrop for egg donation between kinswomen in Ecuador.

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Ecuador’s Economy of Assisted Reproduction Technologies Ecuador has been in a severe economic crisis since the mid-1990s. The effects of this downward economic spiral were exacerbated on a daily level when dollarization occurred, in 2000. Prices escalated exponentially overnight, and entire life savings were wiped out. In terms of consumer goods and rents, Ecuador is one of the most expensive countries in Latin America, but salaries remain very low. Income distribution in Ecuador is among the most severe in the Andean region, with roughly 80 percent of the income share of GDP accruing to approximately 20 percent of the population.5 In 1992, the Ecuadorian news media proudly heralded the birth of Ecuador’s first IVF baby. As of 2004, nine active IVF clinics were in Ecuador (a relatively high number for an extremely poor and rural nation of less than twelve million), with more in the planning stages. These nine clinics conduct a total of roughly 350 to 400 IVF cycles a year. At the time of my research, the cost of an IVF cycle ran from US$3,000 to US$5,000; the average cycle in the United States costs between $10,000 and $15,000. These price differentials are based on differences in labor costs. The cost of importing to Ecuador the tools necessary for IVF is extremely high, but labor costs in terms of staff salary are relatively low (Roberts 2006b). Even though an IVF cycle in Ecuador costs much less than in the United States, most of the patients with whom I spoke estimated that by the time they were through with IVF they had spent between $7,000 and $15,000, an astounding expenditure in a nation in which a middle-class salary in 2003 was around $600 a month. Ninety percent of the IVF patients with whom I had contact characterized themselves as middle class, which turned out to encompass a wide salary range. The salaries reported by patients who said they were middle class ranged from $200 a month to $2,000, demonstrating that a large swath of Ecuadorians had a pervasive desire to identify as middle class. Indeed, one of the surprises of my research was that many Ecuadorians with very limited economic means make their way to these clinics. However, once I knew more about Ecuador’s public health system, I saw that for many people of all classes, using private medicine was a matter of course, often a first stop rather than a last resort given the run-down and dehumanizing state of low-cost public clinics and hospitals. Paying out of pocket for medical services, both biomedical and “traditional” or alternative,”

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is standard. Thus, when having children does not go as planned, many women and men are ready to be patients at private clinics. Working-class and poorer patients scraped together the money for IVF from their families, moneylenders, and small capital improvement loans they had received for their businesses, often resulting in enormous debt. The expense of IVF made for many conversations that often led to discussions of the value (not the dignity) of children. For many patients, their willingness to take on a great amount of debt to alleviate their childlessness signified for them how much their children were wanted and loved. Euro-American bourgeois anxiety about mixtures of family and finance did not enter these narratives; in fact, money was understood as being productive of family intimacy, not threatening it. Whereas Marilyn Strathern (2005) found that in Australia “the ingredients for creating a child may be obtained in the marketplace [but] once a baby is part of the family market, values should no longer intrude,” Ecuadorian parents looked forward to telling their IVF children they were babies they had paid for. Carlos, a working-class man with IVF twins said, “It cost us a lot. We will tell them that they cost us a lot.” Another IVF patient, Laura, said that when she finally had a child she would tally up how much her child cost, which she portrayed as a pleasantly anticipated task, not one that would be a horrifying affront to the dignity of children. Like the Andean market women described earlier, these workingclass IVF patients’ accounts of IVF happily intermingled children and commerce, and kinship and economy.

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Egg Extraction and Egg Circulation The use of eggs as part of a third-party gamete donation has been one of the most contentious issues in the development of reproductive technologies around the world, and much of the anxiety around gamete donation centers on issues of money and recompense (Ahuja, Simons, and Edwards 1999; Robertson 2006). Anxieties about the practice manifest in the use of the term donation, as in several countries young women are in fact paid to “donate.”6 In many of the nations with a ban on remuneration, including most of Europe, Israel, and India, the infertility industry, many infertile couples, the popular media, and medical press have fostered a sense of a worldwide shortage of donor eggs.7 How this shortage came to be when eggs did not exist to be donated twenty years ago entails an understanding of changing modes of production/reproduction involving a vast

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array of new technologies and worldwide demographic and economic shifts. Although paid donation is allowed and remains primarily unregulated in the United States, considerable social tensions remain around issues of payment, anonymity, and disclosure. However, the use of paid anonymous egg donors for women over the age of forty has become standard in many large IVF clinics around the United States, due to the higher pregnancy rates younger eggs provide. Accurate statistics are difficult to gather in the United States, as the assisted reproduction industry is not regulated, but it is estimated that 11.4 percent of all IVF cycles in the United States involve donor eggs (Steinbrook 2006).8 Throughout Latin America, egg donation is commonly offered by IVF centers, although arrangements vary (Borrero 2002). For instance, in some Argentine and Brazilian clinics, patients needing egg donors must provide a donor. These eggs are given anonymously to another patient, and the first patient receives eggs from an unknown donor brought by another patient. Other clinics recruit paid donors; others rely solely on family members. In Ecuador, clinics offering egg donation usually coordinated known donors and the anonymous paid donors recruited by the clinic. In the case of anonymous donation, I frequently met both the patient and the donor and observed their parallel cycles, but the patient and donor were strictly separated. Ecuadorian practitioners recommend egg donation to patients near or over the age of forty and to patients diagnosed with ovarian problems (i.e., having no ovaries or eggs or having a hormonal dysfunction). Practitioners provide anonymous donors for stable heterosexual couples, although they do not need to be legally married. Even though I had much more contact with patients who wanted to use known donors, most doctors wanted their patients to use anonymous ones for the purpose of making the bounds of the family limited and clear. At a clinic in Guayaquil, practitioners firmly encouraged patients to use anonymous donors. Dr. Vega, the clinic psychiatrist, was especially against known donation, because of the possibility of family conflict over the parentage of children. When patients wanted to use a family member to donate eggs, he pushed them to see the “reality” of family donation as overly confusing: Psychiatrists—we have the obligation to bring them to reality. One part of the premise of the maternal instinct, and it is in reality an instinct, is to begin to ask this of this future mother: “What are you going to do with the eggs from your sister, your cousin? Are you ready to begin this with parenthood in doubt?”

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Anonymous donation ensures that the parenthood of the two intended parents is never challenged. Dr. Vega’s antipathy to known donation also serves to prevent female kinswomen from cementing their relationship through the transfer of eggs. His version of the “maternal instinct” can only see these alliances creating confusion. The direct payment of money and anonymity protects the nuclear family, but known donation engages in mixtures he saw as wreaking havoc with it.9

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Paid Donors Although the focus of this chapter is on egg donation between kinswomen, the practice of anonymous paid donation and known donation shares attributes indicative of Ecuadorian egg donation as a whole. Except for the clinicians responsible for arranging their cycles, paid egg donation is a female-centered experience, and as with known Ecuadorian donation, the mixture of commerce and reproduction is, for the most part, unproblematic. The majority of Ecuadorian egg donors are paid $500 to complete a cycle. The twenty paid egg donors I encountered were between the ages of nineteen and twenty-six, were relatively light skinned (see Roberts 2006a), and had finished high school.10 All the paid egg donors I met worked in some capacity, mostly at low-paying white-collar jobs, often parttime if they were students. Several of the paid donors were mothers—some were married, some were raising children without a male partner, some were living with their parents, and some of the donors without children had boyfriends. All the married donors had children, as a married woman without children has not yet utilized her reproductive potential. Most of the paid egg donors had been recruited by other women— friends or relatives working at IVF clinics. Donors told very few people they were selling their eggs, and when they did tell, they confided in mothers, sisters, and female friends. Married women told their husbands, but the majority of those with boyfriends did not. Egg donation was only to be discussed in the company of women, as confidential as the number of one’s lovers or having an (illegal) abortion—realms of female social experience rife with the potential for male attempts at female control. Paid egg donors’ desire to limit male knowledge of their activities was extremely clear when it came to fathers and brothers, who we might think of as having the most interest in supervising reproduc-

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tive potential. Donors believed their fathers would prevent the sale of their eggs or at least strongly disapprove. One young woman decided to become a paid egg donor after her father had forbidden her to donate eggs to her half sister a few years before. At that time, she promised God she would donate eggs when she got older. Other male figures tried to prevent egg donation as well. One donor’s male gynecologist warned her that “this is your child who you are giving away.” Consuelo, an IVF patient, asked her friend Juana to donate her eggs, and Juana agreed. As Juana’s husband had forbidden it, the process involved an enormous amount of subterfuge that included avoiding sexual intercourse with her husband for several weeks. Dramas like these illustrate one of the intangible benefits that donors gained. Donors often used the term experimenter (to experiment), and donation offered them a particular female means to experiment with the outer limits of behavior. It allowed these young women to test themselves, to find out if they could do this, if they would be chosen, and if they could evade their fathers’, boyfriends’, and brothers’ attempts to assert control over their reproductive and sexual potential. In Ecuador, very few young women have regular vaginal exams, which are understood to be the provenance of married women, who are presumed to be sexually active. Although the public ideal of female virginity until marriage is publicly upheld in urban Ecuador, most of the childless egg donors I met had been sexually active at some point. A central issue for several donors was that donation involves multiple insertions of a rather large vaginal ultrasound probe, causing concern that it might question their claims to virginity or sexual moderation. I suspect that when egg sales are permissible (as in the United States, Spain, Cyprus, Russia, and many parts of Latin America), it is an extremely feminized and semisecret experience for the young women involved. However, egg donation should not be construed as overt resistance to gender or class norms on the part of the donors. Becoming an egg donor involves, among other things, heteronormative understandings about helping other women become mothers. Likewise, the donors I interviewed did not imagine themselves as radical or subversive in their decision to sell reproductive body parts: in fact, Ecuadorian egg donors are not particularly savvy sellers. The secrecy that surrounds paid egg donation, which acts to prevent men from knowing their female relatives’ activities, perhaps contributes to the reason these young Ecuadorian egg donors never evinced a sense of collective consciousnesses. Paid donors told me they had been underpaid, but they had never attempted to negoti-

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ate for more. Practitioners looking for paid egg donors often complained that finding egg donors in Ecuador is exceptionally difficult, because Ecuadorian women are “too conservative and closed.” Thus, these egg donors were sellers in what could have been a sellers market, given the “shortage” of anonymous eggs. Instead, they were sellers of a clandestine sort, like sex workers, who find it difficult to make collective demands for better pay and working conditions. In Ecuador, however, attitudes toward financial recompense for egg donation were neutral to positive. I was accustomed to attitudes in the United States and the United Kingdom, where those involved in egg donation worked to diminish the financial aspects. Wary of charges of exploitation, practitioners I knew in Northern California, as well as those interviewed in popular press accounts, were careful to emphasize that donors had been paid for their time and effort, not for the eggs themselves. Thus, in the United States, where egg donors are paid, contracts stipulate that if the cycle is canceled for any reason, the donor will still be paid a prorated amount. In the United Kingdom, donors are only paid transportation and expenses; thus, their donations truly are donations, which fits within the ideals of anonymous social altruism valorized by Richard Titmuss in his 1971 work on blood donation and the gift relationship. The ban on recompense for eggs in the United Kingdom continues to reaffirm the modern divide that should ideally exist between value and dignity. In Ecuador, on the other hand, everyone from the recipient couples to the practitioners to the donors themselves were clear that the main reason to become a donor was the money. This attitude was similar to the IVF patients described previously who took pride in the amount of money spent to have an IVF child. Donors stated that they liked helping otherwise childless couples but would never do it for free. When I asked what the best part of the process had been, almost all emphatically replied, “The money.” In my interviews with couples using anonymous egg donors, all stated they thought egg donors needed money—why else would they do it? The beliefs surrounding payment made clear the underlying philosophical differences between egg-donor programs in the United States and Ecuador. In Ecuador, payments to donors are understood as an exchange for eggs, a product. When no eggs can be harvested, the donor is not paid. I observed this situation three times, when the donors’ follicles did not grow as expected. In all three cases the doctors believed the donors had not taken the medications properly. Two of these donors insisted they had taken the medication as directed; although they were upset, they were not outraged. They had

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no recourse to obtain payment from the IVF clinics, as they had little control over the process. Unlike paid donors, known donors in Ecuador have more control over the process. This is also the case in the United States, where known donors are not kept apart from the receiving couple. A difference between the United States and Ecuador is that known donors must engage in the practice “altruistically,” in effect trading the taint of commerce for the chance to be regarded as an active participant rather than a distant employee. In Ecuador, this distinction is not necessary. Known donors and female recipients are often actively engaged with each other in trade or the transmission of property.

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Donor Relations When seeking a known donor, the patients I interviewed tended to consider female relatives with whom they already had a close relationship. Practitioners had a list of physical attributes they recommend patients look for in a donor. Mostly, she should be in her twenties and without any obvious health problems. However as Frida’s choice of Anabela indicates, blood ties are not essential—the need to reaffirm an existing relationship is more important. The decision about who to ask to be a donor involves rules of relatedness reminiscent of the anthropological literature on marriageability (Barth 1954; Goody 1959; Leach 1951). Instead of determining whom one should marry in order to produce legitimate offspring and create alliances between families, one has to ask who can give eggs and share in the experience of having a child and who would most enhance already-existing female solidarity. Considering one’s kinswomen for their eggs also speaks to notions of biovalue (Waldby 2002) and bioavailability (Cohen 2004), terms that speak to the recent technological ability to extract, manipulate, and store bodily tissues for future use. Biovalue, according to Waldby, is “the yield of vitality produced by the biotechnical reformulations of living processes” (2002: 310). IVF entails the reformulation of living process by extracting a woman’s eggs from her fallopian tubes in order to fertilize them in vitro. Her extracted eggs come to be biovaluable, as they contribute to a vital process. However, egg donation involves the extraction of greater value, because the eggs are desired by someone who needs them and because they are transacted between persons and institutions. Waldby wonders what “kinds of indebtedness will be set in motion” in these new tissue economies (2002).

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Lawrence Cohen, who tracks the intricate pathways that have created the sale of kidneys in Chennai, India, takes up this concern (2005). Mostly, the sellers are women from families with crushing debt. For Cohen, bioavailability, “the selective segregation of one’s cells or tissues and their reincorporation into another body” (83), works within the logic that makes only certain bodies available for harvest within the moral economy of familial affect. Which bodies become bioavailable differs by locale. In Chennai, kidney sellers mostly are female, but in other places, like Moldova, they are male (Scheper-Hughes 2005). Eggs are gendered female, but figuring out which relative will be asked to donate often involves calculations of bioavailability that come from relationships of indebtedness and unequal exchange. As analytic terms, biovalue and bioavailability involve the historical distinctions between value and dignity. These concepts play with the novel historical moment when the human biological and the valuable can be linked, as it has become increasingly technically possible to transact with one’s own tissues. There is nothing new about this, of course: wet nurses have been selling their milk for centuries. What is new is the flux in attitudes about the sale of human tissue and the increasing ability to extract this tissue. The terms biovalue and bioavailability make sense given the crisis of “bodily dignity” in Europe and North America (Rabinow 1999). However, what of situations like Ecuadorian egg donation, in which categories of value and dignity have never been as radically opposed? Although this chapter centers around how egg donation maintains or establishes material and immaterial bonds between kinswomen, another crucial matter is defining the relationship between a child born through familial egg donation and the adults in that child’s life. In parsing all aspects of these relationships, my thinking is informed by practice (Bourdieu 1977), which speaks to Charis Thompson’s work on “strategic naturalizing” in United States infertility clinics (2001). Thompson found that those involved in IVF and gamete donation use a “mixed bag of surprisingly everyday strategies for naturalizing and socializing particular everyday traits, substances, precedents and behaviors” in order to align “procreative intent” with “biological kinship” (2001: 175). In Ecuador, blood was one of the main substances used to strategically naturalize relationships between intended parents and offspring. For many patients, eggs were imagined as “only” a small organ or the physical substance that women needed to conceive. These patients asked, “Whose blood feeds the child in utero?” When kinswomen and their whole fami-

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lies were involved, clarifying parenthood was seen as a manageable task, not an impossible one. In fact, the donor was understood as having an enhanced relationship to any child born through her donation, a relationship that did not threaten the primary parenthood of the egg recipients. Sisters

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Lucia and Ingrid, two working-class sisters from a large family, came from southern highland Ecuador for IVF. Ingrid, age thirty-two, the owner of a small store, donated her eggs to Lucia, her twenty-fiveyear old sister, who had been diagnosed with ovarian-function problems. Ingrid had three children and a husband with whom she was in constant contact during her month in Quito. Ingrid clearly saw herself as Lucia’s guardian during her time in Quito, even though Lucia’s husband would be present at crucial points during the process. It was Ingrid, not Lucia’s husband, who stood with Lucia during the embryo transfer, and it was Ingrid who kept watch over Lucia as she slept in the clinic the night after the transfer. The morning after, Ingrid told Lucia and me about a dream that exemplified how seriously she took her role as protector: I was frightened. I couldn’t get up, couldn’t move. I had seen that she [Lucia] had left with the nurse to get an injection or to urinate, but she had slipped on the stairs, and they fell out—the embryos. She fell, and I ran. And they fell. And there were six that fell. They came out in a little fountain. Like little balls of cotton. Like water. Like gelatin. And I said, “My God!” And the Doctorita Linda came and said, “Fine. We have to try to put them back inside.” And I woke up, and Lucia was sleeping very calmly. I went back to sleep, but I couldn’t leave the dream because of my nerves.

In her dream, Ingrid relied on another woman, Doctorita Linda, the clinic embryologist and case manager, to resolve the problem of the fallen embryos.11 It became clear that Ingrid’s concern stemmed from her own and her whole family’s desire for a child. I asked Ingrid if she would think of a child born from her donated eggs in a different way than she thought of her other nieces and nephews. Unlike Dr. Vega, who thought of a known donor as a cause for familial confusion, Ingrid saw her contribution in a positive light: Clearly. Clearly. It will also be part of myself. I believe that I will always be looking to see that Lucia will care for it [the baby] especially well for me. I told her I am going to feel this way. I am going to feel like it is part of me as well. That is because I have wanted to do it for

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her. And then it will have a part, I don’t know, a part of my heart. My children say, “Mami, what is it that you are going to do?” I say I’m going to take out my love, and they will put it in Aunt Lucia because this is what she lacks, no more, and afterward she will be able to have a baby.

The potential baby’s connection to the larger family emerged from the discussion of what Lucia owed Ingrid for her egg donation. If Lucia became pregnant she would, in effect, owe Ingrid by caring for the child especially well. After her transfer, Lucia mentioned she planned to give Ingrid money for the time she had missed from work. Ingrid said, “If God blesses us, you don’t have to do anything. Your baby will be the best pay. For everyone. For the whole family, because for everyone with this uncertainty we need a payment and the payment will be this [a baby]. We can rest then, everyone complacent and tranquil.” I had witnessed exchanges like these in California, where sisters insisted they did not need to be compensated for their egg donation; however, in those cases, children could only be described in terms of “gifts.” In contrast, Ingrid was comfortable speaking in the idiom of payments; in this case, the payment would be a new baby for a family invested in more progeny.

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Sisters-in-law When Dr. Padilla told Laura she needed an egg donor, she initially resisted: “Well, at first it seemed ugly. I said no, the child would not be totally mine.” Over time, though, she came to see the arrangement as normal if the donor were a family member, and it was Laura’s family who convinced her to use a donor. They imagined that the corporality of carrying a child in utero would make the child hers: “They told me if you are going to have it in your womb, with your blood, all of this, then it is your child.” The issue then became who could donate. Her sisters could not, because they were all much older. Her niece, who would have been ideal, was pregnant. Although she had a date to begin treatment, Laura didn’t have a donor. She was desperate until her brother said that his wife Nanci “can give you what you want because she is liga [had her tubes tied].” Laura and Nanci went through the cycle together, always as a pair, and sometimes accompanied by their husbands. Nanci and Laura had not been particularly close before the donation process, but as Laura said, “It united us.” As it turned out, Nanci’s donation was paying back a long-standing debt between siblings. Nanci was mar-

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ried to Laura’s youngest brother, whom Laura had cared for while their parents worked outside the home. Laura was already godmother to her brother and Nanci’s children, a preexisting exchange relationship. Laura imagined her desire to have a child as involved in another sort of transaction. She explained that if she became pregnant through IVF and egg donation, she and her husband, who had been married in a civil ceremony, would finally have a church wedding, paying back God for the favor of a child.12

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Mothers and Daughters One type of familial donor exchange, using an adult daughter’s eggs, occurred in cases of a woman’s marriage after the divorce from or death of her first husband. This exchange is only possible when the woman has a new husband, because daughters cannot donate eggs that would be mixed with their biological father’s sperm. However, mixing their eggs with their stepfather’s sperm does not seem to provoke concerns about incest or inappropriate sexual relations. Marlena was forty-eight at the time of her IVF cycle and pregnancy, and her husband was thirty-three. Her daughter from her first marriage, Ceci, was a twenty-year-old college student and local beauty queen. Like many patients using family donors, Marlena expected Ceci to feel an intensified connection to the baby; however, she thought Ceci’s social life prevented an interest in babies in general and Marlena’s gestating baby in particular. Marlena thought Ceci would eventually change: “Today we are talking only words, but it is a fact in the moment that she sees the baby. It will have certain features of hers, and then she will have an affinity with the baby.” After the embryo transfer, two embryos were left over and cryopreserved. Marlena wanted those two saved for her daughter: I will guard them for my daughter. Because this is what the doctor told me: “Guard them for her.” She does not care for children. She doesn’t love them because she is still an adolescent. I think that in the future maybe she will have a partner, and if she can’t have children they will go [to the clinic]. Now, no, she is not caring. I was like her, the same, and now I have two, but I didn’t want children when I was twenty.

Marlena saw herself as bequeathing her daughter with something of value, as she planned to share the baby: “You know that she has given fifty percent of it. And so with my husband, we have talked about how we are going to share. That is to say, if something happens to me, then it is not going to be only inheritance of the home.

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He [Marlena’s husband] is going to share and give the child to her as well.” When Marlena died, Ceci would inherit the house, the baby, and the frozen embryos, a narrative of female transmission of property that bypassed Marlena’s husband. In Charis Thompson’s research on North American IVF clinics, Thompson describes cases of intergenerational egg donation involving a daughter and second husband and a surrogate carrying her brother and sister-in-law’s genetic child (2001). These cases have the potential to be labeled as incestuous. Like Thompson, I found that any potential anxieties about incest between a daughter and her mother’s husband were overcome by emphasizing the relationship between the two female protagonists of the conception drama, the egg donor and the recipient, and deemphasizing the role of the intended father, until at least after conception had occurred. In the case of the daughter’s egg donation, Thompson found that the resulting frozen embryos that “conjoined” the daughters’ eggs with her stepfather’s sperm created deep misgivings about “inappropriate kinship” (Thompson 2001). However, in the case of Marlena and Ceci, Marlena saw the embryos as simultaneously economic and familial, property to be transferred from mother to daughter. In my work on surrogacy and egg donation in the United States, it is common for couples to give jewelry or other gifts to their known donors or surrogates, which serves to diffuse the fact that money has changed hands to produce children or to acknowledge the donor for the “gift” of her eggs or uterus. In Ecuador, where the transfer of money for eggs of anonymous donors poses less of a problem, no one I encountered gave material goods to their known donors, who were mostly family members. Instead, a child resulting from a donation was often characterized as a “gift” but even more often as “payment” for the donor as well as the recipient. Niece and Aunt Forty-four-year-old Miriam, a self-employed seamstress, and her forty-six-year-old husband, Hector, a self-employed mechanic, each had children from previous relationships. They had met about a year before showing up at Dr. Molina’s clinic in Quito, intent on having more children despite Miriam’s tubal ligation. Miriam’s twenty-fouryear-old niece, Doris, had agreed to donate her eggs. When I first met Doris, she was lying in bed after the egg aspiration. She seemed impossibly young: watching cartoons and playing with her pink cell phone covered in tiny foil stickers, Doris had recently finished nursing school and was taking a year off. When I asked about her siblings,

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she told me she had two older brothers and a six-month-old sister. Twenty years seemed like an unusually large gap between children, and Doris explained that when she was finishing her nursing training, an “illiterate” woman came into the hospital to give birth. She then gave the child to Doris and left. Doris took the child home to give to her parents but had decided that if her parents hadn’t wanted the baby, she would keep her. Doris’s parents did take the child, whom they also named Doris, and the adult Doris actively cared for baby Doris. By the end of the interview, Doris seemed much older because she had made such a concerted effort to procure children for her parent’s generation. She found a child to fill her parents’ “empty” home, and she provided eggs to her beloved aunt. A few days after the embryo transfer, I interviewed Miriam and Hector for the first time, while Doris sat with us. Although Doris seemed happy to sit back and let us talk, she occasionally jumped in to explain medical terms and procedures to her aunt and uncle, which they very much appreciated—another service provided to her elders. When I was alone with Doris, she told me how she had decided to donate her eggs to her aunt: How it started I don’t know. One day Miriam called me and asked if I could do this. A favor that I can give unos huevitos [some little eggs], but she didn’t explain anything. Then later she explained to me more, and I said, “For me there is no problem.” I had never imagined that I would get to be a donor! That I was going to be the assistant! Miriam told me that she and Don Hector didn’t think of anyone else. The doctors said there are [anonymous donors], but if you have someone it’s much better, because they don’t know whose eggs they are. They thought of me immediately. It’s the affection that they have for me that they thought of me.

Doris was obviously very happy to provide eggs for her aunt—being selected demonstrated how much Miriam cared for her. It was as if Miriam were bestowing Doris with privileged attention. Doris was even willing to participate in subterfuge with Miriam. As Miriam explained, Doris’s mother is my comadre. Doris is my godchild. It all stays in the family. For her, it was something big to say that the donor was to be her child. Yes, she would not deny it. “Comadre,” she said, “there is no problem on my part.” You know that the parents in most cases say no. Because they know that what is going to happen is through the vagina, and they [Doris’s parents] don’t know that it is vaginal. [They think the eggs are taken out] through the stomach, like an operation.

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They don’t understand it’s vaginal, and if they knew they wouldn’t like it.

Miriam employed compadrazgo, establishing ties between godparent and child, and more importantly, godparent and parent, the ubiquitous Latin America strategy for enhancing and reinforcing familial relationships to facilitate egg donation and IVF (Allen 1988; Bastien 1979; Davila 1971; Foster 1953; Hubbell 1971; Mintz and Wolf 1950; Poole 1991). In Quito a year later, I saw Miriam and Hector at the clinic, along with their baby. Both Miriam and Hector were generous with their credit for their child. They called Doris the second mama and described how the doctors, and even I, were crucial to their son’s creation.

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Alliance and Inequality Female ties of kinship, obligation, and commerce are central to all of these egg-donation relationships. Like Frida, Miriam and Marlena were involved in intergenerational egg donation and also were successful comerciantes (retailers). Frida and Marlena were married to younger men who were not (at least yet) as economically or professionally successful as their wives, and the women took primary financial responsibility for the cost of IVF. Their egg donors were younger women connected to them through exchanges of property and other material and immaterial forms of support. Laura and Lucia received eggs from women of their same ages, but these relationships were formed by debts and obligations to their larger families. Laura created a new, stronger relationship with her sister-in-law, whose donation worked to pay back some of her brother’s obligation to her. Ingrid protected Lucia during a perilous time in order to provide her whole family with a new baby. All of these women had relatively stable relations with men and were not critical of normative kinship institutions like marriage. However, like the male partners of the highland market women absorbed with their trading partnerships, male partners retreated during this time of intensified female trade. This was particularly clear in Frida’s case, when her husband flew to Quito months before Anabela’s donation to deposit his sperm, which was to be frozen for later use, but he was fully absent from the egg aspiration and embryo transfer. The participants in these relationships presented their experiences in a fairly positive light. To prevent myself from romanticiz-

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ing interfamilial donation in Ecuador, I would often tell myself a story an IVF patient told me about a kidney donation between two brothers that went awry. After recounting the tortuous family feud that ensued over property after the gift of the kidney, the IVF patient remarked, “Y como sangre duele” (And how blood hurts).13 I was not privy to egg donations in which abuses were obvious, but when younger women are asked to donate eggs to their husband’s relatives, when husbands offer their wives’ bodies for egg donation, and when daughters donate eggs to their mothers, we must be wary of the “gendered moral demands of prestation” (Cohen 2005) involved in making only some women’s bodies bioavailable. In addition, the bioavailability of those involved does not necessarily constitute a wholly different kind of prestation than that of physical labor and financial contributions made as debt relief to one’s kin. These are not relationships of full equality nor are they advertised as such. Debts mount from younger to older generations. These obligations seem to make egg donation especially appealing to known donors, because they can transact such a concrete and rich resource with what seems to them to be relatively little effort. Although the female relationships reaffirmed in known egg donation are not egalitarian, they are nothing like the dystopic future donations imagined so provocatively by Kazuo Ishiguro in Never Let Me Go (2005). In this novel, clones created for organ replacement are raised in the isolated English countryside and never allowed to socialize or engage in any exchange relations with those to whom they donate. They are the ultimate desubjectified, anonymous tissue donors created and raised to literally donate themselves to death. Even though Ecuadorian known egg donors become bioavailable because of their postionality within families, their donation serves to mutually substantiate their ongoing relationships, which they see as eventually benefiting themselves.

Conclusion Unlike Engels and Lewis Henry Morgan, who trafficked in narratives of overcoming matriarchal pasts that could be revived (Engels and Untermann 1902; Morgan 1877), Lévi-Strauss never imagined a possibility for the basis of social life other than the exchange of women between men (McKinnon 2001).14 Attention to the contemporary practices of relatedness and economy involved in Ecuadorian egg donation demonstrates consequential exchanges that are

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directly productive and reproductive of an ongoing sociality between the women involved, their male kinsmen, and their children. These transactions give weight to the argument that participation in social life demands exchange. In the case of Ecuadorian known donorship, these are not the hidden exchanges of unofficial kinship but the central, official, maybe even structural sureties of women who are full and central players in the economy of kinship. One of Rubin’s most devastating critiques of structuralism is its blindness to sex oppression, even though Lévi-Strauss never assumed an “abstract genderless human subject” (Rubin 1975: 171). A consequence of this blindness was how resulting psychoanalytic theories of femininity came to be “based largely on pain and humiliation,” which required some “fancy footwork to explain why anyone would enjoy being a woman” (197). It would have been possible to avoid the complicated footwork surrounding female subjects by paying attention to the enjoyment derived from intrafemale exchange, which clearly makes and marks social life. Instead of clones or fully trafficked women, we have merchant women like Frida and Anabela, maternal figures standing inside the marketplace, making babies and business. Like Laura and her brother, Frida took care of Anabela’s husband, Julio, when he was young. We might imagine, then, that Julio provided Anabela’s eggs as a payment to Frida, and he might have imagined Anabela’s eggs as paying off his debt. If he did think this, it remained unspoken, since during my time with Frida and Anabela, Julio stood outside the recovery room, holding his and Anabela’s baby. The story that Frida and Anabela told was one of finance and affection between two women that was made possible by the man they have in common. We might wonder, then— were they trafficking him? When Rubin describes how the weight of the entire economic system in highland New Guinea can rest “upon one woman in a miserable marriage” (207), she explains that “men are in constant need of valuables to disburse, and they are dependent upon input” (206). In some ways, Anabela and Frida are not so different from these men. When starting out in business, Anabela needed the valuables and input that Frida provided. Eventually, Frida needed the valuables and input (eggs) that Anabela provided. However, as far as I could tell, no one was forced to stay in a miserable marriage, and in the end, Anabela was not pregnant and therefore not “forced” to have another child. The transacted goods, the eggs, which turned into twins, will hopefully not grow up to have miserable childhoods under Frida’s care.

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Although Frida’s doctor encouraged her to use a donor “from outside,” she took another route, which provided her with more than just a child. Incorporating Anabela’s eggs into her reproductive project allowed for continued reciprocity between Frida and Anabela. Their alliance continued to flourish mutually, although, unequally enriched through material exchanges of eggs and market stalls.

Acknowledgements Many thanks to Marcia C. Inhorn and Daphna Birenbaum-Carmeli for inviting me to participate in this volume and for their incisive comments and support. This chapter benefited greatly from the careful reading of my beloved writers group—Rebecca Hardin, Nadine Naber, Julia Paley, and Damani Partridge—as well as the energizing interventions of Lucinda Ramberg and Chris Roebuck, ever my mentors in queering kinship.

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Notes 1. Perhaps it is fitting given Lévi-Strauss’s rather unexamined relationship to the biological that some of the alternate models proposed for the origin of human sociality have been proposed by feminist sociobiologists and physical anthropologists. These accounts have focused on biological survival, such as the reframing project of “woman the gatherer” (Slocum 1975), the theory that human cooperative sociality arose from the adaptation to bipedialism, which made birth more difficult and required aid from other females (Rosenberg 2001), as well as ethological research demonstrating how female primates are engines of political–economic life in their roles as mothers (Hrdy 1999). These theories all center around female activity in producing and brokering social life, something Lévi-Strauss never contemplated. 2. As Raymond Williams points out, the English use of “bourgeois” poses difficulties because of its French origin, linked to a particular aristocratic contempt for the “limited if stable life and ideas of this middle class” (1985: 46). I use “bourgeois” in the sense developed by Marx, to denote the dominating class that arose in the eighteenth century and stamped society with values that came to denote respectability, among them the distinction between love and money. 3. Anthropologists have noted, though, that these distinctions elide another set of understandings of the world, in which, for instance, women can be exchanged for cattle without either category being understood

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4. 5.

6.

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7.

8.

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as objects (Hutchinson 1992; Valeri 1994). Rubin describes how women as exchanged entities are not inherently desubjectified or made into objects, and she also contends that sex oppression did not begin with capitalism. However, when men as wage laborers became the public transactors and women became the private reproducers, power and the rights to one’s self came to rest even more solidly in the hands of those who were able to traffic (Rubin 1975). There is no need for a term to distinguish “market men,” as the market in Euro-American discourse is automatically male. The economic crisis also set in motion an unprecedented migration of Ecuadorians to other nations, especially Spain and the United States (Miles 2004). Two million of Ecuador’s twelve million people now live outside the country, the highest percentage of migration in Latin America. This great migration was evident in all areas of my research. I encountered several Ecuadorians who, like Frida, had migrated to the United States and then returned to Ecuador to undergo IVF, which was cheaper than in the United States. I also encountered IVF patients who dreamed of going to Spain, where they thought the state would pay for IVF. Migration was present in female patients’ stories of how they managed their lives and inseminations without their spouses who were working abroad and when they mourned the impossibility of using their far-flung sisters as egg donors. Migration to the United States or Spain also figured in the aspirations of many female patients in IVF clinics. They, like many other women I met, explained that if the opportunity arose, they would be willing to leave their potential children in order to secure a better future for them. Another important concern about egg donation involves the unknown long-term effects of fertility hormones on the donors. Very few of my respondents knew about the potential health effects of these drugs. See for example, www.smh.com.au/news/national/chronic-shortageof-donors-puts-ivf-clinics-in-jeopardy/2005/09/17/1126750168474 .html; www.reason.com/links/links012306.shtml; http://news.bbc.co .uk/1/hi/health/4002829.stm; http://news.bbc.co.uk/1/hi/health/ 231968.stm; www.timesonline.co.uk/article/011069–230651700 .html; www.marieclaire.co.uk/health/I_found_an_egg_donor_in_Russia _article_92968.html; http://humrep.oxfordjournals.org/cgi/content/ full/14/2/279; www.theage.com.au/news/national/human-egg-donorson-rise/2005/09/06/1125772522524.html; and www.bbc.co.uk/ insideout/west/series3/sperm_and_egg_donation.shtml. Most paid egg donation in the United States is anonymous, but several egg-donation matchmaking agencies in Northern California have initiated paid, known donation. In this arrangement, couples and the potential donor meet before the cycle begins. As I had conducted research on egg donorship and assisted reproduction in the California Bay Area in the early 1990s (Roberts 1998), these arrangements, completely atyp-

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10.

11. 12.

13.

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14.

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ical in the context of worldwide practice, were what I was most familiar with when I arrived in Ecuador, which undoubtedly shaped my perception of how egg donation is practiced elsewhere. Vega’s ideal moral order also works as a raced and classed critique of common indigenous and working-class family forms in the Andes, where child circulation between larger kin groups is exceedingly common (Leinaweaver 2005; Weismantel 1995). In the United States, egg donors can be paid from $4,000 to $5,000, tend to be in college or are college educated, are between the ages of twenty to thirty, and do not have children. Frequently, higher amounts are paid to women from groups considered scarce. Jewish and Japanese donors in particular are in high demand. Most laboratory biologists in Ecuador and throughout the world are women. For many Ecuadorians, a church wedding entails a prohibitively large expense. Working-class and poorer people tend to wait to go through with the ceremony, if they ever do, waiting until they have more money and the marriage seems stable. Egg donation is nothing like kidney donation in terms of invasiveness, recovery time, or the potential for severe problems. We can also wonder what might have happened if Lévi-Strauss had worked through structural accounts of other kinship exchanges, most obviously the exchange of children. The ethnographic record is rife with examples of exchange between women and men and women and women as they move children and other goods between them (Leinaweaver 2005; Modell 1995; Stack 1975). Indeed, one of anthropology’s most heated twentieth-century debates was whether young Samoan women had the right to circulate themselves, not just sexually, but between households in order to find one that suited them (Freeman 1983; Mead 1953). See Scheper-Hughes (1984) for a discussion of the disparate social worlds Mead’s and Freeman’s informants inhabited. As a young anthropologist, Mead worked primarily with young women, and Freeman, an older man, worked with older men and chiefs, who seemed to have a vested interest in denying that adolescent girls had the right to circulate themselves.

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Allen, Catherine J. 1988. The Hold Life Has: Coca and Cultural Identity in an Andean Community. Washington, DC: Smithsonian Institution Press. Barth, Fredrik. 1954. “Father’s Brother’s Daughter Marriage in Kurdistan.” Southwestern Journal of Anthropology 10: 164–71. Bastien, Joseph William. 1979. “Marriage and Exchange in the Andes.” Actes du LXII Congress International des Americainists 6:149–64. Blakely, Mary Kay. 1983. “Surrogate Mothers: For Whom Are They Working?” Ms. 11, no. 9: 18–20. Borrero, Claudia. 2002. “Gamete and Embryo Donation.” In Current Practices and Controversies in Assisted Reproduction, ed. E. Vayena, P. Rowe, and P. D. Griffin. Geneva: World Health Organization. Bourdieu, Pierre. 1977. Outline of a Theory of Practice. Cambridge: Cambridge University Press. Buechler, Hans C., and Judith-Maria Buechler. 1996. The World of Sofia Velazquez: The Autobiography of a Bolivian Market Vendor. New York: Columbia University Press. Cadena, Marisol de la. 2000. Indigenous Mestizos: The Politics of Race and Culture in Cuzco, 1919–1991. Durham, NC: Duke University Press. Clark, Gracia. 1994. Onions Are My Husband: Survival and Accumulation by West African Market Women. Chicago: University of Chicago Press. Cohen, Lawrence. 2004. “Operability: Surgery at the Margin of the State.” In Anthropology in the Margins of the State, ed. V. Das and D. Poole. Santa Fe, NM: School of American Research Press. ———. 2005. “Operability, Bioavailability and Exception.” In Global Assemblages: Technology, Politics, and Ethics as Anthropological Problems, ed. A. Ong and S. J. Collier. Malden, MA: Blackwell Publishing. Davila, Mario. 1971. “Compadrazgo: Fictive Kinship in Latin America.” In Readings in Kinship and Social Structure, ed. N. Graburn. New York: Harper and Row. Durkheim, Emile. 1997. The Division of Labor in Society. Trans. W. D. Halls. New York: Free Press. Engels, Friedrich, and Ernest Untermann. 1902. The Origin of the Family, Private Property and the State. Chicago: C. H. Kerr & Company. Foster, George M. 1953. “Cofradia and Compadrazgo in Spain and Spanish America.” Southwestern Journal of Anthropology 9, no. 1: 1–28. Freeman, Derek. 1983. Margaret Mead and Samoa: The Making and Unmaking of an Anthropological Myth. Cambridge, MA: Harvard University Press. Gimenez, Martha E. 1991. “The Mode of Reproduction in Transition: A Marxist-Feminist Analysis of the Effects of Reproductive Technologies.” Gender and Society 5, no. 3: 334. Goody, Jack. 1959. “The Mother’s Brother and the Sister’s Son in West Africa.” Journal of the Royal Anthropological Institute 89, no. 1: 61–88. Hrdy, Sarah Blaffer. 1999. Mother Nature: A History of Mothers, Infants, and Natural Selection. New York: Pantheon Books. Hubbell, Linda J. 1971. “The Network of Compadrazgo Among Middle-

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Rabinow, Paul. 1999. French DNA: Trouble in Purgatory. Chicago: University of Chicago Press. Ragoné, Helena. 1994. Surrogate Motherhood: Conception in the Heart. Boulder, CO: Westview Press. Ramberg, Lucinda. 2006. “Given to the Goddess.” PhD dissertation, University of California, Berkeley. Roberts, Elizabeth. 1998. “‘Native’ Narratives of Connectedness: Surrogate Motherhood and Technology.” In Cyborg Babies: From Techno-Sex to TechnoTots, ed. J. Dumit and R. Davis-Floyd. New York: Routledge. ———. 2006a. “Equatorial In-Vitro: Reproductive Medicine and Modernity in Ecuador.” PhD dissertation, University of California, Berkeley. ———. 2006b. “God’s Laboratory: Religious Rationalities and Modernity in Ecuadorian In-Vitro Fertilization.” Culture Medicine and Psychiatry 30, no. 4: 507–36. Robertson, J. A. 2006. “Compensation and Egg Donation for Research.” Fertility and Sterility 86, no. 6: 1573–75. Rosenberg, K., and W. Trevathan. 2001. “The Evolution of Human Birth.” Scientific American 285, no. 5: 72–77. Rubin, Gayle. 1975. “The Traffic in Women: Notes on the ‘Political Economy’ of Sex.” In Toward an Anthropology of Women, ed. R. R. Reiter. New York: Monthly Review Press. Sacks, Karen. 1975. “Engels Revisited: Women, the Organization of Production, and Private Property.” In Toward an Anthropology of Women, ed. R. R. Reiter. New York: Monthly Review Press. Scheper-Hughes, Nancy. 1984. “The Margaret Mead Controversy: Culture, Biology, and Anthropological Inquiry.” Human Organization 43, no. 1: 85–93. ———. 2005. “The Last Commodity: Post-Human Ethics and the Global Traffic in ‘Fresh’ Organs.” In Global Assemblages: Technology, Politics, and Ethics as Anthropological Problems, ed. A. Ong and S. J. Collier. Malden, MA: Blackwell Publishing. Schneider, David. 1980. American Kinship: A Cultural Account. Chicago: University of Chicago Press. Simmel, Georg. 1990. The Philosophy of Money. New York: Routledge. Slocum, Sally. 1975. “Woman the Gatherer: Male Bias in Anthropology.” In Toward an Anthropology of Women, ed. R. R. Reiter. New York: Monthly Review Press. Stack, Carol B. 1975. All Our Kin: Strategies for Survival in a Black Community. New York: Harper & Row. Steinbrook, Roberts. 2006. “Egg Donation and Human Embryonic Stem Cell Research.” New England Journal of Medicine 354, no. 4: 324–26. Strathern, Marilyn. 1985. “Kinship and Economy: Constitutive Orders of a Provisional Kind.” American Ethnologist 12, no. 2: 191–209. ———. 2005. Kinship, Law and the Unexpected: Relatives Are Always a Surprise. New York: Cambridge University Press.

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Thompson, Charis. 2001. “Strategic Naturalizing: Kinship in an Infertility Clinic.” In Relative Values: Reconfiguring Kinship Studies, ed. S. Franklin and S. McKinnon. Durham, NC: Duke University. Titmuss, Richard Morris. 1971. The Gift Relationship: From Human Blood to Social Policy. New York: Pantheon Books. Valeri, Valerio. 1994. “Buying Women But Not Selling Them: Gift and Commodity Exchange in Huaulu Alliance.” Man 29, no. 1: 1–26. Waldby, Catherine. 2002. “Stem Cell, Tissue Cultures and the Production of Biovalue.” Health 6, no. 3: 305–23. Weismantel, Mary J. 1995. “Making Kin: Kinship Theory and Zumbagua Adoptions.” American Ethnologist 22, no. 4: 685–704. ———. 2001. Cholas and Pishtacos: Stories of Race and Sex in the Andes. Chicago: University of Chicago Press. Williams, Raymond. 1985. Keywords: A Vocabulary of Culture and Society. New York: Oxford University Press. Zelizer, Viviana, and A. Rotman. 1994. The Social Meaning of Money. New York: Basic Books.

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Chapter 5

LAW, ETHICS, AND DONOR TECHNOLOGIES IN SHIA IRAN Soraya Tremayne

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T

he population policies of the Islamic Republic of Iran won international acclaim for their success in reducing population growth in the ten-year period from 1986 to 1996. Indeed, in 1998, Iran received the United Nations Population Award for its achievements. Within a span of ten years, population growth dropped from 3.8 percent in 1986, to 2.5 percent in 1991, to 1.5 percent in 1996, where it stands to the present day (Statistical Centre of Iran 1998; Tremayne 2004: 181–85).1 The secret to this success was a well-coordinated campaign on the part of health policymakers who showed an acute awareness of the cultural sensitivities in trying to persuade people to have fewer children. The campaign also received the full endorsement and involvement of clerics at the highest level. Islam and Iranian culture are assumed to value fertility, so in order to preempt public objections to the campaign, policy makers avoided the use of words such as “reduction” or “control” and instead used “regulation of the family” (tanzim-e-khanevadeh). At the same time, the campaign emphasized it was not only about reducing family size, but was also about the treatment of infertility, and therefore, special attention

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would be given to infertile couples (Hoodfar 1995: 114).2 This gained great favor with those objecting to the campaign’s anti-natal stance. Following such approval, which coincided with the spread of new assisted reproductive technologies (ARTs) worldwide, the past two decades have witnessed a rapid flourishing of infertility treatment in Iran, and centers making use of ARTs are opening at an increasing rate in the major cities. Currently, around fifty centers exist and range from private to semisponsored to almost-free treatment clinics. ARTs have spread around the world, beyond technologically advanced countries, but “perhaps nowhere is this globalization process more evident than in the twenty-two nations of the Muslim Middle East” (Inhorn 2005). According to Marcia C. Inhorn, “Iran is definitely in the lead among the Muslim countries in the Middle East in the application of these technologies” (2005). For those less familiar with Shia Islam, the speed and relative ease with which Iran has adopted ARTs come as a complete surprise. For a conservative theocracy not only to allow interference in matters of divine creation, but also to race ahead remains a puzzle. This is even more so given that the secular Western countries from which these technologies have come are still struggling to resolve some of the emerging ethical problems. The use of ARTs in Muslim countries has been made possible by the approval of religious leaders because, as “in all of the Middle Eastern Muslim countries, Islamic fatwas have profoundly affected the practice of IVF in ways that are not commonly seen in the West” (Inhorn 2006). Although the application of ARTs in the West is under the scrutiny of various medical, legal, and ethical committees, in the Muslim countries of the Middle East the responsibility for such endorsement has remained largely with religious leaders regardless of whether the state is secular or theocratic. “Infertile couples in these countries are usually extremely concerned about making their testtube babies in the Islamically correct way. To that end, they seek ‘official’ Islamic opinion on the practice of IVF in the form of a fatwa” (Inhorn 2006). The religious leaders in these countries have therefore taken the center stage and play an active role in examining and legitimizing the use of ARTs. In doing so, Sunni and Shia leaders have reached different conclusions. In this chapter, I explain some of the built-in mechanisms available to the Shia sect that pave the way for the legitimization of ARTs without breaking any divine rules. In addition, with Iran being a theocracy, decisions made by religious authorities are all encompassing; once they have issued a

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fatwa, no further approval is required by secular or even other religious authorities. However, fatwas themselves are based not just on lengthy debates between religious authorities, but also by a thorough engagement with secular experts. Although ruling clerics have officially approved the use of ARTs, differences of view remain among jurists as well as senior clerics as to the limits of their application and interpretation of their use (for Ayatollah Madani’s views, see MirHosseini 2000). This chapter focuses on Iran’s process of legitimizing the donation of sperm, eggs, and embryos, and explores the interaction between the three main players involved in the practice of ARTs: religious leaders; biomedical practitioners, who are the ultimate source of knowledge for the application of ARTs; and infertile couples, whose choice of donor are based on their understandings of what constitutes lineage and kinship. I argue that the flexibility of the Shia religion allows sufficient scope for manipulation by all three parties, which, if continued, can lead to a change in the landscape of kinship. The speed with which ARTs continue to invade the market, infertile couples’ high demand for them, religious leaders’ lack of consistency regarding their use, and the failure of the ruling religio-legal fatwas to keep pace with new situations arising from these practices have all created rifts regarding the ethical aspects of the practices and cultural norms. The research conducted so far suggests that the practice of ARTs remains in a state of flux. Only when the “new babies” come of age will the nature and extent of problems, ranging from ethical issues to kinship and gender relations, emerge. The data presented in this chapter is part of a larger study spanning two years (2003–2005) in Iran. The main sites of study were Tehran and Yazd, in central Iran, with some data from Gorgan, in the northeast, and Ardebil, in the northwest. Several clinics in Tehran and Yazd were selected on the basis of being private, semigovernmental, or public, in order to gain access to infertile couples of different social and economic backgrounds. The majority of clinics in both cities, especially the public clinics, focus on female infertility. Preliminary interviews were also carried out at a clinic catering to men whose infertility had resulted from spinal injuries occurring during the Iran–Iraq War. A total of sixty couples were interviewed. Forty-five were recruited from clinics, and others were through personal contacts. The main method used was participant observation. In-depth interviews were carried out with medical staff, psychologists, and ethical experts at the fertility clinics, as well as with senior clerics.

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Assisted Reproductive Technologies ARTs are expanding so quickly in Iran and demand is so high that keeping pace with them has become a major task for all involved. Islamic jurists are often faced with new ARTs being practiced without their approval and have to catch up with this fait accompli rather than determine their legal use in advance. In the early days, the practice of in vitro fertilization (IVF) took place between a wife and a husband and was considered merely another medical technology helping infertile couples reproduce. No third party was involved, and questions related to lineage, kinship, and the changing relationship between wife/husband and parents/children did not arise. However, with rapid advances in ARTs and the emergence of multiple choices, such as third-party donation, legitimization has proved a major challenge to Islamic jurists, who are faced with the dilemma of whether and how to allow ARTs without breaking incest taboos and parentage rules. Islamic law (shari’a) is clear about lineage (nasab), and shari’a meticulously defines the relationship of the kin group. In this system, a child belongs to his or her father and is his property. The mother is only a caretaker and has no rights over her children (MirHosseini 1998; Ebadi 2003). The law of inheritance follows such a stance. Marriage, incest, and adultery are also clearly explained, and social and sexual interaction between men and women is defined by dividing them into two categories, mahram and na-mahram. Briefly, mahrams are parents and siblings, among others (see Khatib-Chahidi 1981). As they are not potential marriage partners, close social contact is allowed. Na-mahrams are potential marriage partners, and therefore, close social and sexual interaction between them is forbidden (haram). Na-mahrams are not allowed to come into close contact with or touch each other, and na-mahram men are not allowed to see a woman’s body except for her face nor can they touch her. Breaking any of these rules involves severe sanctions. In such circumstances, it is not difficult to imagine the extent to which the application of some ARTs would violate these rules, especially that of lineage, and lead to complicated situations for which shari’a has no simple answers or solutions. According to Sunni religious leaders in Egypt and Lebanon, ARTs are limited to IVF between a married couple, and no third-party donation of gamete or embryo is allowed (Inhorn 2003, 2005). Shia clerics in Iran also ruled that ARTs should only be available to those within the marital union but resorted to interpreting the Koran (ijtihad), a practice unique to

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the Shia sect, which in turn led to fatwas allowing third-party donation.3

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Shia Islam and Sperm and Egg Donation IVF has been practiced for nearly twenty years in Iran, but it was not until the late 1990s that supreme religious leader Ayatollah Khamenei endorsed its use between a married couple, as well as third-party donation, by answering the following questions: “Is the application of IVF between a wife and husband allowed?” and “In case of the infertility of the wife or husband, leading to difficulties in marriage and mental problems, is the use of another man or woman’s sperm or egg, which is fertilized outside the womb, allowed?” His replies were, “IVF is not in and of itself legally forbidden as long as no haram acts such as gaze or touch take place.” He extended his approval for both egg and sperm donation on the same basis, emphasizing there is no legal prohibition from receiving an unknown man’s sperm as long as no touch or gaze take place. In answer to the question, “If a wife is unable to produce eggs (because of menopause or other reasons) can the husband’s second wife, whether permanent or temporary, donate her egg to be fertilized and planted inside the infertile wife?” he replied, “In principle such action is not forbidden and there is no difference between the nature of marriage whether it is permanent or temporary” (1999: 281–83). Although Ayatollah Khamenei did not explicitly mention temporary marriage as a solution to legitimize gamete donation, his answers were taken as a cue, and the definition of wife and husband was expanded to accommodate temporary marriage to carry out ARTs. Temporary marriage (mut’a in Arabic and sigheh in Persian), a practice particular to the Shia sect, occurs when a man and woman agree to enter into marriage within a time limit, which can be from one hour to ninety-nine years (see Haeri 1989). To legitimately receive gametes from a third party, the husband of an infertile woman will nominally—meaning that no touch or gaze will take place— marry the donor for one day. Donors should be widows or divorcees and ideally already have children of their own. Such conditions, in theory, prevent virgins and married women from donating eggs. Once the egg has been donated, it is fertilized with the husband’s sperm, outside the womb, and the embryo is planted inside the infertile wife’s uterus. Khamenei’s fatwa on egg donation states that “both the egg donor and the infertile mother must abide by the re-

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ligious codes regarding parenting. Thus, the child of the egg donor has the right to inherit from her, since the infertile woman who received the eggs is considered to be like an adoptive mother” (1999: 282). In the case of sperm donation, the child takes the name of the sperm “owner” (the infertile father) rather than the sperm donor. However, as with egg donation, the child inherits from his biological father, the sperm donor, as the infertile father is considered to be like an adoptive father. These rulings however, are not always followed in practice. In addition to the supreme leader’s written question and answers (esteftaat) and fatwas, special permission on specific issues can be obtained by telephone consultation, but these are not made public (personal communication, April 2004). However, such endorsements, especially sperm donation from unknown men, have been met with the strong disapproval of some senior clerics, and in the case of the husband’s infertility, the couple usually resorts to two options. In the first, the couple receives an embryo from another married couple, and this embryo will be planted inside the wife’s uterus. The second option is for the wife to divorce her husband and wait for three-and-a-half months (edeh), to ensure she is not pregnant. She then nominally marries the sperm donor for a day, receives his sperm, which is fertilized with her egg, outside the womb, and planted in her uterus. She then remarries her own husband. Temporary marriage for women is rare despite some known examples. The director of one of the fertility clinics in Yazd, who is a pioneer in this field, mentioned that temporary marriage for infertile women has never happened in the city, which is labeled as the most conservative in Iran. Initially, the ethical, moral, and legal problems that emerged from the practice of temporary marriage as a means of legitimizing thirdparty donation were not anticipated. All three of the parties engaged in gamete donation—the practitioners, the donors, and the recipients—are frequently faced with new situations, and in the absence of clear religious instructions resolve them as they best can. The examples observed so far indicate that the balance of relationship in the majority of cases leaves women worse off regardless of whether they are the donors or recipients. For example, a considerable number of women donors who had sold their eggs through temporary marriage found it impossible to detach from the child and doggedly pursued the recipient families. In one case, the donor so persistently harassed the couple that they allowed her to live with them. They used her for a second egg donation and when faced with the doctor’s puzzled expression said, “She is not leaving us alone,

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[so] we may as well use her to have a second child.” In a reverse case, an infertile woman arranged for her husband and the donor to temporarily marry from a remote village. The donor became so attached to the child that in order to stay close to him, she became totally subservient to the couple, who ruthlessly exploited her. In some cases, men who had temporarily married the egg donor decided to extend the duration of the marriage and keep the donor as a second wife. Occasionally, the infertile husbands of wives receiving sperm from temporary husbands experienced serious psychological problems after the children were a few years old, developing hatred for and rejecting these children.4

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Practitioners, Ethics, and Shari’a In theory, the issue of third-party donation of sperm and egg seems to have been resolved officially through the supreme leader’s fatwas and questions and answers despite strong objections by some senior leading clerics. However, research reveals a more complex and complicated picture that shows discrepancies between the religious rulings and actual practice, as well as the ease with which fatwas become instrumental in the hands of medical practitioners and donors and recipients to suit their purposes. Although Ayatollah Khamenei has given clear instructions on parenting, lineage, and inheritance (namely, that a child belongs to his biological parents and should inherit from them), whether the identity of donors and recipients is kept confidential depends entirely on the clinic and its practices, and the lines between “confidentiality” and “anonymity” depend on each clinic’s interpretation. Some clinics require donors and recipients to sign forms agreeing not to ask for each other’s identity or pursue one another in the future. Other clinics allow donors and recipients to decide whether they wish to remain anonymous, and in such cases the clinics and recipients encounter myriad ethical and legal problems. For example, some infertile couples use their close relatives as donors, a practice often leading to unforeseen situations and conflicts, which the clinics must resolve. As the head of a specialized embryology team at a fertility clinic mentioned, “In the past most of our donors were relatives of the recipients, and this created conflicts and tensions, but now the donors are anonymous, and we have no further problems.” In some clinics, the matching of donors and recipients is carried out entirely by a medical expert, and the recipients have no say in the choice of donor. In such cases, records

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of the donors are buried so well that it is almost impossible for the recipients or the future children to find them. The question of anonymous donation remains problematic globally. In the United Kingdom, gamete donation had been anonymous since its initiation, but the law was reversed (in 2005), making it compulsory for donors to give their names. This has led to a decline in the number of sperm donors. In Iran, the leading clinics’ increasing tendency to move toward anonymous donation goes against the very rules that are the basis for gamete donation, namely, that donation is only allowed within the marital union. Temporary marriage, which was initially used as the key to third-party donation, becomes a façade. Temporary marriage’s unique feature is that it is based on a direct agreement between a man and a woman, and the application of total anonymity is in defiance of this basic rule. Furthermore, legislators and medical practitioners, in the absence of clear, detailed instructions, are faced with the dilemma of how to protect the child’s identity and rights to his biological lineage and inheritance while keeping the donor’s anonymity in order to prevent serious future ethical and legal problems.

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Motivations Behind Gamete Donation In Iran, the application of ARTs has predominantly been determined by deeply rooted cultural values and notions of maintaining one’s lineage. Whenever possible, the recipients select close members of their families as donors. In doing so, they do not commit incest or adultery. Modern technologies for the treatment of infertility seem to remove some of the barriers of mahram and na-mahram and halal (what is permitted) and haram, which normally apply to fertile couples. The strong desire to reproduce and ensure the continuity of the lineage becomes the driving force behind the decisions of infertile couples. The solutions carry an inherent contradiction with Islamic rules of incest but ironically conform with Ayatollah Khamenei’s rulings that as long as touch and gaze are not involved, donation by a third party is allowed. Often, donors are brothers and sisters of the infertile wife or husband. Although having intercourse with or marrying one’s brother-in-law or sister-in-law is forbidden and considered incest (zena) in Islam, these rules do not apply to infertility treatment. When a woman donates an egg to her sister, there is no hint of sexual union between the donor and her sister’s husband. Likewise, men call on their brothers for sperm donation. In one clinic, I came across

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a man who made a deal with his doctor to use his own brother’s sperm without his wife’s knowledge. In this way, he killed two birds with one stone, namely, no one would discover he was the infertile party and the continuity of his lineage was ensured. Although a man can receive his wife’s sister’s egg and a woman can receive her husband’s brother’s sperm, only siblings of the same sex donate gametes to spouses. No known donation has taken place between a brother and his sister’s husband, or parents and children. Likewise, rules requiring that egg donors should be widows or divorcees who have been proven fertile by having children of their own have been bent to suit the recipients. Most patients may disregard these rules by resorting to family members they know and trust regardless of their marital status but who also have children of their own. As long as these relatives meet age and health requirements, all concerned parties accept them as donors. In one case, an infertile woman brought her husband’s brother’s wife for donation, insisting on her eggs “because she has three lovely children, and I want her to donate her egg. Besides, her husband is my husband’s brother, and it will all be within the family.” The doctors tried to draw her attention to the possibility that their children may fall in love with one other and wish to marry. Although marriage between cousins is desirable, in this case a half-brother and half-sister would be marrying. However, the doctors’ concerns fell on deaf ears, as the possibility was in the remote future whereas the need to have a child was immediate. In the case of donations between the kin group, especially between two brothers or two sisters, temporary marriage is not performed, and donation does not involve any ceremonies to legitimize it. As confusing as it may sound, marrying one’s wife’s sister or husband’s brother would be considered incest. As Simpson puts it, “beyond the paradigm of Euro-American kinship, however, ‘contestations’ over what can be brought together in the name of procreation invoke different ideas of kinship; different ways that is, of understanding how persons see themselves as connected by substances to one another, to their past and to their future” (2004: 44). Donation of gametes between relatives, especially siblings, merits a separate study. Following the importance of kinship, the fertility of the couple is still seen as a matter for the larger kin group and even the community. In this sense, close relatives remain actively involved in the treatment of their kin group and in the fertility decisions they make. For example, much to the dismay of a psychologist from one of the clinics, some clinics do not allow the wife and husband to attend the

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initial consultation session together. In several such cases, the husband’s mother or another senior woman from his family insists on being present. The husband’s family is often suspicious of how his wife will be impregnated and fear undesirable practices by the clinic. They also want to find out whether the daughter-in-law is the infertile party, as male infertility is still a stigma. In other cases, older brothers interfere in the reproductive decisions of their brothers and their wives, arguing with the doctors to persuade them to yield to the wishes of the couple, even if these are against clinic rules. Fertility, in general, remains a matter for the extended family and entitles the other members, especially those from the husband’s side, to be drawn in for consultation and action. However, the fact that the larger kin group feels it their duty to get involved in the reproductive lives of their relatives does not mean that infertile couples necessarily make their problems known to their kin groups. The stigma of infertility remains so strong that some infertile couples seek treatment secretly and therefore must resort to unknown donors. Some of the people I interviewed in Tehran were from the provinces and had not told their relatives they were receiving treatment in Tehran. When their babies were born, they said they had been given some blessed meat from the Holy City of Mecca. Others said they had sought the help of holy men and healers. Those who resort to using their own relatives for donation obviously come from a similar social and cultural background. The relationship between the two parties is initially friendly, with the financial, legal, and kinship disagreements usually emerging later. The ensuing difficulties between relatives have led to such complicated and confusing situations that most clinics have dissociated themselves from the religious and legal aspects by asking the patients to clarify these aspects with their own mojtahid (a senior cleric) before coming for treatment. Mojtahids themselves are not unanimous, as each follows one of the senior ayatollahs, who are sources of emulation (marja-e-taqlid) and may differ in their views. If one mojtahid does not approve of the treatment, patients may sometimes go to one who is more flexible. Those infertile couples without a donor of their own may resign themselves to the rules of the clinic and allow the practitioners to choose a donor for them without inquiring too deeply about the technical details of the treatment. For example, genetic tests are not always carried out in some clinics, but the recipients are not aware of such basic steps and do not raise any questions.5 The majority of donors not related to the infertile couple come from more modest

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social layers of society and often have a low level of education. Their main incentive remains financial, and they have little interest in questioning the technical aspects of infertility treatment. The combination of the recipients’ strong desire to have a child and donors’ equally strong financial needs allow considerable scope for medical practitioners to take charge, shifting the power of decision making and control from the patients to the clinics. However, recipients’ and donors’ lack of knowledge does not imply a lack of agency on their parts. Whenever possible, they try to shape procedures. During an interview with a clinic director, his mobile rang. A woman whose egg was going to be fertilized with her husband’s sperm told him that her husband’s sperm was going to be washed, and she asked if he could put in a good word so that the technicians would wash it properly.6 Even though he replied that the washing process was the same for everyone and there was no need for a special recommendation, she insisted, “All the same, please make sure of it.” It was clear she had not realized the meaning of washing in this context but wanted to use her friendship with him for a “special favor.” To improve the knowledge of both donors and recipients, a few private clinics have taken the initiative to educate donors and recipients. Medical practitioners refer to such education as “creating a culture” (farhang sazi) of infertility treatment. These clinics’ waiting rooms have giant TV screens transmitting the fertilization of the egg.7 With her permission, the woman’s name is shown on the screen while the doctor’s voice explains the procedure. All present in the waiting room usually watch with no surprise or adverse reaction to the public display of the woman’s reproductive organs. In the minds of the audience, the entire operation belongs to the realm of scientific knowledge and medical technology, and is not a display of the intimate parts of a woman’s body. The screening, therefore, does not invoke any thoughts of the violation of the sexual taboos of mahram/na-mahram nor the prohibition of gaze by men. When I asked what the patients think about these direct transmissions, a midwife replied, “We think it is good for them to be informed,” and one of the clinic directors joked, “In Islam, it is the outside of the body of a woman which should be covered. Nowhere has it been said that the inside could not be shown.” Faced with my astonishment, he continued, “To tell you the truth, we have not even thought about this aspect. Our intention has been to educate people.” The lack of patient reaction and the attitude of the medical staff made it clear that for all parties involved there was no connection between

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religious and sexual taboos and the scientific and technological world of biomedicine. In general, practitioners are often patronizing to donors and recipients and humiliate them for their “ignorance.” One of the senior psychologists in a private clinic said, “We think because we make people fertile, we have a right to treat them like animals.” However, in their desperation to have a child, patients remain oblivious to the treatment and humiliations they receive. Patients who believe God has punished them with infertility even see this maltreatment as a chastisement. Medical staff extended a similar reaction to me when I inquired about some of their ethical and cultural practices that breached the boundaries of mahram/na-mahram and incest by donors and recipients. The doctors took a sarcastic view of these and said, “Surely, as an educated person, you do not believe in all this, which from a scientific point of view is all nonsense.” To return to the motivations behind gamete donation, beyond the cultural bonds, another determining factor is that of emotions, either among relatives or between strangers. Two women are prepared to give and receive eggs without any compensation, either from an emotional bond but also perhaps because they do not necessarily place a high value on their eggs. In a study of egg donations in London clinics, Konrad mentions that women were prepared to donate their eggs as a gift because they did not view their donation as “providing unique autonomous and individualized genetic material. These women perceived themselves as donating body parts that were without inherent biogenetic properties” (1998: 651). In Konrad’s study, one woman told the doctor she did not think the egg was hers and that she did not think of her eggs as eggs. Another woman said, “My eggs were like finger nails or something; they are just a normal part like any other part.” My study in clinics in Tehran confirms these findings, as women sometimes told the doctors to “please give some of my eggs to this poor woman, I have too many, and she has none.” The doctors would say, “But this is your body, how can you just give your eggs away so easily?” The women simply could not understand what was so precious about their eggs. In Konrad’s words, “the gifts of eggs that women donate are given to help other women conceive, in generalized terms, rather than being thought of as already formed halves of new genetic identities. Donors see themselves as simply furnishing a means for ‘starting off’ a process that the recipients will ‘finish’” (652). Among the cases I studied in Iran, saving their “poor new friend” the high expense of an egg was also a consideration, and the donors offered their eggs for free.

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A third reason to donate a gamete is purely financial. Although gamete donation should be free and given as a gift, considerable financial transactions take place between the donors and recipients. Infertile couples who do not have relatives as donors or do not wish their relatives to find out they are infertile and/or receiving treatment for infertility, which is still a major stigma, have no choice but to purchase gametes. In such cases, a donor can be found among the couples attending the clinics, and negotiations are carried out between the two parties, or the clinics act as the go-between and suggest fees, which are often large sums, calculated as “costs” to be paid to the donors. The sum is effectively the amount of the ongoing price of the gamete, which is exclusive of the clinic’s charges. The average sum paid for an egg is around five million rials (approximately US$550). This is equivalent to four months’ salary for a schoolteacher.

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Embryo Donation As explained earlier, the legitimization of gamete donation has proved far from perfect in dealing with the inevitable and unforeseeable problems that arise. In the case of embryo donation, when it became clear that ijtihad and fatwas alone could not justify its practice, a law was passed in August 2003. The law’s background is interesting in itself. In 1998, one of the leading infertility clinics organized a symposium titled “Modern Human Reproductive Techniques from the View of Jurisprudence and Law.”8 The religious deliberations made by senior Islamic clerics at this symposium and similar conferences organized by the leading clinics played an important role in presenting a bill to parliament. The ayatollahs’ favorable verdicts influenced parliament’s decision in approving the bill for embryo donation. As with all laws in Iran, this was sent to the Guardian Council (Shorayeh Negahban) for careful scrutiny, and with final approval it became law. The composition of the members of the Guardian Council is noteworthy. Of its twelve members, six are clerics selected by the supreme leader, Iran’s head of state; the other six are lawyers proposed by the head of the judicial branch (selected in turn by the supreme leader) and voted in by the Iranian legislature. This effectively means that embryo donation was met with the approval of clerics at the highest level, with both legislative and enforcement powers. The law’s opening paragraph is paraphrased as,

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The consolidation of the institution of the family, which is the main factor underpinning the social structure, has been one of the most important aims of human beings historically, and any action taken to support the institution of family will lead to its unity and consequently to its equilibrium. One of the most beautiful manifestations of the application of science to reach its spiritual aim is in the field of infertility treatment, including the techniques concerning the donation of embryos to infertile couples.

The law specifies that with the court’s permission, clinics are allowed to treat infertile couples by transferring the embryo, which has been fertilized outside the womb, to the infertile couple. To obtain this permission, infertile couples have to prove they are in good health but infertile. They must be of sound mind, be healthy, not have any incurable diseases or addictions, and must be nationals of Iran. The law, however, remains unclear in several areas, and due to this lack of clarity, some clinics are reluctant to treat infertile couples in need of embryo donation. For example, although the law specifies that only people of the same religion can donate to each other (Muslims can donate to Muslims and Zoroastrians to Zoroastrians, but donation cannot take place between Zoroastrians and Muslims), it is not clear whether Sunnis can donate to Shia. In addition, in spite of the law clearly stating that embryos should be gifts, some clinics build up the “costs” of the transaction to considerable sums that should be paid by the recipients and given to the donors. Demand for embryos is so high that it has already created undesirable and illegal practices. One clinic director was alarmed when contacted by a woman who had set up an agency for embryo donation, charging recipients large sums of money. The director found evidence that the embryos sold by the agency did not belong to married couples, as the law specifies they must be; instead, the eggs had come from prostitutes and fertilized by strangers’ sperm. An embryo that is the result of the union between a prostitute and a stranger’s sperm is effectively an illegitimate child. So far, no lawenforcement agency has looked too closely at the implementation of embryo donation. As with sperm and egg donation, the interface between the law/fatwa, the medical practice, and infertile couples’ choices of donors has not been scrutinized too closely. Another unclear aspect of the law regarding embryo donation is that the donation is a gift, and no money should change hands. Cases abound whereby embryos are traded for money. In one case, a clinic that had developed five embryos from the same donor couple asked the cou-

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ple for permission to donate the other four embryos to infertile couples. The donor couple became suspicious of the clinic and accused it of trying to make money from their embryos and asked for payment for all five embryos. As it happened, only one of the five embryos survived. As discussed previously, the existing gaps between the laws and fatwas with regard to sperm and egg donation created a confusing situation and blurred the lines between “confidentiality” and “anonymity.” This also applies to embryo donation. For example, obtaining a birth certificate is proving to be a major problem, as it is not clear under whose name the birth certificate should be obtained. The real parents are supposed to be the biological parents, but the laws of confidentiality prevent their names from being revealed, and the social or carrier parents are not supposed to apply for birth certificates. Although embryo donation is supposed to be confidential, one clinic director said, “In the present cultural atmosphere it is impossible to protect confidentiality.” The only solution, according to that director, is for a code to be devised so the child will be able to locate the biological parents at a later date. A clinic director highlighted another unclear area of the law when she mentioned that she is faced with a serious dilemma when two different infertile couples have received embryos from the same donor, and she does not know whether to let the recipients know their children have siblings. Uncertainties of this kind abound and, in the absence of clear and detailed guidelines, practitioners are forced to use their own judgment as best they can. These few examples are the tip of the iceberg and are far from being solved, hence some practitioners’ reluctance to carry on embryo donation, at least until the law becomes more comprehensive and covers most of the foreseeable eventualities.

Surrogacy Surrogacy is the most recent ART in Iran, and no specific law endorsing or forbidding it has been decreed as yet. Evidence has emerged that the first cases of surrogacy were carried out after receiving permission from family-court judges, who endorsed surrogacy in the name of the happiness of the family and gave couples permission to proceed by making use of the same law as that for embryo donation. By February 2005, twelve couples had applied for the use of surrogate mothers. Although surrogacy, or a rented mother/womb, could be a financially profitable undertaking, few volunteers have

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been forthcoming. For infertile couples, the main disincentives have been the absence of a law protecting them from a breach of contract, such as a surrogate not returning the baby, and the high costs involved (around US$3,000). As for potential surrogates, the real problem is a cultural one. At the moment, few women are prepared to act as surrogates. Virgins, unmarried women, and widows would find it very difficult to explain their pregnancies, which would stigmatize them. Surrogacy methods are still relatively unknown in Iran, and no one would believe these women were just surrogates. According to infertility-clinic staff, most of the women who become surrogate mothers are relatives or acquaintances of infertile couples. I have not been able to interview those involved in surrogacy. Although from a legal point of view surrogacy may appear to be a more complex procedure than embryo donation, clinics find it easier. The child’s biological parents are known and can apply for a birth certificate in their own names despite the fact that the birth mother usually must apply for the birth certificate. The matter can be solved through court permission. However, surrogacy is still new, and information on its application is sparse.

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Moral and Legal Dilemmas From the brief previous accounts, it is clear that in Iran two powerful sources of authoritative knowledge, religion and biomedicine, determine the practice of ARTs. These two cooperate at times and compete at others. The discrepancies between them provide room for donors and recipients to use their own agency and make their own reproductive decisions. These decisions are often a reflection of cultural priorities, and the way these are negotiated and resolved ultimately shape the outcome of ARTs. So far, donors and recipients have been able to resort to one or the other sphere of knowledge as necessary and by moving between the two worlds with relative ease to ensure the continuity of their lineage wherever possible. However, this active role is gradually diminishing as the clinics move toward a policy of preventing donors and recipients from meeting and by treating information regarding both parties as confidential. Some of the major leading clinics are now beginning to move toward complete anonymity of the donors. Although ethical and legal experts at major clinics are still wrestling with the issues, most clinics’ main preoccupation remains the biological well-being of their patients and their success rates rather than

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concerns over the ensuing moral and ethical eventualities. That ARTs create happy families is beyond question, but in a large number of cases this has been accomplished by negotiations between the patients and the practitioners and at times by breaching some of the ethical and legal rules. The doctors at the clinics are open about these shortcomings. According to them, in some of the semisponsored clinics, control over the ethical and legal aspects of treatment is left to the clinics, and no law-enforcing body inspects the procedures. For example, in some of the clinics used by less-wealthy patients, genetic tests are not routinely carried out before the eggs are transferred. According to a doctor in one of the major public hospitals in Tehran, a veterinary surgeon was allowed to carry out infertility treatments because “he had pulled strings.” A counselor at a major clinic cited the example of a couple who, after achieving pregnancy from a different clinic, came to the clinic where she works. After the examination, it became clear there was no way this couple could have had a baby, and “God alone knows how this woman [had] conceived!” It was obvious the couple had no idea which methods the previous clinic had used to produce positive results.

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Conclusion The flexibility of Shia practices has allowed the adoption and accommodation of ARTs through religious rulings that were the result of senior clerics’ lengthy engagement with other religious and secular experts, and through the proper Islamic procedures of independent reasoning. Once the fatwas are issued, they become the ultimate source of authoritative knowledge and above questioning from secular legal frameworks. However, these religious edicts remain inadequate in their details, as they cannot predict every eventuality arising with the practice of ARTs but are powerful enough and so all encompassing that they have succeeded in legitimizing the practice of ARTs in a relatively short time. In reality, the lack of clarity in religious rulings has left a wide gap in the ethical, moral, and legal aspects of ARTs. The overall protection such approvals provide has inadvertently created a confusing situation for medical practitioners, who face complex situations not covered by religious rules. They therefore make their own rules to suit their priorities, without any apparent breach of religious edicts. Between the spiritual guidance of religion and the scientific knowhow of biomedicine, those utilizing ARTs will try to find solutions

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that will ensure the continuity of their lineage, which remains their ultimate priority. By trying to accommodate and justify the use of ARTs, the fatwas have unintentionally undermined kinship rules as well as social and cultural norms and taboos. The relaxation of thirdparty donation has led donors and recipients to examine their own understandings of kinship and relatedness. In the process, they often break the very rules underpinning kinship that they are anxious to protect. The duality between the text and practice and the liberty taken by users have led to complex and undesirable situations, which ruling clerics attempt to remedy with additional fatwas. So far, the hiatus created by the shortcomings of the religious rulings has allowed ART users to make their own reproductive choices. However, when these gaps emerge and medical practitioners cooperating closely with the “liberal” religious rulers try to close them, the balance of power shifts in favor of biomedical knowledge as the determining and authoritative source of wisdom as far as ARTs are concerned. In the meantime, after nearly two decades of infertility treatment, it is only now that some of the more acute problems are beginning to surface and the need for a completely new set of ethical and legal rules becomes apparent.

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Notes 1. Although the Iranian government took credit for the decline in population growth, many other factors were also responsible (see Tremayne 2004). 2. The World Health Organization estimates that the rate of infertility worldwide is between 12 and 15 percent. There are no accurate figures for Iran, but according to the Ministry of Health, around 15 percent of Iranian couples are infertile. Obviously, not all of these couples seek treatment from clinics, but an increasing number do so. 3. Through Islamic reasoning and interpretation of the Qur’an, senior clerics can reach new decisions, which are given as fatwas. Such edicts have been given since the Islamic Revolution in 1979, on a broad range of issues, including ARTs. The history of ijtihad is an interesting one; for more information see, for example, Keddie and Richard 2003, Mottahedeh 1985, and Mir-Hosseini 2000. 4. Personal communication from Dr. Fahimeh Ramezani Tehrani at the Reproductive Disruptions Conference, Ann Arbor, Michigan, May 2005. 5. A doctor in one of the clinics in Tehran confidentially told me that no genetic tests are carried out in his clinic and in some other hospitals. 6. Washing sperm is a procedure to separate sperm from semen and select active sperm.

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7. I asked one of the clinic technicians for a copy of a transmitted operation, which they did willingly. On scrutinizing it, it occurred to me that this was general Western software that does not show the actual operation being performed on the infertile woman whose name is written on the screen, but a general one used to explain the procedure. However, the patients in the waiting room do not know this. 8. An edited volume of the same name was published as the result of the symposium by the Avisena Research Institute in 2001.

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References Ebadi, S. 2003. Interview with Yas-e-No. 10 October. Haeri, Shahla. 1989. Law of Desire: Temporary Marriage in Iran. London: I. B. Tauris. Hoodfar, Homa. 1995. “Population Policy and Gender Equity in Post-Revolutionary Iran.” In Family, Gender and Population in the Middle East: Policies in Context, ed. C. Makhlouf. Cairo: American University Press. Inhorn, Marcia C. 2003. Local Babies, Global Science: Gender, Religion, and In Vitro Fertilization in Egypt. New York: Routledge. ———. 2005. Opening speech. Reproductive Disruptions Conference. Ann Arbor, Michigan. 18 May. ———. 2006. “Local Babies, Global Science: Gender, Religion, and Gamete Donation in Egypt and Lebanon.” Gamete and Embryo Donation in Infertility Treatment Conference. Avisena Research Institute, Tehran, Iran. 2 March. Keddie, Nikki, and Yann Richard. 2003. Modern Iran: Roots and Results of Revolution. New Haven, CT: Yale University Press. Khamenei, Ayatollah Haj Seyyed Ali. 1999. Ojoubeh al- Esteftaat. (Question Nos. 1271 to 1277). Tehran: Nashre Amir Kabir. Khatib-Chahidi, J. 1981. “Sexual Prohibitions, Shared Space and Fictive Marriages in Shiite Iran.” In Women and Space: Ground Rules and Social Maps, ed. S. Ardener. London: Croom Helm. Konrad, Monica. 1998. “Ova Donation and Symbols of Substance: Some Variations on the Theme of Sex, Gender and Partible Body.” Journal of the Royal Anthropological Institute 4, no. 4: 643–64. Mir-Hosseini, Ziba. 1998. Marriage on Trial: A Study of Islamic Family Law. London: I. B. Tauris. ———. 2000. Islam and Gender: The Religious Debates in Contemporary Iran. London: I. B. Tauris. Mottahedeh, Roy. 1985. The Mantle of the Prophet: Religion and Politics in Iran. New York: Simon and Schuster. Simpson, R. 2004. “Localizing a Brave New World: New Reproductive Technologies and the Politics of Fertility in Contemporary Sri Lanka.” In Re-

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productive Agency, Medicine and the State: Cultural Transformations in Childbearing, ed. M. Unnithan-Kumar. New York: Berghahn Books. Statistical Centre of Iran. 1998. Statistical Yearbook of Iran. Tehran: SCI Publications. Tremayne, Soraya. 2004. “‘And never the twain shall meet’: The Reproductive Health Policies of the Islamic Republic of Iran.” In Reproductive Agency, Medicine and the State: Cultural Transformations in Childbearing, ed. M. Unnithan-Kumar. New York, Oxford: Berghahn Books.

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Chapter 6

INAPPROPRIATE RELATIONS THE BAN ON SURROGACY WITH IN VITRO FERTILIZATION AND THE LIMITS OF STATE RENOVATION IN CONTEMPORARY VIETNAM Melissa J. Pashigian

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Introduction In 2000, three years after the introduction of in vitro fertilization (IVF) in Vietnam, the Vietnamese government approved one of the first cases of gestational surrogacy with IVF in which the sister-in-law of a woman with uterine tumors reportedly carried the pregnancy for her. This case caused tremendous consternation. Authorities had to decide which woman should appear on the child’s birth certificate, the recipient mother or the surrogate (Bernama 2001). In the context of larger economic liberalizations in Vietnam, concerns about kinship, descent, economic exploitation, and a person’s relationship to the state all came into question. In 2003, when the government released the first set of official regulations governing assisted reproduction with IVF, surrogacy with assisted reproduction was officially banned. It remains illegal today.1 In exploring the local and national conditions that have shaped the current integration of IVF in Vietnam, it is impossible to ignore Vietnam’s policies over the past two decades that have had bearing on the dramatic political, economic, social, and cultural transforma-

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tions that have occurred there. The first IVF pregnancy in Vietnam occurred in 1997, only eleven years after significant political and economic reforms (known as Doi Moi, or “renovation”) were initiated to shift Vietnam from a command to a market economy.2 These reforms have since transformed the country from a globally isolated and poor nation to one of the fastest-growing economies in Asia, with a GDP growth rate of 8.2 in 2006 (General Statistics Office of Vietnam 2006). The circumstances surrounding the development of Doi Moi ultimately have created a unique set of factors that, when coupled with the government’s socialist orientation, sets Vietnam apart from other countries (both Western and non-Western), albeit with different political and economic systems, that have integrated assisted reproductive technologies (ARTs), especially IVF, in recent decades, under more stable conditions. The introduction of IVF has greatly and rapidly expanded the selection of reproductive assistance available in Vietnam in a dynamic context of reform, economic growth, and national transformation that has resulted from the emerging market approach. Doi Moi reforms and the introduction, promotion, and subsequent regulation of IVF in Vietnam are highly intertwined. Just as Vietnam’s political leaders have had to contemplate the effects of Doi Moi on daily social life and local practices that are portrayed as representative of traditional Vietnamese culture, the integration of IVF during this same period has forced a reevaluation of the most basic beliefs about reproduction as well as mother– fetus, mother–child, and maternity–paternity relationships. Moreover, much like the tight reins the government has put on Doi Moi reforms to control changes in social practices resulting from new economic freedoms, the government also has worked to shape the uses of IVF, governing what should constitute appropriate reproduction. This chapter concerns the development of IVF in Vietnam following a transnational transfer of technology and training and its impact on infertile women’s lives in relation to the coterminous implementation of Doi Moi. I suggest that among the regulations developed to control the use of IVF, the ban on surrogacy is a moral confirmation of long-standing cultural practices and values that exposes the limits of state renovation as well as both national and local understandings of morality during this time of transition. Moreover, it exposes the uterus as a privileged site on the part of the state and women in which relatedness is created, both with and without IVF, suggesting what I call a uterine identity, an intimate relatedness developed during gestation, as critical to reproducing the next gener-

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ation. Doi Moi is as much an economic reform as it is a moral reevaluation of the basic tenets of Vietnamese society. In Vietnam, both Doi Moi and the introduction of IVF have caused a transformation of the self and how that self is reproduced for both the nation and the individual. Doi Moi has required a revisioning of the nation-self— how the nation reproduces itself, and what Vietnam the nation represents ideologically, economically, and politically under market reform and how this identity challenges social values and practices in this dynamic context. IVF has required the government as well as the populace to scrutinize how individuals and citizens are reproduced and what new practices of reproduction imply for long-standing values of descent and the replication of the next generation with ARTs and donor gametes. Vietnamese women actively pursuing infertility treatments do so because they feel compelled to have children for very personal reasons. On one level, their actions to locate effective treatment in a society that expects them to bear children are not subversive. Rather, these treatments, or at least the pursuit of them, make women complicit in larger cultural expectations for motherhood and give them some ability to negotiate control over their potential for future reproduction. In Vietnam, IVF serves as another avenue to this control through treatment (see Teman 2003 and Cussins 1996 regarding women’s use of agency to assert control over their reproduction using ARTs). On another level, Vietnamese women’s pursuit and use of IVF— which in the case of Vietnam is, indeed, a relatively new reproductive technology, particularly with donor gametes—is transgressive because it hints at the formation of kin social bonds without genetic linkages. As Simpson has found in work on the translation of ARTs into local contexts in Sri Lanka, new modes of family formation made possible by the technologies provoke anxiety at the prospect of “overstepping the bounds of nature” (2004: 231). Complicating the context, because childbearing is seen as natural, it masks the power structures, inequalities, and practices that encourage these women to embrace childbearing such that they are willing to undergo what are at times painful treatments that can expose them to infection in order to bear a child and obstruct the development of alternative and perhaps more radical identities apart from motherhood (Pashigian 2002a; Inhorn and Buss 1993). Within the balance of complicity and transgression, IVF in Vietnam represents a form of potential that plays out in multiple ways. First, it is a new treatment that, in contrast to infertility treatments

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available in Vietnam before IVF, appears to be more effective in generating positive outcomes, given its measured success rates; second, IVF is now available in country, enabling some people who might not have been able to access IVF abroad, due to cost or inability to gain permission to leave the country, to have the opportunity to do so at home; and third, its presence stimulates the “popular imagination” and makes women’s hopes for a cure appear more realistic now that the care is available in country despite practical impediments to access (Simpson 2004: 230).3 This third point reflects the importance of the concept of hope associated with the potential vested in IVF, and Bloch’s (1986) idea of that which has “not-yet” come, a notion that orients individuals toward the future and figures as a way to manage past or present reproductive conundrums.4 IVF provides a mode by which to imagine future reproductive success. The worldly association of IVF as a sophisticated treatment beyond Vietnam’s borders, as well as its measurable effectiveness, makes it a seductive focal point for imagining future reproduction. The potential reconfiguration of relatedness created by the use of IVF challenges some of the essential norms on which Vietnamese society operates and has invited state scrutiny and intervention to preserve elements of traditional social order. Gal and Kligman (2000) and Rivkin-Fish (2005) have highlighted how under socialism in Eastern Europe and Russia, notions of “public” and “private” become blurred with “public” politics entering the home. In Vietnam, with its commitment to family planning and now to renovating infertile bodies, the uterus is the site of a reproductive public, one that involves its restriction in order to promote social stability on the part of the government. The uterus is scrutinized further, by neighbors and others, who serve as a local moral barometer and watch closely for its development in women for whom reproduction has not been easily forthcoming. The skeptical embrace that has greeted IVF reveals the tension that exists between a socialist morality of preserving society and protecting citizens through strict controls of local practice and shifting values of an emerging marketplace of new opportunities for creating families and relationships. In a transnational transfer, the technology itself is sometimes treated as the source of cultural change or alternatively, its integration is made contingent upon the specifics of local recipient culture in creating its meaning and cultivating the ramifications of its presence. Simpson (2004: 232) suggests that “reproductive and genetic technologies, perhaps more than any other, come with their ethics encoded. That is, built into them are ideas

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about the value and meaning of persons and their relationships to one another.” Thus, Simpson proposes that not only should we look for the social implications of these new technologies, but also should we consider “tacit assumptions that lie within new forms of technomedical knowledge” (232). The introduction and development of IVF by state political entities also serve as a focal point for generating nationalized, medicalized, and personalized narratives that shape local constructions of IVF and kinship ideologies (Birenbaum-Carmeli 2004; Bharadwaj 2002). In Vietnam, during this period of transition, IVF represents both a new opportunity to achieve reproduction as well as a new biomedical modernity with trappings of scientific knowledge long embraced in Vietnam, even before Doi Moi, when the state was heavily supported by Soviet funds and ideology. However, it also raises questions of social values in Vietnam. Other studies of assisted reproduction have explored how ARTs are morally disruptive, upsetting religious practices and requiring controls to adhere to religiously approved reproduction, as in the case of rabbis who legislate the use of IVF in Israel (Kahn 2000) and the importance of “official” fatwas and informal interpretations of Islam that shape the use of ARTs in Egypt (Inhorn 2003). In Vietnam, where organized religion has been heavily suppressed by the state, the morally disruptive nature of ARTs is clearly seen at the state level. It is evident in legal judgments to regulate the use of ARTs that I emphasize in this chapter and in transgressions of nature and culture associated with reproduction in the moral lives of Vietnamese women (Gammeltoft 2002). Infertile women must contend with the new opportunities associated with ARTs and the constraints of state regulations that shape the ways they interpret and negotiate the opportunities for infertility treatments available to them.

Methodology This chapter is based on fifteen-and-a-half months of ethnographic research conducted in Hanoi, Vietnam, and surrounding rural areas in 1995, 1997, and 2004, and that focused on social constructions of and treatments for infertility through interviews of fifty married women, ages twenty-one to fifty-five, forty of whom had experienced infertility, and a comparison group of ten who had reproduced without experiencing infertility (Pashigian 2002a). I also interviewed healthcare providers of infertility services, including medical doctors and traditional-medicine practitioners. Most interviews were tape-

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recorded. The primary sample of infertile women was drawn from one urban maternity hospital in Hanoi from women presenting as infertile. Follow-up interviews took place in women’s homes or alternative locations of their choosing. Follow-up research in the summer of 2004 examined changes in assisted reproduction in Vietnam, women’s perspectives on IVF, and the development of legislation regulating the use of ARTs.

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The Impact of Doi Moi In 1986, Vietnam’s Communist Party ushered in a new era in the history of Vietnam with a radical shift from a command economy to a state-controlled market economy. This shift represented a dramatically different approach to economics and politics than had existed before, with notable shifts in local culture and society. The new approach of economic liberalization, Doi Moi, was embraced to bolster Vietnam’s poor economy, and liberalization remains official policy today.5 This same policy, which has significantly altered the economic landscape of Vietnam, has also dramatically shaped infertile Vietnamese women’s reproductive lives, altering the socioeconomic existence of many and augmenting the array of ARTs available in the country. The policy shift from a command to a centrally controlled market economy was a recognition by the Communist Party that the command economic system was not working.6 At the time, Vietnam ranked among the poorest countries in the world. Per capita GNP in the early 1990s was below US$200 (World Bank 1993). Among the changes implemented with Doi Moi were decollectivization of agriculture, elimination of nearly all state subsidies and price controls, devaluation of the state currency to market rates, privatization of state-owned enterprises, a reduction of restrictions on private enterprise, and a dismantling of central planning and central price controls (Turley 1993; World Bank 1993). The changes gradually resulted in greater economic independence of the populace, the growth of private enterprise, comparatively open access to information from overseas, a plethora of consumer goods, and mass-market advertising, among many other changes. The poverty rate has decreased dramatically, from 58 percent in 1992–93 to 37 percent in 1997–98 to 29 percent in 2002 (Thoburn 2004; World Bank Vietnam 2003: 9). During the 1990s, Vietnam boasted a GDP that grew at an annual rate of growth of 8.1 percent, among the fastest rates in the world (Tho-

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burn 2004).7 When implemented in 1989, the new policy promoted expanded economic ties with foreign countries and today continues to make Vietnam increasingly accessible to foreign markets. Part of the Doi Moi agenda in creating “open-door” access to the country was to increase overseas development assistance and to increase the flow of technology from abroad into the country, to improve conditions there (Bezanson et al. 1999). The impact of Doi Moi on women has been varied. With market reforms, women have gained opportunities for entrepreneurial activities and improved standard of living. However, the transition to a market economy has undermined progressive social policies that under pre-market socialism had specifically protected women’s welfare in practice or at least symbolically (Desai 1995). Changes such as the diminished duration of maternity leaves or the continued decline of the presence of female representatives in the National Assembly concern Vietnamese women’s studies scholars (Tran Thi Van Anh and Le Ngoc Hung 1997). Goodkind (1995) suggests that certain increases in gender inequalities are partly the result of Vietnam’s economic transition but also are rooted in trends that began before Doi Moi, including in postwar demographic gender imbalances in the composition of Vietnam’s population, a resurgence of household patterns that privilege sons, and a feminization of poverty. The impact of Doi Moi has not been a gradual progression. To the contrary, its implementation created a dynamic cycle in which openness to new ideas, commercialization, and transparency in economic transactions alternated with periods of sharp conservative reaction to unanticipated cultural change. During the 1990s, there was palpable tension between what were construed as traditional Vietnamese values, which implied cultural purity and morality, and “social evils”—cultural values and ideas that the government charged entered the country through imported commodities. For instance, during my stay in 1997, an official burning of large piles of pornographic videotapes was staged to demonstrate condemnation of these illegal goods. In the case of IVF, Doi Moi made possible the technology transfer and the income growth to support its consumption—the “open door” facilitated international involvement not only through technology provision and training, but also through the provision of necessary pharmaceuticals by foreign pharmaceutical corporations, while the burgeoning economy facilitated individuals’ income growth used to pay for procedures.8 However, much like other foreign imports, the initial use of IVF raised questions about its suitability for Vietnam.

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Doi Moi has also influenced recent developments in health care services in Vietnam. Beginning in 1989, patient user fees were established within the entirely public medical system, creating patient responsibility for payment (United Nations 2005). Such fees have weighed heavily on the rural poor.9 The government also initiated some privatization of medicine. Privatization materialized in the form of private pharmacies and private medical practices. Government hospital doctors also frequently practice in their homes or private offices before and after hours to supplement meager government wages (see United Nations 2005; World Bank 2001). However, private offices generally lack the equipment of a government hospital and are used for patient visits with patients sent for diagnostic tests at the hospital if necessary. Among the women in this study, it was not uncommon for those pursuing biomedical infertility treatments, especially those in urban areas, to seek a doctor at their home practice and have tests done in the government-run hospital where the doctor also worked. More recently, select doctors have been able to acquire costly technology for their private practices, such as ultrasound machines to serve pregnant women, which prove popular.10 However, infertile women expressed to me concerns about the cleanliness of private practices and exposure to infection and disease from unclean gynecological instruments. Despite the rise of private practice, equipment and technology remain primarily in the public government-run hospitals, the primary sites of ARTs, especially IVF. The introduction of IVF has given women new potential avenues of treatment. Potential in that not all women can access this technology because of distance or finances and by virtue of it being available in only a limited number of urban hospitals that are primarily government institutions. Yet its potential enables women to organize their practices and perspectives surrounding IVF in Vietnam. Trang, a woman who pursued infertility treatment for nearly two decades with traditional medicine and biomedicine, had exhausted treatments in the Hanoi area and had suspended pursuing treatment at the time the first IVF pregnancy was announced in 1997. Shortly thereafter she began to talk about how she was saving money to go to Ho Chi Minh City to undergo IVF. Her husband participated in this narrative, explaining to me shortly after the announcement of IVF in Vietnam appeared in national newspapers: For me and my wife it has been a long time [with no children]. We want to protect our happiness to save the harmony of our family. We

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have had a very difficult time with fertility treatment and spent a lot of money on it. We plan to go to Ho Chi Minh City for treatment. They are more up to date.

Trang continued to emphasize this plan several years later in 2000, even to a motorbike taxi driver, a stranger to her, who assisted me in delivering a package to her and her family. The presence of IVF in Vietnam enabled her to organize a narrative around the possibility of being able to access this treatment, something not possible when the only sources of IVF were overseas. She only revised her story to refocus on treatment closer to home once IVF became well established at the national maternity hospital in Hanoi. Treatment for infertility in Vietnam reflects the structure of the health care system. In the rural periphery, only basic primary care is available, whereas tertiary specialty services are concentrated in large urban hospitals (Ministry of Health Socialist Republic of Vietnam 1999). This organizational structure for health care services requires those from rural areas seeking biomedical infertility services to come to the city, sometimes an arduous and expensive journey. Although this is a costly endeavor for many, it is logistically easier now than before Doi Moi. The Doi Moi reforms allow people to organize their daily lives and movements in new ways. The reforms have increased freedom of movement for the patient population of infertile women. As employment has increasingly shifted from government and agrarian jobs to private enterprise, some women can more easily control their schedules and take time away from family businesses to pursue treatment rather than have to obtain permission to take time from work to go to medical appointments from, for instance, a state factory job. As Trang explained to me, prior to 1989, she only pursued infertility treatment near her village home with traditional-medicine doctors. As her husband worked in a government factory at the time, she found it too complicated for him to ask permission to leave work and go into the city, which by their main mode of transport, a bicycle, would have taken up much of the day. Now, as she and her husband are involved in private enterprise (initially selling sundries and turns playing games on their video electronics from their home, among other enterprising ventures) she has greater control over demands on her time and the flexibility to go into the city for treatment. Today, she has a motorbike, which cuts down on her transportation time. She also has sufficient disposable income to cover services for treatment that do not involve IVF. Although not all women have

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made such gains, there has been a general trend in economic improvement since Doi Moi. Before the advent of IVF in Vietnam, treatment for infertility was concentrated primarily in Sino-Vietnamese traditional herbal medicine and simpler forms of Western biomedicine. Traditional medicine continues to be available through individual traditional-medicine practitioners who make diagnoses and fill prescriptions along with those filled in herbal-medicine shops and at the traditional-medicine hospital in Hanoi. Before the introduction of IVF, biomedical hospitals in Hanoi provided a variety of more mechanical infertility services, which included hysterosalpingography and tubal insufflation.11 The hospital where I met many of the women in this study used tubal insufflation both for diagnostic evaluation and treatment in an attempt to clear blocked fallopian tubes. Artificial insemination by donor was also available. Lacking the means to store sperm, one doctor described the method of retrieving a fresh sample from an anonymous donor in one room and carrying the sample down the public corridor to another room, where it could be injected into the recipient. In the hospitals, infertility services were limited and maternity care as well as family planning and abortion services served larger numbers of women. Even since the advent of IVF, not every urban maternity hospital has the IVF technology. These hospitals lack state investment in necessary equipment, labs, and the specialized training of personnel, often originating overseas, to provide IVF, and they continue to provide ARTs that are far from new, as they have since before the advent of IVF.

IVF in Vietnam IVF came to Vietnam with a transnational transfer of knowledge and training from medical institutions in other countries, with heavy involvement from France. It was first made available in Vietnam in 1997, in Tu Du Hospital in Ho Chi Minh City, one of the nationallevel tertiary hospitals in the country. The first series of IVF-assisted pregnancies was performed on married women, with embryos formed from their ova and their husband’s sperm. Of the first group of fortytwo women who underwent IVF, four became pregnant (Nguyen My Ha 1997). These pregnancies and the assisted means used to achieve them received much attention in the national media. The Tu Du Hospital director was inundated with letters from all over the country from infertile women begging for assistance to help them

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bear a child with the new technology. One paper reported that in just the first two months of its availability, more than ten thousand women were on a waitlist for the procedure (Thu Thuy 1997). Newspaper stories explained the procedure to an eager public. Reporters questioned whether the new procedure worked against the tenets of the national family planning program and its goal to reduce the population growth rate of Vietnam to preserve social stability and promote economic development. Indeed, achieving more births at this time appeared counterproductive to the national mission of stabilizing rapid population growth. The hospital director, Dr. Nguyen Thi Ngoc Phuong, who emphasized the importance of IVF in helping married couples who had no other means of getting pregnant, was quoted saying, “The work of the National Family Planning Program is to reduce the population growth and to treat infertility, increasing the happiness of people, two domains that are completely different.” She added, “Why shouldn’t we use the achievement inherited [from countries that have pioneered IVF] to give happiness to several thousand infertile couples today?” (Nguyen My Ha 1997).12 Despite that providing IVF services appeared counter to the national family planning program, a common belief is that all married women need to have children in order to establish close relationships with their husbands (Pashigian 2002b) and if for no other reason than to have someone provide for them in old age.13 Although only 10.5 percent of the first group of IVF recipients became pregnant, the Tu Du medical staff quickly perfected its skills with IVF, and over the next eight years, Vietnam saw not only its first IVF birth, but also, among other scientific achievements, its first birth with intracytoplasmic sperm injection (ICSI)14 as well as its first birth from a frozen embryo, all feats announced in the national media (Vietnam News Briefs 2005; Vietnam News Briefs 2004; Quang Minh 2004). The replication of procedures developed in other countries was impressive, especially the high success rate of the procedures and in such a short period of time. In media interviews, Tu Du reported remarkable success rates, especially for those procedures using frozen embryos (reported over time as varying from 28 to 40 percent) that would make their services as effective or more effective than those provided in wealthier Asian and Western countries (Vietnam News Briefs 2005; Vietnam News Agency 2004).15 In subsequent years IVF has also been introduced to a few additional select national-level state-run hospitals in other parts of the country, including Hanoi. Nevertheless, the desire for IVF services has far outpaced the number of persons who can be accommodated.

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Although the proliferation of IVF in Vietnam preceded many of the efforts to regulate it, de facto regulation took place by virtue of IVF being available initially in just a single hospital that could serve only a small number of infertile patients and with specially trained doctors and specialized equipment not available in other facilities. Essentially it was rationed, by virtue of its scarcity. In Vietnam, IVF is restricted largely to government hospitals and has not been allowed to proliferate in the private sector, unlike countries such as India (Bharadwaj 2002) and Ecuador (Roberts 2006). Thus, there are not enough outlets to serve the population that demands these services. Ability to pay is also not the sole criteria for being able to access IVF.16 Factors such as age are considered—not only being too old but also not being too young such that one is turned away to try on one’s own.17 Nhung, a thirty-seven-year-old university lecturer, sought IVF after having difficulty conceiving her second child. Although she had one blocked fallopian tube, and the other had been damaged during an operation to remove an ectopic pregnancy, she was turned away for services at age thirty-three. She explained: They [the doctors] asked me to be sympathetic toward the older women, who have no children yet and are on the wait list to do IVF. There are many of them. Every year, thousands of people are waiting, and the number of women who can really do it in Vietnam is limited. That means just a few people can do it in a month or a year. Several hundred people. Those who are old and have no children deserve preferential treatment. I had one child already, so I should wait for a while. [Since I couldn’t receive IVF in Hanoi] I even thought of going to the south to do IVF, as by then I was thirty-five or thirty-six years old. Things would be much harder when I turned forty.

She continued: In 2001, I was thirty-three when I went to the hospital to do IVF, and the doctors suggested I try other methods first. If I couldn’t get pregnant by the age of thirty-eight, in three to four years more, then they would help me.

The introduction of IVF has expanded the array of potential options available for the treatment of infertility in Vietnam, rather than serving solely as a replacement or substitute for older technologies that continue to be used. However, it is the presence of IVF coupled with recent changes in daily life such as geographic mobility, increases in disposable income, and the government’s political response to and regulation of the new technology that have opened new avenues

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for women to negotiate their way through the experience of infertility in Vietnam in ways not available ten years ago.

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Regulating IVF with Surrogacy The introduction of IVF in the years following 1997 demanded attention to social and ethical questions accompanying its application and the technical innovations associated with it. Each innovation required the accompanying use of IVF and also required perfecting new techniques—for instance, the jump from IVF with fresh embryos to IVF with frozen embryos, to ICSI. The myriad reproductive possibilities provided by IVF and its related techniques also increased the number of ways that assisted reproduction challenged traditional understandings of reproduction. Most importantly, it challenged traditional clarity of the respective parties involved in producing a baby and their genetic relationship to that baby. Efforts to regulate it brought to the surface existing cultural values about reproduction and in particular the role of women’s bodies during gestation that links a mother and child in a nurturing relatedness that is deemphasized in the overwhelming cultural focus on patrilineal descent. These values were present long before IVF was made available in Vietnam, but I suggest they became more explicit and more explicitly examined through the dual processes of a public coming to accept IVF—in part through media coverage and a growing familiarity with it over the course of the past decade—and a government finding ways to regulate its use. After its introduction, certain legal, social, and cultural quandaries surrounding IVF emerged very quickly in Vietnam that included concerns about trade in gametes and the developmental consequences of fertilization outside the body for the resulting child. Among these perplexing concerns was how to address the issue of surrogates, or to be more specific, how to determine the mother in a surrogacy agreement and how to prevent the exploitation of women who serve as surrogates. The ban on surrogacy encapsulates many of the issues facing the Vietnamese government in its continued attempts to make a smooth social, economic, and political transition from a command economy to a market economy by mediating influences associated with the erosion of Vietnamese society. In Vietnam, surrogacy challenges traditional understandings of family form, hints at sexual impropriety between parties involved, and commodifies bodies. Indeed, one of the Vietnamese-language terms for surrogate

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mother incorporates the idea of commodity. De thue, in literal translation, means “hired (or rented) birth.” The ban also reveals cultural values that would not be tempered to accommodate advancements in ARTs. The 2003 decree governing reproduction with ARTs (Decree No. 12/2003/ND-CP) came nearly six years after the introduction of IVF. It stipulated a variety of restrictions on the use of IVF, related persons, and bodily products, including surrogate mothers and donor gametes. Strictly prohibited were surrogacy and human cloning.18 Although it was permissible for a married woman to use donor ova to bear a child (single women had to have their own ova), surrogacy with ARTs was made illegal. It was not permissible for a woman to hire a surrogate to carry an embryo made from the commissioning woman’s (gestational surrogacy), the surrogate’s (traditional surrogacy), or a donor’s ovum. The legislation effectively barred women whose uteruses could not carry a pregnancy from having children who were genetically related to them. The possibility of surrogacy with IVF raised issues of exploitation and commodification of women, babies, and gametes. The government reiterated its stance against surrogacy in 2005 by instituting a set of fines for those participating in surrogacy agreements with ARTs (20 to 30 million VND, approximately $1,300–2,000 USD) as well as trafficking in gametes (10 to 15 million VND, approximately $650–1,000 USD).19 Tuyet, who at age thirty-nine had a daughter after multiple miscarriages and numerous years spent seeking treatment to promote a successful pregnancy prior to the availability of IVF in Vietnam, surmised that the government banned gestational surrogacy with IVF to avoid issues having to do with a surrogate turning over a baby to a recipient couple. She explained: This kind of problem is very new in Vietnam such that our law cannot assure that the surrogate mother will give the baby back to the couple later. The law now does not protect the rights of the couple. After being pregnant for a while, the surrogate mother may love the child and not want to return it to the couple. … Under current law, it is hard for the couple to ask for the baby back.

The ban on surrogacy with IVF in part helps prevent exploitation of women, particularly women portrayed as poor and from the countryside, which implies they have few resources and less sophistication than those seeking a surrogate (with or without the use of ARTs). It is well documented that surrogacy challenges normative assumptions about reproduction that are taken to be “natural,” that gestation will occur in the body of the woman who will raise the baby,

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that reproduction takes place between a man and a woman who will be the child’s mother, and in the case of marriage, surrogacy upsets expected relations of reproduction by intimating extramarital reproduction (Cook et al. 2003; Teman 2003; Ragoné 1994). In Vietnam, ambiguity surrounds what sort of relationships might constitute surrogacy (both with and without ARTs) and much blurring of categories between a surrogate relationship (one in which a man impregnates a woman other than his wife without the use of ARTs with the hope of claiming the resulting child as his own), adultery, and polygamy in what is referred to as a “second wife” (vo hai) relationship, which is illegal in Vietnam but persist nonetheless.20 Moreover, Vietnamese are familiar with a cultural history of polygamy and concubinage practiced in the seventeenth to nineteenth centuries, in which multiple wives and concubines could not only increase a man’s number of offspring, but also served to bear children when a first wife could not (Yu 1990; Lingat 1955). Given its incidence historically and the ambiguity surrounding behavior that might constitute surrogacy, it is meaningful to distinguish between surrogacy without ARTs that the above relationships at times represent and surrogacy with ARTs. As Nhung commented,

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In many cases the husbands love other women when their wives are infertile. Of course this depends on social classes too. That may not happen to educated people or those who have a strong love with their partners. Otherwise, if men are suffering from [social] pressures or in order to save face with their friends, they are ready to have additional relations with other women.

However, the role of the other woman is one of shifting ambiguity, and it is not always clear whether the relationship is to another woman as a second wife, an affair with the intention of producing a child (a kind of traditional surrogacy), or a love affair that unintentionally results in the birth of a child. The phenomenon of second wives is not limited to men, as women sometimes seek second wives for their husbands when they have difficulty bearing children (Pashigian 2002a, 2002b). Trang and several other women in this study were married to men who sought second wives on their own because their wives were not getting pregnant, one of whom married the second wife without informing his first wife, who subsequently moved back to her natal village but hoped to reconcile with her husband. Trang’s husband had a relationship with a woman who became pregnant and gave birth to a girl, after which he asked Trang if the woman and the baby could come live with them. She refused:

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“I did not agree at all when he wanted to bring her to our house because the marriage law states one wife and one husband only. If he wants to break the law, then it is his responsibility.” Whether this was intended as an adulterous affair or the desire to acquire a second wife is difficult to discern, and its categorization can change retrospectively and upon reflection by different parties involved. The informality and illegality of these relationships make it difficult to categorize whether someone is a second wife, a lover, or a surrogate mother. Although the law is still relatively new, embracing the cultural importance of the uterus in connecting relatedness between persons is not. For individual women, the uterus holds tremendous symbolic and physiologic value. Bearing a child in one’s own womb necessarily holds different social meaning than hiring a gestational surrogate with IVF or a traditional surrogate. The process of gestation, growing the pregnancy inside one’s own body, is believed to enable a woman to create a special connection with the fetus/baby, as her body fosters its development. This connection is thought to be akin to “blood” or biological relatedness even with a donor embryo. Furthermore, the visibility of a woman’s expanding abdomen later in pregnancy validates that the child she brings home from the hospital is indeed related to her (even if not genetically) in contrast to adoption or surrogacy, where she would bring home a child from elsewhere without the symbolism of the pregnant body to create relatedness. As Trang, who adopted a daughter during her nearly twodecade pursuit of treatment, explained to me, “Hiring another woman to do it is the last resort. … If I am seen to carry the baby, people still think it’s my own child [even if donor gametes are used].” If she carried her own pregnancy, even with a donor embryo, and others saw her pregnant, she felt no one could challenge the relationship between her and the baby. Moreover, she felt neighbors would stop gossiping about the stability of her marriage given she and her husband had not had a child together. Without a child between them, people widely believe that married women and their husbands cannot form tinh cam, a deep, sentimental connection created through the generation or gestation of a baby (Pashigian 2002b; Pashigian 2009). The process of gestation enables a woman to bond with her child through bodily nourishment and sustenance over the course of the pregnancy, something that the recipient mother in a surrogacy arrangement would not experience. Tuyet explained, “The wife prefers to give birth to a child by herself [without a surrogate]. As time

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goes by, the child naturally tends to love his mother.” She went on to explain, “At first it is just an embryo. It needs to be fed by the mother to become a baby. … The feelings will be different when the mother and fetus are close together” in contrast to the use of a surrogate, in which the fetus will form feelings for the surrogate even if the ovum comes from the recipient mother. In Vietnam, the nine months of gestation are considered to be the baby’s first year of life and sentiment between mother and baby begins in the womb. Now, in the absence of viable and effective sperm from her husband and sustainable ova from herself, a woman still has the means to create relatedness, a “blood” relatedness, through gestation of a donor embryo, whereas her husband’s relationship to the embryo remains constructed. This uterine identity, the ability to confer relatedness through the uterus, is the basis of women’s relatedness to their offspring, with or without genetic ties, above and beyond the patriline. It is ironic, although not culturally unique, that in a culture in which the patriline and patrilineal descent holds tremendous importance for organizing families, living space, and life and death rituals, maternal relatedness through gestation is thus valued. The legislation designed to regulate IVF reflects, intentionally or not, the overarching importance of the uterus in Vietnamese society. In banning surrogacy and thereby preventing women with physiological problems from bearing a child who is genetically related to them, the state privileges the uterus, stratifying women into those legally fit to gestate and those who are not. The legislation reflects efforts to mediate a new technology that has accompanied economic development and one that has challenged moral tenets of pre-Doi Moi Vietnamese society. One of the major outcomes of banning surrogacy with IVF is the setting of legal precedent that prevents the interchangeability of uteruses (i.e., the ability to use another’s uterus to obtain a child for oneself even if that child is genetically related to the recipient couple). This means that only one’s own uterus can legally be used to birth one’s own children. It also means that regardless of the gametes used, including donor embryos that have genetic relatedness to neither the recipient woman nor her husband, the act of gestating the donor embryo makes that child hers, not the ovum donor’s, according to the law. Explicating this relationship in law reifies the relationship between women, the uterus, and children. It also simplifies bureaucracy. Banning gestational surrogacy with ARTs enables the government to avoid confusion about the child’s place of birth— which is tied through the mother to social-welfare benefits such as

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schooling—and taxing the existing state administrative functions for registering births by making the question of maternity moot.21 One of the curious ramifications of Doi Moi has been its facilitation of choice. Much like the concomitant influx of consumer products, the introduction of IVF offers choice—both consumer and moral choice, even if not everyone can access it. In an effort to preserve its socialist agenda while slowly exposing the nation to the full array of sometimes unanticipated effects of Doi Moi, the Vietnamese government has made efforts to stymie or control choice to protect traditional values, morality, civil society, and other social structures that are valued by the communist state. IVF and subsequently gestational surrogacy have become sites for the preservation of morality with part of the basis of such morality resting in the Vietnamese government’s enduring commitment to socialist principles despite the retreat of the state from many aspects of people’s lives. Choice without restraint, such as gestational surrogacy without regulation, challenges an ideal socialist morality—one in which people are protected from exploitation and corruption and their lives are improved through state endeavors.

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Conclusion Vietnam is still a communist country. Communism remains its dominant ideology and the Communist Party the guarantor of public welfare. With Doi Moi, the party took a decision that the people’s welfare would benefit from a change in the market structure that would permit changes in economic self-direction. However, the party has not relinquished its role as guarantor of public welfare. In the context of Doi Moi, the state continues to provide legal protection to encourage social stability. IVF is no less part of this philosophy in which the state guarantees certain protection from perceived effects of the new technology in an otherwise liberal economic climate. Yet the IVF legislation is bound with culture and political precedence. Surrogacy with IVF challenged ideas about motherhood established in the pre-IVF era, namely, that the woman who gives birth to a baby is also the genetic mother. Suddenly the gestating mother and genetic mother could be different. In banning surrogacy the government has confirmed and defined legally the cultural importance of gestation in establishing relatedness between mother and offspring. The ban precludes confusion over establishing maternity and effectively reinforces the belief that relatedness can be estab-

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lished through gestation regardless of the origin of the gametes. The integration of IVF and the reproduction with surrogacy that it makes possible stimulates questions about how to deal with the effects of the new economy and the challenges they pose to established social practices and cultural values in Vietnam. It raises questions such as, how does the state filter the effects of the new economy, in this case the effects of IVF? What opportunities and constraints does IVF pose for women? And what are the consequences of cultural discourses and practices influencing one another at the locus of assisted reproduction? Although the surrogacy ban and the regulation of ARTs constrain women, especially those who cannot carry a pregnancy, the availability of IVF, even with restrictions, provides new ways for women to attempt to resolve their infertility. For those who cannot access IVF, its existence in the country reinforces an imagined reproductive future in which they might achieve a desired birth. In explicating values associated with IVF, two levels of coincidental interest are apparent: the state’s interest in preserving a certain identifiable relatedness by excluding surrogacy, and women’s interests in having a child identified as their own through gestation for reasons of establishing relatedness. It is curious that both the state and women have focused their efforts on controlling the uterus in trying to preserve kin relatedness, but each somewhat differently. The ban on surrogacy with IVF also limits the ways this new technology of foreign origin is allowed to proliferate in Vietnam and creates the boundaries of what is appropriate for Vietnamese citizens. Vietnamese were already familiar with older forms of surrogacy (polygamy and concubinage), outlawed as part of the incipient socialist state’s efforts to protect public morality through a reinforcement of legally sanctioned nuclear descent—that is, reproduction in the context of a civic marriage. The nuclear marriage created clear and traditional units of bureaucratic control and encouraged in form a conservative sexual morality while still permitting the endurance of a locally valued purpose of marriage, the production of sons to carry on the patriline. The act of imposing a specific ban on surrogacy with ARTs exposes a deep irony of the larger system of relatedness the state seeks to protect, that is, the primacy of gestation and the mother–child as opposed to the father–child relationship. The debate over gestational surrogacy with IVF thus calls into question the assumptions and practices of what is natural and normative, and the regulation of IVF reveals the limits of reform through its encounter

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with Vietnamese social values, part of which are the basis for the Vietnamese state. Finally, the discourse about and state response to surrogacy with IVF in contemporary Vietnam exposes a mediation between the new moral economy and the old, in which certain moral values endure and in which new moralities may emerge. The state’s motivations for imposing the surrogacy ban originate in the desire to protect women and the reproduction of family from exploitation in the context of a market economy and new technologies whose nature and expansion may threaten the legitimacy of a state founded in the name of protecting public welfare. In crafting jurisprudence, the state reveals its enduring concern with the uterus and the regulation of relatedness within certain boundaries. Women eagerly seek ARTs in order to fulfill a cultural expectation to have children and strategize with IVF to gain the benefits of social connectedness that children could give them—and in so doing make explicit the qualities of the Vietnamese culture of reproduction that have heretofore remained implicit and naturalized. In this milieu, ARTs do not so much revolutionize baby making as they perform an exercise in cultural rethinking about reproduction. It is at these points, where traditional values and desires coincide with global cultural influences—the nature of which may expose previously uncontested ground—that new moralities are formed and renovation takes place.

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Notes 1. The research on which this paper is based has been generously supported by a predissertation grant from the Wenner Gren Foundation for Anthropological Research, the UCLA Department of Anthropology, UCLA ISOP, and a Bryn Mawr College faculty research grant. All names of respondents are pseudonyms. I thank Daphna BirenbaumCarmeli and Marcia C. Inhorn for their insightful comments on an earlier version of this chapter. 2. In literal translation, Doi means “change” and Moi means “new,” also translated as and commonly referred to as “renovation.” 3. Simpson (2004: 230) suggests that offering services in country expands the privilege of using ARTs to a wider segment of society, and the positive reception of ARTs in the “popular imagination” in Sri Lanka is related to Sri Lankan men’s and women’s desires to become parents of healthy children. 4. For a detailed discussion of Bloch’s concept of “not-yet” see Miyazaki’s (2004) discussion of its importance in relation to hope in Fiji.

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5. The Doi Moi policy was adopted in 1986. Reforms were largely initiated formally in 1989; however, some reforms reflect activities already in place informally (see Beresford 1989) and have continued to unfold through the present day, culminating most recently in efforts to join the World Trade Organization in 2006 (Bradsher 2006). 6. North and South Vietnam were unified into a single country in 1975, after the military victory of the North over the government of South Vietnam and its American allies. After reunification, the government set about creating a socialist command economy in the South and expanding control of the Communist Party. One of the major consequences of reunification was disruption of the economic system and the near collapse of the agricultural sector due to weather and when mandated collectivization did not produce expected results. This resulted in dire food shortages. Further compounding the already poor living conditions in the country were the border war with China in 1979 and the occupation of Kampuchea from 1979 to 1988, draining resources from a country already strapped for support and still recovering from the devastation brought about by the war with the United States. In addition, in the mid-1980s a misdirected wage and currency reform caused additional economic crisis. With a floundering economy, Vietnam, then among one of the poorest countries in the world, recognized a real need for economic reform (see Beresford 1988). 7. The GDP growth rate for the 1990s and early 2000s has been variously reported as 8 to 9 percent (Nguyen Thang Minh and Popkin 2003: 255) and 7 percent (cited in Gabriele 2006). 8. For example, international pharmaceutical companies promoted their organizations and products in association with the IVF program (Vietnam Economic News 2005). 9. Not unexpectedly, in Vietnam recent evaluation of healthcare inequalities shows that poor households spend a greater share of their incomes on health care, particularly pharmaceuticals and ambulatory care, than wealthier households (Gabriele 2006). Although the standard of living has increased for the population as a whole, it is the middle and upper classes, often urban, that benefit the most from any public investment in the government-hospital system. They are the ones who most utilize the system and can more easily pay the fees associated with care, compared to the poor. 10. With few guidelines for the use of prenatal ultrasound in Vietnam, women check frequently the well-being of their fetuses as they develop (see Gammeltoft 2007). 11. Hysterosalpingography involves the injection of a contrast solution into the reproductive tract and radiology imaging, which reveals the anatomy of the reproductive tract and any blockages in the fallopian tubes. Tubal insufflation involves pumping an inert gas into the reproductive tract while machinery measures resistance in the fallopian tubes to reveal blockages. Tubal insufflation was also used as a form of treat-

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12.

13.

14. 15. 16.

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17.

18. 19. 20.

21.

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ment for blocked fallopian tubes, as doctors said the tubes sometimes became unblocked from the pressure of the insufflation. Dr. Phuong is perhaps referring to a tenet buried in the family-planning policy that stipulates in general terms that “if they desire to have children, childless women may receive medical treatment to enable them to bear a child” (Council of Ministers Decision 162 [October 1988] Concerning a Number of Population and Family Planning Policies, Article 6.6, reprinted in Banister 1993: 82. The original source is the 5 December 1988 issue of Giao Vien Nhan Dan [Teachers of the People] newspaper). Vietnam has a family-planning policy with a two-child limit per family for citizens except minority groups. The closeness between a woman and her husband is believed to be established by bearing a child together. This special form of closeness is called tinh cam (sentiment) and is thought to be possible only by having a child together. This tie of sentiment is all the more important among those couples that are in arranged marriages. “Love” marriages have become more prevalent only in recent years. ICSI involves injecting a single sperm into an ovum in cases of malefactor infertility. It is unclear how these reported rates are calculated. Since 1997, the basic cost for an IVF cycle has ranged from approximately $600 to $2,500 USD, beyond the means of many but comparatively affordable for others. According to government regulations, women must be between twenty and forty-five years of age to qualify to receive donor sperm or donor embryos with IVF, although the regulation does not specify an age range for those women using embryos made of their own ova and their husband’s sperm (Socialist Republic of Vietnam Decree No. 12/2003/ ND-CP, Article 8). Socialist Republic of Vietnam Decree No. 12/2003/ND-CP, Articles 6.1 and 6.2. Socialist Republic of Vietnam Decree No. 45/2005/ND-CP, Articles 31.2.a and 31.1.b, respectively. The Marriage and Family Law of 1959 outlawed forced marriage, polygamy, and concubinage in the North. Luat Hon Nhan Va Gia Dinh (Marriage and Family Law) (1998: 14). Similarly, such relationships were made illegal in South Vietnam. See also Bernama 2001.

References Banister, Judith. 1993. Vietnam Population Dynamics and Prospects. Berkeley: Institute of East Asian Studies, University of California.

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Beresford, Melanie. 1988. Vietnam: Politics, Economics and Society. London: Pinter Publishers. ———. 1989. National Unification and Economic Development in Vietnam. New York: St. Martin’s Press. Bernama (Malaysian News Agency). 2001. “Vietnam Surrogate Pregnancy Brings Legal Questions.” Hanoi: The Vietnam News. http://perso .wanadoo.fr/Patrick.guenin/cantho/vnnews/surro.htm. 6 January. Bezanson, K., J. Annerstedt, K. Chung, D. Hopper, G. Oldham, and F. Sagasti. 1999. Viet Nam at the Crossroads: The Role of Science and Technology. Ottawa: International Development Research Centre. Bharadwaj, Aditya. 2002. “Conception Politics: Medical Egos, Media Spotlights, and the Contest over Test-Tube Firsts in India.” In Infertility Around the Globe: New Thinking on Childlessness, Gender, and Reproductive Technologies, ed. Marcia C. Inhorn and Frank van Balen. Berkeley: University of California Press, pp. 315–33. Birenbaum-Carmeli, Daphna. 2004. “‘Cheaper than a newcomer’: On the Social Production of IVF Policy in Israel.” Sociology of Health and Illness 26, no. 7: 897–924. Bloch, Ernst. 1986. The Principle of Hope. 3 vols. Neville Plaice, Stephen Plaice, and Paul Knight, trans. Cambridge: MIT Press. Bradsher, Keith. 2006. “Terms Approved for Vietnam’s Admission to W.T.O.” The New York Times, 27 October. Cook, Rachel, Shelley Day Sclater, and Felicity Kaganas, ed. 2003 “Introduction.” In Surrogate Motherhood: International Perspectives. Oxford: Hart Publishing. Cussins, Charis. 1996. “Ontological Choreography: Agency Through Objectification in Infertility Clinics.” Social Studies of Science 26, no. 3: 575–610. Desai, Jaikishan. 1995. Vietnam Through the Lens of Gender: An Empirical Analysis Using Household Survey Data. Hanoi: UNDP. Gabriele, Alberto. 2006. “Social Services Policies in a Developing Market Economy Oriented Towards Socialism: The Case of Health System Reforms in Vietnam.” Review of International Political Economy 13, no. 2: 258–89. Gal, Susan, and Gail Kligman. 2000. The Politics of Gender After Socialism. Princeton: Princeton University Press. Gammeltoft, Tine. 2002. “Between ‘Science’ and ‘Superstition’: Moral Perceptions of Induced Abortion Among Young Adults in Vietnam.” Culture, Medicine and Psychiatry 26: 313–38. ———. 2007. “Sonography and Sociality: Obstetrical Ultrasound Imaging in Urban Vietnam.” Medical Anthropology Quarterly 22, no. 2: 133–53. General Statistics Office of Vietnam. 2006. www.gso.gov.vn/default_en .aspx?tabid=491. Accessed 1 January 2007. Goodkind, Daniel. 1995. “Rising Gender Inequality in Vietnam Since Reunification.” Pacific Affairs 68, no. 3: 342–359. Inhorn, Marcia C. 2003. Local Babies, Global Science: Gender, Religion, and In Vitro Fertilization in Egypt. New York: Routledge.

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Inhorn, Marcia C., and Kimberly A. Buss. 1993. “Infertility, Infection, and Iatrogenesis in Egypt: The Anthropological Epidemiology of Blocked Tubes.” Medical Anthropology 15: 1–28. Kahn, Susan Martha. 2000. Reproducing Jews: A Cultural Account of Assisted Conception in Israel. Durham, NC: Duke University Press. Lingat, Robert. 1955. Les Regimes Matrimoniaux du Sud-Est de L’Asie: Essai de Droit Compare Indochinois. Saigon: Ecole Francaise d’Extreme-Orient. Luat Hon Nhan Va Gia Dinh [Marriage and Family Law]. 1998. Hanoi: Nha Xuat Ban Chinh Tri Quoc Gia. Ministry of Health Socialist Republic of Vietnam. 1999. Health Service in Vietnam Today. Hanoi: Ministry of Health Socialist Republic of Vietnam. Miyazaki, Hirokazu. 2004. The Method of Hope: Anthropology, Philosophy, and Fijian Knowledge. Stanford: Stanford University Press. Nguyen My Ha. 1997. “Thu Tinh Trong Ong Nghiem: Niem Hy Vong Cho Cac Cap Vo Chong Vo Sinh [In Vitro Fertilization: A Sense of Hope for Infertile Couples].” Ha Noi Moi Chu Nhat, 20 September. Nguyen Thang Minh and Barry M. Popkin. 2003. “Income and Health Dynamics in Vietnam: Poverty Reduction, Increased Health Inequality.” Population 58, no. 2: 253–64. Pashigian, Melissa J. 2002a. “Conceiving the ‘Happy Family’: Infertility, Gender and Reproductive Experience in Northern Vietnam.” PhD dissertation, University of California, Los Angeles Department of Anthropology. ———. 2002b. “Conceiving the Happy Family: Infertility and Marital Politics in Northern Vietnam.” In Infertility Around the Globe: New Thinking on Childlessness, Gender, and Reproductive Technologies, ed. Marcia C. Inhorn and Frank van Balen. Berkeley: University of California Press, pp. 134– 51. ———. 2009. “The Womb, Infertility, and the Vicissitudes of Kin-Relatedness in Vietnam.” Journal of Vietnamese Studies 4, no. 2: 34–68. Quang Minh. 2004. “Em be thu tinh trong ong nghiem thu 1500 chao doi tai Benh vien Tu Du [1500th in vitro fertilization baby born at Tu Du Hospital].” Tuoi Tre Daily, 18 November. Ragoné, Helena. 1994. Surrogate Motherhood: Conception in the Heart. Boulder, CO: Westview. Rivkin-Fish, Michele. 2005. Women’s Health in Post-Soviet Russia: The Politics of Intervention. Bloomington: Indiana University Press. Roberts, Elizabeth F. S. 2006. “God’s Laboratory: Religious Rationalities and Modernity in Ecuadorian In Vitro Fertilization.” Culture, Medicine and Psychiatry 30, no. 4: 507–36. Simpson, Bob. 2004. “Acting Ethically, Responding Culturally: Framing the New Reproductive and Genetic Technologies in Sri Lanka.” The Asia Pacific Journal of Anthropology 5, no. 3: 227–43. Socialist Republic of Vietnam. 2003. Decree No. 12/2003/ND-CP of February 12, 2003. On Childbirth by Scientific Methods. ———. 2005. Decree No. 45/2005/ND-CP of 6 April 2005. Providing for the Sanctioning of Administrative Violations in the Field of Health.

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Teman, Elly. 2003. “The Medicalization of ‘Nature’ in the ‘Artificial Body’: Surrogate Motherhood in Israel.” Medical Anthropology Quarterly 17, no. 1: 78–98. Thoburn, John. 2004. “Globalization and Poverty in Vietnam: Introduction and Overview.” Journal of the Asia Pacific Economy 9, no. 2: 127–44. Thu Thuy. 1997. “Se khong con noi dau co don…” Lao Dong, 25 September. Tran Thi Van Anh and Le Ngoc Hung. 1997. Women and Doi Moi in Vietnam. Hanoi: Woman Publishing House. Turley, William S. 1993. “Introduction.” In Reinventing Vietnamese Socialism: Doi Moi in Comparative Perspective, ed. William S. Turley, and Mark Selden. Boulder: Westview Press, pp. 1–15. United Nations. 2005. Users Fees, Financial Autonomy and Access to Social Services in Viet Nam, United Nations Country Team Viet Nam Discussion Paper No. 6. Hanoi: United Nations Viet Nam, August. Vietnam Economic News. 2005. “Organon Vietnam Leading in Female Health Care.” 6 February. www.ven.org.vn/view_news.php?id=4283. Accessed 8 September 2005. Vietnam News Agency. 2004. “Tu Du Hospital Transfers IVF Technology to Filipino Experts.” 13 July. www.vnanet.vn/newsa.asap?LANGUAGE_ ID=2&CATEGORY_ID=32&NEWS_ID=108536. Accessed 14 July 2004. Vietnam News Briefs. 2004. “Vietnam Welcomes First Baby Girl Conceived From New Fertility Procedure.” 11 March. ———. 2005. “Vietnam Welcomes 100th Baby Born From Frozen Embryos.” 24 June. World Bank. 1993. Viet Nam: Transition to the Market. Washington, DC: World Bank. World Bank. 2001. Vietnam Growing Healthy: A Review of Vietnam’s Health Sector. Hanoi: World Bank. World Bank Vietnam. 2003. Vietnam Development Report 2004. Hanoi: World Bank Vietnam. Yu, Insun. 1990. Law and Society in Seventeenth and Eighteenth Century Vietnam. Seoul: The Asiatic Research Center, Korea University.

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Chapter 7

CONTESTED SURROGACY AND THE GENDER ORDER AN ISRAELI CASE STUDY Daphna Birenbaum-Carmeli

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A

ssisted reproductive technologies (ARTs) have been largely normalized over the past two decades as a standard component of the medical handling of infertility. Still, an exceptional event occasionally challenges established routines and stirs a public debate around a particular dilemma, constituted and perceived as unprecedented. Such debates call into question foundational issues like the spatial and temporal boundaries surrounding the human body, the relations between the “social” and the “natural” in human reproduction, or the divisibility of an ordinary bodily process like conception into a multiplicity of genetic, gestational, and social components (Luhmann 1985: 230; Gallagher 1987: 140; Franklin 1997; Strathern 1992a; Webster 2002). Often, the dilemma at hand requires a human decision in matters hitherto considered “natural” or as “biological destiny” (Stanworth 1987: 1–2). Owing to the primary character of the questions they open up, such ART-related disputes may have a considerable destabilizing impact. At the same time, this very “weight” can be harnessed to reaffirm the existing order, if only by demonstrating its “tolerance” of or imperviousness to changing circumstances. Scholars have looked thoroughly at the variety of meanings and consequences that ARTs can effect. Earlier thinkers tended to focus

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on their negative repercussions on women’s position (e.g., Corea 1986). Contemporary researchers have expanded the scope and pay close attention to a broader range of ART-related effects. On the more conservative side, ARTs enhance, explicitly and tacitly, some aspects of traditional established worldviews. The intensification of the quest for biological offspring is probably the most evident impact. The expectation—by now completely normalized—that women subject their bodies to extensive medical intervention, even when the impairment lies in the male partner’s body, reaffirms the accepted view of reproduction as a woman’s domain and connotes an image of the female body as requiring repair. On the transformative side, it has been claimed that the routinization of ARTs undermines the taken-for-granted position of foundational concepts like “kinship” or “nature” by unveiling the sociopolitical element in their construction (Carsten 2000; Franklin 1997; Haraway 1991; Hirsch 1995; Strathern 1992a). Furthermore, the foundational nature/culture dichotomy has been eroded with the realization that nature cannot survive without cultural intervention (Strathern 1992a: 74). By explicating “facts otherwise assumed to be foundational … [in vitro fertilization] sets off an irreversible process. The implicit can never be recovered, and there is no return to old assumptions” (Strathern 1992b: 347). The changes do not, however, completely break with the past. Rather, they contribute to a gradual process in which accepted perceptions are being reconfigured and charged with new meanings. Within this dynamic realm, surrogacy presents particularly sharp challenges to traditional notions of “the family.” A recurrent focus of legal turmoil and public interest, surrogacy touches upon basic issues of gender, family, class, and power, demonstrating the diversity of significances that ARTs may acquire. On the one hand, it dramatizes the length to which some women and couples will go in order to have biologically related offspring. On the other hand, it facilitates groundbreaking paths to new kinship formations, like gay and lesbian biological families. In this respect, surrogacy expands traditional notions of procreation and calls into question the role of biology in the construction of kinship ties. Typical of surrogacy-related debates is the grounding of opposing views in similar ideologies. For instance, women’s rights, gender equality, or reproductive freedom could equally be invoked to substantiate support as well as disapproval of surrogacy.1 In what follows, I try to unpack the various social messages conveyed through a surrogacy dispute that took place in Israel in the mid-1990s. This chapter examines the public debate surrounding a

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legal dispute between estranged partners over the right to have their cryopreserved embryos implanted in a surrogate woman’s womb. Involving complex medical intervention and piercing interpersonal and moral dilemmas, the case stirred a heated public debate, generated conspicuous headlines, led judges to overturn their decisions twice, and prompted a wide array of public responses (Weisberg 2005). In this chapter, my interest is in the implications of this debate for Israel’s gender order and women’s societal position. I examine whether and how an intense public debate can set into motion significant social change. The main body of the chapter is devoted to an analysis of key opinions expressed by judges, experts, and journalists, followed by an overview of the aftermath of the case. Methodologically, the chapter consists of press analysis. The material has been taken from Israel’s three most widely read daily newspapers: the highbrow Ha’aretz and the more popular Yedioth Aharonoth and Ma’ariv. The protagonists, their lawyers, court judges, journalists, women activists, and religious authorities were all given ample space to air their views throughout three years of trials. It was the media—newspapers, alongside the electronic media—rather than the 126-page final verdict that conveyed to the general public the courts’ views as well as those of other stakeholders. As such, the press coverage was most influential in terms of social impact. I introduce the case with an overview of reproductive technologies in Israel.

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Reproductive Technologies in Israel Israel is a highly familial society. Despite some erosion of the traditional family, Jewish Israelis of all ethnic and class identities marry more than their North American counterparts; they do so at an earlier age, have fewer births out of wedlock, and have lower rates of divorce (Fogiel-Bijaoui 1999).2 Moreover, although Israel resembles European countries in levels of women’s education and labor-market participation (Swirski et al. 2001), the total fertility rate of Israeli women is considerably higher than that of North American and European women. Whereas in the US, the UK, and Italy the figures in 2006 were 2.09, 1.66, and 1.28, respectively,3 in Israel the total fertility rate, which had indeed declined from 3.80 in 1975 to 3.10 in 1985, was still as high as 2.90 in 2004. Among Jewish women, the respective figures for the same years were 3.39, 2.79, and 2.59.4 The relatively high fertility rates can be traced back to the centrality of the biblical commandment “be fruitful and multiply” as

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both a central goal in one’s life and a collective mission to be accomplished (Gold 1988: 23–27; Safir 1991). In the Diaspora era, the political converged with the private under the equation of individual procreation with community survival (Katz 1971: 29; Swirski 1976: 129–30). In more recent years, the Holocaust trauma and the Zionist ideology have coincided to induce an emphasis on regeneration as a means to ensure Jewish continuity and political survival. Childbearing was then constituted as a contribution to the nation-building effort and was explicitly praised as such (Shuval 1992: 66). The demographic interest was soon translated into an official pronatalist policy.5 Shortly after it had been founded, the state of Israel started to distribute maternity benefits, followed by free maternity hospital care, birth grants, and mother-friendly employment laws and tax exemptions, as well as a universal child allowance that increases proportionately with the number of the child (e.g., the allowance for the fifth child is higher than for the first; Barkai 1998: 44, 36, 63). At the same time, abortion and contraceptives are only partly covered by the public health care system, and sex education is evidently lacking (Birenbaum-Carmeli 2003). In contradistinction, fertility treatments—openly mentioned by politicians as a method to increase the country’s Jewish population (Birenbaum-Carmeli 2004)—have always been fully state funded. Since 1981, when in vitro fertilization (IVF) was introduced to Israel—to be warmly received by professionals and laypersons alike— this treatment has also been covered. Being constituted as a potent remedy in the service of distressed couples and the Jewish people, IVF soon became a field of internationally acclaimed Israeli excellence and a source of national pride (Birenbaum-Carmeli 1997). In Israel, IVF and related technologies are offered free of charge to women up to forty-five years of age (fifty-one if using a donor egg) and of all marital statuses and sexual orientations, including mothers of children, until they have two children from the present relationship. Since 1990, fertility treatments have qualified employees for sick leave, allowing up to eighty days of paid absence a year. Israeli gynecologists are at the forefront of reproductive research, and Israeli women are the world’s most intensive consumers of the technology. In Israel, 3,327 IVF cycles6 are conducted per million per annum; Denmark, in second place, carries out 2,008 comparable treatment cycles. In the United Kingdom, the respective figure is 623 (Nyboe Andersen et al. 2007; Israeli Ministry of Health 2003). Roughly 40 percent of Israelis undergoing treatment already have

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one child or more.7 It is not surprising that treatment-related risks have always been marginalized in the Israeli discourse on IVF. Donor insemination, although entailing a modest user payment, is available to all women, including single and lesbian women, as part of the public health care system.8 Technologies can be combined unrestrictedly, that is, IVF can be applied with donor gametes, and since 1996, when the Embryo Carrying Agreement Law was passed, this technology, too, has been incorporated. Israeli courts have also been generally supportive of controversial cases (e.g., postmortem sperm aspiration), as have the country’s religious authorities (Kahn 1998, 2000; Shalev 1998). Treatment is as freely available to nonJewish Israelis. However, in practice, owing to cultural and religious restrictions and possibly because they are less ardently encouraged to do so, Muslim women do not use these services as intensively. From a women’s rights perspective, this generous state policy is double edged. On the one hand, the great public investment in ARTs conveys the importance of childbearing and glamorizes biogenetic parenthood as superior to alternatives. At the same time, it does render ARTs accessible to all local women beyond differences of class, ethnicity, marital status, or sexual orientation. Furthermore, the license to combine treatment technologies opens up less traditional possibilities to family formation, some of which may be desirable for some women. The case at hand is one such instance.

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The Nahmani Affair: A Chronicle Ruti and Dani Nahmani married in 1984. Three years later, in the course of fertility treatment, Ruti was diagnosed with cancer of the uterus and had her womb surgically removed. When she recovered, the couple wished to undergo IVF and have Ruti’s eggs, fertilized by Dani’s sperm, transplanted into a surrogate mother’s uterus. As surrogacy was not legal in Israel at that time, the Nahmanis appealed to the supreme court and eventually, in 1991, were granted the right to undergo IVF within the public health care system. Following several treatment cycles, the couple generated eleven fertilized eggs, which were cryopreserved. However, just before Ruti’s planned trip to meet with a surrogate in the United States, Dani left her for another woman. In May 1992, Dani wrote to the Israeli and Los Angeles clinics that had handled the couple’s treatment and withdrew his consent. In June 1992, he applied for divorce but was refused by

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Ruti. By 1995, Dani had had two daughters with his new partner. In the meantime (July 1992), Ruti had sued Dani, demanding to have the fertilized eggs transplanted, claiming this was her only chance to become a mother. On 2 September 1993, Ruti—at that time fortytwo years of age and without a womb—won the case at the Haifa Municipal Court. Dani then appealed to the Supreme Court of Israel, where the decision was reversed (3 March 1995), and the fertilized eggs were to be discarded. Four judges supported Dani, versus one dissent.9 However, Ruti and her lawyer managed to have the supreme court reconvened, with eleven of its thirteen judges rehearing the case. This was the second time in the country’s history that such an extended judicial forum was convened (Weisberg 2005: 85). Once again (2 February 1997), the court reversed the previous ruling (seven vs. four judges), granting Ruti the right to have the fertilized eggs transplanted into a surrogate mother’s womb.10 The public debate that surrounded the couple’s conflict lasted for the three-year duration of the court hearings. The length of the legal struggle, the extensive media coverage, and the continued thought invested in the case by jurists, experts, rabbis, and female activists implied the magnitude of the subject. The supreme court’s exceptional rehearing and the eventual overruling further added to the weight of the issue at stake. Indeed, at no point in the process did a dominant view crystallize. Rather, disagreement regarding the foundational questions at hand—autonomy, bodily integrity, parenthood, kinship—persisted throughout the period. I now turn to analyze the main arguments voiced during the trial and to consider their significance in terms of gender power relations in Israel.

The Nahmani Debate and Israel’s Gender Order As expected in a debate stemming from ARTs, the Nahmani dispute offered a stage for the expression of unorthodox ideas. These ideas belonged to a life domain that was normally sheltered and only rarely discussed explicitly in Israel’s public discourse—the family. We may start with the observation that the Nahmani debate revolved around two highly assertive women, Ruti Nahmani and Diana Har-Even, Dani Nahmani’s lawyer. Over the three years of trials, both women were the center of media preoccupation and informally the talk of the day. Both women were featured prominently on the front pages of newspapers and expressed their views at length. Both were highly articulate and seemed perfectly comfortable in their

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“star” positions. Although female “heroes” were not alien to Israel’s public scene of the early 1990s, the gathering scope of the Nahmani affair endowed the two protagonists with exceptional ongoing visibility. But of more significance, Ruti occupied her position very clearly as a woman, that is, her gender identity was at the heart of her public presence. In later stages of the trials, as will be shown, Diana HarEven would also make ample use of her gender identity. In this respect the women not only made their case, but also in fact performed womanhood on Israel’s public stage. This gendered public presence was part of a broader public examination of the local gender order. For instance, the subject of gender roles, primarily those of mother and father, was discussed repeatedly. We may start by listening to Carmel Shalev, a well-known jurist and a former legal advisor to the minister of health. Shalev contended that adoption and nonbiological motherhood as well as nonparenthood were all viable options for a woman to have a meaningful life (Ha’aretz, 16 September 1996). Shalev continued this line of thought with parallel ideas regarding men’s family roles, advocating the involved father who fully participates in his children’s daily lives. Emphasizing that “this is the image that should be guiding us,” she enhanced the claims of Diana Har-Even, who, speaking for Dani, stressed that “I too want to raise my son [sic], wake up with him in the morning, cuddle him in my arms, take him for a walk. …” (Ma’ariv, 7 April 1995). A similar notion was implied in the critique of the image of the father as “a sperm bank and banking machine” that was cynically invoked by Pinhas Shifman, a male professor of family law (Yedioth Aharonoth, 31 March 1995). Although not entirely unfamiliar, these gender roles were far from established in Israel in the 1990s. In those years, the image of the involved father was starting to gain initial popularity, but voluntary childlessness had not gained any significant legitimacy, especially as a woman’s choice. The Nahmani-prompted debate of these subjects, beyond laying out the previous opinions, was also noteworthy for raising these very questions in public. In a country dominated by state politics, where male politicians and army generals have been the primary newsmakers for decades, the extensive public attention paid to two women arguing a civil domestic issue comprised in itself a symbolic challenge to local macho culture. Dani, the male protagonist, with his long hair tied in a ponytail, only added to the contrast with the typical Israeli headline star. It needs to be emphasized that such figures have been well known in Israel’s public landscape. However, as they tended to be encountered in

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other life domains, their ongoing presence on the front pages of the daily news was significant. The challenge may be better appreciated within the broader context of early 1990s Israel. With the peace process appearing to progress steadily and the economy booming, Israelis could divert some attention from security and state politics to civil issues. Within this evolving climate, the domestic Nahmani debate and its female protagonists epitomized a new public agenda that included, among other things, growing openness to women’s concerns and rights. It may even be reasonable to suggest that the case acquired its massive scope (also) because of its timing, when the Israeli public was comfortable enough to divert some attention from state politics to gender and family issues. However, this depiction is partial. The attention of the Israeli public has never been confined to state politics. The diversity and openness that characterized many of the views about the Nahmani dilemma had all been out there and not unknown to the public. The impact of the case and the challenge it presented to local macho culture stemmed primarily from the magnitude of the publicity it accumulated. In this sense, the Nahmani debate contributed to a certain “feminization” of the mainstream public agenda, thereby prioritizing a domain of great concern to women. But then again, the challenge went hand in hand with enhancement of the traditional view of childbearing as the key to a meaningful life. Within this complex and sometimes contradiction-ridden context, the effect of these public voices regarding gender roles is not clearcut. On the one hand, a more involved father might be a welcome change for both mothers and fathers, who could share and benefit more equally from the experience of childrearing. More radically, some women may be relieved to have the maternal imperative moderated, leaving them with greater freedom and life choice. At the same time, other women may perceive greater paternal involvement as an intrusion into their own domain and thus, a threatening interference. The latter may be particularly poignant in Israel, where the family, although rarely debated—probably because of its crucial importance—constitutes a sphere of utmost importance and as such, a source of female pride and power. This may be particularly true for women of fewer social resources, for whom the family is often the main source of personal and interpersonal standing. These complex circumstances also furnished the background for the challenge to the traditional family itself. Single-parent families, like that which Ruti was hoping to establish, have long been accepted in Israel. Probably as part of the local pronatalism, childbearing has

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been welcomed in almost any format. However, with single women having less than 2 percent of all births11 (see also Kahn 2000), such families are still a marginal phenomenon. Different speakers used the Nahmani debate to express contradictory views on the issue. Several stakeholders—journalists, jurists, academics, as well as Dani’s lawyer—were critical of women who preplanned single motherhood. One female social-work academic cited research showing that children in single-mother families fared worse than their counterparts in traditional families (Ha’aretz, 16 September 1996) and disapproved of the former. At the opposite end, other actors and observers were sympathetic to women who established such families. Especially significant in this camp was a female supreme court judge who, despite her support of Dani’s appeal, emphasized that the prospects of establishing a single-mother family should not work against Ruti. The judge further explicated that such families were legitimate and entitled to social and state support (Ha’aretz, 3 March 1995). Ironically, it was Eli’ezer Yaffe, a male professor of social work, who added to his advocacy of single motherhood the ultimate compliment that “Ruti may eventually marry” (Ha’aretz, 16 September 1996). Two layers of significance need to be pointed out in terms of the gender order. First is the public approval, if partial, of single motherhood. Such support obviously advanced the autonomy of women in this life situation. Second, the debate itself, including both supportive and condemning views, helped destabilize the status quo by exposing the contested, negotiable quality of a social structure as foundational as the family. If the family, a stronghold of Jewish Israeli culture, was so debated, then existing gender relations need not be taken for granted, that is, divisions and hierarchies might change. But here again, although women were in many respects disadvantaged in the current order and could potentially benefit from changes, questioning the sound centrality of the family might jeopardize the social grip of many women, especially those of lesser means. At the more immediate level, closer to the woman herself, was the issue of bodily autonomy that was repeatedly invoked throughout the debate. It is noticeable that all of the speakers assumed women’s bodily autonomy as unquestionable. The following excerpt from the words of legal journalist Moshe Negbi is illustrative: Everybody … accepts that from the moment a man has fertilized a woman’s egg … it is her will—and never his—that will determine whether or not they will both actualize their right to parenthood. This inequality, this asymmetry, which privileges the woman’s will

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over the man’s, is of course utterly just. … Since the woman is the sole bearer of the burden of the process and since bringing it to completion or discontinuing it involves intrusion of her body and privacy, justice requires that she alone has the key to the decision. … In the artificial process, as in the natural process, the physical and mental investment of the woman in the painful treatment is tens of times greater than that of her partner. … Therefore … we have every moral and judicial reason not to assume symmetry but to entrust the right to control the process and to decide whether to carry it out or not, in the hands of the woman only (Ma’ariv, 7 April 1995).

Such opinions were far from trivial in the local context. Furthermore, framing the Nahmani dilemma within the natural conception paradigm extended the message of gender equity to implicitly generalize women’s reproductive rights more broadly. However, as typical of the Nahmani affair, even when advancing women’s right to bodily autonomy, this view also paved the way for an equivalent claim by Dani’s supporters. Indeed, judges, jurists, and journalists repeatedly flagged bodily autonomy in protest against “coerced fatherhood” as the strongest argument in his favor. Central to the bodily autonomy discourse and symptomatic of the ambiguity that surrounded it in 1990s Israel was another undecided reproductive concern—abortion. Abortion has been fairly accessible and safe for many years in Israel, but its legal status has been vague. Rooted in the prestate British Mandate law (1917–1948) prescribing a fourteen-year imprisonment for the procurer and five years for the woman, the law was somewhat moderated in 1952 by the newly founded state of Israel to require prosecution only in cases of negligence or if the abortion was not performed by a licensed physician. This dubious status was retained until 1977, when abortion was conditionally legalized, subject to approval by a medicosocial committee. However, two years after the new law had passed, the religious parties, using their crucial weight in coalition formation, repealed the social clause in the abortion bill. In subsequent years they would repeatedly exercise this power to rebuff numerous bills that sought liberalization of the procedure. Although abortion has became increasingly accessible and hospital committees more permissive (Portuguese 1998: 145), only health-related abortions are state funded,12 and some committees are still discouraging and offensive (Amir and Biniamin 1992). In any event, the subjection of all women seeking abortion to intrusive interrogation certainly imperils their bodily autonomy. It is also significant that throughout decades of abortion debates, it has always been the woman’s or the

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baby’s health and never women’s autonomy that justifies pregnancy termination (Portuguese 1998). In the Nahmani debate, abortion was invoked extensively. In all cases, without a single exception, it was taken for granted as a female prerogative. Among Ruti’s supporters the argument was that “just as a husband cannot object to his wife’s decision to abort, so he has no right to discard the eggs that she wants to have transplanted” ([male] Justice Tal). The same logic was applied by Dani’s supporters, who generalized women’s right to abortion to grant men, in the technologically assisted scenario, an equal right to choose nonparenthood. A more fragile perception of women’s abortion rights was implied in the concern voiced by one female journalist supportive of Dani, that linking abortion with the disposal of fertilized eggs might undermine women’s “shaky” right to the latter. The universal presentation of abortion rights as solid enough to guide a contested issue constituted this twilight subject, historically positioned at the softer margins of legitimacy, as decided. That this version of the abortion analogy went unchallenged throughout the Nahmani debate and that no single speaker raised the right-to-life argument as the basis for ruling out the discarding of the eggs may suggest that the encounter with newer ARTs (IVF, surrogacy) rendered older ARTs (abortion) more acceptable, perhaps less threatening to the existing gender order. But again, the typical Nahmani contradiction also inhered in this argument: the affirmation of women’s right to abortion could substantiate men’s right to pregnancy termination and eventually also the potential for pre-embryos’ right to life (for a similar mobilization of the abortion-rights discourse in the United States, see Markens 1997.) The right to abortion and gender equity in general also underpinned the hypothetical gender-reversed scenarios that various stakeholders invoked. In one of these scenarios, a woman had left her husband for another man, with whom she had two children. The deserted husband, by that time infertile, wished to have the eggs fertilized with his sperm implanted in a surrogate mother’s womb in order to exhaust his last chance for biological fatherhood.13 However, the woman refused and demanded that the fertilized eggs be discarded. Three judges, all supportive of Ruti, contended that the woman’s demand would have to be rejected under such circumstances. The ensuing, somewhat cynical reversal of the Nahmani case takes this logic to the absurd. Commenting on the initial supreme court verdict in favor of Dani, human rights lawyer Avigdor Feldman caricatured the appellant as:

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conceiving effortlessly through the somewhat pleasant experience of masturbating into a sterile dish. For five years Nahmani [male form] was carrying a tiny embryo in a lucid glasslike belly, floating in a miniature icy lake of liquid nitrogen at Assuta Medical Center. Now that he has had enough of this prolonged pregnancy, which indeed does not entail any morning sickness or duck-walk, he wants to perform—with the court’s permission—a painless abortion. What a twisted world this is, where the recognition of women’s right to abortion starts with allowing men to abort. As if a man—Nahmani—had to be picked up, to perform a symbolic abortion, in order to grant women the right to abort. Independent women, such as a Ha’aretz journalist and a successful lawyer, praised what appeared to be “a sentimental liposuction” out of conception, birth-giving and parenting. When Nahmani [male form] is pregnant, pregnancy becomes a masculine, direct, and straightforward pursuit (Ha’aretz, 18 April 1995).

Feldman’s mockery of reproductive equality provides an additional illustration of the segment of Israeli society that takes a critical stand against macho culture. Feldman’s critique of privileging men’s interests over women’s interests, and of the dubious status of abortion, as well as his tacit condemnation of women’s inferiority are all part of this challenging perspective. These claims, as well as the absence of any reversed scenarios from the presentations of Dani’s supporters, may suggest that in 1990s Israel, it was indeed easier to compromise a woman’s bodily integrity and her wishes than those of a man, to define her predicament as “biological destiny,” and probably also easier to accept a man leaving his partner for another, than a woman behaving likewise. By the same token, imposed motherhood might have sounded much less deplorable. A few local figures may substantiate this line of argument: in 1993, women’s average wage was 56 percent of their male counterparts;14 only 9.1 percent of parliament members were women;15 and family law has been regulated by religious courts ever since the foundation of the state, subjecting women to open and ideological discrimination.16 Under these unequal circumstances, summoning gender equality as a guiding principle to support a further ruling was in itself somewhat destabilizing. As in the case of abortion, here again, assuming universal acceptance of the gender equality principle drew attention to its inadequate application and, in this respect, promoted women’s rights. Another less direct contribution to women’s rights was made through a symbolic exposure of religious uncertainty. Israel’s religious courts regulate personal status and family affairs. In the Nah-

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mani case, they had no official role to play. Yet, owing to the importance of religion for many Israelis, the views of senior religious authorities were quoted abundantly in the press. And as in other moral systems, the Nahmani debate brought internal disagreement to the surface. Chief Ashkenazi Rabbi Israel Lau praised the verdict in favor of Ruti as concurring with the “Halacha [traditional Jewish law] condemnation of unlawful termination of pregnancy.” This view was shared by Dr. Mordechai Halperin, head of the Medical Center for Infertility and Impotence and an expert on Jewish bioethics, who considered Dani’s withdrawal of his consent to implantation as “a tremendous wrong that contradicts one of Judaism’s central values of harm avoidance.” However, Rabbi Yitzhak Halperin, head of the Technological Institute for Halacha Issues, relying equally meticulously on the Halacha, praised the penultimate ruling in favor of Dani for its implication that each parent could veto implantation, while Chief Oriental Rabbi Bakshi Doron criticized the final verdict on the grounds of a man’s monopoly over the destiny (goral) of his sperm and children. The attribution of conflicting views to the Halacha exposed the crucial role of interpretation and of the speakers’ personal convictions in the shaping of religious dictates. Although disagreement has been an established tradition in Jewish thought, in the Nahmani context, religion as a whole was in some way placed on the same level as other moral systems, as discrepancies surfaced so similarly in all, thus revealing their constructed, relativistic character. With this exposure, the Nahmani debate modestly contributed to a slight curbing of the authority of the religious courts, which openly discriminate against women. Beyond the views discussed previously, which carried destabilizing, equivocal messages, other arguments used the unprecedented case to convey clearer support of patriarchy. Most prominent in this category was the notion of motherhood as crucial for a woman to have a meaningful life. Ruti’s “relentless struggle,” as it was depicted in the press, vividly dramatized the misery of involuntary childlessness. Moreover, though being enabled through advanced technology and though aspiring for an untraditional family, it was biological motherhood that Ruti was struggling for. Indeed, it was the view of biological motherhood as superior to the alternatives that ultimately won her case in court. Although several speakers did suggest that Ruti insisted on mothering Dani’s child in particular, no one problematized her desire for “a child of her own.” In the final supreme court decision, Justice Eliyahu Matza listed Ruti’s options for be-

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coming a mother as “using the embryos, starting a new fertilization process, and adoption,” only to dismiss the latter options as “clearly unattractive.” Tapping into the same sentiment, Dani’s lawyer, Diana Har-Even, in an extensive weekend interview in the country’s most widely read newspaper, established herself as a traditional woman for whom raising her own (biological) sons was “the greatest of all life’s experiences” (Ma’ariv, 7 April 1995). Such a “marriage” of potentially defiant claims with the hegemonic ethos of motherhood has been rather typical of (the rare) women’s struggles in Israel, for it is in the sphere of motherhood that women’s rights are most highly respected (Bilski 2004). Thus, striving to accomplish the traditional goal of genetic motherhood, Ruti Nahmani also advanced, alongside the claim to bodily autonomy and gender equity, the view of biological parenthood as superior to all alternatives. It needs to be stressed that this notion did not necessarily weaken the societal position of Israeli women. However, to a certain extent it did restrict the scope of their public participation, or increase the toll of resistance. Perhaps it was this heterogeneous blend that made Ruti herself, the person, the woman, often disliked in the press. In some instances, the antipathy echoed traditional derogatory female stereotypes. Among the critics, Dani’s lawyer was the most outspoken. In the same weekend interview mentioned previously, published shortly after Ruti’s initial failure in the supreme court, Diana Har-Even used strong judgmental language to discredit Ruti: “Because Ruti has mobilized and manipulated the media very sophisticatedly from the outset, a distorted image has emerged. … [Moreover, Ruti] has decided to waste three precious years and now she claims she is not young anymore.… See, if we examine the arguments seriously, we realize that there is a lot of demagogy here” (Ma’ariv, 7 April 1995). Here, advanced technology was used as a new platform for the enactment of a long-established stigmatic image: the tricky female manipulator who would resort to dubious means (demagogy, distortion) in order to win her case. This female image was contrasted with another traditional portrait, that of Dani’s lawyer, a middleaged doctor’s wife and mother of two who had suspended her professional career until her children had matured. A description of the flower bouquet she received from her husband in honor of her supreme court victory sealed the article. Although contrasting one another, both descriptions reinforced traditional disparaging notions of women’s personalities and life trajectories, which were either derogatory or dominated by restrictive family ties. From this per-

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spective, the destabilizing potential ingrained in the personalities and actions of these two women was largely neutralized by such press constructions. Patriarchal thought might also account for the evasion of the term feminism throughout the debate. Although women’s views and interests were at the heart of the Nahmani trials, and many speakers seemed well versed in feminist theory, feminism itself was only rarely mentioned, always ambiguously, and mostly by Dani’s proponents. Thus, a female journalist praised the initial supreme court verdict against Ruti as “a feminist ruling” (Ha’aretz, 1 April 1995), and a female social-work academic criticized the final verdict in Ruti’s favor as “erasing feminist accomplishments.” One male journalist foresaw “feminists rejoicing at a woman suing her husband for destroying pre-embryos while masturbating” (Ha’aretz, 15 September 1996). In Ruti’s “camp,” feminism was mentioned only to be warded off. Ruti herself denied being a feminist; the women’s lobby praised the ruling in her favor as being “a great step toward stabilizing women’s rights” but refrained from using the explicit term feminism. Both the allusions and silences illustrate how the Nahmani debate tacitly complied with and thereby encouraged the marginalization of feminism in Israel. In this respect, it rendered innovative medical technology a new arena for the reaffirmation of patriarchy. Another potentially subversive issue apparently defused was that of ARTs. As mentioned, ARTs are viewed most favorably in Israel as a benign solution to the problem of infertility and are extremely popular among Israeli women. Still, the total absence of any critical comment on local ART policy or practice throughout the Nahmani debate is remarkable. This supportive silence, which indeed represents openness to technological innovation and to the alternative family formations they enable, is also a consequence of ardent state glorification of childbearing. Whereas the former aspect encourages women’s autonomy, the latter pushes women toward biological motherhood at all costs (e.g., by undergoing over twenty unsuccessful IVF cycles). In the context of the technology-anchored Nahmani debate, the silence embodied the public’s conformity with—and possibly belief in—existing policy and ideology. Neither the complexity of the technological intervention that Ruti required in order to materialize her chance for biological motherhood, nor its implications on her life or body was ever a source of concern. To the best of my knowledge, no speaker has commented on the exceptionality of the Israeli law or called for it to be reconsidered. The intact “survival” of the benign image of ARTs is probably the epitome of its local immu-

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nity. By presenting ARTs as an inconsequential technicality, by equating IVF and surrogacy with natural conception, and eventually by openly declaring—as did one supreme court judge—that the decision in the Nahmani trial must not deter couples from using ARTs in the future, the state-sponsored image of ARTs as benevolent was sustained. On the whole, then, the Nahmani-related silence has probably contributed to the legitimacy and routinization of ARTs in Israel—possibly it even trivialized their application at a higher order.

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By Way of Conclusion: Aftermath of the Nahmani Trial As shown, challenges to and reaffirmations of the existing gender order were immanent in the Nahmani dispute. As heated and dramatic as the public debate was, it did not spur any drastic changes in the local gender order. Rather, the maternal imperative, the superiority of biological parenthood, female stereotyping, the marginalization of feminism, and the benign image of ARTs were all reaffirmed through the debate. Constituted as key values to be preserved or even taken for granted, these traditional notions and the gender relations in which they are anchored were legitimized within a new updated discourse. In the sphere of reproductive medicine, the practice of IVF continued to thrive and expand. The number of IVF cycles conducted in Israel quintupled from 5,169 in 1990, to 10,689 in 1995, to 24,995 in 2005. Births resulting from IVF doubled from 1.7 percent in 1995 to 3.3 percent of all births in 2005 (IMH 2007). Judging by these indicators, the Nahmani affair did nothing to discourage the use of ARTs. At the same time, a few observed changes can be attributed to the Nahmani debate. At the level of everyday IVF practice for the past several years, when a woman starts an IVF treatment with a male partner, the man is requested to sign, in addition to the standard consent forms, a form that grants his female partner the right to use the resulting pre-embryos in any way she sees fit. Although I could not find an official reference to the Nahmani dispute, the connection with this woman-friendly amendment appears quite self-evident. At a broader level was the legalization of surrogacy, a move that was prompted directly by the Nahmani affair. As mentioned, in early 1991, Ruti and Dani Nahmani, still married, appealed to the supreme

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court in order to obtain public funding for IVF treatments aimed to generate pre-embryos to be transplanted into a surrogate mother’s uterus. Following the approval of their appeal, the Ministry of Health and the Ministry of Law nominated a public committee (the Aloni Committee) to examine the broader subject of IVF, including surrogacy. The committee’s recommendations provided the basis for the Embryo Carrying Agreements Law, known as the Surrogacy Law. The new law was processed in the record time of nine months from first draft to final approval (Teman 2003) and was ratified by the Israeli Knesset in 1996. Since then, surrogacy has become tightly state monitored, available only to officially paired heterosexual couples (Benshushan and Schenker 1997). To date, despite tedious bureaucracy and a necessary outlay of $50,000–$75,000,17 over one hundred babies have been born following local surrogacy arrangements. Thus again, while expanding reproductive choices, the surrogacy law has increased the state’s monitoring of procreation and the state’s protection of the traditional family (Cole 1995: 57–58; Strathern 1995: 351–52). The new law has rendered surrogacy the only advanced reproductive technology in Israel regulated by state law (all others are governed by Ministry of Health regulations). Internationally, too, the Israeli law stands out as the world’s first law entirely devoted to this subject.18 The smooth acceptance of the law and of actual surrogacy arrangements in Israel seem closely related to the preceding Nahmani affair. Several years after the Nahmani trials had ended, Supreme Court Justice Dalia Dorner wrote in a professional journal that “although the legal issues that emanate from this technology are new, we can mould existing legal principles to solve the dilemmas in accordance with principles of equality and justice” (Dorner 2000). This acknowledgment of the ability to contain innovations within established values summarizes much of the dynamics of the Nahmani affair and its sociopolitical repercussions: revolutionary changes in the spheres of family, kinship, gender relations, or women’s rights have not taken place. Yet, the ongoing presence of the protagonists and the human dilemma they embodied on Israel’s public agenda seem to have contributed to raising awareness of the domestic “female” issues with which they were grappling. More generally, like other nontraditional modes of procreation (e.g., lesbian and gay families, especially those in which offspring or siblings are genetically related), the Nahmani trials drew public attention to the laws and conventions that govern kinship and family ties and questioned the presumed naturalness of

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accepted family formations and gendered parental roles (Hayden 1995; Lewin 1995). In so doing, the Nahmani debate has helped augment the uncompromising importance of women’s bodily autonomy and to detrivialize the family-gender-technology intersection while exposing intense contradictions permeating these spheres in their contemporary Israeli context. In conclusion, it is worth noting that unlike parallel disputes elsewhere (Markens 2007), in Israel, none of the parties have voiced concern over the commodification of reproductive capacities, the exacerbation of class disparity, or the “unnaturalness” of the procedure. Rather, the debate has focused on the centrality of biology in the construction of kinship and its weight in enforcing familial commitments and obligations. In contrast to gay chosen families, which explicate the choice component in the construction of kinship ties (Hayden 1995; Strathern 1992b; Schneider 1980), the actors in the Nahmani case grappled with the binding force of biology to restrict familial choices even before actual children have come to life. Following the supreme court verdict in her favor, Ruti attempted several surrogate transplantations but none developed successfully. In 2006, when this article was being written, Dani had separated from his second partner. Ruti, on her part, has remarried and adopted a baby girl.

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Notes 1. See Markens’s analysis of the development of New York’s prohibitive policy vs. California’s licensing of surrogacy (2007, Introduction). 2. The present chapter focuses on the Jewish sector. 3. Central Intelligence Agency, The World Factbook, https://www.cia.gov/ library/publications/the-world-factbook/. 4. Israel Central Bureau of Statistics, (2006), Vital Statistics, “Live Births and Fertility Rates, by Population Group, Religion, Age and Mother’s Continent of Birth,” 142, http://www1.cbs.gov.il/shnaton56/st03_13.pdf. 5. Although Israel’s reproductive policy applies to its entire citizenry, various indications suggest that the pronatalist goal is directed primarily at the Jewish population (e.g., some conditions of eligibility for allowances, the formulation of certain laws.) 6. An IVF cycle entails intense hormone stimulation of the woman’s body, followed by surgical retrieval of the resulting eggs. The mature ova are placed in a petri dish with the sperm, after which the fertilized eggs are transferred to the woman’s uterus. Medication is often given at this stage to increase the likelihood of conception.

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7. Irit Rosenblum, “Fertility Treatments in Israel” (in Hebrew), New Family, (2006), http://www.newfamily.org.il/. 8. In contradistinction to countries like Germany, Norway, Sweden, or Australia, where eligibility is restricted to heterosexual couples (de Melo-Martín 1998: 63–78; Shalev and Lev 1999). 9. All of the judges mentioned in this chapter, and indeed all other actors in the Nahmani affair, are Jewish. The majority consider themselves “secular Jews.” The others are referred to as “religious.” 10. The Israeli verdict differed from two well-known precedents in the United States. In both the Davis v. Davis and the AZ v. BZ cases, American courts ruled against transplantation of the embryo of a divorced couple (Clayton 1991; Steinberg 1997). 11. Irit Rosenblum, “One-parent Families in Israel” (in Hebrew), New Family, 2006, http://www.newfamily.org.il/. 12. A private procedure would cost roughly the equivalent of US$1,000. Average monthly wages in Israel in 2005 were approximately US$1,200 (Israel Central Bureau of Statistics, Statistical Abstract of Israel 2006, Table 12.36). Women’s average wages were lower. 13. Throughout the Nahmani case, the terms “to become a father” and “to become a mother” were used without any qualifying reference to nonbiological modes of parenthood. 14. S. Swirski and E. Attias-Konor. “Employers, Employees and the National Income Pie: 2006 Report” (in Hebrew) (2007), Adva Centre, http:// www.adva.org/UserFiles/File/Labor%20Report%202006c[1].pdf. 15. “Women’s Representation in Politics—An International Comparison” (in Hebrew), http://www.iwn.org.il/inner.asp?newsid=15. 16. http://www.family-laws.co.il/hebrew/index.htm (in Hebrew). 17. Motti Gal, “What is the Price of Birth by Surrogacy?” (in Hebrew) (25 August 2004), http://www.ynet.co.il/articles/0,7340,L-2968497,00.html. 18. On the rarity of surrogacy legislation, see Markens 2007, Introduction.

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Birenbaum-Carmeli, Daphna. 1997. “Pioneering Procreation: Israel’s First Test-Tube Baby.” Science as Culture 6: 525–40. ———. 2003. “Reproductive Policy in Context: Implications on the Rights of Jewish Women in Israel, 1945–2000.” Policy Studies 24, no. 2: 101–14. ———. 2004. “‘Cheaper than a newcomer’: On the Political Economy of IVF in Israel.” The Sociology of Health and Illness 26, no. 7: 897–924. Carsten, Janet. 2000. Cultures of Relatedness: New Approaches to the Study of Kinship. Cambridge: Cambridge University Press. Clayton, Ellen Wright. 1991. “Women and Advances in Medical Technologies: The Legal Issues.” In Women and New Reproductive Technologies: Medical, Psychological, Legal, and Ethical Dilemmas, ed. Judith Rodin and Aila Collins. Hillsdale, NJ: Lawrence Erlbaum Associates. Cole, Phillip. 1995. “Biotechnology and the ‘Moral’ Family.” In The Family in the Age of Biotechnology, ed. Carole Ulanowsky. Aldershot, UK: Avebury. Corea, Gena. 1986. The Mother Machine: Reproductive Technologies from Artificial Insemination to Artificial Wombs. New York: Harper & Row. Dorner, Dalia. 2000. “Jurisprudence in the Age of Biotechnology: An Israeli Case Analysis.” Annals of the New York Academy of Science 913: 188–97. Fogiel-Bijaoui, Sylvia. 1999. “Families in Israel: Between Familism and Postmodernism.” In Sex, Gender, Politics: Women in Israel (in Hebrew), ed. D. Izraeli et al. Tel Aviv: Hakibbutz Hameuchad. Franklin, Sarah. 1997. Embodied Progress: A Cultural Account of Assisted Conception. New York: Routledge. ———. 2005. http://www.lse.ac.uk/collections/LSEPublicLecturesAndEvents /pdf/20051124-Franklin_TheReproductiveRevolution.pdf. Gallagher Jean. 1987. “Eggs, Embryos and Foetuses: Anxiety and the Law.” In Reproductive Technologies: Gender, Motherhood and Medicine, ed. Michelle Stanworth. Cambridge: Polity Press. Gold, Michael. 1988. And Hannah Wept: Infertility, Adoption and the Jewish Couple. Philadelphia: Jewish Publication Society. Haraway, Donna. 1991. Simians, Cyborgs and Women: The Reinvention of Nature. London: Free Association Books. Hayden, Corinne P. 1995. “Gender, Genetics, and Generation: Reformulating Biology in Lesbian Kinship.” Cultural Anthropology 10, no. 1: 41–63. Hirsch, Eric. 1995. “New Reproductive Technologies and the ‘Modern Condition’ in Southeast England.” In The Gender-Technology Relation: Contemporary Theory and Research, ed. Keith Grint and Rosalind Gill. London: Taylor & Francis. Israel Ministry of Health (IMH). 2007. “IVF Treatments: Absolute Numbers, Percentages, Medical Facilities and Equipment Licensing Division and Department of Health Information.” Kahn, Susan M. 1998. “Rabbis and Reproduction: The Uses of New Reproductive Technologies Among Ultra-orthodox Jews in Israel.” Working Paper No. 3. Waltham, MA: Hadassah-Brandeis Institute, Brandeis University. ———. 2000. Reproducing Jews: A Cultural Account of Assisted Conception in Israel. Durham, NC: Duke University Press.

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Katz, Jacob. 1971. Tradition and Crisis: Jewish Society at the End of the Middle Ages. New York: Schocken Books. Lewin, Ellen. 1995. “On the Outside Looking In: The Politics of Lesbian Motherhood.” In Conceiving the New World Order: The Global Politics of Reproduction, ed. Faye D. Ginsburg and Rayna Rapp. Berkeley: University of California Press. Luhmann, Niklas. 1985. A Sociological Theory of Law. Trans. Elizabeth King and Martin Albrow. Boston: Routledge & Kegan Paul. Markens, Susan. 1997. “Feminist Rhetoric, Women’s Rights Advocates, and Policy Responses to Surrogate Motherhood.” Paper presented at the American Sociological Association. ———. 2007. Surrogate Motherhood and the Politics of Reproduction. Berkeley: University of California Press. de Melo-Martín, Inmaculada. 1998. Making Babies: Biomedical Technologies, Reproductive Ethics, and Public Policy. Boston: Kluwer Academic. Nyboe Andersen, A. V. Goossens, L. Gianaroli, R. Felberbaum, J. de Mouzon, and K. G. Nygren. 2007. “Assisted Reproductive Technology in Europe, 2003. Results Generated from European Registers by ESHRE.” Human Reproduction 22, no. 6: 1513–25. Portuguese, Jacqueline. 1998. Fertility Policy in Israel: The Politics of Religion, Gender, and Nation. Westport, CT: Praeger. Safir, Marilyn P. 1991. “Religion, Tradition and Public Policy Give Family First Priority.” In Calling the Equality Bluff: Women in Israel, ed. Barbara Swirski and Marilyn P. Safir. New York: Pergamon Press. Schneider, David M. 1980. American Kinship: A Cultural Account. Chicago: University of Chicago Press. Shalev, Carmel. 1998. “Halakha and Patriarchal Motherhood: An Anatomy of the New Israeli Surrogacy Law.” Israel Law Review 32, no. 1: 51–80. Shalev, Carmel, and Boaz Lev. 1999. “Public Funding for IVF in Israel: Ethical Aspects.” Working paper. Shuval, Judith T. 1992. Social Dimensions of Health: The Israeli Experience. Westport, CT: Praeger. Stanworth, Michelle. 1987. “Introduction.” In Reproductive Technologies: Gender, Motherhood and Medicine, ed. Michelle Stanworth. Cambridge: Polity Press. Steinberg, Debora Lynn. 1997. “A Most Selective Practice: The Eugenic Logic of IVF.” Women’s Studies International Forum 20, no. 1: 33–48. Strathern, Marilyn. 1992a. After Nature: English Kinship in the Late Twentieth Century. Cambridge: Cambridge University Press. ———. 1992b. Reproducing the Future: Anthropology, Kinship and the New Reproductive Technologies. New York: Routledge. ———. 1995. “Displacing Knowledge: Technology and the Consequences for Kinship.” In Conceiving the New World Order: The Global Politics of Reproduction, ed. Faye D. Ginsburg and Rayna Rapp. Berkeley: University of California Press. Swirski, Shlomo. 1976. “Community and the Meaning of the Modern State: The Case of Israel.” Jewish Journal of Sociology 18: 123–40.

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Swirski, Shlomo, E. Konor-Attias, Barbara Swirski, and Yaron Yecheskel. 2001. Women in the Labor Force of the Israeli Welfare State (in Hebrew). Tel Aviv: Adva Center. Teman, Elly. 2003. “The Medicalization of ‘Nature’ in the ‘Artificial Body’: Surrogate Motherhood in Israel.” Medical Anthropology Quarterly 17, no. 1: 78–98. Webster, Andrew. 2002. “Innovative Health Technologies and the Social: Redefining Health, Medicine and the Body.” Current Sociology 50, no. 3: 443–57. Weisberg, D. Kelly. 2005. The Birth of Surrogacy in Israel. Gainesville: University of Florida Press.

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Part III

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TESTING GENES AND USING CELLS: ENCOUNTERS WITH ADVANCED GENETIC TECHNOLOGIES

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Chapter 8

THE GENESIS OF EMBRYOS AND ETHICS IN VITRO PRACTICING PREIMPLANTATION GENETIC DIAGNOSIS IN ARGENTINA Kelly Raspberry

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What do we do if … you know, what do we do with an embryo that has abnormal chromosomes? Do we throw it away? And you know, there’s all this sense of the Catholic Church being involved in every step of Argentine life and that’s, people are afraid of that. —Alberto Ruiz, gynecologist at a private infertility center in Buenos Aires1

W

hen does human life begin? What protections should be afforded a three-day human embryo created in an embryology laboratory? What should be the fate of an in vitro embryo diagnosed with chromosomal defects, and who has the right to decide this? These questions and the ways they are approached and resolved are at the center of the debate in Argentina over one of the newest assisted reproductive technologies (ARTs) offered in Buenos Aires: preimplantation genetic diagnosis (PGD). Positioned at the meeting point of ARTs and medical genetics, PGD is an advanced laboratory technique used to analyze the chromosomal makeup of the in vitro embryo. The primary application of PGD is as a prepregnancy screening test for genetic disorders, in which chromosomally normal em-

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bryos can be selected for use in subsequent pregnancy attempts. The PGD International Society estimates that 7,000 cases of PGD have been performed in more than 50 centers around the world since the technique was first successful, in 1990, with approximately 1,000 babies born after its use (http://www.pgdis.org).2 Following this international trend, over the last six years five private ART clinics in Buenos Aires have been offering PGD to the public. The first clinic in Buenos Aires to perform PGD did so for research purposes in 1998, implementing the technique as a clinical service about one year later. Indicative of their palpable desire to provide the latest innovations in reproductive medicine, as of late 2006 four more centers in Buenos Aires had incorporated PGD into their repertoire of ART services. However, legitimizing PGD as a valuable and recommended service has been a complicated, and as yet unresolved, process for Argentine reproductive-medicine practitioners. Several factors make the acceptance of PGD difficult in Argentina, including the high cost of necessary equipment and training. Yet the principal reason is the problematic legal and moral status of the in vitro human embryo in Argentina. PGD, by nature of the technique, requires not only embryo manipulation, but also a protocol for what to do if that embryo is chromosomally abnormal. Like most of Latin America, Argentina is a predominantly Catholic country, and the Roman Catholic Church unequivocally requires the protection of human life from the point of conception. Furthermore, in 1987 the Vatican issued an international doctrine explicitly condemning the use of ARTs. However, in Argentina there is no law prohibiting ARTs nor are there legal definitions of the rights and protections due to an in vitro human embryo. In the absence of specific instructive national legislation, the proper legal and ethical treatment of an in vitro human embryo is undefined and open to interpretation. This ambiguity therefore creates a situation in which Argentine medical professionals are de facto responsible for articulating philosophical and ethical positions that most Argentines deem as fundamental regarding when human life begins and what moral status an embryo holds. This chapter will identify the key components and describe the dynamics of practicing PGD in Argentina, with the underlying premise that the practice of PGD elucidates a more general problematic of doing ARTs: how to define and treat the in vitro embryo. Although infertility specialists have at times been able to navigate around this issue in providing other ARTs, the procedure of PGD necessitates the direct confrontation of the meaning of the in vitro embryo in order

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to proceed with the technique. At the center of this negotiation is the apparent incongruity between (religious) valuation of the embryo as sacred human life and advanced scientific techniques that permit the creation and manipulation of the embryo. This chapter examines these professionals’ attempts to reconcile this conflict, revealing that technology, in practice, is both messy and contradictory. PGD in Argentina is an entry point to understanding how ARTs are transformed according to local conditions of practice even as they transform the societies they newly inhabit. This chapter joins a growing body of literature that examines the global spread of ARTs and reveals that the circulation of biotechnology around the world is not a value-free process of “technology transfer.” Rather, as these ethnographic analyses demonstrate, patients and professionals enact and experience ARTs in culturally specific ways (Becker 2000; Bharadwaj 2002; Ehrich et al. 2006; Franklin 1997; Handwerker 2002; Inhorn 2003; Inhorn and van Balen 2002; Kahn 2000; Roberts 2006; Thompson 2005). Indeed, contextual analyses of reproduction and ARTs serve to denaturalize and make uncertain the “biological facts” of reproduction and kinship and to disrupt the traditional dichotomies of nature and culture (Franklin and Lock 2003; Franklin and Ragoné 1998; Morgan and Michaels 1999; Rapp 1999; Thompson 2001; Strathern 1992). Located at the intersection of ARTs and genetics, PGD as a site for anthropological inquiry also engages work on the new genetics and the emerging “genetically at risk” individual (Finkler, Skrzynia, and Evans 2003; Franklin 2003; Franklin and Roberts 2001, 2006; Heath, Rapp, and Taussig 2004; Novas and Rose 2000; Rose 2001). This chapter is based on three years of dissertation fieldwork (2002– 2005) primarily conducted in Buenos Aires, Argentina, involving participant observation, interviews, and archival research. The analysis presented here is therefore part of a deeper investigation into how local conditions—social, political, economic, and historical—play through and influence the work of ARTs in Argentina, and how this local performance of ARTs produces new forms of family, health, modernity, life, and science. The research focused on the professional reproductive-medicine community in Buenos Aires, where I observed on a daily basis the embryology laboratories, operating rooms, patient-consultation sessions, and ethics-committee meetings of four of the five most influential private infertility centers in the country (one refused). My observations also included visits to four smaller clinics in the provinces of Argentina, to a public hospital in Buenos Aires, to the largest private clinic in Chile, as well as attendance at

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several international conferences on ARTs held in Uruguay and Argentina. Archival materials collected and analyzed include clinic literature on treatment protocols, local law projects, and various popular media discussions of motherhood, infertility, and ARTs. I also conducted sixty-eight semistructured interviews in Spanish with gynecologists, biologists, embryologists, psychologists, lawyers, and scientists engaged in the world of ARTs in Latin America, as well as ten interviews in Spanish with current and previous patients who shared their experiences of infertility treatments in Buenos Aires. As one slice of this broader analysis, this chapter reveals that, as with other ARTs, performing PGD in Argentina engages a slew of competing interests and ethics, including conservative Catholic values, claims to modernity and legitimacy, desperate hopes, and economic incentives (see also Raspberry 2007).

The Problematic of PGD I wouldn’t do the diagnostic testing, because in the case of an abnormal embryo, I wouldn’t destroy it.

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—Fernando Pérez, gynecologist and director of a private infertility center in the greater Buenos Aires area

After more than two years of laboratory preparation and training, in May of 2003, the Center of Assisted Reproduction (CREAR) became the third clinic in Argentina to provide PGD as a routine clinical service. These two years entailed a considerable investment of capital and training time. The laboratory equipment and materials necessary to do PGD, as well as the actual technical knowledge and skill required, are not those used in day-to-day ART services. The requisite equipment includes a fluorescent microscope (for fluorescent in-situ hybridization [FISH] analysis), a Hybrite warming machine, probes, special slides, and filters.3 In Argentina, this equipment is all imported, with minimum costs to begin the service totaling between US$33,400 and $90,000, depending on whether the clinic already has the micromanipulator microscope used for intracytoplasmic sperm injection (ICSI), which most centers in Argentina do. Once the equipment is properly installed, technical mastery of PGD calls for months of practice, as it is a complicated technique that involves great skill with the microscope and specialized knowledge of chromosomes. There are four essential stages of PGD following the initial in vitro fertilization process (creation of the embryos). Learn-

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ing to correctly perform each of these steps requires three to four months of daily practice in the laboratory. The technique begins with an embryo biopsy, performed on a three-day in vitro embryo that will ideally have developed eight cells.4 Each of these cells, called blastomeres, contains a complete set of chromosomes. A small hole is carefully made in the outer covering of the embryo, and one cell (blastomere) is extracted, leaving the other cells in the embryo to continue development. The second step is the fixation of the blastomere on to a special slide. The third phase is the FISH process, the hybridization of the probes with the blastomere DNA. Finally, the tagged chromosomes are analyzed under the fluorescent microscope, known as “reading” the fluorescent probes. Only five chromosomes can be analyzed at a time using FISH, usually in the combinations 13, 18, 21, X, Y or 13, 16, 18, 21, 22. These sets of five chromosomes are identified as the most frequent perpetrators of abnormalities, but testing both sets encompasses only a total of seven chromosomes out of forty-six total (using two rounds of FISH).5 Because of this technical constraint on the number of chromosomes that can be tested, the “normal” embryos identified through the use of PGD may also carry undetected abnormal chromosomes. Among reproductive experts, this limitation is regarded as par for the course; it is not part of the debate over PGD in Argentina. The entire process of PGD takes two days; therefore, results are available at the maximum point of viable in vitro incubation, when the in vitro embryo has developed into a blastocyst, at the fifth day after fertilization. To ensure proper laboratory setup and training, CREAR sent a biologist to São Paolo, Brazil, to learn the fundamentals of laboratory preparation, embryo biopsy, and fixation of the embryo from a specialist (now practicing in the United States). A year later, with the laboratory and equipment in place, CREAR flew in an expert embryologist from Italy for a week of hands-on laboratory instruction in the technique, after which CREAR’s biologists and embryologists continued to practice on their own. This second training session focused specifically on chromosome analysis and “reading” the fluorescent probes, skills previously more familiar to geneticists than embryologists and biologists in a traditional ART lab. The cost of doing PGD is not only one of finances and training, but also requires a shift in thinking about the embryo. At CREAR, resistance to “paying this fee” and revising notions of embryo manipulation delayed the introduction of PGD for several years. Julieta Moretti, the biologist at CREAR who trained in São Paolo, explained this reluctance:

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PGD for a long time was on hold because some of the associates didn’t agree with it, specifically with doing something that would invade the embryo. … When I came back from Cornell, in 1999, I brought the techniques of fragment removal and assisted hatching [techniques that, similar to PGD, manipulate the embryo]. Only recently we started using these because, before, they had objected. A few had the philosophy that the less you do to an embryo, the better.

These objections to “invading the embryo” represent a key conundrum of PGD and ARTs in general in Argentina, with respect to the in vitro embryo: religious morality vs. technical efficacy. Although doing “less” to the embryo translates as preserving the sanctity of human life, doing “more” holds the promise of selecting a “betterquality” embryo, improving success rates of pregnancy and preventing genetic disease. Even though CREAR’s board of directors had finally approved PGD as a clinical technique, the problem of the embryo was far from resolved. Indeed, over the next year the process of accepting PGD as a valuable procedure entailed an entire revision of the center’s policy on the moral status of an embryo, a modification that has implications not only for other ARTs at this clinic, but also for wider social and cultural ramifications. In Argentina, the centers providing PGD as a clinical service do so according to specific medical criteria. The medical rationale for offering PGD corresponds with three objectives: to reduce repeat miscarriage rates, to increase the implantation (and therefore pregnancy) rates of IVF/ICSI, and to prevent heritable genetic diseases from being passed on in families with known genetic risks. Some of the genetic disorders that PGD can be used to identify are Down syndrome, Tay-Sachs, cystic fibrosis, Duchenne muscular dystrophy, hemophilia, and Huntington’s chorea. However, as mentioned earlier, doing PGD does not guarantee the development of a healthy fetus. Indeed, most international reproductive specialists in support of PGD, including those in Argentina, also recommend prenatal testing for post-PGD pregnancies. At least for now, practitioners in Argentina are careful to advocate using PGD only for specific cases, given the debate it provokes and the financial expenses that come with it. Therefore, PGD is not recommended to every couple referred for infertility problems but rather is confined to a target population of those with a history of heritable genetic disease, repeat miscarriages, failed implantation attempts, azoospermia (lack of sperm), or when the woman is over thirty-seven years of age. The utility of PGD for this specific group

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of potential patients is emphasized, according to Nicolas García, a gynecologist and codirector of CREAR:

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For patients with genetic disorders, without a doubt PGD is fundamental. It is fundamental to assure the birth of a child that won’t have a genetic disorder, that’s what PGD is for. But I don’t think, and I might be wrong, that in the future PGD will be done routinely … because it doesn’t make sense to do that. … It will instead be done according to specific indications.

Most proponents of PGD in Argentina do not foresee PGD becoming a widespread technique available to all ART patients in Argentina. They agree with Dr. García about its utility for a select population and in doing so underscore that this is a technique for preventing genetic disease, not for enhancing “choice” or improving the embryo beyond a standard of “normal.” Indeed, at present, the professional debate over the technique dwarfs the actual number of PGD clinical cases these centers perform. For this technique in transition, the patient caseload is still light, ranging between six and fifteen cases per year at most of the clinics.6 In Argentina, the international prestige of PGD as a cutting-edge technique is such that to be recognized as a center that provides PGD is, for now, reason enough. Public demand is sure to follow. In the international reproductive-medicine community, controversy over PGD focuses primarily on defining the appropriate uses of the technique.7 In contrast to Argentina’s restrictive clinical rationale, some tout PGD as beneficial for improving the efficiency of ARTs in general, claiming that it is “surely evolving to become the standard” (Verlinsky et al. 2004a: 294). In recognition of the growing use of PGD around the world, these international ART specialists have convened international symposiums on the ethical issues of PGD, as well as task forces and ethical committees to provide guidelines for the proper application of the technique (ASRM 1999; Edwards 2002; Hudson 2006; Klipstein 2005; Shenfield et al. 2003; Thornhill et al. 2005). In many other countries, the legal status of the in vitro embryo has already been resolved by state legislation, and principle concerns about PGD have been its potentially eugenic and discriminatory undertones and uses. In Japan for instance, PGD is prohibited on the grounds that it enables a form of genetic discrimination by selecting only those embryos that are “genetically” normal, thereby discriminating against individuals with chromosomal disorders (Munné and Cohen 2004). Disability-rights groups

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are also wary of the potential genetic discrimination implicit in PGD, as it extends prenatal testing even earlier in embryonic development (Parens and Asch 2000). There is also debate about whether PGD should be allowed for human leukocyte antigen (HLA) typing, in which an in vitro embryo is selected for its ability to be an HLA match able to provide hematopoietic stem cells to a child who suffers a serious congenital disease (de Wert 2005; Edwards 2004; Verlinsky et al. 2004b). In addition, PGD can be used for sex selection of the embryo for nonmedical reasons, sometimes described as “family balancing.” Preference-based sex selection is widely controversial because of its discriminatory potential and because it entails the possibility that a chromosomally normal embryo will be discarded if not of the preferred sex (Edwards 2002; Malpani and Malpani 2002; Shenfield et al. 2003). Taking into consideration these international concerns over PGD, what is most striking about the case of PGD in Argentina is that the controversy is focused almost entirely on the nebulous status of the human embryo itself. In this sense, the debate in Argentina over PGD shares much in common with the global debate over stem cell research and cloning, which also calls into question the protections due human life. In Argentina, where fundamental anxieties over ARTs and the status of the embryo have yet to be resolved, concerns surrounding genetic testing and the proper use of PGD are not yet as pressing. The circle of inquiry in Argentina is therefore drawn around what rights and protections should be afforded to an in vitro human embryo of eight cells, whether chromosomally normal or not, rather than on potential genetic or sex discrimination. Genetictesting issues are undoubtedly potential concerns in Argentina, but the critical issue for objection to PGD in Argentine clinics—what to do with the abnormal embryo—at present precedes the resulting conflict in other places. As this chapter illustrates, in the unregulated private market of ARTs in Argentina, the ambivalent status of the in vitro embryo is a source of both anxiety and promise for practitioners who support the practice of PGD.

Practicing ARTs in Argentina Technology progresses much faster than our thinking does. You don’t know if that’s good or bad. Even more than that, you don’t know the consequences. —Manuel Giordano, head of an embryology lab at a private infertility center in Buenos Aires

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The first successful IVF procedure in Argentina was officially celebrated with the birth of twins in February 1986. Today in Argentina there are approximately twenty-two private clinics for a population of thirty-six million; one-third of the country’s citizens reside in the greater Buenos Aires area. These private centers provide highcomplexity ARTs, including IVF, ICSI, egg donation, and embryo cryopreservation. As in other parts of the world, the use of ARTs in Argentina is highly stratified by social class and region, with access to these private centers restricted to the mobile upper and uppermiddle class, who can afford to pay the relatively high costs out of pocket (Ginsburg and Rapp 1995). Although the price of IVF and ICSI techniques in Argentina are about one-third of what they are in the United States—between US$3,000 and $5,000—they are beyond the reach of the average middle-class Argentine couple, whose combined monthly salary is slightly less than $500. For a couple undertaking ARTs in Argentina, PGD costs an additional $500 per IVF/ICSI cycle. With the devaluation of the peso in 2001, these techniques (the cost of which is calculated partly in USD) are prohibitively expensive for Argentine consumers, who have even less purchasing power than before the country’s financial crisis. Argentina has nationally funded, universal health care; however, the free public hospitals do not provide ARTs, and only one public hospital (located in Buenos Aires) offers low-complexity techniques such as intrauterine sperm insemination and hormone stimulation. Private health insurance plans do not cover ARTs. Out of the sixteen infertility centers in the city of Buenos Aires, there are five principal clinics that are directed by Argentina’s most renowned gynecologists and embryologists. Combined, these five clinics perform more than 70 percent of all the cases in Argentina, with each one doing between approximately four hundred and nine hundred IVF and ICSI treatments a year. Because the population of Argentines who need, want, and are able to afford an infertility treatment is finite, competition among these five clinics is inevitable. In this competitive environment, if one clinic begins specializing in a new technique, the others feel pressure to follow suit for fear of losing potential patients. In this scenario, consumer “demand” for a given technique is often created by the centers themselves, through physician referrals and subsequently through patient familiarity and desire for the procedure. This is precisely the situation with PGD. By 2005, all five of the principal clinics were providing some form of PGD, and yet the actual number of patients requesting PGD was negligible (especially compared to those asking for IVF). For the time being, PGD is being performed only at these larger infertility clinics

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in Buenos Aires. It is not viable for the smaller clinics in Argentina, because they do not perform enough patient cases of ARTs in general to make it worthwhile to invest in the high-priced training and equipment required for PGD. The incentive to begin offering PGD is not only a market-based competitive one, but also perhaps more importantly is related to the appeal of this technology as a scientifically advanced technique for professionals in Argentina. As participants in an international community of reproductive-medicine experts, Argentine infertility practitioners place high importance on being perceived as “modern” and capable of incorporating the latest medical technology. Despite Argentina’s economic and political collapse in 2001, these health professionals clearly view Argentina as a Latin American nation only by location: in response to my interview queries, they repeatedly asserted that Argentina is more European than and therefore superior to its “underdeveloped” neighbors. The plush waiting areas and hightech laboratories in these private clinics in Buenos Aires resemble those of private centers in the United States, and they are devoid of religious iconography or any other evidence of nonmodernity. The directors of Buenos Aires’s principal ART clinics and laboratories were trained in the United States and Europe and are the “IVF pioneers” in Argentina. These specialists pride themselves on achieving pregnancy rates equal to those at the best clinics in the world. Yet, despite these symbols of modernity, being “modern” is a lived concern for these specialists, who struggle with the seepage of religion into their scientific and medical practices (Latour 1993). The embryologist codirector of CREAR, Tómas Navarro, a practicing Catholic, explained how he views the conflict between religion and science as related to embryonic development: You can’t argue with religious faith. But if you don’t have faith, you can say scientifically, for me, life begins here, or here. … If religion is in the discussion, there is no discussion, because you believe or you don’t. If you take religion out, then you can argue and think of [personhood as beginning with] either two pronuclei, singamy, cleavage, or implantation.

This statement underscores what this specialist sees as an invisible boundary between “biology”—what medicine is concerned with— and “society”—here presented as religious conviction—which is outside the realm of science and medicine and in fact is disruptive if let in. Dr. Navarro resolves the possible contradiction between his work and his Catholic faith by attempting to place the two in separate boxes.

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In this divisible world, only scientific discourse allows for a debate over the beginning of personhood, based on “biological facts.” However, the local morality within which Navarro works is perceptible in his science, as Navarro’s “religion-out” characterization still places personhood at very early stages of embryonic development. Successfully providing high-tech ARTs, including PGD, can therefore be read in Argentina as vital to maintaining this highly desired and at times precarious modernity. To achieve this credential of scientific modernity, infertility experts in Argentina must carefully choreograph their dance of modernity. In order to be enlightened doctors and scientists of ARTs, these specialists downplay the decidedly traditional Catholic ethic toward reproduction and family in wider Argentine society. Yet, they cannot push the boundaries too far, for fear of negative legal and social repercussions. Although the majority of Argentines are not practicing Catholics, Argentine politics and social mores are nonetheless formed in relation to the Catholic Church’s positions in Argentina. As visible players within this conservative milieu, reproductive specialists promote traditional values of family and health in order to legitimize their work in ARTs. Infertility practitioners therefore justify their practices of ARTs by proclaiming that infertility is a biological disease requiring medical treatment. In this society where “woman” is often conflated with “mother,” many Argentine women experience having children as a “social mandate.” ARTs are validated and encouraged as a medical service for heterosexual couples otherwise unable to have children. In concordance, the majority of clinics in Argentina voluntarily deny single women and homosexual couples access to ARTs on the grounds that they are not “biologically infertile.” Although purportedly based on a medical protocol, this denial of access is based on a traditional social judgment supported by the Catholic Church, that only stable heterosexual couples are deemed fit for making a family. By upholding traditional values of reproduction and family, these practitioners lessen potential resistance to these new ARTs, making them more palatable to a society that venerates motherhood. The Vatican’s influence over the practice of ARTs is a subject of concern among Argentine infertility professionals. The Catholic Church’s power in the context of a highly polarized political debate was blatantly demonstrated with the passage of an extremely restrictive 2004 ART law in Italy. Many Argentine reproductive experts fear that this Italian law has potential to be a model for Argentina’s legislature, as it is similar in scope to those that have been backed by the Catholic

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Church in Argentina over the last fifteen years. The Italian law implicitly prohibits PGD, as the law bans embryo cryopreservation, restricts fertilization to only three eggs at a time, and requires immediate transfer of all created embryos. These strict measures are justified out of “respect for the rights” of the human embryo, yet the ruling creates a paradoxical situation in which IVF practitioners are now required to protect the life potential of an in vitro embryo (regardless of chromosomal normality), but abortion following prenatal testing is allowed (Benagiano and Gianaroli 2004). The Catholic Church has also exerted influence over ARTs within Latin America: the supreme court in Costa Rica banned IVF as morally unacceptable in 2000. For now, in Argentina the absence of laws to govern ARTs or to define the appropriate treatment of the in vitro embryo leaves regulation to the forces of professional aspirations and the private market. The senate is currently reviewing three pieces of proposed legislation, but as this is a lengthy process, it is not likely to provide resolution in the near future. In the meantime, several existing legal statutes are ostensibly directly unrelated to ARTs but are often interpreted as relevant according to their declarations on the legal protection of human life. In the absence of an explicit law, these statutes are often used as guidelines. These include two international treaties, which in Argentina were upgraded to the constitutional level, in 1994. The first is the American Convention on Human Rights, Pact of San José, Costa Rica, signed by Argentina in 1984, which declares in Article 4.1 that “every person has the right to have his life respected. This right shall be protected by law and, in general, from the moment of conception.”8 Although this decree clearly recognizes and protects human life at conception, the inclusion of the term “in general” creates an ambiguous situation in terms of when and where conception is considered to occur. Interpreting this law therefore depends on one’s orientation: although a devoutly Catholic Argentine would argue that conception is the moment of union between the sperm and egg, regardless of where it takes place, one who takes a more liberal reading would counter that the life potential of a human embryo outside the uterus is not explicitly protected by this treaty. The second potentially relevant treaty is the Convention on the Rights of the Child, which gives protection to minors under eighteen years of age. In 1990, Argentina signed this international treaty, making an additional declaration that the rights of a child begin at conception. Although this declaration is only a political statement and has no legal authority,

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some conservatives see it as a legitimate reason for protecting an in vitro embryo. Another potentially relevant law, also subject to interpretation, is Article 70 of the civil code, which proclaims that the existence of a human person begins with conception in the uterus and gives certain protections to this human life from that point (although many of these rights are not enforced until the person has been born [persona por nacer]). Given that Article 70 was written in 1865, well before ARTs made conception outside the uterus possible, it is not surprising that it refers to conception in the uterus (en el seno materno). However, taken literally, the civil code can be used to argue that human life created outside the uterus is not protected under the civil code. Also under consideration is the consequence that if an in vitro embryo is defined under law as a “person” with rights, the penal code would also have relevance for ARTs in terms of its prohibition against murder of a human person or possibly the abortion of a fetus. The difficulty lies in that none of these rulings explicitly define when life begins nor do they clarify when such legal protections would take effect—whether at the point of conception regardless where it takes place or when an embryo is implanted in the uterus. In practicing ARTs, clinic professionals may therefore be mistreating the embryo, depending on how the law is interpreted. In addition to the lack of an explicit law, infertility clinics in Argentina are not required to undergo any kind of national accreditation or certification process in order to provide ARTs to the public. As a consequence, standards for practicing ARTs are not subjected to external regulations and vary across clinics, depending primarily on the individual professional codes of training and ethics used at a given clinic. It is notable that the majority of clinics in Argentina are voluntary members of the Latin American Assisted Reproduction Network (RED), which requires a minimum standard for lab and clinic protocols, provides recommended guidelines for practices, and publishes an annual registry (Registro Latinoamericano) of ARTs per country. However, RED is a private, nongovernmental organization that does not function as a directive or regulatory body, nor does membership in RED ensure standardization of practices across all accredited clinics. Although four of the five principal clinics in Buenos Aires belong to RED, the actual protocols enacted in each depend more on the orientation and discretion of the directors than on any dictate from RED. In the unregulated market environment, some ARTs are done quietly, while others are not even discussed. For example, until PGD made the issue unavoidable, the disposal of an in

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vitro embryo was considered a question too taboo for dialogue within the medical community. The fear of generating negative commentary from the Catholic Church in Argentina on ARTs in general imposed a code of silence. Indeed, in May 2003, as public debate over PGD was just stirring, Dr. Navarro spoke of the caution necessary to deflect negative public attention and misunderstanding:

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When it [PGD] becomes more public, I think that there could be people that would denounce us and [name of a clinic in Buenos Aires] and other institutes that do PGD, because of what we do with abnormal embryos, which are “sick children,” according to them. And as you can’t murder a five-year-old child that has Down syndrome, neither can you murder a six-cell embryo because it carries Down syndrome. That’s the idea. I think that you have to be very careful.

As this statement exemplifies, the ambiguity of existing legal statutes and the lack of state oversight therefore places the responsibility for laboratory and clinical actions on reproductive-medicine professionals, who experience this legal uncertainty as both a liability and an opportunity: it does not provide any safeguards for ethical anxieties, but it does allow practitioners the flexibility to determine the extent of embryo manipulation they wish to pursue.9 The ways Argentine reproductive experts resolve this responsibility correspond to particular understandings of the process of embryo development, largely based on either religious or scientific convictions. This variability in definitions of human life, the stage at which an embryo is viable, or when the embryo should be considered a human person, translate into differences in actual laboratory practices. For example, those doctors in Argentina who agree with the Catholic Church’s official position that life begins at conception are thus opposed to doing any potentially damaging techniques after fertilization of the egg, including the cryopreservation of embryos. Others argue that the life potential of a human embryo is a sequential, gradual process of development and the embryo implanted into the uterus at day fourteen deserves different moral considerations than the in vitro pre-embryo and, of course, the child born after nine months of gestation (see Fernández et al. 2004; Krones et al. 2006; and Parry 2006 for patient and practitioner viewpoints on the contingent meaning of the in vitro embryo in PGD and stem cell research). Within a given clinic in Argentina, there is often diversity of personal opinion among professional staff; however, as they are members of an institution, a common protocol dictates practice. Centers in Argentina therefore differ not only in their reception to PGD, but

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also in basic practices such as the average number of embryos transferred; if and when embryos are cryopreserved; the use of IVF, ICSI, or gamete intrafallopian-tube transfer; and the provision of withinclinic egg and sperm-donation programs. Without legal guidelines, state regulation, or a medical consensus on what is permissible, practitioners are left to sort out amongst themselves the thorny issues of viability and personhood of a human embryo as well as the value of human life. As the following example illustrates, the adoption of these technologies are shifting deeply rooted beliefs about the sanctity of human life and the role of technology in manipulating that life.

Ethical and Embryonic Developments It is an expensive technique. The truth is that in Argentina the technique is still being tinkered with to perfect it. And apart from that, imagine how doing PGD implies the selection of embryos to transfer. Imagine how here [at this clinic] they don’t even want to cryopreserve, even less will they want to select in order to discard the rest of them [embryos]. Because they tell you, “Yes, we are cryopreserving them for the day in the future, in thirty or forty years, when a therapy is made for these embryos and we will unfreeze them.” It’s a little … it’s a chimera, isn’t it?

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—Diego Ramos, head of an embryology lab at a private infertility center in the greater Buenos Aires area

By May 2003, CREAR’s proponents of PGD were able to convince the center’s directory board that the value of the technique offset its financial costs. However the moral “cost” of PGD—what to do with the abnormal in vitro embryo—was not resolved for another year. It is the process and product of this “resolution” and its implications for understandings of science and morality that is of interest here. At the time PGD was first being considered as a treatment service, CREAR upheld a within-clinic policy of protecting all in vitro embryos after the pronuclei stage regardless of their chromosomal normality. Although not as stringent as the Catholic Church’s decree that life begins at conception, the directors at this clinic define an embryo as a minimum of forty-eight hours or two days of development postfertilization, at which point they consider the developing cells to be viable life requiring protection. According to this principle, a fertilized gamete of one day is a pre-embryo, a group of undif-

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ferentiated cells, and may be destroyed or manipulated as necessary for the particular procedure at hand. But the human-life potential of an embryo of two days or more will be protected. In not discarding or damaging an embryo, CREAR viewed itself as compliant with a liberal interpretation of a person’s legal right to life. As discussed earlier, the results from PGD are available after the five-day in vitro embryo has already differentiated into a blastocyst. CREAR’s embryo policy therefore created a problematic situation with respect to PGD: the obligatory protection of a potentially chromosomally abnormal embryo. In the event that PGD revealed the tested embryo as abnormal, the only morally acceptable option was to protect the life potential of this embryo by cryopreserving it. Discarding an embryo was prohibited by the clinic’s policy, and transferring it to the uterus would defeat the purpose of PGD.10 To resolve this technical dilemma, CREAR’s professionals initially agreed, as an institution, that the abnormal embryos would be cryopreserved and stored until gene therapy was feasible or a national law defined an embryo as not requiring protection (therefore overruling the clinic’s prohibition against discarding an embryo). One of the gynecologists at CREAR, Matías Serrano, whose personal position was to discard a chromosomally abnormal embryo post-PGD, explained that CREAR could not do that out of fear of negative public opinion: It’s a question of … we are afraid that the newspaper will publish that we are throwing away abnormal embryos, given the idiosyncrasy of this country. I would discard them, but the idiosyncrasy of this country and the religious question influences public opinion a lot. We can avoid this type of problem, of the sensational press in this way [by cryopreserving the embryos].

Although freezing these embryos was a form of deferral rather than a solution, it was easier for CREAR’s professionals to agree on this decision than any other option at the time. Cryopreservation of an abnormal embryo avoided negative press, but it was a short-term solution at best and one that cost the center approximately US$300 per patient.11 Marta Romero, one of the embryologists at CREAR and a practicing Catholic, recognized the limited value of cryopreservation as a solution, but unlike her colleagues, she did not agree with the disposal of an abnormal embryo: The issue is what to do with the abnormal embryos. Depending on what the disorder is, if it is a disorder that is going to take away quality of life. For example, Down syndrome, I wouldn’t throw away an

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embryo carrying Down. But they end up on the streets, poor things. Obviously if you ask me, do I prefer to have a healthy child or a child with Down, [I would say] a healthy child. But the disorders that involve a life or the quality of life as being terrible, or that they live a few years and then die, for those things, I wouldn’t transfer them. I wouldn’t transfer a Down syndrome embryo either, but I wouldn’t discard the embryo, I would cryopreserve it. And the act of cryopreservation, it is postponing the problem for the future.

Marta raises a whole host of issues here, one of them being the fact that the controversy of PGD is in part a controversy over “undesired” embryos that no one actually wants to transfer but everyone wants to protect (for different reasons). In fact, the very technique of PGD—opening a hole in the zona pellucida of the embryo to take out the chosen blastomere (the biopsy)—leaves the embryo vulnerable to the cryoprotectant used in cryopreservation. This direct contact between the exposed cell and the cryopreservation medium is very harmful and causes cell degeneration in the embryo, thus damaging the embryo’s viability. This is not a secret for those who advocate cryopreservation of the abnormal embryo. One of CREAR’s biologists, Julieta Moretti, assured me that “everyone who cryopreserves a biopsied embryo knows that the chance is very low that this embryo will be viable after thawing, because of the cryo-damage due to the removal of a piece of the zona pellucida.” Cryopreservation therefore may have been an easier moral solution for CREAR to adopt, but in technical terms the “protection” it affords the post-PGD embryo is not very great. The solution of cryopreservation can be seen as just one more means of postponing the inevitable choice that must be made in doing ARTs between embryo manipulation and the inviolability of human life. In August 2004, after one year of providing PGD to patients, CREAR’s directors approved a change in clinic policy on the moral status of an in vitro embryo. Partly in response to the impracticality of protecting abnormal embryos through cryopreservation, the directors agreed to a recommendation from CREAR’s bioethics committee. This committee, which provides the clinic nonbinding counsel from ethical, legal, and psychological perspectives, devoted several months of debate and inquiry to the status of the embryo, resulting in a written and published formal statute on the moral status of the embryo. According to this document, the beginning of human life is a process and cannot be pinpointed to a particular stage in development. Therefore, regardless of having two, three, or even five days of development, an in vitro embryo has the potential for human life

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but does not merit the full rights of an actual person. The committee’s assessment was that an in vitro embryo’s life potential should be respected but that a reason of serious moral consequence (una razón moral de peso) can override this protection. This conclusion is necessarily ambiguous in that it allows for a subjective decision regarding the treatment of the embryo to be made according to the particular situation at hand. In terms of PGD, this judgment can be interpreted to mean that a chromosomal abnormality is a reason with significant moral consequence, and therefore, discarding an abnormal embryo is morally acceptable. Although public backlash from the Catholic Church is still a possibility, with this bioethical ruling and in the continued absence of a law saying otherwise, the official policy at CREAR is now that discarding an abnormal embryo post-PGD testing is morally permissible. Yet this change in policy remains largely symbolic. As of October 2005, the clinic had had no opportunity to practically implement it. To some extent, this is due to the technical aspects of the procedure. Despite technical know-how, a center’s caseload of PGD depends partially on the morphological quality of the embryos to be tested. At times, PGD is not a possible technique for an indicated case—as when an embryo has very few cells or when the cells are fragmented and granulated, conditions that make embryo biopsy not feasible. From the initial week of training in 2003 (during which time six cases were performed by the Italian expert) until October 2005, only six additional patient cases of PGD had been performed. Only one of these cases came up after the bioethics committee’s recommendation. In that instance, the embryos had arrested in development before reaching the blastocyst stage, the point at which the decision to cryopreserve or transfer would have been made. In other words, by the time the results of the PGD had been available and a decision on whether to discard the abnormal embryos would have been taken, the embryos were no longer “viable” and no decision was required. In contrast to CREAR first adopting the technology and then resolving the moral dilemmas it poses, other centers in Argentina are resolutely against providing PGD until the status of the abnormal embryo is resolved legally on a national level. This is the case at a smaller clinic in the greater Buenos Aires area, where Pablo López, the codirector, said that he considers PGD to be a great advance of science, as it brings the technological ability to prevent the inheritance of genetic diseases. However, Dr. López is a practicing Catholic and considers embryos, even abnormal ones, to be human life, with the potential to become a person. Because PGD creates the poten-

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tial situation of an unwanted embryo, without a chance for transfer and development in the uterus, he will not advocate for a PGD program at his clinic. Following this logic, he is also against cryopreservation of embryos without the intent to transfer them and only offers this service for exceptional cases. Indeed, the option of cryopreserving embryos diagnosed with chromosomal abnormalities is not viewed as a solution by many in this community, but rather a postponement of dealing directly with the issue. Manuel Giordano, head of the embryology lab at one of the principal clinics in Buenos Aires, provided a common criticism to this deferred approach to PGD, although he is an avid supporter of the technique:

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We don’t even know what we’re going to do here [at this clinic], we still have to discuss it. They are going to cryopreserve them [embryos], probably they will be cryopreserved. But no one wants to transfer them, you know. And neither can they fix or cure them, not now, not now or in fifty years. Not even in one hundred. The truth is that I don’t see that happening. Besides, who is going to cure an embryo one hundred years from now, it seems ridiculous. So to cryopreserve them is synonymous with discarding them. It is like sweeping the dirt under the rug.

Projecting into the future, Dr. Giordano concludes that the frozen storage of these undesired embryos today is “synonymous with discarding them”—given the likelihood that even if gene therapy does exist in one hundred years, it would not be used to “cure” this population of highly defective embryos. Even so, at many of these centers, cryopreservation represents a more socially and morally acceptable option than outright disposal. Such dilemmas and “resolutions” highlight the intimacy between medicine and morality, revealing that the tensions of doing PGD are experienced here as a mutually exclusive choice between the sanctity of human life and scientific modernity. The delaying tactic of cryopreservation allows avoidance, if only temporary, of this conflict-charged “choice.”

Conclusion In this chapter, I argue that performing PGD in Argentina signifies much more than providing patients with access to the newest ARTs. The practice of PGD clearly exposes the problematic at the core of ARTs in general: the legal and moral status of the human in vitro

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embryo and, by extension, the definition and value of human life. As such, this is a local dilemma that reaches far beyond the borders of Latin America, and speaks to widespread concerns over “global human rights” and the “ethical uses” of biomedical technologies. In Argentina, PGD requires confronting and resolving the apparent contradictions between wanting to “do less” to the in vitro embryo and desiring to perform and provide the latest in ARTs, which invariably entail embryo manipulation. Providing PGD to the public, therefore, is not just an issue of adding another laboratory technique to the list of possible options for infertile couples, but is also an important stake in Argentine practitioners’ claims to modernity and scientific rationality. Reproductive medicine is a rapidly advancing field, and new techniques bring new knowledge. This chapter illustrates that with this “new knowledge” come contemporary applications of familiar deliberations over human life, science, morality, and modernity. Who stands at the gates of these critical moral junctures delineating human life and personhood is a matter of some consequence. Currently in Argentina the reproductive-medicine professionals who provide ARTs to the public are society’s moral guardians, deciding when human life begins and which protections are due human life. Rather than through a social process of discussion, these philosophical and ethical matters are being decided in private, behind the closed doors of medical-consultation rooms. To date, the Catholic Church in Argentina has not stirred up extensive controversy over PGD, and the legislature continues to dawdle over proposed legislation to regulate ARTs. The absence of a national law regulating ARTs in Argentina therefore places the reproductive-medicine practitioner in a powerful moral position. This is experienced as both a burden and an opportunity for these professionals working in reproductive medicine. Although clinical and laboratory ART practices are not “protected” under a law, neither are they prohibited. Thus, professionals can decide for themselves what falls under the rubric of “ethical” and acceptable procedures, often on a case-by-case basis. As the issue of PGD evocatively illustrates, such decisions are dynamic and based on many factors, including desires to be “modern,” fears of inciting the wrath of the Catholic Church, competitive market concerns, and anxieties about missing out on the progress of science. The issues at the heart of the PGD paradigm in Argentina are not limited to that part of the globe and indeed share much in common with current controversies over stem cell research and abortion around the world. At the center of inquiry in these “embryo

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debates” is “the ontological and moral status of the embryo and the uses to which it may be put” (Halliday 2004: 40). Such questions over when human life begins and its inviolability raise the specter of global “human rights.” If human life is conflated with personhood, the human rights of in vitro embryos will merit protection, regardless of whether the practice in question is PGD, abortion, or stem cell research. However, just as Lock compellingly argues that the end of life is a threshold that “will not be pinned down once and for all” so too is the beginning of life (2002: 377). With respect to ARTs, any limit placed on when life begins will be an intrinsically social designation determined through the local conditions of medical technology practice. The application of PGD also highlights concerns over genetic discrimination and the medicalization of difference. PGD, like other technologies that identify genetic risk, scans for potential “defects” in the embryo. What is a “normal” embryo and, consequently, what is a “normal life worth living” is being decided by a group of authoritative experts creating PGD protocols and performing the technique. However, definitions of “normal” vary and are slippery at best. This ambiguity is exemplified with the much-discussed hypothetical case of a deaf couple desiring PGD in order to select an embryo carrying the genes for deafness, a situation opposed by many in the international reproductive-medicine community. Indeed, many medical professionals disagree with using PGD to select for (rather than against) an affected embryo, and the European Society for Human Reproduction Task Force on Ethics and Law disallows it (Edwards 2004; Shenfield 2003). In Argentina, the potential discriminatory tones of using the technique are not part of the current discussion, nor are they yet on the table as a matter for future concern. Instead, the current overriding concern for Argentine reproductive-medicine professionals is the moral ambiguity of the embryo. Though not the focus of this chapter, the potential global use of genetic technologies as “preventative” methods—employed to lessen the weight of a “global burden of disease” that chronic illnesses and conditions place on nations around the world—is a prospect requiring further examination. Like other medical technologies, PGD is embedded in social relations activated and transformed in the practice of the technology and as such involves myriad competing desires, choices, and requisites. The variability in resolving this problematic of PGD in Argentina is a revealing example of how cultural matters, such as the “right to life” of an embryo, are both governing and negotiated through medical technologies.

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Acknowledgments This chapter is based on dissertation work generously supported by the National Science Foundation, the Social Science Research Council, the UNC–Chapel Hill Graduate School, and the Wenner Gren Foundation. My deepest gratitude goes to those in Latin America who allowed me access to their clinics, laboratories, and views. I also thank Natalia Adamo for her research assistance. I am indebted to Sara Ackerman, Sue Estroff, Judith Farquhar, William Lachicotte, Miguel Sciancalepore, and Sabrina De Vincentiis for their thoughtful comments on an earlier draft.

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Notes 1. Following anthropological convention, all personal and clinic names are pseudonyms. The majority of the specialists I interviewed consented to the use of their names, but a few did not. As a result, I have fictionalized all names in order to avoid the identification of those who wish to remain anonymous. All interviews were translated from Spanish by the author. 2. The European Society for Human Reproduction (ESHRE) reports even higher numbers of PGD procedures around the world than the PGD International Society. According to its most recent report, sixty-six centers are registered with the ESHRE consortium, with forty-five centers reporting data for 2002–2003 (Harper et al. 2006). The only Latin American center to report procedures to ESHRE in this report is from Argentina. 3. There are two main techniques for chromosomal analysis: FISH (fluorescent in situ hybridization) and PCR (polymerase chain reaction). As only one clinic in Argentina uses PCR and the rest use FISH, I discuss only FISH in this chapter. A different (and more expensive) set of equipment is needed to do PCR. 4. An alternative to doing PGD on an embryo is to biopsy the polar body of the fertilized egg on the day of fertilization (this is done in Chile, where embryo manipulation is prohibited). However, because just the chromosomes from the egg are analyzed, this technique only reveals information from the female side. 5. In Argentina, only seven chromosomes are tested. However, some centers in the world test two additional chromosomes, numbers 15 and 17 (using FISH twice), bringing the total to nine chromosomes tested. 6. As of 2008, there are no published data on exactly how many PGD procedures are being performed in Argentina, most likely due to the rapidity with which it has been taken up by the infertility clinics. The

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8. 9.

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10.

11.

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most recently published Latin American registry (Registro Latinoamericano) on ARTs, with data from 2003, makes no mention of PGD practices in Latin America. Numbers on PGD given here are thus based on personal communication and observation by the author. Data provided on ART procedures in general in Argentina are also approximations, as there is no published source for these figures to date (an Argentine national registry was released to the public in March 2007 but only provides data on eleven self-reporting centers in the country). For comparative purposes, the Latin American registry published by RED (and therefore only including RED member clinics) reports that the total number of initiated ART cycles for Argentina was 4,126 in 2003, thereby making up 19.6 percent of all ARTs practiced throughout Latin America. Argentina is the second-highest producer of ARTs in Latin America after Brazil, which contributes 47 percent of all cycles (see http://www.redlara.com/esp/reg_2003.asp). In referring to the “international community,” I do not mean to present a monolithic version of this community but rather refer to a group of reproductive-medicine professionals from around the world who meet regularly at congresses such as the European Society for Human Reproduction (ESHRE) to share expertise and create guidelines for practice (ESHRE Task Force on Ethics and Law and ESHRE PGD Consortium). http://www.oas.org/juridico/english/Treaties/b-32.htm As far as I can tell, this legal uncertainty has not resulted in the prosecution of any cases of negligence related to ARTs in Argentina. As with other clinic protocols, patients were not involved in the decision-making process of what to do with abnormal embryos. Before undertaking any ART procedure, patients must sign consent forms agreeing to the clinic’s policy on embryos and cryopreservation. Although relevant, the patient perspective on the dilemma of PGD in Argentina is beyond the scope of this chapter. During the time that CREAR mandated the cryopreservation of abnormal embryos post-PGD, the center did not charge patients for cryopreservation post-PGD. Patients otherwise pay US$500 to cryopreserve viable embryos and a yearly maintenance fee of US$100 to keep them in frozen storage.

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Bharadwaj, Aditya. 2002. “Conception Politics: Medical Egos, Media Spotlights, and the Contest Over Test-Tube Firsts in India.” In Infertility Around the Globe: New Thinking on Childlessness, Gender, and Reproductive Technologies, ed. Marcia Inhorn and Frank van Balen. Berkeley: University of California Press. de Wert, Guido. 2005. “Preimplantation Genetic Diagnosis: The Ethics of Intermediate Cases.” Human Reproduction 20, no. 12: 3261–266. Edwards, Robert G. 2002. “Ethics of Preimplantation Diagnosis: Recordings from the Fourth International Symposium on Preimplantation Genetics.” Reproductive BioMedicine Online 6, no. 2: 170–80. ———. 2004. “Ethics of PGD: Thoughts on the Consequences of Typing HLA in Embryos.” Reproductive BioMedicine Online 9, no. 2: 222–24. Ehrich, Kathryn, Clare Williams, Rosamund Scott, Jane Sandall, and Bobbie Farsides. 2006. “Social Welfare, Genetic Welfare? Boundary-work in the IVF/PGD Clinic.” Social Science and Medicine 63: 1213–24. Fernández, Dario, Sabrina De Vincentiis, Claudio Chillik, and Santiago BrugoOlmedo. 2004. “Patients’ Opinions Regarding Preimplantation Genetic Diagnosis in a Latin American Fertility Clinic.” Fertility and Sterility 81, no. 2: 463–64. Finkler, Kaja, Cécile Skrzynia, and James P. Evans. 2003. “The New Genetics and its Consequences for Family, Kinship, Medicine and Medical Genetics.” Social Science and Medicine 57, no. 3: 403–12. Franklin, Sarah. 1997. Embodied Progress: A Cultural Account of Assisted Conception. New York: Routledge. ———. 2003. “Re-thinking Nature-Culture: Anthropology and the New Genetics.” Anthropological Theory 3, no. 1: 65–85. Franklin, Sarah, and Margaret Lock. 2003. Remaking Life and Death: Toward an Anthropology of the Biosciences. Santa Fe, NM: School of American Research Press. Franklin, Sarah, and Helena Ragoné, eds. 1998. Reproducing Reproduction: Kinship, Power and Technological Innovation. Philadelphia: University of Pennsylvania Press. Franklin, Sarah, and Celia Roberts. 2001. “Innovative Health Technologies: The Social Life of the Embryo.” Published by the Department of Sociology, Lancaster University, Lancaster, UK. http://www.comp.lancs.ac.uk/ sociology/papers/Franklin-Roberts-Social-Life-of-Embryo.pdf. ———. 2006. Born and Made: An Ethnography of Preimplantation Genetic Diagnosis. Princeton, NJ: Princeton University Press. Ginsburg, Faye, and Rayna Rapp, eds. 1995. Conceiving the New World Order. Berkeley: University of California Press. Halliday, Samantha. 2004. “A Comparative Approach to the Regulation of Human Embryonic Stem Cell Research in Europe.” Medical Law Review 12 (Spring): 40–69. Handwerker, Lisa. 2002. “The Politics of Making Modern Babies in China: Reproductive Technologies and the ‘New’ Eugenics.” In Infertility Around

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the Globe: New Thinking on Childlessness, Gender, and Reproductive Technologies, ed. Marcia Inhorn and Frank van Balen. Berkeley: University of California Press. Harper, J. C., K. Boelaert, J. Geraedts, G. Harton, W. G. Kearns, C. Moutou, N. Muntjewerff, S. Repping, S. SenGupta, P. N. Scriven, J. Traeger-Synodinos, K. Vesela, L. Wilton, and K. D. Sermon. 2006. “ESHRE PGD Consortium Data Collection V: Cycles from January to December 2002 with Pregnancy Follow-up to October 2003.” Human Reproduction 21, no. 1: 3–21. Heath, Deborah, Rayna Rapp, and Karen-Sue Taussig. 2004. “Genetic Citizenship.” In A Companion to the Anthropology of Politics, ed. David Nugent and Joan Vincent. Oxford: Blackwell Publishing. Hudson, Kathy L. 2006. “Preimplantation Genetic Diagnosis: Public Policy and Public Attitudes.” Fertility and Sterility 85, no. 6: 1638–45. Inhorn, Marcia. 2003. Local Babies, Global Science: Gender, Religion, and In Vitro Fertilization in Egypt. New York: Routledge. Inhorn, Marcia, and Frank van Balen, eds. 2002. Infertility Around the Globe: New Thinking on Childlessness, Gender and Reproductive Technologies. Berkeley: University of California Press. Kahn, Susan M. 2000. Reproducing Jews: A Cultural Account of Assisted Conception in Israel. Durham, NC: Duke University Press. Klipstein, Sigal. 2005. “Preimplantation Genetic Diagnosis: Technological Promise and Ethical Perils.” Fertility and Sterility 83, no. 5: 1347–53. Krones, Tanja, Elmar Schluter, Elke Neuwohner, Susan El Ansari, Thomas Wissner, and Gerd Richter. 2006. “What is the Preimplantation Embryo?” Social Science and Medicine 63: 1–20. Latour, Bruno. 1993. We Have Never Been Modern. Cambridge, MA: Harvard University Press. Lock, Margaret. 2002. Twice Dead: Organ Transplants and the Reinvention of Death. Berkeley: University of California Press. Malpani, A., and A. Malpani. 2002. “Preimplantation Genetic Diagnosis for Gender Selection for Family Balancing: A View from India.” Reproductive BioMedicine Online 4, no. 1: 7–8. Morgan, Lynn, and Meredith Michaels, eds. 1999. Fetal Subjects, Feminist Positions. Philadelphia: University of Pennsylvania Press. Munné, Santiago, and Jacques Cohen. 2004. “The Status of Preimplantation Genetic Diagnosis in Japan: A Criticism.” Reproductive BioMedicine Online 9, no. 3: 258–59. Novas, Carlos, and Nikolas Rose. 2000. “Genetic Risk and the Birth of the Somatic Individual.” Economy and Society 29, no. 4: 485–513. Parens, Erik, and Adrienne Asch, eds. 2000. Prenatal Testing and Disability Rights. Washington, DC: Georgetown University Press. Parry, Sarah. 2006. “(Re)constructing Embryos in Stem Cell Research: Exploring the Meaning of Embryos for People Involved in Fertility Treatments.” Social Science and Medicine 62: 2349–59.

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Rapp, Rayna. 1999. Testing Women, Testing the Fetus: The Social Impact of Amniocentesis in America. New York: Routledge. Raspberry, Kelly. 2007. “Conflicted Conceptions: An Ethnography of Assisted Reproduction Practices in Argentina.” Phd dissertation, University of North Carolina, Chapel Hill. Roberts, Elizabeth F.S. 2006. “God’s Laboratory: Religious Rationalities and Modernity in Ecuadorian In Vitro Fertilization.” Culture, Medicine and Psychiatry 30, no. 4: 507–36. Rose, Nikolas. 2001. “The Politics of Life Itself.” Theory, Culture and Society 18, no. 6: 1–30. Shenfield, F., G. Pennings, P. Devroey, C. Sureau, B. Tarlatzis, and J. Cohen. 2003. “Taskforce 5: Preimplantation Genetic Diagnosis.” Human Reproduction 18, no. 3: 649–51. Strathern, Marilyn. 1992. Reproducing the Future: Anthropology, Kinship and the New Reproductive Technologies. New York: Routledge. Thompson, Charis. 2001. “Strategic Naturalizing: Kinship in an Infertility Clinic.” In Relative Values: Reconfiguring Kinship Studies, ed. Sarah Franklin and Susan McKinnon. Durham, NC: Duke University Press. ———. 2005. Making Parents: The Ontological Choreography of Reproductive Technologies. Cambridge, MA: MIT Press. Thornhill, A. R., C. E. deDie-Smulders, J. P. Geraedts, J. C. Harper, G. L. Harton, S. A. Lavery, C. Moutou, M. D. Robinson, A. G. Schmultzler, P. N. Scriven, K. D. Sermon, and L. Wilton. 2005. “ESHRE PGD Consortium ‘Best Practice Guidelines for Clinical Implantation Genetic Diagnosis (PGD) and Preimplantation Genetic Screening (PGS).’” Human Reproduction 20, no. 1: 35–48. Verlinsky, Yury, Jacques Cohen, Santiago Munné, Luca Gianaroli, Joe Leigh Simpson, Anna Pia Ferraretti, and Anver Kuliev. 2004a. “Over a Decade of Experience with Preimplantation Genetic Diagnosis: A Multicenter Report.” Fertility and Sterility 82, no. 2: 292–94. Verlinsky, Yury, Svetlana Rechitsky, Tatyana Sharapova, Randy Morris, Mohammed Tranissi, and Anver Kuliev. 2004b. “Preimplantation HLA Testing.” Journal of the American Medical Association 291, no. 17: 2079–85.

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Chapter 9

ASSISTED LIFE THE NEOLIBERAL MORAL ECONOMY OF EMBRYONIC STEM CELLS IN INDIA Aditya Bharadwaj

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I

ndia has recently emerged as one of the important global players engaged in imagining and colonizing market-driven “futures” suffused with (bio)technological interventions (Bharadwaj 2006c). These interventions, it is often argued, will complicate our understanding of human physiology in unprecedented ways, leading to an eventual recrafting of human biology and ontology (see Fukuyama 2003). The evidence for such “promissory” biotech futures (Thompson 2005; Franklin 2003b) is most actively sought and graphically literalized in the burgeoning field of stem cell research. In India, as elsewhere, this has principally entailed engaging with biogenetic entities—which range from fetal tissue, umbilical-cord blood cells, bone marrow, and human embryos—as a tangible starting point for the production of such knowledge. Of these, the most contentious, contested, but equally promising sites for the production of such futures are human embryonic entities. Although the use of embryonic entities is embroiled in protracted ethical, legal, social, and religious debates in much of the Euro-American landscape—where the conceptualization of human embryos as sentient beings has mobilized and polarized public opinion for and against such research—in India the use of embryonic and fetal tissue in the service of generating biotech

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products and profit is viewed less critically. This has resulted in the proliferation of embryonic stem cell research and has led many to argue how an apolitical context gives India the edge in global research and development of stem cell entities (Lazaro 2002). The rise in embryonic stem cell research in India has therefore posed hitherto unexamined questions about the globalization of biotechnology and the transnational flow of biogenetic knowledge, expertise, and entities between established and emergent neoliberal formations. This chapter explores how global (stem cell) biotech futures are intimately linked to the current local availability and supply of human embryonic entities. It argues how global and local disparities are creating conditions in which the bodies of those most intimately connected to the supply of embryonic materials—women undergoing treatment at in vitro fertilization (IVF) clinics in India— are being targeted by emerging market-driven calculations of the Indian state. In examining the political economy of embryonic stem cell research in India, two parallel yet ironically cross-cutting themes frame my ethnographic question: How is the “assisted” (created) and “desisted” (destroyed) embryonic form mobilized to assist “life” in an emerging neoglobal order?

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Ethnography This chapter is immersed in ethnographic research examining cultural complexities inherent in the production of embryonic stem cells in India. The research examines and problematizes the supply chain of human embryos from their conception in IVF laboratories to their eventual ongoing manipulation in public and private research facilities. This chapter draws on forty semistructured, open-ended interviews with patients undergoing treatment at two New Delhi infertility clinics. One clinic is located in a south Delhi private hospital, catering to a middle- and upper-middle-class urban clientele. The other clinic, which is publicly funded, is located in New Delhi’s Army Research and Referral Hospital, and the bulk of its patients are soldiers (and their partners) of the Indian army, with rural, working-class backgrounds. For the first time since I began studying the proliferation of IVF in India ten years ago, the technologies of procreation have become available to the public sector. This class disparity gives a rare comparative advantage, as assisted reproductive technologies (ARTs) in India are predominantly an urban and middle-class phenomenon. The narratives of those seeking treatments were analyzed for views

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on giving and receiving gamete donation as well as donating “spare embryos” to research. Clinicians and scientists were asked about the nature of their everyday practices, the ethics of procuring human embryos for research, and the nature and value of informed consent. This research also relied on extensive archival searches, printand news-media analysis, and a systematic review of both existing and proposed Department of Biotechnology and Indian Council of Medical Research guidelines and ethical codes of practice.

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The Neoliberal Embryonic Moral Economy Aihwa Ong conceptualized neoliberalism as a new relationship between government and knowledge through which governing activities are recast as nonpolitical and nonideological problems needing technical solutions (2006: 3). She argues that in the neoliberal model, market-driven considerations infiltrate the domain of politics and governance, and reconfigure the relationship between governing and the governed, power and knowledge, and sovereignty and territoriality. Conceptualizing “neoliberalism as exception” (3), she suggests that the state of exception can be seen as an extraordinary departure from policy that can be deployed to include as well as exclude subjects and citizens. According to Ong, “the politics of exception in an era of globalization has disquieting ethicopolitical implications for those who are included as well as those who are excluded in shifting technologies of governing and of demarcation” (5). Thus, the neoliberal market-led logic of exception impacts lives, rights, and ethics in a globalized world in an ever-accelerating manner. This creates terrains of moral and ethical uncertainty that must be (re)articulated, explained, and contained through further economic calculation, technological application, and a generalized sentiment of purportedly value-free governance and ethicolegal interventions. The social and political predicament of subject-citizens under the neoliberal state of exception, on the other hand, is best appreciated in the words of Paul Farmer, who contends that under the neoliberal doctrine, “individuals in a society are viewed, if viewed at all, as autonomous, rational producers and consumers whose decisions are motivated primarily by economic or material concerns. But this ideology has little to say about the social and economic inequalities that distort real economies” (2003: 5). The economic and scientific rationale underpinning the contemporary neoliberal formations compels an assessment of the moral and ethical corollaries of production

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and consumption practices, the relations and forces of productions that sustain these activities, and the attendant problem of governing and regulating the markets in a rapidly globalizing and “dis-locating” world (Bharadwaj 2006a). The question of ethics and morality under neoliberalism becomes particularly vexed when the biopolitics, or “regulatory controls exerted on populations and individuals in order to harness and extract life forces” (Ong 2006: 13) is considered. It is not surprising, therefore, that developments in the field of biotechnology, where a discernable “shift from kind to brand” is very much in evidence (Franklin 2003a), are seeking to underscore such a shift with market-led imperatives for “ethical production and consumption.” Dealing with the emergent dimension of innovation and market strategy in the business of stem cell manufacture, Sarah Franklin (2003b) describes the ways concerns about public opinion are literally being built into new life forms. In so doing, Franklin invites us to think “what it means for social viability to become part of producing biological viability” (2003b: 99). She points to the cloning of Dolly the sheep and the public reactions to this breakthrough along “the twin poles of public reaction to biotechnology: pride in its achievement and hope for its success alongside fear of its potential dangers and anxiety about its unknown risks” (2003b: 99–102). The unprecedented ethical quagmire created by emerging life forms under the neoliberal formation also creates states of exception where capital, profit, accumulation, production, consumption, and circulation by (marketdictated) necessity become aligned to local/global ethical and moral registers. The search for ethical and moral standards are in turn inextricably linked to the creation of standardized research, assembly and production protocols, routinized manufacturing practices, the purchase and procurement of raw materials, and the expertise contained in standardized supply chains around the globe. This seemingly unified, homogeneous, and monochromatic disciplined process in fact exists in the moral, ethical, and institutional state of exception. Although research practices, manufacturing processes, labor markets to quality controls, and moral, ethical, and governance protocols are mobilized to create a standardized entity (e.g., an embryonic stem cell line or a pair of shoes), political formations and businesses are seldom able to achieve the “ethical end products” without invoking states of exception and dispensation. This neoliberal condition can be described as a moral economy. That is, what kinds of regimes of exploitation, tropes, and technologies of obfuscation and processes of unproblematic, guilt-free consumption are facilitated if one literal-

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izes the “moral” in the economic calculation of new invention, experimentation, and globalization? The notion of moral economy emerges from E. P. Thompson’s 1971 seminal essay, “The Moral Economy of the English Crowd in the Eighteenth Century.” Thompson’s conception of moral economy is confined to confrontations in the marketplace over access to necessities, essential food, profiteering, and emotions surrounding the marketing of food in time of dearth (see Edelman 2005). The concept is further refined and elaborated upon by James Scott, who theorizes peasant movements in Southeast Asia along somewhat similar lines and provides rare insights into the everyday resistance practices of the weak (Scott 1976, 1985). Subsequent excursions into the theory have variously expanded on these original concerns, most notably developing an “experiential theory of exploitation” (Edelman 2005) that argues how “under the prevailing neoliberal dispensation, the nation-state has been largely superseded as the locus of market-rule-making by the WTO, the IMF, and the World Bank” (Edelman 2005: 337–41; Scott 2005: 397). This latter view, however, overlooks the various states of exceptions that nation-states are able to resurrect in order to not only resist, but to also meld with the governing sensibilities of like-minded nation-states to better suit their purposes and to remain economically competitive vis-à-vis other global neoliberal formations. Therefore, in order to better understand the neoliberal state of exception, the notion of moral economy can be gainfully conceptualized as an economic activity hedged in with moralistic reasoning/conditioning. That is, making moral the economic terrain of any kind is to facilitate exchange, surplus, and accumulation seemingly untainted and guilt free. To argue for the emerging moral economy of embryonic stem cells is to refer to the very processes of making “kosher” the creation, isolation, extraction, and exploitation of human embryos to generate and circulate economically viable and globally dispersed biogenetic stem lines. The fashioning of a global “moral consensus” therefore enables a contested and ethically tainted entity in many cultural contexts (most notably, the contested nature of the human embryonic form in the United States and some European countries) to bring forth stem lines profitably. For the moral economy to flourish, the state of exception must either remain systematically misrecognized or become a feature of the autonomous, rational, informed, and freethinking ideological calculus of neoliberal citizenship. A moral economy of this kind facilitates not only guilt-free consumption, but also renders politically viable a dimension of human (bio)commerce

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that has so far remained located at the intersections of diverse religious, moral, and ethical interpretations, objections, and contestations.

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Outsourcing the “Moral” and other “Standards” On 9 August 2001, U.S. president George W. Bush allowed federal funding for embryonic stem cell research on those cells already in existence.1 Around the world, only sixty-four lines could meet this criterion. Of these, ten were in India: three were held at the stateowned National Centre for Biological Sciences, in Bangalore, and seven were under development at a private research laboratory, Reliance Life Sciences, in Mumbai. In early August 2001, the U.S. National Institutes of Health announced that Reliance Life Sciences and the National Centre for Biological Sciences would be among ten of the institutions worldwide receiving federal funding for stem cell research. Both centers met the U.S. administration’s criteria for derivation of human embryonic stem cell lines. This case stands as a watershed in the global politics of generating embryonic stem lines. A globally dispersed network of research centers extracting cells from human embryos and located in diverse political formations can, in theory, be federally funded by the United States. This unprecedented move linked the contemporary biopolitics in the United States and its moral and cultural reasoning to strategic economic and political calculations. Equally, the morally contentious issue of human embryonic form and its sentient potentiality could, for the first time, be “outsourced” to global locales where embryos could be purged of their cellular cargo to yield potentially therapeutic and research-worthy stem lines. In one deft move, President Bush marked those embryos that had been “destroyed” prior to his August 9 decree as profane from their sacred counterparts freezing in a moral liminality of IVF laboratories. These surplus and “orphaned” embryos could, however, be thawed for “adoption” by the Nightlight Christian Adoption-sponsored Snowflakes Program (Ganchoff 2004: 765–66), to (re)establish the “as-if” (begotten, genealogical) principle of American adoptive kinship (Modell 1994). This kinship with a “biogenetic form” is not merely nationalistic (because American embryos must not be “killed”), but is also the religious, moral, and sacred duty of the citizens enjoined by the state. In other words, the state of exception invoked by the sovereign, following Giorgio Agamben, is one that sets apart the citizen (American embryos) and the noncitizen “other,” the homo sacer who “may be killed but not sacrificed” (1998). The sacred body of

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the citizen may be sacrificed on the behest of the sovereign and the nation, but the “bare life” of the homo sacer is deemed “before law,” that is, outside the purview of divine as well as human law (see Agamben 1998; Das and Poole 2004). Positioning certain embryos as before the law and hence “killable,” as opposed to embryos becoming viable citizens under the moral and “divine” law invoked by the state (in August 2001), allows the moral economy of embryonic stem cells to become truly global. A new benchmark is set—that is, American embryos cannot be killed, but in extreme and rare cases may be sacrificed (as in the case of medical termination of pregnancy). However, what this does allow is a conceptual possibility of positing a moral distinction between the “sacrificial” and the “killable.” What this also facilitates is a creative use of the double-edged character of exception in the neoglobal order that, according to Ong (2006), hinges on the creative possibility of mobilizing neoliberalism as exception and exception to neoliberalism, promoting interplay among technologies of governing and of disciplining, of inclusion and exclusion, and of bestowing or denying value to human conduct (and in the case of embryonic stem cells the very idea of what it is to be human and “inhuman”). Parallel to these developments in the United States, different moves were afoot in the United Kingdom. Taken together, these developments in the United Kingdom and United States provide an insight into the Indian response to these global developments and its place in the burgeoning moral economy of embryonic stem cells. In 2003, the United Kingdom instituted the world’s first stem cell bank. Only those stem lines adhering to the bank’s stringent ethical guidelines and provenance protocols validating the human embryonic materials are admissible for donation. This development has posed hitherto unexplored questions concerning how the standardization of ethical and regulatory practices might look in a culturally diverse world. The U.K. stem cell bank is to be a repository for adult, fetal, and embryonic stem cells. Most importantly, the provenance of any donation to the bank, especially the embryonic stem lines, will need to be clearly identified. This means the provenance of embryonic stem lines would extend to include issues of appropriate informed consent, traceability of donors or for that matter their anonymity, clear and unambiguous intellectual property rights, and most importantly, to ensure that the embryos are not created specifically for the purposes of research unless sufficient evidence suggests that spare IVF embryos cannot be used for research (see Glasner 2005). For stem lines to be admitted to the bank and available for future

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research and commercial use, certain standardized benchmarks and quality-assurance processes and protocols must be met, which have coalesced into the Good Manufacturing Process standards (GMPs). To remain a global player in this moral economy, India needs to respond to the moral concerns of its research partners and potential consumers of its research end products. To ensure this, India has begun putting systems in place to meet the GMPs (Financial Express 2005), as well as ethical protocols that require informed-consent embryo donations as a basic admissible standard. In a November 2005 press conference, India’s union science and technology minister described how the Indian government not only sought to strengthen stem cell research in the country by extending accreditation to companies to do research, but also required these companies to follow the GMPs per international guidelines so that their products could be marketed globally (Financial Express 2005). In addition, the Indian state needs to create a viable body of citizens and their cell-yielding embryos, which can be “sacrificed” to fuel India’s participation in the market-driven global moral economy. The generation of informed, autonomous, and rational citizens therefore becomes a priority in this purportedly zero-sum game. Against this backdrop of global developments, the Indian Council of Medical Research drafted guidelines (2005) for stem cell research and regulation, making it mandatory that embryos cannot be produced for the sole purpose of obtaining stem cells, an explicit requirement of the U.K. stem cell bank. Should these guidelines become law, only spare IVF embryos will be considered a legal source of stem cells. The proposal is even stricter than current policy in the United Kingdom, where embryos can, under exceptional circumstances, be legally created and used for the express purpose of research and stem cell extraction. This move appears even more surprising if one considers Indian cultural conceptions about life. The conception of embryonic life is somewhat different from the Euro-American context: in India, there is no consensus on the moral status of the human embryo. Different philosophical, religious, and ideological persuasions define and debate life in an eclectic and open-ended way (Bharadwaj 2005a). This ethical discourse is applied in a less critical manner by the Indian state. The “Indian embryos,” like French DNA, seem partially locatable at the “heterogeneous zone where genomics, bioethics, patients’ groups, venture capital, nations, and the state meet” (Rabinow 1999: 4). However, for biotech India, the U.S. presidential decree of 2001 was probably the first time the local/global moral and business sensibilities met and mutated into a third way of conceptualizing pre-

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viously mundane biogenetic entities. The Bush administration’s decision was truly iconic in one significant respect. By outsourcing morally and ethically contentious embryonic research to India, the administration unwittingly “Bangalored” life itself.2 At about this time, the biotechnology of stem cells was first described as the “next big thing to hit India after the country’s software revolution” (Thorold 2001). India was now seen as “filling the void in stem cell research” (Washington Post 2001). The Indian state, though slow in its response to the emerging biotechnology, by way of enacting legislation/ethical protocols, nevertheless identified stem cell research as a potential future growth area. The Indian state and its future biotech investments are located in this moral geography where the local and the global ethical sensibilities have become curiously “joined up.” In other words, the need to situate the embryonic stem cell science in India within the purview of legal and ethical scrutiny must also be situated in the concern for managing the increasingly collapsing domains of local and global publics. Although the biosociality of Indian publics has yet to attain its full potential (Bharadwaj 2007), the preemptive move is influenced in large part by the Euro-American ethical and governance protocols, which the Indian state appears to have embraced despite its apolitical stance toward embryo research. It is easy to conceive this show of solidarity as yet another instance of the global shaping the local, but the concerns driving these moves in locales like India appear to be more pragmatic. In India, ensuring the provenance and strictest ethical scrutiny of embryonic entities does not appear to be a local cultural response to the question of “life” but, rather, a strategic investment in future global markets, potential scientific collaborators, and probable international lay consumers of embryonic entities and their ethical/moral thresholds.

Life in Pursuit of Assisted Life Moves to monitor and regulate the steady growth of IVF clinics as well as egg and sperm donation in the private sector has created a “furor” in the medical community in India (Express Healthcare Management 2000). The bone of contention lies within the proposed Indian Council for Medical Research guidelines (2005), which prohibit intrafamilial gamete donation. The medical community has reportedly taken strong exception to the ban on sperm donated by a relative or known friend of the “wife” or “husband,” fearing this would trigger paid donation and trade in semen. The consequences

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of such moves may impact family-forming strategies employed within the confines of clinical spaces, where tactical alliances are forged between select family members, infertile couples, and their clinicians to keep donor eggs secret and as close to the “agnatic blood” as possible (Bharadwaj 2003). The question arises as to why the Indian state is inserting the market and contractual commercial transactions in place of a “domestic moral economy” of exchange and kin relations. These transactions are not mere examples of intrafamilial sharing, gift giving, and altruistic exchange, but rather are a context-sensitive and contingent way of making sense of reproductive disruption and family-forming strategies. In many instances, intrafamilial arrangements are “modern” ways of following “tradition” (see Bharadwaj 2006b), that is, negotiating with patriarchal, gendered, and religious injunctions while conforming to the “pro-natalist imperative” (Bharadwaj 2005b). For example, the ancient practice of levirate is still reenacted in IVF clinics, where the sperm of a male agnatic kin is used to induce conception (Bharadwaj 2005b). In the majority of those seeking IVF, the practice of adoption is similarly confined to the wider familial unit for several deeply held cultural reasons (Bharadwaj 2003). However, the neoliberal state in India is seeking to outlaw these practices for reasons far more complex than mere social reform and protecting women from the excessive demands made by the patriarchal ideological order. On the contrary, the new laws have the potential to create a body of medicalized, childless citizens that can be both harnessed and garnered for extracting embryos/gametes to fuel the burgeoning global moral economy in stem cell creation. By putting strict informed-consent procedures in place, instituting a national ethics committee, and ensuring the provenance of any potential stem cell lines accruing from human embryos, the Indian state seeks to isolate “ethical” sources for procuring “raw materials.” These ethical sources are imagined as fully informed, rational, and autonomous consumers seemingly liberated by the market from the fetters of outmoded and traditional reliance on familial support for “assisting life.” These autonomous citizens can now be enjoined to “sacrifice” their biogenetic “spare embryos” with an encrypted provenance in the service of a booming “neoIndia” (Bharadwaj 2006a). The resulting stem lines from “sacrificed”—as opposed to “killed”— embryos forge a global moral alliance, as do acts of self-sacrifice by an informed, autonomous donor. The future of embryonic procurement, stem cell production, and global consumption seems somewhat assured. What kind of citizen is being resurrected? Interviews

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and prolonged interactions with those seeking treatment at New Delhi’s Army Research and Referral Hospital and a private clinic in south Delhi shed light on some possible answers. These interactions provide insight to the subjective location of individuals and couples in search of ARTs and how they might respond when doubly implicated in the project of “assisting life.” Rohit and Jyoti hail from a rural area in the north Indian state of Uttar Pradesh.3 A bright young man of twenty-eight, at the time of our meeting Rohit was a “mere foot solider,” as he put it, in the Indian army. Although he was posted in the western state of Gujarat, he was visiting the Army Research and Referral Hospital on an expedited sick leave for an urgent IVF procedure. Through the course of everyday interaction and one tape-recorded interview, his young wife remained silent, and despite repeated questions, she would only smile and veil her head. With sound cultural reasoning (not to mention strict patriarchal upbringing), she would not speak to a strange man and, most importantly, would not speak in the presence of her husband. The couple had undergone three unsuccessful intrauterine inseminations and were awaiting an embryo transfer. “It could be my shortcoming,” Rohit said. “It is also vidhi [destiny], up to God. … It is something technical [referring to the IVF], so you can’t predict.” When asked how infertility had impacted their daily lives, Rohit became philosophical (as he often did). “Don’t make any weakness so great that it destroys you. … Maybe it’s God, maybe it’s karma from another life. … Clearly society, villagers don’t think. … They will say, ‘Get married again—keep her and bring a new wife as well!’” Jyoti’s glass bangles clinked as she readjusted her veil. It was almost a reflex action for Jyoti, or perhaps she took cover, seeking shelter and refuge under her veil every time she felt threatened; it appeared to be her only safety net in a life riddled with stigma and social ostracism. “In the end, the decision is ours. Mother, father, it is sad, but they can only put pressure on you, it’s small thinking, everyone says, ‘If you have no children what is this life? You are working for what?’ They think like that, and who knows, maybe their thinking is tainted with malice and malicious intent.” Rohit was steadfast in his support for his wife and warded off tremendous social and familial pressure, but countless months of serving on a nonfamily station in faraway Gujarat left Jyoti to bear alone the full brunt of social opposition. Their predicament left one question unanswered: how might this couple or many others like them become “fit” contenders or turned into consenting individuals who willingly part with their embryos

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for stem cell research? Rohit was extraordinary in that he displayed a free and autonomous attitude in standing up to societal pressure to remarry. However, when asked about the issue of stem cell research and some of the moral debates surrounding the potentiality of embryonic form, the “philosopher solider” resurfaced. “In Indian culture, jeev hatya [killing a creature] is a sin. But if a seed is crushed, it is not the same as slaying the tree, that is, killing the bhruan [embryo].” This statement is ironic, because as a solider of the Indian army, Rohit had been trained to kill (though had he been questioned further, he would have explained it away as karm [duty]). His subsequent statement was particularly instructive. “If something from our body can heal and benefit, then it is truly good, it is very good, why turn that into politics? So if you can save someone using my body it is very good, it is not killing! Indian culture says if my body can benefit you I can sacrifice my body. If we can save someone through the sacrifice of bhruna daan [donation of an embryo], then it is good and imbued with a lot of religious merit.” His training as a solider, including his professional oath to protect the nation by making the supreme sacrifice somehow melded with his philosophical musing on bhruna daan. His statement unwittingly echoed the underlying ideological basis of an emergent global moral economy busy developing legislations, protocols, and ethical injunctions encoding embryos with a moral provenance, which in turn can be seen as an expression of informed choice and autonomy. The iconic moment like the 2001 U.S. presidential decree for this reason alone becomes a point of transformation where moral distinctions between sacrifice and killing can, in principle, become the ideological basis for the bioethical discourse. However, what Rohit was seeking to sacrifice was far removed from the principle of the informed autonomous choice to give, but was rather an expression of duty and an extension of his professional life. The duality of an embryo and the “parent’s” body is collapsed, as potential offspring in India, at least in certain contexts, are seen as an extension of the bodily and spiritual self. The notion of sacrifice, therefore, is rooted in the self and cannot be recapitulated to mean killing of an “other.” The idea of sacrifice in India, both as a bodily and spiritual practice, is ingrained in everyday cultural idioms, conventions, kinship norms, familial obligations, and other social practices. Intimate connections between the body and sacrifice are continually reemphasized through storytelling, resurrected myths, and more recently through mass media and popular culture (see Cohen 2001; Uberoi 2006).

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It is possible to conceptualize Rohit’s sacrificial gesture as altruism, situated ethics, gift giving, and morally sensitive donation, but these explanations do not come close enough to the core of the willingness to give to Indian IVF clinics. An interview with a wife of a soldier helps clarify and identify the gesture framing the willingness to give. While I was explaining the difficulties in sourcing human embryos for research in many parts of the world because of the several moral and ethical complexities associated with the embryonic form, Shanta interrupted, “This will never happen in India! Infertile couples in India will not object, people here are very soft hearted, they will never hurt anyone, infertile couples will not be able to say no, people have been through so much. When you face problems, we Indians face a lot of problems with infertility, they’ll accept it, there is no question they won’t.” Shanta had put her finger on the pulse: it was not altruism, but empathy coupled with the reproductive biographies suffused with a socially disabling search for conception that underscored almost all expressions of “giving” to the IVF clinics. These were not informed consumers or rational producer-owners of embryonic entities consenting to altruistic giving. On the contrary, these were emotional, empathetic, sacrificial expressions, significantly different from the kind of rational sacrifice the neoliberal state of exception demanded. In all forty interviews, individuals and couples could not distinguish between clinical research and application. Despite repeated conversations and explanations describing the nature of embryonic clinical research, their predominant refrains were that their embryos might “benefit someone somewhere,” “help elevate suffering,” or “take away the pain.” They viewed their embryonic contributions through the register of suffering and healing. The most telling expression of this emerged in the interview with another wife of a soldier, Savita, who broke down while saying, “I want a child no matter what.” A little later and slightly more composed, she responded to the question of giving up embryos for research by saying, “Imagine if I wanted a donor and no one gave—how would I feel? So you should give, there is no problem in sharing embryos.” Like Shanta, Savita’s image of what giving might accomplish was filtered through her own subjective experience of suffering the “pains of infertility” and by placing herself in the predicament of an unknown other who might, like her, be forced to lead an “incomplete life.” Encounters with the middle-class ART “consumers” in the private clinic were no different. Since the premature birth of her son

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eight years before, Rekha had suffered from secondary infertility. She felt that her son, now a thriving boy, would benefit enormously from a sibling. Soon after his birth, Rekha had become pregnant, but she and her husband had opted to undergo a medical termination of pregnancy (MTP), as looking after their premature baby had been overwhelming. All subsequent attempts to become pregnant had failed, and she was riddled with guilt and even contemplated her secondary infertility as divine retribution for “killing [her] unborn child.” Responding to the question of embryonic research, she said, “If you’re doing it for a cause, research, which will eventually benefit mankind, someone will benefit from it, [but] embryos for research should only be contemplated by people who really want to give. But then again you can’t tell, it’s a thin dividing line.” Later, her biography began to surface. After a long pause, she said, “In the interest of science it’s OK. After all, some sacrifices were made by some people for research and the advances I benefit from right now, some sacrifices were made. … Going through this process you think differently. If I had naturally conceived a couple of children I would not think about it, but I feel I am reaping the benefits of someone’s sacrifices. You realize the value of something. … I now view an embryo as a child. If I had thought like this before I would not have gone for MTP. So, going through this difficulty [secondary infertility] you feel differently. Until I went through this process I viewed it differently, but when it actually hits you, you realize how much of a difference it makes to your life, otherwise it’s drawing-room talk. Only when it hurts you realize how much it hurts.” Rekha’s pursuit for conception was riddled with guilt and frustration. She enunciated the moral distinction between killing and sacrifice by splicing it with her own long emotional and financial struggle to achieve pregnancy. The MTP stood out as a thorny subtext in her reproductive biography, a decision she regretted, but more importantly, a decision that shaped an empathetic connection with her “killed” embryo and caused her to see the embryonic form as a potential sibling for her son. She used the word “chilling” to describe the thought of giving up the embryo for research but also felt sacrifices had to be made. Throughout the interview, she appeared to wander somewhere between the old Rekha, who had opted for the MTP, and the new Rekha, who was shaped by pain, hurt, and regret. The “sacrifice” of embryonic life for the greater good was almost expiatory in her case, as it helped process the guilt of “killing” an embryo that could have completed her perfect family some years ago.

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Conclusion The state of exception invoked through the August 2001 U.S. presidential decree was just that: a state of exception that allowed “bare life” to be harvested for the pursuit of research and profit. All subsequent global production processes have emerged or are morally required to originate from ethically unproblematic sources. In recapitulating bare life into the realm of law, morality, economics, and politics, market-driven neoliberal formations like India are engaged in engineering informed, autonomous, and rational citizens whose bodily surplus can be meaningfully and legally harvested in the pursuit of science, healing, and profit. However, what is relatively unaddressed is the precise reason such individuals consent to giving embryonic materials and how their own biographies are implicated in such purportedly moral transactions. These emotional (as opposed to rational) consumers of conception technologies and producer-owners of embryonic materials are empathetically connected to the cause of giving. They see their sacrifice as being for the good, for elevating the suffering they know and understand all too well. The state, on the other hand, demands sacrifice in the service of a bureaucratic rationality that views both ethics and morality as necessary cogs in the market-driven production process. The morality of these men and women is not linked to the production of guilt-free consumption in the neoglobal order (although they unwittingly contribute to its generation), but rather is empathetically linked to an imagined community of sufferers. This morality is, in fact, about being able to see the self in the other (see Bharadwaj 2006b). The difference between the state and the citizen therefore is best understood not only as one of scale but as one with different ideological points of departure, where the former is more driven to build into biogenetic entities’ global ethico-moral concerns and the latter sees morality in sacrificing to help alleviate suffering. The global moral economy of embryonic stem cells can become viable only so long as human embryos are seen as being “sacrificed” as opposed to being “killed.” The difference is not merely semantic but ideologically driven in the pursuit of creating global normative benchmarks of ethically acceptable and viable standards. That these standards are often market driven with the promise of supplying morally unproblematic commodities that further facilitate guiltfree consumption is the singular strength of the moral economic sensibility.

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Given the globally variable status of human embryos, the conceptualization of the human embryonic form as the sacrificial citizen mobilizes moral sentiments, nationalistic imaginings, and patriotic fervor, unlike the image of the embryo as killable bare life preceding the human/divine law. Although these moves are not expressly stated or gleaned from the existing “moral panics” around the globe on the question of embryos, human oocytes, and stem cells, they are implicit in the global political economy of embryonic stem cell research and development. In this respect, a morality of another kind must be assumed, one of a critical anthropological voice. This is a subjective and politically implicated voice that enunciates the silent but ideologically entrenched assumptions driving the global moral economy of embryonic stem cell production and consumption. It is a mindful politics that is critically conscious and consciously critical. This ethnographic voice is locatable in a morally contested terrain where a diversity of voices from the right of the political spectrum (pro-life) to the left (pro-choice) compete for recognition. Most importantly, the work of critical anthropological approach is to give voice to bodies that get implicated in the global circuits of moraleconomic production and consumption: bodies that become “bioavailable” for extractions and insertions (see Cohen 2005; Bharadwaj 2007). In the final analysis, the aim of a critical ethnographic voice is to lay bare the economic and political underbelly, whether dirty or not, which frames people’s lives in ways that are seldom of their choosing and not always of their making.

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Acknowledgments I am greatly indebted to Marcia C. Inhorn and Daphna BirenbaumCarmeli for their extremely helpful comments and superb editorial stewardship. A warm and heartfelt thanks is also due to the extraordinary women and men who so openly and generously shared their reproductive biographies and their experiences of numerous social and biomedical disruptions. Part of this research was carried out in 2004, under the aegis of the United Kingdom’s Economic and Social Research Council-funded Centre for Economic and Social Aspects of Genomics. This chapter is a condensed and accessible version of some of the main themes I have developed in the monograph Local Cells Global Science: The Rise of Embryonic Stem Cell Research in India (Bharadwaj and Glasner 2008).

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Notes 1. The Obama administration withdrew these restrictions. However, given the ease with which this could be accomplished, the future ethical and legal framing of the embryonic form remains somewhat vulnerable to interventions not too dissimilar to those in 2001. 2. “Bangalored” is an American euphemism for losing one’s job to an Indian worker or any other offshore contractor. 3. All names are pseudonyms.

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References Agamben, Giorgio. 1998. Homo Sacer: Sovereign Power and Bare Life. Stanford, CA: Stanford University Press. Bharadwaj, Aditya. 2003. “Why Adoption is not an Option in India: The Visibility of Infertility, the Secrecy of Donor Insemination, and other Cultural Complexities.” Social Science and Medicine 56: 1867–80. ———. 2005a. “Cultures of Embryonic Stem Cell Research in India.” In Crossing Borders: Cultural, Religious and Political Differences Concerning Stem Cell Research, ed. W. Bender, C. Hauskeller, and A. Manzei. Munster: Agenda Verlag. ———. 2005b. “Diffracting Reproduction: Infertility Encounters Stratified Reproduction.” Paper presented at the American Anthropological Association 104th Annual Meeting. Washington, DC. 30 November–4 December. ———. 2006a. “Reproductive Viability and the State: The Rise of Embryonic Stem Cells in India.” Paper presented at Reproduction, Globalization, and the State Conference. Rockefeller Foundation, Bellagio Study and Conference Center, Italy. ———. 2006b. “Clinical Theodicies: The Enchanted World of Uncertain Science and Clinical Conception in India.” Culture, Medicine and Psychiatry 30, no. 4: 451–65. ———. 2006c. “Contentious Liminalities: Embryonic Stem Cell Research in India and the UK.” BIOS Seminar Series, London School of Economics and Political Studies, London. February. ———. 2007. “Biosociality and Bio-Crossings: Encounters with Assisted Conception and Embryonic Stem Cells in India.” In Genetics, Biosociality and the Social Sciences: Making Biologies and Identities, ed. S. Gibbon and C. Novas. London: Routledge. Bharadwaj, Aditya and Peter Glasner. 2008. Local Cells, Global Science: The Rise of Embryonic Stem Cell Research in India. London: Routledge Cohen, Lawrence. 2001. “The Other Kidney: Biopolitics Beyond Recognition.” Body and Society 7, nos. 2–3: 9–29.

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Cohen, L. 2005. “Operability, Bioavailability, and Exception.” In Global Assemblages: Technology, Politics, and Ethics as Anthropological Problems, ed. Aihwa Ong and Stephen J. Collier. Oxford: Blackwell. Das, Veena, and Deborah Poole, eds. 2004. “State and Its Margins: Comparative Ethnographies.” In Anthropology in the Margins of the State, ed. Veena Das and Deborah Poole. Santa Fe, NM: SAR Press. Edelman, Marc. 2005. “Bringing the Moral Economy Back into the Study of 21st-Century Transnational Peasant Movements.” American Anthropologist 107, no. 3: 331–45. Express Healthcare Management 2000. “ICMR’s Proposed Prohibition Creates Furor.” http://www.expresshealthcaremgmt.com. Farmer, Paul. 2003. Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley: University of California Press. Financial Express. 2005. “Firms with Good Track Record to Get Stem Cell R&D Aid.” Saturday, 5 November. http://www.financialexpress.com. Franklin, Sarah. 2003a. “Kinship, Genes, and Cloning: Life after Dolly.” In Genetic Nature/Culture: Anthropology and Science Beyond the Two-Culture Divide, ed. Alan H. Goodman, Deborah Heath, and M. Susan Lindee. Berkeley: University of California Press. ———. 2003b. “Ethical Biocapital: New Strategies of Cell Culture.” In Remaking Life and Death: Towards an Anthropology of the Biosciences, ed. S. Franklin and M. Lock. Santa Fe, NM: School of American Research Press. Fukuyama, Francis. 2003. Our Posthuman Future: Consequences of the Biotechnology Revolution. London: Profile Books. Ganchoff, Chris. 2004. “Regenerating Movements: Embryonic Stem Cells and the Politics of Potentiality.” Sociology of Health and Illness 26, no. 6: 757–74. Glasner, Peter. 2005. “Banking of Immortality? Exploring the Stem Cell Supply Chain from Embryo to Therapeutic Application.” Current Sociology 53, no. 2: 355–66. Indian Council of Medical Research (ICMR). 2005. Draft Guidelines for Stem Cell Research/Regulation. http://www.icmr.nic.in. Lazaro, F. D. S. 2002. “Stem Cell Research.” Online News Hour. Public Broadcasting Service, 8 April. http://www.pbs.org. Modell, Judith. 1994. Kinship with Strangers: Adoption and Interpretation of Kinship in American Culture. Berkeley: University of California Press. Ong, Aihwa. 2006. Neoliberalism as Exception: Mutations in Citizenship and Sovereignty. Durham, NC: Duke University Press. Rabinow, Paul. 1999. French DNA: Trouble in Purgatory. Chicago: Chicago University Press. Scott, James. 1976. The Moral Economy of the Peasant: Rebellion and Subsistence in Southeast Asia. New Haven, CT: Yale University Press. ———. 1985. Weapons of the Weak: Everyday Forms of Peasant Resistance. New Haven, CT: Yale University Press.

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———. 2005. Afterword to “Moral Economies, State Spaces and Categorical Violence.” American Anthropologist 107, no. 3: 395–402. Thompson, Charis. 2005. Making Parents: The Ontological Choreography of Reproductive Technologies. Cambridge, MA: MIT Press. Thompson, E. P. 1971. “The Moral Economy of the English Crowd in the Eighteenth Century.” Past and Present 50: 76–136. Thorold, C. 2001. “Indian Firms Embrace Biotechnology.” BBC News, 6 April. http://news.bbc.co.uk/1/hi/world/south_asia/1264569.stm. Uberoi, Patricia. 2006. Freedom and Destiny: Gender, Family and Popular Culture in India. New Delhi: Oxford University Press. Washington Post. 2001. “India Plans to Fill Void in Stem Cell Research: Scientists Say Restrictions in U.S. May Give Them Advantage in Development.” 28 August, A07.

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Chapter 10

DOUBT IS THE MOTHER OF ALL INVENTION DNA

AND

PATERNITY

IN A

BRAZILIAN SETTING

Claudia Fonseca

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B

razil has been witnessing an interest in DNA paternity tests that defies imagination. Television showmen delight their spectators by luring to the studios real-life couples ready, in return for a free test, to air conjugal disputes. On a daily basis, we see women pursuing the would-be fathers of their babies and suspicious men doubting their (usually ex-) wives’ fidelity. Major weekly magazines run feature stories, enticing readers with suggestive cover images such as a chubby baby pensively scratching the back of his or her head and carrying a sign that reads, “Searching for father.” Newspapers that a few years ago splashed headlines across the page on how DNA settled the reluctant paternity of Pelé or Mick Jagger today bring the reader more humble accounts, for example, of a backwoods area in northeastern Brazil, where the citizens have decided to make monthly contributions to a communal fund in order to guarantee that poorer families have access to this “privilege.” While tuned in to one of the more popular local radio stations, I heard a song with the refrain “Nao precisa fazer teste de DNA, a criança é a cara de você” [“No need to do a DNA test, the kid’s your spitting image”]. There are signs that the run on tests has gone beyond mere journalistic novelty to commercial interests. In my town in southern

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Brazil, Porto Alegre, ads have cropped up on the back end of buses as well as on street-side billboards recommending, “Clear up your doubts! Come to [such and such] lab, specialized in DNA paternity tests.” Similarly, the yellow pages of the phone book now include a special rubric: “Laboratories for the Analysis of DNA.” In this rubric that doubles in size each year, establishments from all over the country advertise with large announcements such as “Pioneer in paternity investigation … international quality.” What is behind the wide appeal of the DNA paternity test? What idea of paternity is being expressed by this run on labs? How does this technology affect government policies and even national laws pertaining to family relations? Finally, to what extent are gender-related attitudes and practices changing according to this new scenario? To outline tentative answers to these questions, during 2002 and 2003, I centered my efforts on the observation of paternity disputes brought to the attention of judicial authorities in Porto Alegre, capital of Brazil’s southernmost state, Rio Grande do Sul. Working with an array of techniques, from semistructured interviews with litigants to observation of court scenes and analysis of written legal dossiers, I gathered material on nearly one hundred cases. Although the great majority of these paternity suits are decided on the basis of DNA tests, this material aptly highlights the overlap between medical and juridical issues pertaining to gender relations and family values in contemporary society. Throughout this chapter, I have drawn inspiration from discussions in the field of kinship and gender studies. However, with profound implications for our ways of knowing not only who a father is but also what a father is, the situations described in this chapter also suggest a line of investigation for an anthropology of science, centered on the analysis of (in this case, Occidental) belief systems about personal identity and family ties. By documenting the widespread use of DNA paternity tests in Brazil, bringing this example of what some might consider a highly exaggerated importance, I hope to contribute to the reflection of the uses and spread of modern technology. Researchers today tend to agree that technological innovation introduces change and brings new logic to ideas of which we were previously only vaguely aware. My findings, however, do not support theories that technological determinism automatically produces uniform results throughout the world. The fact that DNA is associated with different sorts of investigations—crime, insurance application, or paternity suits—in different parts of the world lends credence to the more recent perspectives in scientific studies, that technology is negotiated and assumes con-

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crete form within particular historical circumstances (Rabinow 1996; Jasanoff 2005; Ong and Collier 2005; Freeman and Richards 2006). I do not propose in this chapter to “explain” why Brazil has taken a wholesale plunge into paternity investigations, but I do hope to amply demonstrate that technology such as DNA testing does not have the same impact everywhere. Its uses are not predetermined. Its effects are not automatically liberating, as many (especially laboratory owners) would have us believe, nor do they necessarily imply some sort of totalitarian doom—an updated version of Aldous Huxley’s Brave New World. Doubt may be “the mother of all invention,” but doubts are never a natural “given.” Just as technology takes on variable forms according to the social (and human) network in which it operates, doubt is examined here as product and catalyst of a specific historical context.

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Kinship and Science It is no coincidence that anthropologists, having accompanied the assisted reproductive technologies (ARTs) of the twentieth century, completely revamped the analytical tools they used to study family and kinship. Up until the 1960s, most analysts unquestioningly adopted a genealogical approach to kinship. Sexual procreation was seen as being at the hub of a system in which blood symbolized the degree of connection between an individual and his relatives. Just as the conjugal family, composed of a heterosexual couple and their biological children, was considered inherent to human nature, the web of kinship, starting with the nuclear family and irradiating out to distant cousins, was seen as universal. During the 1960s, when science as a whole was undergoing considerable epistemological turmoil, Western anthropologists began to see their own cultures— and, by extension, their own science—as an interesting (nay, vital) object of study. Among academics, doubt arose and soon catapulted into a general conviction that the categories of family and kinship that had guided researchers for the past 100 years were little more than Western folk concepts. Paradoxically, by taking the beliefs and values of their own particular (North American, Western European) cultures as valid parameters for the study of all mankind, anthropologists were guilty of what they defined as a capital sin: ethnocentrism (Schneider 1984; Strathern 1992). From this moment on, the relativist approach, which consistently pointed out the enormous variability of family forms, was no longer

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enough. Unmoored from their genealogical anchors and seeking to understand how informants define their “closest relations,” anthropologists began to recognize there were people who did not calculate the degree of social proximity according to sexual procreation. Just as Occidentals consider the semen and blood involved in sexual intercourse as vectors of intimacy, others may see the acts of breastfeeding, sharing meals, or even producing food as symbols of connectedness just as potent (if not more so) than the sexual act (see, for example, Carsten 2000; Franklin and McKinnon 2001). This discussion becomes particularly interesting when used (as in a good part of contemporary anthropology) to challenge our own “native categories.” In Marilyn Strathern’s provocative article “Refusing Information” (1999), she uses ethnographic data from her studies of the New Guinea Hagen as well as other indigenous people to underscore the peculiar way Euro-Americans mix ideas about kinship with personal identity. For example, among the Piro, an indigenous group from the Peruvian Amazon, kinship is defined in terms of a lifelong process of remembering, which is not only about recalling events from the past (e.g., who cared for which children), but also about rekindling this memory through continued acts of food exchange. In this context, information about a child’s physiological origins (i.e., which sexual act resulted in the child’s conception) is of secondary interest, one detail among many others. This sort of information will not determine the foundations of the child’s personal identity or own perception of how he or she fits into the world. On the other hand, in the Euro-American system, notions of kinship rely heavily on externally verifiable knowledge about the natural world and coitus carries particularly intense signification; thus, new or unexpected information about the moment of a child’s conception has a constitutive finality. Despite the acute awareness that procreation is largely “man made,” the idea that kinship is something objective (empirically demonstrable) appears to be stronger than ever. It is ironic that an emphasis on the social construction of “families of choice” (see Weston 1991) may even deepen conviction in some sort of the natural foundation upon which variety is built. Thus, the hard facts revealed by a paternity test may provoke the complete reconfiguration of a person’s identity and, by extension, his or her personal relations. The new information is not merely additive but has the potential to “automatically obliterate another” (Strathern 1999: 75), unmaking status and terminating (or, at least, seriously disturbing) relationships. An individual may have the option of refusing such information, but once revealed, the information brings

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about inevitable consequences: “There is no choice about it; such effects are built in” (Strathern 1999: 75). Strathern’s analysis is designed not to tranquilize us with universal truth but rather to raise doubts where certainties have reigned all too easily. Her reflections alert us to the fact that the very acceptance of DNA exams as absolute proof of paternity is linked to a specific Euro-American way of intertwining forms of information, self-knowledge, and kinship relations. Given the particular constitutive nature of much of the information pertaining to such issues, policy makers might “think again about the partitioning of expertise and the value given to openness” (1999: 80). It is interesting that throughout the Western world public concern inspired by the new ARTs tends to concentrate on issues related to conception and pregnancy: amniocentesis, artificial insemination, sperm donation, and surrogate motherhood (Rapp 2000; Thompson 2005). Paternity tests, when remembered, appear as a less worrisome form of technology, one with straightforward use, beneficial to society in general and women in particular. The analysis of DNA tests in Brazil, however, suggests that this bit of “neutral” biotechnology may be just as problematic as the others.

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A Focus on Masculinity Consistent with a particular branch of gender studies, I have opted in the present discussion to focus on men and their perspectives. In recent years, a wave of studies on male reproductive health and paternity has been a welcome innovation, undermining long-standing stereotypes such as that of the cold and authoritarian Latin patriarch (Connell 1987; Gutmann 1996 and 2003). Nonetheless, there still appears to be considerable accord among Latin American scholars as to the ambivalence men feel about fatherhood. The role of the breadwinning father is an ideal many working-class men have never been able to attain.1 Because of unstable job conditions, many of them could not pay child support if they wanted to. Even in Europe and North America, where men are more likely to have regular salaries (making alimony payments easier to extract), stories of deadbeat dads are legion. In Brazil, where men may prefer to deny paternity rather than bear the shame of being unable to fulfill their paternal role, one should be more leery still about seeing paternity suits as a measure for combating poverty.

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Even when men are among the lucky few in an income bracket that permits them to fulfill the traditional male role of family breadwinner, they still may be reluctant to give up their bachelor existence. In this scenario, a woman’s unplanned pregnancy may be seen as a way to hook her recalcitrant beau. Scholars also point out that whereas women often find fulfillment in motherhood even when they have no husbands, a man’s tie to his children generally hinges on the quality of his relationship with their mother (Arilha, Ridenti, and Medrado 1998; Scott 1996; Goldstein 2003; Fonseca 2003). Thus, as we will see in the many examples that follow, when the conjugal relation breaks down or falls under suspicion, many men not only withdraw from their children, but also attempt to abdicate their paternal identity. To describe the ambivalence men feel about fatherhood, one might evoke Capitu, the heroine immortalized in Machado de Assis’s nineteenth-century classic, Dom Casmurro. With the particular sensitivity that made him Brazil’s greatest portraitist of provincial social life, Assis depicts Capitu as the adored wife of a man haunted by jealousy. The greatest fear of her husband, Dom Casmurro, is that Capitu may have had an affair with his best friend, a fear only heightened after he witnesses her “suspicious behavior”—a teardrop she sheds at her purported lover’s funeral. Even after his rival’s premature death, Dom Casmurro continues to plague his wife (as well as the child she has borne) not with outright accusations but with studied indifference. The novel finishes on a tragic note, with Capitu dead (wasted by her husband’s tacit scorn) and her son (who unfortunately bears some resemblance to the couple’s deceased friend) in exile. The reader is made to understand that Dom Casmurro is foremost among the tragic figures, as he is keenly aware that he has destroyed every hope of his own happiness and all because of a vague doubt. In the hands of this master storyteller, the saga of Capitu is much more subtle than many scholarly articles written on the Mediterranean complex of honor and masculinity;2 however, I do not intend to flog the dead horse of this particular academic debate. Rather, I would like to discuss how the figure of Dom Casmurro, this doubting husband so present in the mind of Brazilians, has today combined with particular political and technological circumstances. After all, the poignancy of Machado de Assis’s novel derives from the fact that neither Dom Casmurro nor the reader is ever really sure whether Capitu was unfaithful and whether her child’s father was her husband or another man. This predicament has acquired a new allure

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in the contemporary Brazilian scene. Had this couple lived in the new millennium, they would know they could put an end to Dom Casmurro’s doubts through the DNA paternity test. “Men,” of course, cannot be considered a homogeneous category. Even within Brazil, “masculinities” vary considerably according not only to geographic region, but also to generation, race, sexual orientation, and class (see Parker 1991; Leal 1991). However, the popularity of the DNA test appears to be nationwide (at the very least), requiring us to think about the interaction of certain general influences—coming from science, commerce, and the law—with the flesh and blood personalities encountered during fieldwork.

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Creating a Product for General Consumption in the Brazilian Context As with other consumer items, the desire to use a DNA paternity test depends on various factors, including marketing, perceived need, and accessibility. This marketing has been fueled in Brazil by the media as well as specific sectors of the scientific world. Blood tests of one sort or another have been used to prove biological affiliation for decades, and the legal codes of various countries have long been adjusted so as to include the new technology in court decisions (Freeman and Richards 2006). The margin of error was initially great: as much as thirty percent. Even with the more recent human leukocyte antigen tests, the accuracy rate was still considered low. Alleging that a five- to eight-percent margin of error renders test results useless, men whose paternity had thus been decreed could appeal their cases with a good chance of success. DNA fingerprinting, a technique developed by Alec Jeffreys of the University of Leicester in 1984, provided new paths to testing parent– child ties. By 1990, a group of researchers in Brazil, working in collaboration with Jeffreys, had refined genetic fingerprinting, adding new indicators that, when used with other sorts of DNA tests, allegedly reduced the margin of error to near zero (Leite 2000). Indeed, the certainty of scientists seems to have fueled the hopes of Brazilian policy makers who, seizing upon the familiar themes of “modernity” and “democracy” (used since the early 1980s as a counterpoint to nearly twenty years of an authoritarian military regime),3 have found in the DNA paternity test the long-awaited solution to Brazil’s widespread poverty. Politicians will quote figures on the sad economic plight of single mothers and their families (twenty-five

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percent of the country’s households) and will then evoke the widely held—and erroneous—belief that one-third of Brazilian children do not have a father listed on their birth certificates,4 thus implying that if only these families had a father, most of the nation’s social and economic problems would be settled. Needless to say, this sort of discussion coincides with common-sense attitudes and is likely to guarantee a certain number of votes in the next election. However, it is somewhat ironic that legislators are eager to furnish universal access to DNA technology in a country where nearly one-fifth of the population lives on less than two dollars a day and funds for public health and sanitary living conditions are constantly lacking.5 DNA tests, which cost from US$200 to $700 per family, are not cheap.6 For a number of years, Brazilians with enough money to pay the fee have had access through the Internet to anonymous mail-order test results.7 However, since the late 1990s, one state after another has been moving to make this service available to all. In 1999, soon after the state of São Paulo allocated around three million dollars per annum for DNA testing, private labs began vying with the government-run Institute of Social Medicine and Criminology for the bulk of contracts. To make inroads on a waiting list that included 13,500 families, the public lab was hoping to expand facilities to accommodate one thousand tests per month. In the state of Rio Grande do Sul, where I carried out my fieldwork, the Department of Biochemistry at the Federal University was contracted to perform the tests for a fee slightly under the usual price. During the second half of 2002, this state was registering around one thousand new paternity investigations every month, nearly seven percent of the number of births during that time.8 Scheduling up to five hundred DNA tests per month, the Judicial Medical Service still faced an enormous waiting list of over eight thousand cases, which could result in a wait as long as twenty months. Indeed, the government’s present pro-paternity policy represents the culminating point of a century-long legal trend. During the first decades of the past century, “natural” sons and daughters, or the illegitimate offspring of consensual unions and other couples who were not legally married, steadily gained ground in regard to paternity claims and inheritance rights, but it was not until 1949 that the law permitted a married man to recognize a child born during an extramarital affair and even then, only after legal dissolution of his marriage (desquite). Rather than being pushed aside, as in previous eras, for being the product of an adulterous relationship, children were authorized to move a paternity action against their purported

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fathers. However, even after the official recognition of a paternal link, these children could lay claim to only half the normal share of inheritance allotted to “legitimate” brothers and sisters. This form of discrimination dwindled with the arrival of the 1977 divorce law, which ruled that once recognized in closed testaments, the filial bond was irrevocable, and illegitimate children could receive the same inheritance rights as legitimate offspring. However, it was only in 1988, with Brazil’s most recent national constitution, that the principle of equality between all children became imperative. Today, the conditions under which a child has been conceived are absolutely irrelevant; the child will have rights equal to those of any children born to his mother or father. Furthermore, in 1992, the so-called “Paternity Law” (n. 8560) specifically promoted the paternity of children born out of wedlock, providing public assistance for investigations in the case of reluctant fathers, and prohibiting any discriminatory mention (e.g., “illegitimate”) on a child’s birth certificate. In fact, from the legal perspective, it would seem that men have never been held more responsible for their biological reproduction. However, laws, like global technology, have a varying impact depending on the context and circumstances in which they are applied. Whether women and children actually benefit from these laws and, more to the point, whether the paternity test works for them is a question that requires a look at actual practices. How is the average citizen using the judicial system? Also, how are judges interpreting and applying the laws? It is this law as practice that now gives us a methodological opening into our subject of inquiry (Ewick and Silbey 1998).

Reaching the Four Corners of the State My fieldwork took place with the aid of three student assistants, in four distinct instances of the judicial system of the state of Rio Grande do Sul. We met people at their “point of entry”—on the narrow, windowless steps of the downtown defensoria (an office providing free legal aid), where many had spent the night waiting in line to see a defensor (court-sponsored attorney). We found our way to the Judicial Medical Service, where women, their children, and the purported fathers were lined up for their blood tests. In addition to observing the interaction between authorities and the clients, we were able to conduct semistructured interviews with random volunteers. As we proceeded, entering locales in which judicial deci-

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sions were being proffered, the level of tension demanded greater discretion, forcing us to dispense with face-to-face interviews. Here, we confined our energies to the observation of “conciliatory sessions” at the local courthouse; in the few minutes allotted, judges would try—almost always in vain—to bring litigants to an amicable accord. Finally, we spent long afternoons reading through legal dossiers at the family court, getting an idea of how few cases ever make it to a final sentence. All these activities were duly registered in detailed field notes and complemented with a systematic survey, during a period of twenty days at the Judicial Medical Service, of quantifiable data (age of litigants, age of child, geographic origin, test results) drawn from over four hundred paternity tests. The description of a routine day in the Judicial Medical Service, where blood is collected Monday through Friday from 8:30 to 11:30 AM, serves as an introduction to this material, underlining the widespread appeal of the test. On one particular morning in the spring of 2002, my first encounter was with a Guarani teenager smoking a cigarette on the front steps of the secretary of justice. This native Brazilian hailed from a reservation on the state’s western border, from whence she had traveled, determined to press charges against her second cousin (and ex-employer’s son) for having fathered her child. As is the case for many of the people coming in for the test, it was this young woman’s first visit to the state capital. She had arrived in the early hours of the morning, after eight hours on an overnight bus, and was hoping to catch a noon bus home. Like many other women of modest means I had met, she had received financial aid from her local town hall to pay for transportation and snacks. At any rate, she had come with a female friend her age who claimed to have already been through the same experience. Between the two of them, they had three young children in tow. After climbing the steps to the second-floor waiting room, I was met with the usual scene of a medley of mostly young women scattered along the row of seats against the wall. With babies snug in their mothers’ arms and toddlers crawling under the seats, the waiting room looked like a nursery school. Of course, some of the “fatherless” children were teenagers or even older. Twice a month, on what lab workers call “the day of the deceased” (o dia dos falecidos), blood samples are drawn from the next of kin of a purported father who has died. On such occasions, it is not uncommon to encounter forty- and fifty-year-olds fighting for a share of the deceased’s inheritance. In general, though, the exams concern young children, around six or under.

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Standing awkwardly at some distance, the purported fathers appeared to be studiously avoiding contact while waiting to be called. According to the medical service’s receptionist, the men are often so ill at ease that they hesitate to respond when their names are called, requiring her to repeat their names two or three times. I rarely had the courage to approach these male figures and often discovered no more than what a visual appraisal might reveal. Police and military men would come in uniform because in these clothes they were exempted from paying bus fare. However, as to the occupation of other men, my only clue was through the vague guesses of the women, many of whom had not seen their ex-lovers for years. Striking up a conversation with a young matron sitting beside a hefty youth, I pieced together a typical saga. Born and bred in the colônia (a rural area that in this case was settled by people of Italian descent) and now comfortably married to a local farmer, she was there for her teenage son. The son, conceived from his mother’s youthful fling with a neighbor and raised since infancy by his stepfather, aimed to set the record straight by forcing his genitor to recognize the family tie. After about half an hour, mother and son were called in to draw blood, but when it became clear that the reputed father had not shown up, the process was aborted. To satisfy court protocol, blood must be drawn in the presence of all three parties involved in the dispute. The young man was frustrated because he had missed a math test but was nonetheless determined to come back. (The general understanding of clients of the system, expressed over and over in the small talk that floats around the waiting room, is that after the purported father fails to show for a third time, the judge will decree that he is the father.9) A little later, I came upon a mentally deficient street dweller from the eastern coast who, her social worker informed me, had been sexually molested by a local workman. Her mother had raised the child, now twelve years old, and only recently had been advised to seek support from the girl’s father. Although I didn’t speak with the (now) elderly man in question, the young woman accompanying him, an adult stepdaughter, was quite garrulous. Surprisingly, her good-humored solidarity seemed to lie more with the women in this case than with her own stepfather. “Men seem to think they can get away with anything!” she quipped before launching into a description of how a friend of hers had also been forced to go through this “rigmarole” before getting her ex-beau to officially declare his child. In fact, among the clients, there appeared to be a consensus that this is an affair of women pursuing men and with a lot of hard work.

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Many cases never even get to the final sentence. Some are shelved because no one is able to locate the purported father, and even when the man is found, it is quite common for him not to appear for the blood exam. Some women just give up, tired of the bureaucracy, trips, lawyers, and audiences; others might desist because their child balks at the idea of meeting this unknown figure. Thus, my twentyday survey of the Judicial Medical Service showed that one-half of the scheduled exams were not performed because at least one of the parties did not show up. However, as I branched out into other legal offices, I began to realize that in many cases it was not women but men who were seeking to judicially clarify their paternity. During my first month at the defensoria, men initiated approximately one-third of all the paternity cases I personally observed. Most requests were variations on the story of a young man who, after registering his child, the product of a transient affair, begins to see signs that he has been duped. I heard, “She won’t let me see the child” or “She doesn’t consult me about anything to do with the child.” I also learned from the defensores (who seemed to have no end to stories on this theme) of older, married men coming in with similar doubts. One man had separated from his wife and raised their two sons on his own. Now that they were practically grown, he was ready to finally “clear up a certain doubt” and had come for the test. Having broken off (or never having begun) an amorous relationship, these men were requesting a paternity test in order to reconsider their paternal ties, apparently seen as subsidiary to the rest. The more I visited the varied instances of the state legal system, the more I became aware of this unexpected aspect of paternity investigations in contemporary Brazil: the manner in which the DNA test seems to have created or exacerbated masculine doubts on paternity. To systematize my reflections on this matter, from the more than ninety legal suits recorded in my notes I have selected four that exemplify variations of the possible situations involved. Running the gamut from men using the law to affirm a social tie, overriding what they perceive as biological truth, to those using this “truth” to break off a social relation, the pool of the DNA test’s potential clients is much larger than originally imagined.

Fathers and Stepfathers in “Brazilian-style” Adoptions In the waiting room of the legal aid office, a young black10 woman was determined to bring a suit against a neighbor, the purported

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father of her child, but had nothing but praise for how her own father exercised his paternal responsibility:

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My brother was born a couple of years before me, but my mother didn’t register him. He only got his birth certificate ten years later, after my mother got together with my dad. They put my father’s name on the certificate. My brother was old enough to say if that was the way he wanted it or not. He liked the idea, and my dad did too. My mom would tell my brother, “You know, that other fellow, so-and-so, is your father,” but he wouldn’t hear of it. For him, “Father” was the man who’d raised him.

In each of the legal spaces I visited I encountered examples of this sort of “Brazilian-style adoption,” in which a man who knows he is not the father registers the child as his own. In most known cases, this falsely declared biological father is the single mother’s new companion. In other words, a man who normally would be known as the stepfather consciously opts for the identity of father. Some go through this process as a footnote to their wedding; however, many do not ever marry. In the case of the latter, one might surmise that registering a girlfriend’s child—a procedure involving considerably less bureaucracy than official adoption or even legal marriage—is seen by those concerned as a lifelong commitment. According to some estimates, this entirely illegal practice was, until very recently, many times more common than legal adoption, a statistic easily understood by those who recognize that the Brazilian working-class population has traditionally lived on the margin of state bureaucracy. Even today, one newborn in five is not declared within the legal deadline, and some children only acquire a birth certificate when they enter first grade or even later, when they start their first regular job or register for military service. In these circumstances, it is not difficult for adoptive parents to pose as birth parents. Of course there are cases of blatant abuse, for example, when babies are stolen from the maternity ward and registered by another couple without the mother’s consent. Jurists will understandably vehemently condemn such practice, branding it as “ideological falsity,” a crime punishable by fine or imprisonment. However, I have yet to hear of a single case in which a stepfather, having acted with his spouse’s consent, was tried and found guilty and the sentence was carried out. On the contrary, in the many dossiers I consulted, lawyers regularly refer to the “evidently noble spirit” that inspired the stepfather to take on paternal status.

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However, the newfound popularity of DNA tests may throw a wrench in this tacit acceptance of customary practice. What are jurists to do if a stepfather decides to deny his paternal status, using the negative result of a DNA test to press suit? Before trying to answer this question, it is necessary to complete this review of reluctant fathers, including cases of married men.

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Before Paying Child Support: Suspicions about an Ex-wife’s Fidelity João Vitor, twenty-nine years old, had studied mechanics at vocational school, but when we met, he was earning a living by transporting goods and people in his minivan. I began to chat with this affable young man at the defensoria, where he had gone for a free DNA test. After eight years of marriage, he had separated from his wife and was involved in a lengthy legal battle. Before paying alimony and child support, he wanted to “clear up a slight doubt” about the paternity of their six-year-old daughter. “We’re the ones who are raising her,” he said, explaining that the “we” included his parents, the owners of a self-service laundromat; he quickly added, though, that the child regularly spent half the week with her mother. Answering to my surprise that he should question his paternal status when he and his family were so close to the child, he assured me, “Oh, no, the results of the test will make no difference in our relationship. We’ll keep on just as we are.” He was equally firm when saying, “I just want to get rid of this doubt. I don’t want to live with this doubt for the rest of my life. I don’t know why they [the legal agents at the defensoria] give me so much trouble. I have a right to know.” I mused aloud that, among many other reasons, there was a financial limitation involved, as the test is not cheap and the state may not consider it the best investment to foot the bill in every case. However, this only made João Vitor more indignant. “Ah, to pay politicians, they have plenty of funds! They’re good at taking our money, taxing everything there is, but to guarantee a person’s rights, for that, there’s not enough money!” I never would have met João Vitor if I had stayed at the medical service or the family court, spaces encountered later in a person’s quest for the public-funded paternity test. Cases like João Vitor’s do not generally go beyond the defensoria, where clerks routinely explain to divorced fathers that even if the test is negative, judges will not readily honor the results without finding another man to fill in

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as genitor on the child’s birth certificate. In fact, all João Victor was able to get from the defensoria was a letter of introduction to the local public hospital, where he would pay for the exam, albeit at a supposedly reduced price. He did not seem to notice what we researchers observed, that the letter referred not to a DNA but to a human leukocyte antigen test, which is less precise and usually half the cost. In fact, judicial authorities do not dare turn away such men because, technically, suspicious divorcees are entitled to their doubts. Despite legal advances compelling unmarried men to register their “fatherless children,” over the past one hundred years the law has progressively broadened the right of married men to refute their paternal status. According to the 1916 Brazilian civil code, a child’s birth certificate was proof of a man’s paternity: “No one can disclaim the status registered on a child’s birth certificate” (Article 348). A man was considered to be the father of his wife’s children if those children had been born after the 180 days following their marriage or within 300 days of their legal separation.11 His only hope to legally deny paternity was to provide proof of total sexual impotence or of prolonged conjugal separation, and even in such cases, he had a two-month limit after the child’s birth to press suit (Article 340). In 1943, the following was added to Article 348: “No one can disclaim the status registered on a child’s birth certificate unless by proving error or false registry.” It is significant that Brazil’s 2002 civil code has retained this addendum while eliminating traditional restrictions. Today, a married man may contest his paternal status without having to demonstrate impotence or worry about time restrictions. A married man may press suit to deny paternal status of his fullgrown children: his right to do so does not expire, ever. There can be no doubt about the connection between the DNA test and changes in Brazilian legislation granting married men the practically unrestricted right to challenge their paternal status. Witness the following pronouncement from the Superior Tribunal Federal: Judicial norms must be understood according to the legal context in which they are embedded and considering that values are valid in relation to a certain historical moment. It would be impossible to interpret a legal principle, ignoring the profound changes the society has undergone, scorning scientific advances and leaving aside alterations in other norms pertaining to the same juridical institutes. Nowadays, there is no justification for applying the restrictions of Article 340 of

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the Civil Code to a husband’s refutation of paternity concerning children born to his wife, when science furnishes notably secure methods to verify the existence of filial ties.12

It is interesting to note that at the same time there has been an ostensible move toward promoting legal paternity, especially of children born out of wedlock, more and more loopholes have been created that endanger the status of those children who were heretofore considered “legitimate.”

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Common-law Unions It is ironic that, in many cases, when lawsuits initiated by women are examined closely, they reveal stories similar to that of João Victor. They show men who even after having lived for years with their partners question the paternity of the children they have raised. The difference between these stories and João Victor’s is that he was legally married and therefore presumed to be the father of his wife’s daughter. For those twenty-five percent of couples living in commonlaw unions, paternal status is hardly automatic. In this case, the man must make a concerted effort to go to the town hall and register the child in his name, a process that often occurs only after his partner’s insistent demands. The case of Eloi, a salaried gardener whose file includes a photo of him at his first child’s birthday, illustrates this situation. Eloi’s ex-partner pressed suit to have him register the three children born during their fifteen-year relationship. He objected, stating in his written defense that “I wasn’t denying that I’d lived with the woman and therefore didn’t agree with the allegation that I didn’t want to recognize the children. It just happens that I hadn’t registered the children … as my [children], because I’d never been sure of their paternity.” The judge conceded that Eloi, being of modest means, had the right to free legal aid, including a publicly funded DNA test. Following the test’s positive results (three times over), Eloi put his name on the birth certificates of all three children. It is symptomatic that although he had repeatedly heard witnesses testify to the couple’s long years of co-residence, the judge required “conclusive evidence”—the DNA exam—before declaring Eloi’s fatherhood. In fact, the need to be absolutely certain of a man’s paternal status may stem from the severity of the very law designed to promote a father’s registration of children born out of wedlock. Article 1 of the

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1992 paternity law rules that once declared, this status is irrevocable. Contrary to the case of married men, there are no exceptions that might allow this sort of father to change his mind. He will have the same status as an adoptive father, that is, it was his choice, and he will have to bear the consequences of his act. Thus, even when a man appears eager to assume responsibility for a child, he may still petition for a DNA test. In response to unmarried men seeking to “clear up a certain doubt” before legally committing themselves, judges tend to grant DNA tests with relative ease. No doubt moved by the desire to grant equal opportunities to all, it is unusual for them to deny publicly funded tests to anyone whose petition has come to their attention. Before asking a man to take on so serious a commitment, it is deemed entirely understandable that science be used to provide “conclusive evidence” to settle the facts. Nonetheless, it is difficult for some men to get as far as the family court. As in the case of João Victor, even if the law allows married men to press suit, the defensores tend to weed out disgruntled divorcees. These men must find a way of paying for a test at one of the local private labs, because it is only after returning with a negative test result that public attorneys will be ready to process their demands and move their cases to family court. To understand the consequences of pushing the law to its limit, I will narrate a final case, observed at the court of conciliations.

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An Unmarried Man Regrets his Overeager Fatherhood In December 2002, I was on the seventh floor of the central courthouse, in a room especially reserved for possible reconciliation of suits proceeding through family court. The room was small: in front of the three tables, which were arranged in a U formation, there was barely enough space to fit a row of four chairs for observers. At the table on my right, two seats awaited the defendant and his attorney; on the left, the seats were for the plaintiff and her attorney. The judge and the prosecutor sat at the slightly elevated middle table, a notch below a picture on the wall, of Jesus Christ. In the corner, behind his computer, the court scribe shuffled papers while waiting for the judge or prosecutor to step in and summon the next couple. On this particular morning, I noted that the prosecutor and scribe, readying to convene the next session, were particularly tense. Musing aloud, they shared their worries with me. They had seen “all sorts” in this room: recalcitrant youths expressing clear ambivalence

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about a girlfriend’s first pregnancy, married men furious about being dragged into court by what they saw as a careless mistress, men who have run away from their common-law families without having legalized their link to female companion or children, and so on. The case they were about to review, however, was different. It concerned a man who was never married and never even lived with the mother of his child. He not only registered his son but also was an exemplary (visiting) father for years. Now, after twelve years of a very satisfying father–son relationship and a thorough integration of the child into his paternal grandparents’ family, the man wanted to remove his name from the child’s birth certificate. What sort of person would do such a thing? I was surprised to see a sandy-haired forty-year-old who was tall but timid and wearing John Lennon-style glasses. His pained, nearly cowed demeanor was vastly different from the swaggering men I had seen file through this room. Accompanied by a female lawyer, he barely glimpsed the layout of the room before silently taking his seat opposite the child’s mother and her court-appointed attorney. While waiting for the judge to return (as he was simultaneously holding court in two adjacent rooms, attending in each a new session every fifteen minutes), I leafed through the judicial dossier, trying to glean the basic facts. Amilcar, the man in question, was a relatively successful carpenter living in a middle-class neighborhood. His written petition, found in the opening pages of the judicial record, spelled out the major points of this emotional drama. Despite the fact that he and the boy’s mother had never really gotten along (the reason they had never lived together), he and his parents had accepted the child’s birth “with great joy.” Not only did Amilcar pay child support, but also regularly took his son on weekends and vacations with various relatives. Years went by in this relatively tranquil routine, and the boy grew into preadolescence. Then Amilcar met and moved in with a new partner, his wife. As Amilcar stated, when he and his wife were looking through the family picture album, someone remarked that the child bore no resemblance to other members of the family. Doubts began to torment Amilcar for days on end until he took the (then) eleven-yearold boy to a private lab for a DNA test. Within days, Amilcar received the result—negative—and pressed suit to legally review the boy’s paternal status. The anguish caused by this situation reverberated throughout Amilcar’s family. As stated by Amilcar, when his parents and other relatives learned of the result, “it was terrible, they wouldn’t accept

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the obvious, and vehemently insisted that the test’s results had to be wrong, that the lab wasn’t trustworthy. They used every argument imaginable to try to deny reality.” The boy’s mother, insisting that she’d had no other suitor but Amilcar during the period of the child’s conception, only added fuel to the fire. The general commotion was so great that Amilcar shelved the suit, but a year later he decided to reopen the case. Determined to take the suit to its legal conclusion, he annexed the negative result of the DNA test officially ordered by the court. Amilcar’s arguments, which relied on highly conventional values, were no doubt aimed at convincing the court that he was the victim of tremendous injustice. However, his plea conveyed suffering that seemed to go beyond mere legal rhetoric:

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The question is truly dramatic and extremely difficult because we’re not dealing simply with rights and obligations, but principally with sentiments. Although affection exists between father and son, now there also exists a feeling of betrayal, shame and humiliation. … Of course, it is not the child’s fault, but how about the plaintiff? Has anyone thought about what he is feeling deep inside, having been misled all those years, believing he had a son who is not his?

The prosecutor broke the silence, bringing me back from my silent reading to the courtroom. “Well, is there any possibility of making an amicable accord?” she asked with apparently little conviction. Faced with a mute audience, she listlessly outlined the reasons for Amilcar to drop his case: “We have here a twelve-year-old boy who is losing his family. … There exists a clear conflict of interests between the child and his father. … The child is being penalized for something he wasn’t responsible for.” Her words were met with the simple affirmation voiced by Amilcar’s lawyer: “The boy has a right to know who his true father is.” Still, no one seemed very convinced. The mother’s lawyer mentioned that the child was in psychological therapy as a result of this dispute, to which the prosecutor answered, along with a barely audible sigh, “What else?” Amilcar’s nervous fidgeting suggested that not even he gave credence to his lawyer’s affirmation. The boy’s mother did not utter a word, nor, for that matter, did her ex-partner. The funereal mood continued even after the arrival of the judge. Hovering over all the proceedings, the results of not one but two DNA tests—both negating Amilcar’s genetic link to his ex-partner’s child—decreed an uncomfortable silence. All other evidence was mere formality. The indisputable final word lay with the

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test. “The boy has a right to know who his true father is”: moral truth follows on the heels of biological fact. In this case, however, the DNA test was not being used to define who was but rather who was not the father. The shared expression on the faces of those present suggested that there would be no winners.

“Irrevocable,” More or Less In cases such as Amilcar’s, the law can be quite confusing. After all, Amilcar had never married the mother of his son, but he had voluntarily recognized the child as his. Wouldn’t this paternity fall among the “irrevocable” cases? It will be no surprise to those who study law that, when interpreting the spirit of the law, there is always margin for negotiation. This fact was made clear to me by a small, typewritten note tacked to the wall of the legal aid office where I carried out fieldwork. It was positioned behind the desk of one of the defensores, evidently to clarify the doubts of professionals dealing with paternity investigations. The note, presumably an excerpt from a judge’s sentence (thereby establishing jurisprudence) speaks of different sorts of paternity, some legally revocable, others not. Close scrutiny reveals something not only of judicial guidelines, but also of the demand that people bring to the state services:

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Suit for the annulment of recognition of paternity. Hypothesis of alleged error: Irrevocability occurs in the hypothesis of a man who, even knowing he is not the father, and fully conscious of this fact, registers the child as though it were his own, and then tries to undo this recognition. It is this sort of father whose suit we have refused. Here, [however] we are not speaking of revoking [paternal] recognition, but rather of the hypothesis of error.

The first clause points to the stepfather who has engaged in a Brazilian-style adoption, the prototype of “a man who, even knowing he is not the father, and fully conscious of this fact, registers the child as though it were his own.” Certainly there are men who, having separated from their spouses, might seek to annul the paternal status of legally declared children; furthermore, they are confident that a DNA test will support their claims. In this sort of circumstance, what are the court attorneys to do? The first phrases of the note suggest there is a firm policy, grounded in the 1992 paternity law, to prevent this sort of man from reneging on fatherhood.

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As pointed out previously, however, the law states two possible motives for permitting disclaimers of data on the birth certificate: false registry or error. Whereas false registry, especially when intentional, no longer seems an accepted justification, the “hypothesis of error” referred to in the last sentence of the previous note is quite another matter. Here, the category appears to include those cases in which the man “erred” in good conscience, that is, in which his wife misled him. Thus, although lawyers, as in the case of Amilcar, will raise the question of the child’s interests, the subtle distinction between false registry and error makes the ultimate difference. It is no longer the father–child relationship that is at stake but, rather, the relationship between men and women. The betrayal overrides all the rest. This betrayal, interestingly enough, is very seldom directly confronted. Although traditional notions of masculine honor and female chastity are often evoked in men’s written pleas, such matters are rarely voiced during courtroom proceedings. In the ostensibly progressive climate of the Rio Grande do Sul judiciary, legal operators prefer to invoke more politically correct arguments, such as a child’s best interests. However, one may surmise that, subtly working the attitudes of those who apply the law, provoking a curious consensus, the introduction of DNA tests have modified the rules of the game. Jealousy and mutual suspicion are certainly not particularly new to amorous relationships. Classic works ranging from Shakespeare to Machado de Assis alert us to the fact that men’s doubts about their paternity go a long way back. Uncertainty about a man’s paternity was traditionally written into the conjugal pact. One might suppose that a man’s acceptance of his wife’s children implied the affection he felt for her and the confidence he had in her. A wife, as sole guardian of the “secret” of her child’s biological paternity, held a sort of trump card in her hand, that is, she alone knew whether she was honoring her husband’s trust (Fonseca 2003). In the past decade, the widespread availability of DNA paternity tests has brought a subtle change to this scenario. With the growing importance of DNA tests and the possibility of knowing the “real truth” of paternity, men and women are no longer at liberty to negotiate their own private relational truths. The “reality” of the father–child tie, in its supposedly objective form, is located outside the couple, in biochemical processes revealed in medical laboratories. Social relations no longer define the father’s identity; rather, biological facts reveal the “truth” of social relationships. Biogenetic blueprinting, by allowing public access to what had heretofore been a woman’s secret, has created

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the Achilles’ heel of conjugal relations, a new element that will in all likelihood modify the power relations within normally constituted couples—and not always happily.

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Conclusion To summarize, there does seem to be a “globalized” facet to biotechnology that cuts across local differences, affecting Porto Alegre slum dwellers, Egyptian professors, and the clients of American fertility clinics alike (Inhorn 2003; Thompson 2005). However, people are not passive subjects submitting without pause to technological manipulations. Indeed, we would be hard put to see the technology involved in DNA paternity tests as separate from the social relations and power plays that have placed it in the limelight. In Brazil, the issues raised by DNA tests are far from settled, but from court decisions, false birth registers, and public policy concerned with child support to class-bound sensitivities of gender and family roles, they provide a promising lead for thinking through and dealing with the forces involved in shaping present-day family paradigms. A first issue involves the particular place DNA occupies in the universe of technological innovations. Anthropologists have generally observed how ARTs have brought profound shifts to our ways of conceptualizing the family. Literature on this subject underlines, in particular, three momentous scientific discoveries: birth control pills, which permitted the separation of intercourse from conception; in vitro fertilization, which permitted the separation of pregnancy from intercourse; and surrogate pregnancy, which permitted the separation of gestation from motherhood. The idea is that, for most Occidentals, biology has not ceased to exist but—as constantly reworked through human intervention—is no longer considered “raw fact,” existing before or outside culture (Strathern 1992, 1995; Franklin 1995; Thompson 2005). On the basis of my work in Brazil, I suggest that, in the past few years, DNA technology used to investigate family ties has provided a fourth milestone, one that reverses the “family-as-choice” trend and instead moves in the direction of biology. Furthermore, it seems that in places like Brazil, where use of ARTs is limited, the DNA “revolution” may have more widespread and long-lasting effects than previous innovations. A second issue concerns the practical applications of DNA paternity tests in programs of social intervention. There may be objections that, in poverty-stricken countries like Brazil, problems such

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as those presented in this chapter are worth the risk when measured against the massive benefits of identifying fathers and thereby introducing a male into single-mother families. It is true that, in the great majority of cases judged by the Brazilian family court, sons and daughters fill in the blank beside the father’s name on their identity papers. Furthermore, if the child is under age, the judge will probably summon the father to pay a modest sum for child support (in general, around thirty percent of a minimum salary, amounting to no more than US$50 per month). However, repeated observations have led me to conclude that, lacking any previous contact between father and child, this “official” relationship seldom yields consequential results, that is, continuing material or emotional support. Nothing guarantees that a man declared “father” by the courts will fulfill his paternal obligations. The establishment of a biogenetic fact, the obedience to a law, and the development of a social relation are distinct (albeit overlapping) processes. Researchers have suggested that the present emphasis on biotechnological parenthood may even hamper interpersonal forms of sociability. In her provocative article on the medicalization of North American kinship, Finkler (2001) builds her argument around the high level of importance doctors give to inherited health traits. Although effective family ties may be few and far between, individuals are obliged to study their genealogical histories, promoting a notion of family “embedded in the very absence of interaction” (247). Furthermore, contrary to traditional forms of Occidental kinship, DNA would be dictating a sort of connectedness that is “devoid of morality or affect. … [I]t is inherently impersonal and does not impose, express, or insist on responsibilities, obligations, or love other than requiring living relatives to furnish blood samples in order to establish genetic markers on chromosomes” (245). Such observations suggest that the more we use DNA testing to write men into families as genetically relevant “genitors,” the more they slip away as socially relevant interlocutors. A final issue dealing with the specificity of Brazilian kinship opens the path to tempting speculations as well as an agenda for future research. Our material on DNA paternity tests highlights the latent antagonism in husband–wife relations documented in other research (Leal 1991; Scott 1996; Fonseca 2003). However, kinship analysis should lead us beyond nuclear-family relations. Elsewhere, I have underlined the inherent rivalry (1991) among Brazilian workingclass families, between a person’s blood relations and relatives by marriage. Rather than seeing the parent–child and husband–wife

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ties as mutually reinforcing, as they appear in the conjugal family model, the solidity of the former appears as both cause and consequence of the precariousness of the latter. Thus, men might be unreliable as husbands or even hostile as ex-mates but are able to maintain strong relationships as sons and brothers. A man who adamantly opposes helping—or recognizing as being related to—a child raised by an estranged spouse is likely to be more cooperative if the child, in the keep of his mother or sister, has been socially assimilated into the rank of blood relations. In light of this argument, we recognize the possibility that positive test results may fortify a child’s place among paternal kin at the expense of the mother’s proximity. If this is the case, it is ironic that family law will have kindled “responsible paternity” to the detriment of the nuclear-family household. DNA tests will have managed to make certain men “socially relevant” in the lives of their children but not in the way lawmakers would have imagined.

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Notes 1. As in many other lower-income populations, the insolvency of males is associated with the heightened importance of matrifocal networks for the care of children (Fonseca 1991; Blackwood 2005). 2. See Pina-Cabral (1989) and Gutmann (1996, 2003) for scholarship that criticizes and goes beyond the perspective of Mediterranean honor. 3. See Caldeira and Holston (2005) for an analysis of government preoccupations since the 1978 democratic reopening. 4. In Brazil, a good number of births are not registered within the legal three-month limit. I believe this figure on “late registries” is often erroneously interpreted as concerning “fatherless” children. 5. According to official government statistics, in 2004, still twenty-four percent of the country’s population is functionally illiterate and nearly forty percent of the urban population does not have access to adequate public sanitation (sewage and piped-in water) (Instituto Brasileiro de Geografia e Estatística, Síntese de Indicadores Sociais 2005). 6. During 2002, the price of the test (involving at least three people—candidates to the status of mother, father, and child) dropped from around 2,000 Brazilian reais to less than 800. 7. According to one site, one has only to “delicately pass a cotton swab on the inside of the child’s cheek” and mail it along with a sample of the father’s tissue. Sample tissue from the mother is preferable, but not indispensable, for the verification of the child’s identity. http://www .dnavirtual.com. Accessed 12 February 2001.

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8. This sum, drawn from computerized judiciary records, does not include tests carried out in private laboratories, many of which remain completely outside the formal judicial sphere. 9. This policy, already the norm in Rio Grande do Sul, was sanctioned by the Superior Tribunal de Justiça in October 2004. 10. Although in this part of Brazil only thirteen percent of the population is officially listed as non-white (black, “dark,” or indigenous), there is a particularly high concentration of these individuals in the lowerincome, urban sectors—precisely those who are most likely to frequent the office of free legal aid. 11. A child born earlier was assumed to be the husband’s child if he was aware of his wife’s pregnancy when they married or if he had voluntarily registered the child in his name. 12. Judge Eduardo Ribeiro, resp. 194866/RS, 1998/0084082–6, 20/04/ 1999.

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References Arilha, Margareth, Sandra G. U. Ridenti, and Benedito Medrado, eds. 1998. Homens e Masculinidades: Outras Palavras. São Paulo: ECOS/Editora 34. Blackwood, Evelyn. 2005. “Wedding Bell Blues: Marriage, Missing Men, and Matrifocal Follies.” American Ethnologist 32, no. 1: 3–19. Caldeira, Tereza, and James Holston. 2005. “State and Urban Space in Brazil: From Modernist Planning to Democratic Interventions.” In Global Assemblages: Technology, Politics, and Ethics as Anthropological Problems, ed. Aihwa Ong and Stephen J. Collier. Oxford: Blackwell. Carsten, Janet, ed. 2000. Cultures of Relatedness: New Approaches to the Study of Kinship. Cambridge: Cambridge University Press. Connell, Robert W. 1987. Gender and Power: Society, the Person and Sexual Politics. Cambridge: Polity Press. Ewick, Patricia, and Susan S. Silbey. 1998. The Common Place of Law: Stories from Everyday Life. Chicago: University of Chicago Press. Finkler, Kaja. 2001. “The Kin in the Gene: The Medicalization of Family and Kinship in American Society.” Current Anthropology 42, no. 2: 235–63. Fonseca, Claudia. 1991. “Spouses, Siblings and Sex-linked Bonding: A Look at Kinship Organization in a Brazilian Slum.” In Family, Household, and Gender Relations in Latin America, ed. Elizabeth Jelin. London: Kegan Paul. ———. 2003. “Philanderers, Cuckolds, and Wily Women: A Reexamination of Gender Relations in a Brazilian Working-Class Neighborhood.” In Changing Men and Masculinities in Latin America, ed. Matthew Gutmann. Durham, NC: Duke University Press. Franklin, Sarah. 1995. “Science as Culture, Cultures of Science.” Annual Review of Anthropology 24: 163–84.

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Franklin, Sarah, and Susan McKinnon, eds. 2001. Relative Values: Reconfiguring Kinship Studies. Durham, NC: Duke University Press. Freeman, Tabitha, and Martin Richards. 2006. “DNA Testing and Kinship: Paternity, Genealogy and the Search for the ‘Truth’ of our Genetic Origins.” In Kinship Matters, ed. F. Ebtehaj, B. Lindley, and M. Richards. Oxford: Hart. Goldstein, Donna. 2003. Laughter Out of Place: Race, Class, Violence and Sexuality in a Rio Shantytown. Berkeley: University of California Press. Gutmann, Matthew C. 1996. The Meanings of Macho: Being a Man in Mexico City. Berkeley: University of California Press. ———. 2003. Changing Men and Masculinities in Latin America. Durham, NC: Duke University Press. Inhorn, Marcia C. 2003. Local Babies, Global Science: Gender, Religion, and In Vitro Fertilization in Egypt. New York: Routledge. Instituto Brasileiro de Geografia e Estatística. 2005. Sintese de indicadores sociais: Estudos e Pesquisas: Informação Demografica e Socioeconomica 17. Brasilia. Jasanoff, Sheila. 2005. Designs on Nature: Science and Democracy in Europe and the United States. Princeton, NJ: Princeton University Press. Leal, Ondina Fachel. 1991. The Gauchos: Male Culture and Identity. PhD dissertation, University of California, Berkeley. Leite, Eduardo de Oliveira, ed. 2000. Grandes Temas da Atualidade: DNA como Meio de Prova da Filiação—Aspectos Constitucionais, Civis e Penais. Rio de Janeiro: Editora Forense. Ong, Aihwa, and Stephen J. Collier, eds. 2005. Global Assemblages: Technology, Politics, and Ethics as Anthropological Problems. Oxford: Blackwell. Parker, Richard. 1991. Bodies, Pleasures and Passions: Sexual Culture in Contemporary Brazil. Boston: Beacon Press. Pina-Cabral, João de. 1989. “The Mediterranean as a Category of Regional Comparison: A Critical View.” Current Anthropology 30, no. 1: 399–406. Rabinow, Paul. 1996. Essays on the Anthropology of Reason. Princeton, NJ: Princeton University Press. Rapp, Rayna. 2000. Testing Women, Testing the Fetus: The Social Impact of Amniocentesis in America. New York: Routledge. Schneider, David M. 1984. A Critique of the Study of Kinship. Ann Arbor: University of Michigan Press. Scott, Russel P. 1996. “Matrifocal Males: Gender, Perception and Experience of the Domestic Domain in Brazil.” In Gender, Kinship, Power: A Comparative and Interdisciplinary History, ed. Mary Jo Maynes, A. Waltner, B. Soland, and U. Strasser. New York: Routledge. Strathern, Marilyn. 1992. After Nature: English Kinship in the Late Twentieth Century. Cambridge: Cambridge University Press. Strathern, Marilyn. 1995. “Displacing Knowledge: Technology and the Consequences for Kinship.” In Conceiving the New World Order: The Global Politics of Reproduction, ed. Rayna Rapp and Faye Ginsburg. Berkeley: University of California Press.

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———. 1999 “Refusing Information.” In Property, Substance and Effect: Anthropological Essays on Persons and Things. London: Athlone Press. Thompson, Charis. 2005. Making Parents: The Ontological Choreography of Reproductive Technologies. Cambridge, MA: MIT Press. Weston, Kath. 1991. Families We Choose: Lesbians, Gays, Kinship. New York: Columbia University Press.

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CONTRIBUTORS

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Aditya Bharadwaj is Lecturer in the School of Social and Political Studies, University of Edinburgh. His principal research interest is in new reproductive, genetic, and stem cell biotechnologies and their global spread. Professor Bharadwaj has published extensively on these subjects and has coauthored the monograph Risky Relations: Family, Kinship and the New Genetics (Berg, 2006). He is the lead author of Local Cells, Global Science: The Proliferation of Stem Cell Technologies in India (Routledge, 2008). Daphna Birenbaum-Carmeli is Associate Professor of medical anthropology in the Department of Nursing at the University of Haifa, Israel. Her primary interest is in medical technologies and gender, with a focus on procreative and genetic technologies. The main field of her inquiry is Israel, where she has investigated health policy, medical practice, and consumers’ perceptions and behavior in matters of fertility treatments and reproductive choice. BirenbaumCarmeli has published extensively on these subjects in a wide range of sociological, anthropological, and health journals. Claudia Fonseca is Professor in the postgraduate programs of anthropology at the Federal University of Rio Grande do Sul, Brazil, and at the University of San Martin, Argentina. Her major ethnographic experience has centered on family organization and gender relations in Brazilian working-class populations, with special emphasis on human rights issues and international adoption. Among her numerous publications are articles in Law & Society Review, Law and Policy, Social Text, and Anthropologie et Société. Marcia C. Inhorn is William K. Lanman Jr. Professor of Anthropology and International Affairs in the Department of Anthropology

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Contributors

and the Whitney and Betty MacMillan Center for International and Area Studies at Yale University. There, she also serves as chair of the Council on Middle East Studies. A medical anthropologist specializing in Middle Eastern gender and health issues, Inhorn has conducted research on the social impact of infertility and assisted reproductive technologies in Egypt, Lebanon, the United Arab Emirates, and Arab America over the past twenty years. She is the author of three books on the subject, Local Babies, Global Science: Gender, Religion, and In Vitro Fertilization in Egypt (Routledge, 2003), Infertility and Patriarchy: The Cultural Politics of Gender and Family Life in Egypt (University of Pennsylvania Press, 1996) and Quest for Conception: Gender, Infertility, and Egyptian Medical Traditions (University of Pennsylvania Press, 1994). She is also the primary editor or coeditor of six volumes, including two in this Berghahn series (Reconceiving the Second Sex: Men, Masculinity, and Reproduction, 2009, and Reproductive Disruptions: Gender, Technology, and Biopolitics in the New Millennium, 2007).

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Yulia Panayotova is Cultural Anthropologist at the Health Psychology Research Center, Sofia, Bulgaria. She works in the fields of reproductive health, infertility, and assisted reproductive technologies, as well as in health promotion actions for women in Bulgaria. She is coauthor of several publications on the sociocultural and psychological impacts of assisted reproduction techniques in Bulgaria. Melissa J. Pashigian is Assistant Professor in the Department of Anthropology at Bryn Mawr College. Her research interests include the politics of reproduction, infertility, comparative systems of medicine, knowledge production, and social constructions of kinship. She has published on social, marital, and legal aspects of infertility and assisted reproductive technologies in Vietnam. She is working on a book manuscript about Vietnamese medicine and hope in the context of infertility. Kelly Raspberry is Postdoctoral Research Fellow at the Center for Genomics and Society at the University of North Carolina at Chapel Hill. Her research interests center on reproductive and genetic technologies, embodiment, medical practices, and modernity. She is currently working on an ethnography of assisted reproduction practices in Argentina. Her published work also includes an examination of lived experiences and understandings of clinical and medical genetics in the United States.

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Elizabeth F. S. Roberts is Assistant Professor in the Department of Anthropology at the University of Michigan. Her articles about in vitro fertilization in Ecuador have appeared in American Ethnologist and Culture, Medicine and Psychiatry. Currently she is completing a book on gamete exchange in Ecuador entitled God’s Laboratory: Eggs and Embryos in the Andes. Irina L. G. Todorova is Director of the Health Psychology Research Center in Sofia, Bulgaria. She is also Senior Research Scientist at the Center for Population Health and Health Disparities at Northeastern University, Boston, and Center Associate at the Davis Center for Russian and Eurasian Studies at Harvard University. With interests in the fields of health psychology, gender and health, and health disparities, Todorova is President-Elect of the European Health Psychology Society.

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Soraya Tremayne is a social anthropologist and Director of the Fertility and Reproduction Studies Group at the Institute of Social and Cultural Anthropology, University of Oxford. Her current work focuses on a wide range of reproductive, fertility, and sexuality issues in Iran. She is writing a book on the uses of assisted reproductive technologies in that country. Tremayne is also the founding editor of this Berghahn book series on “Fertility, Sexuality, and Reproduction.” Lisa K. Vanderlinden is Assistant Professor of Anthropology at Texas Christian University. Her research focuses on health and inequality, with a special interest in the cultural meanings of infertility, the social process of legitimizing illness, and the medical politics of toxicity. She has conducted ethnographic research in Germany and the United States.

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INDEX

A abnormal embryos, 216, 220, 226, 228–31, 235nn10–11 abortion, 62, 124 in Israel, 192, 198–200 after prenatal testing, 224 adoption in Brazil, 269–70, 277 in India, 248 prohibition by the Qur’an, 39, 101 of “surplus” embryos, 244 Africa, 90, 92, 117 Agamben, Giorgio, 244 American Convention on Human Rights, 224 anthropology anthropoligical holism, 10–11 ethnographic method, 11 feminist anthropologists, 117 medical, 87 Argentina, 20, 123 ARTs in, 213–33, 234n6, 235nn8–9 Catholic influence, 213–14, 223, 226–27, 230, 232 modernity within, 222–23, 232 and PGD, 20, 213–33, 234n6 Army Research and Referral Hospital (New Delhi), 240, 249 arrested spermatogenesis, 91 artificial insemination, 173

ARTs. See assisted reproductive technologies Assis, Machado de, 263, 278 assisted reproductive technologies (ARTs). See also infertility; intracytoplasmic sperm injection (ICSI); in vitro fertilization (IVF); male infertility; surrogacy access to, 40, 46, 76, 80, 121, 193 in Argentina, 221 in Argentina, 213–33, 234n6, 235nn8–9 in Bulgaria, 61–81 and the Catholic Church, 222–24 commodification of, 17 in Egypt, 76, 87-90, 96–97, 101–4 ethics laws and, 66 feminist analyses of, 61–62 and gender identities, 12 globalization of, 8 in India, 240, 249, 251 inequalities, 7 in Iran, 18, 101, 145–48, 151, 158–61 in Israel, 19, 193–94, 199, 203–4 in Lebanon, 87–93, 96–104 and male partners, 75–77, 80 in Middle East, 87, 90–91, 104 moral economy of, 8

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Index

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normalization of, 189–90, 203–4 and paternity tests, 262, 279 in patriarchal societies, 13, 97, 101 and PGD, 213–27, 229, 231–33 physical toll on body, 15, 81, 190, 198 and Shia law, 101, 145–48, 160 studies of, 86, 260, 279 in Turkey, 47 “unnatural” experience of, 42 in Vietnam, 164–85 passim assisted reproduction, 164, 168–69, 176, 182 asthenospermia, 86, 91 azoospermia, 13, 86, 91–92, 106n7, 106n9 and PGD, 218 B Becker, Gay, 38 Beirut, 87–91, 105n2 Belgium,16, 100 Berlin, 31, 33 bioavailability, 127–28, 135, 254 biogenetic entities, 239–40, 244, 247, 253 paternity testing, 278, 280 stem lines, 243, 248 biotechnologies, 3, 8, 21, 262, 279 and ARTs, 11–12, 14, 215 and ESC research, 239–42, 246–47 biovalue, 127–28 birth certificates, in Brazil, 265–66, 270, 272–73, 275, 278 and embryo donation, 158 and surrogacy, 159, 164 blastocyst, 217, 228, 230, Bloch, Ernst, 167, 183n4 blood tests, 264, 266–69, 280 Bourdieu, Pierre, 117–18 Brave New World (Huxley), 260 Brazil, 123 adoption in, 269–70, 277 equality of children in, 266

289

laws of, 266, 272 masculinity in, 262–64, 269, 278 paternity testing in, 21, 258–60, 262, 264–65, 269, 279 poverty within, 262, 264, 280 Buenos Aires, 213–16, 221–22, 225, 230–31 Bulgarian Orthodox Church, 63 Bush, George W., 244, 247 C caffeine, 92 Cairo, 87–88, 90–91 Cameroon, 6 Catholic Church, 213–14, 223–27, 230, 232 values of, 216 Center of Assisted Reproduction (CREAR) (Argentina), 216–19, 222, 227–30 Charmaz, K., 68 childlessness, 34. See also infertility in Ecuador, 122 and German Turks, 36, 38–39, 46, 48, 52 and infertility, 86 in Israel, 201 in the Middle East, 95–96 voluntary, 195 Christians, 89 clinics (infertility/IVF), 44, 69–71 in Argentina, 225 in Ecuador, 114, 121–35 passim in India, 240, 247–49, 251 in Iran, 145–46, 149–60, 161n2, 161n5 Middle East, 88–91, 97–104, 106n10 for PGD, 221 in US, 123, 128, 132 cloning, 78 Cohen, Lawrence, 128 communism, 64–65, 181 Communist Party (Vietnam), 169, 181, 184n6 conception, 261–62, 276, 279

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contraception, 33, 65 Convention on the Rights of the Child, 224 Crapanzano, Vincent, 34

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D Daniluk, Judith C., 94 Delaney, Carol, 35, n9 depleted uranium (DU), 92, 105n5 divorce, 103 DNA testing, 258–60, 262, 264–65, 269, 271–81 doctors. See physicians Doi Moi (Vietnam), 165–66 168–73, 180–81, 183n2, 184n5 Dolly the sheep, 242 Dom Casmurro (Assis), 263 donor eggs shortage of, 122 donor embryos, 179–80, 185n17 donor insemination, 94–95, 101, 193 Dorner, Dalia, 205 Druze Muslims, 89 E Ecuador, 8, 175 dollarization of, 121 egg donation in, 113–36 education and masculinity, 97 egg donation, 113–139 passim. See also egg donors, gamete donation, third-party donation in Argentina, 221 in Ecuador, 113–36 familial, 113–16, 128–31, 133–34 fatwas regarding, 148–50, 157–58 financial aspects, 125–27 in India, 247–48 and inheritance, 132, 149 intergenerational, 132, 134 in Iran, 148–52, 155, 157–58 and kinship, 115–20, 128, 134, 136

Index

paid, 119, 123–25 reciprocity, 120, 137 egg donors, 7. See also egg donation; ova donation anonymous, 123–24, 150–51 known, 123–36 passim, 138n8 vs. unknown, 150 motivations of, 155 relationship to recipients, 149–50 secrecy surrounding, 125–26 in US, 139n10 Egypt, 76, 87–90, 96–97, 101–4, 105n2, 147, 168 Embryo Carrying Agreement Law (Israel), 193 embryo cryopreservation, 221, 224, 226–27 of abnormal embryos, 228–29, 231, 235nn10–11 embryo donation, 156–59 embryologists, 89 embryonic materials, 240, 245, 253 embryonic stem lines, 244–45. See also stem lines embryonic stem cells (ESC), 240, 243, 245, 253 research, 14, 254 in India, 21, 239–42, 244–47, 250–52 embryo transfer, 129, 131, 133–34, 157 “End of the Line: Infertile Men’s Experiences of Being Unable to Produce a Child” (Webb and Daniluk), 94 Engels, Friedrich, 135 environmental toxins, 91–92 ESC. See embryonic stem cells Europe, 8, 122, 128 European Society for Human Reproduction Task Force on Ethics and Law, 233 F family formation, 193, 201, 203, 206 infertility as antithesis of, 35

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Index

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investment in ARTs, 97 in Israel, 191, 194–97, 205–6 and paternity testing, 259, 268, 271, 275–76, 279–81 studies of, 260 and surrogacy, 190 Farmer, Paul, 241 fatherhood, 75, 104 ambivalence regarding, 262–63 biological, 199 “coerced,” 198 involved father, 195–96 and paternity testing, 258–59, 265–80 passim fatwas 9, 18, 145–46, 148–50, 156–58, 160–61, 161n3, 168 Feldman, Avigdor, 199–200 female infertility, 146 femininity, 35, 136 feminism, 203–204 fertility, 144 fertility rates, 191 Finkler, Kaja, 280 Franklin, Sarah, 79, 242 G Gal, Susan, 167 gametes, 94, 100, 102 commodification of, 177 trade in, 115, 176 gamete donation, 17, 122, 128 as financial transaction, 156 intrafamilial, 247–48 in Iran, 148–51, 156 motivation surrounding, 155–56 and religion, 9 gamete intrafallopian transfer, 65, 227 gender, 12 as “defect,” 20 divisions, 197 equality, 190, 198–200, 202 identity, 195 inequality, 120, 170 roles, 195–96, 205–6, 279 studies, 259, 262 and surrogacy, 190

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gender order, 191, 194–97, 199, 204 genetic conditions and male infertility in Middle East, 91 genetic medicine, 20 genetic screening, 20 genetic technologies, 8, 20 Germany discrimination against emigrants, 34 medical system, 43, 51 naturalization policies, 29 xenophobia within, 49 German Turkish community use of biomedical technologies, 39, 41–42, 47 experiences of infertility, 38, 43 geocultural displacement, 45–46, 50–53 and IVF, 38 migration experiences, 48–49 stigmatization of receiving fertility treatment in Germany, 51–52 gestation, 165, 176–77, 179–82 gestational surrogacy, 164, 177, 179–82. See also surrogacy globalization, 240–41, 243 Goodkind, Daniel, 170 Good Manufacturing Process Standards (GMPs), 246 Guardian Council (Iran), 156 Gulf War, 105n5 gynecologists. See physicians H Ha-aretz (Israel), 191, 200 Halacha, 201 Hanoi, 168–69, 171–75 Har-Even, Diana, 194–95, 202 Health Insurance Act (Bulgaria), 64 Hizbullah, 106n8 Ho Chi Minh City, 171–73 hospitals, 121 in Argentina, 215, 221 in Vietnam, 169, 171–75

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human embryos, 239–41, 243–44, 248, 251, 253–54 human leukocyte antigen (HLA) typing, 220, 264, 272 human rights, 119 hysterosalpingography, 173, 184n11 I ICSI. See intracytoplasmic sperm injection illness narratives, 30, 38, 43–46, 48–53 passim impotency and male infertility, 86, 95 India, 7, 21, 117, 122, 128, 175 adoption in, 248 ARTs in, 240, 249, 251 clinics (infertility/IVF) in, 240, 247–49, 251 egg donation in, 247–48 ESC research, 21, 239–42, 244–47, 250–53 infertility in, 249, 251 IVF in, 240, 247–48 sperm donation in, 247 Indian army, 240, 249–50 Indian Council of Medical Research, 241, 246–47 indigenous peoples, 119–20 infertility. See also male infertility in Bulgaria, 66, 81 as community concern, 151–53 definition, 86 environmental factors, 91–93 and German Turks, 53 from infections, 6 as illness/disease, 45, 223 impairments of, 94 in India, 249, 251 in Iran, 144–61 passim in Israel, 203 male factor, 88 National Program for the Treatment of, 63 primary, 67 rates, 90–91

Index

satisfaction with treatment, 71–73 secondary, 67, 252 stigmas attached, 35, 66, 98–99, 153, 155–56, 249 treatment. See also assisted reproductive technologies (ARTs) in Argentina, 221 cultural sensitivity, 43 in Iran, 144–45, 151–61 passim for male factor, 33, 90, 94–95 narratives of, 69 satisfaction with, 71 subsidies for, 70 in Vietnam, 166, 168, 171–75 Inhorn, Marcia, 32, 37, 76–77, 145 Institute of Social Medicine and Criminology (Brazil), 265 intracytoplasmic sperm injection (ICSI), 13 access to, 100 in Argentina, 216, 218, 221, 227 in Bulgaria, 65, 70, 72, 78 in Germany, 31–33 in Middle East, 87, 96, 100–4 restrictions upon, 33 stigma of, 88 use by Sunni Muslims, 16, 39, 101–3 in Turkey, 47 in Vietnam, 174, 176 intrauterine inseminations (IUI), 41, 249 in vitro embryo, 213–14, 217–20, 224–30, 232–33 in vitro fertilization (IVF). See also assisted reproductive technologies (ARTs) in Argentina, 218, 221, 227 in Bulgaria, 61, 65–66, 70, 72, 78 costs, 121–22

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Index

and depression, 41 description of, 206n6 in Ecuador, 113–14, 121–22, 125–26 in Egypt, 88, 90, 147 eugenics, 6 fatwas regarding, 145 in Germany, 31–32, 38, 41 growth in the Middle East, 13, 96, 145, 147 in India, 240, 247–48 in Iran, 148 in Israel, 192–93, 199, 203–5 in Lebanon, 97–98, 147 male partner’s experience of, 75–76 pain associated with, 73, 77, 203 among poor, procedure, 127 studies of, 86 and stem cells, 7, 244–46, 251 and surrogacy, 164, 176–83, 204–5 in Turkey, 47 in Vietnam, 19, 164–77, 179–83 involuntary childlessness. See childlessness; infertility Iran, 9 ARTs in, 144–61 ARTs and Shia law, 18, 101, 145–48 egg donation in, 148–52, 155, 157–58 gamete donation in, 148–51, 156 kinship in, 146–47, 152–53, 161 physicians in, 149, 152–55, 160, 161n5 Iraq war, 106n8 Irigaray, Luce, 117 Ishiguro, Kazuo, 135 Islam, 18, 144–45, 161n3 donors, 151, 156, 160 lineage, importance of, 39, 147 in Egypt, 168 in Germany, 50 mandates, 101, 103

293

scriptural beliefs, 101 Islamic Revolution, 161n3 Israel, 168 abortion in, 192, 198–200 ARTs in, 19, 193–94, 199, 203–4 donor eggs, 122 family, 191, 194–97, 205–6 gender in, 190–91,194–200, 202, 204–06 infertility in, 203 IVF in, 7, 168 masculinity, 94–95 surrogacy in, 190, 193, 199, 204–5 wars, 98, 105n5 Italy, 223 IVF. See in vitro fertilization J Jeffreys, Alec, 264 Judicial Medical Service (Brazil), 265–67, 269 K Kahn, S. M., 77 Kant, Immanuel, 119 Khamenei, Shaikh Ali, 101, 148–51 kinship, 8 biological, 128 in Brazil, 280 construction of, 190, 205–6 in Ecuador, 115–20, 122, 128–37 passim economies of, 115–16, 119–20, 122, 136 and egg donation, 115–20, 128, 134, 136 inequality potential, 135 and embryonic stem cells, 244 and infertility, 152–53 in German-Turkish community, 37 “inappropriate,” 132 incest taboos, 116, 147, 151–52, 155 in Iran, 146–47, 152–53, 161 patrilineal ideologies, 101–2

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and PGD, 215 rules, 161 studies, 259–61 structures, 117–18 in Vietnam, 164, 166, 168, 182 Kligman, Gail, 167 Konrad, Monica, 155 Koptiuch, Kristin, 30 Koran. See Qur’an

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L Latin America and Catholic Church, 214, 224 egg donation, 123, 125 PGD within, 222, 232 Latin American Assisted Reproduction Network (RED), 225, 235n6 Lebanon, 9, 87–93, 96–104, 105n5, 147 civil war, 92–93, 98 “summer war,” 98 Lévi-Strauss, Claude, 115–18, 135–36 Lie, M., 74, 79 Lock, Margaret, 233 Lloyd, Mike, 87, 98 M Ma’ariv (Israel), 191 mahram, 147, 151, 154–55 “male factors.” See sperm male infertility. See also infertility; masculinity in Bulgaria, 75 “cult of silence,” 96 in Israel, 94–95 in Middle East, 87–104 destigmatization of, 13, 97 emasculating effects, 94–96 lack of scholarship, 87 and masculinity, 97–100 and morality, 90 rates in Middle East, 91 stigma of, 86, 98–99, 102, 153 marriage disruption from war, 93

Index

and egg donation, 125, 134 and ICSI, 102 and infertility, 90–91 and kinship, 117–18, 134 muta’a, 103, 106n11 polygyny, 103 rate in Middle East, 95 temporary (for gamete donation), 148–52 in Vietnam, 178–79, 182, 185n13 Martin, Emily, 32 masculinity in Brazil, 262–64, 269, 278 Egyptian versus Lebanese, 96–98 and fertility, 75, 87 and Middle Eastern men, 88–104 passim and patriarchy, 95–97 and social identity, 94 and sperm donor threat, 95 and virility, 95–96 Matza, Justice Eliyahu, 201 Mauss, Marcel, 118 McKinnon, Susan, 116 Medical Center for Infertility and Impotence, 201 medical termination of pregnancy (MTP), 245, 252 Middle East ARTs in, 145 educational rates, 97 ICSI use, 100–4 interfamilial marriage within, 91 IVF industry growth, 13 male infertility within, 87–88, 90–92, 95–96, 104 normalization in, 96 traditional treatments of, 100 masculinity in, 88–104 passim Muslim populations within, 15 pollution, 91–92 moral economy definition of, 242–43 global implications, 245–46, 248, 250, 253–54

Assisting Reproduction, Testing Genes : Global Encounters with the New Biotechnologies, edited by Daphna Birenbaum-Carmeli,

Index

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Morgan, Henry Lewis, 135 motherhood, 62, 74–75, 81, 263, 279 in Argentina, 223 biological, 201–03 imposed, 200 nonbiological, 195 single, 197 in Vietnam, 166, 181 MTP. See medical termination of pregnancy Muslims 9, 15–16, 39, 87, 145, 157. See also Shia Muslims; Sunni Muslims in Israel, 193 Middle Eastern men, 95, 101 N Nahmani, Ruti, 193–206 Nahmani, Dani, 193–206 na-mahram, 147, 151, 154–55 National Centre for Biological Sciences (Bangalore), 244 National Health Insurance Fund (NHIF), 64–65, 70, 80, 82n6 National Family Planning Program (Vietnam), 174 National Program for the Treatment of Infertility (Bulgaria), 63 neoliberalism, 239–43, 245, 248, 251, 253 Never Let Me Go (Ishiguro), 135 New Delhi, 240, 249 Nichter, Mark, 45 nontraditional families, 33 nurses, 89, 99, 104 O Occidental belief systems, 259, 261, 279–80 oligospermia, 86, 91 Ong, Aihwa, 241, 245 orchitis, 92 Ortner, Sherry, 50 Ouzgane, Lahoucine, 95 ova, 94, 102, 173, 177, 180, 185n17

295

ova donation. See also egg donation in Ecuador, 17 ovarian problems, 123 Oxford English Dictionary, The New Shorter (Brown), 94 P paternal identity, 263 paternity reluctant, 258, 262 “responsible,” 280 status, 270–73, 275, 277 suits, 259–60, 262, 265, 269, 277 “Paternity Law” (Brazil), 266 paternity tests in Brazil, 21, 258–60, 262, 264–65, 269, 279 in Bulgaria, 75 patriarchy, 201, 203, 248 patrilineage, 35, 180, 182 PGD, see pre-implantation genetic diagnosis PGD International Society, The, 214, 234n2 Phuong, Nguyen Thi Ngoc, 174, 185n12 physicians, 89 and abortion, 198 in Bulgaria, 69, 71, 78–81 doctor-patient relations, 43–44, 49–50 in Ecuador, 114, 123, 125–27 in Iran, 149, 152–55, 160, 161n5 male and male patients, 94 as medical gatekeepers, 33, 51 in Middle East, 91, 104 and PGD, 221, 223 in Vietnam, 171–73, 175 polycystic ovary syndrome, 91 polygamy, 178, 182, 185n20 population control pre-embryos, 199, 203–5 pregnancy, 262–63, 275, 279 pre-implantation genetic diagnosis (PGD), in Argentina, 20, 213–33, 234n6 availability, 221–23

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296

controversies surrounding, 218, 226–33 cost and time required, 217, 221 definition of, 213 discrimination potential, 219–20, 233 and embryo cryopreservation, 224–29 equipment and training required, 216, 222 prevention of genetic disorders, 218–19 prohibition against, 224 and sex selection, 220 technique, 229 procreation

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Q Qur’an, 39, 147, 161n3 R Rapp, Rayna, 32 “Refusing Information,” (Strathern), 261 Reliance Life Sciences (Mumbai), 244 religious beliefs, 74–75, 77 reproduction and ARTs, 166, 177, 183, 189–90, 215, 223 biological, 258 in Bulgaria, 63, 77 and commerce, 124 and communism, 65 as cultural space, 53 and family, 11 as female domain, 4, 119, 166 and German Turks, 15, 30–32, 44 and masculinity, 94–95 medicalization of, 62 “stratified,” 5 structures of, 120, 122 and surrogacy, 177–78, 182–83 in Vietnam, 19, 165–69, 176–78, 182–83 Rio Grande do Sul (Brazil), 259, 265–66, 278, 282n9

Index

Rivkin-Fish, M., 78–79, 167 Rubin, Gayle, 116–17, 120, 136 Russia, 79, 125 S schistosomiasis, 92 Schneider, David, 120 sexually transmitted diseases (STDs), 91–93, 106n7 Shari’a law, 147, 150 Shia law, 18, 101, 145–48, 160 Shia Muslims, 89, 103, 157, 160 and ARTs, 101, 145–48, 160 Simpson, Bob, 166–68, 183n3 smoking. See tobacco Snowflakes Program, 244 socio-economic status of German Turks, 42 sociology actor-network theory, 10 Sofia (Bulgaria), 67–68 Soviet Union. See Russia. Spain, 125, 138n5 “spare embryos,” 241, 248 sperm defects, 86 donation, 146, 148–52, 157–58 in India, 247 and inheritance, 149 prohibitions against, 101 environmental impact on, 91–93 “male factors,” 90 “shooting blanks,” 94 storage, 173 washing, 154, 161n6 spermatogenesis, 91 spermatotoxicity, 92 stem cell banks, 245–46 stem cells, 7, 78. See also embryonic stem cells stem lines 243–45, 248. See also embryonic stem lines Strathern, Marilyn, 122, 261–62 Sunni Muslims, 39, 89 legal restrictions for ARTs, 101, 147

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Index

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surrogacy, in Israel, 190, 193, 199, 204–5 in Vietnam, 164–65, 176–83 ban against, 164–65, 176–77, 180–83 surrogates, 7, 115 business of, 119 exploitation concerns, 19 intergenerational, 132 in Iran, 158–59 Muslim world, 9 and the Nahmani Affair, 191, 193–94, 199, 205–6 prohibitions against, 101 in Vietnam, 164, 176–80 Syria, 89, 102, 106n10 T Technological Institute for Halacha Issues, 201 Tehran, 146, 153, 155, 160 teratospermia, 86 third-party donation. See also egg donation, gamete donation financial aspects, 153–54 in Iran, 147–51, 161 unknown donors, 153 Thompson, Charis, 128, 132 Titmuss, Richard, 126 tobacco, 92–93 torture, 93 Tsing, Anna, 29 tubal insufflation, 173, 184n11 Tu Du Hospital, 173–74 Turkey travel to for ARTs, 47 U United Kingdom (UK), 8, 126, 151, 155 embryonic stem cell research, 245 stem cell bank, 246 United Nations Population Award, 144

297

United States (US), 123, 125–28, 132, 138n5, 139n10 embryonic stem cell research, 245 August 2001 presidential decree, 244, 246, 250, 253 uterus, 177, 179, and legal definition of conception, 224–26 as “public”, 167, 182–83 and uterine identity, 165, 180 V van Balen, Frank, 38 varioceles, 100 vasectomies, 91 Vietnam, 8, 19 ARTs in, 164–85 passim IVF in, 19, 164–77, 179–83 surrogacy in, 164–65, 176–83 economic shifts in, 165–66, 169–73, 180–83, 184nn5–6 marriage in, 178–79, 182, 185n13 W Waldby, Catherine, 127 Webb, Russell E., 94 Weismantel, Mary J., 119–20 White, Jenny, 51 women. See also feminism; gender traffic between, 115–19, 136 women’s rights, 190, 193, 196–203, 205 World Health Organization (WHO), 89–90, 161n2 Y Yedioth Aharonoth (Israel), 191 Z Zachatie (Bulgaria), 63, 67, 80, 82n2 zygote intrafallopian transfer, 65

Assisting Reproduction, Testing Genes : Global Encounters with the New Biotechnologies, edited by Daphna Birenbaum-Carmeli,