Technologies of Reproduction Across the Lifecourse: Expanding Reproductive Studies [1 ed.] 9781800717343, 9781800717336, 9781800717350

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Technologies of Reproduction Across the Lifecourse

Emerald Studies in Reproduction, Culture and Society Series Editors: Petra Nordqvist, Manchester University, UK and Nicky Hudson, De Montfort University, UK This book series brings together scholars from across the social sciences and humanities who are working in the broad field of human reproduction. Reproduction is a growing field of interest in the United Kingdom and internationally, and this series publishes work from across the lifecycle of reproduction addressing issues such as conception, contraception, abortion, pregnancy, birth, infertility, pre- and post-natal care, pre-natal screen and testing, IVF, prenatal genetic diagnosis, mitochondrial donation, surrogacy, adoption, reproductive donation, family-making and more. Books in this series will focus on the social, cultural, material, legal, historical and political aspects of human reproduction, encouraging work from early career researchers as well as established scholars. The series includes monographs, edited collections and shortform books (between 20 and 50,000 words). Contributors use the latest conceptual, methodological and theoretical developments to enhance and develop current thinking about human reproduction and its significance for understanding wider social practices and processes.

Published Titles in This Series Egg Freezing, Fertility and Reproductive Choice Authored by Kylie Baldwin The Cryopolitics of Reproduction on Ice: A New Scandinavian Ice Age Authored by Charlotte Kroløkke, Thomas Søbirk Petersen, Janne Rothmar Herrmann, Anna Sofie Bach, Stine Willum Adrian, Rune Klingenberg and Michael Nebeling Petersen Voluntary and Involuntary Childlessness Edited by Natalie Sappleton When Reproduction meets Ageing: The Science and Medicine of the Fertility Decline Authored by Nolwenn B¨uhler Lived Realities of Solo Motherhood, Donor Conception and Medically Assisted Reproduction Authored by Tine Ravn

Surrogacy in Russia: An Ethnography of Reproductive Labour, Stratification and Migration Authored by Christina Weis Reproductive Governance and Bodily Materiality: Flesh, Technologies, and Knowledge Edited by Corinna Sabrina Guerzoni and Claudia Mattalucci Anti-Abortion Activism in the UK: Ultra-sacrificial Motherhood, Religion and Reproductive Rights in the Public Sphere Authored by Pam Lowe and Sarah-Jane Page

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Technologies of Reproduction Across the Lifecourse: Expanding Reproductive Studies EDITED BY VICTORIA BOYDELL University of Essex, UK

And KATHARINE DOW University of Cambridge, UK

United Kingdom – North America – Japan – India – Malaysia – China

Emerald Publishing Limited Howard House, Wagon Lane, Bingley BD16 1WA, UK First edition 2022 Editorial matter and selection © 2022 Victoria Boydell and Katharine Dow. Individual chapters © 2022 The authors. Published under exclusive licence by Emerald Publishing Limited. Reprints and permissions service Contact: [email protected] No part of this book may be reproduced, stored in a retrieval system, transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without either the prior written permission of the publisher or a licence permitting restricted copying issued in the UK by The Copyright Licensing Agency and in the USA by The Copyright Clearance Center. Any opinions expressed in the chapters are those of the authors. Whilst Emerald makes every effort to ensure the quality and accuracy of its content, Emerald makes no representation implied or otherwise, as to the chapters’ suitability and application and disclaims any warranties, express or implied, to their use. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN: 978-1-80071-734-3 (Print) ISBN: 978-1-80071-733-6 (Online) ISBN: 978-1-80071-735-0 (Epub)

Table of Contents

List of Tables and Figures

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About the Contributors

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Foreword Rene Almeling

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Acknowledgements

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Chapter 1 Introduction: Technologies of Reproduction Across the Lifecourse Katharine Dow and Victoria Boydell Reflection One: Knowledge Victoria Boydell and Katharine Dow

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Section One: Reproductive Technologies Across the Lifecourse Chapter 2 ‘I Feel Like Some Kind of Namoona’: Examining Sterilisation in Women’s Abortion Trajectories in India Rishita Nandagiri

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Chapter 3 When Time Becomes Biological: Experiences of AgeRelated Infertility and Anticipation in Reproductive Medicine Nolwenn B¨uhler

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Chapter 4 Delaying Menopause, Buying Time? Positioning Ovarian Tissue Cryopreservation and Transplantation Technologies for Delaying Menopause in the Context of Women’s Embodied Reproductive Choice and Agency Across the Lifecourse Susan Pickard Chapter 5 Chronic Uncertainty and Modest Expectations: Navigating Fertility Desires in the Context of Life With Endometriosis Nicky Hudson and Caroline Law Reflection Two: Choice Victoria Boydell and Katharine Dow

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Section Two: Lifecourses of Reproductive Technologies Chapter 6 Contraceptive Futures? The Hormonal Body, Populationism and Reproductive Justice in the Face of Climate Change Nayantara Sheoran Appleton

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Chapter 7 Spectacular Reproduction Revealed: Genetic Genealogy Testing as a Re(tro)productive Technology Sallie Han

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Chapter 8 Getting the Timing Right: Fertility Apps and the Temporalities of Trying to Conceive Josie Hamper

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Chapter 9 Bio-Genetics and/at the Border: The Structural Intimacies of LGBTQ Transnational Kinship Sonja Mackenzie

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Chapter 10 A Balancing Act: Situating Reproductive Technologies Across Time in the UK Victoria Boydell

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Reflection Three: Relationality Victoria Boydell and Katharine Dow

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Table of Contents

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Section Three: Reading Across Reproductive Technologies Chapter 11 ‘Well, She’s Entitled to Her Choice’: Negotiating Technologies Amidst Anticipatory Futures of Reproductive Potential Ben Kasstan Chapter 12 Men as Irrational Variables in Family Planning? Understanding the Landscape, Technological Advancements, and Extending Health Psychology Theories and Models Amanda Wilson

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Chapter 13 Inclusion, Exclusion, Anticipation: How the Politics of Intimate Relationships Structure Innovation 247 Ryan Whitacre Chapter 14 Integrating Reproductive and Nonreproductive Technologies: Egg Freezing and Medical Abortion Lucy van de Wiel

Afterword Victoria Boydell and Katharine Dow

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List of Tables and Figures

Table 1.

Table 2. Figure 1. Figure 2.

MOHFW’s Financial Incentives for Private Facilities and NGOs. All in Indian Rupees (INRs) (1 INR 5 0.014 USD) (MOHFW, 2016). Data on Vasectomies, Tubectomies and Abortions in Karnataka (2017–2018). Table 1: Evra Users (All-Subjects Treated) in Studies 2004, 2003, 2002. Table 3: Phase III Efficacy/Safety Studies. Submitted to the European Medicines Association in the New Drug Application for Evra.

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About the Contributors

Professor Rene Almeling is Professor of Sociology at Yale University, where she holds courtesy appointments in the Department of American Studies, the School of Public Health and the School of Medicine. She is the author of GUYnecology: The Missing Science of Men’s Reproductive Health (2020) and Sex Cells: The Medical Market for Eggs and Sperm (2011). With Sebastian Mohr, she co-edited a special issue on ‘Men, Masculinities, and Reproduction’ for NORMA: International Journal for Masculinity Studies (2020). Dr Nayantara Sheoran Appleton is a Senior Lecturer at the interdisciplinary Centre for Science in Society, Te Herenga Waka | Victoria University of Wellington, Aotearoa New Zealand. Trained as a feminist medical anthropologist and STS Scholar, her first project is a book manuscript titled Demographic Desires: Emergency Contraceptive Pills and the (re)Imagined Family Planning Project in Contemporary India. Her research interests are in the following areas: Feminist Medical Anthropology and Science and Technology Studies (STS); Cultural Studies and Media; Reproductive and Contraceptive Justice; Population and Demographic Politics vis-`a-vis climate change; Critical Kinship; Ethics and Governance; Regenerative Medicine; Critical Science Communication; Immigrant and Indigenous Relations; and Qualitative Research Methods. Dr Victoria Boydell is a Lecturer in Global Public Health at the University of Essex and a research fellow at the Global Health Centre, the Geneva Graduate Institute. Her research looks at the longer range social and cultural dynamics and rights dimensions around reproductive technologies and health care, particularly contraception. She has spent many years in the non-governmental sector working in research around sexual and reproductive rights, including with the International Planned Parenthood Federation, UNWomen and the World Health Organization. She has published widely in a number of journals including BioSocieties, Ethnos, Journal of Sex Research, BMC Women’s Health and the BMC International Journal for Equity in Health. Dr Nolwenn B¨uhler is an Anthropologist of biomedicine and health, specialised in gender studies. She currently works as a Senior Researcher at the STSlab (UNIL) and a research manager at Unisant´e. Her research explores the contemporary reconfigurations of public health in the era of ‘personalised health’. Since November 2020, she is also leading the project SociocoViD (SNSF-PNR78,

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Unisant´e) and a project on chemical exposure in agriculture (FBM-UNIL (IHM). Initially trained in nursing, she obtained her PhD from the University of Zurich, where she dealt with the production of knowledge on reproductive ageing and the role assisted reproductive technologies play in it. She also explored the ontological and political effects of the medically assisted extension of fertility in Switzerland. Her book When Reproduction Meets Ageing: The Science and Medicine of the Fertility Decline was published in 2021. Dr Katharine Dow is a Senior Research Associate in the Department of Sociology and Deputy Director of the Reproductive Sociology Research Group (ReproSoc) at the University of Cambridge. She specialises in public discourses around reproduction and reproductive technologies and in intersections between reproduction and environmental concerns. She is the author of Making a Good Life: An Ethnography of Nature, Ethics, and Reproduction (Princeton University Press, 2016). Dr Josie Hamper is a postdoctoral researcher at Queen Mary, University of London. Her work focuses on the personal and social implications of new reproductive technologies. Her postdoctoral research explored patients’ experiences of IVF and their perspectives on the introduction of new biomedical technologies in fertility treatment. This work was funded by the Wellcome Trust. Josie completed her PhD research on women’s use of fertility and pregnancy apps in the School of Geography, also at Queen Mary, and has published on reproductive technologies, visual culture, parenting and relatedness. Professor Sallie Han is Professor of Anthropology at the State University of New York (SUNY) Oneonta. A specialist in the anthropology of reproduction, Professor Han is the co-editor of The Routledge Handbook of Anthropology and Reproduction (Routledge, 2021) and The Anthropology of the Fetus: Culture, Society, and Biology (Berghahn Books, 2018), and the author of Pregnancy in Practice: Expectation and Experience in the Contemporary United States (Berghahn Books, 2013). Other major areas of interest include gender, kinship and care. Her current and recent work includes projects on pregnancy and climate change, and the Academic Carework initiative, which examines the challenges of caregiving while pursuing careers in higher education. Han is a recipient of the SUNY Chancellor’s Award for Excellence in Teaching. Professor Nicky Hudson is a Medical Sociologist with particular expertise in the social and cultural significance of reproduction, infertility and assisted reproductive technologies. Her work also focuses on the sociology of chronic illness. Uniting these themes is an emphasis on intersectionalities and questions of individual-biomedicine-society relations. She has received funding for her work from the Economic and Social Research Council, the Wellcome Trust, Foundation for Sociology of Health and Illness and the National Institute for Health Research. She leads the Centre for Reproduction Research, an interdisciplinary centre of expertise dedicated to the production of scholarship on the social, cultural and political aspects of human reproduction based in the Faculty of Health and Life Sciences at De Montfort University.

About the Contributors

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Dr Ben Kasstan is a Vice Chancellor’s Fellow at the Centre for Health, Law & Society at the University of Bristol and is also affiliated with the Department of Sociology & Anthropology at the Hebrew University of Jerusalem. His research explores the cultural politics of protection that emerge at the intersection of health, religion and state. Ben’s recent monograph Making Bodies Kosher was recently published with Berghahn in their series on Fertility, Reproduction & Sexuality. Dr Caroline Law is a Senior Research Fellow at Centre for Reproduction Research, De Montfort University. Her research interests include endometriosis, particularly the social and gendered aspects of the condition, the impact on partners and relationships, and advancing healthcare for women. Her work takes an applied focus seeking to advance understanding of the condition and its social and psychological impacts, contribute to healthcare policy and enhance support and information for women and couples. Her other research interests include reproductive timing and ageing, particularly the timing of fatherhood, and men and reproduction; and experiences of in/fertility and reproduction and changing landscape of family formation and reproduction more broadly. She is a sociologist whose work primarily utilises qualitative methods. Dr Sonja Mackenzie is Associate Professor in the Public Health Program at Santa Clara University, USA. In 2021, Dr Mackenzie was Visiting Scholar with the Department of Sociology in the Reproductive Sociology Research Group (ReproSoc) at Cambridge University. Her scholarship lies at the intersections of public health, sociology and gender and sexuality studies to analyse and intervene in social and structural inequities in health among racial/ethnic and sexual and gender minorities. Her current project examines the structural intimacies of LGBTQ kinship as the conjoining of social structural patterns with intimate lives, building on her 2013 book, Structural Intimacies: Sexual Stories in the Black AIDS Epidemic. She is the author of numerous peer review publications and public scholarship on social structural patterns of the US Black AIDS epidemic and LGBTQ kinship and health. Dr Rishita Nandagiri is an LSE100 Fellow at the London School of Economics and Political Science (LSE). She is finishing her ESRC Postdoctoral Fellowship (2020–2021) at the LSE’s Department of Methodology. Her research focuses on abortion, reproductive (in) justice and reproductive governance in the Global South. She serves on the International Union for the Scientific Study of Population’s Abortion Research Panel, and on the editorial advisory board of the journal BMJ Sexual and Reproductive Health. Professor Susan Pickard is Professor of Sociology in the Department of Sociology, Social Policy and Criminology at the University of Liverpool, UK. Her research interests lie in the fields of ageing, gender, sexuality, health and illness and she has published widely in a number of journals including Sociology, British Journal of Sociology, Sociology of Health & Illness and Ageing & Society. Her latest book is Age, Gender and Sexuality Through the Lifecourse: The Girl in Time, published by Routledge.

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Dr Ryan Whitacre is a Postdoctoral Research Fellow in the Global Health Centre at the Graduate Institute, and a Visiting Fellow in the Center for Social Medicine at UC Berkeley. Ryan defended his doctorate in Medical Anthropology at UC Berkeley and UC San Francisco (2018), specialising in the anthropology of clinical research, public health and pharmaceutical markets. Through multidisciplinary enquiry and collaborative research, he aims to sharpen theory in medical anthropology and improve practice in global public health. His work has been supported by a fellowship from the US National Science Foundation, research grants from the UC Berkeley, and project grants from the European Research Council and Swiss National Science Foundation (PI: Nguyen VK). Dr Lucy van de Wiel is a Lecturer at the Global Health and Social Medicine department at King’s College London. She also is a member of the Wellcome-funded Changing In/fertilities network hosted by the Reproductive Sociology Research Group at the University of Cambridge. She is the author of Freezing Fertility: Oocyte Cryopreservation and the Gender Politics of Aging (NYU Press, 2020). Dr Amanda Wilson is a Lecturer in Psychology at De Montfort University. She is a public health psychologist, with expertise in engaging men in family planning behaviours. To date she has explored men’s engagement from the perspectives of men themselves, health services, nurse practitioners, training manuals, female partners, male contraceptive methods and seminal constructs. She has also used quantitative methods to explore large data sets to explain men’s use of vasectomy services, including vasectomy reversals, and to explain men’s use of condoms, spermicide and natural family planning. Dr Wilson has further worked with collaborators in China around mental health of second infant delivery and the implementation of the two-child policy, as well as the mediating factors of post-partum depression in both mothers and fathers.

Foreword

There is sometimes a strange moment toward the end of a research project where the main noun, the primary object of one’s analysis, begins to shimmer, starts to feel unstable and seems as though it might actually slip out of view completely. This happened to me as I was finishing my most recent book, GUYnecology (2020), a history and sociology of why there has been so little attention to men’s reproductive health. As I was writing the conclusion, a phrase I had used throughout the book, and which I’ve encountered hundreds if not thousands of times in the work of others – ‘reproductive body’ – suddenly seemed vague. More than vague: thoroughly devoid of substantive meaning. What was, and is, a reproductive body? Using ‘a’ as an article instead of ‘the’ in front of reproductive body seems to open up the possibilities a bit, but does not begin to answer crucial questions about which parts of whose bodies would one demarcate as specifically (exclusively?) reproductive? Reading through this marvelous collection of research essays edited by Vicky Boydell and Katie Dow makes me think that this phenomenon, the feeling of losing one’s grasp on precisely the thing you’ve just spent months or years studying, can happen not only with particular research projects but with entire fields. It appears to be happening at the moment in the social scientific study of reproduction, as scholars train their attention on some of the core terms in the field, raising questions about how they have been defined, what they include and what they do not, and identifying the assumptions on which they are based. Far from cause for concern, I think this process heralds the continuing growth and expansion of a field, and it makes possible exciting new opportunities for thinking about what comes next. In the Introduction to this volume, Boydell and Dow argue for the integration of research on reproductive technologies, noting that they are defining both ‘reproductive’ and ‘technologies’ in expansive ways. In doing so, they are building on long-standing efforts by anthropologists, sociologists and historians to examine the wide range of social, cultural and historical processes that shape individual experiences of reproduction, which can include pregnancy, birth, contraception, abortion and a wide array of reproductive technologies. Faye Ginsburg and Rayna Rapp (1991) offered a powerfully generative label for conceptualising these processes – the politics of reproduction – and the subsequent outpouring of research provided the basis for my own working definition of reproduction: ‘the biological and social process of having or not having children’ (Almeling, 2015, p. 430).

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Boydell and Dow’s integrative framework takes up this approach to reproduction and enlivens it with empirically innovative studies of reproductive technologies. In particular, the essays in this volume illustrate the importance of comparative research, such as comparisons of how individuals experience different kinds of reproductive technologies (Kasstan; Van de Wiel; Whitacre) and comparisons of their experiences at different points in the lifecourse (Nandagiri; Boydell). Indeed, Boydell and Dow’s emphasis on temporality ensures that scholars are thinking longitudinally not only about the past and the present (Hudson and Law; Han) but also how reproductive technologies figure into ‘anticipated futures’ (Buhler; Hamper; Pickard). Importantly, this volume expands beyond the experiences of cis-women, the typical population researched by reproductive scholars, to include men’s and LGBTQI people’s experiences of reproductive technologies (Mackenzie; Wilson; Appleton). And like so many others working in the vibrant politics-of-reproduction tradition, the editors and contributors to this volume emphasise how the inner workings of governments and markets and biomedicine have real consequences for the reproductive aspects of people’s everyday lives. In essence, Boydell and Dow’s integrative approach to research on reproductive technologies expands the viewscope well beyond the traditional ‘snapshot’, in which researchers concentrate on a single reproductive technology at a particular point in time and place for one group of people. It makes possible new questions about the relationship between processes that are usually considered somewhat distinct, such as those around contraceptive and conceptive technologies. Going forward, there is an ongoing need to analyse how reproductive technologies and reproductive processes more broadly, from the cellular to the global, are shaped not only by gendered norms and beliefs but also by inequalities rooted in racism and heteronormativity, as well as widely varying levels of economic and educational resources across and within countries (e.g. Briggs, 2018; Roberts, 1997; Ross & Solinger, 2017). In addition to several of the essays in this volume that take an intersectional approach, I would also encourage readers to seek out Natali Valdez and Daisy Deomampo’s (2019) excellent special issue of Medical Anthropology on race, racism, and reproduction. Of course, there will never be one correct, true-through-all-of-history answer to questions such as what is a reproductive body or what is reproduction or what is reproductive justice. Decades of social scientific and humanistic scholarship on science and bodies, and especially research on processes surrounding gender, race, sexuality, ability and their intersections, reveal that definitions, understandings, and experiences of reproductive processes are rooted in particular times and places and approaches, the latter of which can be academic, activist or neither. The impossibility of objectivity is not a fact to mourn, but an invitation to consider the full range of complexities in how knowledge is made and the uses to which it can be put. It is a chance to deepen our understanding of the nouns we work with, to examine the assumptions built into these seemingly straightforward words and an opportunity to use such reflections to ask new questions. Rene Almeling New Haven, Connecticut June 2021

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References Almeling, R. (2015). Reproduction. Annual Review of Sociology, 41, 423–442. Almeling, R. (2020). GUYnecology: The missing science of men’s reproductive health. Oakland, CA: University of California Press. Briggs, L. (2018). How all politics became reproductive politics: From welfare reform to foreclosure to Trump. Oakland, CA: University of California Press. Ginsburg, F., & Rapp, R. (1991). The politics of reproduction. Annual Review of Anthropology, 20, 311–343. Roberts, D. (1997). Killing the Black Body: Race, reproduction and the meaning of liberty. New York, NY: Pantheon. Ross, L., & Solinger, R. (2017). Reproductive justice: An introduction. Berkeley, CA: University of California Press. Valdez, N., & Deomampo, D. (2019). Centering race and racism in reproduction. Medical Anthropology, 38, 551–559.

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Acknowledgements

We are fortunate to be part of this collective and collaborative effort to examine, challenge and reflect on the fact that many people design, imagine and use different technologies throughout their lifecourse, and to promote methodologies aligned with a social and reproductive justice approach. First and foremost, we would like to thank all the contributors for their partnership and their patience in shaping this edited collection over an 18-month period. We are also grateful to the people who participated in the original workshop in Geneva in November 2019 but who were not able to contribute chapters, namely Lisa Harris, Aditya Bharadwaj, Ritu Sadana, Irene Maffi, Sezin Topçu and Marina Plesons. The contributors have been generous with their time and their efforts to think together through the political, social, economic, legal and cultural implications of reproductive technologies as they are developed, distributed, used and imagined. You have all exceeded our expectations for constructive collaboration. This book would not have been possible without the help of many people. We would like to thank Kim Chadwick who guided us through the publication process and Nicky Hudson and Petra Nordqvist, the series editors, for their encouragement for this project and for enriching our thinking across various drafts. We are grateful to Rene Almeling for enthusiastically agreeing to write the foreword and for her thoughtful reflections. We are also grateful for our respective host institutions for their ongoing support while we were coordinating this volume: the Global Health Centre, Geneva Graduate Institute and the Reproductive Sociology Research Group (ReproSoc), University of Cambridge. We would also like to thank the following for funding support for the co-editors: the Brocher Foundation, University of Cambridge Returning Carers’ Scheme and the Wellcome Trust Collaborative Award, ‘Changing (In)Fertilities’ (grant 209829/Z/17/Z).

Chapter 1

Introduction: Technologies of Reproduction Across the Lifecourse Katharine Dow and Victoria Boydell

Abstract This edited collection proposes an interdisciplinary and integrated approach to the study of reproductive technologies (RTs), which reflects the fact that many people use different technologies throughout their lifecourse and resists the disciplinary siloing of research on these technologies. The ever-expanding availability of RTs, the continued roll-out of ‘family planning’ and maternity services across low- and middle-income settings and the rapid development of the fertility industry mean that it is more likely than ever that individuals, especially women and trans* people, will engage with more than one RT at some point in their life. These multiple engagements with RTs will affect users’ expectations and uptake, as well as the technologies’ availability, commercial success, ethical status and social meanings. We offer this book as part of a wider movement in the study of reproduction and RTs, which takes inspiration from the reproductive justice framework to address forms of exclusion, discrimination and stratification that are perpetuated in the development and application of RTs and the ways in which they are studied and theorised. Here, we introduce the project and outline the structure of the book. Keywords: Reproductive technologies; lifecourse; reproductive justice; methodology; biomedicine; inequality This book comes out of a workshop hosted on the picturesque Lake Geneva. By those same shores, just over 200 years earlier, Mary Shelley conceived her most famous novel, Frankenstein. Frankenstein emerged as a popular trope in early public discussions of assisted reproductive technologies (ARTs) (Turney, 1998), signifying an intense discomfort with ideas of ‘playing god’. It is fitting that both

Technologies of Reproduction Across the Lifecourse, 1–19 Copyright © 2022 Katharine Dow and Victoria Boydell Published under exclusive licence by Emerald Publishing Limited doi:10.1108/978-1-80071-733-620221001

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Frankenstein and its technology of reviving the long-dead, in order to create new lives, are (science) fictional, since much of the controversy around ARTs is based in speculations about what might be done with them and how they could be put to use in the ‘wrong’ hands, which still resonate with Shelley’s warning to her readers about tinkering with natural forces. Shelley could be described as one of the earliest theorists of reproductive technologies (RTs). Like many social scientists studying RTs, she used the example of Dr Frankenstein and his Creature as a lens to examine broader social and political currents and to warn about what happens when those with dubious goals and few scruples are given power over life and death. Frankenstein is not anti-technology or anti-science: Shelley makes it clear that technologies are anthropogenic, and so humans must take responsibility for their use, and the meanings and values that drive those uses. Two centuries after Frankenstein’s publication, both the facilitation and the prevention of human reproduction are mediated through many technologies, which may appear ‘ordinary’ or ‘extraordinary’ (Han, 2013), ‘low-’ or ‘high-tech’. In this book, we draw on Rene Almeling’s helpful definition of reproduction as ‘the biological and social process of having or not having children’ (2015, p. 430); we understand this to encompass conception, contraception, pre-conception care, pregnancy, infertility, birth, abortion and neonatal and infant care. We use the term ‘technology’ to include pharmaceuticals, devices, tools, digital applications, clinical and diagnostic procedures. Crucially, while ‘RT’ has often come to be a shorthand for ARTs, we consider any technology that facilitates the biological and social process of having or not having children, or which is imagined to do so, a RT. In Frankenstein, Shelley draws on the Gothic genre to depict the destructive power of those with wealth and position, arguing that political systems have the capacity to victimise those who are empowered as well as those who are disempowered, illustrated by the fates of Frankenstein and his Creature (Bennett, 1998). While we would modify this to take account of the fact that, while politics has the capacity to corrupt all, its potential for violence is typically disproportionately aimed at the already disempowered, we do agree with Shelley’s focus on the political, moral and social forces that drive technologies. Technologies are shaped by the epistemic norms, cultural values, financial pressures and political possibilities of the contexts in which they are developed and made available. The cultural scripts of developers and promoters can make technologies (un)thinkable, yet these precepts and values are not necessarily replicated in local practice or individual experience and may in fact also be sites of creativity and resistance (Beaudevin & Pordi´e, 2016; Cuboniks, 2018; Hardon & Moyer, 2014; Lewis, 2019; Sanabria, 2016; Sheoran, 2015). But, this is not a one-way process – we agree with Lock and Nguyen (2018, p. 20) that ‘technologies should be understood as both produced through culture and as productive of culture’. We embrace a fairly broad definition of RT here – for example, the chapters include genetic testing, Viagra and HIV medication – and we do so deliberately, to provoke thinking about RTs that breaks down methodological assumptions and disciplinary silos, as we will explain in this introductory chapter. We recognise that focusing on RTs can provoke an assumption of a technologist bias, yet it is our explicit intention to cover a range of quite ‘ordinary’ technologies alongside

Introduction: Technologies of Reproduction

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the more high-tech. As Sallie Han’s chapter in this book shows, even apparently playful RTs such as home genetic testing kits can have spectacular and upsetting results, while as Sonja Mackenzie’s chapter shows something that is not usually thought of as an RT like birth certificates, passports or borders can still be enmeshed in questions of who counts as a parent. We also point out that medicine and medical technologies play a role in a large number of people’s lives and RTs are widely known and/or available (at least in theory) in high-, middle- and low-income countries (Franklin, 2013; Wahlberg, 2016). Indeed, in many contexts, it is fair to say that RTs have become normalised to the extent that their use is determined as a moral or cultural imperative (Franklin & Roberts, 2006; Gammeltoft & Wahlberg, 2014; Murphy, 2017; Sandelowski, 1993; Russel, Thompson, & Sobo, 2000; Solinger, 2001; Strathern, 1992; Wahlberg, 2008). Reproduction is the result of series of ongoing decisions, made individually and collaboratively, with more or less agency and with different levels of support. This could be envisaged as a series of socio-ecological concentric circles that surround an individual as they relate to reproduction and RTs at different points in their lives. The immediate circle would be their everyday (and, in many cases, long-term) relationships with partners, children, kin, friends, mentors and co-workers. Thinking about this circle reminds us of an obvious point, though it is often occluded by a focus on individuals in the discourse surrounding reproductive decision-making, that reproduction is relational. Another circle that surrounds and shapes an individual’s reproductive life is technology itself, and the industries and infrastructures that facilitate its use, availability and accessibility. Beyond this, is the circle of culture and society, with its structures of political, economic and moral power and its intersecting inequalities, and alongside this, public discourses and media representations that contribute to the meanings and assumed use(r)s of different RTs. Another further circle represents globalised and universalising forces that help shape national and local contexts. This is particularly evident if we consider global discourses and programmes around ‘family planning’, which are enshrined in many international agreements such as the UN’s Sustainable Development Goals. The central tenet of this collection is that RTs are not imagined or experienced in isolation by the people who use them. However, clinical, public health and even social scientific research often reflects a parcelling out of reproduction into specialist areas of biomedical intervention. Studies tend to be bound to specific physiological events, technologies (particularly those that are more obviously high-tech or novel) and people – namely cis, heterosexual women. Yet, with the ever-expanding horizon of RT and the rapid development of the fertility industry, the reality is that many individuals will engage with more than one RT at some point in their life. Their differential access to and experience of one technology is therefore likely to be shaped by their previous or concurrent experience with another, and this will have effects on their expectations and uptake, as well as the technologies’ availability, commercial success, ethical status, legal regulation and social meaning. This point is poignantly illustrated by Sharmila Rudrappa’s (2015) account of transnational surrogacy in India in the early twenty-first century, in which the ubiquity of female sterilisation made relatively poor women’s

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bodies ‘bioavailable’ (Colen, 1995) for surrogacy and built Indian medical professionals’ expertise in obstetrical and gynaecological surgery (see also Nandagiri, this volume), which we consider exemplary of an integrated account of RTs. As Rudrappa puts it, ‘surrogacy in India cannot be understood outside the context of population control programs. Markets in life – and surrogacy is a prime example of such a market – have to be located in the larger medicotechnical interventions that make certain bodies, specifically those of working-class Indian women, the foundation for reproductive assembly lines’ (2015, pp. 10–11). In this example, working-class Indian women’s bodies were intervened in to both curtail their own fertility, which was deemed undesirable according to the logics of historical and contemporary population control, and to facilitate the reproduction of middleand upper-class (and, at the time, typically white Global North) families who accessed their reproductive capacity through financial means. Studies of RTs have provided important empirical data about the social meanings and personal experience of RTs in recent decades. Reproductive scholars have also made substantial theoretical contributions to our understandings of gender, race, disability, sexuality, religion, nature, genetics, medicine, ageing, kinship, marriage, adoption, parenting and much more. This book seeks to encourage further reflection on what reproductive studies have achieved and also what methodological, empirical and theoretical blind-spots have built up as the field has developed. Building on interdisciplinary dialogue between sociology, anthropology, history, epidemiology, gender studies, psychology, cultural studies and public health, in this book, we identify overlaps and discontinuities both in users’ experiences and analytical approaches to these technologies. The following chapters explore the local dynamics surrounding RTs, their use and their effects, alongside the broader interrelated logics that drive their production, promotion and use. It also reflects on what the intended and unintended effects of our methodologies for researching RTs are. In this introduction, we will draw on the reproductive justice framework to explain why we think it is important to take an integrated and comparative approach to the study of RTs, as well as to propose how to build such an approach. However, our intention is to be more experimental than didactic, so this book also serves as an invitation to encourage others to take up and test these propositions, too. The workshop in November 2019 was sponsored and hosted by the Fondation Brocher in Switzerland, which promotes pluridisciplinary research on the ethical, legal and social issues (ELSI) arising from new medical development and health policies.1 The workshop brought together sociologists, anthropologists, gender studies and science studies scholars, clinicians and public health professionals of the World Health Organization. The participants spanned a range of career stages and together represent a broad expertise in RTs and different methodological approaches to their study. We had two days of traditional workshop format, punctuated with refreshing views of Lake Geneva and mini Toblerones provided by the Foundation. On the third day, we used creative and collaborative approaches to identify our exact aims for the project and to consider what might be the best contribution we could make to academic knowledge and even to policy discussions. Many of the original workshop members agreed to contribute a

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chapter to this book. We have also invited a handful of others to contribute, with the aim of broadening and deepening the range of topics and experiences we present here. For many of the contributors, this has been an opportunity to go back to data they always wanted to do something with, but were unsure how to do so, or to have the opportunity to draw comparative links between different datasets, which has been a joyful process for us, as editors, to midwife. Around a year after the original workshop, we held a further set of workshops – online, this time, due to COVID-19 restrictions – in which authors were paired up as discussants on each other’s draft chapters. This allowed us both to provide in-depth feedback to each author and to foster a sense of collective engagement with and involvement in the book amongst the contributors. This book focuses particularly on time, timing and temporality in people’s engagements with RTs, proposing an approach to studying RTs that takes greater account of the lifecourse. This is an attempt to get at the richness of people’s experiences, whilst also trying to retain a sense of the complex, social, political, economic, religious, moral and cultural forces that shape that experience – and how they might shift over time and at particular historical moments. The chapters in this collection aim to show the different temporalities at work in the operation of RTs, including how different RTs come to make sense (or not) at different points in individuals’ lifecourses; how technologies themselves have lifecourses, which may reflect the current pre-occupations of (putative) users, and also the state of technology and the broader socio-political and demographic concerns of the time. Another aspect of this is the ways in which RTs themselves do and do not work together across lifecourses – some technologies are imagined to complement and extend each other, while others are thought to negate the need for or replace others, while some technologies are used in ways that were not anticipated by their developers or promoters. In this way, we take a relational approach to time that considers how people relate to, with and over time. In the remainder of this introduction, we explain in more detail what an integrated approach to the study of RTs means and propose how it might be achieved (see also Boydell & Dow, 2021). In the next two sections, we outline why we think the reproductive justice framework is vital to the study of RTs and how it is relevant to the integrated approach that we are proposing, before going on to argue that we need to take account of the lifecourse of individuals, families and technologies in order to fully understand RTs and the context in which they are used (and refused). Focusing on the lifecourse – which we never imagine to be a singular or universal experience – helps us to explicate the importance of time and temporalities in the lives of RTs and their users and to consider how we might extend and adapt our methodologies to reflect this; this point is taken up in the following section. We end on a summary of the book’s structure, synthesised with a description of some of the main themes from the chapters, to propose what an integrated approach might look like. The empirical chapters are divided into three parts, which will all also have their own short introductions in order to explore the themes in a little more depth.

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Reproductive Justice and Technologies of Reproduction While, as many of the chapters in this collection show, individuals are constantly exercising agency and resisting norms and political pressures, it is important to recognise that reproductive decision-making is rarely, if ever, a free choice, because everyone is constrained by the contexts in which they live, the relationships of which they are part and, quite simply, by the availability of technologies themselves. As the different examples in the chapters show, individual experiences are situated within wider structures that determine different groups’ access to and use of RTs, according to gender, race, sexuality, religion, disability or health status and class. Importantly, access to RTs is not understood here as simply whether one can afford or is legally allowed to use a technology, vitally important as that is, but also encompasses the subtle ways in which some technologies appear to be unthinkable or unsuitable for certain ‘types’ of people, according to insidious beliefs about whose reproduction should be facilitated and whose curtailed (Colen, 1995; Davis, 2019; Murphy, 2017; Roberts, 2017; Rudrappa, 2015; Solinger, 2001). Reproductive justice scholars and activists have criticised second-wave feminists and reproductive rights campaigners for focusing on access to abortion at the expense of considering other forms of reproductive injustice that people face, as well as occluding the fact that access to any RT is determined by intersecting inequalities based on race, class, sexuality and disability as well as gender. Instead, they propose a three-part framework that is based in social justice: ‘(1) the right not to have a child; (2) the right to have a child; and (3) the right to parent children in safe and healthy environments’ (Ross & Solinger, 2017, p. 9). This framework is vital for building a more representative picture of reproduction, reproductive rights and the ways in which inequality and injustice determine people’s ability to fulfil their sexual and reproductive desires. It is also highly relevant for our project here. As Rishita Nandagiri points out in her chapter in this collection, studies of encounters with RTs that are attentive to individual experiences and local contexts, but which also take account of (trans)national and historical circumstances, can ‘centre women’s lived realities in the interrogation of power, making visible the mechanisms of injustice and the potential for activism in the pursuit of reproductive freedom’ [p. 42]. Reproductive justice reminds us to take account of the complex contexts in which reproduction does and does not take place and the part that technologies play in upholding and/or circumventing those contexts. Treating RTs as singular technologies or their use as isolated experiences is not only na¨ıve, but reproduces a privileged view that is wilfully blind to the experiences of vast numbers of people across the world who are subject to reproductive injustice. As noted, as well as attending to the concentric circles that contextualise any reproductive experience, in this book, we aim to pay particularly close attention to time. Reproductive justice is a movement that looks both forward and back, exhorting scholars and activists to remember the injustices of the past and how they structure the present, but also to work towards a liberatory future. Reproductive justice comes out of a particular set of experiences, specifically those of women of colour and Indigenous

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women in the United States. It is a movement with its own lifecourse and we should be careful about applying it to other contexts, especially in the cases of those with relatively high levels of socio-economic privilege. Nonetheless, we feel that the key principles are an apt analytical framework in many, if not all, contexts and that applying these principles across a range of settings is a way of building solidarity between different movements for equality, social justice and reproductive autonomy.

Reproduction and the Lifecourse Following Rene Almeling’s (2015) call to re-conceptualise reproduction as ‘a multi-layered biological and social process’, we propose applying a life-course approach as a heuristic which places greater emphasis on time and historicity in conceptualising lives and our encounters with different technologies. This also accords with the three principles of reproductive justice outlined above, which establish the point that different RTs make sense at different points in people’s lifecourses, depending on whether conception is desired or not and on what barriers might be in place to achieve this aim. RTs are encountered within specific historical moments in which people’s lives unfold. For example, both reproductive justice activists and historians of medicine have shown how eugenic campaigns and the early feminist movement worked together to facilitate access to contraceptive technologies in the early twentieth century and how that determined who was given access, under what conditions and to which technologies (Marks, 2001; Watkins, 2012). IVF, meanwhile, has become a ‘platform’ for a host of biotechnological applications (Franklin, 2013), yet, at the time it was developed in the late 1970s in the United Kingdom, it was presented as ‘controversial’, yet rapidly accepted as a means for facilitating the natural desires of ‘respectable’ heterosexual couples to have children (Dow, 2018). Historians and social scientists have shown that technologies have their own histories and that these are often interlinked with other technologies’ successes and failures (Hartmann, 1995; Oudshoorn, 2003; Solinger, 2001), while Rayna Rapp (1999) notably characterised how early users of amniocentesis were put in the position of being ‘moral pioneers’ and Charis Thompson (2005) characterised the ‘ontological choreography’ of the first generation of intended parents using ARTs. An idea that stubbornly persists throughout these different histories is the assumption that women are primarily responsible for reproduction and its management and are therefore the main target for technological interventions (Almeling, 2020; Inhorn, 2020; see Wilson, this volume). Relatedly, RTs have been primarily envisaged as serving heterosexual (and in many cases, specifically married) couples, though this seems likely to shift as increasing numbers of LGBTQ 1 intended parents use RTs, thereby reshaping the technologies themselves, as well as inevitably provoking developers to explore new ‘markets’ (see also Mackenzie, this volume). Just as there is no universal lifecourse, reproducing and preventing reproduction each make sense at different times in people’s lives – and of course there

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are many who never wish to reproduce at all. In studying people’s histories and experiences, we must address the lived past and anticipated futures, but also how early experiences set the stage for future ones. As this suggests, the lifecourse might be seen as less a series of separate events and more as a cumulative process. RTs themselves have a very limited focus on preventing or facilitating conception (or ‘live birth’). This is also, understandably, the focus of those who develop, administer and promote these technologies, or at least that is how they are presented (see van de Wiel, Whitacre this volume). But for (intended) parents, conception, pregnancy and birth, or their prevention, are not isolated events, but are a point on the lifecourse and a means towards a particular future – a live birth is not the end of the story, but in many ways, the beginning; this is certainly the case for the newborn child. This point also resonates with the third principle of reproductive justice, which enshrines the right to raise and care for children in healthy environments and here we also note our support for the argument put forward by Charlotte Faircloth and Zeynep Gurtin (2017) to create more space for dialogue between reproductive studies and parenting studies. Lifecourses are made up of expectations, imaginaries and aspirations as well as concrete experiences. Disruption and surprise are common experiences, often associated with the use of technologies which can reveal new knowledge or make the unexpected or previously impossible happen. In many of the chapters of this book, engagements with RTs reflect and provoke ambivalence, uncertainty and the recalibration of expectations in relation to the lifecourse. This relates also to the ways in which public discourses and media representations play into positive and negative valuations of different stages in the lifecourse, as illustrated by Susan Pickard’s chapter in this volume on media discourses around menopause and its biomedical management. A lifecourse approach reminds us that individuals’ ideas, aspirations, identities and relationships shift over time. Similarly, as noted, taking an integrated and comparative approach brings out the relational dimensions of RT. Again, this is revealed by focusing on how RTs relate to people’s imaginaries and experiences of the(ir) lifecourse. Many studies of RTs offer insights into the ideologies and practices of the nuclear family, and particularly the pressures it brings in relation to expectations of balancing professional and domestic duties and living up to aspirations of ‘good’ parenting, but, as many chapters here show, reproduction is often a multigenerational affair. Focusing on conception and clinical encounters can obscure this, so we encourage studies of reproduction that look beyond the walls of the clinic or even the intended parents’ home and consider what part their broader network of kin and other supporters plays in their reproductive imaginaries and realities. Furthermore, many studies of ART in the Global North focus on infertility related to later childbearing, but for many people around the world, secondary infertility is a pressing problem. The array of RTs available to women (in particular – see Wilson, this volume) over their lifecourse creates endless decisions and scrutiny for those decisions – covering the clinic, the home, work, intimate relationships and leisure activities. Many RTs are associated together in clinical practice, both explicitly and implicitly – for example, foetal screening is often tied up with an assumption of

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abortion following a positive result (Gammeltoft & Wahlberg, 2014; Rapp, 1999). With a wide, and expanding, array of RTs on offer and as (high-)technology has become a normalised aspect of reproduction, it is important to understand how different RTs relate to each other over a person’s life, for example how egg-freezing is tied into contraceptive use, pregnancy testing and ARTs and seems to both extend fertility as well as assume (future) infertility, as explored in Kylie Baldwin’s 2019 monograph in this book series (see also van de Wiel, 2020). Focusing on the lifecourse draws attention to the multiple and competing temporalities that we work with at different points in our lives. As the chapters by ¨ Nolwenn Buhler, Josie Hamper and Susan Pickard show, past experiences and bodily knowledge form a template for a particular reproductive trajectory and future (Adams, Murphy, & Clarke, 2009). We live at a point in history in which the hegemonic expectation is that people, conceptualised as individuals who can make free choices, should manage their time and optimise their lifecourse through diligent planning, facilitated wherever necessary by technologies. Yet, the reality of this expectation, even for those with relatively high economic, social and cultural capital, is a sense of uncertainty, failure and inability to control time, or to synchronise demands that are, in fact, inherently contradictory. Reproductive labour is still highly feminised, so the greater burden remains on women. This is encapsulated in Victoria Boydell’s chapter, in which her research participants express a longing for – but also, over time, scepticism about – the pursuit of balance, despite having access to a panoply of RTs. It is also laid bare, as Nicky Hudson and Caroline Law’s chapter shows, by the experiences of women with endometriosis and the disruptions and altered expectations that this condition presents for both their well-being and fertility. LGBTQ 1 people’s experiences of using RTs underline the importance of time and temporality in reproduction, whether in the case of LGBTQ 1 people’s engagement with contraception (Walks, 2007), their shifting imaginaries about the thinkability of becoming parents with new legal and medical possibilities (Pralat, 2018), or, as Petra Nordqvist has shown, the role of grandparents in lesbian parents’ reproductive trajectories (2014). While Lee Edelman (2004) has helpfully drawn attention to the heteronormativity of ‘reproductive futurism’, many LGBTQ 1 people are finding ways to use RTs to meet their needs, even when their rights are not recognised in law or reflected in clinicians’ expectations of a typical patient, and, as Sonja Mackenzie discusses in her chapter, not necessarily in ways that reproduce heteronormative assumptions about reproduction, kinship, gender and parenting (see also Smietana, Thompson, & Twine, 2018). This collection is not representative of the full range of reproductive experiences or positionalities, but it does draw attention to some under-studied aspects of reproductive life and, by showcasing the advantages of comparative and longitudinal research, it aims to suggest ways forward for the study of reproductive technologies which are steeped in the realities of reproductive injustice and stratification. At the same time, we wish to acknowledge the role that researchers’ own positionalities play in the study of RTs, from topic selection to the recruitment of research participants, as well as how these are buttressed by the priorities

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of funders, peer reviewers, institutions of higher education, supervisors and colleagues. However, in pushing for a more integrated approach, we wish to draw attention not only to differences and exclusions but also to overlaps and potential solidarities. Technologies of Reproduction across the Lifecourse originates in our experiences of having a foot in reproductive studies and a foot elsewhere. We met whilst doing our PhDs together in social anthropology at the London School of Economics, bonded by our shared interest in anthropology ‘at home’ and the anthropology of reproduction, which was something of a niche concern in our department at that time. Victoria Boydell was then also working in global health, and continues to do so, for organisations including IPPF, UN agencies and private foundations alongside pursuing academic research at the Graduate Institute in Geneva. Katharine Dow has largely remained in academia, and currently works as deputy director of the Reproductive Sociology Research Group at the University of Cambridge, but has also worked beyond academia including in the UK parliament. This book, our second edited collection (see Dow & Boydell, 2018), marks roughly a decade from when we were awarded our PhDs. In that period, we have had time to reflect on reproductive studies then and now, as well as what came before and what might persist into the future. We have seen different RTs come and go, as Vicky’s chapter in this book illustrates. We have had daughters of our own and so our personal experiences of RTs have expanded, too. While we are both cis white, middle-class British citizens and therefore, like Mary Shelley, hold a considerable amount of personal privilege, we have always approached reproduction somewhat from the margins, always motivated by questions of power, rights and justice, trying to effect what Donna Haraway has described as the ‘double vision’ of situated knowledge (1997). In particular, this book represents an attempt to put intersectional feminist methodologies into practice, by using the resources available to us to create a collaborative, interdisciplinary and non-hierarchical space in which the participants might share their expertise on equal terms. In this book, we have tried to provide examples from the margins as well as from more familiar ground; though as noted below, we are aware that this book is by no means representative of the reproductive pluriverse. In particular, while the contributions at the original workshop from which this book emerges covered a fairly broad geographical area, the chapters in this book represent a more limited range of contexts, with a number of them focusing on the United Kingdom. As noted, this book is an invitation for others to take up the integrated approach to studying RTs and so we look forward to seeing more examples from many other parts of the world. Importantly, it should be clear that we do not focus only on the margins in order to provide interesting examples of how some people do things differently, helpful though that might be in terms of representation, but also to ask critical questions of normative practices and ideologies (see also Wilson, 2018). Within this, while we encouraged all of the contributors to be in conversation with reproductive justice in preparing their chapters, we have also tried to enable a range of views and political standpoints to emerge from the chapters included here.

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Methodological Reflections In addition to inviting reflection on the lifecourse of reproductive studies, this book represents a methodological intervention, inviting scholars of reproduction to consider how their own precepts about reproduction and technology shape how they go about researching RTs, including in their specific choice of research methods, topics and participants. While this book presents qualitative data, there is no reason why more studies should not combine quantitative and qualitative data, and in fact doing so might not only add richness to scholars’ accounts but also allow for greater interdisciplinarity and collaboration and afford greater opportunities to engage with different publics, including policy-makers. Scholars of reproduction are very good at integrating textual and visual analysis alongside ¨ data that capture lived experience (see Hamper, Buhler, this volume). This is something we strongly encourage, both for the better sense this gives of the contexts in which research participants are operating and in acknowledging the important role that public discourses play in our understandings and experiences of RTs (see Pickard, Hamper, this volume; see also Dow, 2016). Thinking about the different RTs that a person might encounter in a lifetime suggests the value of longitudinal research. This is illustrated by Victoria Boydell’s chapter in the volume, which shows how much we can learn by revisiting research participants at different points in their lives. Such a method (which is rarely facilitated by research funding schemes) goes against the tendency, noted earlier, for biomedical approaches to focus on conception alone, as well as allowing for participants to reflect and comment on their own experiences over time, which seems an important way of allowing for them to provide their own insights both on their experiences and the contexts that have shaped them. One way to get at the relationality of reproduction is to collect data not only from individuals but also from the significant figures in their lives. This can be done ¨ through couple interviews, as exemplified by the chapters by Nolwenn Buhler and by Nicky Hudson and Caroline Law, or by focusing on the children who are born through RTs and their parents, as Sallie Han and Sonja Mackenzie do in their chapters. Such studies also help to mitigate the over-representation of women in reproductive studies. As Ben Kasstan’s chapter shows, though, it is not only close relatives who have a part in reproductive decision-making and practices but also a range of professionals who support or restrict access to certain forms of healthcare; including them in data collection can help us to understand the different perspectives and rationales that guide their actions and which guide patients’ decisions. It is still quite rare to see studies of two or more RTs together, or of people who use one RT alongside those who reject or are excluded from using it. This can be captured by longitudinal research methods and/or comparative approaches. The chapters in the third section of the book exemplify the value of this. For example, both Ryan Whitacre’s and Lucy van de Wiel’s chapters are unusual that they compare two RTs that are not commonly thought of as related and in their attention to the development of RTs. Their chapters should prompt readers to pause and consider the implications these insights provide for how we tend to

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think about and conduct research on RTs. What makes an RT fitting to be studied and what drives our assumptions about how specific RTs may or may not be related to one another (see also Wilson, this volume, for how gender biases shape research and development). On a different topic, but with some similar aims, Nayantara Sheoran Appleton’s chapter plays with the different uses of hormonal contraceptives and their constituent ingredients. While some chapters show how different RTs might be used to facilitate the same kinds of goals, Appleton shows how what is essentially the same material – synthetic hormones – can be employed to effect radically different ends. This shows that technologies can be used in ways that were not anticipated by their developers or other users; this example also provides opportunities for reflecting on the broader assumptions that accrete around certain technologies, their users and their reasons for using them.

Structure of the Book This edited collection is structured to model what we consider to be some characteristic features of an integrated approach, which requires working at different scales. Reproductive technologies, like any other technology, can be studied across both temporal and spatial axes. In relation to time, the book’s first section considers how RTs relate to individuals’ lifecourses and the ways in which different RTs do, and do not, come into play at certain points and in relation to people’s particular experiences and relationships. We also recognise that specific RTs themselves have specific and inter-linked histories, genealogies and biographies and this is the focus of the second section. The final section is comparative and considers the complex interactions between different RTs, their users and providers, offering new perspectives on what particular RTs have in common and where they diverge, in terms of their usage, promotion and development and their social, ethical and political meanings. Each section is prefaced by a short reflection on a persistent theme in reproductive studies – knowledge, choice and relationality – which allows us to draw out further insights from each of the chapters. The fact that most of the chapters could easily belong in more than one section of the book is a strength because it shows, for us, the integrated approach at work. The first section explores RTs within a person’s biography and examines how different technologies intersect across lifecourses, as well as how lifecourses are structured through reproduction and the use, or refusal, of RTs. This section focuses on both empirical and discursive accounts of how RTs relate to individuals’ lifecourses. Reproduction and time are perhaps most obviously linked through ideas about timing, planning and decision-making. Early behavioural theories of contraceptive practice suggest linear change from individual intention formation to enacting a behaviour, yet increasingly research shows that contraceptive decisions are regularly revised with new experiences and knowledge. Over time, the experience of using contraception accrues and decisions are not based on a distant future, but rather more immediate concerns (Downey, Arteaga, Villasen, & Gomez, 2017). The meanings and values associated with contraceptives not only accrue over time

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but are also influenced by knowledge and experiences of other contraceptive methods as well as other RTs, whether it be abortion, egg freezing or medicalised childbirth. This is reflected in Rishita Nandagiri’s chapter in this volume, which examines both sterilisation and abortion experiences within women’s reproductive lifecourse in India and reminds us that, as she puts it, ‘Reproductive decision-making – to have a child, to not have one, to parent – are a series of connected events and experiences occurring over a woman’s lifecourse’ [p. 31]. When we look at RTs across the lifecourse, the intersections and interactions between gender, reproduction and age become clear. Susan Pickard’s chapter homes in on the gendered structure of temporality that generates time anxiety and age-related scrutiny of women. The fact that certain RTs are associated with particular age groups reflects assumptions about how age, gender and reproduction (should) intersect. This seems to be driven by some implicit Goldilocks principle, where all the conditions are ‘just right’ for reproduction, which propels the development and consumption of a range of technologies and interventions ¨ that works so as not to reproduce ‘too young’ or ‘too old’ (see also Bulher, 2015; van de Wiel, 2014). These questions of timing are given further poignancy when we consider the effects of chronic conditions which seem to pit personal well-being against reproductive hopes. In their chapter, Hudson and Law make the important point that studies of RTs have not paid as much attention to experiences of chronic conditions as they might have. Drawing on research with couples whose reproductive trajectories are shaped by the lived experience of endometriosis, they examine how the constant uncertainty which participants described as characteristic of this condition led them to approach RTs with low or modest expectations. This contrasts with the hope and, in some cases, hype, that has tended to surround ARTs since the late 1970s (Dow, 2017; Franklin, 1997; see also van de Wiel, this volume). It also adds a further layer to our understanding of how expectation, timing and ‘choice’ intersect with technology, begging questions about who RTs are serving – and whose needs they overlook. Looking at the interactions between different RTs across the lifecourse helps to surface several rich analytical seams. Hudson and Law’s chapter also points to the emotional effects of (in)fertility and of using RTs, barriers to access to particular forms of healthcare, and the ways in which people come to embody different temporalities point to the relationship between physical health and mental health. As Josie Hamper states in her chapter in the second section, ‘[t]he lived experience of pre-empting events in an unknown future often entail emotional registers of anxiety and apprehension’ [p. 197]. This resonates with analyses of the anxious pursuit of balance (Boydell, this volume) and Sallie Han’s account in this volume of the shock of learning about one’s problematic origins and potential new relations through a technology that is supposed to be fun. The second section of the book focuses on histories of RTs themselves, and on understanding how they are shaped by the specific contexts and constraints within which they are operating, which may go well beyond what is typically considered to be the reproductive sphere. Several notable efforts have been made to document the lifecourse of specific RTs and how historical norms shape the conditions

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for today’s technologies and practices, including Nelly Oudshoorn’s (2003) study of the male contraceptive pill. Accounting for historical contexts helps us to better trace how prevailing social norms have come into play in product design and evolution. We need to take into account the historical contexts in which the technologies become developed and used, and the social and temporal situatedness of individuals and their encounters with them (see also Whitacre, this volume). Nayantara Sheoran Appleton’s chapter, an examination of oral contraception in different social and temporal settings, reveals a long-standing relationship between concerns about population growth and averting environment crisis which reproduces colonial agendas and cements gender binaries (Ojeda, Sasser, & Lunstrum, 2020). Oral contraception has been mobilised at different times to serve different agendas: from economic development, ‘sexual revolution’ and ‘empowerment’, to preventing poverty, war and climate crisis (Bashford, 2014). Appleton’s account reminds us that technologies are not static. Many authors have charted the trajectory of RTs from experimental techniques at the frontier of science to becoming part of the standard-of-care (see Wahlberg, 2016). Clarke, Shim, Mamo, Fosket, and Fishman (2003) have described the same trend in biomedicine more generally, in that innovations from earlier eras become the invisible infrastructure of the next. RTs may well move from ‘novelty to norm’ (Leavitt, 2006), but earlier generations of RTs are no less engineered nor less significant in people’s lived experiences (see also Ross, 2018; Sanabria, 2016). Han (2013) reminds us that RTs like sonograms moved from being spectacular in the 1960s to the mundane and expected routine care by the end of the century – through those less ‘spectacular’ routine engagements individuals themselves actively invite and incorporate capital and surveillance into their lives: governmentality at its most forceful (see also Gammeltoft, 2014). Sallie Han’s account of the role of commercial genetic testing and the secret children of Dr Donald Cline in this volume illustrates how engagements with RTs extend beyond the moment of use into the past and into the future, describing how RTs can create kinship in hindsight. Hindsight works in other ways: several chapters describe how RTs help to re-write the past, whether it is historical data ¨ (Hamper, this volume) or re-classifying past relationships (Buhler, this volume). The temporality of RTs is more than just anticipatory; it can enable a reworking of the past to match the present or in service of the future. The widespread acceptance of the genetic testing industry provides a window onto the commercial forces surrounding RTs. Many of the ‘new’ RTs covered in these pages are products of crafty repackaging of existing technology by commercial bioscience. Josie Hamper’s account of fertility tracking with smartphone apps in heterosexual women’s lives after contraception and before fertility treatment speaks to how fertility tracking intersects with other RTs. These personal accounts illustrate how bodies intersect with extended temporal registers of the lifecourse that encompass historical archives of bodily data captured on the app, which are then used to calculate, predict and anticipate the future, tied to wider discourses of rationality and individual responsibility. Hamper connects the contemporary self-monitoring techniques of fertility apps with a longer

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established tradition of fertility awareness in women’s health, while Pickard points out how Ovarian Tissue Cryopreservation and Transplantation is a commercially viable spin-off from fertility preserving treatment for women undergoing cancer treatment (see also van de Wiel, this volume). By looking at the histories of technologies, we capture how they are re-fitted through processes of digitisation, financialisation and commercialisation, and in doing so create new possibilities for bodies, time, technologies and reproductive health advice. Sonja Mackenzie’s chapter takes a broader approach to RTs, considering how borders and the regimes that govern them act as RTs. Drawing on autoethnography and building on her previous conceptualisation of structural intimacies (Mackenzie, 2013), Mackenzie deftly reveals how borders reinforce heteronormative, patriarchal and white supremacist ‘bloodlines’ which constrain who counts as family, a parent, at home and/or as ‘legal’. Mackenzie’s experience at several reproductive frontiers reveals the assumptions and expectations embedded in states’ formulations of relatedness and citizenship, as well as the acute vulnerabilities of ‘alternative’ forms of kinship and reproduction when they butt up against highly conservative immigration policies. Victoria Boydell’s longitudinal research with women using a range of RTs over a ten-year period draws out the many ways that women invoke ‘balance’ when talking about the different RTs they have engaged with in their lives, and how this has shifted over time. Regardless of the RT under discussion, the references to balance always related to bridging the public and private parts of themselves, which has become associated with contemporary feminist ideals in which women are expected to want, work for and have ‘it all’. Similarly, in the final section of the book, we look at examples that compare different RTs and different people’s use of the same technology. Comparison brings to light perspectives that can be excluded or drowned out by an analytical focus on the experience of using specific technologies. Through comparative methodologies, we can see how different technologies are working together, how different technologies facilitate the same goals and illustrate that, with so many technologies at play, the desires and aspirations they seem to enable are far from straightforward. Several of the chapters in this section also build on the points raised in earlier sections about the financial and cultural logics that shape how RTs are developed and marketed. Ben Kasstan’s chapter compares data from two religious (and ethnic) minority groups in the United Kingdom, analysing how specific RTs may be used by particular individuals and communities to effect anticipated future reproductive potential. This comparative approach allows Kasstan to show the limits of the discourse of choice in reproduction, in its inattention to the relationality of reproduction and the situated constraints in which individuals operate – which may reflect both the specificities of particular moral, religious and cultural expectations about reproduction and gender roles, but also the difficulties of living within a minoritised group within the United Kingdom’s ‘hostile environment’. Of course, it is not only religious and ethnic minorities who live with structural constraints and other chapters in the book show the different forms this can take, even for those with relatively greater privilege or apparent autonomy.

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Amanda Wilson’s chapter addresses an important, and telling, lacuna in reproductive studies, which is the relative invisibility of men. Wilson shows how this has played out in the development of RTs, most of which continue to be aimed at and practiced on female bodies and even when, as noted, reproduction is a relational process. For example, Wilson describes how the invention of the electron microscope has transformed how sperm is perceived, both literally and figuratively. More sophisticated visual technologies improve and complexify scientific understandings of sperm and therefore conception and (in)fertility, but these new visions can also counter the gendered understandings of reproductive substances’ form, movement and functionality, with consequences for where future clinical interventions are targeted. Ryan Whitacre and Lucy van de Wiel both trace how certain ideas and norms cut across RTs, whether in their development or in practice. Whitacre examines the histories of biomedical technologies and shows how their development has been infused with ideas and ideologies of intimacy. Ideas about women, men, babies, drugs and diagnostics converge in clinical research and propel products out onto global pharmaceutical markets. Lucy van de Wiel takes two apparently unrelated or contradictory RTs, egg freezing and abortion, and considers how their similarities and differences illuminate contemporary reproductive politics and the workings of the highly lucrative fertility industry. Her analysis reveals how regimes of accumulation, risk and control intersect in what she calls reproductive and non-reproductive technologies, as well as how the use of online platforms in the provision of egg freezing start-ups and abortion telemedicine are re-spatialising reproductive decision-making and practices.

Note 1. The participation of Katharine Dow was also supported by a Returning Carers grant from the University of Cambridge, which supports those returning to work after a period of parental or caring leave to participate in events and projects that might benefit their career – so, in its way, a form of reproductive technology.

References Adams, V., Murphy, M., & Clarke, A. (2009). Anticipation: Technoscience, life, affect, temporality. Subjectivity, 28, 246–265. doi:10.1057/sub.2009.18 Almeling, R. (2015). Reproduction. Annual Review of Sociology, 41, 423–442. Almeling, R. (2020). Gunecology: The missing science of men’s reproductive health. Berkeley, CA: University of California Press. Baldwin, K. (2019). Egg freezing, fertility and reproductive choice: Negotiating responsibility, hope and modern motherhood. London: Emerald Studies in Reproduction, Culture and Society. Bashford, A. (2014). Global population: History, geopolitics, and life on earth. New York, NY: Columbia University Press. Beaudevin, C., & Pordi´e, L. (2016). Diversion and globalization in biomedical technologies. Medical Anthropology, 35(1), 1–4. doi:10.1080/01459740.2015.1090436

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Bennett, B. T. (1998). Mary Wollstonecraft Shelley: An introduction. Baltimore, MD: Johns Hopkins University Press. Boydell, V., & Dow, K. (2021, July 19). Adjusting the analytical aperture: Propositions for an integrated approach to the social study of reproductive technologies. BioSocieties. doi:10.1057/s41292-021-00240-w ¨ Bulher, N. (2015). Imagining the future of motherhood: The medically assisted extension of fertility and the production of genealogical continuity. Sociologus, 65(1), 79–100. Clarke, A., Shim, J. K., Mamo, L., Fosket, J. R., & Fishman, J. R. (2003). Biomedicalization: Technoscientific transformations of health, illness, and U.S. Biomedicine. American Sociological Review, 68(2), 161–194. Colen, S. (1995). Stratified reproduction and West Indian childcare workers and employers in New York. In F. Ginsburg & R. Rapp (Eds.), Conceiving the new world order: The global politics of reproduction (pp. 78–102). Berkeley and Los Angeles, CA: University of California Press. Cuboniks, L. (2018). The Xenofeminist manifesto. A politics for alienation. London: Verso Books. Davis, D. (2019). Reproductive injustice: Racism, pregnancy, and premature birth. New York, NY: New York University Press. Dow, K. (2016). Making a good life: An ethnography of nature, ethics, and reproduction. Princeton, NJ: Princeton University Press. Dow, K. (2017). ‘The men who made the breakthrough’: How the British press represented Patrick Steptoe and Robert Edwards in 1978. Reproductive BioMedicine and Society Online, 4, 59–67. Dow, K. (2018). “Now she’s just an ordinary baby”: The birth of IVF in the British press. Sociology, 53(2), 314–329. Dow, K., & Boydell, V. (Eds.). (2018). Nature and ethics across geographical, rhetorical and human borders. London: Routledge. Downey, M. M., Arteaga, S., Villasen, E., & Gomez, A. N. (2017). More than a destination: Contraceptive decision making as a journey. Women’s Health Issues, 27(5), 539–545. Edelman, L. (2004). No future: Queer theory and the death drive. Durham, NC: Duke University Press. Faircloth, C., & Gurtin, Z. (2017). Fertile connections: Thinking across assisted reproductive technologies and parenting culture studies. Sociology, 52(5), 983–1000. Franklin, S. (1997). Embodied progress: A cultural account of assisted conception. London: Routledge. Franklin, S. (2013). Conception through the looking glass: The paradox of IVF. Reproductive BioMedicine Online, 27, 747–755. Franklin, S., & Roberts, C. (2006). Born and made: An ethnography of preimplantation genetic diagnosis. Princeton, NJ: Princeton University Press. Gammeltoft, T. M. (2014). Haunting images: A cultural account of selective reproduction in Vietnam. Berkeley, CA: University of California Press. Gammeltoft, T. M., & Wahlberg, A. (2014). Selective reproductive technologies. Annual Review of Anthropology, 43, 201. Han, S. (2013). Pregnancy in practice: Expectation and experience in the contemporary United States. New York, NY: Berghahn Books.

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Haraway, D. J. (1997). Modest Witness@Second_Millennium. FemaleMan©_Meets_ On coMouse™: Feminism and technoscience. New York, NY and London: Routledge. Hardon, A., & Moyer, E. (2014). Medical technologies: Flows, frictions and new socialities. Anthropology & Medicine, 21(2), 107–112. doi:10.1080/13648470.2014. 924300 Hartmann, B. (2016 [1995]). Reproductive rights and wrongs: The global politics of population control. Chicago: Haymarket Books. Inhorn, M. C. (2020). Reproducing men in the twenty-first century: Emergement masculinities, subjectivities, biosocialities, and technologies. NORMA, 15(3–4), 299–305. doi:10.1080/18902138.2020.1831157 Leavitt, S. (2006). ‘A private little revolution’: The home pregnancy test in American culture. Bulletin of the History of Medicine, 80(2), 317–345. Lewis, S. (2019). Full surrogacy now: Feminism against family. London: Verso Books. Lock, M., & Nguyen, V. K. (2018). An anthropology of biomedicine. New York, NY: Wiley-Blackwell. Mackenzie, S. (2013). Structural intimacies: Sexual stories in the black AIDS epidemic. New Brunswick: Rutgers University Press. Marks, L. (2001). Sexual chemistry: A history of the contraceptive pill. New Haven, CT: Yale University Press. Murphy, M. (2017). The economization of life. Durham, NC: Duke University Press. Nordqvist, P. (2014). Bringing kinship into being: Connectedness, donor conception and lesbian parenthood. Sociology, 48(2), 263–278. doi:10.1177/0038038513477936 Ojeda, D., Sasser, J. S., & Lunstrum, E. (2020). Malthus’s specter and the anthropocene. Gender, Place & Culture, 27(3), 316–332. doi:10.1080/0966369X.2018. 1553858 Oudshoorn, N. (2003). The male pill: A biography of a technology in the making. Durham, NC: Duke University Press. Pralat, R. (2018). More natural does not equal more normal: Lesbian, gay and bisexual people’s views about different pathways to parenthood. Journal of Family Issues, 39(18), 4179–4203. Rapp, R. (1999). Testing women, testing the fetus: The social impact of amniocentesis in America. London: Routledge. Roberts, D. E. (2017). Killing the black body: Race, reproduction and the meaning of liberty. New York, NY: Vintage Books. Ross, E. (2018). Provisionally pregnant: Uncertainty and interpretive work in accounts of home pregnancy testing. Health, 22(1), 87–105. Ross, L. J., & Solinger, R. (2017). Reproductive justice: An introduction. Oakland, CA: University of California Press. Rudrappa, S. (2015). Discounted life: The price of global surrogacy in India. New York, NY: New York University. Russel, A., Thompson, M., & Sobo, E. (2000). Contraception across cultures: Technologies, choices, constraints. London: Routledge. Sanabria, E. (2016). Plastic bodies: Sex hormones and menstrual suppression in Brazil. Durham, NC: Duke University Press. Sandelowski, M. (1993). With child in mind: Studies of the personal encounter with infertility. Philadelphia, PA: University of Pennsylvania Press.

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Sheoran, N. (2015). ‘Stratified contraception’: Emergency contraceptive pills and women’s differential experiences in contemporary India. Medical Anthropology, 34(3), 243–258. doi:10.1080/01459740.2014.922081 Smietana, M., Thompson, C., & Twine, F. W. (2018). Making and breaking families–reading queer reproductions, stratified reproduction and reproductive justice together. Reproductive BioMedicine and Society Online, 7, 112–130. Solinger, R. (2001). Beggars and choosers: How the politics of choice shapes adoption, abortion, and welfare in the United States. New York, NY: Hill and Wang. Strathern, M. (1992). After nature. English kinship in the late twentieth century. Cambridge: Cambridge University Press. Thompson, C. (2005). Making parents: Reproductive technologies and their ontological choreography. Cambridge, MA: MIT Press. Turney, J. (1998). Frankenstein’s footsteps: Science, genetics and popular culture. London: Yale University Press. van de Wiel, L. (2014). For whom the clock ticks: Reproductive ageing and egg freezing in Dutch and British News Media. Studies in the Maternal, 6(1), 1–28. doi: 10.16995/sim.4 van de Wiel, L. (2020). Freezing fertility: Oocyte cryopreservation and the gender politics of ageing. New York, NY: New York University Press. Wahlberg, A. (2008). Reproductive medicine and the concept of quality. Clinical Ethics, 3(4), 189–193. Wahlberg, A. (2016). The birth and routinization of IVF in China. Reproductive Biomedicine & Society Online, 2, 128–135. Walks, M. (2007). Breaking the silence: Infertility, motherhood, and queer culture. Journal of the Motherhood Initiative for Research and Community Involvement, 9(2). Retrieved from https://jarm.journals.yorku.ca/index.php/jarm/article/view/ 13808 Watkins, E. (2012). How the pill became a lifestyle drug: The pharmaceutical industry and birth control in the United States since 1960. American Journal of Public Health, 102(8), 1462–1472. doi:10.2105/AJPH.2012.300706 Wilson, K. J. (2018). Others’ milk: The potential of exceptional breastfeeding. New Brunswick, NJ: Rutgers University Press.

Reflection One: Knowledge Victoria Boydell and Katharine Dow

Abstract Here we provide a short reflection on the persistent theme of knowledge in reproductive studies which allows us to draw out further insights from each of the chapters. Keywords: Knowledge; biomedical knowledge; situated knowledge; embodied knowledge; reproductive technologies; reproductive studies Early studies of (assisted) reproductive technologies (RTs) in the 1990s were driven by a quest to understand the complex thought processes that informed women’s decisions to utilise these technologies. This reflected a fear amongst some feminists and others at the time that infertile women were being ‘duped’ into, as it were, putting all their eggs in the basket of assisted reproduction (Franklin, 2001). In fact, exemplary studies of that time, such as Sarah Franklin’s Embodied Progress, showed the sophisticated ‘ontological choreography’, to use Charis Thompson’s slightly later term, that patients put to work in navigating these technologies and their desire to become parents, but also that these technologies are always also about knowledge. As Marilyn Strathern (1992) has argued, RTs ‘literalise’ deep-seated cultural precepts about reproduction, kinship, inheritance, genetics, identity, individuality, diversity and much more – all of which are also matters of knowledge. Many types of knowledge interact in the production and use of RTs. The chapters in this section draw on the research and scholarship on varied ideologies and knowledge systems surrounding RTs. These knowledge systems provide an explanatory account of why things happen and a set of knowledge practices around how one can intervene in and shape reproductive processes, often using some combination of ordinary and extraordinary RTs (Han, 2013). The examples presented in these chapters, which are united by an attention to how different reproductive technologies interact across individuals’ lifecourses, point to various knowledge systems at play and the complex ways that they intersect and interact.

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Three knowledge systems feature throughout these chapters: biomedical, situated and embodied – and these differ in the degree of codification surrounding them and how recognised or reified they are by the actors concerned. Biomedical knowledge, the most codified and reified of the lot, understands reproduction in terms of universalised biology and gives a scientific explanatory account of why things happen the way they do and how to go about resolving them. Within this biomedical frame, reproduction can be examined by means of standardised techniques and procedures which offer technological methods for ‘repairing’ ‘abnormal’ bodies (Fausto-Sterling, 2000; Haraway, 1988; Martin, 2001). Drawing on presumed universal laws and corresponding statistical constructs, ideas of what is normal in biomedicine are tied to ideas about how things ought to be. Expected outcomes are rooted in ideologies of a pure and fixed nature and biology, which obscure the underlying assumptions that reproduce what counts as normal or natural (Dow & Boydell, 2018). This authoritative framework shapes the orientations and embedded practices of scientists and clinicians so much so that it is a culture unto itself (Hahn, 1996). Within this explanatory model, biology and biological facts have a privileged role (Franklin, 2001). Early, and still highly influential, scholarship in reproductive studies, such as the work of Rapp (1999) and Thompson (2005), provides vivid examples of how women actively engage with medical language and practice to achieve their ends, however ambivalent those might be. The chapters in this section are filled with accounts of people interacting and engaging with biomedical knowledge and practice, as well as practising it themselves. Biomedical rationales and ideas are constantly in play – particularly around ideas of age-related infertility and ¨ menopause (see chapters by Pickard and Buhler) and around what we think are the desired outcomes of biomedical interventions (see Kasstan in this volume). Biological facts are so imbued with authority and legitimacy that any exceptions to these facts lead to further technological interventions which (re)make bodies, rather than serious consideration of the ‘facts’ themselves (see Hamper and Han in this volume). Many RTs are first ‘known’ through public discourse and not through personal ¨ experience (see Pickard, Buhler, and Han this volume; Dow, 2016). RTs have often been described as a ‘lens’ onto broader social currents and in her chapter in Section 2, Sallie Han proposes that ‘a concept of spectacle might offer a corrective lens to examine how most of the rest of us understand reproductive technologies – that is, how our encounters with extraordinary reproduction from a distance might shape and inform our expectations and experiences of ordinary reproduction in our everyday lives’ [p. 132]. In her chapter, Susan Pickard’s analysis of media representations of menopause focuses on tensions between the positive and negative perceptions of menopause that are expressed in response to the commercial provision of ovarian freezing techniques (OTCT, or ovarian tissue cryopreservation and transplantation) in the United Kingdom. She traces how the biomedicalisation of menopause and the ability to optimise the ageing female body occlude positive experiences associated with menopause in the public sphere. In media accounts, there are two contrasting positions: on the one hand, there are the benefits for childless women of extending their childbearing years, on the other

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hand, there is a contrasting narrative of how these technological advances devalue women’s ageing and the post-reproductive life stage, making it difficult to see menopause in anything other than unfavourable terms, exposing the normative assumptions in biomedical discourse and cultural formations of age, lifecourse and gender. This raises parallels with Emily Martin’s (2001) analysis of biomedical accounts of the female body from the 1990s. In this collection, Josie Hamper explores fertility tracking with smartphone apps – which are used to both facilitate and prevent conception, much like ‘natural’ family planning methods – in heterosexual women’s experiences of trying to conceive. Hamper provides a powerful account of the attempts of women attempting to align their bodies with biomedical parameters through the ‘push’ function of the app. Transforming bodies into digital data makes them more valuable than other types of data such as embodied knowledge, as this kind of knowledge more easily translates into biomedical epistemology. Fertility tracking in the present creates data that, over time, constitute a digital archive of the body through which reproductive opportunities (i.e., ovulation) are calculated, predicted and anticipated. Data have thus become a reproductive substance and a reproductive technology in their own right (see also van de Wiel, 2019). Alongside biomedical knowledge, many of the chapters in this collection detail how knowledge, experience and meanings about reproduction and RTs are informed by local cultural understandings, social roles and moral values. Such knowledge reflects the knower’s particular perspectives, which are often shaped and conditioned by their social positioning. This knowledge is more dispersed, and filters how biomedical knowledge is interpreted and evaluated through people’s own lenses and experiences (Greenhalgh, Howick, & Maskrey, 2014; Martin, 2001; Rapp, 1999; Timmermans & Berg, 2010). In this collection, we have examples of how this situated knowledge is reflected in how RTs are developed (see van de Wiel and Whitacre), in their media representations (Han and Pickard), and in our ideas about who uses RTs and for what purposes (Kasstan, Nandigiri and Sheoran Appleton). Capturing situated knowledge (Haraway, 1988) does more than reflecting the knower’s perspective; it demonstrates the importance of how social positioning conditions knowledge and thereby helps us to better attend to the power relations surrounding the knowledge practices of RTs. Rishita Nandagiri’s chapter in this section examines the intersections between sterilisation and abortion within women’s reproductive lifecourse in India. Drawing on reproductive justice, she reminds us that ‘Reproductive decision-making – to have a child, to not have one, to parent – is a series of connected events and experiences occurring over a woman’s lifecourse’ [p. 31]. Examining the links between abortion and sterilisation, which are often treated as separate in women’s lived experiences, surfaces the pervasiveness of reproductive stigma and shame in limiting fertilities and how this manifests across the reproductive lifecourse. Nicky Hudson and Caroline Law’s poignant account of the interactions of women with chronic endometriosis with different RTs in the United Kingdom foregrounds how embodied knowledge tempers biomedical knowledge. Endometriosis is a common enough condition, yet there has been little work that

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considers the impact this chronic illness has on reproductive decision-making and the ways RTs (contraceptive and conceptive) intersect with the medical and surgical management of endometriosis. Drawing on the experiences of heterosexual couples in the United kingdom, Hudson and Law show how the uncertain and indeterminate character of endometriosis results in low expectations about RTs with more modest future orientations. Like Hudson and Law, several authors point to the more fluid knowledge of lived experience. This is knowledge grounded in bodily experience, including sensory information and tacit skills learnt through observation, imitation and practice. This knowledge encompasses the uncertainties, ambiguities and messiness of everyday life. ¨ Nolwenn Buhler’s ethnographic study on the effects of anticipation on Swiss couples’ experiences and negotiations of age-related infertility and assisted reproductive technologies (ARTs) brings to the fore the anticipatory dimension of RTs, in which decisions in the present project forward onto future reproductive decisions (Adams, Murphy, & Clarke, 2009), and this future-oriented temporality is reflected across the collection. By contrasting biomedical practitioners’ ¨ accounts against those of couples engaging with assisted reproduction, Buhler illustrates how ideas about lifecourse spurred by age-related infertility and ARTs are reduced to a biologically defined temporality that co-exists uneasily with a multiplication of uncertain, complex and resistant biologies which are known ¨ through bodily experience. In Buhler’s account, women describe a vague feeling or presentiment that something was not quite right before undergoing IVF. Her analysis speaks to the ‘turn to matter’ of new materialisms, away from a post-structuralist focus upon texts, ‘systems of thought’ and ‘discourses’ (Thanem & Knights, 2019). These chapters point to how several knowledge systems and practices rub up against each other as part of a process of making sense of our bodies and managing the tensions between lived bodily experiences and cultural meanings that may be ‘written on the body’. Charis Thompson’s (2005) concepts of ontological choreography and strategic naturalising continue to be helpful in understanding how different orders of knowledge not only co-exist but also can create new practices, identities, institutions and ways to reproduce. Ultimately, the chapters in this section, along with others in this volume, show that biomedical, situated and embodied knowledges work in interaction, each providing ways to (mis) understand the other – and one’s own reproductive experiences and lifecourse. In recent years, (in)fertility activists have called for greater fertility education and awareness as a means to counter an apparent lack of knowledge amongst women and other minoritised genders about age-related fertility decline (Harper, 2021; Harper et al., 2017). While education and awareness-raising are always valuable, they need to be accompanied by forms of consciousness-raising, which help people understand that the ‘choices’ that are apparently available to them are constrained in ways which reflect both intersecting inequalities and long-standing systems of authoritative knowledge, which have done little to engage seriously with the experiences of those who do not fit the white, able-bodied, heterosexual male norm of biomedical models. Resources are poured into high-tech treatments like egg-freezing not only because they can help a small number of (relatively

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wealthy) people conceive a child, nor because this is a profitable technology for those who offer it but also because of classist, ableist, heterosexist and racist stigma against family formations that are deemed less desirable according to social and political norms. Awareness will not transform hegemonic ideas of what fertility, reproduction or biological sex are, nor will it necessarily change the outcomes for many people.1 In the United Kingdom where we are based, for example, biogenetic relatedness is valued alongside intensive parenting, but achieving the financial stability, life experience and psychological readiness that popular representations of parenthood demand is largely impossible for anyone without inherited wealth or a very high salary (i.e. they are out of reach for the vast majority). So, while some women may express a wish that they knew more about the dreaded drop in oocyte quantity and quality that comes with age, it is not clear that this knowledge would ‘empower’ them to have achieved the normative expectations of middle-class parenthood by 35 anyway. Consciousness-raising might not help people achieve these goals either, but it could equip them to question whether they are the best ones in the first place, both for themselves as individuals and the society in which they live.

Note 1. To confuse matters further, ‘fertility awareness’ can also refer to what is also known as natural family planning or the rhythm method.

References Adams, V., Murphy, M., & Clarke, A. (2009). Anticipation: Technoscience, life, affect, temporality. Subjectivity, 28, 246–265. doi:10.1057/sub.2009.18 Dow, K. (2016). Making a good life: An ethnography of nature, ethics, and reproduction. Princeton, NJ: Princeton University Press. Dow, K., & Boydell, V. (Eds.). (2018). Nature and ethics across geographical, rhetorical and human borders. London: Routledge. Fausto-Sterling, A. (2000). Sexing the body: Gender politics and the construction of sexuality. New York, NY: Basis Books. Franklin, S. (2001). Biologization revisited: Kinship theory in the context of the new biologies. In S. Franklin & S. McKinnon (Eds.), Relative values: Reconfiguring kinship studies (pp. 302–322). Durham, NC: Duke University Press. Greenhalgh, T., Howick, J., & Maskrey, N. (2014). Evidence based medicine: A movement in crisis? British Medical Journal, 348, 725. Hahn, R. A. (1996). Biomedicine as a cultural system. In R. E. Hahn (Ed.), Sickness and healing: An anthropological perspective (pp. 131–172). London: Yale University Press. Han, S. (2013). Pregnancy in practice: Expectation and experience in the contemporary United States. New York, NY: Berghahn Books. Haraway, D. (1988). Situated knowledges: The science question in feminism and the privilege of partial perspective. Feminist Studies, 14(3), 575–599.

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Harper, J. (2021). Your fertile years: What you need to know to make informed choices. London: Sheldon Press. Harper, J., Boivin, J., O’Neill, H. C., Brian, K., Dhingra, J., Dugdale, G., … Balen, A. (2017). The need to improve fertility awareness. Reproductive Biomedicine and Society, 4, 18–20. doi:10.1016/j.rbms.2017.03.002 Martin, E. (2001). The woman in the body: A cultural analysis of reproduction. Boston, MA: Beacon Press. Rapp, R. (1999). Testing women, testing the fetus: The social impact of amniocentesis in America. London: Routledge. Strathern, M. (1992). Reproducing the future: Anthropology, kinship, and the new reproductive technologies. London: Routledge. Thanem, T., & Knights, D. (2019). Introduction: The embodied turn in social science research. In Embodied research methods (p. 1). 55 City Road: Sage Publications. Thompson, C. (2005). Making parents: Reproductive technologies and their ontological choreography. Cambridge, MA: MIT Press. Timmermans, S., & Berg, M. (2010). The gold standard: The challenge of evidence-based medicine and standardization in health care. Philadelphia, PA: Temple University Press. van de Wiel, L. (2019). The datafication of reproduction: Time-lapse embryo imaging and the commercialisation of IVF. Social Health Illness, 41, 193–209. doi:10.1111/ 1467-9566.12881

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Chapter 2

‘I Feel Like Some Kind of Namoona’: Examining Sterilisation in Women’s Abortion Trajectories in India Rishita Nandagiri

Abstract Sterilisation in India (and globally) has a contentious and deeply politicised history. Despite this troubling legacy, India continues to rely on female sterilisation as the main form of contraception and family planning. Abortion, which has been legal under broad grounds since 1971, intersects with sterilisation at different points over women’s reproductive lifecourse. Drawing on three case studies exploring women’s abortion trajectories in Karnataka, India (2017), this chapter examines sterilisation as a reproductive technology (RT) in women’s abortion narratives. These include experiences of failed sterilisation necessitating abortion, as well as narratives around pre- and post-abortion counselling with sterilisation conditionalities. Women report healthcare workers shaming or scolding them for not being sterilised after their last pregnancy – demonstrating the prominence of sterilisation as an enforced social norm using ‘health’ frames. Using reproductive justice (RJ) as a lens, I analyse how sterilisation interacts with abortion and the narratives of shame and stigma that surround the two technologies and make visible the ways in which it results in the denial and restriction of women’s reproductive freedoms. Keywords: Abortion; sterilisation; intersectionality; India; reproductive justice; reproductive stigma; reproductive trajectories I wasn’t angry – I was just upset that this happened to me. That it [sterilisation operation] failed for me. It felt like a prick in my heart and I was angry about that. I still don’t feel like it was fair or just

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Rishita Nandagiri for it to happen to me. […] I couldn’t understand how this happened – I feel like some kind of namoona.1

At 27, Tasheen’s sterilisation is reflective of broader sterilisation patterns in India. Female sterilisation is the most prevalent form of modern contraception in India – among currently married women aged 15–49, 36% are sterilised, with 6% using male condoms and 4% using contraceptive pills. The median age at which women are sterilised is 25.7 (IIPS and ICF, 2015).2 Tasheen also experienced a failed procedure – unfortunately also not uncommon in India (Date, Rokade, Mule, & Dandapannavar, 2014) – necessitating her quest for abortion care. Tasheen’s abortion trajectory is shaped by and intertwined with her failed sterilisation operation, reflecting the delays and reproductive stigmas she was required to navigate when attempting access to abortion care. Understanding her sterilisation and abortion experiences within her reproductive lifecourse situates it within the broader socio-economic conditions that shape available options and pathways. It challenges the framing of abortion as a singular, disconnected reproductive experience, expanding – through Reproductive Justice (RJ) (Ross, Roberts, Derkas, Peoples, & Bridgewater Toure, 2017) – understandings of the spectrum of women’s reproductive desires and the interruptions they experience. In viewing these events alongside each other, it highlights the conditions of reproductive injustice and its cumulative nature (Davis, 2019). In this chapter, I draw on three narratives to examine sterilisation as a reproductive ‘event’ over the course of women’s abortion trajectories.3 Exploring sterilisation and abortion as linked reproductive events offers deeper insights into how they interact and in which ways. Using the RJ framework, I situate sterilisation and abortion within the matrixes of oppression (Ross et al., 2017) that govern reproduction in India, interrogating the narratives of stigma and shame that surround the two technologies and make visible the ways in which it can result in the limiting or denial of women’s reproductive freedoms. As Ben Kasstan (this volume) argues, reproductive freedoms and choices are tied to such technologies (e.g. contraception, sterilisation, abortion) which carry opportunities and implications that require negotiating and navigating.

Reproductive Justice, Sterilisation and Abortion Reproductive Justice, conceptualised by Black feminists in the United States, critically examines the structural and institutional mechanisms that control, limit and shape women’s reproductive lives and the conditions that they live in (Ross, 2017). Partly shaped by Black women’s experiences of state-sponsored sterilisation abuse, RJ ‘examines the meaning assigned to reproductive relations and externally imposed policies and practices’ (Ross, 2017, p. 287). Population policies – like those relating to sterilisation and abortion – can reproduce and exploit systemic inequalities that shape reproductive decision-making around childbearing and parenting, particularly affecting vulnerable women and girls. RJ, thus, champions (1) the right to have a child under conditions of one’s own

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choosing; (2) the right not to have children and (3) the right to parent children and raise families in safe and healthy environments (Ross & Solinger, 2019). Reproductive decision-making – to have a child, to not have one, to parent – is a series of connected events and experiences occurring over a woman’s lifecourse. The conditions under which abortion and sterilisation occur – the services available, the restrictions imposed, the delays experienced – shape the extent to which women exercise reproductive autonomy or experience injustice. Interventions – direct and indirect – on reproduction may be underpinned by judgements of whose reproduction is de/valued and deemed un/worthy (Roberts, D (2000) in Asian Communities for Reproductive Justice, 2005). While sterilisation is seen as reproductive empowerment for some, it can be experienced as reproductive coercion for others (Brunson, 2020), particularly where it is marked as ir/rational by providers, the State or a number of other actors (Mishtal, 2012).4 For example, women living with HIV have experienced forced and coerced sterilisation in El Salvador, Honduras, Mexico and Nicaragua; with healthcare providers claiming their HIV status ‘annulled their right to children’ (Kendall & Albert, 2015, p. 1). In many countries, trans persons are forced to undergo sterilisation to meet requirements for legal gender recognition (Lowik, 2018). It evidences how reproduction is experienced in stratified ways (Colen, 1995), tied to understandings of whose bodies and reproduction are valued (Saunders, 2020). Where sterilisations are heavily encouraged, subsidised, incentivised, or linked to welfare programmes, they particularly target poor and vulnerable communities. In the United Kingdom, the two-child limit for those receiving welfare support limits full reproductive choice. By demanding that women ‘think carefully about whether they can afford to support additional children’, this policy forces them to choose between greater financial insecurity and hardship for their existing family and their reproductive desires (BPAS, 2020). This policy has largely affected Black and minority women in the United Kingdom, heightening existing reproductive and social vulnerabilities (Pearson, 2019). During the COVID-19 pandemic which exacerbated job and financial insecurities, women cited the policy and its impacts as part of their abortion decision-making (Butler, 2020). Smith-Oka (2009) details how indigenous women in Mexico, enrolled in a conditional cash transfer programme (‘Oportunidades’) as part of ‘economic empowerment’ initiatives, are made vulnerable to sterilisation through the scheme. Medical practitioners, who monitor indigenous women’s compliance with Oportunidades requirements, utilise their authority to compel them to accept sterilisation, constraining women’s reproductive autonomies. In countries where efforts are underway to reduce population growth or meet other related population stabilisation goals, social norms around ‘ideal’ family size may be utilised to encourage sterilisation (Brunson, 2020). Under some conditions, this can manifest as contraceptive coercion (Senderowicz, 2019) in structural forces and individual actions. Where a full range of contraception options may be unavailable or inaccessible, making sterilisation the only option to manage reproduction; it is a form of coercion and of structural violence (Nandagiri, Coast, & Strong, 2020). Additionally, sterilisation procedures may fail, which have been linked to method and age of the woman; with one study

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finding that women over the age of 40 have the lowest failure rate (Joshi, Khadilkar, & Patel, 2015). Analyses of sterilisation and abortion have been treated as separate and siloed events in women’s reproductive lifecourse. Abortion stigma, constructed and reproduced locally, is a negative attribute ascribed to women who terminate a pregnancy, marking them (internally or externally) as inferior to ideals of womanhood (Kumar, Hessini, & Mitchell, 2009). ‘Womanhood’, while context-dependent, is underpinned by normative constructs (sexuality for procreation, motherhood as inevitable and women as natural nurturers). By linking sexuality to procreation, abortion becomes a marker of illicit, non-procreative sex (Kumar et al., 2009; Norris et al., 2011). Abortion stigma enables a hierarchy of ‘good’ and ‘bad’ abortions, underpinned by perceived ‘good’ or ‘bad’ reasons that are framed and assessed in relation to existing social norms and values (Norris et al., 2011). Reproduction is also deeply stratified, with some peoples’ reproduction encouraged and valued while others are discouraged and devalued (Colen, 1995), Policies and programmes (e.g. family planning and sterilisation) embedded with these norms, give rise to the idea of ‘responsible’ reproductive management: the proper spacing, timing and number of children (Sasser, 2018). Deviating from these standards marks individuals as ‘irresponsible’ with their fertility, justifying interventions to discipline them (Nandagiri, 2021). Sterilisation and abortion are linked through the production of reproductive stigmas which function as mechanisms of social control, legitimising modes of social and structural inequalities. Like sterilisation is tied to stigma surrounding ‘high fertility’ or the reproduction of ‘unworthy’ persons, abortion is also linked through social and structural processes of abortion stigma (Millar, 2020) to understandings of ‘good’ and ‘bad’ forms of reproduction. In some cases, abortion can act as a marker for women’s lack of sterilisation – a reflection of their ‘irrational’ reproduction and a marker of their non-procreative sexuality, requiring intervention (Nandagiri, 2019a). Access to abortion may also be made conditional, requiring post-abortion sterilisation (Open Society Foundations, 2011). Examining sterilisation in relation to women’s abortion trajectories can reveal how reproductive stigmas interact and manifest across different dimensions, at different points in the trajectory (i.e. before abortion, post-abortion), compounding social and structural inequalities and injustices.

Sterilisation and Abortion in India: Targets, Incentives and Injustice Sterilisation and abortion in India need to be contextualised within the larger structures of oppression that mediate these experiences. These include state-sponsored mechanisms like target-driven sterilisation provision in low-income, rural communities; coupled with poor financing and infrastructure to meet a range of contraceptive or abortion needs. These indirect forms of ‘structural violence’

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(Galtung, 1969) in reproductive healthcare give rise to more direct forms of interpersonal violence like coercive sterilisation or abortion conditionalities (Nandagiri, Coast, & Strong, 2020). These forms of reproductive violence are stratified. Dalit, Adivasi and Muslim women whose fertilities are framed – socially and politically – as ‘high’ are particular targets (Singh, 2020; Wilson, 2015); legitimising their bodies as particular sites for reproductive violence through these mechanisms (Jena & Biswal, 2015).5,6

Sterilisation in India In India, access to a full range of contraception options remains unfulfilled, with the current contraception method mix dominated by female sterilisation (Pradhan & Dwivedi, 2019). Female sterilisation endures as one of the main fertility control and regulation options available in the country, with 36% of married/in union women between 15–49 being sterilised. The vast majority of sterilisations (82%) were conducted in public health facilities (Vinod Joseph, Mozumdar, Lhungdim, & Acharya, 2020). Sterilisation in India has a contentious and deeply politicised history, especially during the Emergency period where incentives and coercion were widely used to meet set targets in order to achieve population stabilisation. These were particularly borne out by poor men in rural India, but was also filtered through gender, religion, class and caste identities (Scott, 2017; Williams, 2014).7,8 Despite this legacy, India continues to rely on female sterilisation as the main form of contraception and family planning. In 2012 and 2014, multiple women – largely Dalit and Adivasi women – died at sterilisation camps held in Jharkhand and Chhattisgarh (Pulla, 2014) and in 2016, the Supreme Court directed the central government to ensure that sterilisation camps were discontinued by state governments within three years (Supreme Court of India, 2016). The Supreme Court also observed that sterilisations infringe on the ‘reproductive freedoms of the most vulnerable groups of society whose economic and social conditions make them easy targets to coercion’ (ESRC-Net, 2017). Yet, even with these directives and prescriptions in place, sterilisation camps remain prominent forms of fertility control in rural India. Recent cases reflect how coercion and poor quality of care remain rife, risking the health and lives of women (Bhonsle, 2020). Sterilisation also remains socially and politically sanctioned, tied to decades-long policy to implement a two-child family norm and meet national development goals through a programme of population control (Wilson, 2018). These goals have been reframed under India’s commitments to the Family Planning 2020 initiative, but fundamentally stay the same (Wilson, 2018). Sterilisations remain incentivised, targeting people as well as service providers. For example, the Ministry of Health and Family Welfare (MOHFW) offers accredited private and NGO providers in so-called ‘high fertility’ states like Bihar and Uttar Pradesh a ‘financial package’ to provide sterilisations. The cost incentives are differentiated by tubectomies and vasectomies (Table 1) (MOHFW, 2016).

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Table 1. MOHFW’s Financial Incentives for Private Facilities and NGOs. All in Indian Rupees (INRs) (1 INR 5 0.014 USD) (MOHFW, 2016). Tubectomy (Interval and PostAbortion)

Facility Client Total

Post-Partum Sterilisation

Vasectomy

Existing

New

Existing

New

Existing

New

2,000 1,000 3,000

2,500 1,000 3,500

2,000 1,000 3,000

3,000 1,000 4,000

2,000 1,000 3,000

2,500 1,000 3,500

Despite officially disavowing a target-driven approach to sterilisation (and other family planning programmes), these continue in practice and in broader reporting structures (e.g. ‘expected levels of achievement’) (Wilson, 2017). The MOHFW’s Annual Report (2018–2019), for example still reports ‘state wise performance’ for sterilisation uptake (MOHFW, 2019). These target-driven approaches are tied to incentives for lay community health intermediaries (CHIs) like Accredited Social Health Activists (ASHAs) and medical personnel to ‘motivate’ sterilisation and other family planning uptake. Reports of linking sterilisation to abortion provision or part of as routine post-partum maternal healthcare are common and are also borne out in the data. ‘Acceptors’ of sterilisation are offered financial incentives or promised other ‘in-kind’ incentives, which may not always be fulfilled. Adivasi women from the protected Baiga tribe, for example report not receiving the promised cash incentives or being given rice and eggs instead (Bharadwaj, 2014). Since 2013, the National Family Planning Indemnity Scheme compensates acceptors or their family members in case of death, failure or complications (MoHFW, 2018). An estimated 7% of women experience sterilisation regret (Bansal & Dwivedi, 2020; Singh, 2018). Poor quality services, which reflect gendered and structural injustices, are linked to sterilisation regret (Bansal & Dwivedi, 2020). National Family Health Survey (NFHS) rounds 3 (2005–2006) and 4 (2015–2016) data show that one in three women were not informed sterilisation was a permanent method, and two in three women did not receive information on its side effects (Singh, Singh, & Singh, 2021).

Abortion in India In contrast to state infrastructure around sterilisation, abortion is under-resourced. Legally available in India under a broad range of grounds (contraception failure, socio-economic conditions, rape/incest, foetal health, or risk to mental and/or physical health) under the Medical Termination of Pregnancy Act (1971), abortion services can only be provided by trained and registered doctors and registered or authorised clinics. In 2020, new amendments

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extended abortion access to 24 weeks, requiring approval of one service provider up to 20 weeks’ gestation and two providers’ approval between 20–24 weeks’ gestation (GoI, 2021). Women over the age of 18 do not legally require spousal or parental consent but evidence show that providers condition parental or spousal consent before abortion provision (Sri & Ravindran, 2012). Yet, despite the broadly liberal laws, access to abortion remains difficult. In 2015, of 15.6 million abortions; 73% (12 million) were medical abortions (MA)9 conducted outside health facilities (Singh et al., 2018). Evidence on women’s abortion pathways shows a lack of accurate information, reproductive stigmas, and poor availability of services (Stillman, Frost, Singh, Moore, & Kalyanwala, 2014). Unlike sterilisation and family planning efforts, abortion services are not associated with strong financing or infrastructure. The shortage of trained providers – particularly in rural areas – dramatically affects abortion care provision through formal health settings. Women report sterilisation conditionalities are tied to abortion provision (Ramachandar & Pelto, 2002; Sri & Ravindran, 2012). Sterilisation, particularly post-abortion, is also linked to (not) meeting ideal sex composition of children (Edmeades, Pande, MacQuarrie, Falle, & Malhotra, 2012), with providers drawing on persistent son-preference norms to insist on or refuse services (Calhoun et al., 2013). CHIs, who play key roles as enablers or barriers to care in women’s abortion trajectories, use sterilisation as a counterpoint to abortion. They may shame women for not undergoing sterilisation and thus needing an abortion, or they may encourage continuation of pregnancy followed by sterilisation instead of an abortion (Nandagiri, 2019b).

Study Context Data were collected in two rural districts (Belgaum and Bagalkot) in north-west Karnataka in 2016–2017. I collected data at the level of the Primary Health Centre (PHC) – the frontline of the Indian public health system. In Karnataka, sterilisations are incentivised for public and private facilities. CHIs like ASHAs and other health personnel are incentivised to ‘motivate’ sterilisation or other family planning uptake. Between April 2016 and March 2017, the state’s Family Planning Indemnity Scheme paid claims for complications (7), death (11) and failure (175) (Health and Family Welfare Service, 2017). In the following year April 2017–March 2018, claims were paid out for complications (5), deaths (6) and failure (127) (Health and Family Welfare Service, 2018). These data are likely to be incomplete as the scheme is not well known and the claims process is lengthy and cumbersome (Masih, Barpanda, & Wynee, 2018). Other injustices also shape women’s reproductive experiences – Xavier, Vasan, and Vijayakumar (2017), for example detail forced hysterectomies of Dalit women, while other data show that disadvantaged women received poorer ante natal care than their more privileged counterparts (Rani, Bonu, & Harvey, 2007). To situate my evidence and the world it operates in, I present additional state and district level data on sterilisations (vasectomies and tubectomies) and abortions in 2017–2018 (Table 2).

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Table 2. Data on Vasectomies, Tubectomies and Abortions in Karnataka (2017–2018).9 Vasectomies (Public 1 Tubectomies (Public 1 Induced Abortions Private) (%) Private) (%) (Public)a

Karnataka - Belgaum - Bagalkot a

672 (0.3%) 105 (0.5%) 7 (0.1%)

232,288 (99.7%) 19,463 (99.5%) 13,730 (99.9%)

11,361 480 12

Data on induced abortions conducted in private facilities are unavailable.

Karnataka – and the two districts my study is located in – follows India-wide patterns on sterilisations, with women bearing the brunt of the procedure. 19% of all tubectomies were conducted post-partum and a reported 1.4% of sterilisations were performed post-abortion. Yet, as Guttmacher modelling demonstrates (Singh et al., 2018), the induced abortion data in public facilities are likely to be underreported; affecting the reported post-abortion sterilisation rates. Additionally, there are inconsistencies in data entry (Dehury & Chatterjee, 2018). During data collection in my study sites, Auxiliary Nurse Midwives (ANMs) – who are tasked with entering data into the Health Management Information System – described sometimes underreporting abortion data under instructions from medical officers or other senior PHC staff. These data demonstrate the near-ubiquitousness of sterilisation, the skewed emphasis on tubectomies and the consistent underreporting of abortion data. It highlights how government priorities tied to notions of development function through the mechanisms of dis/incentives – financial and social, and barriers to knowledge, access, or quality care – to govern sterilisation and abortion in women’s lives. I locate my study and findings in this context of poor method mix, incentivisation of certain services and tasks, and strong reproductive stigmas around so-called ‘high fertility’ and abortion. This allows a deeper examination of how sterilisation and abortion interact in women’s reproductive lives and over the course of their abortion trajectories, making visible their experiences of and encounters with RJ.

Methods Data on women’s experiences with abortion and sterilisation were collected over 11 months (2016–2017), as part of a larger project investigating women’s abortion trajectories (Nandagiri, 2019a). Ethics approval was granted by the London School of Economics and Political Science in the United Kingdom [REC ref #

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000,493], and by the KLE Academy of Higher Education and Research in India [Ref: KLEU/EC/2017–18/D-4287]. Supported by a research assistant (GM), I conducted one-off semi-structured interviews with women (n 5 31) within three weeks of their abortion. Potential respondents meeting study criteria were first identified and contacted by local ASHA workers to gauge interest in participation. ASHAs were already trained as part of other programmes in informed consent and privacy maintenance but were given additional training on confidentiality, consent and non-judgement as part of the study protocols. Once potential participants agreed to a conversation, the ASHA worker organised a meeting with the study team. Meetings were arranged at a time and place of the participant’s choice – whether a private room in the PHC, a local Anganwadi centre, or in their homes. For some participants, where sites like the PHC are imbibed with power (Elwood & Martin, 2000), these can be rather unsafe environments. Spaces like their own homes, even when surrounded by others, can offer privacy within a shared or public space – as participants explained, it would be more suspicious to request privacy than to have a seemingly innocuous conversation in plain view. If asked, we explained our presence as part of a general study on women’s health (Nandagiri, 2020). All participants provided written consent, including for audio recordings. Interviews were conducted in Kannada or Hindi by me and GM. The recorded interviews were transcribed and translated for analysis. Transcripts were anonymised and participants were assigned pseudonyms. I used hybrid thematic analysis (Fereday & Muir-Cochrane, 2006) to analyse the data. Gender and caste are immensely powerful forces in India, shaping my research design, approach to data collection and analyses, and requiring an interrogation of how my specific locations as an Indian, savarna woman shape and influence these interactions and the study. While my Indian identity and local language skills marked me as an ‘insider’, my accent and other signifiers often marked me as an ‘outsider’. This led to participants and interlocutors questioning me about my life, destabilising the idea of an interview as a unidirectional encounter. Discussing abortion in a space shaped by this sense of trust challenges the idea of abortion as ‘taboo’ and ‘sensitive’, instead allowing it to be understood through the prism of sharing and keeping secrets, and holding confidences (Nandagiri, 2020). This ‘insider-outsider’ dichotomy, as well as my caste and class locations, underscore that my data and the secrets shared with me are all partial. I only observed, heard and experienced what I was allowed to, and these data are refracted through my own interpretations, requiring an engagement in the ‘reflexivity of discomfort’ (Pillow, 2003, p. 192). I offer a more in-depth and reflexive account of my positionality and its impact on my research and analyses elsewhere (Nandagiri, 2017, 2019a, 2020).

Sterilisation Narratives in Abortion Trajectories I explore three narratives (Tasheen, Janani and Rajalakshmi), interrogating how and where sterilisation and abortion interact, and the ways in which reproductive

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stigmas shape care-seeking experiences. Sterilisation is present at different points in women’s abortion trajectories, shaping how women seek care, experience care-seeking, and the quality of care that is ultimately provided. Tasheen was a 27-year-old married Muslim woman with three children – her youngest was 18 months old. She was sterilised when her child was three months old. She says: I thought ‘Okay, this is how it is, and anyway operation [sterilisation] has been done, and after some years it will happen [a regular menstrual period]’. This is what I was thinking, and with this idea I didn’t do anything or bother overly much about it. Tasheen’s post-sterilisation experience was painful, but she attempted to cope. She checked with the PHC (where her sterilisation was performed) about her irregular menstrual period and was assured that it would stabilise. She was not given any additional information about her procedure nor were any concerns raised about a failed sterilisation. We went to the PHC here. When we went there, and I explained my issues and they were like, ‘You are pregnant’. We said, ‘Okay, sir, but I have had an operation [sterilisation]. How can this be? What should I do now?’ And they said, ‘No…what can you do then? You can have the child’. The failed sterilisation led to a delay in confirming her pregnancy, impacting the options available to her and her next steps. In addition to the reactions of PHC staff to an unsupportable pregnancy (Macleod, 2019), she received little information or help. Due to her failed sterilisation, she required an ultrasound confirmation of gestational age before she could access an abortion. Tasheen had to travel to the district capital for an ultrasound – which took nearly a week of navigating bureaucracies before she turned to the private sector at a much higher cost. She was 10 weeks pregnant at the time of the ultrasound, just over the legal limit for a medical abortion (nine weeks). She then had to identify a surgical provider, once again forced to opt for the private sector after further delays in the public health system. The failed sterilisation shaped Tasheen’s abortion trajectory: delays in confirmation, her subsequent pathways to abortion care, and the kind and quality of care she received. It affected not just the timing of her abortion but the method and cost of care. It also impacted her post-abortion experiences – increased pain and worry, loss of wages and concerns abouta requiring an additional sterilisation. For Rajalakshmi, on the other hand, sterilisation was present in her interactions with health workers as she attempted to access an abortion. Rajalakshmi was 23 years old, Lingayat, married at 16 and had two children. She considered sterilisation after her second child but decided against it.11

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[Doctor] told me that I should get operated. In January, even my mother told me that. I thought I would get it done a bit. In March, I thought, I will get it done. Within that, this [pregnancy] happened… Rajalakshmi attempted to access and abortion through four different public facility providers over the course of her trajectory. Her interactions with providers were marked with shame and judgement for being ‘careless’ with her fertility (i.e. lack of sterilisation or effective contraception use). They said things like, ‘the operation should have been done earlier, when you delivered. After all this has happened, why are you coming now? […] Why are you asking for [abortion] pills now?’ In one of the facilities, Rajalakshmi was asked to consent to post-abortion sterilisation as a condition of accessing abortion care. Distressed, and concerned about the delays, she travelled to her natal village to self-manage her abortion with support from her mother and sister. Like Tasheen, Rajalakshmi’s trajectory was shaped by sterilisation – except, in this case, it was the failure to be sterilised. Her abortion was a marker of her lack of sterilisation and her transgression of the established sterilisation norm; locating her body as ‘unruly’ (Love, 2020) and requiring disciplining through the health system in order to meet set goals and priorities.

Sterilisation, Abortion and Reproductive Stigmas In the narratives on their abortion trajectories, the intertwined nature of sterilisation and abortion stigmas is evident. The structural processes manifest as a mechanism (Millar, 2020) to individualise blame – for an ‘irrational’ pregnancy, marking the lack of sterilisation and the desire for an abortion as transgressions of fertility norms. This individualisation not only marks specific behaviours as irrational but is then applied to individual women to frame them as irrational actors (De Zordo, 2012). These are also tied to Tasheen, Rajalakshmi and Janani’s social positions across class, caste and religion, which further mark them as requiring disciplining. The linked forms of reproductive stigma, then, manifest in shame and judgement, reproducing conditions of reproductive injustice (Davis, 2019) in which Tasheen, Rajalakshmi and Janani attempt to realise their reproductive desires. Tasheen narrates: When I was pregnant with my third child, I was dizzy and fainted in the PHC. They shouted at me and said, ‘Why haven’t you had the operation [sterilisation]?’ And now I’ve done it- they’re the ones who now speak badly [judgementally]. And they’re also the ones that ask, ‘how is it possible?’ [to be pregnant].

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In contrasting the judgement and shame she has experienced over her reproductive lifecourse: her third pregnancy, her failed sterilisation and her abortion care-seeking; she identifies the multiple binds that surround reproduction. Tasheen, as a Muslim woman, is understood within the rhetoric of ‘high fertility’– that her pregnancy, her failed sterilisation and her need for an abortion are all proof of her innate, ‘hyper fertile’ biology (Singh, 2020). It blames Tasheen for being a namoona, her body defying efforts to control hyperfertility; absolving the state of its failure of responsibility to provide a range of quality services and cater to women’s needs. Tasheen, too, grapples with this individualised sense of responsibility – her body, a namoona that failed her in attempting to realise her reproductive desires, at the same time as feeling the failures of the state in an embodied way. Rajalakshmi’s experiences also reflect the presence of reproductive stigmas that frame her as norm-breaking, requiring disciplining. She is shamed and scolded for not being sterilised after her last pregnancy, demonstrating the prominence of sterilisation as an enforced social norm using ‘health’ frames and mechanisms. She is able to navigate around this by turning to abortion self-management, removing herself from spaces of state intervention. Janani (married, approximately 40 years old, three children, and was Dalit, part of the Madiga caste) circumvented the health system entirely – she did not approach any facilities or clinics, completely self-managing her abortion. She explained her decision to self-manage as partly motivated by shame – a pregnancy at her ‘advanced’ age – and a desire for secrecy. She discussed the social stigma of having ‘too many children’, and her lack of sterilisation as shaping provider and public attitudes towards her pregnancy and her subsequent abortion decisionmaking. It’s disgusting, they will say. As after so many years of marriage, I got pregnant again […] they’ll ask, ‘Can’t she control herself?’. At my age, to get pregnant again ,shakes head, long pause.. They will speak badly. […] ‘She’s so old now, why does she need children?’ Janani identifies multiple reproductive stigmas: age and sexuality relates stigmas in addition to sterilisation and abortion stigmas. By linking sexuality to procreation, abortion becomes a marker of illicit, non-procreative sex. Similarly, considering or choosing abortion acts as a sign of an unwanted pregnancy (Norris et al., 2011). Believed to be past ‘appropriate’ child bearing years, Janani’s abortion is a display of her sexuality and perceived as a result of ‘too much sexual desire’ (Anandhi, 2007). Tasheen, Rajalakshmi and Janani’s narratives also reveal their resistance to the imposition of these frames. Their persistence in seeking and finding abortion care in spite of being continuously faced with interpersonal, institutional and structural barriers reveals how women’s agencies confront the state in micro-level interactions, attempting to procure services under conditions of their own choosing. Janani and Rajalakshmi’s circumvention of the health system – one that

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did not serve them or their needs – in favour of self-management is also a reflection of their agency and refusal of the state’s interference in their lives. Tasheen’s persistence – despite facing numerous barriers – is also reflective of a claiming of reproductive freedom.

Conclusion In this chapter, I aimed to examine sterilisation and abortion as linked reproductive events in women’s abortion trajectories, demonstrating how stigma and shame can limit and deny full reproductive freedom. By analysing them as linked events instead of as separate and siloed incidents, I offer an extension of RJ literature; focusing on the right not to have a child, under conditions of one’s own choosing. Examining sterilisation as a reproductive event in women’s abortion trajectories demonstrates how reproductive autonomy and coercion are claimed, experienced and felt at different points. It also highlights the conditions under which autonomy and coercion flourish or are constrained. Rather than namoonas, Tasheen, Rajalakshmi and Janani’s narratives are reflective of abortion and reproduction in India. Their abortion care-seeking efforts make them and their fertilities visible to the state, marking their bodies as sites for intervention. Reproductive stigmas surrounding fertility, sterilisation, abortion and sexuality are evident in these interventions. These stigmas act as a mechanism of social control, championing the small family norm at the same time as shaming any alternate behaviours or constructions as deviations or transgressions. Their abortion narratives demonstrate the pervasiveness of reproductive stigmas, particularly around the control of their fertilities and how it manifests at different points over their reproductive lifecourse. These findings contribute to literature on abortion stigma (Kumar, 2018; Kumar et al., 2009), and specifically literature on abortion stigma as a social and structural process (Millar, 2020) linked to reproductive governance (De Zordo, 2012; Mishtal, 2019). Reproductive experiences are not shaped just by particular reproductive histories, but the conditions under which their reproductive lives and decision-making occur: the state-set priorities of fertility control through the mechanism of the health system, in a context of poorly resourced reproductive health services. These narratives make visible the matrix of oppressions – and structural violence – that reproduction in India operates under, giving rise to a series of injustices carried out by the state and borne out on women’s bodies and lives (Nandagiri et al., 2020). Stratified across different axes: age, religion, caste and class, it penalises poor Dalit and Muslim women; placing responsibility and blame on individual behaviours and acts (Jena & Biswal, 2015; Wilson, Loh, Purewal, Ung Loh, & Purewal, 2018). This shifting of responsibility absolves the state of its responsibilities and duties but continues to enable it to ‘discipline’ wayward bodies through specific interventions like targeted sterilisation programmes.

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This chapter complements this collection’s interdisciplinary work through an examination of the conditions that surround reproduction and the technologies, timings and trajectories that intersect with them. Linking reproductive events to examine them at the individual level and locating it in larger (trans)national contexts, speaks to RJ’s tenet to centre women’s lived realities in the interrogation of power, making visible the mechanisms of injustice and the potential for activism in the pursuit of reproductive freedom.

Acknowledgements I remain indebted to the women who trusted me with their abortion narratives- I hope I continue to hold true to them. I am grateful to the KLE Academy of Higher Education and Research for supporting my data collection in India (2016–2017). Thanks to Geetanjali Mungarwadi for her invaluable research assistance and Rashmi Rao for her support with translation and transcription. Many thanks to Vicky Boydell, Katie Dow, Susan Pickard, Ben Kasstan and all the participants of the Integrating Reproductive Technologies workshop, December 2020, for their comments and suggestions. Thanks also to Professor Ernestina Coast, Dr Flora Cornish, Dr Tiziana Leone, Dr Luc´ıa Berro Pizzarossa and Joe Strong for their critical insights. Data I reflect on here were collected during my PhD, funded by the LSE PhD studentship (2015–2019). My work on this chapter was supported by the Economic and Social Research Council [grant number ES/V006282/1] as part of my ESRC postdoctoral fellowship (2020–2021).

Notes 1. Namoona [Hindi, Urdu], noun: a specimen to be examined (implied to be an oddity) [author’s translation]. 2. The median age at first birth among women aged 15–49 is 21 (IIPS and ICF, 2015). 3. Trans and non-binary persons also experience reproductive injustice over their reproductive lifecourses. I use the term ‘women’ as my sample population were women – all of whom identified as such. I focus on their subjective – heteronormative and cisgendered – experiences. I did not want to tokenise trans and non-binary persons’ experiences and struggles by co-opting political terminology without substantive work underpinning it. I do, however, recognise the importance and relevance of utilising more inclusive and accurate language in reproduction studies. 4. I acknowledge that sterilisation, when accessed with full informed consent, can be reflective of reproductive autonomy. I also recognise that some may be prevented from accessing sterilisation due to medical professionals’ fears of sterilisation regret if they are nulliparous women or based on their age (Hintz & Brown, 2019). I would contend, however, that these stigmas are similar to those underpinning judgements of whose reproduction is de/valued and under which conditions. It is beyond the scope of this chapter to explore this in greater depth.

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5. Dalit, meaning oppressed, describes those classified within the Hindu caste system as the ‘lowest’ caste. The term was adopted by Dalit activists and scholars to identify the structural, social and cultural mechanisms that create and maintain conditions of oppression, rejecting the savarna [upper caste] frames and gaze of terms like ‘Harijan’ or ‘Untouchable’. The legal terminology within the Constitution is [broadly] ‘scheduled castes’. 6. ‘Adivasi’ is a collective term for the indigenous communities of India. The legal terminology within the Constitution is ‘scheduled tribes’. 7. Over a 21-month period in 1975–1977, the Indira Gandhi-led government imposed a state of Emergency. They suspended civil and political liberties, enforced press censorship, imprisoned political opponents, and carried out a mass, state-sponsored forced sterilisation programme. 8. The forced vasectomies experienced under Emergency saw an immense and sustained anti-vasectomy backlash that continues to present day. It resulted in a singular focus on women’s fertilities and its control (Connelly, 2006; Sarojini, Ambhore, & Venkatachalam, 2015). 9. Oral pharmacological drugs like mifepristone and misoprostol or misoprostol alone to induce abortion. 10. Department of Health and Family Welfare, Karnataka (2018). Performance of Key HMIS Indicators (up to district level) for Family Planning (April–December). https:// nrhm-mis.nic.in/hmisreports/frmstandard_reports.aspx (Retrieved 25 November 2020). I am unable to report data for 2016–2017 (when the study was conducted) as government data are incomplete. 11. There is some dispute on classification within the caste system (particularly amongst Dalit movements who highlight the Lingayats’ caste privilege). The Lingayat community is legally categorised as a ‘scheduled caste’.

References Anandhi, S. (2007). Women, work and abortion practices in Tamil Nadu. In L. Visaria & V. Ramachandran (Eds.), Abortion in India: Ground realities (pp. 62–99). New Delhi: Routledge. Asian Communities for Reproductive Justice. (2005). A new vision for advancing our movement for reproductive health, reproductive rights and reproductive justice. Bansal, A., & Dwivedi, L. K. (2020). Sterilization regret in India: Is quality of care a matter of concern? Contraception and Reproductive Medicine, 5, 1–12. doi:10.1186/ s40834-020-00115-8 Bharadwaj, A. (2014). Many women of protected tribe sterilised, they got no cash, ‘only 5 eggs, half kg dal’. The Indian Express. Bhonsle, A. (2020). A coerced sterilisation, a senseless death. [WWW Document]. People’s Archive of Rural India. Retrieved from https://ruralindiaonline.org/ articles/a-coerced-sterilisation-a-senseless-death/. Accessed on November 26, 2020. BPAS. (2020). The two-child limit on welfare supports. London. Brunson, J. (2020). Tool of economic development, metric of global health: Promoting planned families and economized life in Nepal. Social Science & Medicine, 254, 112298. doi:10.1016/j.socscimed.2019.05.003

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Butler, P. (2020). Two-child benefit cap influencing women’s decisions on abortion, says BPAS. The Guardian. Calhoun, L. M., Speizer, I. S., Rimal, R., Sripad, P., Chatterjee, N., Achyut, P., & Nanda, P. (2013). Provider imposed restrictions to clients’ access to family planning in urban Uttar Pradesh, India: A mixed methods study. BMC Health Services Research, 13. doi:10.1186/1472-6963-13-532 Colen, S. (1995). “Like a mother to them”: Stratified reproduction and west Indian childcare workers and employers in New York. In F. Ginsburg & R. Rapp (Eds.), Conceiving the new world order: The global politics of reproduction (pp. 78–102). Berkeley, CA: University of California Press. Connelly, M. (2006). Population control in India: Prologue to the emergency period. Population and Development Review, 32, 629–667. doi:10.1111/j.1728-4457.2006. 00145.x Date, S. V., Rokade, J., Mule, V., & Dandapannavar, S. (2014). Female sterilization failure: Review over a decade and its clinicopathological correlation. International Journal of Applied and Basic Medical Research, 4, 81. doi:10.4103/2229-516X. 136781 Davis, D.-A. (2019). Reproductive injustice, reproductive injustice. doi:10.18574/nyu/ 9781479812271.001.0001 De Zordo, S. (2012). Programming the body, planning reproduction, governing life: The ‘(ir-) rationality’ of family planning and the embodiment of social inequalities in Salvador da Bahia (Brazil). Anthropology & Medicine, 19, 207–223. doi:10.1080/ 13648470.2012.675049 Dehury, R., & Chatterjee, S. (2018). Assessment of health management information system for monitoring of maternal health in Jaleswar Block of Balasore District, Odisha, India. Indian. Journal of Public Health, 62, 259. doi:10.4103/ijph.IJPH_ 203_17 Edmeades, J., Pande, R., MacQuarrie, K., Falle, T., & Malhotra, A. (2012). Two sons and a daughter: Sex composition and women’s reproductive behaviour in Madhya Pradesh, India. Journal of Biosocial Science, 44, 749–764. doi:10.1017/ S0021932012000119 Elwood, S. A., & Martin, D. G. (2000). “Placing” interviews: Location and scales of power in qualitative research. The Professional Geographer, 52, 649–657. doi:10. 1111/0033-0124.00253 ESRC-Net. (2017). Devika Biswas v. Union of India & Others, Petition No. 95 of 2012. Retrieved from https://www.escr-net.org/caselaw/2017/devika-biswas-vunion-india-others-petition-no-95-2012 Fereday, J., & Muir-Cochrane, E. (2006). Demonstrating rigor using thematic analysis: A hybrid approach of inductive and deductive coding and theme development. International Journal of Qualitative Methods, 5, 80–92. doi:10.1177/16094069060 0500107 Galtung, J. (1969). Violence, peace and peace research. Journal of Peace Research, 6, 167–191. Government of India (GoI). (2021). The Medical Termination of Pregnancy (Amendment) Act, 2021, Pub. L. No. 8. Health and Family Welfare Service. (2017). Annexure II: Status of FPIS claims. Health and Family Welfare Service. (2018). Updated list of beneficiaries of FPIS from April-2017 to March-2018.

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Hintz, E. A., & Brown, C. L. (2019). Childfree by choice: Stigma in medical consultations for voluntary sterilization. Women’s Reproductive Health, 6, 62–75. doi: 10.1080/23293691.2018.1556427 International Institute for Population Sciences (IIPS) and ICF. (2015). National Family Health Survey 4-India. Mumbai. Jena, A., & Biswal, M. (2015). Whose body is legitimatized for sterilization after all? Society and Culture in South Asia, 1, 195–199. doi:10.1177/2393861715581675 Joshi, R., Khadilkar, S., & Patel, M. (2015). Global trends in use of long-acting reversible and permanent methods of contraception: Seeking a balance. International Journal of Gynecology & Obstetrics, 131, S60–S63. doi:10.1016/j.ijgo. 2015.04.024 Kendall, T., & Albert, C. (2015). Experiences of coercion to sterilize and forced sterilization among women living with HIV in Latin America. Journal of the International AIDS Society, 18, 19462. doi:10.7448/IAS.18.1.19462 Kumar, A. (2018). Disgust, stigma, and the politics of abortion. Feminism & Psychology. doi:10.1177/0959353518765572 Kumar, A., Hessini, L., & Mitchell, E. M. H. (2009). Conceptualising abortion stigma. Culture, Health and Sexuality, 11, 625–639. doi:10.1080/13691050902842741 Love, G. (2020). Abortion stigma, class and embodiment in neoliberal England. Culture, Health and Sexuality, 1–16. doi:10.1080/13691058.2019.1709659 Lowik, A. J. (2018). Reproducing eugenics, reproducing while trans: The state sterilization of trans people. Journal of GLBT Family Studies, 14, 425–445. doi:10. 1080/1550428X.2017.1393361 Macleod, C. I. (2019). Expanding reproductive justice through a supportability reparative justice framework: The case of abortion in South Africa. Culture, Health and Sexuality, 21, 46–62. doi:10.1080/13691058.2018.1447687 Masih, M., Barpanda, S., & Wynee, Z. (Eds.). (2018). Mistreatment and coercion: Unethical sterilization in India. New Delhi: Human Rights Law Network. Millar, E. (2020). Abortion stigma as a social process. Women’s Studies International Forum, 78, 102328. doi:10.1016/j.wsif.2019.102328 Ministry of Health and Family Welfare (Government of India). (2016). Annexure-1, Mission “Vikas parivar.” New Delhi. Ministry of Health and Family Welfare (Government of India). (2018). Annual report family planning, in: Annual health report 2017–2018. Ministry of Health & Family Welfare, Government of India. Ministry of Health and Family Welfare (Government of India). (2019). Annual report 2019–2020. Mishtal, J. (2012). Irrational non-reproduction? The “dying nation” and the postsocialist logics of declining motherhood in Poland. Anthropology & Medicine, 19, 153–169. doi:10.1080/13648470.2012.675048 Mishtal, J. (2019). Reproductive governance and the (re)definition of human rights in Poland. Medical Anthropology, 38, 182–194. doi:10.1080/01459740.2018.1472090 Nandagiri, R. (2017). Why feminism: Some notes from ‘the field’ on doing feminist research. Engenderings blog, LSE 1–5. Nandagiri, R. (2019a). Nirdhāra: A multimethod study of women’s abortion trajectories in Karnataka, India. London: London School of Economics and Political Science.

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Nandagiri, R. (2019b). “Like a mother-daughter relationship”: Community health intermediaries’ knowledge of and attitudes to abortion in Karnataka, India. Social Science & Medicine, 239, 112525. doi:10.1016/j.socscimed.2019.112525 Nandagiri, R. (2020). “Can you keep a secret?”: Methodological considerations for qualitative abortion research. Nandagiri, R. (2021). What’s so troubling about ‘voluntary’ family planning anyway? A feminist perspective. Population Studies, 75, 221–234. doi:10.1080/00324728. 2021.1996623 Nandagiri, R., Coast, E., & Strong, J. (2020). COVID-19 and abortion: Making structural violence visible. International Perspectives on Sexual and Reproductive Health, 46(Supplement 1), 83–89. doi:10.1363/46e1320 Norris, A., Bessett, D., Steinberg, J. R., Kavanaugh, M. L., De Zordo, S., & Becker, D. (2011). Abortion stigma: A reconceptualization of constituents, causes, and consequences. Women’s Health Issues, 21, S49–S54. doi:10.1016/j.whi.2011.02.010 Open Society Foundations. (2011). Against her will. Forced and coerced sterilization of women worldwide. Pearson, R. (2019). A feminist analysis of neoliberalism and austerity policies in the UK. Soundings, 71, 28–39. doi:10.3898/soun.71.02.2019 Pillow, W. S. (2003). Confession, catharsis, or cure? Rethinking the uses of reflexivity as methodological power in qualitative research. International Journal of Qualitative Studies in Education, 16, 175–196. doi:10.1080/0951839032000060635 Pradhan, M. R., & Dwivedi, L. K. (2019). Changes in contraceptive use and method mix in India: 1992–1992 to 2015–2016. Sexual and Reproductive Healthcare, 19, 56–63. doi:10.1016/j.srhc.2018.12.006 Pulla, P. (2014). Why are women dying in India’s sterilisation camps? BMJ, 349. g7509. doi:10.1136/bmj.g7509 Ramachandar, L., & Pelto, P. J. (2002). The role of village health nurses in mediating abortions in Rural Tamil Nadu, India. Reproductive Health Matters, 10, 64–75. doi:10.1016/S0968-8080(02)00022-8 Rani, M., Bonu, S., & Harvey, S. (2007). Differentials in the quality of antenatal care in India. International Journal for Quality in Health Care, 20, 62–71. doi:10.1093/ intqhc/mzm052 Ross, L. J. (2017). Reproductive justice as intersectional feminist activism. Souls, 19, 286–314. doi:10.1080/10999949.2017.1389634 Ross, L. J., Roberts, L., Derkas, E., Peoples, W., & Bridgewater Toure, P. (Eds.). (2017). Radical reproductive justice: Foundation, theory, practice, critique. New York, NY: First Feminist Press. Ross, L., & Solinger, R. (2019). 2. Reproductive justice in the twenty-first century. In L. J. Ross & R. Solinger (Eds.), Reproductive justice (pp. 58–116). Berkeley, CA: University of California Press. doi:10.1525/9780520963207-003 Sarojini, N., Subha, B. S., Ambhore, V., & Venkatachalam, D. (2015). Bilaspur sterilisation deaths: Evidence of oppressive population control policy. Indian Journal of Medical Ethics, 12, 2–5. doi:10.20529/IJME.2015.001 Sasser, J. (2018). On infertile ground: Population control and women’s rights in the era of climate change. New York, NY: New York Unieversity Press. Saunders, K. (2020). ‘I think I stick out a bit’: The classification of reproductive decision-making. Sociological Research Online. doi:10.1177/1360780420909139

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Scott, G. (2017). ‘My wife had to get sterilised’: Exploring women’s experiences of sterilisation under the emergency in India, 1975–1977. Contemporary South Asia, 25, 70–84. doi:10.1080/09584935.2017.1292212 Senderowicz, L. (2019). “I was obligated to accept”: A qualitative exploration of contraceptive coercion. Social Science & Medicine, 239, 112531. doi:10.1016/j. socscimed.2019.112531 Singh, H. D. (2018). Sterilization regret among married women in India: Trends, patterns and correlates. International Perspectives on Sexual and Reproductive Health, 44, 167. doi:10.1363/44e7218 Singh, H. D. (2020). Numbering others: Religious demography, identity, and fertility management experiences in contemporary India. Social Science & Medicine, 254, 112534. doi:10.1016/j.socscimed.2019.112534 Singh, S., Shekhar, C., Acharya, R., Moore, A. M., Stillman, M., Pradhan, M. R., … Browne, A. (2018). The incidence of abortion and unintended pregnancy in India. Lancet Global Health, 6, e111–e120. doi:10.1016/S2214-109X(17)30453-9 Singh, P., Singh, K. K., & Singh, P. (2021). Factors explaining the dominion status of female sterilization in India over the past two decades (1992–2016): A multilevel study. PLoS One, 16, 1–18. doi:10.1371/journal.pone.0246530 Smith-Oka, V. (2009). Unintended consequences: Exploring the tensions between development programs and indigenous women in Mexico in the context of reproductive health. Social Science & Medicine, 68, 2069–2077. doi:10.1016/j. socscimed.2009.03.026 Sri, B. S., & Ravindran, T. K. S. (2012). Medical abortion: Understanding perspectives of rural and marginalized women from rural South India. International Journal of Gynecology & Obstetrics, 118, S33–S39. doi:10.1016/j.ijgo.2012.05.008 Stillman, M., Frost, J. J., Singh, S., Moore, A. M., & Kalyanwala, S. (2014). Abortion in India: A literature review. New York, NY: Alan Guttmacher Institute. Supreme Court of India. (2016). Devika Biswas versus the Union of India. India. Vinod Joseph, K. J., Mozumdar, A., Lhungdim, H., & Acharya, R. (2020). Quality of care in sterilization services at the public health facilities in India: A multilevel analysis. PLoS One, 15, 1–19. doi:10.1371/journal.pone.0241499 Williams, R. J. (2014). Storming the citadels of poverty: Family planning under the emergency in India, 1975–1977. Journal of Asian Studies, 73, 471–492. doi:10.1017/ S0021911813002350 Wilson, K. (2015). The “new” global population control policies: Fuelling India’s sterilization Atrocities. DifferenTakes 87. Wilson, K. (2017). In the name of reproductive rights: Race, neoliberalism and the embodied violence of population policies. New Formations. doi:10.3898/newf:91. 03.2017 Wilson, K. (2018). For reproductive justice in an era of Gates and Modi: The violence of India’s population policies. Feminist Review, 119, 89–105. doi:10.1057/s41305018-0112-0 Wilson, K., Loh, J. U., Purewal, N., Ung Loh, J., & Purewal, N. (2018). Gender, violence and the neoliberal state in India. Feminist Review, 119, 1–6. doi:10.1057/ s41305-018-0109-8 Xavier, T., Vasan, A., & Vijayakumar, S. (2017). Instilling fear makes good business sense: Unwarranted hysterectomies in Karnataka. Indian Journal of Medical Ethics, 2, 49–55. doi:10.20529/ijme.2017.010

Chapter 3

When Time Becomes Biological: Experiences of Age-Related Infertility and Anticipation in Reproductive Medicine Nolwenn B¨uhler

Abstract This chapter investigates knowledge and practices relating to the ‘right timing’ in reproductive biomedicine in Switzerland. More precisely, it focuses on the effects of an anticipatory regime (Adams, Murphy, & Clarke, 2009) on women’s experiences of age-related infertility. As assisted reproductive technologies (ARTs) promise to intervene in the fixed ‘biological facts’ of fertility decline to render reproduction and the timing of motherhood more flexible, manageable and controllable, this chapter explores the effects of anticipation on women’s experiences and negotiations of age-related infertility and ARTs. It sheds light on an anticipatory regime which can be called ‘motherhood as right timing’. It shows how, in this regime, the temporality of the lifecourse is brought back to a biological temporality and how expectations and injunctions towards managing and controlling time contain the possibility of their failure, as they are associated with a multiplication of uncertain, complex and resisting biologies. At the core of the practices and politics of anticipating fertility decline, there is a tension between acting upon and being acted upon time, which are embedded in a moral economy of responsibility and volition in which women are blamed, or blame themselves, for not anticipating what is by definition beyond individual control and anticipation. Keywords: Age-related infertility; assisted reproduction; biology; biomedicalisation; anticipation; moral responsibility

Technologies of Reproduction Across the Lifecourse, 49–65 Copyright © 2022 Nolwenn B¨uhler Published under exclusive licence by Emerald Publishing Limited doi:10.1108/978-1-80071-733-620221006

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Introduction ‘If it is easy not to have children, if one does not want to, it is more difficult to have one, when one wants’ states Merck’s brochure for its age and fertility products. Building off the second-wave feminist slogan ‘A child, if I want, when I want’, Merck’s statement is indicative of a shift in how we think about controlling reproductive biology with biomedical technologies in which timing becomes central. Increased medical and social warnings about age-related fertility decline and the risk of unwanted infertility have superseded concerns about the ‘if’ of motherhood that was at heart of the fight to access abortion and contraception. It has now become a question of ‘when’. In this chapter, I investigate the knowledge and practices relating to the ‘right timing’ of motherhood in reproductive biomedicine in Switzerland. I focus on the effects of a biomedical anticipatory regime on women’s experiences of age-related infertility (Adams et al., 2009). There has been much scholarly attention to the many ways in which temporality is at stake in scientific and biomedical endeavours (Lapp´e, 2014; Llewellyn & Higgs, 2021), but how it is experienced by individuals remains under-elaborated (Mattingly, 2019; Stephan & Flaherty, 2019). Assisted reproductive technologies (ARTs) promise to intervene in the fixed ‘biological facts’ of fertility decline to make reproduction and the timing of motherhood more flexible, and controllable, but how is this promise embodied in women’s experiences? Is the ‘biological clock’ becoming more flexible? Addressing these questions, this chapter examines women’s negotiations of anticipation, age-related infertility and ARTs. My focus is on the productive effects of an anticipatory regime on women’s embodied experiences of the ‘biological clock’ at the core of which, I argue, there is a tension between ‘acting upon time’ and ‘being acted upon by time’ at stake when women are dealing with the ‘biological clock’. In order to situate these experiences, I will start by briefly describing how anticipatory logics materialise and play out in biomedical practices in Switzerland. I will show that a very specific conception of time, as linear and irreversible, is at the core of discourses and practices around fertility decline. Women are indeed expected to anticipate the timing of motherhood based on medical knowledge about the fertility decline that is on the temporality of biological processes. I will then turn to women’s accounts of infertility and ARTs and document the productive effects of this temporal regime on their embodied experiences of fertility decline. I will shed light on the ambivalence at the core of the regime, which I call ‘motherhood as right timing’, characterised by a gendered injunction for women to anticipate fertility decline and therefore enable them to have agency over time. I will then show how, in the context of ARTs, anticipatory logics produce within themselves the possibility of their own failure through which other enactments of fertility decline emerge. In contrast to expected linear temporalities, sensitive, uncertain and resisting biologies pervade the embodied experiences of anticipation and ARTs, indicating the deep entanglement between acting upon and being acted upon by time.

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The Biomedicalisation of Fertility Decline In European countries, there has been much public concern about declining fertility rates and later childbearing since the 1970s (Balbo, Billari, & Mills, 2013; Billari, 2008; Menken, 1985). Discourses around the medical risks of late pregnancies and fertility decline after the iconic age of 35 warn women to have a child before it is too late and remind them that their ‘biological clock’ is ticking (see Amir, 2007 for an analysis of the emergence of the biological clock concept). The ‘biological clock’ crystallises public and moral concerns about fertility decline and its perceived drivers. As a result of social reforms since the 1970s, white, middleto upper-class, well-educated women have entered the workforce, a change supported by increased access to safer contraception and abortion, technologies promising to help women choose the timing of motherhood. The ‘biological clock’ surfaces the resulting discrepancy between the different temporalities in women’s lifecourse, especially the temporality of work which leads women to delay or postpone childbirth, the temporality of partnering and the norms of ‘romantic love’ (Brown & Patrick, 2018; Inhorn, 2020; Inhorn, Birenbaum-Carmeli, Yu, & Patrizio, 2021; Waldby, 2014), as well as the temporality of fertility, as delaying childbirth expose women to the risk of unwanted childlessness due to age-related fertility decline, which not only reduces chances of pregnancy, but also increases the risk of medical problems when a pregnancy occurs (i.e. Alonzo, 2002; Jolly, Sebire, Harris, Robinson, & Regan, 2000; Joseph et al., 2005; Londero, Rossetti, Pittini, Cagnacci, & Driul, 2019). The possibility of controlling reproductive biology and timing is at the core of technologies of contraception and abortion that facilitated the shift from a regime of ‘motherhood as destiny’ to ‘motherhood as choice’ (Bajos & Ferrand, 2006). Advances in reproductive biomedicine ushered in a new regime of ‘motherhood as right timing’. Producing new knowledge, standards and norms of age-related infertility and developing possible technological solutions, ARTs participate in the wider biomedicalisation of reproductive temporalities at the biological, individual and populational levels (Clarke, Mamo, Fosket, & Shim, 2010). Age-related decay of ovarian reserve is thought of as a ‘fact of life’ (Franklin, 1997) and, therefore, something that individuals usually have no control over. It structures the lifecourse by symbolically separating the reproductive and non-reproductive parts of women’s lives and organising generational succession ¨ (Buhler, 2015). It is highly gendered as it is socially assumed that only women encounter age-related fertility, reinforcing gendered assumptions about ageing – ¨ in which men are ageless and women deteriorate with age (Lowy, 2009). However, the biomedicalisation of reproduction creates the possibility of more flexible arrangements in a woman’s lifecourse by technologically circumventing decreasing ovarian reserve (Brown & Patrick, 2018). Building on Marilyn Strathern (1992), I argue that with ARTs, our ideas of what is natural lose their grounding in physiological function and thus biological limits are transformed into a matter of choice. Such biomedical possibility reshapes the expected timing of the lifecourse, of biology, and, in a longer view, of population growth. As a consequence, issues of controlling, resisting and escaping the biology of the

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fertility decline are at the centre of ethical and medical debates surrounding fertility extension possibilities, but also central in women’s intimate experiences of reproductive treatment and timing (see Susan Pickard in this volume). To understand how the biomedicalisation of age-related fertility decline impacts notions and subjective experiences of reproductive timing, I draw on Adams et al.’s (2009) conceptual framework of biomedicalisation and anticipation, which is useful to grasp how reproduction is increasingly regulated through temporal norms. Of particular interest is Adams’ notion of the anticipatory logics in which the orientation to the present is superseded by speculative forecasting and predictive knowledge, and individuals think and live the present moment in an affective mode that is turned towards the future (Adams et al., 2009). Characterised by its moral dimension, the anticipatory regime makes individuals responsible for living in preparation for potential threats and to optimise and secure in the present, the best possible future, often through biotechnology. Uncertainty is constitutive of this future-oriented management of time, as the ‘promise of certainty […is] coexistent with the acknowledgement of an ongoing deferral of truth as ever changing’ (Adams et al., 2009, p. 247). In this chapter, I explore the effect of anticipation on women’s subjective and embodied experiences of ARTs and timing, indexical of a regime of ‘motherhood as right timing’. As medical knowledge of the biology of fertility decline is central to this regime, I am particularly interested in showing how various understandings of this biology relate to the ideal of the ‘right time’ to have a child. Questioning both the narrative about the technologically enabled flexibility of biology and the lifecourse, and the one about their inherent fixity, I am especially interested in how these women navigate the normative assumptions and injunctions associated with the timing of reproduction. I will show how, in this context, the temporality of the lifecourse is brought back to a biologically rooted temporality. Drawing on Adams et al.’s (2009) argument that uncertainty is a constitutive part of anticipation, I demonstrate how expectations and injunctions about managing and controlling time contain the possibility of their failure as they are associated with multiple uncertain, complex and resisting biologies. The practices and politics of anticipating fertility decline are characterised by a tension between acting upon and being acted upon time, where both the fixity and mutability of the biological are subtly reconfigured and reshaped over time.

Methods This paper draws on research with women and couples who are experiencing involuntary childlessness and are undergoing or have undergone assisted reproductive treatment to have children and build their family. They were contacted through personal contact and by using the snowball principle (Atkinson & Flint, 2001), via a French-speaking internet forum dedicated to pregnancy, motherhood and family issues, including infertility and reproductive medicine, as well as a collaboration with a reproductive medicine unit of a university hospital.1 My analysis is based on ethnographic interviews (Beaud & Weber, 2003; Sherman

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Heyl, 2007) with 34 women or couples undergoing reproductive treatment and 21 with clinicians and other experts involved in reproductive medicine; observations during interviews, conferences, information sessions and at the reproductive medicine unit; and a corpus of scientific and medical articles, as well as legal and media texts relevant to the Swiss context. Ethical approval was obtained on 21 September 2011 from the Ethical Commission of the Canton de Vaud. All identifying information was removed or changed to protect the participants’ anonymity.2 In Switzerland, the legal framework restricts access to IVF to couples in a stable heterosexual relationship and in an age range enabling them to take care of their children until the age of majority. In vitro fertilisation (IVF) is not reimbursed by health insurance providers and egg donation is prohibited. Egg freezing is authorised but must also be paid out of packet by patients. These parameters restricted who was able to participate in this research. The participants were heterosexual, in their late 30s or early 40s, predominantly white, and had for the most part the financial means to pay for IVF out of pocket. Moreover, first contacts were always made with women reflecting the ‘bio-responsibility’ (Pande & Moll, 2018) they still have in regard to reproduction. However, they were not all financially well off, and I observed various financial arrangements put in place by people with limited financial resources.

Embodied Experience: Ticking Clocks and the Right Time to Have a Child In medical discourse, the inevitability that fertility declines with age is an unquestioned certainty, though it is near impossible to predict on an individual basis. This discourse plays an important role in women’s ideas about the ‘right time’ to have a child and start a family. Reproductive medicine in Switzerland is characterised by the idea that age-related fertility decline should be anticipated by women and that they should take action in the present by planning their reproductive lives based on their awareness of appropriate medical knowledge (see e.g. Bleichenbacher, Heitlinger, & Imthurn, 2010). There is an anticipatory logic at play that is expressed in the assumption that women are expected to actively anticipate decreasing ovarian reserve to secure a future with children and, thus, they are blamed for turning to ARTs too late or for overestimating the power of reproductive technologies to help them to have a child. The population level trend towards late motherhood and infertility are explained by women not anticipating the effects of ageing and over-relying on reproductive medicine to make their bodies fertile at a time that suits them. However, experts acknowledge that there are no diagnostic tools to predict this decline; that it is more dynamic and relational than assumed, especially when they recall that the enduring lack of children results from the unique combination of two partners’ fertility potential. In clinical practices, chronological age remains the main marker of success. This is drawn from population-level statistics and has limited use in predicting an individual’s fertility. The emphasis on women’s apparent ignorance about the fertility decline

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combined with professional demands that lead them to time motherhood at an age which is not optimal biologically makes information and counselling appear to be possible preventive solutions to infertility. However, rather than being unaware of the inevitability of the decline and in need of more information and counselling, women are constantly reminded that their ‘biological clock is ticking’ by their friends, relatives, or the media. It seems almost impossible for them to forget that fertility declines with age. These social reminders convey contradictory normative expectations about the timing of reproduction. Women are considered socially fit to have a child only at a specific moment based on the careful calculation between two sets of expectations: not too early so as not to undermine personal and professional development, and not too late in order to avoid fertility problems related to age. This is premised on the assumption that childbearing and motherhood are constitutive of women’s identities and reproductive lives, in contrast to men. These expectations are underpinned by a specific understanding of biological temporality, which is linear, irreversible, calculable and predictable in advance. The idea that women can and should act upon time is central to ideas about the ‘right timing’; in other words, they are expected to rationally anticipate and plan the right time to have a child. When we turn to women’s subjective accounts of ARTs and timing, the same anticipatory logic is reflected, the prospect of acting upon biology conflates with exercising agency over time revealing how acting upon biology, conflates with exercising agency over time. For some women these constant reminders of the ticking clock have a galvanising effect as they encouraged women to imagine their reproductive future and prompted them to act in the present by initiating a child project and re-position themselves towards the time of biology and the time of the lifecourse. It was less a question of whether or not they wanted a child, which was assumed, than a felt sense of pressure to start planning the ‘when’ of motherhood. These reminders also contribute to women internalising the idea that time impacts their fertility potential. While they have general knowledge that fertility does decline, these external reminders transform it into a matter of personal biology. Their own bodies become the markers of reproductive ageing understood in a fixed sense, as something they cannot act upon. The experience of Charlotte, age 39 at the time of the interview, and her partner, Alexandre, 31, illustrates this point. They started trying to have a child four years earlier and turned to IVF after a year and a half of diagnosis tests and examinations, and the removal of her fallopian tubes: C:

We started to speak about having a child four years ago, after 6 years of being a couple. I am 8 years older than Alexandre, therefore I have a biological clock problem, a little. And around us, it is true that my brother has children, he had already two at that time, his [Alexandre’s] brother, they have also two, his sister, well we were surrounded by kids, so with years, me, I was of age now of having children, I did not think, I had this idea that it might not be easy, because I know people around me who have had a difficult

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trajectory, but well we never imagined that it happened to us, of course! And this is it, I stopped taking the pill. Just, how old were you? You are speaking about biological clock… I was… then I was 35, 34 in fact, I had not turned 35 yet. And I thought it was the right age, I had enjoyed my life very much, it is true, we travelled a lot, we did many things, so for me it was the moment. For Alexandre less, maybe, well [speaking to Alexandre] I will let you speak, but he is younger, so inevitably the ‘urgency’ aspect, in quotes, is less important for him, of course, but we agreed nevertheless… (Charlotte and Alexandre, 20 May 2011)

For Charlotte and Alexandre, the reminder of the ticking clock first emerged from their friends and relatives. Their siblings’ children made Charlotte and Alexandre feel ‘surrounded by kids’ and acted both as a mirror of their own situation and as a normative cue that they may have reached a time in life when it is appropriate and socially desirable to have children. The duration of their relationship, and their free time without children, also played a part in producing the ‘right timing’. Charlotte’s reference to the biological clock signifies the biological time of reproductive aging. She sees this as linear and irreversible, which generates a sense of ‘urgency’ that pushes them to act in the present by stopping taking the contraceptive pill, before it is too late. Because of their age differences and its relationship to the expected stages of the lifecourse – becoming a stable couple, enjoying life, building a career and then having kids – deciding the ‘right time’ to have a child was explicitly negotiated. Negotiating the ‘right time’ forced them to orient themselves towards the future, but also changed her relationship to the past. She read her past history through the lens of this new future-oriented temporality, in a way which mixed the temporality of reproduction and the temporality of the lifecourse, especially in regard to the formation of her couple relationship. Charlotte considered the length of her previous relationships which did not turn out as stable enough to build a family to be key to her current decisions and negotiations. A previous relationship was seen to be a loss of time and accelerated the decision to have a child in her subsequent relationship. The decision to have a child appears here as an opportunity to re-read and re-narrate one’s past in light of the future one is preparing for oneself. The linear, non-repetitive and irreversible nature of the ‘biological clock’ generates a kind of pressure to plan motherhood, and, in some cases, with a real sense of urgency. Most of the women I met expressed that they felt that they had to catch up. They were running behind in comparison with others, based on the normative stages of the lifecourse. But they were also running behind in chronological age and fertility decline. The social and medical gendering of the biological clock, locating time in women’s bodies, and not in men’s, impacts women’s experiences as they express the pressures surrounding reproductive aging, and are more proactive in their reproductive journey. Dalia, who was 41-years old when I

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met her, was unemployed after leaving a demanding job, married for two years and just starting inseminations, expressed this sense of urgency: It is age that puts pressure on us. I am 41 years old, and my husband is…, well it is not a real problem for men, it is especially for women, because fertility declines from 35 years old. … I cannot wait one year or three months, I cannot wait even one month! So, I have to rush things, even though I have to pay for it myself. So, I took the risk of signing the papers, because a baby has no price. (Dalia, 3 February 2012) Dalia’s words convey how ARTs are seen as a solution to the pressures of time passing, giving her hope that she can act upon time rather than being acted upon by time. ‘Racing against the clock’ is a phrase often used by women and clinicians to refer to the tension between reproductive ageing and the pace of treatment; expressed as the fear of losing time when it may be already too late, or before it is too late. Louise, 33-years old when I met her, describes how questions about the ‘right time’ and whether it is biologically and/or socially determined are not resolved by treatment but rather exacerbated by it. She explains how she and her partner plan to spend a year in a foreign country in a very big city, for professional reasons, and how she is torn between her desire to enjoy their year abroad or start a new IVF cycle there in an unknown clinic, because she is aware that time is passing, and her chances of getting pregnant. Concluding that there is no perfect timing, she says that they will go on with treatment, even though it might not be the best time for them, from a lifecourse perspective, but also because it has become impossible for her to imagine taking a break and pausing her treatment; for Louise, ARTs becoming the only way to act upon the time of biology. The effects of the anticipatory logic play out in two ways for women undergoing ARTs. First, when it comes to the question of planning a pregnancy, the reproductive trajectory that had been embedded in the longer temporality of the lifecourse becomes reduced to a biologically defined time, which reflects how reproductive potential is thought to diminish with age. Secondly the question of the ‘right time’ to have a child extends from the decision itself and encompasses the potential success or failure of the ART itself. The ‘right timing’, rather than being determined by the ideal of a future lifecourse, is played out in reproductive treatment itself and becomes a matter of the successes and failures of IVF cycles, which both opens up the possibility of acting upon time, but also constantly reminds women that time is acting upon them. Accelerating or slowing down treatment cycles, as Dalia’s and Louise’s accounts show, is envisioned to be the only way of intervening in a biological fact of life. As a result, in contrast with the assumptions underlying the anticipatory discourse of the biological clock, namely that the biology of the fertility decline is linear, ineluctable and knowable and that the time of reproduction is manageable and controllable in advance, women’s experiences of ARTs increase the embodied feeling that they are being acted upon

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by time, a biological time which is less predictable than expected and they have little control over.

Troubling Anticipatory Logics A closer reading of women’s experiences of age-related infertility and ARTs provides more details on how the anticipatory logics, typical of reproductive biomedicine, manifest in women’s lives. In this logic, fertility decline is knowable and the timing of motherhood is manageable and controllable through the technological manipulation of biology. Here I point to ways in which the pervasive biomedical anticipatory logics contain the possibility of their failure. In trying to anticipate and control the decline with technology, experiences of sensing, resisting and uncertain biologies emerge from women’s accounts.

The Uncertain Biologies of the Non-Anticipated The anticipation of fertility decline plays an important role in determining the ‘right time’ to have a child. Before diagnosis and starting fertility treatment, women have general knowledge about diminishing fertility with age, but they do not know to which extent their own bodies and personal reproductive biologies are affected. Louise was 33-years old at the time of the interview, and had been undergoing reproductive treatment, donor inseminations and ICSI, for three years. She describes a gap between the unanticipated effect of age on her own reproductive potential and general knowledge about age-related fertility decline: I am well educated, I should have known that a woman after 40, it becomes more difficult. I had no idea that after 32–35, I mean 20–38, for me it was the same battle. I wasn’t stressed at all and I was very much of a teenager in my lifestyle. When you study at the university, at 27 you are much less mature, than somebody who is already working at the same age. So first my friends told me, I was 26, Louise, you should stop acting like a fool. The biological clock is ticking you know. … And I am angry at my mom who told me all these years, that there would not be any problem, that she had my sister at 36 and that I am like her, but it is not the same situation. (Louise, 17 November 2011) The tension between general knowledge about age-related fertility decline and individual biologies generate the uncertainties upon which anticipation works (Adams et al., 2009). Val´erie, who was 42 when I met her, expressed the gap between knowing – the general knowledge that everybody knows about ageing and fertility decline – and not knowing – how her own reproductive potential is affected by age and how her own body will react to reproductive treatment. Val´erie explained:

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Nolwenn B¨uhler I am 42, after all. I would like to be provided with a more accurate picture than just hearing, ‘let’s try again’. I am not stupid; I know what fertility is. I was expecting that I would be told that it was not really possible, or that naturally it was not going to be easy. What I was not expecting is… I imagined that ARTs could do many things, and that even with an aging body, or at least aging oocytes, it was nevertheless possible to sort out embryos to ensure pregnancy, which is actually not the case. So, I was monitored on my June cycle, we did really all the exams. Hormonal levels were not very good, other results not better. And then the gynaecologist told me that the solution for me was egg donation, and I was like, no, it is not possible! And then I got pregnant naturally, because we had done it at the right moment. And I was like: ‘What are these doctors saying, they talk rubbish, egg donation? This is a nonsense, this is rubbish!’. And it kept going during a month and a half, and then I miscarried. … After that I started to look for more information. I had heard about miscarriages, that risk was increased, but in my mind, I was just thinking: ‘Great, I can get pregnant, there is no reason it is not going to work’, but after the miscarriage I started to question it again. (Val´erie, 7 October 2011)

Val´erie’s account illustrates the uncertainty surrounding how time affects specific biologies. The transformation of general awareness about age-related infertility into personal experience is often experienced as a ‘slap in the face’ (Dani`ele, 46, 13 February 2012) or a ‘small death’ (Louise, 33, 17 November 2011). The effects of time in the form of poor ovarian reserve and enduring inability to have a child are unexpected, and its materialisation when entering reproductive treatment is experienced as an unanticipated shock. Uncertainty extends beyond the measurements of ovarian reserve because these are only indicators and cannot accurately predict the chance of pregnancy. The biological temporality of the decline remains outside the realm of biomedical control and contradicts the medical discourse on age-related fertility decline. Val´erie’s account shows how contradictory and complex biologies are used strategically throughout reproductive treatment – diagnosis, at the moment of deciding to turn to egg donation, before/after miscarriage – to stress both the linearity and inescapability of time passing and the body’s ability to defy the clinical predictions about possible futures with or without children. It illustrates how acting upon and being acted upon by time are two facets of the same experiences.

The Sensitive Biologies of Somatic Anticipation Sensing that age and time might represent an obstacle to the realisation of a future with children is common. Many couples engage in sensory pre-emptive practices,

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what Cussins (1996) named ‘anticipatory socio-naturalisation’, in order to have a better idea of their own fertility potential. For instance, women track their body using fertility charts in an attempt to maximise chances of conception (see also Hamper, this volume). To illustrate this point, I turn to the story of Emilie and Frederic, in a relationship for seven years and both 38-years old when I first met them at a consultation with the counsellor of the medical unit. Emilie felt that something might go wrong because of her advancing age. It was a vague feeling rather than precise biomedical knowledge, a presentiment that it is already too late and that time might be against them. She explained to the counsellor how, during a whole year of trying to get pregnant, she diligently tracked her menstrual cycles by measuring her bodily temperature daily and recording the results on graphs. After a year of tracking with no success, the couple were referred by her general practitioner to a reproductive medicine specialist. The couple explained to me how this specialist glanced at her careful charts and then discarded them and said that it was insane to have done that for such a long time, leaving the couple feeling disappointed and cheated. In Emilie’s account, one can see that before undergoing diagnostic examinations and starting reproductive treatment, age-related fertility decline was something she was afraid of, but that age, the risk factor of fertility decline and criterion in determining the swiftness of medical intervention, remained as general knowledge, something that everybody knows, that concerns every woman but also no one in particular. What matters for her are the regularity and length of menstrual cycles, the small variations in bodily temperatures, the timing of sexual intercourse and the enduring lack of children in spite of their efforts. The presentiment that time would be against the couple, plays a role, however, in the sense that the couple somehow already started to assist reproduction in their own way. Sensing something is not right was a factor pushing them to increase their control over getting pregnant, to maximise their chances of conception and to make it as efficient as possible. Age-related fertility decline remains a dispersed threat rather than personally relevant. Even though it is imagined as belonging to the future, it is enacted as if it could already be here. Somehow, it matters before it gets real. Sensing can thus be understood as an embodied modality of anticipation, pushing individuals to act pre-emptively, but not based on risk statistics or predictive knowledge but rather through observing, feeling, tracking and documenting carefully the bodily signs of fertility and making sense of them, transforming the woman’s body into a fertility sensor permeable to external, as well as internal, modulations, and able to produce knowledge on reproductive biology.

The Resisting Biologies of Enduring Reproductive Treatment The temporality of reproductive treatment, which is cyclical and repetitive, complicates the politics and practices of anticipation. The linearity of anticipation is challenged by women feeling that they can act on time and biology yet at the same time feel like they are limbo in regard to their lifecourse (Franklin, 1997) and are continually returning to a starting point (Thompson, 2005). The waiting

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during a treatment cycle stretches time, extending towards a promissory future, but also a sense of powerlessness in relation to the passage of time; a sense of feeling stuck, of not advancing, as the promise of IVF fades away into an increasingly distant future. I was told many times that patience and perseverance were key to successful IVF. However, the repetition of failed treatment cycles has an effect on hope, each cycle provoking questions about the decision to continue, whether it is still the right moment to have a child and at what point to stop. ARTs, by opening up the prospect of managing biological time, not only biologically, but temporally through the management of treatment cycles, which can be sped up, slowed down or paused, highlight the moral economy of responsibility at stake in the regime of motherhood as right timing. Slowing down treatment is associated with the idea of volition (Sandelowski, 1990), suggesting that if a woman really wants a child at this moment in life, she should make reproduction a priority, and have treatment cycles in quick succession. Focusing on other priorities, such as education, training, vacation or time for oneself, can be read as lack of a real desire for a child, and thus as a lack of volition. Charlotte expressed this as guilt: Time, I let it run on, it is true. On the one hand, I realise that is has been 6 months that I let time run on, and 6 months at 39, it is a lot, isn’t it [smiling]? It is true, I feel guilty, yes, because if we want to try another IVF, well it would be all that time lost that I am taking now, but well… (Charlotte, 20 December 2011) For Charlotte, the question of age did not come as the stress of having to pause treatment and postpone a new cycle, as in Louise’s case when she had to decide whether or not to suspend treatment when going to New York city, a prospect she found full of promissory discoveries (presented above). Charlotte experienced hyper-stimulated ovulation that produced enough zygotes that could be frozen for several future rounds of IVF; hence, she did not feel stress by the biological temporality of the fertility decline.3 A feeling which might be similar for women freezing their oocytes and suspending or banking time (Waldby, 2014). Age became a question when she had to decide about undergoing a new ovarian simulation, and about the age, she – and her eggs – would be at the time of ‘starting again’, but not really in the current moment of treatment, when she allowed herself the flexibility of planning treatment cycles when it best suited her needs – emotional and physical, in relation to work. People who started their treatment young, like the couple of Bastien and Valentine, 28- and 30-years old at the time of the interview, usually say that they feel relieved that they have time ahead of them, even though they may go through many failed cycles. For them, even if it takes 10 years to have a child, they will not be ‘old’ parents and they feel lucky in this respect. They feel that they have time to try, and if necessary, to start an adoption process, which can take considerable time (Valentine and Bastien, 14 June 2012).

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Having to decide the pace of treatment cycles transforms time into a resource or a bio-capital that can be lost, saved and caught up, in order to have a child at the ‘right time’. The repetition of treatment cycles is largely determined by the couple – they can decide to have a quick succession of cycles or slow them down for personal, professional, or financial reasons. The timing of cycles is associated with a moral economy of volition and individual responsibility, in which the pace and duration of treatment are interpreted as signals of one’s ‘true’ desire for a child, and women are made ‘bio-responsible’ (Pande & Moll, 2018) for the results of ARTs. Scholars working on ARTs have shown how treatment comes to seem compulsory (Becker, 1994; Franklin, 1997; Thompson, 2005). Statistics and hope fuel the belief that the next cycle may work and that all chances are not exhausted. The repetition of treatment cycles can be encouraging and positive. Alexandre explained that the statistics worked in their favour, so the more they try, the more chances they have that it will work at least once. For others, the repeated treatment exhausted hope leading to increased detachment, as was the case for Alexandre’s partner Charlotte. The length of the treatment, the time spent thinking about timing medical procedures, doing daily injections, the sense of not advancing and of feeling stuck in repetition, combined together, led her to consider ending treatment, rather than undergoing a third round of IVF, turning abroad for egg donation or another kind of treatment that might be appropriate. The question of the right time to have a child turns, then, into the right time to end treatment, a complex choreographing of different elements, where age is the exhaustion of reproductive substance after years spent in reproductive treatment but works also as a legitimate reason to stop treatment after repeated attempts. Time was key in Agatha’s (39 when I met her) experience of ending treatment. She was torn between her decision to start a new professional specialisation that she was unable to postpone because of age limits that she would reach soon, and the awareness that she might be losing time with its deleterious effects on her fertility. She felt that if she really wanted a child, she should set that as her priority. On the one hand she says that her time has already passed, that it is already too late, but on the other, that she has not tried every possibility. She feels that to make her life liveable, she should not remain stuck in treatment, but have other activities, particularly her career. Her ambivalence comes thoroughly clearly in the following quotation: After explaining to me what it is – tubes blocked with liquid – the gynaecologist goes on with telling me about the treatment process. It was back in 2007, we are in 2012, it is 5 years ago, I was 32 years old when, 30 when I got married, 32, when we started to think seriously about it, then we decided to go see the doctor, I was already 34, one attempt after the other, the time to change, and well time goes by quickly. Here I am, 39, and I am not able to dedicate 100% of my time to this story of procreation, because now I am committed to this specialised qualification, which takes all my time. … But now there is this pressure of time, it is really as one says the last hour, if I give up, I can’t, I don’t want to give up this

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Nolwenn B¨uhler specialisation, I am committed now, but afterwards there is regret, I feel that if I don’t finish, I will regret it my whole life, I will regret that I did not dedicate myself 100% to this story of children, I don’t know, and here I am in this dilemma again, in this confusion, in this pro and contra, and all that undermines my self-confidence, in the sense that I don’t have any certainty, I don’t know what to do anymore, I’ve lost the recipe, I’ve lost the guiding thread, am I doing the right thing? I am going to regret, that’s all. (Agatha, 11 June 2012)

As the management of treatment becomes the site in which to manage the possibility of reproduction and the lifecourse, the enduring absence of children in spite of repeated attempts transforms the question of the ‘right time’ to have a child, into the ‘right time’ to end treatment and accept that perhaps one’s ‘time has passed’ (Agatha, 12 June 2012). Moreover, what the narrative of Agatha also makes clear is how ‘anticipated regrets’ (Baldwin, Culley, Hudson, & Mitchell, 2019) towards an unknowable future work as a powerful affective state. The turn to IVF, initially accepted as a response to the prospect of age-related fertility decline, based on the idea that it could help to act upon time, produces instead so much uncertainty that being acted upon by time becomes the only certainty she has. Over time, uncertainties and ambivalence take the shape of anticipated regret and guilt.

Conclusion Anticipation is the palpable sense that things could be (all) right if we leverage new spaces of opportunity, reconfiguring ‘the possible’. (Adams et al., 2009, p. 246) The promise of acting upon time by preparing for the best moment for motherhood and securing a future with children in the present based on ideas of the ‘biological clock’ is dispersed throughout reproductive biomedicine. The careful balance between not too early in regard to temporality of the lifecourse and not too late in regard to the temporality of biology is at the core of the anticipatory regime which regulates reproductive temporalities and might be called ‘motherhood as right timing’. By focusing on women’s subjective accounts of infertility and ARTs, I show how anticipation contains the possibility of its failure within itself, as uncertain, sensing and resisting biologies, which are not as knowable or predictable as they are expected to be, materialise in the embodied experiences of fertility decline. A tension emerges from the experiences of anticipation. On the one hand, with ARTs, the lifecourse and the stages of motherhood and menopause seem to become

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more flexible and open to individual reconfigurations, or to a disentangling of reproductive and temporal trajectories (Brown & Patrick, 2018). This has for consequence of increasing individual moral responsibility towards the timing and optimisation of reproduction. On the other side, reproduction seems increasingly more strictly regulated temporally, the logics of anticipation reinforcing both a linear and naturalistic definition of age-related fertility decline or the biology of reproductive ageing, considered to be real, concrete or threatening enough to undergo an invasive biomedical procedure, and a linear definition of the lifecourse which implies that women must pass through definite stages, among those, motherhood, which is constructed as inescapable. In other words, the increasing plasticity and flexibility of the lifecourse granted by biotechnological interventions work in parallel with growing normative expectations to anticipate the fertility decline and optimise the timing of reproduction as a balance between biological processes of reproductive ageing and the biographical stages of the lifecourse. ARTs open up the prospect of ‘acting upon time’ at the same time that they enact a notion of age-related infertility as ‘being acted upon by time’. Instead of opposing them, these are two facets of the same coin of the anticipatory regime of motherhood as right timing; that the more control over time and biology is expected, the more uncertainties and resistances are produced. Anticipation is embedded in a moral economy of responsibility and volition (Sandelowski, 1990), which makes women individually bio-responsible for the temporal management of their reproductive lives. It revives thus historical assumptions about failure of volition and women’s agency in the domain of (in)fertility (Sandelowski, 1990), in which age-related infertility becomes the unwanted price of voluntary postponement. The inseparability of ‘being acted upon time’ and ‘acting upon time’ illustrates the structural violence of being morally blamed for not anticipating what is by definition not anticipable.

Notes 1. Empirical material was collected between 2011 and 2015 in the context of two projects funded by the Swiss National Science Foundation (SNSF): (1) “Fertility and Family in Switzerland: Local Processes of Reproduction and Kinship in Transnational Contexts of Biomedical Technologies” (2010–2013), directed by Prof. Willemijn de Jong (Department of Social Anthropology and Cultural Studies, ISEK, University of Zurich); (2) “Reproductive technologies, biological clock discourses and the extension of fertility time: gender, kinship and biopolitics ¨ of reproductive ageing in Switzerland” (Buhler, Gender and Women’s Studies Department, UC Berkeley 2013–2014). 2. All names of people met in the fieldwork are pseudonyms. Only when published papers are cited, are real names mentioned. 3. At that time according to the Swiss Reproductive Medicine Act only zygotes could be frozen and not embryos.

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Inhorn, M. C., Birenbaum-Carmeli, D., Yu, R., & Patrizio, P. (2021). Egg freezing at the end of romance: A technology of hope, despair, and repair. Science, Technology & Human Values. doi:10.1177/0162243921995892 Jolly, M., Sebire, N., Harris, J., Robinson, S., & Regan, L. (2000). The risks associated with pregnancy in women aged 35 years or older. Human Reproduction, 15(11), 2433–2437. doi:10.1093/humrep/15.11.2433 Joseph, K. S., Allen, A. C., Dodds, L., Turner, L. A., Scott, H., & Liston, R. (2005). The perinatal effects of delayed childbearing. Obstetrics & Gynecology, 105(6), 1410. doi:10.1097/01.AOG.0000163256.83313.36 Lapp´e, M. D. (2014). Taking care: Anticipation, extraction and the politics of temporality in autism science. BioSocieties, 9(3), 304–328. doi:10.1057/biosoc.2014.14 Llewellyn, H., & Higgs, P. (2021). Living suspended: Anticipation and resistance in brain cancer. In C. Vindrola-Padros, B. Vindrola-Padros, & K. Lee-Crossett (Eds.), Immobility and medicine: Exploring stillness, waiting and the in-between (pp. 251–271). Singapore: Springer. Londero, A. P., Rossetti, E., Pittini, C., Cagnacci, A., & Driul, L. (2019). Maternal age and the risk of adverse pregnancy outcomes: A retrospective cohort study. BMC Pregnancy and Childbirth, 19(1), 261. doi:10.1186/s12884-019-2400-x ¨ Lowy, I. (2009). L’ˆage limite de la maternit´e : Corps, biom´edecine, et politique. Mouvements, 59(3), 102–112. Mattingly, C. (2019). Waiting: Anticipation and episodic time. The Cambridge Journal of Anthropology, 37(1), 17–31. doi:10.3167/cja.2019.370103 Menken, J. (1985). Age and fertility: How late can you wait? Demography, 22(4), 469–483. doi:10.2307/2061583 Pande, A., & Moll, T. (2018). Gendered bio-responsibilities and travelling egg providers from South Africa. Reproductive Biomedicine & Society, 6, 23–33. doi:10. 1016/j.rbms.2018.08.002 Sandelowski, M. J. (1990). Failures of volition: Female agency and infertility in historical perspective. Signs, 15(3), 475–499. Sherman Heyl, B. (2007). Ethnographic interviewing. In P. Atkinson, S. Delamont, A. Coffey, J. Lofland, & L. Lofland (Eds.), Handbook of ethnography (pp. 369–383). London; Thousand Oaks, CA; New Delhi; Singapore: Sage. Stephan, C., & Flaherty, D. (2019). Introduction: Experiencing anticipation. Anthropological perspectives. The Cambridge Journal of Anthropology, 37(1), 1–16. doi:10.3167/cja.2019.370102 Strathern, M. (1992). After nature: English kinship in the late twentieth century. Cambridge: Cambridge University Press. Thompson, C. (2005). Making parents. The ontological choreography of reproductive technologies. Cambridge, MA: MIT Press. Waldby, C. (2014). “Banking time”: Egg freezing and the negotiation of future fertility. Culture, Health and Sexuality, 1–13. doi:10.1080/13691058.2014.951881

Chapter 4

Delaying Menopause, Buying Time? Positioning Ovarian Tissue Cryopreservation and Transplantation Technologies for Delaying Menopause in the Context of Women’s Embodied Reproductive Choice and Agency Across the Lifecourse Susan Pickard

Abstract Menopause discourse plays a powerful cultural role in the west, serving to mark a (negative) shift in women’s social status, shaping both social norms and women’s self-appraisals and dividing women’s lifecourse into two: fertile and post-fertile, with value attributed only to the former. However, in 2019 a new ‘solution’ to the problem of menopause entered public discourse in the form of a new surgical technology, offered by the private health provider ProFam, to delay menopause via ovarian freezing techniques. Aimed in the first instance at women seeking to avoid the disruptions of severe symptoms, it also quickly became framed as a way in which (especially childless) women might extend their fertility. In this chapter I explore menopause discourse as it appears in medical and popular sources associated with this new technology, looking at the continuities and discontinuities with earlier forms of menopause discourse. I also take a broader view in placing technologies for delaying menopause in the context of reproductive technologies used by women at all stages of the lifecourse, critically examining the claims that they give women choice, freedom and control over time. I suggest that in fact they are implicated with rather more complex temporal structures, captured in the concept of ‘ambivalence’ and characterised by a mixture of gendered expectation, anticipation and suspension of agency. Finally, I explore Technologies of Reproduction Across the Lifecourse, 67–81 Copyright © 2022 Susan Pickard Published under exclusive licence by Emerald Publishing Limited doi:10.1108/978-1-80071-733-620221007

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Susan Pickard whether it is menopause itself, rather than its delay, that, in serving to disrupt such temporal ambivalence among other things, can in fact introduce the possibility of freedom. Keywords: Menopause; ovarian freezing techniques; reproductive technologies; time; temporality; gender; choice

Twenty years ago Margaret Morganroth Gullette (1997) drew attention to the way in which menopause discourse served a powerful cultural role, in marking a (negative) shift in women’s social status, shaping both social norms and women’s self-appraisals and dividing women’s lifecourse into two: fertile and post-fertile with value attributed only to the former. Its reappearance at a time when women have enjoyed access to education and professional status, she suggested, served to undermine those gains in a powerful combination of misogyny and ageism. Gullette’s focus was on hormone replacement therapy (HRT) specifically, in which female ovarian ageing is considered to be synonymous with pathology in medical discourse (and wider culture), ushering in a number of potentially devastating health conditions, from heart problems to osteoporosis and frailty. However, in 2019 a new menopause discourse entered the cultural domain, with the emergence of a new ‘solution’ to the problem of menopause via a surgical technology that had formerly only been available for younger women undergoing medical treatment that compromised their fertility. Offered by the private UK-based health provider ProFam, to women aged under 40, the technology delays menopause via ovarian freezing techniques (henceforth: OTCT, or ovarian tissue cryopreservation and transplantation). It has the dual aim of preventing menopausal symptoms and extending fertility, according to individual need and choice. Like other reproductive technologies, control over the body is also control over time and in this case, control over ageing itself. In this chapter I look in more detail at menopause discourse as it appears in the medical and popular literature associated with this new technology, focussing particularly on tracing the continuities and discontinuities with earlier forms of menopause discourse. In particular, I will look at the development of the medical approach towards menopause in disease terms whilst the social context that underpin the devaluing of women from midlife onwards is obscured. I then focus on the new technology to delay menopause considering its own claims that, on the one hand, rest on a fundamental problematisation of menopause and on the other offer a novel solution to buying time. That is, unlike HRT, which ‘cures’ the deficient body, OTCT facilitates the reproductive body by extending its duration and thus giving a woman more time. I then go on to explore cultural responses to this new technology in the media, focussing on two contrasting views by women at different points of the lifecourse. Whilst the first response, written by a childless journalist in her late thirties, is enthusiastic, the second, a post-menopausal journalist, points out that the menopause has been highly beneficial to her in psycho-social terms and on those grounds regrets its delay. This viewpoint is one that lies completely outside the parameters of menopause discourse as it is

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currently constituted. I then take the first response as my starting point and consider how, whilst shortage of time is experienced as a problem more broadly over women’s lifecourse, delaying menopause is not an isolated reproductive technology but must be seen within the broader context of a woman’s reproductive choices over the lifecourse. Finally, I will return to the second perspective and consider what embracing menopause might add to a woman’s conception of her lifecourse, especially in terms of time, freedom and agency.

Menopause Discourse: Contemporary and Historical Menopause, though recognised in medical history for centuries as a time of crisis and change in a woman’s life, has not always borne negative connotations. For example, in Greek medicine, whilst women’s bodies were considered to be inherently flawed, this notion of pathology was fundamentally arranged around the reproductive system and the menses. Menopause was helpful in bringing a woman’s body closer to that of a man (Foxcroft, 2009, p. 37). The beginning of the ‘menopause as a problem’ discourse came in the eighteenth century with the advent of early modern medicine. Physician Edward Tilt produced the first full-length book on menopause, and it highlighted a vast array of problems, albeit very different ones to those featured in our contemporary accounts: one would not find today menopause linked with ‘pseudo-narcotism’, for example, or ‘aphonia’, or find, as in the work of A.F Currier, a comparison with epilepsy, hysteria or malaria. Within such medical texts, the uterus and later the ovaries were considered the source of women’s problems. Moving to the early twentieth century, the discovery of the endocrine system introduced a hormonal explanation to the understanding of menopause, and this explanation stressed ‘deficiency’ rather than change (which indeed has become medicine’s approach to ageing particularly since the late twentieth century.) Indeed, in medicine more generally, the ageing body is necessarily viewed as being in decrement, with the youthful body the standard, health itself being associated with the maintenance of youthful bodily norms and functions (Pickard, 2012). That is, in this scientific framing of women’s bodies, as in the broader cultural discourse, there is no sense that post-fertility is a valuable developmental stage in a woman’s lifecourse. It is also linked with a particular view of ageing and decline in women that begins early in the lifecourse, depicted in terms of ovarian reserve; indeed one recent article on OTCT notes, among many criticisms, the necessity of women’s youth for this technique to work ‘with 25 years already possibly being too old for many women’ (Kolibianaki, Goulis, & Kolibianakis, 2020, p. 65). Today, in the west, menopause is associated with a vast range of symptoms, both physical and psychological, which are extensive but often elusive: as historian of menopause Louise Foxcroft notes: ‘These myriad symptoms take in every bodily system – vasomotor, cardiovascular, metabolic, sensory, digestive, skeletal, glandular and the central nervous system’ yet the only (near) universally agreed symptom is the hot flash (2009, p. 7). Menopause is also considered to usher in a

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prolonged time of poor health and to signal a risky future state. Although many women do report health problems associated with menopause, this experience is certainly not universal and furthermore it is inflected with class and other positional attributes; women with social disadvantage and a previous experience of anxiety and depression are more likely to experience severe menopausal symptoms and these persist longer than for other women (Avis et al., 2015; Newhart, 2013). Indeed feminist sociologists have seen menopausal symptoms and experiences as a product of ‘local biologies’ which, in serving as expressions of social suffering, make menopause a ‘cultural syndrome’ (Mattern, 2019) through which to express somatically, for example, role conflicts and other friction and tensions that cannot be otherwise articulated. Recent cross-cultural research suggests here that social class cultures and, relatedly, the comparative degree of male domination may be more important in menopausal experiences than geographical cultures (Delano¨e et al., 2012). By contrast, the contemporary biomedical discourse views menopause entirely in disease terms with HRT as the potential ‘cure’ for the changes in a woman’s body which are referred to as pathological. These discourses themselves play a large role in the devaluing of older women; Gullette makes a careful distinction between menopause and menopause discourse and suggests that it is the latter that make many women sick because ‘they accept the culture’s conclusion that it’s a biological marker of decline’ (1997, p. 184). Many women report how menopause is a central element to their devaluation from midlife onwards, including being blocked from opportunities for promotion and professional development and more generally finding work environments unsupportive. The British Medical Association (BMA) recently reported a strong pattern of senior female clinicians in menopause leaving work or reducing their hours, which, as well as suggesting an unsupportive working culture, also indirectly suggests the harm that the biomedical emphasis on decline and pathology has on its own practitioners (Hill, 2020). Beyond the impact of attitudes to menopause and a lack of flexibility at work, women of menopausal age are likely to be impacted by accumulated disadvantage impinging on midlife, a raft of lifecourse inequalities bearing bitter fruit in terms of stalled career, poor health and well-being and associated relationship difficulties that are ‘explained’ by the menopause event, as if biology itself were the one and only problem. This reductionism also impinges on the interpretation of symptoms themselves, for example, so-called ‘sexual dysfunction’, associated with menopause, and/or vaginal dryness may simply signify a woman being less likely to feel ready for sexual intercourse because of stress, fatigue or the vagaries of a long-term relationship, or alternative priorities, and indeed may have little or nothing to do with menopause. A new answer to the, by-now undisputed ‘problem’ of menopause, according to one pioneering clinical company based in Birmingham, UK, is provided by an innovative clinical intervention that promises to delay its onset for up to 20 years. I turn to this next.

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ProFaM and Contemporary Menopause Discourse Cryopreservation of ovarian tissue has been a viable technology for some years, and its potential role in reversing or preventing menopause has been theoretically possible also. Based on decades of both research and clinical practice with younger cancer patients, ProFam, led by Professor Christiani Amorim, is the first commercial organisation to offer healthy female customers the option of preserving their fertility together with the possibility of a continuation of ‘natural hormones’ – their own, as compared with HRT – for use in delaying menopause. ProFaM opened its doors in 2019, as a collaboration between industry, the NHS and the University of Birmingham and offers customers paying £7–£11,000 (at the time of writing) an elective procedure for delaying menopause, via OTCT, involving ovarian freezing with the intention of replanting this at a time when menopause may otherwise be starting and thereby introducing a continued supply of hormones. ProFaM’s CEO is Professor Simon Fishel, who worked, at an early stage of his research career, with the clinical pioneers involved in the first IVF baby in 1978. The procedures involve small portions of the ovary being removed, processed into tiny strips and cryopreserved for later use. In the future, possibly even decades later, they can then be thawed and grafted back into the body of the older woman, providing eggs for reproductive purposes or hormones to postpone menopause. ProFaM itself claims that this procedure may delay menopause for up to 20 years (although this claim has been contested by many reputable organisations, such as the BMA, e.g. BMS, 2019). More interesting for the purposes of this chapter than a debate over the veracity of its claims, however, is the nature of the menopause discourse appearing in the clinical literature on this technology. For example, looking at a critique of the technology in one of the most recent publications (for the writing of this particular article), namely a 2020 article in Maturitas (Kolibianaki, Goulis, & Kolibianakis, 2020), the authors begin by highlighting the ‘problem’ as one occurring because of increased life expectancy on the one hand and the fixed age of menopause on the other, meaning that women will potentially spend decades in this post-menopausal phase. This means, according to the authors, that women will face ‘physical and psychological challenges’; the critical literature goes onto talk about ‘management of these women’ (and it recommends use of HRT). Whilst sharing the same points about the negative nature of menopause, the literature that is positive towards this kind of technology also highlights the role that technology can play in helping younger women juggle careers and motherhood citing reasons that women may delay pregnancy including education, career planning, financial instability or difficulty in finding a partner (Rivas Leonel et al., 2019). Indeed, the latter thread has acquired increasing prominence in ProFam’s approach. Initially the benefits of delaying menopause were emphasised, with its Chief Scientific Officer, Christiani Amorim, explaining how she thought up the idea many years before when witnessing her own mother struggling with menopause (Gregory, 2019); more recently there has been an emphasis on beating the biological clock. ‘Years of meticulous research has now allowed women to delay

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their biological clock’, ProFaM’s website proclaims (see http://www.profam.co.uk/).This is echoed in the following comment made by the daughter of Professor Fishel. In a 2020 interview with the BBC, Savannah Fishel, aged 22, waxes enthusiastic about her father’s procedure, telling BBC’s Today and Victoria Derbyshire programmes that she is ‘definitely not wanting to pop out babies anytime soon’ and notes that she is ‘definitely not focused on…having kids’ at this point. She goes on: ‘I love my job and there’s so many other things I want to do before then’. She refers to mental freedom from planning or worrying about motherhood, made possible by her father’s technology, declaring: ‘I don’t want in the back of my mind that if I do want kids, I’ve got to get it done now, get a ring on my finger’. (see https://www.bbc.co.uk/news/health-51269237). In the next section, I explore how this new technology is viewed by women themselves, and here I will be drawing on two articles in The Guardian and The Sunday Times respectively, both published fairly soon after ProFaM opened its doors for business. These articles are not intended to be representative but rather illustrative of cultural attitudes towards delayed menopause and emanate from women writers at two distinct points in the lifecourse, one approaching the end of her childbearing years and the other post-menopausal. These articles illuminate two contrasting perspectives: (1) OTCT’s benefits for childless women in extending their childbearing years and (2) the degree to which the technology, along with HRT and its related discourse, devalues women’s ageing and the post-reproductive stage, making it difficult to view this life stage in anything other than negative terms. I will also include in my analysis themes derived from readers’ comments made below the line (BTL) on digital versions of each article. For women like me, postponing the menopause would be a blessing. Sodha (2019) Regular Guardian columnist Sonia Sodha’s interest in ProFaM’s technology focuses on its promise of extended fertility, and she describes reading about it with ‘a sense of excitement’. She explains that, like most childless women reaching the end of their childbearing years (she is in her late 30s), the reason she is not a mother is that she has not yet met the right partner, although, she adds quickly, ‘Even though I shouldn’t have to, I would have made the choice to sacrifice career progress to have had children at this point’. In the event of structural inequalities and norms that undermine professional women’s ability to have children, she observes: ‘It is time to grapple with the fact that the profoundly positive social development of women’s increased educational and professional success might mean that we need to use science to rethink aspects of our biology’. Readers’ BTL comments can be grouped into some of the following broad themes: (1) a negative approach to delayed menopause in terms of resisting the emphasis on individual change, one reader noting ‘don’t alter the body to fit the world, alter the world to fit the body’; (2) Some suggestions that women need to prioritise reproduction at earlier points in their lifecourse with one reader stating:

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I prioritised finding a good man early on… to the detriment of my career, but we got three years together before having our first at 25/ 35 and eight years on, thanks to hubby earning a good wage and our decision to live just out of a small town, I’m happy at home growing food and teaching my kids. I’ve no regrets. I have always been mindful of the extra risks past 35 and started young to ensure I would be finished by 35, tops. One minor theme was recognition that this technology fed into women’s temporal indecisiveness: ‘Could the technology just increase the time available to procrastinate?’ Finally, a small number of readers suggest that menopause is not a problem for them but one of the best times of their lives. One example: ‘Menopause is one of the best things that ever happened to me. My depression disappeared as a result of the massive chemical changes in the body that menopause produces. On top of that, I no longer bleed every month and have no premenstrual symptoms’. The second article amplifies this latter aspect and thus implicitly highlights the role menopause might play in a society which valued women’s ageing and maturity. If I thought the menopause would last 17 years, I would leap at this treatment. Knight (2019) India Knight, a woman in her early fifties with three children, offers a contrasting perspective. After sympathising with women who struggle with menopausal symptoms, and confessing that she had dreaded the menopause as a young woman, ‘largely because I knew so little about it and it sounded both shameful and horrible’, Knight pens a eulogy to the post-menopausal stage of life. Knight reflects: There are good things about the menopause. I really like being middle-aged. I feel far more confident and competent than I did when I was younger, and I have stopped caring about things that don’t matter. I am comfortable in my skin. All of these feelings crystallised around the time of menopause. I’d been waiting for them all my life. They are not something I’d want to delay. This observation suggests that the long-standing embodied norms of femininity can be disrupted at menopause, and a new selfhood constructed, where, by contrast, delaying menopause serves to extend those norm of gendered sexuality over a longer period of the lifecourse. Several readers’ BTL comments echo Knight’s sentiments. One reader notes: ‘I have felt better than I have in year since I went through the menopause… having found my new quality of life, I wish it could be brought forward rather than delayed’. Another declares: ‘I’m much calmer, have more perspective and emotional balance than I ever did. The fertile

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years are full of drama… glad I’m out the other side’. A third reader agrees enthusiastically: ‘The other side is great!’ I will return to this theme later in the chapter, but first I will explore in more detail the argument developed by Sonia Sodha, and highlighted by ProFaM itself, concerning ‘buying time’. To do this, I will take a lifecourse perspective, including how women approach a variety of other reproductive technologies, with the intention of exploring how they are perceived by women to help them manage time in a number of ways.

Reproductive Technologies, Gender and Temporality Lived time, or temporality, and time as a social structure, have been highlighted as factors in women’s continued inequality in contemporary times. The context for this lies in the entry of women en masse into the workplace, whilst retaining responsibilities at home. As a lived experience, this has been captured through the concept of ‘timescapes’ (Adam, 2000). The latter refers to the multiple times that coexist and intersect but are not all equal, with some (e.g. work) hegemonic over others (such as caregiving or childcare). It also highlights the qualitative difference in the rhythm structure of these temporalities between, for example, relational and clock-times, which has to be managed at an individual level (see Pickard, 2018, 2020). In short, women struggle to juggle these contrasting times, and struggle too with a related ‘lack’ of time as compared to men. Whilst OTCT joins a number of other technologies that claim to buy women time, for women making reproductive choices, however, there are a number of deeper, invisible structures that also shape their temporal experience. One of these is femininity itself which, as a learnt embodied mode, comprises a number of gendered dispositions, including spatial and temporal dispositions. These gendered dispositions can be approached analytically through the concept of ‘habitus’ (Bourdieu, 2000) which Bourdieu describes as embodied history that works to reproduce the social hierarchy including in its class but also gendered dimensions. They persist, Bourdieu suggests, at a deep, tacit and pre-conscious level that is hard to grasp, perceive or articulate, and are enduring despite new contexts of broader experiences of social change. The contemporary context involving both public work and caring responsibilities may introduce ‘hybridgendered’ dispositions (Budgeon, 2014) including both those associated traditionally with masculinity and those associated with traditional femininity. This may fit with what Bourdieu describes as the ‘habitus cliv´e’ or divided habitus, which describes a subjective sense of self ‘torn by contradiction and internal division’ (2000, p. 16; quoted in Friedman, 2016, p. 130). So, whilst planning and forward-projection are ‘masculine’ temporal dispositions, which women may acquire through their presence in the work economy, they hold these alongside a more quiescent, relational temporal disposition of ‘gendered expectation’ (Leccardi & Rampazi, 1993) associated with the feminine realm of caring, relationality and domesticity. Gendered expectation is not a clear intentional arc towards the future but a ‘gendered representation of the future’ (Leccardi & Rampazi, 1993, p. 369)

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and thus a constrained form of agency. In this sense, reproductive technologies such as the contraceptive pill and egg freezing, whilst providing women with a more immediate sense of control and freedom, may also feed, and be fed by, the temporal disposition of gendered expectation. We can trace such temporal crosscurrents through a number of empirical studies of women’s reproductive decision-making. For example, in Carroll and Krolokke’s study involving women mostly in their later childbearing years (over 35 and into their early 40s), women freeze eggs in order to have time to establish a traditional heterosexual marital-style relationship. They note: ‘Participants were banking on a particular normative understanding of love, defined as finding the right guy and establishing a nuclear heterosexual base, which we call “anticipatory coupledom”. Romantic love became a pre-requisite to several participants yet also a sign of respectable femininity and maternal qualities’ (2018, p. 999). Catherine Waldby’s study found that egg freezing as a process promises to enable women (both heterosexual and lesbian) to orchestrate the various, incompatible, temporal strands running through their lives, something that is particularly necessary in what she describes as the ‘high-stakes game of family formation’ (2015, p. 473). That is, it presents itself as a way of managing the ‘different trajectories of career, relationships, ageing – that interweave at different rates through the life course’ (2015, p. 475). Here ‘freezing’ can be read on both a literal and metaphorical level, as cryopreservation allows eggs to be removed ‘from its web of temporal, biological interactions’ (p. 475). Some strands – for example, the biological trajectory – that would demand faster attention, once frozen can be addressed after career and household formation (which exists on a slower trajectory). However, the decision to reproduce is not made but effectively put off for a later date. Similarly, this does not necessarily facilitate harmonious synchronisation of the other temporal threads of a woman’s life and nor is it particularly rational and pragmatic as it still incorporates elements of expectation linked to a heteronormative ideal of coupledom and family life. Waldby reflects: ‘Women purchase this synchronic power not in the service of immediate conception, but as a way to create a margin for deliberation and relational negotiation’ and in this sense, ‘their actions were not prudential but hopeful, oriented to the creation of future possibilities for life and family’ (p. 480). The terms ‘deliberation’ and ‘hopeful’ describe the mentality of gendered expectation perfectly, and one that is compatible with work on the self of the kind that opens up the possibility for fulfilment to come from the outside, a constrained version of agency, in which work is done on the self whilst waiting for that external (usually male) agent that is typical of the kind of mentality encouraged in self-help literature (Taylor, 2012). Carroll and Krolokke note: ‘By freezing their eggs as a form of acting in the present, some women in the study believed it would optimise their potential romantic future by making their reproductive potential a risk-managed asset to create their own genetically related “perfect” children’. They continue: ‘As noted by Rosa in reflecting upon her current dating situation: People often ask me, like, “Oh, do you have eggs?” and it’s like “I do have eggs!”’ (2018, p. 1000). Indeed, the folding back of an anticipated future into the present serves to construct what Nowotny (1994) has termed an ‘extended present’ in which women live suspended

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between present and future and which is further associated with chronic ambivalence towards the making of timely life choices (Leccardi & Rampazi, 1993; Pickard, 2020). This raises important questions as to how far reproductive technologies in practice actually facilitate a woman’s agency and choice. Hopes of romantic love lie as much in the realm of ‘fate’ as in that of choice or will, a fact that Sodha’s retrospective regret at prioritising career over love does not acknowledge. Further, despite immediate control over reproductive choices, those spheres that lie outside the reproductive domain may also be compromised. Although the freezing of the ‘biological clock’ theoretically gives space for women to fulfil other trajectories, in practice, in feeding gendered expectation, it can act as a brake on developing long-term plans, for example, in career-terms, something that Sheryl Sandberg (in)famously observed in her observation that women fail to ‘lean in’ (2013). Indeed women using reproductive technologies in several studies acknowledged holding back on career ambitions in order to keep their personal options ‘open’ (Baldwin, 2017; Brown & Patrick, 2018), a term that captures the ethos of relational time. Similarly, empirical studies suggest that most women do not carry out egg freezing in order to ‘lean in’ career-wise, but rather to enable a focus on ‘pure’ relationships disentangled from family plans. This suggests that the gender gap associated with motherhood starts much earlier than studies relying on quantification, such as counting career breaks or numbers of children, can identify. Rather, it suggests that the gap impacts both on actual mothers and on women planning for and hoping for motherhood, however vaguely, including those engaged in both IVF and egg-freezing practices and now indeed in delaying menopause, none of which may lead to the birth of a(nother) child. In all cases, in the discursive emphasis on individual ‘fixing’ of time problems, whether this be a mother fitting work and childcare into her life, or a childless woman searching and succeeding or failing to find the ‘right time’ for motherhood, the underlying social inequalities, both interpersonal and institutional, are barely identified, much less challenged. Maude Perrier’s research with mothers, moreover, suggests a high chance that these different strands of time in a woman’s life can never be satisfactorily brought together, even for those women who go on to experience motherhood. For the women she interviewed, as she points out, it ‘was more a case of finding the least “wrong” time’ (2013, p. 82). This again suggests that ‘planning’ is not a wholly accurate term to describe reproductive choices. As Perrier reflects, in a way that resonates with the above: ‘Indeed for my participants the timing of their pregnancy had been shaped, in varying degrees, by the coming together of biographical, psycho-social and biological circumstances and so was not purely the outcome of choice’ (p. 71). Whilst the notion of the ‘right time’, moreover, is embedded in middle-class trajectories of the lifecourse involving self-actualisation and a slower track to full adulthood, these same trajectories both fit the middle-class women’s bodies imperfectly and also influence young working class mother’s perceptions of being ‘derailed’ or suspended from their own planned trajectories, trajectories which similarly emphasised self-development. That is, like the notion of the biological clock, the concept of the ‘right time’ serves to

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obscure the fact that there are multiple coexisting times and that these times relate to deep social structures beyond a woman’s individual control. As Vicky Boydell shows in her chapter in this volume, and drawing on the work of Catherine Rottenberg (2018), for women who are at the point in their lives when they are propelled to choose, ‘ambivalence’ may be replaced or joined by the quest for ‘balance’ an aspirational notion of finally getting the temporal juggling right. Among the women Boydell interviewed, multiple kinds of regret are in evidence as they look back on their reproductive choices: leaving it too late for conception, finding that even carefully planned careers were disrupted by motherhood; finding that the assumptions of equal parenthood have not been born out in practice. The ‘hermetic ideal of family life’ (McRobbie, 2020, pp. 7–8) means that more equal kinds of parenthood, involving a fair contribution by fathers, as well as robust state support for childcare, are no longer prioritised in contemporary cultural discourse, as they were in decades associated with second wave feminism, with the emphasis instead being placed on an individual mother’s successful juggling of temporal conflicts and priorities. Similarly, alternatives to motherhood – such as childlessness and/or singlehood – have become undesirable in the early twenty-first century. Interestingly, for Boydell’s respondent Helen, who decided fairly early on that she did not want children, ‘the veil of balance fell away much easier, and many previously unthinkable possibilities emerged for her’ (Boydell, 2022, p. 77). Many of the women in Boydell’s study were prompted to make the decision to become mothers for fear of running out of time. Indeed, both the individual fear of running out of time, and the negative attitude towards ageing are fed by broader social currents around future time. For example, Adams, Murphy, and Clarke (2009) suggest that a future orientation is germane to late modern governmentality with an onus on the self to be prepared for future contingencies in a way that is never completed. In relation to technologies of reproduction, this temporality fits less with medicalisation, concerned with control, than with biomedicalisation, concerned more with transformation in anticipation of future risk (Clarke, Shim, Fishman, Fosket, & Mamo, 2003). As the ProFaM website asks rhetorically: ‘Will you be ready? You never know what the future holds, so freeze the biological clock and prepare for the future!’ Whilst linked here to a woman’s reproductive body, such perceptions of the future are also embedded in a broader biogerontological discourse which sees biological ageing as synonymous with illness, viewed not only as curable (as with HRT) but potentially preventable, meaning action is required even if one has ‘beaten’ the biological clock. Ultimately, and going much further than cryopreservative techniques, Aubrey de Grey, controversial co-founder of the SENS Research Foundation in California, talks of creating new ovaries through tissue engineering as well as replenishing stem cells eliminating, rather than delaying, the menopause altogether (Devlin, 2014). Returning to the earlier newspaper opinion pieces, the sentiments expressed by India Knight, however, and by the readers who concur with her suggest that something is missed in the medical ‘solutions’ to menopause, both in the view of ‘health’ as equivalent to youth and, beyond this, in the rendering of existential questions as ones whose only reasonable answers lie in the medical field. For

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example, it could be that one feature of a post-menopausal timescape is that the temporal frictions associated with the reproductive stage of a woman’s lifecourse, to a degree, are resolved once the potential for conception is over. If that is the case, by contrast, delaying one’s menopause effectively prolongs such ambivalence and expectation and thus delays access to the temporal freedoms and agency otherwise available to the menopausal woman (as well as to younger women such as Boydell’s respondent, Helen, who decisively opted out of motherhood). To be clear, while menopause does not bring an end to ‘hybrid’ temporalities altogether nor the juggling of complex timescapes in many cases, especially for women of the ‘sandwich generation’, it does facilitate entrance to a more comfortable temporal existence, involving more personal control and potentially a more integrated subjectivity.

Discussion and Concluding Remarks There are a range of reasons why menopause may be difficult and undesirable; however, these can only be understood with reference to a woman’s experience of her reproductive body as she attempts to negotiate multiple roles and temporalities over the whole of her lifecourse. Increasingly, however, the medicalisation of menopause, which removes menopause from any sense of context either within the lifecourse or in society, is being replaced by biomedicalisation, which includes cryopreservation of ovarian tissue for the transformation (and rejuvenation) of the older body. Entirely absent from these approaches is any sense of the positive psycho-social factors also associated with menopause, and indeed this has its roots in a conception of the lifecourse as linear, and one moreover framed by the ‘decline narrative’ (Gullette, 1997). Older conceptions of the lifecourse, however, which glint in a subterranean fashion from histories of medicine’s approach to the menopause, recognise the post-menopausal stage as a powerful, meaningful period equal in value to that of the other ages and stages of a woman’s life (and indeed one that may be characterised by the best health of all). Scholar of women’s myth, Christine Downing reminds us that the ancient Greeks posited three seasons of a woman’s life, ‘growth, flowering and ripeness’, which corresponded to three aspects of the goddess Hera, ‘Hera Parthenos’, ‘Hera Teleia’ and ‘Hera Chera’ , that is, ‘maiden, wife and post-connubial woman’. The underworld ‘is ruled by the Eleusinian triad – maiden, mother and crone’. She notes that these three seasons to a woman’s life apply ‘irrespective of whether she is heterosexual, homosexual, or celibate, quite apart from whether she has ever conceived or borne or nursed a child: from birth to menarche, menarche to menopause, menopause to death’ (1987, p. 13). This tripartite division also echoes Beauvoir’s analysis of women’s subjectivity (1997), divided into an androgynous and free subjectivity, associated with childhood, a ‘second sex’ comprising a fragmented subjectivity, comprising irresolvable temporal and spatial tensions, and a post-menopausal ‘third sex’ stage in which she once more regains her full subjectivity (or, as she puts it, a time when ‘she is unsexed but complete’). Beauvoir’s system, unlike the ancient Greek, foregrounds the way these structures emerge from the hierarchical gender system of patriarchy.

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Of course, such frameworks may be open to the charge of essentialism, especially in today’s theoretical climate, with the soaring ascendancy of neo-Cartesianism, in the form of queer theory in the academy and of biomedicalisation and post- or trans-humanism in the wider domain including science and medicine. However, a framework that places women’s embodied lifecourse at its centre offers a challenge to this trend where, far from the infinite malleability and plasticity of will and imagination over matter, this reminds us that the body has a ‘will’ of its own. It also better aligns with the experience of women in the global south for whom, for example, in contemporary Iran, the menopause is also experienced as liberating and empowering (Amini, 2021). Without such a framework, the positive vision of ageing conjured is difficult to convey, especially to younger women living in a culture that devalues age and the ageing post-reproductive woman’s body. Illuminating the temporal dimension associated with gender, and its part in constructing the ‘second sex’, may well begin to make the benefits of this latter stage more transparent, as well as fostering feminist formulation of a deeper criticism of hegemonic time, into which reproductive technologies at all stages feed. Finally, women’s positive, lived experience of the post-menopausal phase may also make the attraction of delaying menopause less obvious and in that sense give the gift to all women of ‘more time’.

References Adam, B. (2000). The temporal gaze: The challenge for social theory in the context of GM food. British Journal of Sociology, 51(1), 125–142. Adams, V., Murphy, M., & Clarke, A. E. (2009). Anticipation: Technoscience, life, affect, temporality. Subjectivity, 28, 246–265. Amini, E. (2021). Older Iranian women’s experiences of sex and sexuality. British Journal of Sociology, 72(2), 300–314. Avis, N. E., Crawford, S. L., Greendale, G., Bromberger, J. T., Everson-Rose, S. A., Gold, E. B., . . . For the Study of Women’s Health Across the Nation (SWAN). (2015). Duration of menopausal vasomotor symptoms over the menopause transition. JAMA Internal Medicine, 175(4), 531–539. doi:10.1001/jamainternmed. 2014.8063 Baldwin, K. (2017). ‘I suppose I think to myself, that’s the best way to be a mother’: How ideologies of parenthood shape women’s use of social egg freezing technology. Sociological Research Online, 22(2). doi:10.5153%2Fsro.4187 Bourdieu, P. (2000). Pascalian meditations. Cambridge: Polity Press. Boydell, V. (2022). A balancing act: Situating reproductive technologies across time in the UK. In V. Boydell & K. Dow (Eds.), Technologies of reproduction across the lifecourse (pp. 185–201). Bradford: Emerald Publishing. British Menopause Society. (2019). New menopause procedure could delay menopause by twenty years–response. Retrieved from https://thebms.org.uk/2019/08/ new-medical-procedure-could-delay-menopause-by-twenty-years-bms-response/

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Brown, E., & Patrick, M. (2018). Time, anticipation, and the life course: Egg freezing as temporarily disentangling romance and reproduction. American Sociological Review, 83(5), 959–982. Budgeon, S. (2014). The dynamics of gender hegemony: Femininities, masculinities and social change. Sociology, 48(2), 317–324. Carroll, K., & Krolokke, C. (2018). Freezing for love: Enacting ‘responsible’ reproductive citizenship through egg freezing. Culture, Health and Sexuality, 20(9), 992–1005. Clarke, A. E., Shim, J., Fishman, J., Fosket, J., & Mamo, L. (2003). Biomedicalization: Technoscientific transformations of health, illness, and US biomedicine. American Sociological Review, 68, 161–194. de Beauvoir, S. (1997). The second sex. London: Vintage. Delano¨e, D., Hajri, S., Bachelot, A, Draoui, D. M.,Hassoun, D., Marsicano, E., & Ringa, V. (2012). Class, gender and culture in the experience of menopause. A comparative survey in Tunisia and France. Social Science & Medicine, 75(2), 401–409. Devlin, H. (2014). Science close to ending the menopause. The Times, September 20. Downing, C. (1987/2020). Journey through menopause: A personal rite of passage. Sacramento, CA: Mandorla Books. Foxcroft, L. (2009). Hot flushes, cold science: A history of the modern menopause. London: Granta. Friedman, S. (2016). Habitus Cliv´e and the emotional imprint of social mobility. The Sociological Review, 64(1), 129–147. Gregory, A. (2019). Mother’s battle sparked scientist’s mission to delay onset of menopause. Sunday Times, August 4. Gullette, M. M. (1997). Menopause as magic marker: Discursive consolidation in the United States and strategies for cultural combat. In P. A Komesaroff, P. Rothfield, & J. JDaly (Eds.), Reinterpreting menopause: Cultural and philosophical issues (pp. 176–199). New York, NY and London: Routledge. Hill, A. (2020). Female doctors in menopause retiring early due to sexism, study says. The Guardian, August 6. Knight, I. (2019). If I thought the menopause would last seventeen years, I would leap at this treatment. Sunday Times, August 4. Kolibianaki, E. E., Goulis, D. G., & Kolibianakis, E. M. (2020). Ovarian tissue cryopreservation and transplantation to delay menopause: Facts and fiction. Maturitas, 142. 64–67. Leccardi, C., & Rampazi, M. (1993). Past and future in young women’s experience of time. Time & Society, 2(3), 353–379. Mattern, S. P. (2019). The slow moon climbs. Princeton, NJ: Princeton University Press. McRobbie, A. (2020). Feminism and the politics of ‘resilience’: Essays on gender, media and the end of welfare. Cambridge: Polity. Newhart, M. R. (2013). Menopause matters: The implications of menopause research for studies of midlife health. Health Sociology Review, 22(4), 365–376. Nowotny, H. (1994). Time: The modern and postmodern experience. Cambridge: Polity Press. Perrier, M. (2013). No right time: The significance of reproductive timing for younger and older mothers’ moralities. The Sociological Review, 61, 69–87.

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Pickard, S. (2012). A new political anatomy of the older body? An examination of approaches to illness in old age in primary care. Ageing and Society, 33(6), 964–987. Pickard, S. (2018). Age, gender and sexuality through the life course: The girl in time. London: Routledge. Pickard, S. (2020). Waiting like a girl: The temporal constitution of femininity as a factor in gender inequality. British Journal of Sociology. doi:10.1111/1468-4446. 12733 Rivas Leonel, E. C., Lucci, C. M., & Amorim, C. A. (2019). Cryopreservation of human ovarian tissue: A review. Transfusion Medicine and Hemotherapy, 46, 173–181. Rottenberg, C. A. (2018). The rise of neoliberal feminism. Oxford: Oxford University Press. Sandberg, S. (2013). Lean in: Women, work and the will to lead. New York, NY: Knopf. Sodha, S. (2019). For women like me, postponing the menopause would be a blessing. Guardian, August 11. Taylor, A. (2012). Single women in popular culture: The limits of postfeminism. London: Palgrave Macmillan. Waldby, C. (2015). ‘Banking time’: Egg freezing and the negotiation of future fertility. Culture, Health and Sexuality, 17(4), 470–482.

Chapter 5

Chronic Uncertainty and Modest Expectations: Navigating Fertility Desires in the Context of Life With Endometriosis Nicky Hudson and Caroline Law

Abstract For the millions of women living with endometriosis, significant disruption to normative life expectations and a considerable impact on everyday life are common. Whilst for many women concerns about and experiences of infertility may be a central feature of life with the condition, little work has considered the impact that chronic illness has on reproductive decision-making or on the ways in which a medical condition is managed in relation to plans for conception. This chapter considers how heterosexual women with endometriosis and their male partners experience the intersection of fertility desires with the use of reproductive technologies (contraceptive and conceptive) and how these experiences intersect with the medical and surgical management of endometriosis. Three themes drawn from interview data are presented: the first considers how the uncertain and indeterminate character of endometriosis shapes imaginaries about future fertility, conception and childbearing. The second focuses on how endometriosis mediates expectations about the success of fertility treatments and technologies; exploring in particular the manifestation of low expectations in relation to possible success. The third theme considers how endometriosis and fertility pathways intersect, creating specific disruptions whereby fertility treatment may be delayed by endometriosis care, and where endometriosis care may be interrupted or paused by fertility desires. Our data show how endometriosis shapes reproductive desires, decision-making and experiences and has important implications for understanding how for those living with a chronic illness, plans for having children are made within a context of biographical and biomedical contingency.

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Nicky Hudson and Caroline Law Keywords: Chronic illness; uncertainty; fertility; reproduction; disruption; imaginaries; endometriosis

Introduction Characterised by diagnostic uncertainty and a diverse and complex range of symptoms, endometriosis has been referred to as the ‘missed disease’ (Overton & Park, 2010) since there is no definitive cause and average time to diagnosis is between 5 and 8.9 years (Culley, Law, et al., 2013).1 It occurs when endometrial-like tissue is present outside the uterus producing a range of symptoms. Prevalence is difficult to estimate but it is generally thought to affect 2 and 10% of women of reproductive age (Eskenazi & Warner, 1997), or approximately 178 million women worldwide (Rogers et al., 2009).2 Considered relatively rare even in the early 1980s, more recently cases have risen steeply (Seear, 2014). Common symptoms include chronic pelvic pain, heavy periods, painful sexual intercourse, bowel and bladder problems and infertility, but importantly these range in severity, not all women have all of these symptoms, and symptoms do not always correspond to what clinicians and scientists classify as the observable extent of the disease. In addition to its diagnostic uncertainty, the cause of endometriosis is unknown and, for most, there is no definitive cure, so management focuses on symptom relief and/or control (European Society of Human Reproduction and Embryology (ESHRE), 2013, The National Institute for Health and Care Excellence (NICE), 2017). This can involve analgesics, hormonal therapy (including the contraceptive pill), both minimally invasive and radical surgery, and, where relevant, fertility treatment, with varying rates of success (ESHRE, 2013). Endometriosis treatment plans often proceed on a trial-and-error basis and concern has been expressed about knowledge of the condition amongst general practitioners, with women reporting experiences of delegitimation in encounters with professionals (Denny, 2009). Given its ambiguous aetiology and unclear management, endometriosis has been conceptualised by social scientists as medically uncertain and biographically contingent (Denny, 2009; Hudson et al., 2016; Seear, 2014). For the millions of women living with endometriosis, significant disruption to normative life expectations and a considerable impact on everyday life are common (Culley, Law, et al., 2013; De Graaff et al., 2013; Denny, 2009; Hudson et al., 2016). A growing body of research demonstrates that work, education, intimate relationships, fertility and mental health are disrupted by the condition (Culley, Law, et al., 2013; Jones, Jenkinson, & Kennedy, 2004; Young, Fisher, & Kirkman, 2015). Because endometriosis is an inflammatory gynaecological condition, it can impact on fertility, and therefore reproductive discontinuities are among one of the many ways lives are interrupted (Gomez, Arteaga, Ingraham, & Arcara, 2019; Hudson et al., 2016; Young, Fisher, & Kirkman, 2016). Uncertainty around diagnoses and contingent endometriosis treatment protocols create ambivalences and uncertainties around planning for and having children, both in

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terms of the intersection of different treatments as well as decision-making about caring for children in the context of a chronic illness. Whilst for many women concerns about and experiences of infertility may be a central feature of life with the condition, to date this has only received limited attention within social science research (Culley, Hudson, et al., 2013; Hudson et al., 2016; Jones, Jenkinsn, & Kennedy, 2004). Studies report women receiving varied but often insufficient information about the impact of endometriosis on fertility from healthcare practitioners and wanting more and better information (Cox, Ski, Wood, & Sheahan, 2003; Denny, 2009; Navarria-Forney et al., 2020; Young et al., 2016). Recent studies report high levels of concern about infertility amongst women with endometriosis (Navarria-Forney et al., 2020) and as well as unhappiness amongst some women with healthcare practitioners appearing to prioritise fertility over other aspects of endometriosis care and symptom relief without properly consulting women (Young et al., 2016). Consideration of how life lived within a context of medical and trajectory uncertainty might shape reproductive decision-making, and the use of reproductive technologies has been relatively underexplored. Taking inspiration from authors working within the sociology of expectations (Fitzgerald, 2014; Gardner, Samuel, & Williams, 2015; Swallow, 2017), this chapter considers how within the context of endometriosis, embodied uncertainty and reproductive desires intersect with symptom management to produce a distinctive set of experiences in relation to fertility and future parenthood. Whilst much of the work on the sociology of expectations has considered the optimism, hope and hype, which are central to interactions with biomedical technologies (Petersen & Wilkinson, 2014), there has been less attention given to the production of low expectations in the context of biomedical innovation. Authors working to develop these ideas have drawn attention to the ways in which ambivalence, uncertainty and contingency are navigated in the context of biomedical innovations (e.g. Fitzgerald, 2014; Gardner et al., 2015). Whilst the sociology of expectations has focused on hope and promise, these authors suggest that low expectations relate to more modest future orientations and less certainty. This work has emerged from studies of biomedical innovation, particularly where there are questions of contingency, uncertain diagnosis and biographies, such as in the context of diagnosis of and treatment for Alzheimers (Swallow, 2017), autism (Fitzgerald, 2014; Hollin, 2017) and Parkinson’s disease (Moreira & Palladino, 2005). What these studies show is that whilst low expectations are related to less certainty, they are nevertheless productive, capable of enrolling patients and creating change, and can also be performative and ‘vision-constructing’ (Gardner et al., 2015). This relates both to the ways in which uncertainty is an embedded feature of a technology (e.g. Akrich & Pasveer, 2000), as well as to the contingency talk and affective and subjective practices which accompany the use (or not) of particular innovations by patients. This chapter considers how heterosexual women with endometriosis and their male partners experience the intersection of fertility desires and reproductive planning with the use of both reproductive technologies and endometriosis care and management.3 It considers the ways reproductive technologies (contraceptive

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and conceptive) intersect with the medical and surgical management of endometriosis, shaping and ‘recalibrating’ lifecourse expectations to accommodate ambivalences, uncertainties and chronicities around biomedical solutions for infertility and endometriosis. We draw on data from the ‘Endopart’ study, which was designed to explore the impact of endometriosis on heterosexual couples. Whilst a now substantial body of work considers the impact of endometriosis on women’s lives, less focus has been given to the impact on intimate, heterosexual relationships, a gap that the Endopart study sought to address. In the study, 22 heterosexual couples took part in separate in-depth interviews (n 5 44). Inclusion criteria were: the presence of symptoms of endometriosis for at least a year; a laparoscopic diagnosis of endometriosis; and that partners were living together at the time of interview. Amongst the women, 14 were white British, six were South Asian and two identified themselves as coming from ‘other’ ethnic backgrounds. Amongst the men, 13 were white British, six were South Asian and three identified as coming from ‘other’ ethnic backgrounds. The average age of women was 34.8 years (range 25–50) and the average age of men was 36.3 years (range 26–57). At the point of interview, the average length of relationship was 9.1 years (range 3–21 years). The average length of time since onset of symptoms was 13.6 years (range 2–37 years) and the average length of time since diagnosis was 4.5 years (range one month to 20 years). Data analysis was informed by a dyadic, relational approach (Hudson et al., 2018), foregrounding the meanings participants applied to their experiences, treating interviews as accounts and exploring partners’ accounts in relation to one another. Ethical approval was received from the host university, and from the East Midlands Leicester NHS Local Research Ethics Committee UK (reference 12/EM/0015). The study was concerned with women’s accounts, and those of their partners, seeking to explore how the condition impacts on both everyday life and on biographical trajectories and the lifecourse. It was also concerned with the relational impact of the condition and relational experiences within couple units. In order to enable each participant to ‘tell the story from his or her own perspective, without having to consider the reaction of the other’ (Eisikovits & Koren, 2010, pp. 1643–1644; see also; Morris, 2001; Ummel & Achille, 2016), to allow participants to share information that they would be unwilling to share in a couple interview (Valentine, 1999), and to avoid the likelihood of women (understandably and justifiably) achieving quantitative dominance in joint interviews (Seale, Charteris-Black, Dumelow, Locock, & Ziebland, 2008), women and their partners were interviewed separately and in most cases simultaneously by different interviewers (Hudson et al., 2018). Such an approach allows a unique relational insight into the impact of chronic illness on couples by illuminating both shared and individual interpretations, experiences, understandings and meanings. The ethical and practical challenges of this approach are discussed elsewhere (Hudson et al., 2018). Three themes drawn from our interview data are presented in this chapter: the first considers the ways in which the uncertain and indeterminate character of endometriosis shapes imaginaries about future fertility, conception and

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childbearing. The second focuses on how endometriosis mediates expectations about the success of fertility treatments and technologies; exploring in particular the manifestation of low expectations in relation to possible success. The third and final theme considers how endometriosis and fertility pathways intersect, creating specific disruptions whereby fertility treatment may be delayed by endometriosis care, and where endometriosis care may be interrupted or paused by fertility desires. We present data from both the women’s and the men’s interviews.

Uncertainty Multiplied: Fertile Imaginaries in the Context of Endometriosis Cultural imaginaries position parenthood as a normal and expected life event, especially for women, with infertility constituting a significant biographically disruptive event (Becker, 1997, 2000; Hudson, 2020). Prevailing cultural imaginaries of idealised family life and family forms can have powerful impacts on both our present and our hopes and expectations for the future (Smart, 2007). As a result, involuntary childlessness can have a considerable impact on both women and men (Fieldsend & Smith, 2020; Hadley, 2018; Payne, Seenan, & van den Akker, 2019). Endometriosis can affect fertility, though the precise mechanisms involved are debated and evidence is limited. Some studies have suggested that 47% of infertile women have endometriosis (Meuleman et al., 2009). Of course not all women or couples wish to have children, but for the majority of couples in this study, the condition had affected their plans for family building (18 out of 22 couples). Couples who found themselves unable to have children experienced considerable loss as their future family imaginaries gradually crumbled: It’s a horrible thing to go through because obviously everybody wants to be a mum in their life and it is hard. (female partner)4 Coming to terms with not having children of our own and the whole process of IVF, going through it is really traumatic and for me that’s been the most painful element of the whole process. (male partner) Amongst the couples who had not (as yet) sought medical fertility investigations or treatment, many women experienced, or had in the past experienced, ¨ considerable anxiety about anticipated infertility (Martin, 2010). As Buhler (this volume) demonstrates, anticipation of future childlessness is increasingly situated within women’s imaginaries of their reproductive futures and their lifecourse. Within this study, women, far more than their male partners who were more likely to resist thinking too far into the future, described feelings of worry, anxiety, panic and fear. It always comes back to this, my panic to have a child … the panic is there when really our first year of marriage should be very calm

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Both experienced and anticipated infertility unsettled taken-for-granted notions of planning, choice and control and disrupted imagined fertile futures for both women and men. Amongst these couples, biographies were not individualised and these biographical disruptions, as well as the biographical appraisals and revisions they necessitated, were experienced as relational phenomena (see Hudson et al., 2016). I think we’d always envisaged stereotypically that we would have two kids and I suppose that’s, when we met, get married and we kind of had that imaginary, what’s the word, idea in your heads. (male partner) The experience of endometriosis and concern about potential infertility impacted on couples in a range of ways. Some couples anticipated that they may experience difficulties in conceiving and therefore tried to have children sooner than they would otherwise had done, had it not been for endometriosis; in some cases, where couples conceived quickly, this meant couples had children earlier in their timelines than they may have ideally planned. Others decided not to pursue parenthood, or not to try to have a second child, due to the female partner’s ill-health. Other couples found themselves pursuing options, such as fertility treatment and adoption, that they would not have expected to had it not been for endometriosis. Concerns around infertility were described as particularly significant for couples who identified as belonging to a minority ethnic group (especially for women), who spoke of increased pressure to have children from families and the wider community5: Amongst Asian couples if you can’t have a child, it’s almost like you’re a waste of space, they don’t want to have a daughter-in-law or a wife who can’t have a baby. (female partner) The impacts of endometriosis on planning for and having children were diverse (see also Culley, Hudson, et al., 2013; Hudson et al., 2016). For some women, parental imaginaries were interrupted by a diagnosis of endometriosis even before they had started the process of trying to conceive, demonstrating the significance of endometriosis for lifecourse expectations. For those who had actual experience of infertility, endometriosis created a double layering of uncertainty with regards to doubt about pregnancy as well as ambiguity about life with a long-term condition. Life with endometriosis was therefore central to future lifecourse imaginaries, and parenthood projects were planned around and in relation to the condition, creating multiple ambivalences and uncertainties. This uncertainty was further amplified in the context of endometriosis treatment protocols and the use of reproductive technologies.

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Endometriosis, Fertility Treatment and Low Expectations A recent scholarly focus on low expectations has particular salience when examining reproductive technologies and their affective dimensions; especially within the context of a chronic illness. As this volume illuminates, reproductive technologies do not exist in isolation: they manifest specifically in relation to other reproductive technologies, and more generally within in a wider context (Boydell, this volume; Boydell & Dow, this volume). For women and couples living with endometriosis, the experience of this condition, including its symptoms and treatments, provide a powerful context which shapes and mediates experiences with reproductive technologies. Endometriosis is a condition of multiple uncertainties: diagnostic uncertainty, symptomatic uncertainty and trajectory uncertainty (Denny, 2009). Women with endometriosis approaching fertility treatment may have a long history of unexplained symptoms, of trial-and-error approaches to management and failed treatments, and of delays and disruptions within both their treatment regimens and their biographical trajectories (Hudson et al., 2016). Such experiences may prime women and couples for disappointment and for failures of technologies and treatment: endometriosis as a condition characterized by uncertainty may set a context for reproductive technologies to also be characterized in this way. Whilst much of the social science literature on experiences of fertility treatment describes hopeful imaginaries and anticipated success, at least at the outset of treatment (e.g. see Becker, 1997, 2000; Franklin, 1997; Thompson, 2005; Throsby, 2004), many of the couples within this study who went on to undergo fertility treatment approached reproductive technologies with modest or low expectations. Their contingent narratives reveal how expectations about fertile futures and possibilities for parenthood were characterised not by wide-eyed optimism but by an appreciation that treatment may or may not be successful. In the end we [me and my husband] agreed that I would try it [IVF], at least let me try it once. If I try it once and it doesn’t work then at least I can have the hysterectomy and say I’ve done everything. (female partner) The productive and performative aspects of low expectations function not only at the level of biomedical innovation and delivery within a clinical setting (Gardner et al., 2015), but also the individual and couple level, where low expectations are employed strategically and work to aid the avoidance of future (and further) disappointment, as one woman who went through six rounds of IVF, including two using donor eggs, described: I could not even allow myself to hope anymore, as the disappointment would be so crushing when my period started every month. (female partner)

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Male partners appeared to demonstrate more hope than their female partners, perhaps because they had not had the embodied experience of moderate, low and fluctuating/short-term endometriosis-related treatment efficacy that their female partners had. Nonetheless, some men also employed low expectations in a strategic way, again illustrating the productive nature of this position. I think the fertility has kind of hit me quite hard and I’m kind of trying to come to terms with it. Just trying to put myself in the worst case scenario and just trying to see myself in that situation and think ‘ok if I can’t have a family, can’t have children then if that’s the way it’s got to be, that’s the way it’s got to be’. (male partner) The production of low expectations appeared to develop over time. For many couples, finding effective endometriosis treatment as well as navigating routes towards family building including reproductive technologies was a long journey, and expectations were not static but instead shifted as the journey progressed. Reproductive technologies are situated within a biographical process and timeline, and their use and affective dimensions and expectations of this use are heavily mediated by previous experiences (such as difficult prior experiences of endometriosis symptoms and treatment) and imaginaries for the future (such as unsuccessful fertility treatment and a life without children). At the relational level, the management of one’s own shifting and fluctuating feelings of hope and of low expectation was further complicated by their intersections with one’s partner’s feelings of hope and of low expectation, which were also dynamic and subject to change. Hope and low expectations may be seen to materialise and be deployed in relation to one another. While individuals in the study tended to demonstrate an orientation to lower or modest expectations, elements of hope were also apparent, with individuals sometimes employing ‘entangled registers of both promising hope and deflated uncertainty’ (Fitzgerald, 2014, p. 241). In some instances, hope was recast as a dangerous and burdensome investment. We didn’t want to go through IVF because we had talked about options and it wasn’t the financial, I think it was just the whole pressure. And if it doesn’t succeed and the hope, and I didn’t want to live a life like that, just hoping. (female partner) Fertility treatment is characterised by a series of interruptions, setbacks and false starts, leading to the now well-used analogy of the IVF ‘roller coaster’. Women with endometriosis describe an amplification of this process. For some, the burdensome nature of hope was only fully revealed as their journey progressed and they ‘let go’ of hope. It is almost a relief now that we have had four IVF attempts and two egg donations, to take an indefinite break from this fruitless

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quest. We are now focusing on enjoying our lives together. (female partner) For my own peace of mind, my own sanity, as in that part of the impact that everything has on you fertility wise, I probably feel a little bit more at ease in myself that way [now I have had a hysterectomy] because it’s an end to it. There’s no way I can get pregnant from that point of view, whereas before there’s always been, even though we’ve got the [adopted] girls, there’s always been that, ‘what if? What if, if only’, that, and I don’t think that leaves you until you have that final, well for me, until I’ve had that final appointment. (female partner) The mobilisation of reproductive technologies, and the expectations which one invests in them, is also relational: it occurs within, and is contingent on, networks of social actors (Boydell, this volume; Boydell & Dow, this volume; Smart, 2007). For one woman, the reinforcement of low expectations from a consultant acted as a ‘pivot point’ for setting expectations: I found it really hard to make that decision [to not undergo another IVF cycle]. I remember sort of saying to him [consultant], ‘I’m only going to do it if you’re going to tell me it works … I’m only doing it if it works, I’m not putting myself through that again’. He was like, ‘well I can’t give you that’. (female partner) Couples were also enmeshed in wider social networks beyond their own couplehood and interaction with healthcare practitioners. Expectations regarding reproductive technologies were also shaped by wider relations as illustrated by one couple who had one child but had originally wanted two: We had the whole question about conceiving and the consultant basically said to us, you are looking at IVF treatment further down the line … We decided that IVF wasn’t something for us because friends of ours have tried for 5 or 6 years and experienced failure and I just thought that’s not something we can really, really do. So we did kind of have it in our head that that’s it, that’s the end of the story. (male partner) The entanglement of high and low expectations (Fitzgerald, 2014; Pickersgill, 2011) within the context of endometriosis and in/fertility highlights how reproductive technologies can simultaneously represent both hopeful and disappointing futures. This case demonstrates how ambivalence materialises in biomedical treatment landscapes: in the case of endometriosis, expectations around fertility treatment are continually recalibrated to accommodate the possibility of failure.

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Endometriosis and Fertility Trajectories: Mutually Constitutive Disruptions For many of our participants, endometriosis trajectories – including the use of treatments to manage and reduce symptoms – were inextricably interconnected with fertility desires and treatments. We refer to this intersection as the endo-fertility treatment nexus, as it demonstrates how reproductive technologies, including fertility treatments, do not function in isolation but manifest in direct relation to other technologies, treatments and experiences. A central way in which this interaction manifested here was as that of a disruption. Women and couples seeking to undergo fertility treatment were often subject to endometriosis-related disruptions and delays to their treatment trajectory – disruptions and delays that would not occur in the trajectories of women without endometriosis undergoing fertility treatment. Fertility pathways could therefore not easily be disentangled from endometriosis treatment. Typical treatment for endometriosis involves surgical ablation of endometrial tissue performed via laparoscopy (ESHRE, 2013; NICE, 2017). For women with mild to moderate endometriosis, this technique can help to improve ongoing (spontaneous) pregnancy rates (ESHRE, 2013). There may also be benefits of surgery prior to the use of reproductive technologies (in terms of improved conception rates), but evidence is largely inconclusive (ESHRE, 2013). In line with this approach, some participants described having to pause fertility treatment in order to accommodate surgery that was intended to enhance the likelihood of a successful outcome. This added an additional stage to the usual fertility treatment-seeking trajectory: We had an appointment through to come for the IVF… and I remember going in thinking, ‘we’re going to have an appointment all about IVF and we’ll get a date etc’. and whatever happens. And it ended up being a conversation all about endometriosis… it ended up being all about that because from my scan he was like, ‘I don’t recommend you having IVF until, you need another operation before’. I was like, ‘another one?’ (female partner) Fertility treatment was therefore organised around, between and in relation to endometriosis protocols. However, this is not to say that endometriosis and infertility are managed in conjunction with one another. The reverse is often true: they are treated and managed discretely, involving different doctors and departments, or in some cases healthcare settings. For some women, this disconnect in the management of the two conditions – endometriosis and infertility – further complicated the process. The gynaecologist said, ‘oh I think it’s fine because it’s [cyst] only small, I think it’s just preferred if you go straight for the IUI’ … Got to the IUI and the nurse said, ‘who’s referred you to have the IUI?’ I said, ‘the [hospital]’.6 She goes, ‘I don’t think you can have

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the IUI because of your cysts, they look quite big to me now’. But she goes, ‘we’ll take the Clomid and we’ll try it’. Took the Clomid, went back in after seven days, and they seen it and they said, ‘oh your follicles are quite big, yes that’s good’. But they said, ‘your cysts are actually covering your follicles’ … So [fertility consultant] came in and he seen me and he goes, ‘who’s referred you to this straight away?’ He goes, ‘because it should have been dealt with before having the IUI’. He goes, ‘if you want to you can carry on but it’s not going to work, you’re just going to waste your time and it’s going to waste your goes’, because you only get like two goes with the IUI and two goes with the IVF. And he goes, ‘I don’t want to go ahead’. (female partner) Accounts in the study demonstrated that this disruption also happened in the other direction, that is, fertility desires can disrupt endometriosis treatment trajectories. This was the case in relation to the use of contraceptives and other hormonal drugs which inhibit conception (e.g. the Mirena IUD or Zolodex), which are used to limit the symptoms of endometriosis caused by the effects of oestrogen in the body.7 These contraceptive and hormonal technologies are routinely prescribed as a central endometriosis treatment modality. This has the result that in the context of endometriosis, the purpose of contraceptives transform: their primary function becomes to minimise endometrial symptoms, and their contraceptive function becomes an unintended, and sometimes unwanted, secondary function. This case demonstrates the complex ways in which reproductive technologies can transform in their very nature in the context of gynaecological chronic illness. However, this puts women and couples in a difficult position: contraceptive and hormonal technologies must inevitably be ceased when women are seeking to become pregnant. Yet while ceasing (or rejecting) hormonal treatment may allow for a biogenetic pregnancy (although this is by no means guaranteed: as subfertility is a symptom of endometriosis), for some women it may also mean having to live with extreme pain as a subsidiary. For some, the cessation of hormonal contraception in the context of trying to conceive therefore caused anxiety and worry about being overwhelmed by endometriosis pain. I’m so scared because I’ve actually now stopped the pill … to a view to start a family. But I’m also so petrified that the pain, of it all kicking back in, because I haven’t got the hormones in me to control the bleeding … I haven’t got a choice because there isn’t anything else. (female partner) While the contraceptives described above are temporary in nature, some endometriosis ‘treatments’ put a permanent end to both genetic and gestational motherhood. Total hysterectomy (removal of the uterus, ovaries and fallopian tubes) is considered the only option for the successful treatment of endometriosis symptoms in some women.8 In such cases, hysterectomy may be the ‘ideal’

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method of endometriosis symptom management medically speaking, but for those women and couples who wish to have biogenetic children, this option was heavily complicated by their fertility desires. Such complications were exacerbated when partners had differing priorities. For example, one woman whose experience of endometriosis pain and other symptoms was particularly severe described how, despite discussing the possibility of a hysterectomy with healthcare practitioners and her husband, who was desperate for her to have a hysterectomy due to the impact of endometriosis pain on both her and their quality of life, she was reluctant to pursue this before attempting IVF: There’s a physical pain and there’s an emotional pain, I have all that to try and explain. If I didn’t have children and I hadn’t tried everything [i.e. IVF] I couldn’t see myself being ok emotionally … I know I’m strong enough for the physical pain [of endometriosis] but I don’t know if I’m strong enough for the emotional pain [of involuntary childlessness]. It’s irreversible to have that procedure. (female partner) Even for those women who had, to a degree, accepted that they would not have children through a biogenetic pregnancy, the meanings associated with hysterectomy meant this form of endometriosis treatment was experienced as deeply painful, constituting another layer of loss. One woman who was due to undergo a hysterectomy at age 50 described: They are going to do it [hysterectomy] and I have got my head round it now. I probably will have a few tears because it does actually say no children definitely. Because although I know I can’t have them, there’s always that little tiny silly, silly thought that says… oh… but I’m coming up for 51, it would be silly, Down Syndrome and all sorts of things could happen to women who have a child in their later stages of life. (female partner) As Dow and Boydell discuss in the introduction to this volume, reproductive labour is highly feminised with the greater burdens of reproductive technologies falling on women. Amongst the couples in the study, while both partners were invested in the endo-fertility treatment nexus, female partners’ bodies were the sites at which both sets of technologies and treatments were situated and the experiences of and impacts (particularly affective impacts) arising from these disruptions were more keenly felt by women.

Conclusion This work has important implications for understanding fertility desires and reproductive decision-making in the context of chronic illness. It shows how life with a long-term condition is uncertain and contingent and any plans for having

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children are made within a context of biographical and biomedical contingency. Little work has considered the impact that chronic illness has on reproductive decision-making or on the ways in which a medical condition is managed in relation to plans for conception (Gomez et al., 2019). Our data show how, as a chronic condition with no cure and uncertain management, endometriosis shapes reproductive desires, decision-making and experiences in a number of ways. The findings also demonstrate how lifecourse disruptions and uncertainties are relational and mediated by gender and intimate relationships. Within the context of endometriosis, imaginaries about fertility and future parenthood become increasingly contingent and uncertain. Given that experiences of infertility are themselves chronic, fragmented and uncertain, this had the effect of multiplying uncertainty around childbearing. The indeterminate nature of endometriosis means that conception comes to be disrupted in two main ways: participants experienced both anticipated and actual infertility in relation to a diagnosis of endometriosis while the temporality of childbearing shifted in response to its chronicity. For those who do go on to need to use fertility treatment, prior experience with uncertain biomedical management for endometriosis appears to shape expectations about potential use and success with treatment for infertility. Experience with unexplained symptoms, trial-and-error management and unsuccessful regimens mean that disappointment is a familiar experience and expectations are correspondingly low. The trajectory uncertainty of endometriosis is multiplied in this context since its indeterminate origins and symptomology make decisions about fertility treatment fraught with concern and doubt. Women’s situated and embodied knowledge of endometriosis shapes their expectations about the potential for fertility treatment ‘success’; giving rise to a different set of expectations to those amongst women without the condition. Finally, our work shows that when people are trying to conceive, endometriosis and fertility pathways become entangled. The main outcome of this entanglement is disruption – which materialised in two ways. First, fertility treatment is disrupted by the need for endometriosis treatment, most often here in the form of laparoscopic surgery. Second, the desire for parenthood meant that some women avoided the use of certain treatments which would curtail their chance for pregnancy. We therefore introduce the concept of the endo-fertility treatment nexus, to show how reproductive technologies, including fertility treatments, do not function in isolation but manifest in direct relation to other technologies, treatments and experiences.

Acknowledgements Our sincere thanks to all the women and men who gave generously of their time to take part in the Endopart study. Thanks also to the Principal Investigator on the study Professor Lorraine Culley, and the Co-investigators Dr Helene Mitchell, Professor Elaine Denny and Mr Nick Raine-Fenning. Thanks to the Centre for Reproduction Research writing group who provided critical feedback on earlier versions of this chapter and to the convenors and participants at the ‘Integrating Reproductive

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Technologies’ symposium, Brocher Foundation, November 2019, for their helpful comments and suggestions.

Notes 1. Diagnosis by laparoscopy with histological analysis is considered the ‘gold standard’ (ESHRE, 2013), however due to its invasive nature it is often not a first line approach. 2. In this chapter we use ‘women’ to refer to the participants in our study who had endometriosis, and to reflect the gendered expression on which participant recruitment was based. Study materials referred to ‘women’ and ‘heterosexual couples’, and in volunteering to the study, participants identified themselves as fitting these categories. While we did not explicitly ask people about their gender identity, no participants identified themselves as trans or non-binary. When referring to other studies we have also used ‘women’ to be consistent with the practices of those authors and the presumed conduct of their studies. However, we recognise that since the time of our data collection (2012–2013), awareness has grown considerably about diversity in gender identify and expression and that the experiences of people with endometriosis who do not identify as women, such as trans men and non-binary people, are also of considerable importance. While we have used gendered language to reflect the specific conditions upon which the present study was based, more generally we support the move towards more inclusive terminology of ‘people with endometriosis’. 3. While recognising the crucial point that parenthood is not a universal desire and not all women and couples seek to become parents (Blackstone & Stewart, 2012; Young et al., 2016), this chapter focuses largely on the experiences of those who do wish to have children. 4. Descriptive labels, identifiers or pseudonyms have not been included within quotations in order to maintain anonymity within the couple unit (i.e. to prevent participants from identifying quotes from their partner) (see Hudson et al., 2018). 5. As previous research had revealed ethnic differences in the experience of endometriosis (Denny, Culley, Papadopoulos, & Apenteng, 2010) a sub-sample of South Asian couples (Pakistani, Bangladeshi and Indian) were purposively included in the study. 6. Intrauterine insemination: a fertility treatment whereby sperm are directly inserted into a woman’s uterus. 7. Oestrogen encourages endometrial tissue to grow and shed. 8. However, a hysterectomy is not the preferred course of treatment for many women, especially those who do not have children, and some women report reluctance amongst healthcare practitioners to course this line of treatment. In addition, it is not considered a definitive solution as endometriosis can return following the surgery.

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Reflection Two: Choice Victoria Boydell and Katharine Dow

Abstract Here we provide a short reflection on the persistent theme of choice in reproductive studies which allows us to draw out further insights from each of the chapters. Keywords: Choice; pro-choice; informed choice; reproduction; reproductive technologies; autonomy Choice is the perennial hot-button issue in relation to reproduction and reproductive technologies (RTs). What choice means and how it functions differs between its advocates and its detractors, between scholars and activists, between health practitioners and patients. These conflicts are happening at precisely a time when sexual and reproductive rights are under attack from global and national(ist) conservative forces and while the overloaded category of choice works to mask the ever-decreasing options available under late capitalism (Briggs, 2017; see also; Bracke & Hern´andez Aguilar, 2020). Together, the chapters in this volume help us to reflect on these wider debates surrounding choice. The chapters in this section do so with particular reference to the lifecourses of specific technologies, adding a further historical or longitudinal dimension to notions of choice in reproduction and RTs. In this way, it also adds to the history of the concept of choice and the knotty relationship between ideologies of choice and technology. These chapters pose pointed questions including: whose choices do technologies serve, which technologies enable choice and is choice a technology in itself? Choice is the defining ideology of late capitalism, in which the idea persists that the more choices we have, the greater our freedom and autonomy, and the better our overall well-being (Iyengar, 2011; Saleacl, 2010; Schwartz, 2012). With deep roots in Western social and political thought, choice dominates every aspect of our lives. It manifests in how we define ourselves through the decisions we make about lifestyles, careers and families, and characterises our relationships with the state, market, community and our bodies. This same logic is reflected in neoliberal Technologies of Reproduction Across the Lifecourse, 101–105 Copyright © 2022 Victoria Boydell and Katharine Dow Published under exclusive licence by Emerald Publishing Limited doi:10.1108/978-1-80071-733-620221009

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approaches to reproductive choice, where women’s status as autonomous and rational actors depends on ‘correctly’ choosing technologies to control ‘unruly’ feminised reproductive processes (Firestone, 1971; Weingarten, 2012). The scholarship around choice is rich and diverse. Economists, political scientists, psychologists and public health scholars have debated whether the right or wrong choices are made, or how people may be influenced to make the ‘right’ choices. Such studies are critiqued for their implicit moral tones, conflating the ideals of choice with what happens in practice, neglecting the social dimensions, and promoting unrealistic ideas about human cognition (Bohom, Henning, & Krzyworkzeka, 2012; Granzow, 2010), whereas anthropologists and sociologists have been more concerned with how choices are embedded in the interaction between individuals, authorities and social structures (Ginsburg, 1998). Critics contend that the expansion of choice has had negative effects, such as decision paralysis, dissatisfaction and anxiety (Iyengar, 2011; Schwartz, 2012). The term ‘choice’ has taken on a particular register in relation to reproduction, as the term ‘pro-choice’ was coined by a generation of activists struggling to extend abortion rights in United States in the mid-1960s onwards. As outlined in the introduction to this volume, this more restricted definition of ‘choice’ as access to abortion reflects the narrow priorities of those in positions of social advantage and neglects a broader analysis of the racial, economic, cultural, religious and structural constraints on reproductive decisions, which have been illustrated by reproductive justice scholars (Solinger, 2001). While this configuration of ‘choice’ has been widely critiqued (Ross & Solinger, 2017; SisterSong, n.d.), the notion remains active in the world of reproductive healthcare provision and everyday clinical encounters – indeed, it is something that ‘best practice’ aspires to. The persistence of ‘choice’ in the sphere of reproductive health has a much more complex pedigree than ‘pro-choice’ and this may go part of the way in explaining its conceptual resilience. The term choice channels the idea of ‘informed choice’ embedded in medical ethics and patient rights. Variants of patient-centred care, users’ experience and patient engagement to support ‘informed choice’ have made it a staple of any clinical counselling experience. Beyond ‘informed choice’ in clinical practice, choice is also fuelled by behavioural theories of decision-making (and how to shape them) that underpin programming to change health-seeking behaviours, see Wilson in this volume (Ajzen, 1985). These different lineages, along with systemic inequalities which deem some people’s reproductive decisions more desirable than others’, are directed through the term ‘choice’; combined together, this heady mix propels and compels its continued use. The complex heritage of choice gives it a tenacious grip, which only comes to the fore when looking at choice across disciplines. The empirically grounded examples of choice shared in these chapters, which focus intersecting knowledge(s) and practice, offer a further corrective to the restricted parameters of a ‘pro-choice’ lens in the sphere of reproduction and help to round out the contours of choice. Several chapters illustrate how choice is constrained by ideas about risk, responsibility and obligations that work together to diminish options and leave people feeling powerless to effect change (see also

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Granzow, 2010; Lee, 2014; Lowe, 2016). For many, the use of RTs is not experienced as a choice, but as a necessity and an obligation (Franklin & Roberts, ¨ 2006; Ruhl, 2002). Both Buhler’s and Boydell’s chapters in this volume illustrate how (relatively privileged) women are compelled to use RTs to achieve an expected lifecourse and as part of fulfilling their personal responsibility. As more and more RTs become available in the name of choice, there is increased surveillance on what decisions are made, which can foreclose alternatives (and especially those which are less profitable). Several chapters refer to the ‘right time’ to get pregnant, this ‘right time’ has strong normative injunctions and these relate to deep structures that are beyond a woman’s personal control, yet which are normatively conceptualised as down to individual choice (see Hamper, Pickard, ¨ Buhler, van de Wiel, & Boydell in this volume). Over 30 years ago, Rosalind Petchesky (1990, p. 11) told us that …women make their own reproductive choices, but they do not make them just as they please; they do not make them under conditions they create but under conditions and constraints they, as mere individuals, are powerless to change. More recently, Laura Briggs (2017, p. 16) has articulated the dilemmas of balancing the normative expectations of achieving career progression and economic stability against reproductive ageing as ‘structural infertility’ and described how ARTs have presented themselves as the solution, yet remain one with such high failure rates that notions of choice seem rather hollow. Several of the chapters illustrate how choice is deeply contingent. Ben Kasstan compares the relationships of care surrounding two religious minority groups’ engagement with RTs in the United kingdom and interprets these two experiences through a reproductive justice lens. In both instances, the actions taken by providers of care appear, at first glance, to perpetuate harmful traditions that curtail liberal notions of choice and autonomy, but are, in fact, attempts at facilitating choice and autonomy within the social worlds of the women themselves. For Kasstan, how providers consider the lived constraints of women is indicative of inclusive care, which is part of the journey to reproductive justice. Victoria Boydell’s longitudinal study of women’s use of contraceptive pill and other RTs over a 10-year period in London illustrates how women internalise and embody neoliberal expectations for ‘modern’ women, thereby being made complicit in a system and worldview that obscures structural inequalities and appears to suggest that anyone can have it all if they work and plan hard enough. The constraints around choice and what options are available should not detract from acts of resistance and refusal that are indicative of autonomy and choice in and of itself. Nayantara Sheoran Appleton’s chapter in this volume also examines the oral contraceptive pill, in different social and temporal settings. She illustrates how oral contraceptives have a social life often beyond their intended or imagined uses. Using examples of how different actors use the pill to navigate local mores and state attempts at ‘population control’ or off-prescription uses to address structural conditions that lead to period poverty, she shows that RTs are not only

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shaped by the conditions surrounding their use, but also by the unimagined and subversive practices of the users themselves. Oral contraception can operate as an oppressive, repressive or emancipatory technology, and this creates an opening for an emancipatory, anti-colonial, non-binary body politics. Sallie Han’s chapter provides us with a powerful account of connecting two technologies over time – that of donor conception and commercial genetic testing – and how the intersections between them affect the ways of relating between generations and across individuals’ and their close relatives’ lifecourses. Sallie Han’s account of the role of commercial genetic testing in the discovery of the secret children of Dr Donald Cline illustrates how engagements with RTs extend beyond the moment of use into the past and into the future. Here Han deftly describes how RTs that are used to repair disrupted reproduction affect children and future generations. Focusing on technologies over time encourages us to account for the perspectives of people with different positions in relation to RTs and the importance and necessity of approaching these relationships as temporally dynamic. Han’s chapter points to some further temporal considerations, namely how genetic testing technologies for families of assisted reproduction produce children, parents and kinship in hindsight. Sonja Mackenzie’s chapter similarly points to the problematics of choice when one’s capacity to be thought of and counted as a parent, or recognised as (part of) a family, is called into question at the border of the country in which one was born and raised. Mackenzie’s thoughtful and sophisticated analysis points once again to the hollowness of ideologies of choice in the use of RTs, when the lived experience of conception and kinship may be denied, re-categorised, invalidated or deemed illegal. Choice is complicated, encompassing free-will, self-making, compliance, constraint, pragmatism and resistance. Seemingly personal decisions to use or refuse RTs are socially produced through social interactions and institutional structures that shape knowledge, access and support. Rather than treating these slippages as poor concept development, it may be more useful to think about it as choice’s unique ability to imply several meanings at once. As a category, it has the capacity to act as a reference for the intrinsic quality of free will, to constitute an essential part of self-making, and be a pragmatic response to constrained options. Allowing for conceptual elasticity provides the opportunity to challenge the problematic assumption that choice is just one thing.

References Ajzen, I. (1985). From intentions to actions: A theory of planned behaviour. In J. Kuhl & J. Beckmann (Eds.), Action-control: From cognition to behaviour (pp. 1–39). Heidelberg: Springer. Bohom, A., Henning, A., & Krzyworkzeka. (2012). Horizon of choice: An ethnographic approach to decision-making. Anthropology and decision-making: An introduction. Focaal —Journal of Global and Historical Anthropology, 65, 97–113. Bracke, S., & Hern´andez Aguilar, L. M. (2020). “They love death as we love life”: The “Muslim Question” and the biopolitics of replacement. British Journal of Sociology, 71, 680–701. doi:10.1111/1468-4446.12742

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Briggs, L. (2017). How all politics became reproductive politics – from welfare reform to foreclosure to trump. Oakland, CA: University of California Press. Firestone, S. (1971). The dialectic of sex: The case for feminist revolution. New York, NY: William Morrow and Company. Franklin, S., & Roberts, C. (2006). Born and made: An ethnography of preimplantation genetic diagnosis. Princeton, NJ: Princeton University Press. Ginsburg, F. (1998). Contested lives: The abortion debate in an American community. Berkeley, CA: University of California Press. Granzow, K. (2010). De-constructing ‘choice’; the social imperative and women’s use of the birth control pill. Culture, Health and Sexuality, 9(1), 43–54. Iyengar, S. (2011). The art of choosing. London: Abacus. Lee, E. (2014). Introduction. In E. Lee, J. Bristow, C. Faircloth, & J. Macvarish (Eds.), Parenting culture studies (pp. 1–24). Basingstoke: Palgrave Macmillan. Lowe, P. (2016). Reproductive health and maternal sacrifice. Women, choice and responsibility. London: Palgrave. Petchesky, R. P. (1990). Abortion and woman’s choice: The state, sexuality and reproductive freedom. Boston, MA: Northeastern University Press. Ross, L. J., & Solinger, R. (2017). Reproductive justice: An introduction. Oakland, CA: University of California Press. Ruhl, L. (2002). Dilemmas of the will. Uncertainty, reproduction and the rhetoric of control. Signs, 27(3), 641–663. Salecl, R. (2010). Choice. London: Profile. Schwartz, B. (2012). Choice, freedom and autonomy. In P. R. Shaver & M. Mikulincer (Eds.), Meaning, morality and choice: The social psychology of existential concern. Washington, DC: American Psychological Association. SisterSong. (n.d.). What is reproductive justice? Retrieved from http://www.sistersong. net/ Solinger, R. (2001). Beggars and choosers: How the politics of choice shapes adoption, abortion, and welfare in the United States. New York, NY: Hill and Wang. Weingarten, K. (2012). Impossible decisions: Abortion, reproductive technologies and the rhetoric of choice. Women’s Studies, 41(3), 263–281.

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Chapter 6

Contraceptive Futures? The Hormonal Body, Populationism and Reproductive Justice in the Face of Climate Change Nayantara Sheoran Appleton

Abstract Hormonal contraceptives are complicated reproductive technologies – both biologically and socially. Deeply embedded in global political-economic agendas and historically underpinned by eugenic movements, hormonal contraceptives have a social life often beyond their intended or imagined uses. Because so much of the discussion around contraceptives focuses on their complex history and volatile present, there has been minimal space to talk about the future of hormonal contraceptives. In this chapter I show that while the past and present are complex, the future is even more so! As the threat of climate change becomes more palpable, two key anxieties (re)surface. First, a fear around growing populations in the Global South (while in reality Total Fertility Rate (TFRs) are in decline) and second, that of a hormonal body out of sync in the face of environmental changes. Similar anxieties have historically mobilised draconian ‘family planning’ measures in countries (like India) in the first instance. And in the second instance, hormonal manipulations to find ‘balance’ in the body, as opposed to balancing (or coming to a reckoning with) contemporary environments with/in which the body exists. This chapter is an attempt to bring to the fore the importance of studying hormonal contraceptives in environmentally unstable times. To imagine a space beyond coercion or ‘choice’ as variously imagined, when it comes to reproductive justice vis-`a-vis hormonal contraception. I suggest that, just as contraceptives have allowed us access to conversations about both women’s autonomy and reproductive control, they now allow us to unpack the limits and potentials of hormonal management via the hormonal contraceptive pill.

Technologies of Reproduction Across the Lifecourse, 109–129 Copyright © 2022 Nayantara Sheoran Appleton Published under exclusive licence by Emerald Publishing Limited doi:10.1108/978-1-80071-733-620221011

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Keywords: Contraception; hormones; populationism; climate crisis; India; Aotearoa New Zealand It was a wet and windy night in Wellington in September 2019, as I finally parked my car after circling the school campus ground twice. While I wished I was tucked up on my couch, seeing all these parked cars overwhelming the physical space of these grounds, reassured me that I had made the right decision. I was there to attend Dr Libby’s ‘Overcoming Overwhelm - Wellington’ event. And while I too was overwhelmed since, let’s be fair, I did have a 1.5 year old child at that time, a full time academic job and was attempting to launch a new research project on the social lives of sex hormones, I was not here to figure out a way to be less overwhelmed. I was here to begin fieldwork in the space of hormonal management. Dr Libby, the speaker, is a ‘nutritional biochemist’ who writes, is a public personality and hosts large events encouraging people to ‘better’ themselves through ‘self-care’ practices and nutrition. She came to my attention because of a famous tour she had organised in Australia and New Zealand titled the ‘hormonal factor’ tour. As I entered the school theatre, after showing my ticket, I walked past a book booth with all of Dr Libby’s books. I shuffled along with a crowd of women and found myself a seat in the back. The seats in the front section were all occupied, by women who clearly knew the popularity of these shows and had planned for an early arrival. As a medical anthropologist, I am quite used to going to events, clinics, meetings, as a solo attendee, while everyone else present is part of a group (patient families, support personnel, doctors and nurses, etc.). Not at this event though. The women attending ranged from a lot of solo women dressed in comfortable clothes and sneakers alongside groups of women who were ready for a ‘night out’. I wondered if there was a ‘health juice’ bar on the other side of the entrance that I had missed. The talk started, reached its crescendo around eating and managing stress for ‘hormonal’ health and balance, and ended with promises of books, next events and an opportunity to win a recipe book. I wondered at my own academic trajectory from emergency contraceptive pills (ECPs) to hormonal management as viewed in light of the climate crisis. Since attending this talk in September 2019, I have been interviewing women (cis, intersex and trans) on hormonal contraception and management in Aotearoa, while unpacking these details in light of the environmental crisis and reproductive justice. These conversations, in Aotearoa, happen alongside events in contemporary India, my other field site; they also help me see my older data from India in a new light. A month prior to me attending Dr Libby’s talk, in August 2019, as part of India’s Independence Day speech, the Indian Prime Minister Narendra Modi had said, ‘we need to worry about the population explosion’. He suggested that population explosion was detrimental to development and only those with ‘small families’ were responsible Indian citizens. He has not been the first to make this claim in and about India. Indira Gandhi, a former Indian prime minister in the 1970s, launched a 25-point programme as part of its goverments ‘development

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programme’ during the declaration of the State of Emergency in India. One of the key parts of that programme was family planning (Dayal & Bose, 1977; Gwatkin, 1979; Tarlo, 2003). Within and about India, the second most populous nation in the world, the overwhelming anxiety about population growth control as a detriment to development (within India) and environmental degradation and economic burden (outside India) has been a continual colonial project. Interestingly, these anxieties around population in contemporary India are unfounded. While the country has a large population, the population explosion narrative is an anxiety not based on demographic facts. As per the newly released (November 2021) National Family Health Survey – 5 (2019–2021), the national Total Fertility Rate (TFR) is now below replacement levels at 2 (Kaul & Dutt, 2021; Sheriff & Roy, 2021). This is the first time that the TFR in India is below the replacement levels; however, fertility has been on a steady decline since the 1960s. In the previous national 2018–2019 economic survey, India had a national TFR of 2.2 in 2018 (Government of Goverment of India, 2019). 2.1 is the replacement fertility rate, and clearly India has dipped under with stark 1.6 TRF in urban India. This is a phenomenal demographic shift if one considers the fact that in 1960 the TFR in India was almost 6. The last five decades tell an interesting demographic story through women’s lives that ranges between coercion and ‘choice’ enacted/enabled through a range of technologies. However, for this chapter, I focus on contraception as one such technology to not only talk about population control projects but also how contraception allows menstruating bodies autonomy to think and act beyond the reproductive body thus highlighting the hormonal malleability of bodies. Contraception thus then sits between coercion and choice, as variously understood (mapped out by the editors in the ‘interlude’ earlier). Hormonal contraception historically has been attached to population control in light of scarcity of resources and the climate crisis. However, if we can unsettle that historical precedence, we can see the potential in hormonal contraception in light of environmentally impacted lives we all live right now. In this chapter I outline how hormonal contraception makes tinkering with biology appear mundane, thereby making possible a conversation on biological malleability beyond binaries. In these environmentally troubled times, the hormonal contraceptive future is full of potential for gender revolution(s) that recognise the gendered body as fluid. I also try to/want to make clear that focusing on hormonal contraceptive as technologies that make futures of gender fluidity possible does not ignore the environmental degradation we live and participate in daily. Rather, it encourages us to focus our attention on capitalistic ruin and our bodies moving through that ruin because of the constant reminders to manage our individual bodies. Further, in thinking with and through hormonal contraception allows us not to deflect to population control as sites of concern vis-`a-vis climate crisis because, as I show in the following, the last six decades of hormonal contraceptive use has had an impact on fertility rates but no impact on global carbon emissions. I see the agentive possibilities/futures of hormonal contraception – while acknowledging its limits as well. Throughout this chapter, I move between India and Aotearoa,

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between the past and the future and between the limits and possibilities of hormonal contraception. Hormonal contraception is a paradox: from its origin implicated with/in population concerns (Marks, 2001) or uptake in white suburban households (Takeshita, 2011; Tone, 2001) to providing women ways to manage their biologies for more than just reproductive control. Contraception has been an integral part of understanding the politics of reproduction and not just a contemporary project vis-`a-vis the environment, but to study contraception (and concomitantly emergency contraception) allows us to see the historical moves that made it possible to connect environmental concerns with population control. In a review article, Martine Lapp´e, Robbin Jeffries Hein and Hannah Landecker map out the debates we need to pay attention to regarding the environmental politics of reproduction. They write as follows: The environmental politics of reproduction is an intensifying zone of contestation, advocacy, medicalization, pollution, monitoring, moralizing, intervention, and care. By describing it, we do not mean to imply that more classic issues such as stratified caregiving labor, reproductive autonomy, and in vitro fertilization – or more recent topics such as surrogacy, embryonic stem cells, or emergency contraception – have lost any urgency. Yet these will also shift with the scene of environmental politics of reproduction described here. (Lapp´e, Jeffries Hein, & Landecker, 2019, p. 139) Inspired by their mapping of the field of scholarship that outlines environmental and reproductive entanglements, in this chapter I suggest the importance of studying contraception alongside and as an integral part of the ‘environmental politics of reproduction’. This is not only because contraception (or emergency contraception) is or will shift in response to the environmental politics of reproduction they outline but in fact because contraception has been instrumental in shaping practices and discourses of the environmental politics of reproduction. To study the zones of contestation and care that they identify, we have to examine emergency contraception and contraception, because of their deeply political mobilisations both in the past and present. To study contraception is an important project not just as a historical event or a ‘women’s issue’ but because it reminds us to be vigilant about population control policies and practices. Contraception sits at the nexus of environmental concerns vis-`a-vis population concerns, reproductive control and a nuanced understanding of the hormonal body. In an article in the early years of the field of the anthropology of reproduction, Faye Ginsburg and Rayna Rapp wrote on the politics of reproduction (and this inspired the above article on the environmental politics of reproduction). Of birth control, they write as follows:

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No discussion of contemporary state power can fail to note the intricate national and international connections among the rise of medical professions and industries, global markets in labor and pharmaceuticals, and ideologies and policies explicitly linking economic development to population control. From a liberal-individualist perspective, many choice-enhancing developments such as the creation, distribution, and accessibility of relatively reliable, safe, and inexpensive forms of birth control, abortion, and obstetrical care have occurred. At the same time, these technologies are accompanied by and enable increasingly effective methods of social surveillance and regulation of reproductive practices. (Ginsburg & Rapp, 1991, pp. 314–15) The paradox that Ginsburg and Rapp identify is one evident even today, however, with the intensified complexity of environmental stress and hormonal management. They, alongside others, identified that contraception has been mobilised at different historical moments to serve different political aims ranging from ‘family planning’ to the ‘sexual revolution’ (Marks, 2001; McCann, 2016; Smyth, 2000; Whittaker, 2018). From scholars like Betsy Hartmann and Mohan Rao who have continually problematised the role of contraception in the Global South (Hartmann, 1995; Rao, 2005) to the contemporary, where scholars are examining the political economic underpinnings of the global population control establishment (Ojeda, Sasser, & Lunstrum, 2020; Sasser, 2018), it is clear that contraception and contraceptive technologies are deeply embedded in and are shaping the social. Today, hormonal contraceptives continue to be used for reproductive management but also for rethinking the reproductive body in light of environmental shifts (Ah-King & Hayward, 2014; Davis, 2015; Pollock, 2016). Hormonal contraceptives allow us the opportunity to recognise our sex hormones (Roberts, 2003, 2007), sometimes in the guise of managing our hormones. Hormones are biological material but not the body. They complicate our understandings and binary thinking around sex and gender (Fausto-Sterling, 1985; Sanabria, 2010, 2016). And yet, at the same time, they make it possible to expand our binary understanding of sex and gender. This chapter, then, draws on research on how people talk about hormonal contraceptives, which in turn allows us to see how people talk about and recognise their bodies – as moving and malleable across a lifespan, environment and across difference. This chapter brings together conversations on environment, population control and the hormonal body – unpacking and simultaneously further complicating the relationship between coercion and choice across lifespans for people using hormonal contraceptives. I divide the chapter into three parts: Contraceptive Pasts, Contraceptive Presents and Contraceptive Futures. I have refrained from a detailed mapping of the conversations around hormones in reproductive studies in medical anthropology and feminist and queer science and technology studies, but these are the literature I draw upon and contribute to alongside a post-colonial

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studies lens. This organising of the chapter into these three sections is an attempt to continually keep unsettled the presumed settled – both the science and experiences of hormonal contraceptives. As I have argued previously, When it comes to contraception, the temptation to imagine this ‘old’ technology as debated and thus settled is understandable. However, in extending Winner’s argument, I assert a feminist need to continually unsettle what is presumed settled. In each unsettling lies the potential to ask for better for women, and in this particular case, better contraception options for women. However, this asking for better contraception places an emphasis on improved research programmes, not more innovative marketing campaigns to sell fancier patches and vaginal rings based on the same old hormonal technology. It also needs to be couched in the importance to recognize and respect refusal. Feminists, both academic and activist, ask simultaneously for four things: first, better contraception; second, access for women who want or need it at affordable prices; third, getting men involved in sharing the contraceptive burden; and finally, to have structures in place where women who want to refuse contraception are not cast as deviant radical others who will not participate in this particular ‘progressive’ project. We need to acknowledge that different women, across time, bodies, and communities, will have different contraceptive needs. (Appleton, 2017b, p. 93) In paying attention to this unsettling, new research on hormonal contraception is vital – both for birth control, but also for so much more. Recently, research from Deboleena Roy (2004) on the relationship between melatonin’s role in contraception and reproduction brings home the fact that research on contraception is far from settled – and instead needs a continual femo-queer analysis.1 Her feminist research project started out with the aim of including men into the contraception equation, but her findings suggested that the singular aim of ‘widening the net’ to include men by using melatonin could in fact had negative consequences for reproducing biologies. She writes, in a reflection essay on the thesis as feminist scientific project (not her actual thesis): Women have repeatedly been targets for contraceptive technologies. Male contraception does not seem to receive the same amount of attention. The Purpose of Inquiry of my thesis was to examine the effects of melatonin on GnRH, which is a hormone involved in regulating both male and female reproductive systems. Since I found that melatonin downregulates GnRH, I showed that no scientific basis exists for why both male and female contraception

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by melatonin cannot be envisioned. This would help to eliminate some of the existing constraints based on sex that are blatantly apparent in contraceptive technologies. However, since I found that melatonin may have antigonadotropic effects at the level of the brain, and despite the health risks women have taken for the sake of contraception, I did not advise the use of melatonin for male contraception either. This is a case in point for the benefits of feminist science for men as well as for women. (Roy, 2004, p. 268) The vitality of continuing to study contraception is a scientific project, but also one that has a deep post-colonial feminist politics attached to its ethos. Hormonal contraception was designed to control our Black and brown bodies – but today, post-colonial feminist scientists and social scientists are re-configuring hormonal contraception to ensure a progressive future(s). This chapter is contribution to the cause that allows us to see futures of hormonal contraception decoupled from its problematic histories. In the following, I briefly outline the history of hormonal contraceptives and then draw on some empirical evidence from fieldwork in India to highlight how the contraceptive pasts in places like India look different from the ones in the Global North. I then look at the contraceptive present and hormonal management in Aotearoa New Zealand and how this contemporary moment may set us up for a more progressive contraceptive future. In the last section, on hormonal contraceptive futures, I outline the way pasts have corrupted the way we talk about hormones and hormonal contraceptive, while the present(s) open up new possibilities – IF we are careful not to give into a simplistic populationism. I suggest that, in thinking about the enviro-cultural, we can imagine new ways to mobilise hormonal contraceptives by co-opting them to manage our biologies, but also for recognising the fluid nature of hormones across bodies and lifespans. But before talking about futures, presents and pasts, it is imperative to see hormonal contraceptives in and of themselves as not simply emancipatory or draconian technologies – not pure coercion nor perfect choice!

Contraceptive Technologies Hormonal contraception is an early transient technology as it travelled from the North to the Global South and shaped women’s lives as it moved slowly across the globe (Tone, 2001). Historical accounts of the development of the contraceptive pill alone tell a story of how it was developed to address population problems and re-assess the simplistic claim that the pill alone fuelled the sexual revolution (Marks, 2001). The absence of mass marketed male contraceptive options (Oudshoorn, 2003) makes women the burden-bearers of reproductive control and holds them responsible for failed contraception. The journey of the pill, from the humble yam (Laveaga, 2009) to the adventures of Margaret Sanger with scientists in lab coats (Chesler, 2007; Cullen-DuPont, 1999; Sanger, 2012,

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2014), is a well-documented story that can be continually unpacked; however, for this chapter, I work with the premise that the contraceptive pill has come a long way in shaping women’s social and biological. In talking about the newer and novel methods of contraception (starting at the pill and developing into vaginal rings and hormonal patches), Watkins argues that there is nothing ‘new’ or innovative about these methods of contraception, since they rely on similar modes of hormonal modification as that of previous generations (Watkins, 2012, p. 1464). Scholarship has also looked at ECPs (Prescott, 2011) and how they circulate within the public sphere in the United States (Prescott, 2011; Wynn & Trussell, 2006) and India (Appleton, 2019a; Sheoran, 2015). In my work, I write of India as a former colony and Aotearoa New Zealand as a settler colony – both are crucial sites of analysis for these technologies’ social lives, as here they operate variously as oppressive, repressive or emancipatory technologies. In many ways the launching of contraception in the 1960s individualised reproductive control. A win by all accounts, as it afforded (some) women the autonomy to make a choice (however constrained that choice may have been as has been pointed out above by the editors).

Hormonal Contraceptive Pasts ‘The pill’ was the start of many things, including my own research career.2 Conducting fieldwork on ECPs in India in 2008 often led me to hear older women’s narratives of another contraceptive pill that had first been introduced in India – Mala-D in the late 1980s – to a very low acceptance rate. An oral contraceptive pill (combined oral contraceptive (COC) pill) with 21 days of active ingredients and seven days of placebo (which in the case for Indian women contained iron, as opposed to being sugar pills) allowed me to hear narratives of women who had been embarrassed by the first time Mala-D was advertised on Doordarshan (the state-sponsored television channel).3 Indian media had mostly refrained from portraying sex, sexuality or reproduction on public media (radio, public hoardings and print predominantly) until the mid-1980s. Even in the 1990s, it was only with state-promoted advertising (through private advertising houses) that condoms, family planning and contraceptive pills made it to public media spaces – though with very little information about sex or sexuality, but rather with aggressive nationalistic messages around population control (see Appleton, 2019a; Mazzarella, 2003). The women I spoke with talked about the pill in very complex ways including trying it and finding it too disruptive to their everyday lives and biologies. Introduced in 1987 by the Government of India (GOI) as part of its social management of the population ‘problem’ (Jethwaney, 2016, p. 60), Mala-D was made available for free at all medical facilities and pharmacies. It continues to be distributed as part of the GOI ‘family planning’ strategy (or ‘basket of options’) as executed by the Ministry of Health and Family Welfare (MoHFW). However, the acceptance rate amongst Indian women was abysmally low. In the more contemporary past, when the ECP was introduced (2005 onwards), it became

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evident that women in India were willing to take the ECP, but the regular contraceptive pill had not had a similar uptake (Chhaya, 2010; Khullar Relph, 2010). There were concerns about women turning to ECPs and not partaking in the monthly regular contraceptive pill, which was for numerous reasons including lack of privacy in homes, lack of information and the hormonal impacts experienced when taking pills like Mala-D. While I have written elsewhere about these reasons and its implications, it is one of the conversations around Mala-D that I highlight in the following (which was repeated in multiple interviews) that I will focus on here. Rupa, one of the middle-aged ladies I spoke to in Delhi, said, We used to use the Mala-D, the way girls now use the i-pill [ECPs were often referred to by their brand name of i-pill as opposed to being called ECPs]. If something happened at night, the next morning we would take about 5…and it would generally be okay. (Interview, translated from Hindi) This similar logic of using multiple combined oral contraceptive (COC) pills after unprotected sex to prevent a pregnancy was shared by a lot of my older women respondents. The number of COC pills taken ranged from four to six. This would put the intake to approximately 1mg of levonorgestrel, which is roughly the same dosage as some emergency contraception. In the 1990s and early 2000s, when most of these older respondents would have taken these pills, none of them would have had access to the internet or literature that would have told them the inherent logic of taking multiple pills to manage their hormonal bodies after unprotected sex. When I asked them how they found out about this ‘trick’, they did not have an answer. Generally they said that they ‘just talked amongst ourselves’. The same women also told me that, while they were willing to take multiple pills of Mala-D (now also sold and distributed as Mala-N) as an emergency measure, they did not take it daily. In a study conducted in 1997 by Ravindra and Rao in Madras to check preference of diaphragm over Mala-D, the participants complained of headaches, nausea and giddiness when on Mala-D (Ravindran & Rao, 1997). Similarly, the older women I spoke to remember their encounters with Mala-D that overwhelmingly included complaining of cramps, nausea and thakhat (general mental and physical exhaustion), women refrained from the daily consumption of these hormonal pills that continue to influence hormonal bodies and reproductive decision-making in the Global North. However, in my interviews, it was also clear that women wanted the information about these pills and took them when they were given access. However, because of the side effects, they were careful about when they used them. As Meena didi, an older woman past her reproductive prime living in Dehradun, told me, When I think back to the time when we were young, I remember after my marriage, the nurse bibi gave me the Mala-D. I did not

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Nayantara Sheoran Appleton know about these things, but I kept them because I did not want to say no and get into trouble. Later I used it only once, but she kept giving them to me till I had my first child. [Interview, translated from Hindi]

Though most of my interviews were with younger women and about ECPs, of the older women I spoke with, it was clear that they took these COCs from their service providers and kept them, but only used them for emergencies. They learned early on how to manage their hormonal lives, sometimes with the aid of these early pharmaceutical interventions in their lives. All the women I spoke with lived in cities and while acknowledging their rural roots, never spoke of a ‘natural’ way to manage their hormonal bodies once the pharmaceutical and synthetic option was available. While I have written about the problematic and troubling history of contraceptives in India (Appleton, 2019a; Sheoran, 2015); it is for the first time here that I am writing about these conversations on Mala-D and the logics that circulated about it in extremely informal and almost subversive networks. Saying no to medical professionals was not an option for many of these women, but choosing to use the pills on their own terms was their way of asserting agency through the hormonal contraceptive. Mala-D, the first generation of COCs in India, allowed women to manipulate their hormonal bodies at their own discretion in the privacy of their homes, while rejecting the state’s objectives of creating a whole generation of women on the pill as a way to participate in the ‘population control’ project. These women resisted the intended logics of the pill, but shared information freely about their unintended logics (Appleton, 2019b) – in this case hormonal management for reproductive autonomy. They were open to hormonal management, but on their terms and in ways that benefited them. They were not willing to take on hormonal shifts that they could not manage in their daily life, but understood that their bodies had a certain fluidity that was mobilised through this particular intervention. While this is an early exploration of a very complicated issue, I see this historical moment as rife with potential. The art and craft of hormonal management, either to prevent pregnancies or live more productive lives, has been situated in women’s collective ancestral knowledge prior to formal medicalisation of this information (Koblitz, 2014). For example, women in India and Sri Lanka consumed semi-ripe papayas in order to manage their fertility and also balance their hormones. In many a conversation growing up in India, I was advised to eat copious amounts of cilantro or jaggery to bring on a delayed period. Both helped to regulate my hormonal body. In Ayurveda, some of these remedies are still recommended. And yet, even though I talk about ‘historical’ knowledge in non-biomedical spaces of the hormonal body (Ayurveda being one), I am careful not to sign up for a glorification project of ‘old Hindu’ knowledge systems. Banu Subramaniam and Anne Pollock’s scholarship is a timely reminder that even as post-colonial scholarship works to dismantle colonial scientific (and other) legacies, we have to be careful not to make space for regressive (Hindutva) forces to co-opt our work(Pollock & Subramaniam, 2016; Subramaniam, 2000). Hormonal contraceptives made it possible for women

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disconnected from their rural roots in busy urban lives to remember that their biologies are malleable. And while this remembering may have been associated with the technology of hormonal contraception deeply embedded in colonial and eugenic logics, it provided women in India an opportunity to actively reject or subversively manipulate their bodies through synthetic interventions (COCs) through non-indicative use.

Hormonal Contraceptive Presents Moving from Indian women’s conversation about their reproductive decision-making in the 1980s to contemporary Aotearoa New Zealand, I draw on two key narratives that emerged as part of my fieldwork. The first was around the tensions that emerged in 2018 around research that young women were taking hormonal contraceptive pills to manage their periods, in the face of period poverty. New Zealand’s Family Planning Adviser, Dr Beth Messenger when talking to Radio New Zealand explained that ‘Her clients found the cost of contraception that stops a menstrual cycle cheaper than paying for pads and tampons’ (Cook, 2019). These conversations around contraception use in lieu of access to cheap and affordable sanitary products had come to a head in 2018, when local supermarkets collectively worked together to bring down the price of sanitary products. Below is a direct quote given at one of the supermarket events where price reductions were being announced. Ms Chapman, who is chief executive of Kids Can, a youth charity, and has been pushing for free or cheaper products to manage period poverty, was quoted as saying: I think the one that has shocked me the most, which I’m just going to read to you, is ‘some girls even take the pill now to stop their bleeding’, Ms Chapman said. So these are our babies, and we’re talking really young girls, who are doing whatever they can to avoid having to deal with their periods, and basically they’re trying to micromanage them by taking the pill. Now that to me is shocking. We’ve been aware of this issue, we’ve started putting sanitary items into schools about five years ago but we’ve seen it progressively get worse, in particular this issue. (TVNZ Bureau, 2018) Period poverty, in this case, is addressed by young women using contraceptive pills to manage their period in the absence of having adequate access to and supply of sanitary napkins. Manipulating their young hormonal bodies in order to address a structural deficit is deeply troubling. The fact that young women are willing to manipulate their bodies because they cannot get access to sanitary products is indeed a problem. However, can we use this incredibly difficult moment to imagine another world?

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While I address the above question a bit later in this section, I want to highlight a particular understanding of hormonal fluidity, shared by these young women accessing hormonal pills to manipulate their menstruation and young trans women who struggle to get access for hormones that are used for non-indicative use. These women know what hormones can do for them and their wellbeing, while also acknowledging the ways the ease of access is limited to some women. Jayshree, a trans woman when talking about access to hormonal pills, said, They [Pharmac] really need to understand that hormonal needs are not limited to indicated uses.4 There is a constant shortage and I have to hunt them down from pharmacy to pharmacy. It’s exhausting. Why can’t they just acknowledge non-indicative usage formally…medicine takes too long to catch up with our bodies. (Interview, February 2021) We went on to talk about medical instructions and practices in light of trans health and wellbeing, but it was clear that Jayshree, like most (all?) trans women understood the possibilities inherent in hormonal medicine. If cis and trans young women are aware of the way their biological bodies are dependent on their hormonal levels – which move and can be moved across their lifespan – then they are more likely to see their bodies as hormonal bodies with an inherent fluidity. An inherent fluidity that allows for a body to be anything on a range of hormonal options with female, male, intersex, trans bodies as just starting positions. In the introduction of this edited volume the editors write: Relatedly, RTs have been primarily envisaged as serving heterosexual (and in many cases, specifically married) couples, though this seems likely to shift as increasing numbers of LGBTQ 1 intended parents use RTs, thereby reshaping the technologies themselves, as well as inevitably provoking developers to explore new ‘markets’ (see also Mackenzie, this volume). (Dow and Boydell, Introduction) And when it comes to contraceptive futures, it is in taking account of LGBTQ(IA)1 contraception for both reproductive and hormonal management purposes that opens up multiple possibilities. Futures that are not hinged on hormonal contraceptives preventing pregnancies or participating in ‘overpopulation’ prevention projects but, rather, fully and absolutely co-opting this colonial technology for an emancipatory body politics that allows for a femo-queering across our lifespans.

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Hormonal Tinkering for Contraceptive Futures There is a discursive and material space that is opened up by hormonal contraceptives, a space that allows for recognition of the malleable, moving, hormonal body. And yes, this new space is very tenuous and can be easily used to reinforce old, colonial and heterosexist hierarchies (see also Mackenzie, this volume). This space is also made possible, not just by hormonal contraceptives, but by the fact that these technologies now mobilise a particular tension in contemporary societies anxious about a hormonal body out of sync: out of sync because of how our lifestyles contribute to the degradation of the environment. Just as the 1960s was the era where hormonal contraceptives were seen as technologies to manage reproduction (either for empowerment or disempowerment based on where you were situated) (Hartmann, 1995; Tone, 2001), the near-contemporary is the era where hormonal contraceptives are seen as technologies to manage biologies (Sanabria, 2010, 2016) and populations in neoliberal regimes (Rao, 2005; Rao & Sexton, 2010; Simon-Kumar, 2010). In this temporal narrative, the future of contraceptives requires attention – not because we need to think beyond reproduction or biologies, but rather because both reproduction and biology are logics being mobilised as we come to terms with the environmental crisis bestowed upon us by the consumption-driven socioeconomics of the Global North. As the threat of climate change becomes more palpable two key anxieties (re)surface. First, a fear around populations in the global South and second, that of a hormonal body out of sync in the face of environmental changes. In many recent books, documentaries, policy framings and news stories, climate change and ‘over-population’ have been linked in ways which reproduce these problematic ideas (Appleton, 2017; Sasser, 2018). Even in the face of COVID-19, one on the predominant memes circulating on social media was ‘Humans are the Virus’, with images of nature taking over. Viewing human beings as a problem in light of the climate crisis is indeed making a recent resurgence, just as awareness of the climate crisis makes its way back into the mainstream (Bashford, 2018). This logic that connects population to environmental crisis is also evident in the recent scholarship by leading (white) feminists Adele Clarke and Donna Haraway in their edited volume Making Kin, Not Population (Clarke & Haraway., 2018). While some of the contributors to the volume (like Michelle Murphy and Kim TallBear) refute some of their claims, their edited volume begins and ends with the premise that making kin and not babies is the way to address the environmental crisis. Making Kin compels us to think about population and kin in light of the climate crisis. Having read everything Clarke and Haraway have ever written and being inspired as a graduate student and then a junior scholar working on contraceptive and reproductive politics, this book, however, was a bit troubling (and perhaps that is why I continue to stay with this trouble, at the cost of losing my reverence for them, my academic elders). Clarke writes: In 1900, world population is estimated to have been 1.6 billion people; today it stands at 7.6 billion and is estimated to exceed 11

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These are powerful numbers, shared in and amongst ‘concerned citizens and scholars’ when expressing their anxiety around the climate crisis. But the numbers hide very complex realities about everyday life. And aspirational words that follow allow us to imagine a better future. The call to ‘mak[e] kin, especially non-biological kin’ ignores the fact that making kin – biological or otherwise – has historically been a relatively easy privilege for white women (Dow & Lamoreaux, 2020). For other women, kin making has often been denied – from enslaved people in the American South unable to nurture and raise their own babies to mass sterilisation camps that targeted women (and men) in places like India. I am afraid that Making Kin, though fortunately not a bestseller like Ehrlich’s The Population Bomb (Ehrlich, 1968), is playing a very dangerous game. When senior, highly respected scholars focus on the spectre of population explosion and its impact, calling on ‘allies’, they call for particular allies. With this recent work, these scholars who had worked with scholars in the South in the past have refused to engage with feminists and activists from the Global South. More productively, we should be highlighting scholarship that outlines the impacts of Eugenic Feminisms (Nadkarni, 2014) and engaged more with the politics of populationism (Bhatia et al., 2019; Hendrixson et al., 2019; Ojeda et al., 2020) and its dangerous legacies. As India, one site of constant concerns vis-`a-vis babies and population, dips below replacement TFRs (see numbers presented earlier) and continues to have carbon emissions four to five times lower than Euro-American nations, the conversation presented in Making Kin could be viewed in a more balanced tone (though it should be pointed out again, that some of the chapters in the volume push back against this introduction and the editors’ chapters). It needs repeating multiple times, and by many scholars, ‘Overpopulation is not the problem’ (Subramaniam, 2018), in the hope that we can focus correctly on the real problems. In many ways, I, along with other feminist academics (and activists) from the Global South, see Making Kin as a betrayal – one we’re familiar with when it comes from white liberal feminists. The betrayals are not new nor will they be the last. However, calling them out is vital, as it allows us to move the conversation to a place where we can outline how the liberal narrative around ‘women’s empowerment’ and population control needs to be decoupled.

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To read, engage and continue to critically resist the narrative that connects women’s reproductive lives to population increases to environmental degradation is vital, just as resisting the obverse where women’s empowerment via access to contraception to have fewer children is essential to ensure reproductive autonomy. In September 2019, I was asked to view and sit on a discussion panel for the movie 2040 (2019, director Damon Gameau) being screened in a boutique cinema in Wellington Aotearoa New Zealand. In the movie, the well-intentioned white liberal Australian journalist-turned-filmmaker asks the audience to come along on a journey where he imagines a better future for his daughter (and us) in the year 2040. In the movie, the technocratic solutions to ensure continued consumption and quality of life known in the Global North are proposed with savvy diagrams and beautiful images. And in there, gently and kindly sneaked in, is the suggestion that ‘empowering girls’ in countries like India and Bangladesh will be better for a world that is trying to figure out how to feed a growing population. In this narrative, the environmental degradation and crisis can be averted, if we have more technology (no discussion was undertaken on the ecological footprint of data and technology storage and maintenance) and more empowered women reproducing less – making fewer babies. Contraceptive futures will have to resist this cis-white/upper-class/caste-liberal eugenic creep in the face of environment degradation. There was no pure romantic past for the large swathe of humanity that has lived under colonial legacies for over 500 years, and there will be no future at all, so long as we continue to talk in the same language that got us here. Anne Pollock, writing about how science and scientific researchers write about environmental degradation queering behaviour in birds, says, Scientific and journalistic interest in endocrine disruption comes at the same time as increased interest in the sexual diversity of animals broadly, such that biology’s purview has expanded beyond ‘reproductive behavior’ to attend to ‘nonreproductive sexual behavior’ that has been there all along. Scientists are willing and able to see gayness in animals in a way that earlier models that equated animal sexuality with reproduction never could. Since, as Jennifer Terry points out, ‘animals provide models for scientists seeking to determine a biological substrate of sexual orientation’, this has been seized on by those who want to say that gayness is natural. For my part, I am not interested in what is natural, only what is, and what might be. (Pollock, 2016, p. 190) And this is something that hormonal contraceptive futures might allow us to attend to, if they are not continually dragged into population, reproductive control, empowerment or environmental degradation debates. The overlaps between the hormonal regimens of contraceptives to manage periods and treatments taken by trans people makes available to us another way to think about a malleable body.

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Conclusion In my writing I outline how hormonal contraceptives give us access to language and imagining(s) for our hormonal future(s) to be seen, studied and understood as experiences in non-binary. As Subramaniam reminds us, narratives matter (Subramaniam, 2019, p. 37). This future will require us to see our hormonal bodies not as out of sync, but the environments they have to live in as out of sync. We should celebrate contraceptives hormones as technologies that can be used for more than reductive reproductive control, but rather as sites of co-optation where bodies take a colonial technology and mould it to serve an anti-colonial project – be it to reproduce or to live a hormonally non-binary life. There is a space that has been opened up by hormonal management, a space that allows for recognition of the malleable, moving, hormonal body. And yes, this new space is very tenuous and can be easily used to reinforce old, colonial, cis and heterosexist hierarchies. This space is also made possible, not just by hormonal contraceptives, but by the fact that these technologies now mobilise a particular tension in contemporary societies anxious about a hormonal body out of sync. Contraceptives’ role in our future is not only to manage reproduction in the face of our environmental crisis but also to account for how to ensure reproductive and hormonal justice for diverse bodies in the face of climate change. This will require an articulation of Contraceptive Future(s) that are feminist and which queer the role of hormones in the biological, political and environmental. Contraceptives, in resisting their singular logics as prophylactics, will have the opportunity to finally grow out of their problematic legacies. A project that ‘dethrouples’ hormonal contraception, population control and climate crisis would need to be collective and cooperative. Access to reproductive wellbeing will be assured through use and/or denial of hormonal contraception, BUT they will need to be projects that allow all people to make decisions under different conditions – social, economic and environmental. Contraceptive futures cannot be about only preventing conception or limited to not making babies. Contraceptive futures have to be about acknowledging the chemical lives we live and how to go about transforming the ecological, economic and structural conditions which lead us to consume hormonal contraceptives to particular ends. We are at a historic moment where technological innovations offer us the potential to separate the assumed relationship between contraception and reproductive ‘women’. Yes, there is no doubt that contraception offers progressive autonomy to some women and is necessary in others for women to have control of their own contraceptive choices, but perhaps as more information about pharmaceutical contraceptives becomes available to us and the implications of those on our bodies, we can start to imagine a contraceptive reality outside one with severe long-term health implications or one underpinned by larger political agendas. However, even to contemplate a move towards a new contraceptive future, we need to pay attention to the biological alongside the social lives of pharmaceutical contraceptives. Earlier in this chapter I wrote about the Indian prime minister’s clarion call for ‘smaller families’ and how this has mobilised policy that aims to control the

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reproductive lives of Indian citizens (especially women). This mobilisation or call also serves another particular politics – the politics of deflection. If large swathes of people in the consuming world (including among the elite in India and China or elsewhere) are convinced that population is the problem vis-`a-vis our climate crisis and curtailing it a needed solution, then the focus on extractive and exploitative economic structures is deflected to more personal and individual acts of reproductive surveillance.5 It allows the ‘over population’ rhetoric to resurface as respectable debate, with implications for women’s reproductive lives, which are often addressed through conversation about access to and/or denial of hormonal contraception – thereby limiting the potential of hormonal contraception. The uses and perceived abuses of hormonal contraceptives are essential for understanding and appreciating the complex entanglements between bodies, biological materials, society, politics and the environment. However, to disentangle hormonal contraception from reproductive control is one first step in addressing the future potentials of this humble yet complex technology, while enriching the conversation on the environmental politics of reproduction. Contraceptive futures require contradictory conversations that force us to think beyond simplistic hormonal binaries – even if it means to stay continually unsettled, unmanaged and out of sync. I clearly remember leaving Dr Libby’s talk (that I open this chapter with) that wet night in Wellington and thinking to myself that there are only so many green vegetables I can eat, and still not be able to counter the fact that I live downstream of a toxic landfill or am overworked or raise a child in a nuclear familial unit. I wanted Dr Libby to see that my hormonal body – moving, changing, doing, loving – was not the problem. It was not a body out of sync that needed to be managed back into gender binaries through individualised regimens of management. But rather, the body and its hormonal malleability, made visible largely through the hormonal contraceptive pill, was perhaps the way for us to imagine a future that recognises an environment out of sync and then works collectively to fix it.

Notes 1. Femo-queer – this is a term that I have been recently using to identify queer aligning feminists and/or feminist aligning queer folx. Far from theorised thus far, it is a term that has allowed me to teach and engage with students through a politics that is in opposition to TERFs and moves beyond the limits of some white feminist standpoints (something I address here in this chapter in regards to the ‘making kin, not babies’ scholarship). 2. The hormonal contraceptive pill was the first, and only, medicine in history to be called – just ‘the pill’. 3. Indian women have a lower BMI and chronically low iron – which have implications for women’s health, especially reproductive health. The decision to include iron instead of sugar as part of the regimen was a way to get nutritional supplements to women.

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4. Pharmac, officially known as The Pharmaceutical Management Agency of New Zealand that is responsible for deciding which medicines and pharmaceutical products will be made available in the public health care system. 5. It is no coincidence that BP invented the term ‘carbon footprint’!

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Chapter 7

Spectacular Reproduction Revealed: Genetic Genealogy Testing as a Re(tro) productive Technology Sallie Han

Abstract This chapter discusses an instance of spectacular reproduction that circulated in US media during the late 2010s. Through the use of commercial DNA tests, it was revealed that a fertility doctor, Donald Cline, had used his own sperm to impregnate scores of women who had sought fertility treatment from him during the 1980s. More than 60 biogenetic children, now in their mid to late 30s, were identified by early 2020. This instance illustrates several concepts and concerns that might further guide the social and cultural study of human reproduction and especially the uses of reproductive technologies: (1) Most of us encounter instances of extraordinary reproduction from a mediated distance, yet they may shape and inform our expectations and experiences of ordinary reproduction in our everyday lives. How might the concept of spectacle help us understand what is perceived and understood about reproductive technologies? (2) Reproductive technologies offer ‘fixes’ for disruptions of not only reproduction but also kinship. A focus of this chapter is on genetic genealogy tests as a re(tro)productive technology, which produces children, parents, and kinship in hindsight. (3) The social and cultural study of reproductive technologies ought to take a longitudinal approach that both includes a lifecourse perspective and takes into account the historical contexts in which the technologies become developed and individuals encounter them. Keywords: Spectacle; genetic genealogy; reproductive technologies; kinship; fertility; secrecy

Technologies of Reproduction Across the Lifecourse, 131–147 Copyright © 2022 Sallie Han Published under exclusive licence by Emerald Publishing Limited doi:10.1108/978-1-80071-733-620221012

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Introduction In recent years, several instances of what I will call spectacular reproduction have circulated in US media. Of these, the most startling and sensational has been the revelation that a fertility doctor, Donald Cline, had used his own sperm to impregnate scores of women who (with their spouses) had sought treatment at his Indiana fertility clinic during the 1980s. This was done without the knowledge or consent of these women or their husbands. Some couples believed that the husbands’ own sperm had been used to conceive their children; others sought donor insemination and had been told there was an anonymous third party whose sample would be used, no more than two or three times. The discovery itself had been made possible by the use of commercial direct-to-consumer DNA tests. To date, more than 60 biogenetically-related half-siblings have been identified. The revelations surrounding Cline’s ‘secret children’, as the headlines have referred to them, provides an example of key concepts and concerns that I suggest might further guide us in the social and cultural study of human reproduction and especially the uses of reproductive technologies. First, I propose that a concept of spectacle might offer a corrective lens to examine how most of the rest of us understand reproductive technologies – that is, how our encounters with extraordinary reproduction from a distance might shape and inform our expectations and experiences of ordinary reproduction in our everyday lives. Indeed, the discussion presented here is drawn not from embeddedness and familiarity with the individuals living through these moments, but from media accounts themselves comprising the spectacle, such as newspaper and magazine articles, television news segments and a podcast series, all of them available through a simple search of the web. Second, I am interested in thinking with and through a concept of disrupted reproduction and kinship as well as of an understanding of the significance of secrets and lies in navigating and repairing these ruptures. What led women and men to seek fertility treatment in the first place, then to conceal it? What also led at least some of their children to seek information about and connection with biogenetic kin? Each of these situations might be understood as instances of disrupted reproduction or deviations from what is socially and culturally understood at a particular historical moment to be a ‘normal’ course of reproduction. It is at these junctures that reproductive technologies become engaged. Initially, it was the experience of unwanted childlessness and infertility that led the now-parents to pursue intrauterine insemination (IUI). Later, it was the now-adult children’s various interests in exploring their lineage – some broadly curious about their ancestry and others specifically focused on finding family members, particularly siblings – that led to revelations that in turn threatened to rupture their already existing kin and family relationships. Third, a particular focus of this discussion will be on the use of direct-toconsumer (DTC) genetic testing as a re(tro)productive technology, which produces children, parents and kinship in hindsight. This instance of spectacular reproduction ‘begins’ not with women and men seeking fertility treatment from Donald Cline during the 1980s but with individuals submitting their genetic

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material to commercial services in the 2010s. Like our awareness of the reproductive technologies of assisted conception or of prenatal diagnosis and the potentialities that both represent, commercial DNA tests also influence our ordinary experiences and expectations of reproduction and kinship. This leads directly to the final points I intend to make – about the importance and necessity of a longitudinal approach to the social and cultural study of reproductive technologies, for which the authors in this volume argue. Such an approach takes into account not only the historical contexts in which the technologies become developed but as important, the social and temporal situatedness of individuals and their encounters with them. More particularly, a lifecourse perspective brings into focus the shifting of situations.

The Instance This chapter discusses a specific instance of spectacular reproduction – the story of individuals who discovered they had been conceived with the same fertility doctor’s sperm – as reported in journalistic accounts in the aftermath of the doctor, Cline, having faced criminal charges. Cited here are the news articles that were published in prominent regional and national news media, The Chicago Tribune (Cohen, 2018), The New York Times (Zaveri, 2018) and The Atlantic (Zhang, 2019a, 2019b). In addition, an important source is a public radio-founded investigative journalism podcast series, Sick (Bavis & Harper, 2019), which featured interviews with some of the children and their mothers. Summarised here are the details of this instance: Cline had been a respected fertility doctor in Indianapolis, where he opened his clinic in 1979. What was then called ‘artificial’ insemination was among the treatments he offered. In his practice, Cline treated married heterosexual couples only, and he claimed to use sperm either from the husbands of the women he treated or from anonymous third parties who Cline typically said were medical residents at a nearby hospital. However, later Cline admitted to having used his own sperm 50 times, although he has never explained his reasons for doing so. None of the women receiving treatment from Cline were informed before or after the procedure that the doctor had used his own sample. The discovery was made by the biogenetic children conceived with Cline’s sperm – now-adults in their mid to late 30s – who had submitted their DNA to commercial testing services, notably Ancestry and 23andMe. Initially, as later recounted in the Sick podcast, a group of eight of the half-siblings had discovered each other (Bavis & Harper, 2019). Although each of them had been interested in finding family members, none of them had expected to find as many connections as they had. Learning that all of their mothers had sought fertility treatment from the same doctor led them to suspect Cline himself might be their biogenetic father. The half-siblings went public in 2015, prompting a criminal investigation of Cline, who was ordered to provide his genetic material for paternity testing. The story then became a media sensation as other individuals pieced together that they, too, were secret children. Some of the children had known from their parents that they had been conceived with sperm from a donor, about whom they were curious.

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Others, however, had no idea that their parents had ever pursued fertility treatment. By early 2020, about 60 half-siblings had been made known to each other, but some of them have preferred to remain anonymous in public. Because there is no federal or state law regulating the use of donor sperm, much less banning the doctor’s use of his own sample, and because Cline’s actions in fact did not meet the definition of rape, he was charged only with obstruction of justice for not initially responding to investigators. He received a one-year suspended sentence and, although already retired, he also lost his medical licence. In media reports, the secret children have described the distress, shock, trauma and emotional upheaval they have experienced, along with that of their parents and other members of their families. At the doctor’s sentencing, Jacoba Ballard spoke on behalf of herself and the other secret children, telling the judge ‘there has not been one part of my life that has not suffered’. Liz White, 66, one of the mothers, later told a reporter: ‘I feel like I was raped 15 times’ (Zhang, 2019a). She had undergone 15 inseminations, one on each of three days she had tracked close to her ovulation over the course of five months. Some of the secret children and their mothers who had been Cline’s patients have become advocates of more oversight and stricter regulation of donor insemination, such as the recognition of ‘fertility fraud’ as a crime. Donald Cline’s defenders have claimed that the doctor had been motivated by his desire to help his childless patients – and after all, they had the children they wanted to have – and even suggested that although times had changed, his actions would have been acceptable in the past.

Spectacular Reproduction For the individuals who discovered their connection to Donald Cline, which had been previously unknown to them – and more precisely, kept secret from them – this instance is experienced as personal, intimate and immediate. The rest of us, however, witness this instance as one that is public, distant and mediated. It is, in a word, a spectacle. William O. Beeman (1993) succinctly defined spectacle as ‘a public display of society’s central meaningful elements’ (380), not limited to events and performances, but as ‘a general social phenomenon’ (381). A spectacle is experienced sensorially (in particular, visually) and emotionally – so that, although the experience of spectacle is for most of us one of observation, not participation, it can have powerful effects on what we think we know and how we think we ought to believe and behave.1 Many of us come to witness spectacle through our consumption of the news, on which S. Elizabeth Bird (2010) offers an anthropological perspective: ‘People do not evaluate news stories in isolation, but incorporate them into their already established worldviews’ (12). French social theorist Guy Debord called attention to the paradoxical impacts of spectacle in media-saturated contemporary contexts. A member of Situationist International, a group of avant-garde artists and thinkers of the 1960s, Debord articulated a Marxist critique of spectacle, observing there is on one hand lively and heightened engagement with and through the spectacle and on the other hand the alienation between ‘directly lived’ and ‘merely represented’ that results in the

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deadening of consciousness about their conditions of life and labour. ‘The spectacle keeps people in a state of unconsciousness as they pass through practical changes in their conditions of existence’ (Debord, 1967/2002, p. 5). My own previous research included an examination of a spectacle of reproduction. Foetal ultrasound imaging has become embedded as a rather ordinary routine and ritual of contemporary American pregnancy (Han, 2014). However, when Life magazine featured, in 1965, a spread of full-colour images of foetuses – not sonograms – it celebrated the ability to open a window into the womb as an extraordinary achievement of science and technology and employed the same breathless tones it used in its coverage of the US space programme and the Apollo missions to the moon (Han, 2018). Today, the sonogram has become a somewhat more familiar and less spectacular spectacle, which exhibits and enforces what Beeman called society’s central meaningful elements, notably concerning reproduction, kinship and family. Yet, Debord might find the sonogram’s mundanity itself troubling as it also exhibits and enforces technology, capital and surveillance, which individuals themselves actively invite and incorporate into some of the most significantly transformative experiences of the lifecourse. A concept of spectacle seems useful to think within the study of reproductive technologies. Notably, the number of individuals with personal experiences of assisted conception, while certainly growing, still remains relatively small. Yet, our awareness of these technologies and their potentialities filter our perceptions of what reproduction is. Indeed, as Katharine Dow (2016) observed in her ethnographic account of the ‘ordinary’ ethics surrounding reproduction, all of us – including significantly those who have no personal involvement with reproductive technologies – are implicated. In the United States, only 2.1% of all infants born in 2019 were conceived with the use of what the Centres for Disease Control and Prevention (2021) call advanced reproductive technologies; of course, this percentage still refers to tens of thousands of births per year. CDC’s Assisted Reproductive Technologies surveillance report gathers the statistics primarily for in vitro fertilisation, which comprise 99% of ART procedures performed at US fertility clinics. It is much more difficult to track reliable numbers for IUI, also called artificial insemination. A 1988 report of the Office of Technology Assessment, an agency of the U.S. Congress, reported on the results of a survey on physician-assisted insemination and estimated about 35,000 births from artificial insemination by husband (AIH) and 30,000 births from artificial insemination by donor (AID). This report predates other medical–scientific and social–legal developments that support both increased rates of conception and greater accessibility to and use of a broader range of reproductive technologies in the first place. These included expanded use of in vitro fertilisation (IVF), the development of intracytoplasmic sperm injection (ICS), and the desires and conditions that make imaginable motherhood without heterosexual marriage or partnership (i.e., same-sex couples and single mothers by choice). The numbers of births resulting from assisted reproductive technologies quoted earlier might read as quite small or large – in either case, they have spectacular impacts. Notably, spectacles of assisted conception reinforce the understanding

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that technology brings hope to people, with stories of ‘miracle’ babies born to parents who had yearned for children for years. The instance of Cline’s secret children does not diminish the hope of technology; indeed, the number of half-siblings suggests its spectacularly overwhelming success. However, it also lays bare the potential to do significant harm even when the intended aim has been accomplished. Cline’s female patients became mothers, as they had hoped. Most US women and men who seek fertility treatment are kept informed and give consent, and most US children who are conceived with donor sperm are likely to have few if any biogenetic half-siblings. Yet, as media reports of instances like this one of Cline’s secret children become published, shared and circulated widely, even going viral on the web, there are widening perceptions of the uses and especially misuses and abuses of reproductive technologies. These build upon other already existing fears and suspicions about ‘switches’ both unintended and intended, doctors and scientists, money and profit, sexual predation, and other wrongs and injustices against people whose ordinariness – as not experts and not rich and as female patients seeking help from male doctors to become mothers – makes them vulnerable. Here, it is instructive to contrast the Cline spectacle with another instance of spectacular reproduction—the 2009 birth of Nadya Suleman’s octuplets who were conceived with reproductive technologies. While early reporting raised questions about the health risks for Suleman herself and her children and the practices of her doctors, Dana-Ain Davis (2009) notes ‘the potential cause of harm was redirected away from the ethics of the fertility clinic and directed toward Ms. Suleman for her irresponsibility and moral ineptitude’ (Davis, 2009, p. 106). In this instance, reproductive technologies became associated not only with their misuses by questionable doctors but also their abuses by a woman made questionable because of what appeared in public discourse to be her uncertain identity. Davis notes Suleman’s ‘legality’ as a US citizen and her race or ethnicity became a focus of speculation, reflecting racist assumptions about Black and brown women’s fecundity and dependency on government assistance. While it became revealed that Suleman had a mixed Middle Eastern and Eastern European heritage, it ‘came too late to rescue her from being maligned relative to the dominant racial privilege associated with ART’ (Davis, 2009, p. 109). It is significant that race is not discussed in the news coverage of the Cline spectacle. Neither Cline nor the women whom he treated as his patients are described as ‘White’. The Cline secret children have been at the centre of the spectacle and also witnessed it from a distance. Spectatorship also initially drew in some of half-siblings who were living in the Indianapolis area. They began asking questions of their parents and then seeking DNA testing after seeing or reading the news reports about Cline on TV or the web. One woman made the connection when some of the secret children made an appearance on the national talk show, ‘Dr Phil’. In addition to the roles played by the reproductive technology of donor insemination and the re(tro)productive technology of genetic testing, other forms of media technologies were critical here, too.

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Disruptions of Reproduction and Kinship It was an awareness of a rupture in kinship and a desire to address it that led some of the adult children to search for others conceived from the same donor – their biogenetic half-siblings. Even before they took their 23andMe DNA tests, a few of them had submitted personal profiles on the Donor Sibling Register. This led eventually to the discovery of the deceptive actions of Donald Cline and to additional disruptions echoing and reverberating most immediately in the lives and relationships of the secret children and more distantly to the rest of us who caught sight of it as spectators. Thus, I suggest it might be productive to think with a concept of disrupted reproduction and kinship. Some examples of reproductive disruption include infertility, pregnancy loss, adoption and childhood disability. In addition, Marcia Inhorn (2007) suggests a more broadly conceived understanding of disrupted reproduction as deviations from what is socially and culturally understood at a particular historical moment to be a ‘normal’ course of reproduction and who is taken for granted to ‘naturally’ constitute the members of one’s own family. Anthropologists of reproduction have produced ethnographic accounts detailing the considerable social and cultural efforts that users put toward navigating and repairing these ruptures. Such efforts also include the secrets and lies concealing these ruptures. Cline’s actions are not the same as the actions and decisions of the couples who sought his help and then did not later disclose this knowledge themselves to their children. However, Cline’s deceptions were undetected and successfully unknown for so long because they operated under cover of secrets and lies that families may keep and tell themselves. Aditya Bharadwaj (2003) noted the importance and even necessity of secrecy for married couples in India, who pursued fertility treatment and in particular donor insemination in preference over adoption. ‘Absence of offspring in a marriage… becomes more visible than their presence’, he explains. ‘Any measures to restore the “visuality” of fertility must traverse socially defined and approved routes bound by the sacrament of marriage’ (1870). The rupture of infertility is addressed by the use of reproductive technologies that enable a previously childless couple to have children, thus restoring the invisibility of fertility and the normalcy of their marriage. However, the particular use of donor insemination or of donor sperm in IVF induces additional ruptures, which become held together with secrecy. Bharadwaj describes fertility doctors advising their patients, ‘Don’t tell the family’, and maintaining a taboo on speech concerning both the use of assisted conception and of donor sperm especially. In the podcast series, Sick, which traced the Cline saga, the US mothers of secret children described their own concerns with concealment in connection with their difficulties with becoming pregnant, whether it had been diagnosed as ‘their’ problem of (female) infertility and especially when it concerned their husbands (Bavis & Harper, 2019). Looking back from 2019 at their experiences in the 1980s, they described more stigma and less awareness surrounding infertility and its treatment. In episode one of the podcast, one of the mothers, Liz White, recalls the silent devastation of learning about her husband’s infertility: ‘And I said, I’m

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really sorry for you… sad for you. And then we really didn’t talk about it after that’. White confided in no one and went unaccompanied, even by her husband, to her appointments with Cline. Addressing male infertility, as medical sociologist Liberty Barnes (2014) has noted, in fact requires treating female bodies and making women (not men) the patients. White underwent a number of cycles before she became pregnant. ‘I kept the privacy of having my periods start and the sadness really more to myself. I really carried that’, White remembers in her interview, describing also her feeling the need to protect her husband. ‘I didn’t want him to feel any worse than he felt. So the disappointment I felt I hid from him. He knew I was going. But it wasn’t like a conversation where, oh I’m sorry you had your period again. I did it alone’. In episode 7, another of the mothers, Dianna Kiesler, recalls receiving the news from her daughter, Julie, who had seen the media reports about Cline and then got DNA testing. Kiesler, however, had been one of Cline’s patients who was supposed to have conceived with her husband’s sperm, so the news was an especial shock to their family: [Julie] called me at work one day, and she’s crying. And I said honey, what’s wrong? And she said, ‘Mom, I’m not dad’s child.’ And she says, ‘I’m Dr. Cline’s.’ Well that just … we both broke out crying. It was all I could do to just even think that day. Because all I kept thinking about was what he did to me. I was just numb. Well then I’m thinking, oh god how am I going to tell my husband this? After Kiesler broke the news to her husband, she said, ‘Well, he sat there for a moment and then he started crying. And he said to me that “This has taken everything away from me”’. Since then, Kiesler told the interviewers: ‘I’ve tried to be strong for my husband and I try not to say a lot here at home and I keep it inside me’. In the aftermath of the discovery of Cline’s deceptive action, Kiesler now is forced to keep secret her own troubled feelings and emotional turmoil. Secrecy also poses a number of other anxieties about the future of these children who have been so effortfully conceived. The existence of secret half-siblings presents the threat of rupture, notably the risk of their meeting and unwittingly becoming entangled in intimate relationships. It is a point that one of the secret children, Todd Foster, a biological anthropologist, makes in episode seven of the Sick podcast (Bavis & Harper, 2019). This is a particular reason that becomes cited in the United States for the regulation and oversight of sperm donation. Embedded in parents’ experiences of disrupted reproduction, then, are their anxieties about the future disruptions of reproduction and kinship for their children. For example, the concerns of parents on behalf of their children have guided the disclosure and non-disclosure of information about parentage in modern legal adoption – which in turn have been a model for the policies and

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practices concerning sperm donation. In the United States, there has been a move from ‘closed’ to ‘open’ adoptions, indicating some preference for disclosure. However, this is not a preference that is universally shared, and there remain significant reasons why privacy and secrecy might be deemed necessary, particularly for the biogenetic parents (as in the case of mothers/women in abusive relationships). The claim that non-disclosure serves the best interests of children is well disputed by now. Notably, it is recognised that non-disclosure more clearly or at least more immediately serves the interests of the parents, whether adoptive or biogenetic. The interest of children in having access to family medical histories – indeed, their right to it – is regarded now as an argument compelling enough to allow the disclosure of some information to those children when they reach legal adulthood at the age of 18. This may or may not include the identities of the biogenetic parents, which might remain private. The focus in anthropological studies of disrupted reproduction has been on the parents, and it seems important and necessary to understand also how the ruptures might also be experienced later by their children – that is, how might these reproductive disruptions continue to reproduce and disrupt? A range of questions have been raised about the physical health and psychological well-being of donor-conceived children, which point to the importance and necessity of longitudinal and lifecourse perspectives on reproductive technologies (discussed in the following). However, studies like that of Elena Ilioi, Blake, Jadva, Roman, and Golombok (2017) suggest ‘the earlier that disclosure takes place, the more positive the outcomes for children and their parents’ (323). The disruption of reproduction and kinship is a lens through which we might view the establishment of organisations like the Donor Sibling Registry, which has the otherwise stated mission of connecting biogenetic siblings with each other and with their biogenetic parents and the significance of commercial DNA testing.

A Re(tro)productive Technology According to a 2019 report in MIT Technology Review, more than 26 million DNA testing kits have been sold by commercial services such as 23andMe and AncestryDNA. Individuals may use these tests for a range of reasons, but the services themselves appeal to users, in their branding, advertising and marketing, primarily in one of two ways. Services like AncestryDNA appeal to genealogy enthusiasts interested in learning more about their family histories or connecting with relatives from other branches of their family trees. For Black Americans, genetic genealogy holds out the hope of filling in the gaps of written records, which did not necessarily include the names of their enslaved ancestors (Ah´eb´ee, 2021). Among other Americans who are at least a few generations removed from immigration, there is an interest in discovering one’s ethnic heritage, perhaps confirming family stories about when and from where one’s forebears might have arrived.2 Other services, notably 23andMe, promise a personal genomic health profile alongside information on one’s ancestry and ‘traits’ like baldness, cheek dimples and freckles.

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The popularity of commercial DNA testing has prompted questions and cautions for a number of reasons. First, AncestryDNA and 23andMe are privately held, for-profit businesses. Their value is dependent on the numbers of individuals who submit their genetic samples to become compared and incorporated into the companies’ proprietary databases. (Moreover, individuals even pay for their own submissions.) Thus, the concerns have been raised about ownership and privacy. One company, FamilyTreeDNA, had allowed the U.S. Federal Bureau of Investigation to access its database without the knowledge of the individuals who had submitted their DNA to the service. Second, while these direct-to-consumer tests are promoted as tools to inform health care, similar to other types of genetic screening, many scientists have sounded cautions about their limitations and referred to them as ‘recreational genetics’ (Bandelt, Yao, Richards, & Salas, 2008). 23andMe has come under particular criticism for the delivery of potentially sensitive medical information – like the results of genetic testing for cancer risks – without adequate counselling and support. For some of the diseases for which 23andMe tests, such as Alzheimer’s Disease and Parkinson’s Disease, there are few therapies of varying efficacy. For women whose results show the presence of the BRCA genes, and therefore the increased risk of breast and ovarian cancer, the recommendation may include the removal of breasts and ovaries even before any sign of the presence of cancer. Indeed, the almost playful representation of these services in their advertising and marketing appear to have contributed directly to the distress and shock of users who had not grasped the potential gravity of the information they might receive. ‘It seemed like a game – like those personality tests people often take online’, recalls Dani Shapiro (2019), the author of a memoir describing her experience of discovering, at the age of 54, that the man who had raised her was not her biogenetic father. Stories like those of Shapiro and the Cline secret children and others that now regularly appear in media reports serve as spectacular reminders that relatives may be surprising for unanticipated and unwelcome reasons, which nevertheless also speak to the enduring ideologies and idealisations that surround family. For the Cline half-siblings, services like 23andMe initially represented re(tro)productive technologies that promised to build kinship and family. One of the secret children, Jacoba Ballard, had learned when she was 10 years old that she had been donor-conceived, and although she had an older half-brother from her mother’s previous marriage, she had wished for other siblings. The playfulness with which commercial services in the United States and elsewhere in the Global North promote themselves – and primarily White and middle class consumers approach them – stands in marked contrast to the historical context in which genetic genealogical testing first became developed and then applied as human rights intervention in the Global South. Lindsey Smith (2016, 2017) describes how the technologies originated in Argentina as part of the reckoning with the country’s ‘dirty war’ (1976–1984) during which 30,000 people, primarily young activists and critics of the government, were kidnapped and killed. The mothers of the ‘disappeared’ themselves formed an activist movement that uncovered the trafficking of the infants and young children of their missing

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children – their grandchildren – who had been abducted or born in captivity then adopted into the homes of government officials. DNA testing both established grandparental relationships between individuals and led to the prosecution of the officials who took in the children, becoming the means of what Smith (2016) calls the ‘re(con)constitution’ of kinship and nation. Similarly, Laura Foster (2016) discusses both the scientific and popular interest in genetic genealogy testing in post-apartheid South Africa as a consciously anti-racist tool for building a sense of belonging to and in the nation. Both scholars are critical of the commercial and criminological interests now shaping DNA testing in the Global North, which Smith (2017) characterises as a shift from solidarity to security. The discovery of DNA (or more particularly its double helix structure) and the relatively rapid development of technologies both to analyse it and apply this knowledge – for example, the identification of specific mutations associated with certain types of cancers – have prompted anthropologists to reflect on how persons today might conceive of themselves as genetic individuals and what effects their concept of DNA personhood might have in their experiences of everyday life (cf., Finkler, 2000; Konrad, 2003). In sociocultural anthropology, a vast literature has addressed the importance and meaning ascribed to biology in defining peoples and persons. Concerning peoples, the work of early physical anthropologists was directed toward the identification of traits that marked distinct biological races – a project and notion that have since been discredited and disproved by the work of subsequent biological anthropologists. Yet, genetic genealogy tests still make claims about ancestry and represent ethnic identities, conflated with nationalities, as visible in the genome and quantifiable as a percentage in one’s DNA make-up. Concerning persons, in Systems of Consanguinity and Affinity, now considered a founding text of the anthropological study of kinship, Lewis Henry Morgan gave attention to relationships established by ‘blood’ as a metaphor of biology and by the social arrangements of marriage. Bronislaw Malinowski noted the importance of the socially recognised father or pater, which might be distinguished from the biological father or genitor.3 Not only for Malinowski but also for the scholars and researchers who followed, the distinction between pater and genitor represented a necessary cultural tool given that biological paternity could not be established with certainty. The typing of blood became a means of testing for paternity in the early twentieth century, with the development of other serological and then DNA testing. With the availability of genetic genealogy testing, there are widespread reports of the death of family secrets, which may or may not be greatly exaggerated.4 Indeed, secrecy has been an important topic in anthropology that is worth further exploration specifically in connection with reproduction and kinship. When information is known to be unknown, particularly when its state of being known and unknown is regulated institutionally, we typically call it privacy – so, for example, the identities of biogenetic parents have been kept private from the individuals who had been adopted as infants or young children and those who have been raised with the knowledge that they were conceived with (anonymous) donor gametes. In other cases, however, individuals only come to understand that what previously had been known to them was false or at least partially untrue (a

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lie) and that other information had been kept hidden unknown to them (a secret) by others to whom they are connected intimately. This may include individuals who had no knowledge of having been adopted, conceived with donor gametes, or conceived under other social circumstances that proscribed or prevented their being recognised, accepted and raised by their biogenetic parents.

History and Lifecourse The final point I will make here concerns the importance and necessity of approaches to the social and cultural study of reproductive technologies that take into account the historical contexts in which the technologies become developed and used, and the social and temporal situatedness of individuals and their encounters with them. Particularly because technology is associated with progress and innovation, the technologies of the past are described in terms of not only the obsolescence of devices, instruments and machines, their materials, and/or their functions and operations but also of the attitudes, behaviours, wants and needs that guided their uses. People did not know or think any better ‘back then’, the story goes, but they do now. Thus, Donald Cline’s defenders claim that his actions in the 1970s and 1980s were acceptable at the time. Not only is this specific claim disputable – and it is worth noting that Cline remained in practice until the 2000s – but it also points to an even more troubling history. What Liz White today describes as rape indeed would have been recognised in the United States as a violation of a woman in the 1980s and in the decades before then. Kara Swanson (2012) describes a 1909 account in medical world from a Minnesota doctor who claimed to have witnessed the performance of artificial insemination while a medical student in Philadelphia in 1884. The readers who wrote letters in response to it expressed their revulsion and denounced the actions of the medical professor. In particular, Swanson notes: ‘The details given portrayed artificial insemination by donor in a particularly unattractive light, as the author described the insemination of the wife while chloroformed, without prior discussion with her or her husband. The donor was one of the students present at the examination. The husband was supposedly later told, but at his request, the wife was left ignorant of the procedure’ (604). So, on the one hand, actions like those of Cline are not merely aberrations and abuses, but consistent with the historical development of donor insemination. On the other hand, none of them has been considered acceptable or right. Because the ideas and practices of the past have direct bearing on those of the present, we must stay attuned to these histories. Donald Cline’s actions, like those of the medical professor a century before him, were made possible within the particular conditions at the time. In the 1980s, these included an assumption of both the importance and necessity of maintaining secrecy around fertility treatments. Secrecy itself had been understood to be the responsibility of individuals not to tell. Today, the development, availability and accessibility of DNA testing appears to have subverted the keeping of secrets. Indeed, this had been the aim of forensic genetic technologies as they were first developed and applied in the

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aftermath of Argentina’s dirty war and in the context of the reckoning of truth and of kin. However, there are also likely other currently unanticipated consequences that we will face ahead of us. In Argentina, for example, Smith (2016) notes that as of April 2016, only 119 individuals have been identified of the 500 disappeared grandchildren or Nietos. ‘Based on interview data, the prosecution of the individuals that raised these Nietos is the most challenging part of the process of recovery, as many, but not all, feel profound love and care for the people that raised them’ (Smith, 2016, p. 1049). Alongside this broadly more historical longitudinal perspective, the social and cultural study of reproductive technologies also must include the perspectives of multiple actors and account both for their intersections and interactions and for the shifting of actors’ interests and interpretations over the lifecourse. The rewriting of the reproductive life histories of Liz White, Dianna Kiesler and the other mothers from memories of hope and happiness to narratives of harm and hurt is one especially painful example. Another is the secret children’s questioning of what had been the certainties and facts of their lives. Heather Woock, one of the secret children, had not even been aware that her parents had pursued fertility treatment. It made all the more shocking the results she received from a 23&Me DNA test, which her husband had given her as a Christmas gift. For a time, the new knowledge caused a rupture, as Woock recounts in episode six of the podcast, Sick: ‘Right after finding out, I was completely furious with my parents. We were super close and had a really great relationship. To know that that entire time they’d been lying to me was just something that I still have a hard time wrapping my head around. I just don’t understand. It makes it feel like that close, honest relationship wasn’t real’ (Bavis & Harper, 2019). She describes an ensuing identity crisis: ‘I went to work without makeup or without my hair done for probably at least a week. I couldn’t look in the mirror and think about where did my eyes come from? Where did my hair colour come from?’ (Bavis & Harper, 2019). Matt White, Liz White’s son and one of the Cline half-siblings, had known that he was donor-conceived, but had not been particularly curious about the donor. He also felt particular distress learning that he was born from a wrong done to his mother, as he describes in an interview in episode two of the Sick podcast: ‘for the sheer fact that a part of me is from an individual who took advantage of women. He was playing God. You know, you kind of think did he get into this profession to basically violate women and get off on it? So that messes with you. Am I who I am sometimes because of him?’ (Bavis & Harper, 2019). The questions about resemblance were not limited only to physical traits but also to other fears and worries, including problems with infertility, which both Woock and Matt White experienced as adults. For White, in particular, it is like the father who raised him and unlike the biogenetic father, Cline. White himself became the father of two children who were conceived with donor sperm and in vitro fertilisation. As Katharine Dow and Victoria Boydell emphasise in their introduction to this volume, ‘Reproduction is the result of series of ongoing decisions, made individually and collaboratively, with more or less agency and with different levels of support’ (Dow & Boydell, 2022, p. 3). Following Rene Almeling, they suggest a

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comparative lifecourse approach to the study of reproductive technologies. Notably, in the use of DNA ancestry testing and the disclosure of information about biogenetic parentage, the wants, needs and values of individuals positioned as children may differ from those of individuals positioned as parents. In addition, the interests of individuals and their abilities to act on them change over the lifecourse from childhood to adulthood. Further, the priorities of individuals in their position as children may shift – or because adults remain the children of other adults even while they become parents themselves of other children, their priorities may be held in tension. As the children conceived with donor gametes themselves become adults, notions about the ‘protection’ of children give way to those of the ‘rights’ of children, particularly as they become adults who in turn seek to become parents themselves. The shifting of attitudes that surround the weighing of privacy and secrecy for gamete donors and recipients against disclosure and truth for offspring requires not only an understanding of history but also of lifecourse. There are impacts on what becomes imaginable and permissible in the uses of reproductive technologies. For example, assessing the bases on which several of the Cline half-siblings have filed civil lawsuits, bioethicist Bonnie Steinbock (2019) takes issue with their claim that the doctor had wronged them. Citing what philosophers call the ‘non-identity problem’, Steinbock claims that without Cline’s actions, the children either would not have existed or, if other third-party sperm had been used, they would have been different people. She concludes: ‘Cline’s behaviour was immoral, unethical, and blameworthy, but not a violation of the children’s rights. If there are to be any medical malpractice suits against Cline, these should be limited to the parents, not the children’. (https://www. thehastingscenter.org/whats-wrong-with-a-fertility-doctor-using-his-own-sperm/). The shortcomings and failures of this legal and philosophical framework result from the assumed stasis of who are parents, adults and children and points to the importance and necessity of approaching these relationships as temporally and relationally dynamic.

Conclusion The aim of this chapter has been to outline key ideas and approaches to the social and cultural study of reproductive technologies, drawing from the instance of Donald Cline and his ‘secret children’ to illustrate these points. First, I presented a concept of spectacle – and of spectacular reproduction in particular – to describe how our indirect and mediated encounters with reproductive technologies in turn influence our ordinary reproductive experiences. Second, I considered the significance of disrupted reproduction and kinship and the importance and necessity of secrets and lies both to conceal and to repair these ruptures. Third, I suggested an analysis of genetical genealogy testing as a re(tro)productive technology that promises to recreate kin and family connections – and demands historical awareness and wariness of the interests they do and do not serve.

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In sum, this discussion of an instance of spectacular reproduction and of genetic genealogy tests is instructive for scholars and researchers in the social and cultural study of reproduction because it illustrates the active negotiation of the layered interests of multiple parties – who are bound together in the social relations of reproduction and kinship – over time.

Notes 1. Ren´ee Ann Cramer (2016), in her recent study of celebrity pregnancies, makes similar claims about celebrities as individual persons who come to represent of ‘a culture’s founding ideologies and contemporary priorities’ (14). Or here, we might describe celebrities as spectacular individuals. 2. White Americans in particular talk about themselves as people with ‘mixed’ ancestry, describing the different European nationalities (Irish, Italian, German) apparently represented in their lineages. Black Americans may be interested in finding their African roots, but they are as likely to share (quite literally) European relatives. 3. In another chapter in this volume, Sonja Mackenzie discusses the legal re-definition of father in the United Kingdom (‘person who is treated as a parent of the child’) intended to recognise a broader range of family forms. 4. For a number of years, it had been claimed that there was a 10% rate of ‘false’ paternity. However, evolutionary anthropologist Kermyt Anderson, in a 2006 study, suggests that the rate could be as low as 1.7%.

References Ah´eb´ee, S. (2021). For African Americans, DNA tests offer some answers beyond the ‘wall of slavery’. WHYY, May 21. Retrieved from https://whyy.org/segments/ tracing-your-ancestry-through-dna/ Anderson, K. G. (2006). How well does paternity confidence match actual paternity? Evidence from worldwide nonpaternity rates. Current Anthropology, 47(3), 513–520. Bandelt, H. J., Yao, Y. G., Richards, M. B., & Salas, A. (2008). The brave new era of human genetic testing. BioEssays, 30(11–12), 1246–1251. Barnes, L. W. (2014). Conceiving masculinity: Male infertility, medicine, and identity. Philadelphia, PA: Temple University Press. Bavis, L., & Harper, J. (2019). Sick [podcast series]. Retrieved from https://sickpodcast. org/. Accessed on January 18, 2021. Beeman, W. O. (1993). The anthropology of theater and spectacle. Annual Review of Anthropology, 22, 369–393. Bharadwaj, A. (2003). Why adoption is not an option in India: The visibility of infertility, the secrecy of donor insemination, and other cultural complexities. Social Science & Medicine, 56, 1867–1880. Bird, S. E. (2010). The anthropology of news & journalism: Global perspectives. Bloomington, IN: Indiana University Press. Cohen, S. (2018). An Indiana fertility doctor kept a devastating secret. Decades later, the children of his victims form a special bond. Chicago Tribune, February 25,

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2018. Retrieved from https://www.chicagotribune.com/nation-world/ct-indianafertility-doctor-insemination-20180225-story.html Cramer, R. A. (2016). Pregnant with the stars: Watching and wanting the celebrity baby bump. Stanford, CA: Stanford University Press. Davis, D. A. (2009). The politics of reproduction: The troubling case of Nadya Suleman and assisted reproductive technology. Transforming Anthropology, 17(2), 105–116. Dow, K. (2016). Making a good life: An ethnography of nature, ethics, and reproduction. Princeton, NJ: Princeton University Press. Dow, K., & Boydell, V., (2022). Introduction: Technologies of reproduction across the lifecourse. In V. Boydell & K. Dow (Eds.), Technologies of reproduction across the lifecourse (pp. 1–19). Bingley: Emerald. Finkler, K. (2000). Experiencing the new genetics: Family and kinship on the medical frontier. Philadelphia, PA: University of Pennsylvania Press. Foster, L. A. (2016). A postapartheid genome: Genetic ancestry testing and belonging in South Africa. Science, Technology & Human Values, 41(6), 1015–1036. Guy, D. (1967/2002). The society of the spectacle. Canberra: Hobgoblin Press. Han, S. (2014). Pregnancy in practice: Expectation and experience in the contemporary United States. New York, NY: Berghahn Books. Han, S. (2018). Pregnant with ideas: Concepts of the fetus in the twenty-first-century United States. In S. Han, T. K. Betsinger, & A. B. Scott (Eds.), The anthropology of the fetus: Biology, culture, and society (pp. 59–80). New York, NY: Berghahn Books. Ilioi, E., Blake, L., Jadva, V., Roman, G., & Golombok, S. (2017). The role of age of disclosure of biological origins in the psychological wellbeing of adolescents conceived by reproductive donation: A longitudinal study from age 1 to age 14. Journal of Child Psychology and Psychiatry, 58(3), 315–324. Inhorn, M. C. (2007). Reproductive disruptions: Gender, technology, and biopolitics in the new millennium. New York, NY: Berghahn Books. Konrad, M. (2003). From secrets of life to the life of secrets: Tracing genetic knowledge as genealogical ethics in biomedical Britain. The Journal of the Royal Anthropological Institute, 9, 339–358. Shapiro, D. (2019). How a DNA testing kit revealed a family secret hidden for 54 years. Time, January 3, 2019. Retrieved from https://time.com/5492642/dna-testresults-family-secret-biological-father/. Accessed on January 18, 2021. Smith, L. (2016). Identifying democracy: Citizenship, DNA, and identity in postdictatorship Argentina. Science, Technology & Human Values, 41(6), 1037–1062. Smith, L. (2017). The missing, the martyred and the disappeared: Global networks, technical intensification and the end of human rights genetics. Social Studies of Science, 47(3), 398–416. Steinbock, B. (2019). What’s wrong with a fertility doctor using his own sperm? Retrieved from https://www.thehastingscenter.org/whats-wrong-with-a-fertilitydoctor-using-his-own-sperm/. Accessed on January 18, 2021. Swanson, K. (2012). Adultery by doctor: Artificial insemination, 1890–1945. Chicago Kent Law Review, 87(2), 591–633. U.S. Centers for Disease Control and Prevention. (2021). State-specific assisted reproductive technology surveillance. Retrieved from https://www.cdc.gov/art/ state-specific-surveillance/index.html. Accessed on May 30, 2022.

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Zaveri, M. (2018). A fertility doctor used his sperm on unwitting women. Their children want answers. The New York Times, August 30, 2018. Retrieved from https://www.nytimes.com/2018/08/30/us/fertility-doctor-pregnant-women.html. Accessed on January 18, 2021. Zhang, S. (2019a). The fertility doctor’s secret. The Atlantic, April 2019. Retrieved from https://www.theatlantic.com/magazine/archive/2019/04/fertility-doctordonald-cline-secret-children/583249/. Accessed on January 18, 2021. Zhang, S. (2019b). A decades-old doctor’s secret leads to new fertility-fraud law. The Atlantic, May 7, 2019. Retrieved from https://www.theatlantic.com/science/archive/ 2019/05/cline-fertility-fraud-law/588877/. Accessed on January 18, 2021.

Chapter 8

Getting the Timing Right: Fertility Apps and the Temporalities of Trying to Conceive Josie Hamper

Abstract Fertility apps are digital tools for recording menstruation and bodily signs of fertility, with the aim of predicting future ovulation dates. For women trying to conceive, these predictions can be used to time heterosexual intercourse or insemination close to ovulation and thus increase chances of conception. This chapter explores women’s use of fertility-tracking apps and the consequences of this for their experiences of trying to conceive in heterosexual relationships. I draw on findings from a thematic analysis of app content and interviews with women in the United Kingdom who had used apps to help them conceive, to show how these apps are often present in the in-between or transitional times and spaces of reproductive life. Apps are used to increase chances of pregnancy, but they are also used to navigate the many uncertainties of trying to conceive. Through a critical engagement with notions of control, anticipation and awareness, I explore how apps shape and are shaped by an increasingly demanding social and cultural context of reproduction. Keywords: Fertility apps; conception; self-tracking; data; ovulation prediction; anticipation

Reproduction in an Age of Apps Fertility app Kindara’s 2017 catchphrase ‘Your body is telling you a story!’ implies a ‘story’ that is intrinsic to the body and waiting to be discovered through the app’s prescribed methods of observation. This story is narrated according to a very particular way of ordering, mapping and thinking about the body that relies on the idea that transforming bodily signs into quantifiable data and patterns will reveal new and better insights into interior bodily processes (Lupton, 2014; Smith & Vonthethoff, 2016). While the self-monitoring techniques of fertility apps are Technologies of Reproduction Across the Lifecourse, 149–162 Copyright © 2022 Josie Hamper Published under exclusive licence by Emerald Publishing Limited doi:10.1108/978-1-80071-733-620221013

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grounded in a long history of established women’s health and fertility awareness movements (DeNora, 1996), and are thus not in themselves ‘new’, apps offer a material transformation of these techniques that creates new possibilities for – and relationships to – bodies, time, technologies, data and reproductive health advice. Through people’s use of apps, personal information and data are drawn into a global digital data economy with significant personal, social, economic and political consequences (Andrejevic, Hearn, & Kennedy, 2015). As Lupton (2015) has noted, akin to how ova have been separated from the body and entered a bio-economy of reproductive bodily material, data about fertility and reproductive bodies have also been transformed into commodities of bio-value. This is a highly gendered bio-economy, where women in particular are compelled to collect and voluntarily ‘share’ their personal and bodily data, and thereby undertake new forms of labour through their interactions with these technologies (Foster, 2012). In the case of fertility apps, women may feel obliged to monitor their fertility in order to learn about their bodies and increase their chances of conception. These individualised forms of responsibility for facilitating conception speak to the many other reproductive labours and obligations – or ‘bio-responsibilities’ – that are placed disproportionately on women (Pande & Moll, 2018). Exploring the intersection of bio-citizenship, gender and responsibility reveals both the intimate experiences of acting responsibly and how processes of responsibilisation generate economic value and assist ‘the expansion and normalization of new biomedical technologies’ at a much larger, global scale (Pande & Moll, 2018, p. 24). Insights from feminist science and technology studies foreground the importance of context, history and scale for understanding how technologies evolve with women’s bodies ‘in a specific time, and in a specific place’ (Roy & Subramaniam, 2016, p. 36). In the case of pharmaceutical development, Pollock (2012) has proposed the concept of ‘medicating’ to describe the situated social and biological processes through which ‘bodies and technologies come together in medicine’ (2012, p. 4). Rather than bodies being external to and acted on by processes of medicalisation, the notion of medicating emphasises the ongoing co-production of bodies and medicine. Following this argument, fertility tracking can be conceptualised as a mutually unfolding process of bodies and technologies (including the entangled network of apps, measurements and data). Data are not simply material that are extracted from bodies, but shape, and are shaped by bodies through practices of self-tracking (Lupton, 2018). The rise of health apps has prompted a burgeoning of critical research into the ways that apps reproduce and intensify disciplining and normative assumptions about reproductive bodies, health and data (Doshi, 2018; Fox & Epstein, 2020; Hamper, 2020, 2021; Hamper & Nash, 2021; Johnson, 2014; Thomas & Lupton, 2016). Fertility apps, also known as fertility or ovulation trackers, offer a digital tool for recording bodily signs of fertility that change across the menstrual cycle. The app user is usually invited to input details about menstruation, cervical mucus consistency and basal body temperature, as well as a broad range of other personal details, symptoms, test results and information about heterosexual intercourse or insemination. While there is great variation in the analytical capacities of fertility apps, they generally extrapolate the recorded data to offer

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predictions of future menstruation and ovulation dates. In the context of trying to conceive, these predictions can be used to plan heterosexual intercourse or insemination during the fertile days prior to ovulation. The importance of planning and ‘getting the timing right’ is emphasised in the following quote from the app Fertility Friend: ‘Your most fertile days are the two days before ovulation and the day of ovulation. For most people trying to conceive, getting the timing right relative to ovulation is more important than any other factor that is within their control’.1 This quote appears under the ‘How to Get Pregnant’ tab and illustrates an emphasis on timing and control – and being in control of time – to facilitate conception. Being in control involves understanding the role of ovulation to conception, developing an anticipatory awareness of future ovulation dates and planning everyday lives accordingly. Through practices of fertility tracking with an app, the body and the rhythms of everyday life are brought into contact with rhythms that are encoded in the app’s design, such as the timing of notifications or data input. Practices of fertility tracking attempt, as Sanz (2017) has described albeit in a different context, ‘to bring these very different rhythms into alignment, into synchrony’ (2017, p. 188). Being able to predict ovulation becomes indicative of an alignment – or synchronisation – between the body, app and tracking methods. Fertility apps assert that more regular and accurate data entry holds the promise of improved predictions of future ovulation dates and thus improved chances of pregnancy. Adams, Murphy, and Clarke’s (2009) notion of abduction describes a similar imperative to draw on past experience as a way to orient oneself towards ‘probabilistic anticipations of the future’ (2009, p. 255). An aspect of this, they suggest, is the ‘lived experiencing of “trying to know” what to do in time’ (2009, p. 255), which involves active interventions in the present that are informed by ¨ imagined future scenarios (see Buhler, this volume). The uncertainty of ‘knowing what to do’ given an unknown future is central to the temporal experiences of trying to conceive that I examine in this chapter. These experiences are shaped by modes of prediction that are activated through fertility apps and their associated self-monitoring practices. Notions of improving one’s future chances of pregnancy are tied to a wider culture where women, positioned as potential mothers, are expected to develop a close awareness of their reproductive health, which propels intensive self-surveillance at earlier pre-conception stages (Waggoner, 2015).

Research Background From 2014 to 2017, I conducted research on fertility and pregnancy apps, which involved a thematic textual and visual analysis of app content and marketing materials (Rose, 2016) and 42 in-depth interviews with 24 women in the United Kingdom. Interview participants had used fertility and pregnancy apps to aid conception or to monitor their own pregnancies. Integrating the analysis of

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textual, visual and interview data was an explicit attempt to acknowledge how the function, contents and marketing of apps are inseparable from people’s lived experiences of app use. In this way, the methods and analysis that underpin this chapter speak to the wider collection’s support of methodological relationality in studies of reproduction (see Dow & Boydell, this volume, p. 11). Interview participants were recruited through flyers and online advertisements or in-person at parent groups in east and north London. Interviews took place around participants’ other commitments and in locations that were convenient to them. This was particularly important given that many of the women had very young babies at the time of interviews and preferred to make flexible arrangements. The interviews covered an extended timeline, including pre-conception, conception, pregnancy and early parenting. Many participants described difficult experiences during this time, including infertility, health concerns, pregnancy loss and complex birth situations. It was important not to silence women’s narrations of these more difficult aspects of reproductive life, but care was taken throughout the interview encounters to ensure that participants felt comfortable in talking about potentially sensitive experiences. Inviting women to take part in two interviews on separate occasions was an attempt to understand how lives are felt to move forward or stagnate (Grinyer & Thomas, 2012), and how hopes for and visions of reproductive futures change accordingly. In this chapter, I focus on the findings from interviews with 16 women who used fertility apps to help them conceive, but I also draw on conversations with other participants about their decisions to abandon apps. Apart from one participant who was in her forties, the women in this sub-group of participants were all in their thirties at the time of the interview. The interest and motivation that participants showed in learning about fertility and engaging with apps, including their decisions to stop using apps if they were not deemed useful, start to reveal the privileged positions of research participants. All the women interviewed were in relationships with men, and the majority were white, broadly middle-class and educated. Issues of class, race, sexuality and age are never far from the surface when it comes to fertility app use, where normative images of ‘good’ and ‘bad’ femininity, reproduction and motherhood are reproduced and locate individual app users as closer to or different from idealised – but highly exclusionary – images of healthy female subjects (Doshi, 2018; Sanders, 2016). These ideals are deeply racialised and connected to the cultural positioning of socially disadvantaged women as ‘bad’ mothers and their potential infertility as less deserving of assistance or resources (Bell, 2009). As I have mentioned, women who monitor their fertility signs ‘well’ by observing and recording accurate and continuous data are rewarded through apps by potentially being offered more accurate advice and predictions of fertile days. But extending from this, women who are invested in fertility monitoring are also rewarded for engaging with particularly middle-class ideals of pregnancy planning, reproductive choice and motherhood (Han, 2013; Lowe, 2016). Fertility apps cannot be separated from a wider culture that places different value on women’s reproductive hopes and futures.

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In turning to the empirical material, I firstly explore fertility apps in relation to women’s experiences of actively trying to conceive. I then focus on two significant ‘times’ during which apps and associated self-tracking took on particular significance for participants as they described shifts in their reproductive intentions or plans. The first of these is the transition from preventing pregnancy through contraception to trying to conceive, where I explore how apps were adopted in response to a feeling of time pressure. Secondly, I explore how apps worked as a precursor to fertility treatment for participants who experienced difficulties conceiving. These cases attend to distinct temporal orientations of fertility tracking after contraception and before fertility treatment. This chapter therefore speaks to the broader themes of the edited collection through an emphasis on how women’s fertility tracking with an app intersected with other reproductive technologies along an extended temporal scale that connects the past, present and future.

The Temporalities of Actively Trying to Conceive The decision to start ‘actively’ trying to conceive was presented as a particular time of apprehensive excitement for many of the women interviewed. During this time, their hopes, visions and plans for children felt achievable in the foreseeable future but certainly not guaranteed. While women often talked about initially taking a casual approach to trying to conceive, they also described a sense of needing to use their time efficiently and not ‘waste’ time given the biological pressures of increasing age. Narratives of control and the disciplinary temporal regimes of self-monitoring that these provoke are tied to wider discourses of rationality and individual responsibility (Lupton, 2014), which prompt increasingly intensive efforts to conceive as time passes (Wilkinson, 2020). As Throsby (2006) has shown in her research with women undergoing IVF that failed, actively trying to conceive becomes evidence of the active desire for a child and thus ‘trying’ takes on moral value. Apps were frequently normalised by participants as offering an unobtrusive and convenient tool for tracking their fertility, yet their engagement with apps also demonstrated their material effort, responsibility and a moral imperative to improve conception chances on behalf of the couple (Hamper, 2021). The case of fertility tracking with an app demonstrates how women’s reproductive labours are both extended and intensified through their use of new technologies (Foster, 2012; Pande & Moll, 2018). While some participants were unsure of how accurate their app’s predictions of fertile days were, these predictions generally constituted a significant influence on their planning of sexual intercourse for conception. As I have detailed elsewhere (Hamper, 2020), participants often talked about their fertility apps as different from other forms of manual ovulation monitoring with a pen and paper due to the apps’ particular ability to instruct, advise or ‘tell’ them what (or what not) to do at particular moments in time. As summarised by Jen: ‘I mean it’s not like it [the app] dictated when we had sex, but it did to a certain extent. You’re more likely to then if you’re trying to have a baby’.2 Almost all of the participants stated that

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they would not have engaged in fertility tracking without an app, indicating that apps potentially introduce established methods of ovulation monitoring to a wider population (Gambier-Ross, McLernon, & Morgan, 2018). Others were critical of the power of fertility apps to become overly prescriptive. Ashley had been trying to conceive for about two and a half years when she became pregnant through IVF. Her fertility tracking had fluctuated in intensity. It had included some periods of time where she monitored daily basal body temperature measurements and others where she had undertaken a more basic tracking of menstruation dates. Sometimes, she said that trying to conceive ‘took over my whole life’ and she reflected on her use of fertility apps at these times: I think the thing is, they [the apps] fit into your life at times when you are, I’m sure not everybody, but [when] people probably tend towards the obsessive and crazy, either because you’re sleep deprived or because you’re totally focused on trying to get pregnant or whatever. The notion of being proactive and excited but not allowing attempts to conceive to become all-consuming demonstrates the multiple levels of self-control that women are expected to engage with. Mia explained how apps could introduce a rigid temporal frame to conception efforts that was undesirable. The calendar referred to in the following quote is the app’s calendar of predicted ovulation dates: You know you can share it with your partner, your calendar, if you want to sync it up with him. But you know, that’s very… timing, you know, it’s all about timing. It’s just not really like… I’m not really a military operation like that. Mia explained that she eventually decided to abandon her app: ‘I kind of thought; you know, actually I’m not going to use it, I’m going to go with the flow, not worry about things and kind of listen to my body a bit more’. An opposition arises in Mia’s account between ‘going with the flow’ and following the app’s tracking regimen, where the former approach to conception prioritises intuition and self-knowledge. She also highlighted how using an app to help her conceive, and indeed reproduction as a whole, is relational (see Hudson and Law, this volume). The ‘timing’ that she referred to did not only pertain to the management of her own time, but also that of her partner, who needed to participate in intercourse at the right times (Hamper, 2021). A perceived incompatibility between the routinised timings of fertility tracking and the lived temporalities of sexual enjoyment and spontaneity was emphasised by Maria, who had used the same fertility app prior to two pregnancies. She conceived both times after about three months of monitoring. When asked if she had any initial reservations about using fertility apps, she responded:

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I’m lucky in that we got pregnant really quickly, but knowing my personality of being a bit in control, of liking to be in control of a situation, I really didn’t want it [trying to conceive] to become a science project. You know, I wanted to enjoy the experience of trying for a baby and not be like ‘well the app says we can’t do it now’. So that was the one thing I was a little bit hesitant about. The instructional or prescriptive tone of apps as well as the imperative to observe, measure and record are reminiscent of a school science project, which involves following a series of set instructions and doing certain acts at certain points in time. While participants acknowledged the importance of timing intercourse relative to ovulation, they also frequently talked about how apps introduced a more formalised temporal frame that contradicted an idealised image of enjoyment in trying to conceive. Maria also indicated another familiar conundrum in participants’ experiences of trying to conceive, which is the explanatory value of control versus luck. Others have noted the role of luck and gambling metaphors in relation to infertility and the negotiation of reproductive risk (Raspberry & Skinner, 2011) and how assigning conceptive success or failure to luck offers some relief from the weight of individual responsibility (Giraud, 2020). Maria located her fertility tracking as part of a broader tendency towards ‘liking to be in control’ but she attributed her quick conception to being lucky, and thus beyond the sphere of influence. Importantly, while she did not accredit her pregnancies to her fertility tracking or her app, when reported to the app, these pregnancies become part of the app’s success rates. Fertility apps often advertise the number of reported pregnancies in their marketing material and Maria’s pregnancies therefore become embroiled in her app’s claims of efficacy and worth.

Contraceptive Histories and Paused Reproductive Time Fertility tracking to conceive is clearly about anticipating future conception, yet participants talked about their adoption of fertility apps as closely tied to their reproductive histories, especially their previous contraceptive use or experiences of menstrual irregularity. Many participants had stopped using contraceptives, including the oral contraceptive pill, contraceptive implant or intrauterine device, specifically because they wanted to start trying to conceive. In these cases, apps were involved in experiencing and making sense of the gradual return of what was referred to as a normal or natural state of menstruation after being on contraception that caused highly regular withdrawal bleeding, heavier or lighter menstruation, or amenorrhea. Regularity is a temporal mode that is frequently associated with the contraceptive pill and thus deeply entwined with a history of menstrual control and medico-social constructs of menstrual cyclicity and normality (Mamo & Fosket, 2009; Martin, 1987; Oudshoorn, 1994). Some apps include a regularity index as a quantified measure of menstrual cycle length.

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Menstrual regularity, as Doshi (2018) has noted, offers a limited representation of fertility, ignoring the reality that for many women, having regular menstruation does not ensure that they can conceive, nor is irregular menstruation indicative of fertility problems. Women often described how contraceptive methods had led to a sense of being out-of-sync, distanced or removed from an embodied sense or experience of menstruation, which prompted attempts to regain a connection to this bodily process. Olivia was in her mid-thirties at the time of our first conversation, and she explained how she had downloaded an app to ‘get a bit of control over my life’. She described the relationships between trying to conceive, giving up the pill, downloading a fertility app and a feeling of time pressure in getting pregnant: The pregnancy thing and the worrying about the pregnancy thing came from the fact that I gave up my pill. So it’s all sort of interlinked really. I started wanting to get in control because I’d given up my pill, but when I’d given up the pill I started to worry that I was no longer able to [get pregnant] because it had taken a few months. I think it was Christmas I gave up the pill and then end of April was when we conceived. So actually, it really wasn’t that long a time but it was long enough for my brain to start scenarioing. Oh my god what if I can’t, you know? For Olivia, giving up the pill and the kinds of regularities that this had produced led to a feeling of losing control, which she attempted to regain through her fertility tracking. The lived experience of pre-empting events in an unknown future often entails emotional registers of anxiety and apprehension (Adams et al., 2009). Worries about an unknown reproductive future, including the risk of infertility, were frequently part of women’s decisions to engage in fertility tracking and reveal how reproductive temporalities are strongly gendered (see Boydell, ¨ Buhler, & Pickard, this volume). Contraceptive history and pre-emptive worries about getting pregnant also came together to shape Emily’s decision to track her fertility. Emily talked about how she previously had a ‘simple’ understanding of her body and had felt ‘out of touch’ with processes like ovulation due to being on the contraceptive pill for 15 years. Using a fertility app in this case was not about seeking precise predictions of future ovulation dates, but it was part of ‘working out’ her menstrual cycle: [I came off the pill] and I just didn’t get a period, and the two other times I’d come off the pill in that 15 years I didn’t have a period either. So I kind of thought I should probably get this checked out because I knew that we would want to have kids in the next couple of years. So they did some tests. I mean I did start to get periods but very, very irregular. And I had to see a gynaecologist who said that I had cysts on my ovaries and that, it was as simple as: ‘it might take you a very long time to conceive so if you want to have children you might want to start sooner rather than later’ […] So

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that’s why I was doing the tracking and stuff, because partly, I was already tracking because my periods weren’t very regular before I even was thinking of having a baby, [and then] to try and work out what was happening with them. Through this chronological account, Emily narrated her contraceptive history, a pattern of irregular menstruation and a medical diagnosis, which came together to form a mode of prediction (‘it might take you a very long time to conceive’) that prompted her to act (‘sooner rather than later’) in order to progress in her plans to have children. Past experiences and bodily knowledge thus form a template for a particular reproductive trajectory and future (Adams et al., 2009). These predictions did not materialise, however, and Emily conceived after a few months of trying, which was much sooner than she had anticipated. In addition to altered or absent menstruation, which are common side effects of many contraceptive methods, pregnancy and breastfeeding were other reasons for amenorrhea that participants reported. The temporary absence of menstruation was often talked about as a pause in reproductive time, where the suspension of menstruation at the scale of the body could extend to the suspension of reproductive plans (Sheller, 2020). Several women described actively watching and waiting for their menstruation and signs of ovulation to return in order to start planning subsequent children. Others described additional pressures of trying to conceive their second child due to increasing age, the desired age gap between children and less frequent sexual intercourse. These added pressures were posited as additional reasons for needing to ‘get the timing right’ as well as ‘make time’ for sexual intimacy. One of the modes of anticipation conceptualised by Adams et al. (2009) involves ‘being ready for’ and ‘poised awaiting the predicted inevitable’, which they argue engenders ‘alertness and vigilance as normative affective states’ (2009, p. 254). Anna described how she returned to her fertility app to record the gradual return of fertility signs after pregnancy and breastfeeding, especially because she was thinking about having a second child: In the holidays I had the first sort of… discharge, which I was very aware of then we were trying. And I was like ‘ooh I wonder if’… you know, because my periods haven’t returned since I had him because I’ve been breastfeeding. I was like ‘I wonder if’ and I put it on the app, just as a kind of, just to see what… yeah, a note to myself. Just to start using the app again I guess, for the first time since. Because we’d talked about, not straight away, but we would like to have another one so it is something I could see myself going back to and using again as a way to keep track. Past records form a digital archive of data that is valuable for women who envision returning to the data or app. Fertility apps and their data can be re-activated after periods of dormancy to mirror the ‘re-activation’ of bodily reproductive processes and the renewed awareness of fertility signs. Participants

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did not usually use their apps continuously, but rather as tools that they would engage with during particularly relevant periods of time and with varying levels of intensity.

Preparing for Fertility Treatment In this final empirical discussion, I focus on the role of apps for two participants who had been trying to conceive for several years prior to fertility treatment. Through these accounts, I explore how apps became imbricated with a whole range of efforts to prepare and manage their bodies for treatment. In particular, I consider how notions of menstrual regularity did or did not materialise through their fertility tracking and the consequences of this for their experiences of trying to conceive. Chloe’s experience of fertility tracking was shaped by two years of trying to conceive prior to 18 months of intermittent treatment with intrauterine insemination. Central to her experience was the fact that her treatment was reliant on her having regular and more frequent periods, which prompted her to track her fertility alongside other attempts, including fertility medication, to regulate her cycle: What happened with us was that we, so we had lots of Clomid treatment on and off, on and off, and then… Oh, they kept putting me back on this other drug to regulate the cycles, so it was kind of, they were like ‘we can’t give you Clomid until you’re getting more regular periods’ so that was what was happening.3 Chloe had engaged in detailed tracking of fertility signs while trying to conceive and paid for an app upgrade to enable further data analysis features, but she did not find the app’s predictive capacity to be particularly helpful due to the irregularity of her menstruation and elusive ovulation. Chloe used the app as a diary where she would record details about menstruation, fertility signs and medication alongside a broad range of notes about diet and health, or as she described: ‘whatever kind of data I happened to have’. Importantly for her, the app offered a tool for coordinating a range of efforts that she was making to encourage more regular menstruation: ‘when we were trying and nothing was happening it became more pressing, you know, trying to regulate your cycle and eat the right foods, things like that, that all became really important’. Chloe therefore used her app towards a specific objective, but she did so in a way that made sense to her as opposed to following the app’s prescribed methods of fertility tracking. Monitoring practices that decontextualise and transform menstrual cycles into ‘objective’ data can allow these to take on new meaning as they are brought into new sites or used specifically towards a particular purpose. Fertility apps are involved in making ovulation intelligible and subject to action, but the historical archive of fertility data also constitutes a particular kind of object. Sophie had conceived her first child through IVF, and in her mid-forties, she was having IVF

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again in the hope of having a second child. Prior to deciding to try to conceive the first time, Sophie was already in the routine of tracking her menstruation in an app, which she had been doing for over five years. She therefore had a substantial historical record of her menstrual cycle, and she presented this record to the fertility consultant during one of her first appointments: As we decided we should have a kid it was actually really interesting to have that back date of information and go, actually, more or less all the things seem to be pretty regular. And actually, for us when we were trying and we couldn’t, and we realised it was unexplained infertility, and that kind of, I suppose helped the doctors in a way to go ‘okay well it’s not as though you’ve got really heavy bleeds or you’re not like dodgy cycle times or anything’. It was just unexplained and therefore [the app was] quite helpful as a tool. For Sophie, her fertility data took on significance as a historical document of her body. The data were presented as evidence of her regular menstrual cycles, which she extended to signify the normality of her body and demonstrate her suitability as a fertility patient. By presenting her smartphone in the consultation room, the digital archive of fertility data was ‘activated’ by Sophie for a particular purpose (Lupton, 2013). Her fertility tracking practices became entangled with the highly technological context of the fertility clinic and participated in constituting Sophie as a ‘good’ patient in this setting (Thompson, 2005). Sophie had returned to the same app in between IVF procedures to track the return of menstruation following a period of lactational amenorrhea. Again, she used the records from her app to demonstrate that her menstrual cycle was ‘back on track’: Other than putting in your first day of your period there’s not much else to do with that tracker for IVF when you’re actually in [treatment]. I think leading up to it, I think it was good when I stopped breastfeeding to go ‘okay, when’s the thing going to happen then’ and actually to know that I got back on track really quite quickly with sort of twenty-six or twenty-eight day cycles. Again, for me to be able to go to the clinic and say it’s unexplained, my hormone levels are generally okay, this is what my body normally does like for the last six months, eight months or so, it’s kind of back on track, here you can see what’s happening. There is a particular value assigned to quantitative data and patterns over women’s own descriptions of their bodies (Lupton, 2014, 2015). Sophie actively navigated the fertility clinic through participating in and inviting the objectification of her menstrual cycle through data and of herself as a potential IVF patient. Her agency in this context ‘requires periods of objectification’ (Thompson, 2005, p. 185, original emphasis) and the fertility data figures centrally in

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Sophie’s active self-making at the site of the clinic. Not only does this reiterate the temporal longevity of fertility data as a valuable biographical archive but it also shows how apps could aid women in traversing different sites and times that pertained to their circumstances.

Reflections on Time The women interviewed never talked about their practices of fertility tracking with an app as an isolated and easily contained activity. Instead, they described how they used their apps alongside a wide range of other technologies. Fertility tracking in the present creates data that, over time, constitutes a digital archive of the body upon which future conceptive opportunities (ovulation) are calculated, predicted and anticipated. Women’s felt imperatives to grasp these opportunities are framed by the possibility that it may take a long time to conceive. The temporalities embedded in this process are dynamic, where fertility app use is intensively focused on the present while also engendering a constant awareness of the past as well as future hopes and risks. Examining the place of fertility apps in women’s everyday lives shows how contemporary practices of digitised fertility tracking can produce new spatial and temporal opportunities for encountering normalised discourses that compel women to be proactive in their efforts to conceive (Throsby, 2006; Wilkinson, 2020). Apps are also compelling for how they seem to offer a convenient tool for navigating periods of life that are characterised by uncertainty and transition: from preventing to facilitating conception; from trying to conceive through intercourse to starting fertility treatment; and from having one child to planning subsequent children. As I have shown, these transitions demand different temporal orientations of fertility tracking. Apps can be relevant after contraception, before or during fertility treatment, but woven through all of these embodied shifts was a sense of dealing with the unknown. This chapter has attended to how women move through their reproductive lives. The lifecourse unfolds through the everyday and is characterised by change, movement, uncertainty, obstacles and ‘failures’ to progress, rather than clearly defined or bounded life stages (Sheller, 2020). The women in this study who had become pregnant often described an element of surprise in how it had taken less time or longer to conceive than they had expected, indicating how reproductive bodies and lives often do not comply with pervasive notions of predictability, planning and control.

Acknowledgements Thank you to all the women who generously gave their time to this study. I would also like to thank Tim Brown and Catherine Nash in the School of Geography at Queen Mary University of London for our many conversations about the research material and their continued support. The research was funded by the UK Economic & Social Research Council, grant number ES/J500124/1.

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Notes 1. This quote also appears on Fertility Friend’s website at: https://www.fertilityfriend.com/Faqs/How-To-Get-Pregnant.html (last accessed 15.01.2021). 2. Pseudonyms are used throughout this chapter. 3. Clomid is an oral medication that stimulates the production of ova and ovulation.

References Adams, V., Murphy, M., & Clarke, A. (2009). Anticipation: Technoscience, life, affect, temporality. Subjectivity, 28, 246–265. Andrejevic, M., Hearn, A., & Kennedy, H. (2015). Cultural studies of data mining: Introduction. European Journal of Cultural Studies, 18(4–5), 379–394. Bell, A. (2009). ‘It’s way out of my league’: Low-income women’s experiences of medicalized infertility. Gender & Society, 23(5), 688–709. DeNora, T. (1996). From physiology to feminism: Reconfiguring body, gender and expertise in natural fertility control. International Sociology, 11(3), 359–383. Doshi, M. (2018). Barbies, goddesses, and entrepreneurs: Discourses of gendered digital embodiment in women’s health apps. Women’s Studies in Communication, 41(2), 183–203. Foster, L. A. (2012). Patents, biopolitics, and feminisms: Locating patent law struggles over breast cancer genes and the Hoodia plant. International Journal of Cultural Property, 19, 371–400. Fox, S., & Epstein, D. (2020). Monitoring menses: Design-based investigations of menstrual tracking applications. In C. Bobel, I. Winkler, B. Fahs, K. Hasson, E. Kissling, & T. Roberts (Eds.), The palgrave handbook of critical menstruation studies. Singapore: Palgrave Macmillan. Gambier-Ross, K., McLernon, D., & Morgan, H. (2018). A mixed methods exploratory study of women’s relationships with and uses of fertility tracking apps. Digital Health, 4. Giraud, A. (2020). (Not) wanting to choose: Outside agencies at work in assisted reproductive technology. Reproductive Biomedicine & Society Online, 11, 89–95. Grinyer, A., & Thomas, C. (2012). The value of interviewing on multiple occasions or longitudinally. In J. Gubrium, J. Holstein, A. Marvasti, & K. McKinney (Eds.), The SAGE handbook of interview research: The complexity of the craft (2nd ed.). London: SAGE Publications Ltd. Hamper, J. (2020). ‘Catching ovulation’: Exploring women’s use of fertility tracking apps as a reproductive technology. Body & Society, 26(3), 3–30. Hamper, J. (2021) A fertility app for two? Women’s perspectives on sharing conceptive fertility work with male partners. Culture, Health and Sexuality, 1–16. [online first]. Hamper, J., & Nash, C. (2021). Bonding work: Spacing relations through pregnancy apps. Transactions of the Institute of British Geographers, 46, 584–597. Han, S. (2013). Pregnancy as a literacy event. In S. Han (Ed.), Pregnancy in practice: Expectation and experience in the contemporary US (pp. 29–58). Oxford: Berghahn Books. Johnson, S. (2014). ‘Maternal devices’, social media and the self-management of pregnancy, mothering and child health. Societies, 4, 330–350.

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Lowe, P. (2016). Reproductive health and maternal sacrifice: Women, choice and responsibility. London: Palgrave Macmillan. Lupton, D. (2013). The digitally engaged patient: Self-monitoring and self-care in the digital health era. Social Theory & Health, 11, 256–270. Lupton, D. (2014). Quantified sex: A critical analysis of sexual and reproductive self-tracking using apps. Culture, Health and Sexuality, 17(4), 440–453. Lupton, D. (2015). ‘Mastering your fertility’: The digitized reproductive citizen. In A. McCosker, S. Vivienne, & A. Johns (Eds.), Negotiating digital citizenship: Control, contest and culture. London: Rowman and Littlefield. Lupton, D. (2018). How do data come to matter? Living and becoming with personal data. Big Data & Society, 5(2), 1–11. Mamo, L., & Fosket, J. (2009). Scripting the body: Pharmaceuticals and the (re) making of menstruation. Signs: Journal of Women in Culture and Society, 34(4), 925–949. Martin, E. (1987). The woman in the body: A cultural analysis of reproduction. Boston, MA: Beacon Press. Oudshoorn, N. (1994). Beyond the natural body: An archeology of sex hormones. New York, NY: Routledge. Pande, A., & Moll, T. (2018) Gendered bio-responsibilities and travelling egg providers from South Africa. Reproductive Biomedicine & Society Online, 6, 23–33. Pollock, A. (2012). Medicating race: Heart disease and durable preoccupations with difference. Durham: Duke University Press. Raspberry, K., & Skinner, D. (2011). Negotiating desires and options: How mothers who carry the fragile X gene experience reproductive decisions. Social Science & Medicine, 72(6), 992–998. Rose, G. (2016). Visual methodologies: An introduction to researching with VisualMaterials (4th ed.). London: SAGE Publications Ltd. Roy, D., & Subramaniam, B. (2016). Matter in the shadows: Feminist new materialism and the practices of colonialism. In V. Pitts-Taylor (Ed.), Mattering: Feminism, science, and materialism. New York, NY: New York University Press. Sanders, R. (2016). Self-tracking in the digital era: Biopower, patriarchy, and the new biometric body projects. Body & Society, 23(1), 36–63. Sanz, C. (2017). Out-of-sync cancer care: Health insurance companies, biomedical practices, and clinical time in Colombia. Medical Anthropology, 36(3), 187–201. Sheller, M. (2020). The reproduction of reproduction: Theorizing reproductive (im) mobilities. Mobilities, 15(2), 188–195. Smith, G., & Vonthethoff, B. (2016). Health by numbers? Exploring the practice and experience of datafied health. Health Sociology Review, 26(1), 6–21. Thomas, G., & Lupton, D. (2016). Threats and thrills: Pregnancy apps, risk and consumption. Health, Risk & Society, 17(7–8), 495–509. Thompson, C. (2005). Making parents: The ontological choreography of reproductive technologies. Cambridge: MIT Press. Throsby, K. (2006). The unaltered body? Rethinking the body when IVF fails. Science Studies, 19(2), 77–97. Waggoner, M. (2015). Cultivating the maternal future: Public health and the prepregnant self. Signs: Journal of Women in Culture and Society, 40(4), 939–962. Wilkinson, J. (2020). Technologies of time: Women’s practices of trying to conceive with ovulation biosensing. Sociology of Health & Illness, 42(7), 1597–1610.

Chapter 9

Bio-Genetics and/at the Border: The Structural Intimacies of LGBTQ Transnational Kinship Sonja Mackenzie

Abstract This essay brings structural intimacies – theorised as the meeting of social structural patterns with interpersonal lives – to the border to consider transnational LGBTQ kinships. Specifically, the paper considers ‘the border’ and its state-driven bio-regulations as a reproductive technology that produces LGBTQ, racial/ethnic and social class inequities through the consolidation of heteronormative, bio-genetic kinship institutions and ideations of family. Structural intimacies harnesses intimacy as both subject and as an analytic lens for queering reproductive sociology that insists on re-conceptualizing institutions central to our lives. Structural intimacies move our analytic gaze from how the border structures sexuality, and vice versa, to consider the border as at once a structural and an affective domain. Structural intimacies is a conceptual tool useful for cross-disciplinary inquiry into the social and structural contexts in which reproductive technologies render meaning, as well as produce families, and to illustrate the analytic necessity of storying both content and method as integral to queer/ing scholarship. Straddling the most proximal forms of daily care and labor patterning everyday intimacies with the policies and practices of the state, the concept of structural intimacies reveals moments of encounter between state institutions with the most intimate components of a person’s life and identity, in this case amplified by the bio-politics of the border. Keywords: Border; LGBTQ; kinship; structural intimacies; bio-genetics; transnational

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Sonja Mackenzie Intimate life is the endlessly cited elsewhere of political public discourse, a promised haven that distracts citizens from the unequal conditions of their political and economic lives, consoles them for the damaged humanity of mass society, and shames them for any divergence between their lives and the intimate sphere that is alleged to be simple personhood. (Berlant & Warner, 1998, p. 553)

Border Questions ‘How are you travelling together?’ The question came simply but clearly through the glass kiosk and layered mask of the immigration agent. My family and I had just landed in the strangeness of a person-less pandemic Heathrow Airport, days after the COVID-19 B117 variant sent the UK into panic and lockdown standstill. The day we arrived saw cases and deaths in the UK reaching an unprecedented peak.1 Why would anyone land in the middle of this? It was a question we had asked ourselves many times. But now we had a new question – how are you traveling together? ‘We are a family’. My response came quickly, sharply. This apparently simple question – raised, not insignificantly, at the border – seemed to me more a proclamation of the heterosexual, bio-genetic family system that we were not, asking us to narrate our kinship within the legibility of compulsory heterosexuality (Rich, 1980) and the ‘always-already heterosexual’ relations of kinship (Butler, 2002). I refused to answer these unspoken questions, wanting the officer to do the work. I handed forward our four passports, less stamped stories of our travels across countries’ physical boundaries and more structural intimacies of kinship – tracing as they did the insistence of bio-genetics, meanings of family, and their production at the border – even as we stood there as physical and experiential evidence to the contrary. And yet – what other questions may be held within this border enquiry? Is it necessarily an overdetermined heteronormative proclamation, or could it be read as an invitation into an open-ended kinship narrative? How do borders serve as ‘imaginaries’ of social reproduction (Unnithan-Kumar & Khanna, 2015), reproducing the heterosexual family, state and nation, even as queerness permeates and shifts them. What are the many and varied relationship/s between the state, queer and racialized family formations, and the migration of bodies? Here, and within the framework of structural intimacies, context matters.2 Indeed, had it not been for the prior months of institutional erasure from my long-held identity as parent while I navigated UK immigration systems that had rendered my (non-birth) daughter as not my child, and me as not her parent; had it not been for the color-coded folders weighing down our backpacks, holding hundreds of pages of the documents of life to present at our border crossing – birth certificates, adoption forms, bank statements, income verification, domestic partnership declaration, housing status, work documentation (to name a few); had it not been

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for the ongoing uncertainty of our ability to live together as a family as I returned home to the UK for the first time to live as a queer family – I may in fact have welcomed such an enquiry as less interrogation and more curiosity.3 How (in fact, please tell us) are you traveling together? Perhaps this question holds within it a not knowing, an opening onto the varied, ever-growing forms of non-traditional kinship that cannot be held within the boundaries of border-speak. Indeed, isn’t queerness itself a commitment to non-boundedness, a necessary troubling of borders? The meticulousness of thinking and effort required to prepare all relevant documents for our border encounter to substantiate our existence together as a family within required state narratives was met only by the acuity of our anxiousness as we anticipated what the border may hold. It was in the wee hours of sleepless nights that all possible stories took form, and it was in the late evenings, after the children were asleep and the silence of the house could hold our growing trepidation, the feeling of it all, that we started avidly sorting these stories in color-coded folders. The logics of the folders created a container for our existence, even as the border instilled a growing sense of multiple consciousness. Varied anticipatory versions of our family unfolded. If we were all together at the border, option 1: both folders. If we were separated, option 2: we each had a folder with several narratives, rendered in excruciating detail; discussion after discussion; parent narrative; child narrative. The pandemic allowed us to at least attempt to configure queer possibilities in the face of our inability to access a heretofore taken-for-granted institution for a 14-year old - school. All - the truth. All – queering the truth. And yet what is ‘truth’ to a state that won’t hear it?

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Our stories were, to the state, incomplete, and fear built as we approached our departure date. We managed our folders while the state managed our family. And yet, as one more regulatory event in a line-up over the course of my life as a queer parent, the reproductive power of the border distils critical connections and questions about the state, the bio-regulation of kinship and intimacies, and the production of worthy citizens through its ‘immigration control apparatus’ and its reproduction of oppressive gendered, racialized and classed sexual norms enacted at the border and within the nation-states it surrounds (Luibh´eid & Ch´avez, 2020, p. x). The past decade has seen the rapid growth of queer and trans migration studies as a corrective to the silences on immigration in sexuality studies alongside the sexual silences in immigration literature (Gorman-Murray, 2009; Herr & Vatovek, 2011; Luibh´eid, 2002; Luibh´eid & Ch´avez, 2020; Manalansan, 2006). Transnational scholarship defines migrants as those who ‘take actions, make decisions, and feel concerns, and develop identities within social networks that connect them to two or more societies simultaneously’ (Schiller, Basch, & Blanc-Szanton, 1992). Increases in transnational migration and mobility can be understood as both a determinant and a result of shifts in global capital, and changing conceptions of self, family and the nation-state (Unnithan-Kumar & Khanna, 2015). Scholarship in migration studies variously focuses on the cultural, social and political and economic dimensions of migration, adaptation and assimilation, with various understandings of the centrality of the state and how it stratifies populations through systems of migration control and surveillance. The critical emergence of queer and trans migration studies as a field over the past decade as well as the sociological study of queer reproductive technologies in transnational contexts (some of which is referenced at the outset of this paper) have been instrumental in queering scholarship on the racial/ethnic and economic stratifications reproduced by queer family-building projects across borders. While the contributions of the field are many, of note are considerations of how the immigration system’s ‘anxious production of hetero-patriarchal families’ is connected to reproducing racial and class exclusions (Luibh´eid, 2002, p. xv), and how the boundaries of nations are constantly shifting through practices of discipline and surveillance directed at migrants. Many of these have taken as their analytic domain the uses of reproductive technologies and the inequitable flow of biological material to achieve pregnancy, though fewer still take up migration patterns and prohibitions over the lifecourse of queer family formations and the ways in which states discipline queer bodies through birth or bio-genetic relationships to maintain the ‘straight state’ (Canaday, 2009). This essay brings structural intimacies – theorized as the meeting of social structural patterns with interpersonal lives – to the border to consider transnational LGBTQ kinships (Mackenzie, 2013).4 Building on queer reproductive justice frameworks (Mamo, 2018; Smietana, Thompson, & Twine, 2018), I consider the specific ways that structural inequalities rendered through reproductive technologies of the border affect the possibilities and constraints on LGBTQ family forms. As ‘one of the most enduring social norms, identities and

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experiences in (American) culture’ (Mamo, 2018), bio-genetic parenthood and the re-production of racialized hetero- and homonormativities are the subject of an increasing body of work in varied countries. This work is primarily focused on assisted reproductive technologies (ARTs) and their queer engagements (Jones, 2005; Nordqvist, 2017; Russell, 2018) as well as the ever-more queer (yet homo-normative) projects of baby-making and their stratifications of inequity through the global circulation of biological materials necessary for reproduction ¨ (Bjorklund & Dahl, 2020; Faircloth & Gurtin, 2017; Mamo, 2018; Nebeling Petersen, 2016; Smietana, Rudrappa, & Wies, 2021). The contemporary cultural salience of biological parenthood in the UK reflects the ‘geneticisation of the popular imagination’ in British society over the past decade (Nordqvist & Smart, 2014). Further sociological analyses are needed of the institutions that structure the very practices of queer family-making across the lifecourse, particularly those leveraged through the border, and the biomedical, racial and economic inequities perpetuated therein and over time. Specifically, the paper considers ‘the border’ and its state-driven bio-regulations as a reproductive technology (Nahman & Vertommen, 2019) that produces LGBTQ, racial/ethnic and social class inequities through the consolidation of heteronormative, bio-genetic kinship institutions and ideations of family. The border is a reproductive technology that operates to arrange and limit queer kinships not just through border crossings but through institutional practices and processes over time that are set up to legitimate heterosexual, bio-genetic kinship from birth. In this way, critical work on migration narratives of queer racial/ethnic minority communities considers the ways in which sexual politics are embedded in processes of globalization and how the immigration control apparatus serves to surveille and discipline sexuality along lines of race, class ¨ and gender (Hegde, 2021; Holzberg, Madorin, & Pfeifer, 2021; Lewis, 2019; Manalansan, 2005, 2006; Somerville, 2005; White, 2013). As such, this analysis attends to the symbolic realm of immigration – the meanings of inclusion, belonging and identification and their representations (Hall, 1992) while interrogating the normative assumptions that render inclusion as a failed solution.5 The expansion of reproductive technologies has been both a tool used by predominantly white, wealthy LGBTQ individuals to ‘reproduce futures’ ¨ (Bjorklund & Dahl, 2020) while further stratifying the inequities upon which these exchanges rely.6 This expansion has been integral to shifting the purview of the state and immigration control’s identification and surveillance of bio-genetic materials and lineages to demarcate hetero-citizenship and ‘acceptable’ bodies. This presents a particularly salient analytic site not just for the growing number of transnational LGBTQ families, but for building diverse engagements with scholarship on reproductive technologies that reflects their relevance over the lifecourse (Boydell & Dow, 2021) while addressing Boydell and Dow’s concern that both the use of reproductive technologies and their study can involve perpetuating harmful forms of social inequities (Boydell & Dow, 2021, p. 5). The paper examines the ongoing processes of state involvement in constructing – and reinforcing – heteronormative biological family formations over the course of a child’s life – in particular through the reproductive technologies of the ‘border’.

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From initial classification of heteronormative male–female parentage legitimated on a birth certificate to the exclusions of citizenry traced by biological lineage via the exclusion of non-biological children from the nation-state, processes of hetero-kinning take place across thresholds of belonging over the lifecourse. These urge a broader consideration of reproductive technologies as they reinforce heteronormative kinship formations defined through parent–child relationality over key moments in time. In this paper, I integrate auto-ethnography (Laslett, 1999; Wall, 2006) through a brief sketch in an ongoing migration case study of recent events in my life with scholarship at the nexus of reproductive sociology and sexuality and migration studies. I include consideration of several visual and narrative materials used to regulate queer kinship over time and across borders as structural intimacies of queer kinship. In so doing, I aim to present structural intimacies as a conceptual tool useful for cross-disciplinary enquiry into the social and structural contexts in which reproductive technologies render meaning, as well as produce families, and to illustrate the analytic necessity of storying both content and method as integral ´ 2019; Manalansan, 2014; to queer/ing scholarship (Baird, 2020; Lee & Leon, Pascoe, 2018; Ward, 2018). Straddling the most proximal forms of daily care and labor patterning everyday intimacies with the policies and practices of the state, the concept of structural intimacies reveals moments of encounter between state institutions with the most intimate components of a person’s life and identity, in this case amplified by the bio-politics of the border.

Queering Reproductive Borders Through Structural Intimacies To consider intimacy is to contend with the ways that we live lives in relation to institutions. In my 2013 book, Structural Intimacies: Sexual Stories in the Black AIDS Epidemic, I proposed the framework of ‘structural intimacy’ as a theory for understanding how structural inequalities affect possibilities for and constraints on intimate lives and, in so doing, impact health (Mackenzie, 2013). Structural intimacies are stories at the meeting of social structural patterns and interpersonal lives, focusing on the agency of storytellers as they negotiate and narrate power and render local worlds based on lived experiences of inequality, struggle, and resistance. In the book, I consider three discursive examinations of structural intimacies in the context of the Black AIDS epidemic in the US and argue that so-called ‘risk’ for HIV is in fact inextricable from structural inequities of race, class and sexuality.7 The book finds that late twentieth century shifts in economic production (globalisation, increases in un/under-employment, outsourcing of jobs, impact of technologies on the global labour market) have had a significant impact on working- and middle-class Black communities in the US and considers the ways in which these structural factors become articulated through stories of sexual lives conditioned by economic, social and political vulnerabilities. Structural intimacies are structural: they denote those social institutions, material circumstances and relationships between the state and populations that are played out through forms of domination. This optic onto the structural and the intimate

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is informed by critical race theory (Collins, 2004; Crenshaw, 1995) and theories of embodiment (Bourdieu, 1990), and through a critical engagement with the construct of intimacy as narratives, or ‘archives of feeling’ that circulate in the affective domain (Cvetkovich, 2003). Intimacies connote social relationships and practices – and, equally, their ideals, fantasies – of kinship, love, care, familiarity and friendship, including sexual and romantic relationships (Berlant, 1998; Constable, 2009).8 Structural intimacies harness intimacy as both subject and as an analytic lens for queering reproductive sociology (Wilson, 2012) that insists on re-conceptualizing institutions central to our lives. Considering the affective and instrumental dimensions of intimacy hones our focus on the ways that intimate attachments ‘make people public’ and, conversely, how normative practices and institutions structure people’s lives. Heteronormative intimacies dominate not only in the public imaginary but also in the materiality of legal and social institutions, which serve to ensure the reproduction of capitalism, white supremacy and marital hetero-patriarchal families as the outcome/goal of reproductive intimacies. And still, queer family intimacies have developed (Montegary, 2018), including queer of colour family intimacies (Patton-Imani, 2020), often as ‘counter-intimacies’ (Berlant & Warner, 1998) alongside what US critical theorist Lauren Berlant refers to as the ‘virulent form of revitalized national heterosexuality’ central to citizenship that is ‘completely’ white and middle class (Berlant, 1997). The recent ‘turn’ to intimacy in transnational scholarship allows for a queering of kinship, race and nation – and the production of borders they serve to uphold. In this vein, I engage structural intimacies as an analytic site for queering transnational analysis of reproductive technologies. Structural intimacies have been used to examine key directions in the future of intersectional sociological enquiry on HIV/AIDS (Watkins-Hayes, 2014); to consider the ‘technologies of race’ in the production of public health knowledge about Black queer and transgender lives (Bailey & Stallings, 2017); to advance critical intimacy studies (Lenon, Luhmann, & Rambukkana, 2015) and critical race analyses of public health (Benkert, Cuevas, Thompson, Dove-Meadows, & Knuckles, 2019; Epstein & Mamo, 2017; Jaiswal & Halkitis, 2019; Jaiswal, Singer, Siegel, & Lekas, 2019); and to consider LGBTQ-assisted reproductive technology engagements and their ‘tensions’ through a queer reproductive justice lens (Mamo, 2018; Mamo & Alston-Stepnitz, 2014). In this work, Laura Mamo conceptualizes ‘queer reproductive justice’ as a link between reproductive justice movements and queer theory and critical kinship to examine the embeddedness of LGBTQ people in ART bio-economies and ‘how queer politics can be mobilized to transform intimate life, forms of relatedness and kinship’ (Mamo, 2018, p. 28). By calling for ethical accountability of all actors in reproductive engagements – those labouring in the reproductive economy, the recipients of their labour, and those theorizing the dynamics therein – Mamo reframes the very idea of choice and individual engagement in ART to illuminate the processes through which reproductive inequalities are reinforced. In the case of transnational queer kinships, the global bio-economies of assisted reproduction and the stratified reproductions (Colen, 1995) upon which these are based and to which they

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contribute tend to be examined through a lens foregrounding individual-level decision-making and agency. This occurs at the expense of nuanced political economic analyses of kinship, including of ‘intimate economies’ (Wilson, 2012), and the ways that these are racialized, as per (Nahman & Vertommen, 2019; Petchesky, 2017; Rudrappa, 2015; Vertommen, 2017; Wiegman, 2002). Structural intimacies describe encounters with institutionalization that occur through the often-violent ruptures of interaction and feeling (the border, the questioning) as well as through the silent ever-presence of institutions that people become conditioned to live with, and often unaware of or numb to in daily life. This is well captured as a theory of power and institutionalization, as Sarah Franklin states: ‘You know you’re in an institution when you come up against it’. (Franklin, 2021) Structural intimacies narrate and capture the centrality of human emotion and its embeddedness in the structural through refractions of the everyday institutionalisation of daily life – exposing what is already there. Through the border, structural intimacies move our analytic gaze from how the border structures sexuality, and vice versa, to considering the border as at once a structural and an affective domain. In this vein, we can further consider structural intimacies as technologies of amplification as well as reproduction (Franklin, 2021). In the space of the border lies the violence of the state, always already there, yet amplified through the encounters therein. Critical race analyses note that, given shifts in the latter part of the twentieth century away from immigration policies that include explicitly discriminatory measures based on race/ethnicity and sexuality (Ramirez, 2010; Somerville, 2005) to those of apparently neutral bureaucracies, the less transparent forms of power and oppression that remain may be misunderstood as ‘rare and aberrational rather than as systemic and ingrained’ (Crenshaw, 1995, p. xvi). This misunderstanding relies on the dangerous fallacy that racism and heterosexism are not held within migration systems or felt in its effects. For example, in the US, racial criteria were removed from immigration law in 1965 in the Immigration and Nationality Act and were replaced with a system based on family ties that aimed to exclude immigrants of colour.9 However, assumptions of biological kinship upon which familial connections are based render a system that both presumes and perpetuates compulsory heterosexuality, leading to continued vulnerability to discrimination for LGBTQ migrant families, and in particular multiply marginalized BIPOC LGBTQ families, who do not cohere to such family structures through a reliance on bio-genetic meanings and practices. These shifting bureaucracies of immigration enshrouded in bureaucratic ‘neutrality’ and their heterosexist, racist and classist effects are the very systems that structural intimacies can expose as reproductions of the border. Even (or indeed especially) if these encounters take place in the absence of explicitly discriminatory policies and regulations, or what critical race scholar Kimberl´e Crenshaw refers to as ‘cramped conceptions of … domination’ (Crenshaw, 1995, p. xv), this case example examines how immigration control practices embedded at the border systemically maintain social hierarchies of heterosexuality and ideals of nationalism. And so we return to the border story to consider this example of the structural intimacies therein. It is here that we must theorize the biological as a ‘fascinatingly

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ambivalent resource through which to fashion essentialising, but malleable, meanings of gender, kinship, and shared reproductive substance’ (Franklin, 2014), while examining the role of state institutions in re-producing biological, heteronormative forms of kinship.

Constructing Citizenship: Queer Reproductive Technologies of the Border The letter had come three months prior to our border-crossing:

HM Passport Office Decision Letter, Excerpt – 31/10/2020 But I was a British Citizen at the time of her birth. Being my daughter’s mother is so embedded that I had to read this several times before the sting of this proclamation hit home. She is my first child, the child I had planned and obsessively prepared for with my partner, the child I had welcomed into my hands and into the world that rainy January night years ago. She is also the older sibling to my son, whose UK citizenship approval and UK passport would arrive just weeks later by virtue of the fact that I am his birth parent. It slowly took form – I am not my daughter’s mother. Further, it was my status as a British citizen that made me have no claim to parenthood of my daughter.10 UK immigration policies had rendered one of my children as a ‘legitimate’ UK citizen and the other as not a citizen – as ‘illegitimate’ with regard to the state by virtue of the necessity of her birth out of legal wedlock (Murray, 2012).11 Indeed, if my daughter had been conceived after 6 April 2009, I could be considered by Her Majesty’s Passport Office at least as some form of parent to her, specifically within the sub-category of father as a ‘person who is treated as a parent of the child’, based on updates to parentage laws under the second female parent provision of the Human Fertilisation and Embryology Act of 2008 (Sections 42 and 43). These provisions aimed to broaden understandings of parentage in line with the shifts in family forms engendered by advances in reproductive technology (McCandless & Sheldon, 2010). At least this would involve recognition as some form of parent in relation to her – even if as a sub-category of ‘father’; ‘mother’ being defined strictly as the ‘woman who gestates and gives birth to the child’ (Fox, 2009; McCandless & Sheldon, 2010).12 In this case, the problematics become clear: through demarcating nationhood along lines of birth status and/or biology, the UK immigration office does not consider me a parent to my daughter because I did not carry or give birth to her, de-legitimating non-biological parenthood while upholding my biological parenthood.

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While heteronormative tropes of birth-parent nationalism were a new experience for my family as we attempted to configure life together as a family in the country where I grew up, the institutional impossibility/erasure of queer parentage was not particularly new to me. Indeed, I am already formally defined as my daughter’s father on her California state birth certificate, albeit with the designation that, at the time, allowed us to include ‘parent’ as queer resistance within the assumed/forced heteronormative mother–father parent designation (see Excerpt).13

Certificate of Live Birth, Excerpt – State of California, 2006 It had been clear throughout my 15 years as a queer parent that bio-genetics is less a fact of biology and more a state-driven project for constructing worthy citizens through a production of acceptable family forms. And yet the role and power of the border and its regulatory systems in constructing and maintaining normative families had become painfully clear. Our family’s passports, birth certificates and evolving immigration records and visual renderings told stories and held silences of ‘intimate citizenship’ (or non-citizenship) (Plummer, 2011). These traced state narratives of our kinship structure and configured compulsory heterosexuality in and through the border. Borders and the terrain they regulate (the state, the nation) are mutually reinforcing systems, wherein regulation of sexuality at the border evolves from and also contributes to systems of regulation of individuals who have been excluded from full belonging within the country. Crossing borders, access to schools and other social institutions, lack of access to healthcare and reproductive services, and even the (failed) guarantee of physical togetherness and care – these are all structural intimacies of LGBTQ kinship narrated across the lifecourse through birth certificates, passports and imaging of bodies via biometric technologies that attempt to situate bodies in heterosexual practice and space. I am not my daughter’s parent according to the UK’s immigration regulations, and I am her ‘parent–father’ on her US California birth certificate – in neither of these spaces whether at the border or within the nation itself is there institutional recognition adequate to narrate forms of queer kinship. In this way, border areas ‘provide a means to understand how immigration control practices implicate citizens who have historically been excluded from full belonging in the nation-state’ (Luibh´eid, 2002, p. xviii).14 Further, the non-category of ‘parent–father’ allocated at birth travels with my child throughout her life to show up again at the border and beyond, conditioning her identity, the possibilities of her existence, and our family structure. Amid these

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ingrained but often dispersed operations of power over time, how might we understand the nodes of contestation that permeate the border, similarly distributed but often not explicitly expressed?

Biometrics and Beyond: Visualizing Queer Family Citizenship

Biometric Appointment Reminder (Visually Altered), March 2021 The biometrics appointment confirmation landed in my inbox weeks before the date, its speckled language of digital exclusivity portending the visualization of life to come. Through the valence/obfuscation of neutrality, this portal contained all relevant data for our family’s ongoing hetero-citizenship process. Biometric technologies, the state’s ‘border technology par excellence… [as] a classification process fueled by xenophobic anxieties and intimately connected to capitalist enterprise’ (Magnet, 2011), provide the requisite measurements of finger prints and visual ‘evidence’ to substantiate a UK citizenship application. Biometric scientific practices presume that the human body exists as a ‘stable, unchanging repository of personal information from which we can collect data about identity’ (Magnet, 2011). These technologies assume a key role in the construction and regulation of borders through state-driven cultures of security and their exclusionary effects, by controlling and classifying vulnerable populations and serving as an instrument of race, class, sexuality, ability and gender oppression (Wevers, 2018). Biometric surveillance technologies of sexuality and gender serve to consolidate bodily normativity and state power through surveillance practices (Clarkson, 2020; Kafer & Grinberg, 2019; Manalansan, 2006) and the consolidation of binaries of trans bodies through surveillance practices (Clarkson, 2020). As instruments of ‘governmentality and management’, technologies of the border act not just as tools of repression but can foster migrant subjectivities in shaping migration spaces and experiences (Moffette & Walters, 2018).

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The dramatic winter-sunset view of Birmingham’s industrial-yet-modern skyline from the seventh-floor pandemic ‘premium lounge’ UK immigration office provided a perhaps appropriately layered backdrop for our presence at my daughter’s required biometrics appointment. We were here to participate in the requisite process of classification of my daughter’s body as a failed citizen, and our queer family as a potential risk to the state. All the while, children squirmed impatiently and translators sought to render linguistic sense of the process while photos were taken and fingerprints were marked among the hopeful-citizens-to-be lined up in the technologies of citizen-making. Despite being caught up in what Donna Haraway has described as the ‘corporeal fetishism’ of biometrics and the profoundly problematic erasure of the situatedness of its knowledge (Haraway, 1997), the queer stakes at hand found us also strangely relieved to be here as my daughter brought her bodily material forward for visualization/regulation as a worthy UK citizen. ‘No, fingers together like this’ – she lined her fingers up, now appropriately, for the state. Our administrator let us know that he was going to review the data on her application. Moments passed, silence. He paused, looking up at me from his kiosk. Sonja Mackenzie – father. XX – mother. Is that right? My daughter and I glanced at each other, smiling knowingly behind our masks. Yes, that’s right. Sonja Mackenzie – Father. Ok, are you ready for me to submit your application? Yes. The rain fell hard, and the wind blew as we left the office, running arm in arm down the abandoned streets of Birmingham that night, caught up in all it meant to be in these systems and yet, we hoped, soon to officially be able to remain together as parent and child. Soon to be able to attend school, no questions asked. My daughter saw beauty from those windows. I see the window itself, holding within it a tangle of urban arteries pulsing lives and loves once more through a silent orange sundown.

Towards Structural Intimacies of Transnational LGBTQ Kinship And so, in closing, a return to the border question that opened our enquiry – How are you traveling together? The twists of arteries in Birmingham and beyond carry us still. The pulse of bio-blood still determines our lives. We are still here at the border – and since birth across the world – defined by the state as father– daughter. And yet, the question – how are you traveling together – continues to open up queer spaces and technologies of reproduction at the border and beyond.

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While recognition of parentage in itself can be understood to be an aspiration of queer liberalism seeking sameness and incorporation into hegemonic kinship structures (of the two-parent, white married form), a structural intimacies frame on transnational kinship moves beyond claims for recognition to draw attention to the structural exclusions these elipses engender. As a queer optic onto justice, structural intimacies foregrounds the necessity of critical analyses of power and oppression as a corrective to neo-liberal individualist frames; conjoins the historical rootedness and current manifestations of compulsory heterosexuality with structural racism as it intersects with and affects queer lives; and foregrounds the affective dimensions and narratives of intimacies alongside their material and narrative production. In this way, reproductive justice follows in the redressing of inequities and in the accountabilities of all reproductive actors – and institutions – involved therein. Through foregrounding moments of encounter between state institutions and intimate worlds, structural intimacies present an opening onto reproductive justice through integrating the affective with the material domain. Structural intimacies urge a simultaneous consideration of both the affective and material domains in relation to kinship, in line with critical kinship studies’ project to resist humanist narratives of kinship and to queer late capitalist ¨ homonormative aspirations for family ‘normality’ – considering, as Bjorklund ¨ and Dahl put it, ‘has queer kinship failed to be queer?’ (Bjorklund & Dahl, 2020, p. 14). A relational analysis of reproduction understands family relationships and kinship formation from preconception through birth, infancy and throughout childhood. In this way, queer families must continue to grapple with reproductive technologies long after the often-studied questions of reproductive technologies for producing babies (or not) have faded away. State legitimation of heteronormative bodies takes place through technologies of personhood enacted at reproductive ‘frontiers’, including birth certification and border crossings, that continue over the course of a child’s life. This paper, then, calls for an analytic lens onto reproductive technologies as they frame both ‘anticipated’ and, importantly, unanticipated futures. The unfolding of reproductive lives and possibilities of kinship based on reproductive practices are not equally distributed. Some may encounter these unanticipated reproductive frontiers more than others – including, as considered here, the ways in which LGBTQ families encounter, among other unanticipated technologies, border crossings over the lifecourse. Here questions of so-called ‘choice’ around reproductive lives are less relevant in light of more pressing questions of distribution, equity, access and queer reproductive justice as these are re/produced through institutional structures over time. Narratives of lived experience animate the material and ethical impacts of these ruptures. In particular, it is imperative to consider the methodological considerations and implications of the auto-ethnographic lens of this piece. Focused as it is on reproductive processes experienced through key moments in my daughter’s life, this paper brings to light a methodological imperative to consider reproduction as it conditions the life experiences of children born via reproductive technologies.

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Given that the voice of this auto-ethnographic piece is mine, two points are important here. First, I was cognizant of the ethical considerations in crafting a piece such as this that delineates vulnerability on the part of a child, in this case my daughter. As such, it was important to me that my daughter act as the first reviewer of this manuscript – first, to be aware of its existence and of this version of events in her life circulating in the public domain and, secondly, to offer substantive feedback and edits, and to indicate any content that she did not wish to be public.15 Secondly, while there is a growing body of public work written by young people born of reproductive technologies, the ethical and substantive concerns of relationality across the reproductive lifecourse point to the growing imperative of people, including children, born via reproductive technologies themselves to render their embodied experiences. Structural intimacies are, and are about, the intimacies of everyday life; holding within them closeness and pleasure, longing and silence, and often tenuous struggles for life itself. As rewritings of power, and as acknowledgments of its hidden workings in the social body, these narratives provide rich material for furthering understandings of power considering structural, cultural and historical contexts. Through everyday practices that hold within them possibilities for transforming not just meanings of citizenship but of kinship and the conditions of its queer re-productions, structural intimacies of LGBTQ transnational kinship indicate that structural vulnerability is rendered in the blood, in the possibilities and constraints on kinship, and in the rhetorics of their telling.

Notes 1. The context of Covid-19 for border-crossing is significant for this auto-ethnography. Covid-19 continues to render immigration institutions inaccessible and protracts the timely bureaucratic processes of the border while imposing new stratifications of inequity through the construction of an elite colonizing vaccine-class delimiting border crossings and nationhood. The ways in which Covid-19 exacerbates pre-existing racialized global and local inequities has been well theorized (Whitacre et al., 2021), with important work underscoring the necessity of critical race theory and decolonial thought in the UK context (Meghji & Niang, 2021). While a full analysis of Covid-19 and the border is beyond the scope of this paper, how it amplifies migration inequities along multiple axes will remain a critical topic to theorize for LGBTQ and racialized communities in the years to come. 2. Even as I raise these questions, I recognize the vast space of inquiry and set of stakes – and lives – at hand here. I offer this piece as a partial, situated account to build on - and invite further – critical work at these intersections. In so doing, I recognize the ongoing work of activists and LGBTQ and racial/ethnic minorities who cross borders in life or death contexts of state repression or violence and who embody the lived realities of migration across borders, as well as the growing body of critical scholarship in the legal, political science, health, and sociological spheres that aims to support the agency, well-being and survival of migrants. My

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own positionality as a white, queer middle class cisgender woman who is an activist-scholar and unmarried but partnered parent (both biogenetic and non birth) born in Scotland and straddling global north US-UK contexts holds within it significant privileges and also informs my relationship to this material – as rendered through the auto ethnographic work. As Charis Thompson reminds us in her cogent geneology of separation, separation of families from children is used as a central strategy in ‘migra-political’ times (Thompson, 2018). Thompson classifies these separations into domains of the stigmatized and sacred, noting the many historical and ongoing forms of violent racialized and gendered family separation such as slavery, sterilization, workhouses, war and conflict, mass incarceration, border crossings, separation in LGBTQ communities (to name a few) – and urges us to “do more than just counter separation with a sacralized intimate personalized appeal to the happy domestic family.” Her work leverages an urge to change the state and material conditions and laws that lead to such separations in the first place, beyond mere appeals to naturalized understandings of reproducing the domestic as per harmonizing “Families Belong Together” rhetorics. Transnational scholarship defines migrants as those who “take actions, make decisions, and feel concerns, and develop identities within social networks that connect them to two or more societies simultaneously” (Schiller, Basch, & Blanc-Szanton, 1992). Increases in transnational migration and mobility can be understood as both a determinant and a result of shifts in global capital, and changing conceptions of self, family and the nation-state (Unnithan-Kumar & Khanna, 2015). In leveraging a critique of heterosexist, exclusionary immigration and state policies with regard to queer families, I want to be clear that I do not equate ‘progressive’/inclusive LGBTQ policies with the progressive ‘nature’ of the country, as per Puar’s homonationalism, or the mobilization of LGBTQ diversities as a necessary component of a progressive state narrative (Puar, 2007). It is the dispersal of state engagements over the life course of queer families – the ways these are set in and over time through the visual and written documentation of reproductive events – these are the structural intimacies of LGBTQ kinship. State and immigration apparatuses are related, relying on one another and enacting their forms of bio-power at unanticipated, defining and often life-changing moments in the course of queer kinships. I use the umbrella ‘LGBTQ’ intentionally to designate the fact that, while the bio-availabilities involved in reproduction necessary for family forms with or without sperm, eggs, and/or uteruses with or in which to grow a fetus vary considerably, and therefore the impacts on stratified reproduction are very different, all people who participate in assisted reproductive practices are involved economically, ethically and affectively in the extractions and labor of others who are – also economically, ethically and affectively - involved in the exchange – whether sperm retrieved from a sperm bank, or the extraction or implantation and growth of a fertilized egg in a uterus. The ethical implications are unevenly distributed – as Mamo (2018) and others note, and gendered impacts are significant, and must be considered discretely, with reliance on women’s labor, whether formally or informally, as integral to gay men’s ability to have children, and therefore integral to considerations of the in/equities at hand,

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Sonja Mackenzie as discussed in Camisha Russell’s critical analysis of rights, justice and suggestion of ‘procreative liberties’ – building on Dorothy Robert’s 1999 work, Killing the Black Body, Race, Reproduction and the Meaning of Liberty - to consider gay men’s reproduction (Roberts, 1997; Russell, 2018). The three structural intimacies I examine in the book are: narratives of a ‘liquor store on every corner,’ ‘never a Black Brokeback Mountain,’ (white supremacy and the so-called ‘down low’); and the HIV/AIDS conspiracy counter-narrative’. These narratives are based on ethnographic data collected over two years, including in-depth interviews with over 40 Black men and women living with/in proximity to HIV and secondary analyses of policy documents, popular media and community sources. These sexual stories in the early 21st century reflect the centrality of class oppression and structural racism’s embeddedness in the sexual. Intimacy is typically understood to play out in spaces of close contact and knowing: in kinships and ‘kinning’ practices (Howell, 2003), through friendship, and/or connoting the personal, interior and/or ‘private’ domain. The 1965 Immigration and Nationality Act, also known as the Hart-Celler Act, served to overturn the National Origins Formula, which had been the premise of US immigration law since 1921 and which had aimed to “preserve the ideal of US homogeneity” by limiting immigration from Asian countries, Southern Europe and Eastern Europe. The Hart-Celler Act established a preference system with seven categories that gave priority to immigrants who were relatives and children of US citizens and permanent residents, professionals or people with specialized skills, or refugees (Barkan, 2013). This status was initially established in the British Nationality Act of 1981 and further modified through the British Nationality Proof of Paternity (Amendment) Regulations of 2015 (Anon, 1981, 2015). I use the term ‘illegitimacy’ critically. For a relevant argument examining the rise of what legal scholar Melissa Murray calls the ‘new illegitimacy’ as a narrative that centers non-marital birth status, and its injuries, as a salient legal construct in the marriage equality arguments in the US that perpetuates historically racist and anti-Black meanings and functions of the institution of marriage to marginalize poor Black and brown families, see Murray’s cogent 2012 analysis, What’s So New about the New Illegitimacy (Murray, 2012). Of note is that part of what the Human Fertilisation and Embryology Act of 2008 aimed to enact was a legal de-coupling of bio-genetics from motherhood – rather than assuming that mothers are genetic parents, it defines the legal mother as the person who gestates and gives birth to the child (Fox, 2009). And yet, as has been noted in critiques of these reforms, alongside the effort to designate the birth mother as ‘legal’ mother has come a ‘concomitant downplaying of the significance of genetic or social mothers,’ as well as the ongoing challenges with the secondary status in the eyes of the law inferred by the language of ‘female parent’ (Fox, 2009, p. 338). In 2016, California became the first state in the United States to recognize LGBTQ and gender inclusive parentage on birth certificates with the option to select any combination of ‘parent,’ ‘mother, or ‘father’ on a birth certificate. Birth certificates can also be changed retroactively. In an indication of the gradual policy and bureaucratic transition to this designation between 2006 and 2015, when AB 1951 was introduced (and then signed into law by Governor Jerry

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Brown), in 2009, birth certificates included two formal categories of parentage: 1) ‘Name of Mother/Parent’ and 2) ‘Name of Father/Parent.’ These categories allow for the importantly non-gendered designation of ‘parent,’ but still default to an assumed heteronormative parental structure. 14. The exclusion of lesbian and gay immigrants from entry into the US was lifted with the Immigration Act of 1990. This Act removed ‘sexual deviation’ as a medical ground for barring entry of homosexuals into the US, language that was established in the 1965 Immigration and Nationality Act but of LGBT exclusion that has been traced to the Immigration Act of 1917, which prohibited people labelled as ‘constitutional psychopathic inferiors’ from entering the US (Luibh´eld ´ 2005, p. xii). & Cantu, 15. My daughter did not have any content feedback or edits, however after an initial response in which she noted our shared understanding of the “Father – Mackenzie” moment in Birmingham - “Oh mama, you’re Father Mackenzie!”- she said she felt it was important that people understand these parts of her life. She noted this in relation to broader publics as well as in her adolescent social world where she has felt further marginalized (and rendered invisible as part of a queer family) through dominant understandings of queerness as sexual identity rather than broader understandings of queer kinship and family structures.

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¨ Holzberg, B., Madorin, A., & Pfeifer, M. (2021). The sexual politics of border control: An introduction. Ethnic and Racial Studies, 44(9), 1485–1506. doi:10.1080/ 01419870.2021.1892791 Howell, S. (2003). Kinning: The creation of life trajectories in transnational adoptive families. The Journal of the Royal Anthropological Institute, 9(3), 465–484. doi:10. 1111/1467-9655.00159 Jaiswal, J., & Halkitis, P. N. (2019). Towards a more inclusive and dynamic understanding of medical mistrust informed by science. Behavioral Medicine, 45(2), 79–85. doi:10.1080/08964289.2019.1619511 Jaiswal, J., Singer, S. N., Siegel, K., & Lekas, H.-M. (2019). HIV-related ‘conspiracy beliefs’: Lived experiences of racism and socio-economic exclusion among people living with HIV in New York City. Culture, Health and Sexuality, 21(4), 373–386. doi:10.1080/13691058.2018.1470674 Jones, C. (2005). Looking like a family: Negotiating bio-genetic continuity in British lesbian families using licensed donor insemination. Sexualities, 82(2), 221–237. Kafer, G., & Grinberg, D. (2019). Queer surveillance. Surveillance and Society, 17(5), 592–601. Laslett, B. (1999). Personal narratives as sociology. Contemporary Sociology, 28(4), 391–401. doi:10.2307/2655287 Lenon, S., Luhmann, S., & Rambukkana, N. (2015). Intimacies/affect. Atlantis: ´ Critical Studies in Gender, Culture & Social Justice/Etudes Critiques Sur Le Genre, La Culture, et La Justice, 37(1), 3–5. Lewis, R. (2019). Queer migration in homonationalist times. GLQ: A Journal of Lesbian and Gay Studies, 25, 649–656. doi:10.1215/10642684-7767823 Luibh´eid, E. (2002). Entry denied. NED (New edition). University of Minnesota Press. ´ L. (2005). Queer migrations: Sexuality, U.S. citizenship, and Luibh´eid, E., & Cantu, border crossings. Minneapolis: University of Minnesota Press. Luibh´eid, E., & Ch´avez, K. R. (2020). Queer and trans migrations: Dynamics of illegalization, detention, and deportation. Chicago and Springfield: University of Illinois Press. Mackenzie, S. (2013). Structural intimacies: Sexual stories in the Black AIDS epidemic. New Brunswick, NJ: Rutgers University Press. Magnet, S. (2011). When biometrics fail gender, race, and the technology of identity. Durham: Duke University Press. Mamo, L. (2018). Queering reproduction in transnational bio-economies. Reproductive Biomedicine & Society Online, 7, 24–32. doi:10.1016/j.rbms.2018.10.008 Mamo, L., & Alston-Stepnitz, E. (2014). Queer intimacies and structural inequalities: New directions in stratified reproduction. Journal of Family Issues, 1–22. Manalansan, M. F. (2005). Race, violence and neoliberal spatial politics in the global city. Social Text, 23(3–4), 141–155. Manalansan, M. F. (2006). Queer intersections: Sexuality and gender in migration studies. International Migration Review, 40(1), 224–249. doi:10.1111/j.1747-7379. 2006.00009.x Manalansan, M. F. (2014). The ‘stuff’ of archives: Mess, migration, and queer lives. Radical History Review, 2014(120), 94–107. doi:10.1215/01636545-2703742 McCandless, J., & Sheldon, S. (2010). The human fertilisation and Embryology act (2008) and the tenacity of the sexual family form. The Modern Law Review, 73(10), 175–207.

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Meghji, A., & Niang, S. M. (2021). Between post-racial ideology and provincial universalisms: Critical race theory, decolonial thought and COVID-19 in Britain. Sociology. doi:10.1177/00380385211011575 Moffette, D., & Walters, W. (2018). Flickering presence: Theorizing race and racism in the governmentality of borders and migration. Studies in Social Justice, 12(1), 92–110. doi:10.26522/ssj.v12i1.1630 Montegary, L. (2018). Familiar perversions. New Brunswick, NJ: Rutgers University Press. Murray, M. (2012). What’s so new about the new illegitimacy? The American University Journal of Gender, Social Policy & the Law; Washington, 20(3), 387–436. Nahman, M., & Vertommen, S. (2019). Borders as reproductive technologies. Bristol. Nebeling Petersen, M. (2016). Becoming gay fathers through transnational commercial surrogacy. Journal of Family Issues, 39(3), 693–719. doi:10.1177/0192513X16676859 Nordqvist, P. (2017). Genetic thinking and everyday living: On family practices and family imaginaries. The Sociological Review, 65(4), 865–881. Nordqvist, P., & Smart, C. (2014). Relative strangers: Family life, genes and donor conception. Palgrave Macmillan. Pascoe, C. J. (2018). What to do with actual people? Thinking through a queer social science method. In D. Compton, T. Meadow, & K. Schilt (Eds.), Other, please specify: Queer methods in sociology (pp. 291–303). Berkeley, CA: University of California Press. Patton-Imani, S. (2020). Queering family trees. New York, NY: NYU Press. Petchesky, R. (2017). Security as reproduction: The biopolitics of walls in Israel/ Palestine and beyond. Cambridge. Plummer, K. (2011). Intimate citizenship: Private decisions and public dialogues. Seattle, Washington: Washington University Press. Puar, J. (2007). Terrorist assemblages. Durham, NC: Duke University Press. Ramirez, H. N. R. (2010, January 1). Introduction: Homoerotic, lesbian, and gay ethnic and immigrant histories. Journal of American Ethnic History, 29(4), 5–21. Rich, A. (1980). Compulsory heterosexuality and lesbian existence. Signs, 5(4), 631–660. Roberts, D. (1997). Killing the black body race, reproduction, and the meaning of liberty. New York, NY: Vintage Books. Rudrappa, S. (2015). Discounted life. New York: NYU Press. Russell, C. (2018). Rights-holders or refugees? Do gay men need reproductive justice? Reproductive Biomedicine & Society Online, 7, 131–140. doi:10.1016/j.rbms.2018. 07.001 Schiller, N. G., Basch, L., & Blanc-Szanton, C. (Eds.). (1992). Towards a transnational perspective on migration: Race, class, ethnicity, and nationalism reconsidered. New York, NY: New York Academy of Sciences. Smietana, M., Rudrappa, S., & Wies, C. (2021). Moral frameworks of commercial surrogacy within the US, India and Russia. Sexual and Reproductive Health Matterrs, 29(1), 1–17. Smietana, M., Thompson, C., & Twine, F. W. (2018). Making and breaking families – reading queer reproductions, stratified reproduction and reproductive justice together. Reproductive BioMedicine and Society Online. doi:10.1016/j.rbms.2018. 11.001

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Somerville, S. B. (2005). Sexual aliens and the racialized state: A queer reading of the 1952 U.S. Immigration and nationality act. In E. Luibh´eid & L. Cantu´ (Eds.), Queer migrations, sexuality, U.S. Citizenship, and border crossings (pp. 75–91). Minneapolis, MN: University of Minnesota Press. Thompson, C. (2018). On separation: Reproduction in migra political times. In ReproSoc annual lecture. Cambridge: Cambridge University. Unnithan-Kumar, M. & Khanna, S. K. (Eds.). (2015). Cultural politics of reproduction: Migration, health and family making (1st ed.). Oxford: Berghahn Books. Vertommen, S. (2017). From the pergonal project to kadimastem: A genealogy of Israel’s reproductive-industrial complex. BioSocieties, 12(2), 282–306. doi:10.1057/ biosoc.2015.44 Wall, S. (2006). An autoethnography on learning about autoethnography. International Journal of Qualitative Methods, 5(2). Ward, J. (2018). The methods gatekeepers and the exiled queers. In D. Compton, T. Meadow, & K. Schilt (Eds.), Other, please specify: Queer methods in sociology (pp. 51–66). Berkeley, CA: University of California Press. Watkins-Hayes, C. (2014). Intersectionality and the sociology of HIV/AIDS: Past, present, and future research directions. Annual Review of Sociology, 40, 431–457. Wevers, R. (2018). Unmasking biometrics’ biases: Facing gender, race, class and ability in biometric data collection. Journal for Media History, 21(2), 89–105. Whitacre, R., Oni-Orisan, A., Gaber, N., Martinez, C., Buchbinder, L., Herd, D., & Holmes, S. M. (2021). COVID-19 and the political geography of racialisation: Ethnographic cases in San Francisco, Los Angeles and detroit. Global Public Health, 16(8–9), 1396–1410. doi:10.1080/17441692.2021.1908395 White, M. A. (2013). Ambivalent homonationalisms. Interventions, 15(1), 37–54. doi: 10.1080/1369801X.2013.770999 Wiegman, R. (2002). Intimate publics: Race, property, and personhood. American Literature, 74(4), 859–885. Wilson, A. (2012). Intimacy: A useful category of transnational analysis. In G. Pratt & V. Rosner (Eds.), The global and the intimate: Feminism in our time (pp. 31–56). New York, NY: Columbia University Press.

Chapter 10

A Balancing Act: Situating Reproductive Technologies Across Time in the UK Victoria Boydell

Abstract This chapter describes how ambitious, educated, professional women engage with a range of reproductive technologies across their lifetime in an attempt to achieve the much-lauded post-feminist ideal of the perfect ‘work-life balance’ and ‘having it all’. Drawing on interviews, this chapter shares women’s experiences of using several reproductive technologies over a 15year period and how their configurations of bodies, technologies and responsibilities change. In our initial conversations, bodies were seen as a source of disruption to well-laid plans; bodies bled, throbbed, conceived, aborted and were often incompatible with the many social expectations and demands on young women’s lives to balance their professional and private lives. At this time, women were attempting to control and direct their malleable bodies using different technologies, a tool, that were accompanied with new gendered responsibilities to make the right choices about if and when to menstruate, to get pregnant, to become a mother and to be intimate. Over time these technologies proved to be imperfect and often failed to deliver the promised future and a counter-narrative emerges in which bodies are not so malleable and technologies are less of tool and more of an additional burden. By looking at interactions of several reproductive technologies over time, experiences of bodies, of technologies and of responsibilities change; they are not static but more cumulative. Keywords: United Kingdom; reproductive technologies; neoliberal feminism; longitudinal qualitative research; work-life balance; refusal Early one afternoon in 2019, I sat with Anne, and it was the first time we had met in person since she participated in my original research project nearly 10 years

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earlier. After a series of emails to track her down, we coordinated our calendars and met at her office in London. Much like our conversations 10 years ago, we talked about how her experiences with reproductive technologies intersected with her professional and family life.1 Ten years on, she explained to me ‘It [life] is not a very exciting life at the moment’. Her sense of boredom with her life contradicted with the complicated demands on her time as a working mother of three children under 10 years. As our conversation unfolded, it quickly transpired how she was struggling with a taxing job in which she dealt with health emergencies in the UK (prior to COVID-19), how she was getting further professional qualifications to advance her career and how she was caring for her three children, as well as her ageing and recalcitrant mother. These different demands on her time often contradicted each other, and she felt that she was constantly failing on all fronts. The same sense of juggling expectations came through in our conversations a decade earlier when we were both in our late twenties. As an upwardly mobile young woman, she had been diligent in managing her career aspirations with her desire to start a family. At that moment, she was trying to figure out how she could ‘have it all’, and she asked me: ‘How can you fit in a baby with what you want to do?’ She was clear about how she was purposefully using contraception and then later a range of pre-pregnancy techniques to coordinate family with career. This awareness of managing often different expectations was a marked continuity over her life, yet how she understood and managed these tensions had changed. This expectation of carefully managing competing demands at work and at home – and the endless pursuit of balance between them was a common thread in the accounts of reproductive technologies across time in this study and points to a normative injunction that acts upon women to deftly combine their professional and private lives. In following chapters, I draw out the different ways that balance is expressed in relation to different reproductive technologies at moments. Regardless of the reproductive technology under discussion, women always described how they were trying to bridge the expectations about their public and private lives, which is associated with the contemporary feminine ideal in which women are expected to want, work for and ‘have it all’. But in taking a longer view, a counter-narrative emerges in which technologies are not a solution and promised futures are not possible as bodies and society are not so malleable to change. This paper draws from longitudinal qualitative research with the same women over a decade: the first interviews were conducted in 2007 and the second interviews in 2018. The initial research examined contraceptive use in five central London contraceptive services and how contraceptive use was entwined with broader social processes surrounding a generation of women who came of age when they were expected to successfully combine their personal and professional aspirations. No one talked about contraception on its own. Rather, contraception use was related to using pregnancy tests, having or avoiding abortions, and combined with some earlier generation of ovulation apps. These early emic

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insights about the interrelationship between technologies and the body being the unit of analysis, not the technology, shaped the analysis used here. As the initial research was set within a clinical setting, it was governed by strict clinical research ethics. Self-selected volunteers were informed about the study, the purpose and the use of data and have the ongoing right to withdraw. The young women who attended the clinics and volunteered to participate in this study were predominantly upwardly mobile, socially advantaged, white, middle class and university educated, and worked in the high-skilled professions. The majority of respondents shared the same social position as myself that engendered a high degree of empathy between us. Using a longitudinal design, I interviewed 12 of the same women 10 years later, and this time they talked about a wider range of reproductive technologies they had used in the intervening years and how this tied into in broader social expectations about combining their private and public lives. The majority of the women I spoke to went on to become working parents but about quarter opted not to have children. This kind of longitudinal approach brings unique insights as it allows us to examine individuals’ experiences with RTs over time and to distinguish between what are enduring traits from those that are more transient, and it is possible to explore how changes are differentially experienced and acted on by individuals and groups.

Balance and the Rise of Neoliberal Feminism When I started my fieldwork in central London in 2007, the UK was in the midst of an economic boom that was fed by a generation of educated young women who had come of age without the institutional and legal barriers of their forebears. This economic upswing was matched by the culmination of reforms that rewrote the social expectations for educated young women well beyond marriage and family and saw women quickly outpacing their male peers in education and the workplace. There were new representations of young women – smart, professional, confident, taking charge and making it on their own – that both challenged and excited public imagination. This moment is often described as ‘postfeminist’ as everything allegedly became possible for women, gendered inequalities had fallen away, and that women could ‘have it all’ – there was no longer a feminist struggle to be had.2 Feminist theorists, mostly drawing from media studies at the time, began to chart the changes in the feminist subject and the emerging new feminine ideals in this new context that actively encouraged women’s participation in the public sphere. Scholars reflecting on this noted how earlier feminist orthodoxies, which fought for the recognition of women in public roles, tackled the structural barriers to women’s public participation and disavowed any singular association of femininity with the private sphere, were replaced with popular discourses that the feminist agenda had now achieved. More recently, there has been a widespread and visible mainstream support for a renewed feminist cause. Public debates about women’s struggle to ‘have it all’ and ‘lean in’ from the likes of Sheryl Sandberg, Karin Slaughter and Michelle Obama are indicative of what

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emancipatory womanhood now looks like now – what Catherine Rottenberg (2020) has coined neoliberal feminism. A new generation of feminist scholars contested the argument that feminist agenda was complete and instead pointed out how feminism was being put to work for neoliberal purposes (Banet-Weiser, 2018; Gill, 2016; McRobbie, 2009). Angela McRobbie (2009) details the ‘new sexual contract’ as follows: to become equal and visible, young women were to take advantage of the opportunity to study, gain educational qualifications, work, gain control over their fertility, explore their sexuality and enthusiastically uphold the unrealistic demands of the ‘fashion beauty complex’ (Bordo, 1993; Wolf, 2013). This was a double-move, whereby mainstream feminism was co-opted and twisted by neoliberalism for its self-serving purpose (Fraser, 2013; McRobbie, 2009). Building on this scholarship, Catherine Rottenberg (2020) has charted these changes in what we consider to be ‘an emancipated woman’ (e.g. the feminist subject), from a woman who makes choices between her family and her profession (often associated with liberal feminism) towards a woman who can successfully combine the two and can bridge the expectations at home and at work, neoliberal feminism. Helpfully, she describes this new emancipated woman as ‘a professional woman able to balance a successful career with a satisfying family life’ (Rottenberg, 2020, p. 14). Central to our new ideas of an emancipated woman is ‘bridging’, the expectation that women to balance the public and private aspects of self, and perform as a worker and as a mother. The effort to keep these potentially powerful women on a particular normative path in the present so that they can ostensibly reap the fruits of the (self) investment in the future not only includes professional advancement and enhancement prescriptions but also injunctions regarding how to regulate and potentially explicit their reproductive capabilities. Women’s value as women and their individual futures and returns are still linked to being able to have children. (Rottenberg, 2020, p. 95) Balance, therefore, has become an internalised syntax through which to interpret one’s own experiences and to judge one’s successes and failures; its promissory nature directs women’s desires, aspirations and behaviours and hence constitutes neoliberal governmentality (Rottenberg, 2020). The valourisation of balance works to produce entrepreneurial subjects who invest and regulate themselves and are entirely personally responsible for their own and their families’ happiness and well-being. The individual responsibility for securing their well-being obscures the entrenched socio-economic or cultural structural causes of this inequitable division of labour between and within genders (Fraser, 2013; Rottenberg, 2020). Inspired by Wendy Brown (1995) and Joan Scott (2012), Rottenberg further elaborates how neoliberal feminism is tied up with ideas of ‘futurity’, where attention is focused on shaping the future through your present actions, rather

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than on any kind of immediate benefit. For example, a woman’s success and happiness are perceived to rest on her ability to carefully sequence her educational and professional achievements so as to firmly establish her career before she starts planning her family, which secures dividends in the future for herself and for her desired children. Over time, successful balancing transforms into the ability to be both an engaged and available professional and meet the expectation of intensive mothering at the same time. This sequence has become a culturally accepted and encouraged pathway that can yield promissory dividends of a ‘good life’. An emancipated woman’s ability to ‘balance’ and achieve fulfilment and happiness under the neoliberal feminism presupposes certain preconditions. This includes the opportunities to enter the public sphere, but it also assumes women can determine when they will get pregnancy, have a child and become a mother. I argue that the working of balance and the generation of the neoliberal feminist subject are underwritten by women’s perceived and real-world access to technologies through which they can control their reproductive physiology to align with other expectations. The wide availability of reproductive technologies has co-evolved with the many social reforms that gave rise to neoliberal feminism. In the 1960s, hormone replacement therapy (HRT) and abortion became available in the public sector; and by 1969 pregnancy tests were offered in local pharmacies. In the next 20 years, the oral contraceptive pill (OCP), emergency contraception, ultrasounds and medical abortion became freely accessible in Britain. In the early 2000s, three full cycles of in vitro fertilisation (IVF) treatment became available free of charge for women aged 40 who had failed to get pregnant after two years of trying. With this work, I hope to illustrate how the expansion and normalisation of reproductive technologies are part and parcel of emerging feminist subjectivities. Moreover, reproductive technologies share the same logic of futurity typical of neoliberal feminism. Adams, Murphy, and Clarke (2009) illustrate how an anticipatory logic, whereby ‘the present is governed, at almost every scale, as if the future is what matters most (248)’, refract futurity throughout reproductive biomedicine. They elegantly state: Anticipation, as a lived condition or orientation, gives speculation the authority to act in the present … Anticipation is not just betting on the future; it is a moral economy, in which the future is inhabited in the present. Through anticipation, the future arrives as already formed in the present, as if the emergency has already happened. (Adams et al., 2009, p. 249) Science and technology scholars have long noted how biomedical technology is bound with ideas about the future, aspiration and ‘the political economy of hope’ (Clarke, 1998; Novas, 2001; Rose, 2007). Reproductive technologies are no different. They are a source of optimism and hope and a means to act on or bring about certain desired futures (Franklin, 1997, 2013; Rapp, 1999; Sheoran, 2015; Thompson, 2005). Buhler and Law and Hudson in this volume make a similar

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point about reproductive technologies, namely assisted reproductive technologies, as wound up with people’s hopes and aspirations for the future. Similar neoliberal logics are at work in biomedicine and in feminist subjectivities, and reproductive technologies bridging them both, in practices, experiences and temporality. Feminist scholars examining new subjectivities under neoliberal feminism provide us highlights of useful theoretical tools for understanding the experiences and imaginaries surrounding women lives, including reproductive technology. But as Shani Orgad (2018) has argued, the key advances in feminist scholarship on feminist subjectivities are drawn from the insights of media studies, where the objects of study are visual or textual representations, with much less emphasis on women’s lived and embodied experiences. In this chapter, I hope to further contribute to our understanding of how feminist theory relates to women’s lived experiences, and vice versa. The language of balance manifests itself in many more ways than is currently elaborated in feminist scholarship. These subjective accounts of balance enrich those of text driven conversation in feminist theory.

Trying to Achieve Balance with Technologies Balance was often expressed when women were describing circumstances when they were handling competing expectations and demands, most frequently related to the tensions between their professional and reproductive responsibilities. How balance was described or expressed varied. At times, it was the outcome of studied and meticulous planning; at other times, it was more an ad hoc real-time response to ceaseless demands. There are many valences to balance, each with a unique configuration of private and public selves. Since our first conversations, or when reflecting back on their younger selves, the sense that they needed to balance their public and private selves came across in conversations about reproductive technologies. A typical example was when describing using modern contraceptives to postpone pregnancy until they had completed their higher education and established their career. Reproductive technologies, particularly those related to contraception and abortion, were understood and used to anticipate the future by investing in the present education and professional opportunities in order to reap dividends in the future and hence, a means to balance women’s professional and parental expectations. In her late twenties, Anne, who was introduced earlier, was inspiringly ambitious and wanted a career in global public health. She fastidiously planned her work experience to ensure that she presented well on her CV; she had obtained a master’s degree from a leading university, worked as an intern overseas and worked for a charity. When we met, she was not quite ready for children because she wanted to reach a particular position in her career first. Anne told me: It is so difficult for women. You want to have a career, but you want to have children. When do you do this? You’ve got to find the balance, and some will put it off … It’s not putting it off, because I’ve consciously decided that in two years’ time, I’d say, I will be

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ready to start to think about having children. It’s just that not getting pregnant is really convenient and useful and beneficial in all sorts of ways. For Anne there was no question of not having a child and a successful career; becoming a mother would require investments now and then entail changing her priorities as her life would start to revolve around a child, much in line with the expectations of intensive mothering (Hays, 1998). She was carefully planning for her future and responsibly protecting against any risks such as unexpected pregnancies. This was such a serious consideration for her that she used condoms and OCPs simultaneously for eight years with the same sexual partner. Heidi was a similar age when we met, and she was equally ambitious. She had moved from rural Wales to London to start a successful media career, and each time we met over two years, she had been progressively promoted at work. At the time, she was petrified of getting pregnant as it would affect her personal and professional life, so much so that she also used condoms and the pill at the same time. At 28, she felt it was not the right time to get pregnant: If you worked hard and you try to do right in school and you try to get a higher education, and you try to get a good career, and then you want somewhere to live, you have to pay an unrealistic amount to get the smallest flat that you can get … It is something that I feel quite frustrated about … and then if you leave having a child a bit later, then you get potentially criticised for that whole sort of body cost thing, and then all these sorts of risks come in. A bit of a minefield really, to be honest, I don’t know … If you’re talking about a woman, as an animal, as a reproductive mammal, then I think that between the ages of 16 and 25 is probably the best time to have a child. But if you’re talking about bringing up a child and having a roof over their head and you’re not a single mother in south Wales and you actually want to buy somewhere and look after them that way, then most women wait until their 30s. Anne and Heidi’s efforts to carefully balance their careers and future families using contraceptive technologies mirror Rottenberg’s description of balance: they were making smart and responsible investments in the present for returns in the future. This future-focused rationality has long been noted as trait of contraception, where an entrepreneurial logic is played out in the assumption of a rational and responsible self-regulated individual assessing the risks that she might get pregnant and the risks of being pregnant (Murphy, 2017; Paxson, 2004). The use of reproductive technologies to achieve balance was also expressed in another way. Here women believed that they had over-invested in their careers and put their chances of having children at risk due to age-related infertility. Again the focus of these efforts is to shape an anticipated lifecourse. Anne also expressed this configuration of balance. Much had happened since Anne and I

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had first spoken. In our later conversations when she was 35-years old, she stopped taking the pill which she has been on continuously for 16 years. She felt she had reached a time in her career where she was more established and she was safely eligible for full maternity leave, and she felt more settled with her partner of 10 years. She married her partner of, stopped taking the pill and started to prepare her body for her long-anticipated pregnancy. She quickly got pregnant with her first and second child, and at 38, anxious about her age, she decided to try for a third. When she did not get pregnant immediately, as she had previously, she tried to predict her fertility using ovulation test strips. When this did not work, she became anxious that she had left it too late; she felt a ‘little bit old’, and she managed to convince herself that she was pre-menopausal. For the first time in her life, she went to a private clinic and paid to have a series of a fertility test. Once pregnant, her age-related anxiety about her fertility got the better of her again, much like those couples in Switzerland in Nolwenn Buhler’s chapter in this volume, and she returned to the private clinic to test for foetal abnormalities, which again had clear results, and she continued with a healthy pregnancy. In contrast to her younger ideas about balance, Anne used reproductive technologies to counterbalance her perceived over-investment in career that now threatened her desired reproduction. Sarah had a different story. We met when she was 24-years old and had moved from a Mediterranean island to London to work in TV production. When we first met, she was not ready for children and was using contraception to responsibly plan her private and professional life. She explained: I haven’t lived my life enough to just start devoting it to, you know. I know I would give everything up for a little baby but I’m not ready. I want to build my career, I want to make more money, and then start thinking of having a family. Maybe moving back to [the Mediterranean], because living in London and bringing up children is the worst thing … My career comes first. When we spoke again, she was 37 and had set up her own award-winning documentary production company in London and worked remotely from her family home in the Mediterranean. In our recent conversations, her sense of balance had dramatically shifted. She felt that when she had focused on establishing her career, and in that time, her egg quality had ‘taken a nosedive’. At first she was anxious about how a pregnancy could limit her career, and her anxiety then changed to how her demanding career was costing her fertility and family life. A specialist in her home country suggested that she start her first course of in vitro fertilisation, which resulted in a sole ‘perfect AA egg’ that she carried to term. Sarah blamed this imbalance between her desired career and family on her career ambitions. She remarked:

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When people used to say, ‘Oh, 35, nosedive’, you never think it would happen to you. I’m pretty healthy, I really don’t drink, I go to bed early. I still don’t understand why it’s happened to me. Perhaps stress, work: probably more that than anything. Sarah blames herself for not being more responsible and is very aware of how the imperative to balance changed. She reflected on the irony of how her ideas about balance had shifted from her twenties to her thirties: I think the time limit that women are given is … the hardest thing to get your head around. It’s something that all my friends talk about, like, ‘I’m nearly 39 and I haven’t had a baby yet’. It’s this pressure all the time of having to have it all and worrying about it. These different valences of balance all relate to the same structural tension between the private and public aspects of self. Wendy Brown (1995) and Joan Scott (2012) argue that the dichotomous domains of public and private continue to provide a robust infrastructure in liberal economies where the public sphere is associated with autonomous and self-determining individuals freely acting out their rights, which as gendered male, and remains separated from the private realm of the familiar, needs and affect that is identified with women. Despite many attempts to chip away at this artefact, it is still impossible to think about or organise contemporary life that does not involve the public/private opposition in some way or another. Here, emancipated women have to split their identification between private and public and actively try to bridge the free-choosing public self with their private relational subjectivity. This same tension between public and private and the need to bridge them was also present in how women talked about their bodies. When Anne started taking the OCP in her late teens, she did so to manage her irregular and painful period and bad facial acne. She explained how she felt that her body did things on its own accord and affected how she interacted in public spaces: ‘I am not actually that vain, but it (acne) just really affected me. I didn’t want to go out, I felt really embarrassed, I felt low self-esteem and it [taking the pill] helped with that. I feel more confident to face the world’. Heidi also started the OCP in her late teens because her heavy menstrual periods made her deeply self-conscious. What was happening with her body was out of her control and made her feel that she couldn’t go out and do ‘normal’ things: When you are younger, you are often in very restricted environments. My job used to be really strict about what hours you had to be in, and when you are in uni, you are in lectures for three hours at a time. So just that inflexibility makes you want to be more in control, whereas now, if I have an irregular period and I am not prepared for it or whatever, I can excuse myself and go around [the supermarket] and everything is okay.

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The private functions of the body associated with the reproductive process jar with the expectations and constraints of a public environment that both of them expected and intended to inhabit. Here women use reproductive technologies to control the private functions of the body, so they no longer surfaced in public spaces. The relief of balancing the private and public is well expressed by Heidi when she described how she started the OCP: ‘To be able to decide what I wanted to wear or where I wanted to go and not having to necessarily worry about it’. Women’s split identification between the private and public spheres and the need to bridge this tension is embodied. Regardless of their age or life stages, the respondents always talked about their bodies needing to be managed or controlled. Menstruating, lactating and menopausing bodies were intruding on their aspirations and plans or attempts at achieving balance. Iris Young and Susan Bordo, among others, argue that female bodies, which unpredictably menstruate, procreate and lactate, are ‘ruled out of order’ (Bordo, 1993) in a way that male bodies are not. In both cases, RTs are the tools by which to control and determine bodies, and reproduction, in line with other social expectations and mores. Balance, in its many valances, was accompanied by a strong sense of personal responsibility for making the embodied right choices to bridge the public and private selves. Sarah who experienced age-related infertility felt the weight of her responsibility for reproductive outcomes: So I’m not having to worry about quality and if I drink a glass of wine, will this affect the quality [of eggs] … You sit there and you feel, you look back on your life and you do have regrets of why it happened four years ago… And yeah, of everybody I know, I’m the healthiest, I’m the fittest, and it’s just like … Yeah. I just don’t know what I could’ve done. This personal responsibility was ‘just biology’ and simply one of those ‘facts of life’. This tension and its management are a personal responsibility akin to the personal responsibilities to optimise health and minimise risks away from the state that is typical of bio-citizenship (Rose & Novas, 2005). Moreover, this is a gendered process. Amrita Pande and Tessa Mol (2018), drawing on the experiences of travelling egg providers in South Africa, illustrate how the expansion and normalisation of new technologies disproportionally place the obligation on the women involved. Gendered bio-responsibilisation points to the gender nature and consequences of individual responsibility in context of bio-citizenship.

Counter-Narratives of Imbalance, Compromise and Contestation Having recently been all-consumed by a strict regime of fertility treatment and workplace hostilities towards working mothers, Sarah was embittered about how her life had worked out. She had worked hard to responsibly plan and follow the preferred pathway by using a range of reproductive technologies, self-investment

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and chasing the perfect balance in the timing of her career, her marriage and her pregnancies. But the future she had anticipated that she had been working towards crumbled away. She felt cheated: I had no idea. No idea … I feel like I’ve grown up or just been hit with a massive reality check. I think, people don’t know enough, and that’s the sad thing. I wish doctors would give more guidance to women over 30 or even younger. If I had the chance, I would have frozen my eggs at 28 and would never have to go through these … mental and physical changes and pressures. She was remorseful about having focused on her career over childbearing: I would have thought about things. I probably would have tried to have children sooner. I wouldn’t have been able to afford IVF seven years ago, that’s for sure. But I would have thought about things differently. I would have probably tried to plan my life out a little bit better. There was a sense of powerlessness over lifecourse and bodies in her experience; the body was not as malleable to the control and self-determination encapsulated in the syntax of balance. The breakdown of her anticipated future, despite her best efforts, made her question the idea of balance itself and the feminist subject. She described how she began to question her control and anticipate and blaming herself: There’s nothing you can do, and nature takes its course and you lose it. And you don’t get a reason why and you sit there blaming yourself. Maybe it’s because I walked too much down the road, or maybe it’s because I didn’t sleep well, or maybe I ate something. You start questioning everything. In contrast, Anne thought of herself as lucky with her three healthy children, an interesting job and a committed long-term partner. However, there was a tinge of regret in how she talked about her life. The career she had so intently invested in had suffered since becoming a mother of three. She thought she would be more senior in her career and was not getting any of the posts she applied for. When we spoke, she was doing an additional qualification to help secure the more senior roles on top of raising three children and a full-time job. She explained: ‘[Further education is] a good thing to do, but it’s putting pressure on family life at the moment, definitely. I work at the weekend. I work in the evenings. I would feel like I’ve achieved something at the end of it’. Accounts of miscarriages, unplanned pregnancies, pregnancy complications, the havoc of polyps, cysts and fibroids and mortal dangers surrounding childbirth appear to chip away at the belief that you can control your body and reproduction and technological interventions do not necessarily provide the solution or

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lead to the desired outcomes. Family responsibilities coming into direct conflict with expectations at work, the demands of coordinating costly childcare and the resentment that children are being raised by other women were a few of the frustrations, limits and compromise associated with pursuing balance that were a far cry from the promised well-being and happiness. The promised dividends of balance and the years of working for an un-obtained desired future that underpin the neoliberal feminist subjectivity are presented as hollow promises. In reality, the workplace had not adapted and had remained inflexible to family responsibilities, actively discriminated against them; many losing their jobs or respect in the workplace following a pregnancy (Orgad, 2018; Williams & Dolkin, 2012). Anne talked about how people in her workplace were unsympathetic or oblivious to working moms, who had often been up for several hours and had already organised the day for the rest of the family before their workday even began. She talked about her desire to be further advanced in her career and pursuing advanced professional qualifications to move forward, which ate into her time and attention at home. She carried a deep sense of guilt towards her children: I feel like I want to be a better parent. I feel like I do spend too much time working. I spend too much time either tired or ratty and I would love to, when I come home, just not be thinking, ‘Oh God. I need to get to bed and then I need to think about getting everything ready for tomorrow, and is there enough food in the fridge?’ I feel like I’m constantly thinking about the next steps and I just want to play a game with them or do whatever it is that they want to do. I don’t often do that half an hour of Guess Who or whatever game. Here the anticipatory logic of balance shifts gears. Anticipating when her career will be stable enough to have a child is anticipation at the level of the lifecourse whereas there is also that the more immediate anticipation in daily life, for example, what food is in the fridge for dinner, have the kids finished their homework, what is tomorrow’s workday, etc., the more pragmatic character of balance. Sarah had similar struggles as a working mum, and her commitment to her career came with guilt towards her children and her failure to meet the standards of intensive mothering: The guilt of having somebody else feed them, change their nappy, put them to sleep, be there when they cry. Yeah. I would hate coming home from work and the nanny telling me, ‘Oh, she did this today. Oh, she said this word today’. You know. And you’d be like, hmm. Or she would come and I could hear her say ‘Mama’ to the nanny, you know. That’s hard too.

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The guilt coexisted with her love of her job and company she had built. She told me, ‘I’ve done way too much to get to the point where I’ve got to and I’m not going to give it up now’. Ensuring this balance was not as straightforward because, after four months of maternity leave, she came back to work to find she had been replaced by her maternity cover and she had to fight to keep her position in her own company. ‘I refuse to allow myself to lose everything that I have built up. I am not losing this job’, Sarah said. Mounting social and physical disappointments accumulated and undermined the anticipatory logic driving balance as the promised returns are not delivered. Moreover, the structural and biological constraints that curtail women’s ability to act on their personal choices become more evident. The metaphor of futureoriented balance, which implies the perfect and successful blending of two countervailing forces, becomes a language of compromise characterised by acceptance of less than desirable situations and a shift in understanding of where responsibilities lie for outcomes. Abandoning balance and recognising the evitability of making compromises did not mean concessions or lead to acceptance or defeat for the women I spoke to, but rather created new possibilities and tactics of contestation. For example, Anne had previously thought that reproductive decisions were a woman’s responsibilities, but the physical costs of reproduction altered her thinking about this. She told me: ‘We have the babies. We carry them, we breastfeed them if we can. My body, oh my goodness, after three kids will never be the same again. Of course, it’s an amazing body, and I feel, well done, but the man, nothing. They can sail through those years without physical harm’. She now wanted her partner to take on some of the burdens and make things more equal. In a gesture of resistance, she was stubbornly refusing to find a contraceptive method, and they were forced to use condoms or withdrawal because she wanted to ‘share the responsibility now and I think that what I am trying to do’. Whereas Anne had focused on challenging her own personal circumstance, Sarah had a wider social justice agenda. She wanted to warn other women about the dangers of the ‘balance’ pathway. She regularly told her family and friends about age-related fertility decline so no one would get caught out. She said: ‘I’m really pushing for people my age, or a bit younger to go and get tested. More than this, as a senior executive, she has been actively implementing new workplace policies that support working mothers’. Sarah also explained: Over the last couple of years, there is this allowance of flexible working and I’m very much trying to help women who have been in the industry to get back in the industry. So, at the moment, I’ve got two women who do job share. It’s not a great situation, but I’m willing to try to help to get these people back into working again. And all of my managers, practically 80% of them, are mothers and they’ve been offered other work elsewhere. And they say to me, the only reason they want to continue working with me is because I

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For Heidi, the veil of balance fell away much earlier, and many previously unthinkable possibilities emerged for her. When I called her after 10 years, I expected that she would have children as she worried at length about how she would time her career and start her family. But something changed in her early thirties; she had definitively decided not to have a child. There was a crisis moment for her: her period was late, and she suspected that she might be pregnant. Her then-partner told her that if she was pregnant, they would get married. She vividly recalls her thought process while she was waiting for the pregnancy test results: I think probably after that moment where I realised that when I was doing the pregnancy test, I wasn’t hoping for a baby, I was hoping to get married. This is a horrible thing to say, for me to hear myself say it, it was almost like … it was a weird situation, the idea that having a baby would be the only way that I could get my partner to commit to me and I really loved him, but he was very non-committal. I really, really loved him and … I think that just clarified for me where my priorities were, that I’m peeing on this stick thinking I want it to be positive because then I could get married. That’s a sad situation. I know some people might have said, ‘Well, if I was pregnant and I was in the wrong relationship, then I would be excited to be bringing up the child anyway’. I had no excitement about the idea of bringing up a child. I only had excitement about the fact that if I was pregnant, my partner would commit to me. The potential unplanned pregnancy had been a watershed moment: she realised that she did not want children and, therefore, she no longer needed to seek balance. She had been very explicit about her decision and how sharing her decision forced people to question their assumptions: ‘I think it makes people reflect on their lives. One of my friends said, “I didn’t know I had a choice about not having children”. Nobody came to me and gave me that option’. Because of her decision not to have children, she has been featured in a national tabloid newspaper and has been mercilessly trolled ever since. She feels that this choice has levelled the playing field: ‘All of the absolutely rubbish excuses that people use when they want to discriminate against women are not legitimate with me. They’re not legitimate, anyway’. Her decision-makes her feel ‘fierce and quite powerful and like I want to fight on behalf of women’s rights even more than I ever did’.

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Reflections These accounts of reproductive technologies bear witness to the rise and magnitude of neoliberal feminism subjectivity outlined by feminist scholarship. Balance and the need to bridge the private/public divide is a powerful and pervasive syntax that runs across conversations of reproductive technologies. These accounts of reproductive technology in context of neoliberal feminism speak to need for a contextualised analysis of reproduction. This very much speaks to the situated nature of technologies. In her study of how people in rural Scotland think about reproduction and assisted reproductive technologies, Katharine Dow (2016) has pointed how reproductive technologies are inseparable from wider imaginaries, values and principles of social, political and ethical life. She argued that reproduction is not in reality relegated to the private or domestic domain. We need to study it as a part of life, tracing the imaginaries, values and principles that structure reproduction, as well as how reproductive experiences shape other parts of social, political and ethical life; how RTs relate to social norms, and how norms are reaffirmed but also come to be part of embodied practice. In a related vein, these longer-range accounts illustrate two interrelated considerations for our understanding of bio-citizenship. Firstly, drawing on subjective accounts and using an emic understanding of technologies, it is clear that several technological interventions happen to one body over time and it can be analytically worthwhile to switch the unit of analysis from the technology to the body that experiences multiple technological engagements. With the body as the analytical starting point, we see that bio-citizenship is not only gendered but cumulates and evolves over time. By looking at interactions of several reproductive technologies over time, experiences of bodies, of technologies and of responsibilities change; they are not static but more cumulative.

Notes 1. Here, I refer to reproductive technologies as a broad category that could include includes pharmaceuticals, devices and digital applications, clinical and diagnostic procedures that intervene in the biological and social process of having or not having children (Almeling, 2015; Murphy, 2017). 2. The original reference is taken from Helen Gurley Brown (1995) ‘Having It All: Love, Success, Sex, Money…Even if You’re Starting with Nothing.’

References Adams, V., Murphy, M., & Clarke, A. E. (2009). Anticipation: Technoscience, life, affect, temporality. Subjectivity, 28, 246–265. Almeling, R. (2015). Reproduction. Annual Review of Sociology, 41, 423–442. Banet-Weiser, S. (2018). Empowered: Popular feminism and popular misogyny. Durham, NC: Duke University Press.

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Bordo, S. (1993). Unbearable weight: Feminism, western culture, and the body. Berkeley: University of California Press. Brown, W. (1995). States of injury: Power and freedom in late. Princeton, NJ: Princeton Press. Clarke, A. (1998). Disciplining reproduction: Modernity, American life sciences, and the problem of sex. Berkeley, CA: University of California Press. Dow, K. (2016). Making a good life: An ethnography of nature, ethics, and reproduction. Princeton, NJ: Princeton University Press. Franklin, S. (1997). Embodied progress: A cultural account of assisted conception. London: Routledge. Franklin, S. (2013). Conception through the looking glass: The paradox of IVF. Reproductive BioMedicine Online, 27, 747–755. Fraser, N. (2013). The fortunes of feminism: From women’s liberation to identity politics to anti-capitalism: From state-managed capitalism to neoliberal crisis. London: Verso Book. Gill, R. (2016). Post-postfeminism? New feminist visibilities in postfeminist times. Feminist Media Studies, 16(4), 610–630. Hays, S. (1998). The cultural contradictions of motherhood. New Haven, CT: Yale University Press. McRobbie, A. (2009). The aftermath of feminism: Gender, culture and social change. London: Sage. Murphy, M. (2017). The economization of life. Durham, NC: Duke University Press. Novas, C. (2001). The political economy of hope: Patients’ organisations, science and biovalue. Paper presented at the postgraduate forum on genetics and society, University of Nottingham, June 21–22, 2001. Orgad, S. (2018). Heading home: Motherhood, work and the failed promise of equality. New York, NY: Columbia University Press. Pande, A., & Moll, T. (2018). Gendered bio-responsibilities and travelling egg providers from South Africa. Reprod Biomed Soc Online, 19(6), 23–33. doi:10.1016/j. rbms.2018.08.002 Paxson, H. (2004). Making modern mothers: Ethics and family planning in Urban Greece. Berkeley, CA: University of California Press. Rapp, R. (1999). Testing women, testing the fetus: The social impact of amniocentesis in America. London: Routledge. Rose, N. (2007). The politics of life itself: Biomedicine, power, and subjectivity in the twenty-first century. Princeton, NJ: Princeton University Press. Rose, N., & Novas, C. (2005). Biological citizenship. In A. Ong & S. Collier (Eds.), Global assemblages (pp. 439–463). Malden, MA: Blackwell Publishing. Rottenberg, C. (2020). The rise of neoliberal feminism. Oxford: Oxford University Press. Scott, J. (2012). The vexed relationship of emancipation and equality. History of the Present 2(2), 148–168. Sheoran, N. (2015). ‘Stratified contraception’: Emergency contraceptive pills and women’s differential experiences in contemporary India. Medical Anthropology, 34(3), 243–258. doi:10.1080/01459740.2014.922081

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Thompson, C. (2005). Making parents: The ontological choreography of reproductive technologies. Cambridge, MA: Massachusetts Institute of Technology Press. Williams, J. C., & Dolkin, J. (2012). The opt out revolution revisited. In B. D. Jones (Ed.), Women who opt out: The debate over working mothers and work-family balance (pp. 151–176). New York, NY: NYU Press. Wolf, N. (2013). The beauty myth: How images of beauty are used against women. New York, NY: Random House.

Reflection Three: Relationality Victoria Boydell and Katharine Dow

Abstract Here we provide a short reflection on the persistent theme of relationality in reproductive studies which allows us to draw out further insights from each of the chapters. Keywords: Relationality; kinship; children; gender; comparative methods; reproductive technologies Biomedicine and its affiliated technologies tend to focus on individual bodies and behaviours as the locus of investigation, intervention and data. This focus on the individual as the unit of analysis can bleed into the study of biomedicine and its technologies by social scientists, threatening to obscure the relationality surrounding reproductive technologies (RTs). We draw inspiration from Petra Nordvist’s suggestion that individual reproductive practices and identities need to be understood within a web of relationships. This means shifting our analytical focus from the individual to ‘the connections, relationships and processes of relating that frames [people’s] lives’ (Nordqvist, 2021, p. 5). As Nordqvist reminds us, reproduction literally brings people into relation to each other and creates relations. Another important dimension of relationality is the connections, relationships and processes of relating between RTs. The chapters in this section describe how different technologies relate to each other and how their development and uptake has been driven by particular ideologies and values. The chapters in this collection highlight a range of connections, relationships and processes of relating provoked through engagement with RTs. They also remind us that relationality is often what provoke these engagements in the first place. Most obviously, these can be around relating as potential parents and as a couple. Several chapters in this book highlight these forms of relationality, bringing to the fore the gendered dimensions of engaging technologies as well as the fact that they are not only used by individuals. But, recalling the metaphor of the concentric circles surrounding an individual outlined in the introduction, relationality can be broader, too. This is illustrated by Ben Kasstan’s chapter, Technologies of Reproduction Across the Lifecourse, 203–206 Copyright © 2022 Victoria Boydell and Katharine Dow Published under exclusive licence by Emerald Publishing Limited doi:10.1108/978-1-80071-733-620221016

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which focuses on medical practitioners and their relationships with both their clients and broader cultural and religious mores. Kasstan cites Kate Hampshire and colleagues’ point that, ‘social and kin relations are important not only in shaping responses to infertility; they are also pivotal in the processes through which reproduction (or lack thereof) becomes defined as problematic in the first place’ (Hampshire, Blell, & Simpson, 2012, pp. 1050–1051). Relationality therefore brings us back to the importance of different forms of knowledge and the complexity of choice already established in earlier chapters. As the chapters in the previous section show, RTs, like all technologies, have their own histories. The chapters in this book reflect the fact that some technologies have been consistently developed and improved, in a sense creating new generations of the technology as well as new generations of people. Others have not reached the drawing board, stalled in development or been replaced. As the chapters by Han, Wilson, Whitacre and van de Wiel show in particular, the ‘choice’ of which technologies to prototype, develop or enhance is not random, but infused with particular ideological, financial and governmental aims. A reproductive justice lens prompts us to ask why private investment is poured into technologies like IVF ‘add-ons’ and egg freezing, while access to abortion continues to be politicised and restricted for some patients, and regimes of forced sterilisation, particularly targeted at women of colour, have been reported in Californian prisons and immigration detention centres in the state of Georgia (Jindia, 2020; O’Tootle, 2020). These and other current instances of reproductive injustice such as Uyghurs being forced to submit to sterilisation and contraceptive technologies (BBC, 2020), despite the lifting of the One Child Policy and the vast take-up of assisted reproductive technologies (ARTs) by non-Uyghurs in China, remind us that RTs have long been, and continue to be, used for eugenic aims. These points have been poignantly articulated through analyses of the ramifications of transatlantic slavery and the specific sexual and reproductive violences that this regime effected (Davis, 2019; Hartmann, 2016; Weinbaum, 2019). In addition to demonstrating abhorrent necropolitical and genocidal aims, all of these instances of injustice deny the targeted groups of relationality and cut them off from their capacity to make and nurture future generations, and this has deep and long-lasting effects for those personally affected as well as for demography and politics. Comparing technologies, including those that seem to have dissonant aims, can surface commonalities, whether in research and development or in distribution models. Studies of RTs have not only tended to focus on individuals but also, more specifically, on women (Almeling, 2020; Inhorn, 2020). As Amanda Wilson’s chapter shows, examining technologies that are aimed at men reveals implicit gendered assumptions about men’s part in reproduction, namely their passive role, so that most clinics do not even have policies about recording clinical information about men. Rather, male-oriented technologies, such as Viagra, perpetuate heteronormativity and hegemonic masculinity, associating men with virility rather than (in)fertility, while RTs are mainly targeted at female bodies. Alongside this, in many cultural contexts, men are more likely to be viewed as standalone individuals compared to women, yet research on men and (in)fertility

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shows this does not represent reality (Inhorn, 2020). Powerful gendered norms shape the representation of men within reproductive research and consequently the type of technologies that are, and are not, developed. Yet, men are also important consumers of RTs, whether as partners or as single fathers, and refusing to recognise this in production development and provision of services surely only bolsters persistent gender imbalances in domestic and care-giving labour. As noted in the introduction, reproductive justice focuses on three rights, which can be summarised as the right to facilitate a pregnancy, the right to prevent a pregnancy and the right to raise children in healthy environments. Ryan Whitacre traces the techno-scientific histories of three pharmaceutical RTs which reflect these three rights, through ovulation induction, hormonal contraception and prevention of mother-to-child transmission of HIV/AIDS, and shows how they have been infused with intimate ethics. Intimacy, understood as ‘the messy life worlds of individuals, partners, strangers, romantic others, and couples, who carry a set of ethical and affective dispositions that draw one person to another’ [p. 247] is written into the very making of RTs, even those with quite different aims. This clearly resonates with Mackenzie’s chapter in this volume, which develops her concept of structural intimacies (Mackenzie, 2013), articulating how structural inequalities shape intimacy and, thereby, conditions of possibility for health and reproduction. Whitacre adds another layer to this, showing how intimacy is integral to invention, including in clinical research, where intimacy is a form of clinical labour, and how intimacy figures in the development of measures of efficacy. Lucy van de Wiel’s chapter also focuses on the development and provision of technologies and compares technologies with contrasting aims. She details how the booming egg freezing industry, which is reaching women through marketing and insurance packages, contrasts with the provision of medical abortion through telemedicine. Despite their differences, her comparison shows shared concerns and connections between the technologies and their provision, including the role of anti-abortion sentiments in shaping the current and future landscape of assisted reproduction, the politics of safety in reproductive care, the role of hidden financial flows in organising the availability of reproductive care and the significance of online platforms in disrupting fertility in the twenty-first century. Building on the many excellent studies of reproductive substances and how they have come to matter and materialise in the history of reproductive studies, van de Wiel analyses how the embryo and its politicisation and commercialisation in the (post-)Trump administration in American context leads to very different environments and regimes of governance for particular RTs and the substances which they animate. Comparative methods could, then, be seen as form of methodological relationality. Comparative research allows researchers to take relationality into account in designing and carrying out their studies. It is also a way of incorporating relationality into methodology, which we believe resonates with intersectional feminist approaches. For example, we could imagine two different studies by two different researchers, one which looks at experiences of teen pregnancy

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and the other at egg freezing. Immediately, we might imagine the rather different research participants and the different challenges of recruiting and doing research with them, such as assumptions that the former group might be ‘hard to reach’, while the latter might be ‘too busy’ to engage. If we think about the themes that each imaginary project raises, including gendered norms of reproductive age(ing), stratified reproduction, sexual moralities, unequal access to healthcare and ideologies of ‘good’ mothering, we can start to see how these apparently very different sets of research participants are in fact subject to many of the same expectations, pressures and anxieties, even while their own subject positions afford them more or less agency overall. In other words, we see another goal of integrated research to be about creating opportunities to listen to and understand other perspectives. An integrated approach aims to build solidarities between those with more or less privileged, as part of an attempt to transform society and effect reproductive justice.

References Almeling, R. (2020). GUYnecology: The missing science of men’s reproductive health. Oakland: University of California Press. BBC. (2020). China forcing birth control on Uighurs to suppress population, report says. BBC. Retrieved from https://www.bbc.co.uk/news/world-asia-china-53220713. Accessed on June 29, 2020. Davis, A. D. (2019). Reproductive injustice: Racism, pregnancy, and premature birth. New York, NY: NYU Press. Hampshire, K. R., Blell, M. T., & Simpson, B. (2012). ‘Everybody is moving on’: Infertility, relationality and the aesthetics of family among British-Pakistani Muslims. Social Science & Medicine, 74(7), 1045–1052. doi:10.1016/j.socscimed. 2011.12.031. Epub 2012 Feb 3. PMID: 22349077. Hartmann, B. (2016). Reproductive rights and wrongs: The global politics of population control. Chicago, IL: Haymarket Books. Inhorn, M. C. (2020). Reproducing men in the twenty-first century: Emergent masculinities, subjectivities, biosocialities, and technologies. NORMA, 15(3–4), 299–305. doi:10.1080/18902138.2020.1831157 Jindia, S. (2020). Belly of the Beast: California’s dark history of forced sterilizations. The Guardian. Retrieved from https://www.theguardian.com/us-news/2020/jun/30/ california-prisons-forced-sterilizations-belly-beast. Accessed on June 30, 2020. Mackenzie, S. (2013). Structural intimacies: Sexual stories in the Black AIDS epidemic. New Brunswick: Rutgers University Press. Nordqvist, P. (2021). Telling reproductive stories: Social scripts, relationality and donor conception. Sociology. doi:10.1177/0038038520981860 O’Toole, M. (2020). 19 women allege medical abuse in Georgia immigration detention. LA Times. Retrieved from https://www.latimes.com/politics/story/2020-10-22/ women-allege-medical-abuse-georgia-immigration-detention. Accessed on October 22, 2020. Weinbaum, A. E. (2019). The afterlife of reproductive slavery. Biocapitalism and Black feminism’s philosophy of history. Durham: Duke University Press.

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Chapter 11

‘Well, She’s Entitled to Her Choice’: Negotiating Technologies Amidst Anticipatory Futures of Reproductive Potential Ben Kasstan

Abstract This chapter critiques the relationality between care and context to demonstrate how notions of routinised technologies are disrupted when considering the reproductive realities and situated constraints of ethnic and religious minority women. The chapter integrates ethnographic and qualitative data from two minority contexts, including maternity care provision for Orthodox Jews and how providers approach requests for sex-selective abortion (SSA) when caring for women from South Asian backgrounds. By examining responses to caesarean sections and abortion care among ethnic and religious minorities in the United Kingdom, the chapter critiques how routinised interventions are entangled in the anticipation of future reproductive potential. The idea of anticipatory futures serves as a reflection on the reproductive lifecourse, where technologies carry opportunities and implications that women and carers alike are tasked with negotiating. Taking inspiration from the reproductive justice framework, the chapter builds on a body of work that demonstrates how the concept of ‘choice’ is contingent and not inclusive of the situated constraints that can affect the reproductive lives of women from minority backgrounds. By delving into everyday reproductive constraints, the chapter raises implications for what inclusive woman-centred (or person-centred) care can involve, how providers approach ‘choice’, autonomy and justice in practice, and how their considerations reconfigure the otherwise ‘routine’ delivery of reproductive health services and technologies. Technologies increasingly invest the reproductive lifecourse with potential and anticipation, and the chapter calls on feminist

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scholars to understand the dilemmas posed for inclusive models of care beyond the discourse of ‘choice’. Keywords: Abortion; childbirth; choice; minorities; reproductive future; routinised technologies Anthropologist Marcia Inhorn has argued that ‘In understanding women’s health concerns, health scientists and policy makers must take heed of the fact that context does matter—that health research and interventions aimed at changing women’s behaviour must take into account the broader conditions shaping women’s lives and women’s resultant (in)ability to enact health-promoting changes in their living conditions and actions’ (2006, p. 348). This chapter demonstrates the centrality of situated relationships in understanding the reproductive realities and situated constraints of ethnic and religious minority women vis-`a-vis their engagement with routinised technologies. In what follows, I take the case of caesarean sections and abortion care among ethnic and religious minorities in the United Kingdom to capture how routinised interventions are entangled in the context-specific anticipation of future reproductive potential. The idea of anticipatory futures serves as a reflection on what is perceived as ‘possible, probable and preferable’ (cf. Adams, Murphy, & Clarke, 2009; Textor, 2005, p. 2) across the reproductive lifecourse, where technologies carry opportunities and implications that women and carers alike are tasked with negotiating. This chapter integrates ethnographic and qualitative data from two minority contexts. It focuses on doulas supporting the maternity care practices among Haredi Jews, who constitute a minority in the United Kingdom and among the country’s Jewish population, and how providers approach requests for sex-selective abortion (SSA) when caring for women from South Asian backgrounds. Reproductive technologies emerge as being relational, reflecting various forms of compliance with kin as well as cosmologies that complicate the ethical value of ‘choice’ in women’s healthcare. Taking inspiration from the reproductive justice framework (Ross & Solinger, 2017; SisterSong, n.d.), the chapter builds on a body of work that demonstrates how the concept of ‘choice’ is contingent and not inclusive of the situated constraints that can affect the reproductive lives of women from minority backgrounds. While championing women’s choice and autonomy has long been the cornerstone of the reproductive rights movement, advocates of reproductive justice argue that autonomy is constrained by structural conditions and social collectives. The reproductive justice framework is instrumental in centring analytical attention on the structures of oppression that women face and seeks to re-address societal inequalities to afford women the resources they need to fulfil their reproductive decisions and desires (Ross & Solinger, 2017). Within this approach, however, I suggest that there is a space to discuss how care providers attempt to facilitate as much autonomy and justice as possible within the situated constraints that women are living in and vis-`a-vis their future reproductive life. Such a discussion underscores how inclusive care is performed amidst the broader

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struggle for justice – which is itself part of an anticipatory future. I signal the analytical links between inclusion and justice in women’s healthcare and ethnographically illustrate how context shapes those links in the following section.

Justice and Inclusive Care The reproductive justice framework, as mentioned, is celebrated for moving beyond an exclusive concern with ‘pro-choice’ abortion activism and addressing the intersectional, underlying and relational constraints that determine reproductive lives – especially for women and people of colour in the United States (Ross & Solinger, 2017; SisterSong n.d.). Activists have articulated justice as ‘the right not to have a child, the right to have a child and the right to parent children in safe and healthy environments. In addition, reproductive justice demands sexual autonomy and gender freedom for every human being’ (Ross & Solinger, 2017, p. 9). Reproductive justice is then profoundly concerned with human rights (Luna, 2020), and the diverse ways that structural racism mediates the quality of care that minority ethnic women and people can expect to receive and the decisions they can make. Black American, or African American, women in the United States are the most poignant example of how systemic exclusion materialises in inequities and injustices surrounding access to reproductive health technologies and care (Roberts, 1998). The United States offers an insight into how rates of maternal and neonatal mortality are rising in a high-income country; Black American women are two-to-three times more likely to die from pregnancy-related issues than White women, and the risk of death increases with age (Peterson et al., 2019). Similarly, in the United Kingdom, Black women are five times more likely to die and Asian women twice as likely to die during pregnancy or post-birth than White women (Knight et al., 2018). Unlike the reproductive justice movement in the United States, the United Kingdom has experienced a relatively slower move to confront medical racism and to consider the experiences and expectations of minority women when it comes to reproductive care (Decolonising Contraception, n.d.; Hamilton, 2020; Public Health England, 2018). Commentators in the United States note that the issue of higher maternal mortality among Black women is intersectional; risk is influenced by immigration status, class and race (Peterson et al., 2019). What is striking is that the heightened risk of death cuts across socioeconomic status – so even Black women of a higher social and economic position are likely to die than poorer White women. To understand the issue of poorer maternal health outcomes among Black American women, scholars advocate for a need to understand how racism is applied through health interventions and technologies. Anthropologist D´ana-Ain Davis (2019) proposes the concept ‘obstetric racism’ to analyse Black women’s pre- and post-natal encounters in terms of racism and to theorise how Black women interpret their encounters with medical staff by illustrating the harm caused. The body of work that Dorothy Roberts (1998), Davis (2019), and Hamilton (2020) advance showcases the lived realities and situated roots of reproductive politics for minority groups in high-income country settings. However, my

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interest is in how ethnic and religious minorities raise implications for what inclusive woman-centred and person-centred care can involve, how providers envision ‘choice,’ autonomy and justice in practice, and how their considerations reconfigure the otherwise ‘routine’ delivery of reproductive health services and technologies. This approach is important because the ethnographic record highlights how cultural, racial and religious stereotyping and typecasting occurs across the continuum of reproductive healthcare, from antenatal and maternity care to contraceptive, infertility and abortion care (e.g. Blell, 2018; Davis, 2019; Kasstan & Unnithan, 2020; Purewal, 2003, 2010). Taking these debates forward, this chapter is concerned with how providers consider the lived constraints of women and how they construct and encounter ‘diversity’ in reproductive healthcare. Inclusion emerges as being analytically linked to reproductive justice, insofar as social context raises practical implications for how autonomy in women’s healthcare is perceived, enabled and facilitated. Autonomy over reproduction can also be impacted by the social and religious contexts of women, which raises broader implications for the politics of reproduction. Anthropologist Kate Hampshire, Blell, and Simpson (2012) use the term ‘relationality’ as a conceptual tool to understand the role and responsibilities of kin in defining and shaping the experience of infertility among British Pakistani Muslims. They note that ‘social and kin relations are important not only in shaping responses to infertility; they are also pivotal in the processes through which reproduction (or lack thereof) becomes defined as problematic in the first place’ (Hampshire et al., 2012, pp. 1050–1051). Petra Nordqvist (2021, p. 678) notes how reproduction is ‘a deeply relational event’ (my emphasis), yet a view across the lifecourse illustrates how reproduction is fraught with a multiplicity of relationalities between technologies, kin ties and constraints. As Rishita Nandagiri (2022) shows in this volume, reproductive events are not ‘siloed incidents’, but are linked across the lifecourse and to larger structures of oppression. Proponents of reproductive justice would agree, I think, that while we would all prefer to live in a world where reproductive autonomy is upheld, healthcare providers nonetheless have to respond to the daily challenges that women face in their reproductive lives (cf. Sheldon, 2012). This reality makes responding to the situated constraints of women, as a form of inclusion, a necessary ethic of care amidst the social and legal pursuit of justice. In what follows I take the case of how Jewish doulas advocate against caesarean sections and how abortion providers approach requests for selective abortion to illustrate how they navigate framings of ‘choice’ and ‘justice’ when caring for women and how they mediate anticipatory futures of reproductive potential.

Reproduction in Two Minorities Reproduction is a major conjugal responsibility in Haredi or ‘ultra-Orthodox’ Judaism, with the imperative for men to ‘be fruitful and multiply’ the collective body and the pressure for women to be its bearer, imparted through a range of scriptures and legal codes. Haredi Jewish women have among the highest total

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fertility rates in the country – over three times that of White British women (Staetsky & Boyd, 2015), also reflecting similar demographic patterns in the Jewish populations of Israel and the United States. Much attention to Orthodox and Haredi Jews in the social study of reproduction has focused on the ethical dilemmas of technologies, interventions and bodily education, and the careful navigation of religious authorities (Kasstan, 2017; Taragin-Zeller, 2019; Taragin-Zeller & Kasstan, 2020; Teman, Ivry, & Bernhardt, 2011). Haredi Jewish women are engaged in continuous childbearing and childrearing until they reach the menopause (Teman et al., 2011, p. 70), which positions maternity services as a unique site to understand how technologies, care and anticipation continuously mould the lifecourse. Contraception among Haredi Jews takes on a conceptual shift as techniques to space births (Birenbaum-Carmeli, 2008), indicating how technologies are used as part of the aspiration to have large families. Looking at routinised interventions, such as caesarean sections, capture how healthcare services constitute a borderland where multiple – and at times opposing – notions of bodily governance encounter each other, and where concerns around cultural perpetuation are performed (Kasstan, 2019). Whilst forming a very different minority in England, women of Bangladeshi, Indian and Pakistani origin offer an interesting comparison to explore how the reproductive lifecourse is anticipated. There are wide variations in total fertility rates between these minority groups, and sociological research has noted how higher total fertility rates among British Pakistani women are sustained by pro-natal worldviews – ‘childbearing is viewed by women as culturally mandatory and childlessness as socially unacceptable’ (Culley & Hudson, 2009, p. 252; also Blell, 2018; Shaw, 2004). Yet, the absence of a son can constitute a form of ‘social infertility’, and can be equated with childlessness (Hampshire et al., 2012). Social pressure around reproduction exists along a continuum, and for example, the pressure to produce specific children as part of selective reproduction constitutes ‘a form of intimate, gendered, and kin-based control’ (Rapp, 2018, p. viii). Scholars note that son preference is shifting, and that son preference does not necessarily engender prejudice against daughters (e.g. Purewal, 2010). Moreover, scholars have observed that shifts towards matrilateral kinship have taken place among British Pakistanis (Qureshi, 2016; Shaw, 2004), which signals how strong mother–daughter bonds influence values around gender. Whilst the reproductive care needs differ between the two minority groups presented in this chapter, my comparative approach pinpoints how healthcare providers encounter and approach relationality between care and context.

Methods, People and Place This chapter draws on ethnographic and qualitative data from two separate projects, one focusing on maternity and infant care among Haredi Jewish women in Manchester (2013–2016) and childbearing decisions among women of Bangladeshi, Indian and Pakistani descent across England (2017–2019). Semi-structured interviews were conducted in both studies, in English. Interviews

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were recorded using a digital audio recording device, when permission was granted, and detailed notes recorded. Recordings from interviews and other encounters in the field were transcribed verbatim and analysed on both a separate and comparative basis. Participants provided verbal or written consent.

The Haredi Jews of Manchester Haredi Jews account for, at most, 16% of the UK’s Jewish population (approximately 275,000) at the time of the 2011 census (Staetsky & Boyd, 2015). Haredi Jews live their lives in accordance with the teachings derived from the Hebrew Bible as well as a voluminous body of rabbinic literature, commentary and rulings. Haredi Jews can be distinguished from other Jewish streams (Progressive, Conservative and Orthodox) by their self-protective stance and avoidance of secular education and professional training. This selective engagement with the outside world, in turn, presents implications for healthcare, with forms of male (rabbis) and female (doulas) expertise mediating the delivery of health services, interventions and technologies. In practice, the Haredi sector consists of multiple groups, each with their own religious leaders (rabbis), teachings and observances. This population can be loosely divided into Lithuanian yeshiva-based (Torah learning) communities, Hasidic dynasties and Sephardi Haredim (who trace their origins to the Iberian Peninsula, North Africa and the Middle East). Differences aside, all the sector’s members are easily identified by their more or less uniform dress code: black hats and darks suits for men; and similarly coloured ankle-length skirts, long sleeves and head coverings for women. Manchester has among the fastest growing Jewish populations in the United Kingdom and Europe due to higher total fertility rates among Haredi women (Staetsky & Boyd, 2015). Twelve months of ethnographic research was conducted in Manchester (2014–2015) to evaluate perceptions of maternity care and infant health among Haredi Jewish families. Key research participants were parents as well as a network of Haredi Jewish doulas who provide the full continuum of antenatal, birth and postpartum support to local Jewish women. A brief note on gender is important for understanding relationality between myself and my interlocuters. The fact that the doulas and midwives were married, and mothers, meant that they were willing to talk to me about sensitive issues that compromised standards of modesty in a religiously conservative and self-protective minority. Meeting alone with young unmarried women would have been perceived as an inappropriate conduct, if not scandalous, given the strict gender relations that govern everyday life.

Women of ‘South Asian’ Origin in England The term ‘Asian’ in the United Kingdom is often used as a collective category for people of Bangladeshi, Indian and Pakistani origin, who constitute the largest ethnic minority group, numbering approximately 5.3% of the population (just under 3,000,000) at the time of the 2011 census. The collective categories of

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‘South Asian’ or ‘Asian’ that appear regularly in academic and public discourse, in reality, obscure a diverse mosaic formed of colonial and migration histories, religious traditions (Christianity, Hinduism, Islam, Sikhism), languages, social hierarchies (e.g. caste system and class) and intra/inter-group relations that influence reproductive decision-making in nuanced ways. In this chapter, I draw on data from 16 semi-structured interviews conducted with abortion care providers, including administrators, midwives, nurses, physicians and clinic managers, on the issue of SSA in England. The purpose of the study was to explore whether, and how, providers encounter requests for SSA, and how they reconcile requests with legal and ethical parameters. My links with abortion rights and advocacy groups in the United Kingdom facilitated access to care providers, and trust was also engendered by the fact that ethical approval to conduct research was granted by the management teams. These pathways of building trust should be understood against the backdrop of unethical attempts by journalists to deceive and covertly record abortion providers in England in attempts to produce ‘evidence’ that they were routinely breaking abortion legislation (Lee, 2017). Abortion providers were open and willing to discuss their experiences of care provision to women from ethnic and religious minority backgrounds, and some were themselves from minority backgrounds.

Caesarean Sections Mrs Sofer has been practising as a doula in Manchester for 20 years, and she told me that state maternity services are among the few times that Haredi Jews ‘touch the outside world’. In taking maternity care as a point of overlap between two social worlds, the doulas see themselves as strategic for enabling access to public healthcare. Their roles are about caring for biological as well as social reproduction which reproductive technologies are perceived to threaten – and in turn require negotiation from the doulas. Obstetric interventions, especially caesarean sections, form a particular concern for Haredi Jews due to the relationality between care and cosmology, requiring careful negotiation and intervention to protect processes of social reproduction. In Manchester, there is a network of Jewish doulas who supported women when seeking maternity care, and some seek to secure particular birthing outcomes. Mrs Nadler has also been providing doula care to Haredi Jewish women for over 20 years and had become increasingly concerned that if a caesarean is performed on a woman’s first pregnancy then there was an increased likelihood that a caesarean would be performed in future pregnancies as a practice of risk management. She was concerned that ‘you can only have so many caesareans’, which could limit a Jewish woman’s reproductive potential. Mrs Nadler’s concerns reflect increasingly routinised biomedical realities and practices. When rising rates of primary caesarean section are coupled with a decrease in the numbers of vaginal birth after caesarean (VBAC) being performed, then it is likely that the number of women having to undergo subsequent

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and multiple caesareans will rise (see Nisenblat et al., 2006). As a result of the heightened social value of regular childbearing among Haredi Jews, Mrs Nadler said, ‘in the frum [Yiddish, pious] world, people would rather not have caesareans’. For this reason, Mrs Nadler often advocated against caesarean sections that she perceived to be medically unnecessary and avoidable. In one encounter surrounding an undiagnosed breech, Mrs Nadler recalled: The doctor said, ‘right, this has got to be a caesarean’, and I told the [pregnant] lady, ‘leave the talking to me, please’. I said to the doctor, ‘she doesn’t want a caesarean. She’s labouring nicely and she’s happy to try for a natural [vaginal]’. So the doctor said, ‘I’ve never delivered a natural breech’. I said, ‘I hear you, but this is her request’. A bit later she came in to say, ‘Miss so-and-so who is the top consultant on the unit is coming out’. This was four in the morning, and the staff whispered to me, ‘we have never seen this before.’ I said, ‘well she’s entitled to her choice’. (April 2015) Mrs Nadler felt the need to intervene in this clinical encounter, and to formulate and assert the birthing woman’s ‘choice’, because of her personal and professional concern about how birthing technologies were becoming routinised in ways that did not consider the implications for future childbearing. While she went on to acknowledge that operative births can be lifesaving in some instances, she explained there ‘are few reasons that I would say need to have caesarean’. Not all Haredi Jewish women, however, felt that the advice given by doulas was appropriate or at risk of ‘overstepping the mark’. While studies note that the presence of a doula in NHS maternity care can reduce the likelihood of a caesarean being performed, it is also worth noting that the presence of a doula also indicates that women desire and pursue particular birthing outcomes (Brigstocke, 2014). The care practices of Mrs Nadler may be read as coercive against clinical policies that are centred on respecting individual patient autonomy, though in a context of Haredi Judaism, the individual is directly centred in the reproduction of collective life (Kasstan, 2019). Part of Mrs Nadler’s opposition to caesarean sections lies in the fact that the intervention can disrupt processes of social reproduction and the chance of a firstborn son having a Pidyon HaBen (Hebrew, redemption of the first born). This birth rite is bestowed when a first-born child, who is male (bechor), reaches the 30th day of life. However, this rite of birth is only held under certain conditions. The ceremony is held when a bechor ‘opens up the womb’ of the mother, but this ‘opening’ is interpreted as being strictly by way of vaginal birth – whereas ‘if you’ve had a caesarean, the baby has not come through the womb and opened up the womb’. This ethnographic vignette forms one part of a broader issue around the routinisation of caesareans in women’s healthcare. The number of caesareans performed around the world does not reflect the ideal rate of 10–15% of births advocated by the World Health Organisation (2015), meaning that many

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caesareans are performed for reasons that do not reflect clinical need or necessity. Scholars have subsequently sought to examine how caesareans are entangled in the politics and economics of healthcare (B´ehague, 2002; Davis-Floyd, 2004), by questioning what counts as evidence in the production of obstetric knowledge and medical risk (Topçu, 2019; Wendland, 2007), how caesareans can reflect a ‘misrecognition of need’ (Tully & Ball, 2013) and maternal ‘choice’ (Romanis, 2020). The intervention of Mrs Nadler reflects broader interests in reducing medically unnecessary caesareans, though what is different is the relationality with context. When the ability to produce large families can enable women to perform and achieve highly prized notions of motherhood, caesarean sections can be refused and opposed. Anthropologist Lucy Lowe (2019) has demonstrated how Somali refugee women in Kenya can oppose caesareans to protect their ‘fertile futures’ amidst uncertainty, migration and chronic precarity. She notes how, ‘Cesarean sections are a heavily relied-on solution to obstetric problems, yet they can result in profound crises for women and their families who perceive motherhood not in the singular act of producing a child but in the ongoing process of perpetual reproduction’ (Lowe, 2019, p. 199). The care work of Jewish doulas captures how opposition to caesarean sections reflects an interest in safeguarding reproductive potential beyond the case of displacement, and according to vernacular values placed on childbearing. Attention to how biomedical ‘technologies of saving,’ as Davis (2019) puts it, are negotiated then reveal broader concerns with saving reproductive potential across the lifecourse as well as the saving of collective identities that play out on women’s bodies.

Abortion Abortion, especially for sex-selection, illustrates how pregnancies can be terminated as part of a pressure to pursue particular reproductive futures – especially regarding sons and male heirs. SSA is a form of selective reproduction, which entails ‘personal assessments of the economic burdens and benefits that the birth of a particular kind of child will entail’ (Wahlberg & Gammeltoft, 2018, p. 16; also; van Balen & Inhorn, 2003). The preference or pressure to bear a son can intensify at higher birth orders, amidst conditions of lowering fertility, and often, the economic imperative of having smaller family sizes. The following conversations took place against the backdrop of public disputes surrounding SSA in the United Kingdom since 2012, where abortion politics had involved a discursive focus on son preference among South Asian families. While re-narrating the disputes is beyond the scope of this chapter, what is important to briefly reiterate is how ideas of appropriate reproductive choice and rights were projected and attempts to restrict national abortion laws were engendered (for a full critique of events see Lee, 2017; Unnithan & Dubuc, 2017). In the United Kingdom, SSA can be permissible if a woman’s mental health or socioeconomic position may be at risk if a pregnancy were to continue (Greasley, 2016; Sheldon, 2012). Yet, practitioners perceived SSA in diverse ways and sought to include requests in the scope of care.

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Delores is a registered midwife in her 1950s and had joined abortion provision in 2016 after serving in maternity care for many years. She explained how she would be upfront and say to a woman that a request for abortion on the grounds of sex-selection ‘is an illegal reason’. While, as mentioned, SSA can be lawfully provided depending on the explanations presented by women, Delores would highlight the legal constraints around abortion as a technique to extract as much information as possible to inform access to care: If she was honest in saying, ‘we’re doing it ‘coz of sex selection’, then I think I’d have to ask for more information. It wouldn’t make me feel any different about doing the abortion. I would write as much detail as possible, but then I would probably discuss it with the Manager. It would shock me, but I still wouldn’t judge somebody on it because [then] I wouldn’t be pro-abortion. (October 2018) While being careful to convey her commitment to being pro-choice (‘proabortion’), in another breath, Delores would be shocked by a request for SSA and would escalate the request to senior management. Senior management approached SSA as a ‘protective’ form of care for women when unable to exercise choice over their reproductive decisions, as Monica explained: Actually, it could be a protective factor for a woman having a child of the ‘wrong’ sex, to have a termination actually. A large proportion of our clients don’t actually have very much choice in terms of who they marry or how many children they are going to have. If they decide to leave a relationship, they’ll know that if they leave that relationship, they’re going to have to leave their children behind. So, if you extend that argument into the kind of decisions behind sex-selection, it could actually be a very protective thing for a woman who’s knocked out three or four girls if she knows she’s having another girl. (November 2018) Dr Ahmed, a Bangladeshi physician, described that she had not encountered a pressure to bear sons and abort a female foetus in her 10 years of work at a woman’s health clinic in London. More common, she said, was the general economic pressures on women that lead to abortion. Suriya, an abortion counsellor, had encountered requests for SSA in her 30 years of experience but noticed a shift: Ten years ago it was a little bit more common, but now Asian people have reduced this sort of ‘you’ve got five girls, and now you’re going to have another girl’, but now I have noticed that even though they have got a few girls and no boys, they’re not

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talking like that. They’re coming for abortions because of financial situations and things like that, but not because of the gender [sex]. (November 2018) These abortion providers placed a high value on being ‘pro-choice’, as a necessary ethic of care, yet negotiated reproductive ‘choice’ alongside power dynamics that range from financial hardship and, in the specific case of SSA, patriarchal family structures. The difference, however, was that SSA was recognised by providers as forming part of an anticipatory future of bearing sons to protect their position vis-`a-vis kin relations. At the same time, some providers indicated a sense of ‘shock’ around the issue of SSA, perhaps falling outside the domain of routine care (Kasstan & Unnithan, 2020), and signalling how such requests may result in decisions to delay access to care. While sonography to identify foetal sex and SSA is criminalised in India, the practice can be used as part of reproductive planning and to achieve a sex-balanced and small family size among professionals who move to New Delhi (Khanna, 2015). Physicians in Northern India view the practice as a ‘social service’ amidst a ‘social fact’ of gender inequality and when the ability to bear a male heir can secure the position of lower- and middle-class Hindu and Muslim women (Unnithan-Kumar, 2010). Yet, Rishita Nandagiri (2019) has demonstrated how community health intermediaries in the South-West of India can conflate laws around abortion (legal) and sex selection (illegal), which compounds stigma and perpetuates ideas of ‘good/bad’ abortions that determines access to a critical area of women’s health care. Abortion care providers, in this case, attempt to offer protective interventions to support women within their lived and situated constraints (which was perceived to be shifting by Suriya). Care is not always practised or envisioned as part of a one-off clinical encounter or short-term intervention, but as part of a woman’s lifecourse and the longer-term implications that a pregnancy might entail. Moreover, the practices of abortion providers signal the tensions in providing care amidst social change and constraint. By acknowledging and responding to the diverse realities of women, providers practice reproductive inclusion amidst an anticipatory future of justice.

Conclusion This chapter has sought to highlight how reproductive technologies are negotiated as part of anticipatory futures of reproductive potential and in ways that reveal how care is not always concerned with a singular action or event 2 but rather the lifecourse. The power of anticipation lies in the value of reproduction as a strategy to cultivate personhood, and in the cases at hand, to secure and attain social status. It is important to reiterate that there are considerable differences between the minority groups presented in this chapter, marked by positionality in contemporary Britain and engagements with state reproductive health services (Blell, 2018; Hampshire et al., 2012; Kasstan, 2019; Qureshi, 2016). My

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comparative approach nonetheless highlights the continuities and discontinuities in how context matters (cf. Inhorn, 2006), as reproductive technologies and interventions are negotiated in anticipation of the lifecourse and to meet the social and religious expectations that shape reproduction. While caesareans form part of a repertoire of ‘technologies of saving’ (cf. Davis, 2019) that are increasingly routinised, they can be viewed as an intervention with implications for social reproduction among Haredi Jewish doulas. Abortion care is a critical area of women’s health, yet the issue of son preference leading to SSA raises ethical and legal dilemmas that providers are tasked with negotiating carefully. By focusing on reproduction in ethnic and religious minority groups, decisions and desires emerge as relational and are often negotiated in line with cosmology and kin in ways that might be read as being in conflict with clinical guidelines premised on consent and autonomy. The healthcare workers in both settings placed a discursive value on women’s ‘choices’, while consciously and unconsciously revealing the constraints that shaped decision-making. While the concept of ‘choice’ has been widely critiqued in the social study of reproduction as a fallacy (Ross & Solinger, 2017), it clearly performs a salient role in healthcare provision and everyday clinical encounters. The reproductive justice framework is a revolutionary force in engendering academic debates and social change surrounding women’s and people’s reproductive health and decisions beyond the confines of ‘choice’, but justice is also a process. While the reproductive justice movement privileges the lived realities or lived experiences of women in ‘their drive to possess reproductive autonomy’ (Ross & Solinger, 2017, p. 7), my interest in care provision signals how justice is approached within lived constraints and how providers mediate the parameters of inclusive and woman-centred care. These healthcare providers, I suggest, recognise that the relationality between context and care will not disappear overnight and that care decisions are made as part of a continuously shifting social life. Anthropologists have been prolific in capturing how medical professionals disregard the needs, desires and decisions of pregnant and birthing women from minority backgrounds, which Davis (2019) conceptualises as ‘obstetric racism’ in the US context. Yet, I have demonstrated how healthcare providers attempt to listen to women’s needs and read between the lines of constraint and consent, and facilitate reproductive autonomy while that autonomy is constrained by social, cultural and religious expectations. Reproductive healthcare is an intimate area of biomedicine where carers draw on a situated knowledge of women’s lives in their everyday clinical encounters, acting as barriers and enablers to woman-centred and person-centred care (Nandagiri, 2019). Feminist scholars should continue to examine how the slow dismantling of entrenched inequities on the basis of sex and sexuality, age, race, ethnicity, religion and ability impacts reproductive healthcare at local levels amidst the global pursuit of reproductive justice. On an empirical level, the chapter contributes to this collection’s interdisciplinary and integrated approach to the study of reproduction by demonstrating how technologies in one pregnancy are situated in the anticipation and calculation of future potential. Conceptually, the chapter raises further questions and provocations concerned with the politics of reproduction, and the forces that

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determine what is possible, probable and preferred (Franklin & Ginsburg, 2019; Ginsburg & Rapp, 1991; see also Textor, 2005, p. 2). Technologies increasingly invest the reproductive lifecourse with potential and anticipation, which calls on feminist scholars to understand the dilemmas posed for inclusive models of care beyond the discourse of ‘choice’.

Acknowledgements My thanks to all interlocutors whose voices have informed this chapter. I am grateful to Vicky Boydell, Katie Dow, Rishita Nandagiri, Kate Hampshire and Maya Unnithan for their support. This research was funded in whole, or in part, by the Wellcome Trust [1011955/Z/13/Z]. The research received ethical approval from the Chair of the Research Ethics and Data Protection Committee at the Department of Anthropology at Durham University. The chapter also draws on research into abortion care provision funded by an ESRC Impact Accelerator grant awarded by the University of Sussex to Maya Unnithan (PI) and myself (CO-I). Ethical approval was obtained from the University of Sussex. The research was aligned to a broader investigation into son preference and sex-selection against females in the United Kingdom, funded by the ESRC and led by Sylvie Dubuc (PI) and Maya Unnithan (CO-I), grant code: ES/N01877X/1. This chapter builds on data previously published in Making Bodies Kosher: The Politics of Reproduction among Haredi Jews in England (Berghahn Books, 2019) and Arbitrating Abortion: Sex-Selection and Care Work Among Abortion Providers in England (co-authored with Maya Unnithan in Medical Anthropology, 2020).

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Franklin, S., & Ginsburg, F. (2019). Reproductive politics in the age of Trump and Brexit. Cultural Anthropology, 34(1), 3–9. Ginsburg, F., & Rapp, R. (1991). The politics of reproduction. Annual Review of Anthropology, 20, 311–343. Greasley, K. (2016). Is sex-selective abortion against the law? Oxford Journal of Legal Studies, 36(3), 535–564. Hamilton, P. (2020). Black mothers and attachment parenting: A black feminist analysis of intensive mothering in Britain and Canada. Bristol: Policy Press. Hampshire, K., Blell, M. T., & Simpson, B. (2012). ‘Everybody is moving on’: Infertility, relationality, and the aesthetics of family among British-Pakistani Muslims. Social Science & Medicine, 74, 1045–1052. Inhorn, M. C. (2006). Defining women’s health: A dozen messages from more than 150 ethnographies. Medical Anthropology Quarterly, 20(3), 345–378. Kasstan, B. (2017). Haredi (material) cultures of health at the ‘hard to reach’ margins of the state. In T. Carroll, D. Jeevendrampillai, A. Parkhurst, & J. Shackelford (Eds.), The material culture of failure: When things do wrong (pp. 95–111). London: Bloomsbury. Kasstan, B. (2019). Making bodies Kosher: The politics of reproduction among Haredi Jews in England. Oxford and New York, NY: Berghahn Books. Kasstan, B., & Unnithan, M. (2020). Arbitrating abortion: Sex-selection and care work among abortion providers in England. Medical Anthropology. doi:10.1080/ 01459740.2019.1709183 Khanna, S. K. (2015). ‘A City-Walla prefers a small family’: Son preference and sex selection among Punjabi migrant families in Urban India. In M. Unnithan-Kumar & S. K. Khanna (Eds.), The cultural politics of reproduction: Migration, health and family making (pp. 152–168). Oxford: Berghahn Books. Knight, M., Bunch, K., Tuffnell, D., Jayakody, H., Shakespeare, J., Kotnis, R., ... Kurinczuk, J. J. (2018). Saving lives, improving mothers’ care: Lessons learned to inform maternity care from the UK and Ireland confidential enquiries into maternal deaths and Morbidity 2014–2016. MCRRAACE-UK. Retrieved from https://www. npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20Maternal %20Report%202018%20-%20Web%20Version.pdf. Accessed on October 28, 2020. Lee, E. (2017). Constructing abortion as a social problem: ‘Sex selection’ and the British abortion debate. Feminism & Psychology, 27, 15–33. Lowe, L. (2019). Refusing cesarean sections to protect fertile futures: Somali refugees, motherhood, and preciarious migration. American Ethnologist, 46(2), 190–201. Luna, Z. (2020). Reproductive rights as human rights. New York, NY: New York University Press. Nandagiri, R. (2019). ‘Like a mother-daughter relationship’: Community health intermediaries’ knowledge of and attitudes to abortion in Karnataka, India. Social Science & Medicine, 239(112525). doi:10.1016/j.socscimed.2019.112525 Nandagiri, R. (2022). ‘I feel like a kind of Namoona’: Examining sterilisation in women’s abortion trajectories in India. In V. Boydell & K. Dow (Eds.), Integrating reproductive technologies: Propositions for a lifecourse approach in social studies of reproduction. Bingley: Emerald Publishing Limited. Nisenblat, V., Barak, S., Griness, O. B., Degani, S., Ohel, G., & Gonen, R. (2006). Maternal complications associated with multiple cesarean deliveries. Obstetrics & Gynecology, 108(1), 21–26.

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Nordqvist, P. (2021). Telling reproductive stories: Social scripts, relationality and donor conception. Sociology, 55(4), 677–695. Peterson, E. E., Davis, N. L., Goodman, D., Cox, S., Syverson, C., Seed, K., ... Barfield, W. (2019). Racial/ethnic disparities in pregnancy-related deaths-United States, 2007–2016. CDC Morbidity and Mortality Report, 68(35), 762–765. Public Health England. (2018). What do women say? Reproductive health is a public health issue. Retrieved from https://assets.publishing.service.gov.uk/government/ uploads/system/uploads/attachment_data/file/731891/What_do_women_say_ reproductive_health_is_a_public_health_issue.pdf. Accessed on December 20, 2020. Purewal, N. (2003). Re-producing South Asian Wom(b)en: Female feticide and the spectacle of culture. In N. Puwar & P. Raghuram (Eds.), South Asian women in the diaspora (pp. 137–156). Oxford: Berg. Purewal, N. (2010). Son preference: Sex selection, gender and culture in South Asia. Oxford: Berg. Qureshi, K. (2016). Marital breakdown among British South Asians: Conjugality, legal pluralism and New Kinship. London: Palgrave Macmillan. Rapp, R. (2018). Foreward: The egg imaginary. In A. Wahlberg & T. M. Gammeltoft (Eds.), Selective reproduction in the 21st century (pp. v–viii). London: Palgrave MacMillan. Roberts, D. (1998). Killing the black body: Race, reproduction and the meaning of liberty. New York, NY: Vintage Books, a Division of Random House LLC. Romanis, E. (2020). Addressing rising cesarean rates: Maternal request cesareans, defensive practice, and the power of choice in childbirth. International Journal of Feminist Approaches to Bioethics, 13(1), 1–26. Ross, L., & Solinger, R. (2017). Reproductive justice: An introduction. Berkeley, CA: University of California Press. Shaw, A. (2004). British Pakistani elderly without children: An invisible minority. In P. Kreager & E. Schroeder-Butterfill (Eds.), Ageing without children: European and Asian perspective (pp. 198–221). Oxford: Berghahn Books. Sheldon, S. (2012). Abortion for reason of sex: Correcting some basic misunderstandings of the law. BPAS Abortion Review, 37, 2–3. Retrieved from https:// kar.kent.ac.uk/29453/1/AR_issue_37.pdf SisterSong. (n.d.). Reproductive justice. Retrieved from https://www.sistersong.net/ reproductive-justice. Accessed on October 20, 2020. Staetsky, L. D., & Boyd, J. (2015). ‘Strictly orthodox rising’: What the demography tell us about the future of the community. Institute for Jewish Policy Research. Retrieved from http://archive.jpr.org.uk/object-uk285. Accessed on October 18, 2020. Taragin-Zeller, L. (2019). Conceiving god’s children: Toward a flexible model of reproductive decision-making. Medical Anthropology, 38(4), 370–383. Taragin-Zeller, L., & Kasstan, B. (2020). ‘I didn’t know how to be with my husband’: Religion-state struggles over sex education in Israel and England. Anthropology & Education Quarterly. doi:10.1111/aeq.12358 Teman, E., Ivry, T., & Bernhardt, B. A. (2011). Pregnancy as a proclamation of faith: Ultra-orthodox Jewish women navigating the uncertainty of pregnancy and prenatal diagnosis. American Journal of Medical Genetics, Part A, 155, 69–80.

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Textor, R. B. (2005). Introduction. In M. Mead & R. B. Textor (Eds.), The world ahead: An anthropologist anticipates the future (pp. 1–28). Oxford: Berghahn Books. Topçu, S. (2019). Caesarean or vaginarean edidemics? Techno-birth, risk and obstetric practice in Turkey. Health, Risk & Society, 21(3–4), 141–163. Tully, K. P., & Ball, H. L. (2013). Misrecognition of need: Women’s experiences of and explanations for undergoing cesarean delivery. Social Science & Medicine, 85, 103–111. Unnithan, M., & Dubuc, S. (2017). Re-visioning evidence: Reflections on the recent controversy around gender selective abortion in the UK. Global Public Health. doi: 10.1080/17441692.2017.1346694 Unnithan-Kumar, M. (2010). Female selective abortion-beyond ‘culture’: Family making and gender inequality in a globalising India. Culture, Health and Sexuality, 12(2), 153–166. van Balen, F., & Inhorn, M. C. (2003). Son preference, sex selection, and the ‘new’ new reproductive technologies. International Journal of Health Services, 33(2), 235–252. Wahlberg, A., & Gammeltoft, T. (2018). Introduction: Kinds of children. In A. Wahlberg & T. Gammeltoft (Eds.), Selective reproduction in the 21st century (pp. 1–24). Cham: Palgrave Macmillan. Wendland, C. L. (2007). The vanishing mother: Cesarean section and ‘evidenced-based obstetrics’. Medical Anthropology Quarterly, 21(2), 218–233. World Health Organization. (2015). WHO statement on caesarean section rates. https://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng. pdf. Accessed on May 4, 2022.

Chapter 12

Men as Irrational Variables in Family Planning? Understanding the Landscape, Technological Advancements, and Extending Health Psychology Theories and Models Amanda Wilson

Abstract Men are often considered by the health care system to be a disengaged accessory when it comes to family planning. In reality they act as an equal part in the reproductive equation. Despite qualitative research suggesting some men currently do take primary responsibility for family planning, men are further marginalised being classed as an irrational variable in large national datasets. Reports ignore men in general by failing to record basic demographics, for example, age is not captured and ethnicity has two options: white and non-white. This leaves little ability to analyse men’s family planning knowledge, attitudes and beliefs. Technological advancements have resulted in new forms of male contraceptive methods reaching phase III testing (from pills to gels), and the market is moving towards diversified options that will allow even more men to take primary contraceptive responsibility. Other advancements include the sexual enhancement product Viagra becoming available over the counter, and reproductive wellbeing apps have been created to allow men to test their fertility at home. Without research to understand the ever-changing landscape for men we are ill-prepared to understand what these new products and advancements mean for men’s role. Using various forms of publicly available online data and previous empirical research, this chapter will review men’s response to new contraceptives, sexual enhancement products, and reproductive wellbeing apps. The results will be discussed in relation to updating the Subjective Expected Utility (SEU) Theory, the Theory of Planned Behaviour and the

Technologies of Reproduction Across the Lifecourse, 225–246 Copyright © 2022 Amanda Wilson Published under exclusive licence by Emerald Publishing Limited doi:10.1108/978-1-80071-733-620221020

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integrated developmental and decision-making contraceptive models used by health psychologists. Keywords: Men and family planning; large data sets; qualitative data sets; life span development; reproductive technology; health psychology models

Introduction Women’s reproductive behaviour has rightfully remained at the forefront of research and practice because women’s bodies are subjected to carrying a pregnancy, terminating a pregnancy, and childbirth, which they often do so as second-class citizens (Wellings et al., 2013). Men’s part in reproduction on the other hand has historically been perceived through a limiting lens of hegemonic masculinity, where traits like strength or stoicism take precedence (Lohan, 2015). These gendered beliefs have restricted men as passive participants in relation to reproduction, marginalising them in both the clinic and research (Wilson, Fylan, & Gough, 2018). Journals that publish research on men and masculinities have a small number of studies that add to our understanding of contraception (Mohr & Almeling, 2020). In fact, men are more likely to be pictured in a negative light when it comes to reproduction, like in the previous chapter where the common narrative of ultra-Orthodox Jewish men was explained to restrict their role to being ‘fruitful and multiple’, having a deleterious effect on their female partners (Inhorn, 2020). These gendered beliefs have constructed men to be like an irrational variable that cannot be expressed as a fraction, but instead as a continuous decimal point infinitely expanding and largely unexplored. Regardless of how much or little they are included in decision-making around planning a family, men are involved in reproduction; the requirement of sperm makes them the other half of the equation (Culley, Hudson, & Lohan, 2013; Mohr & Almeling, 2020). Likewise, the dynamic of negotiations between men and women also varies across cultures with the current discourse around reproduction being driven by these existing sociocultural beliefs (Inhorn, la Cour Mosegaard, & Tj, 2009). Again, a glimpse into these sociocultural discourses were discussed in the previous chapter around Asian/South Asian culture in regards to things like colonial/migration history and the influence this has on the discourse of ‘choice’ in terms of abortion care. However, while the sociocultural background of women, gay men and men in low- to middle-income countries have been largely explored, they are only beginning to be addressed in terms of the engagement of men in family planning in Western society. Almeling (2020) argue that ideas about men and reproduction stem from having a gendered knowledge of reproduction that results in an omission of specialised medicine for men, allowing for political precedence to construct reproduction as a ‘women’s issue’. Building upon Grainger and Almeling’s argument, this chapter explores how hegemonic cultural ideas about gender shape men’s reproductive health in terms of what reproductive technologies are not only developed but also made available. This chapter also discusses how

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behavioural theory has nearly erased men from reproductive decision-making, which is in stark contrast with the theorising around men’s health in the era of HIV/AIDS (see Inhorn, 2020), to be discussed further in the next chapter. By looking across the different reproductive technologies aimed at men, we can better see the relationship between gender norms and the construction of medical knowledge. As our understandings of family and reproduction are at a turning point for substantial change with technological innovation, this chapter will focus on de-constructing the heteronormative hegemonic masculine norm. There have been a number of technological advancements made that can either change the way we understand men’s reproductive health or act as a unique insight that shapes how we provide men the opportunity to become more engaged. There are four main arguments that will emerge throughout this chapter. Firstly, historically men have been a programmatic and analytical blind spot in reproductive health care and reproductive technologies. This is tied to hegemonic masculinity and men’s passive role in relation to reproduction, as well as the gendering of reproduction and reproductive technology. Secondly, in recent years there has been increasing efforts across different fields to address these gaps. In reproductive health care there has been the male engagement agenda of family planning and this has been present in a range of reproductive technologies that relate to new contraceptives, sexual enhancement products and reproductive wellbeing apps. Thirdly, looking across a range of male-oriented reproductive technologies and at behavioural theory about men – what can we learn about ideas around masculinities and why has this focus on men come about at this moment in time? What can it tell us about the generation of new knowledge? Finally, behavioural theory has given little thought about men as a variable when creating contraceptive decision-making models. The theory has been data-driven, but with little data to drive any theoretical modelling our understanding of men as reproductive beings is limited.

Integrating Men Into Family Planning Engaging men in family planning has been a political priority for many years, it became part of the global health agenda around the mid-1980s, 20 years after the global push for population control in the 1960s (Gallen, Liskin, & Kak, 1986). This placed men as active participants both inside and outside of the clinic (Forrest, 1986; Swanson, 1984). By the 1990s, the first global discussions on men had occurred at the 1994 International Conference on Population Development (ICPD) in Cairo (DeJong, 2000) and at the 1995 Fourth Women’s International Conference in Beijing (Sternberg & Hubley, 2004). By 1997 the United Nations Population Fund (UNFPA) had placed engaging men as an official global priority, publishing a booklet on how to do so post Cairo and Beijing (United Nations Population Fund, 1997). The next milestone was as part of the 2015 United Nations Millennium Development Goals (Wanner & Wadham, 2015), where upon review, several countries successfully reported improvements to maternal health through engaging men (see Armstrong, 2003; Armstrong et al., 1999;

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Fotso, Higgins-Steele, & Mohanty, 2015; Mbizvo, Chou, & Shaw, 2013; Portela & Santarelli, 2003; Yargawa & Leonardi-Bee, 2015). Turning to today, the United Nations’ Sustainable Development Goals (SDGs) provide targets to address challenges that will affect people globally by 2030 (United Nations, 2020). The political priority given to engaging men in family planning has not translated into research that can support better programming. We simply do not know what is happening with men nor whether the programmes that were designed are effective in bringing about change. Gender bias also then affects what and how data are collected. In the United Kingdom evidence-based research on men has been sparse. In 1997 there was the ‘It Takes Two’ campaign, which sought to increase engagement of men with family planning services (Measor, Tiffin, & Miller, 2000) and ‘The New Man’ campaign in 2008 that sought to understand how men currently perceived services (Family Planning Association, 2008). These campaigns lacked rigorous evaluation, and there have been few health-based initiatives to engage men in the United Kingdom since. The oral contraceptive pill is the most common form of contraceptive used in the United Kingdom (NHS, 2017; Pearson, 2003a), reinforcing the construction of reproduction as a ‘women’s issue’. Furthermore, men in the United Kingdom access social support for family planning less than their female partners (Pearson, 2003a), and since 2009 the number of men attending family planning services has declined yearly (National Health Service, 2017). We do not know why there is a decline in men’s service use (Pearson, 2003b) and this is still true in 2022. This lack of research priority on men’s use of contraceptive services is further problematised by gender bias in routine data collection. Basic demographic data on men are largely missing around contraceptive method(s) used, age is not recorded from men who visit clinics and ethnicity is ignored with options being white and non-white (Person & Clarke, 2007). When visiting as part of a couple the patient is recorded as female, even male condoms are presented in data sets as the woman’s contraceptive method used (National Health Service, 2017; Pearson, 2003a). These inbuilt biases in the data collection reinforce the discourse that family planning is a woman’s responsibility. This leaves little ability to analyse men’s family planning knowledge, attitudes and beliefs. Recent qualitative research has explored the barriers men face in accessing family planning services and concluded that the training manuals for health professionals act to marginalise men in family planning (Wilson et al., 2018); that nurse practitioners have concerns over men’s ability to use contraception effectively (Wilson, 2018b); and that men do not like the cost nor do they like procurement of condoms from clinics because clinic environments are perceived as feminised (Wilson, 2020).

Integrating Men and Family Planning Into Technological Advancements Recent technological advancements in men’s reproductive health can help to de-construct the heteronormative hegemonic masculine norm surrounding family planning, changing the way we understand men’s reproductive health or it acts as unique insights into men’s engagement. These advancements include a new generation of male contraceptives, which are currently under development.

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Technological advancements have further resulted in new forms of male contraceptive methods reaching phase III testing (from pills to gels), and the market is moving towards diversified options that will allow even more men to take primary contraceptive responsibility. Other advancements include the sexual enhancement product Sildenafil (Viagra) becoming available over the counter. The invention of Viagra and other male sexual enhancement drugs have also provided men with the ability to overcome erectile difficulties and engage in sex longer and at later ages, resulting in a larger potential contraceptive market and re-shaping of men within the reproductive realm (Potts, 2004). Most recently, technology has advanced where there are now smart phone apps aimed at men who are trying to conceive or who have undergone a vasectomy (Kobori, Pfanner, Prins, & Niederberger, 2016) to allow men to test their own fertility at home. Without research to understand the ever-changing landscape for men’s reproductive technologies, we are ill-prepared to understand what these new products and advancements mean for men’s decision-making and practice. The research gap around male infertility (Culley et al., 2013) is being addressed by a growing canon of qualitative literature focusing on men’s experiences of infertility and egg freezing (see Baldwin, 2019; Dolan, Thomas, & Ghobara, 2017; Law, 2019). In addition to this, technological advancements now exist, which allow for new family compositions. The use of a surrogate by gay men has become better understood and sophisticated in scope (see Norton, Hudson, & Culley, 2013) as well as transgender pregnancy (see Riggs, Pfeffer, Pearce, & Hines, 2020). Overall, the recent literature suggests that research on men and family planning is beginning to address the heteronormative bias, by expanding the use of surrogates by gay men and transgender pregnancy, making this a pivotal moment for transforming our understanding of reproductive norms.

Biological Essentialism and Scientific Technology: Electron Microscope and 3D Microscopy A crucial shift around masculine norms have come from the invention of the electron microscope, which has changed the way we biologically understand sperm. Prior to the electron microscope, the egg was considered passive and receptive of the final sperm, the sperm head drilling through the egg resulting in conception. With the electron microscope the egg was seen as active, grasping at the sperm and acting as an energetic entity, directing it toward the nucleus of the cell for conception to occur. This changed our understanding by promoting a cooperative process between the active sperm and active egg. The image facilitated the argument that it is difficult to separate the sperm or egg, making neither one an easier target for preventing conception (Nelson, 2017; Schatten & Schatten, 1983). Another advancement came with the creation of the 3D microscope; under a 2D microscope the sperm shows a whip-like wave motion from the tail (that was assumed as symmetrical). Using a 3D microscope, we can see the sperm move in a corkscrew or spinning motion due to the asymmetry of their tail, making the wave seen in a 2D microscope an optical illusion. Sperm movement under the 3D microscope has implications for the process of diagnosing male

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infertility, making it important to know how the sperm rotates. It also suggests there is a need to change the bench marks for sperm measurements, with asymmetry being important in shape, rather than symmetry as previously presumed (Gadˆelha, Hern´andez-Herrera, Montoya, Darszon, & Corkidi, 2020). These advancements directly challenge the biomedical argument that it is harder to intervene in millions of sperm than one egg. In fact, some biologists argue the opposite that it is the female reproductive system that is more difficult to inhibit (Oudshoorn, 2003). The theory of biological essentialism is based on this idea that sperm are virile and possess hyper-masculine traits, which are projected onto what should be an unbiased science. It perpetuates a discursive resource that can be used to justify men’s disengagement in family planning. It also further perpetuates a lack of reproductive awareness among men, facilitating an unrealistic discursive practice that when men want to have children, they simply need to have un-contracepted sex. What these two cases show is that our scientific understanding of sperm is limited by the technology available and that science is less objective than believed, particularly as technology begins to advance and disprove gendered assumptions of biological ‘facts’ (Wilson, 2018a).

From Pills to Gels and in Between: New Male Contraceptives on the Horizon Advancement of male contraceptives has been slower than the advancements for women or people with a womb, with women and people with a womb having a wider variety of methods to choose from, and men having the choice of vasectomy, withdrawal/natural family planning or condoms. The male pill has been under development since the 1970s yet has failed to reach the market, making it a confusing cultural symbol (Oudshoorn, 2003). Findings from studies on a male contraceptive pill in the United Kingdom suggest that men would only use it if there were no side effects and if they were in a long-term relationship (Brooks, 1998; Walker, 2011), with women more likely to be open to a male contraceptive pill than men (Eberhardt, van Wersch, & Meikle, 2009). Qualitative studies support the finding that men in long-term relationships feel positive toward a male contraceptive pill (Ringheim, 1996). However, a pill has been perceived by men as feminine, particularly among single men, so the gendered ideology needs to change before it would be marketable (Dismore, van Wersch, & Swainston, 2016; Wilson, 2018a). Furthermore, in a more recent study men have stated they would not use a male contraceptive pill and that only a minority of men in long-term relationships would find it an acceptable form of contraception (Wilson, 2018a). For a male pill to be successfully marketed, acceptance, trust, side effects, perceptions of responsibility and the impact on masculine identity need to be addressed (van Wersch, Eberhardt, & Stringer, 2012). Meaning it is unlikely we will see a male pill reach the market anytime soon. As science, biomedicine and engineering continue to develop, new safe and effective contraceptive options have become a potential reality to meet the demand for men to take control of their own reproduction (Townsend, Sitruk-Ware, RamaRao, & Sailer, 2020). Landmark studies investigating new hormonal male contraceptive methods began in the 1980s and 1990s, which saw clinical trials for advancements like a weekly injectable, scrotal implant and

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transdermal gels to suppress sperm. Other methods showing positive results in early clinical trials include non-hormonal technological contraceptives like thermal treatment, intravasal agents and future microchip technology (Reynolds-Wright & Anderson, 2019). Contraceptive gels are in phase II and phase III trials, which need to be completed prior to reaching the market. When combined in a gel, Nestorone and Testosterone (NES-T) rubbed on skin can act together to suppress spermatozoa to the point where conception becomes inhibited (Zitzman et al., 2017). Early double blind control trials have shown an 80% acceptability rate from a diverse set of users (Anawalt et al., 2019), and overall, 51% would recommend it to other men as a primary contraceptive (Roth et al., 2014). A main concern of the transdermal gel is the transfer to partner and/or child; however, a small pilot study showed the likelihood of transfer can significantly be reduced if a shirt is worn to prevent contact and if a shower is had two hours after application (Yuen et al., 2018). In a forthcoming chapter looking at British men’s online responses to a transdermal gel and interviews with reproductive scientists, the findings show that UK men are slightly more receptive to the idea of a transdermal gel and that reproductive scientists are hopeful that a transdermal gel will provide men with another option for controlling their own reproduction. However, reproductive scientists have shared potential barriers to the method reaching the market that include the difficulty of recruiting men and their partners for the duration of the study. Furthermore, there has yet to be a pharmaceutical company interested in funding the trials beyond phase IIb testing. (Mantey & Wilson, 2021). However, this research is preliminary and further research is needed around the acceptability of a male transdermal contraceptive gel. Another possibility is Reversible Inhibition of Sperm Under Guidance (RISUG), a gel that is injected into the vas deferens (Lohiya, Alam, Hussain, Khan, & Ansari, 2014). Sharma et al. (2019) are leading the development and phase III clinical trials in India. Before injection of the gel, which is composed of polymers, a local anaesthetic is applied (Gupta & Kumari, 2020). The gel has a high acidity so that when sperm pass through the gel they become damaged. The polymer also changes the electrical charge of the sperm inhibiting the sperm from swimming. It is entirely reversible by injecting another substance that acts as a solvent, and the gel will last 10 years if not dissolved. RISUG also has antimicrobial potential and could be tested to produce semen that are HIV-free (Khilwani, Badar, Ansari, & Lohiya, 2020). As the next chapter will discuss in more detail, there are other biomedical technologies to ensure children are born free of HIV. RISUG though could be a method, for men living with HIV, which needs further research to ensure ejaculation is HIV-free, providing men or couples who do not want to conceive a method they can still feel intimate with if they do not like using condoms. In the clinical trials of RISUG around 80% of men, within two months, reached a low enough sperm count where conception was impossible and the remaining 10% reached this point within 6 months (Sharma et al., 2019). RISUG is currently awaiting government approval in India (Gupta & Kumari, 2020); research outside of India is yet to be conducted and there is no research on the experience of RISUG users and their partners. It

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is important to note that a 15-year review of vasectomy in the United Kingdom has showed a 62.21% decrease of the contraceptive method and an 81.2% decrease in vasectomy reversals (Wydera & Wilson, 2021). Whether RISUG would be well received in the United Kingdom needs attention, with preliminary data being collected on the acceptability (Slack & Wilson, 2021), given the significant decreases in vasectomy. As of yet, RISUG, like the male pill and gel, has not reached the contraceptive market.

Viagra and Other Sexual Enhancement Products In stark contrasts, sexual enhancement products act as a biomedical response to the medicalised condition around having and maintaining an erection. These methods have been available for over 30 years. Implicit in this biomedical response is the assumption that as men age, they must maintain the same sexual prowess as in their youth, which many researchers argue is fed by the social constructs behind technological sexual enhancement products such as Viagra, Levitra and Cialis (Gross & Blundo, 2005). Discourses of masculinities place men in the subject position of power within the sexual relationship, creating practices and resources that reinforce the necessity of an erection – without an erection they become feminised and this is where Viagra comes into play, to provide masculine capital (Grace, Potts, Gavey, & Vares, 2006). Thirty years after the marketing of first erectile medications, the discourse of risk of erectile dysfunction now extends to men of all ages, and backgrounds, and that all men need to maintain a dominant phallic positioning (Gurevich, Cormier, Leedham, & Brown-Bowers, 2018). Men can now purchase Viagra directly over the counter in UK pharmacies. Whether erectile medication should be available over the counter is still debated among UK pharmacists, with some arguing that providing Viagra over the counter is dangerous due to potential complications (Rollins, 2014), and others arguing that regulating the drug has reduced the risks that come with men buying counterfeit medication online (Aronson, 2009). To mediate the first risk, only pharmacists, not pharmacy technicians, can administer Viagra over the counter. This allows for a one-hour consultation with a pharmacist that provides blood pressure and glucose checks and screening for family history of health conditions (Rubin & Wylie, 2009). Research in New Zealand provides the only study of pharmacists’ experiences’ with over-the-counter Viagra, finding pharmacists to be knowledgeable of who can and who cannot take Viagra and that furthermore they feel comfortable prescribing it, with a wide satisfaction rating of the training received (Braund et al., 2018). Whether this is the same for other pharmacists is unknown, there are no studies looking at the experiences, attitudes or beliefs of pharmacists and there is little understanding of any shifts in masculine discourses that have occurred within the pharmacy setting. Currently a mixed-methods study is being completed to understand how community pharmacists in the United Kingdom engage men in sexual and reproductive health, as well as any training needs (Wilson, 2021).

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Male Fertility Apps Apps created to test semen at home have been marketed as a private and convenient way to test whether a man should get further fertility investigations or as a confirmation for men who have had a vasectomy (Yu et al., 2018). For home tests, cameras and sensors on smartphones are used to assess the sperm and also provide the option to share data with a professional laboratory. Some apps are basic and attach a microscope lens to the smartphone called optical attachments; they assess concentration and mobility of sperm for a low retail cost ($5–7), while others are more complex, involving pipettes and powders to prepare a slide using a specimen cup and assessing sperm concentration, swim count and motility (cost around $59.95) (Parekh, Vij, & Agarwal, 2020). Some of the more advanced smartphone attachments that can be purchased are the YO Sperm Test and an application by Kanakasabapathy and colleagues (Kanakasabapathy, Pandya et al., 2017; Kanakasabapathy, Sadasivam et al., 2017). Caution is placed around replacing laboratory semen analysis with app-based analysis by untrained men (Drobnis & Rothmann, 2018). Further studies are needed to understand the feasibility of men using these apps to explore their own reproductive bodies. There are few empirical studies around men’s experiences of fertility apps; this is the rationale for a grant application I am writing to hopefully alleviate the gap in the literature. Online data are absent in the form of reviews of apps, blogs and discussion forums, making it difficult to begin to explore the impact of the new technology on men, which is known as the ‘Big Sperm’ market. Kroløkke’s (2020) discursive research provides some insights into marketing material for three products from three different countries. The first product allows men to test their sperm count at home and is called ExSeed Health App; the second, Cool Men, and third, Snowballs Underwear, are products that aim to cool the testicles and improve sperm count. Discourses of empowerment/enhancement and natural virility emerge from the Kroløkke’s findings, which draw on the assumptions that men ‘fix it’, using a masculine home improvement narrative that natural virility can be achieved through less invasive means of modifying one’s biology. There is also an underlying racial tone, which sets the precedent that white middle class ‘new’ men are considered worthy of fertility support in order to promote the reproduction of white infants. Kroløkke argues that app-based technology has resulted in a shift in responsibility where men have become individually responsible for infertility and management of their own reproductive health through surveillance methods versus larger systemic and external influences on sperm such as environment (see Hamper this volume). Overall, while the above technological advancements provide changes to the way in which men will be able to take responsibility for contraception in the future and understand their own bodies, the ways in which they are marketed and understood (re)produces a hegemonic norm. It does so through enforcing strong gender stereotypes, which influences what is being developed for men – technologies are created that fix things, such as erectile dysfunction medication, and these technologies being developed are self-managed, such as male fertility smartphone apps. Self-management suggests both a self-propelled and active form of

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hegemonic masculinity, which is also associated with the perpetuation of biological essentialism backed by the guise of a ‘strong science’. With biological essentialism also being responsible for the delay is new male contraceptives reaching the contraceptive market, making contraception indifferent to the discourse characterised by lag and delay. This is in contrast to the political construction of men as partners in family planning, where men are engaged from a diverse range of backgrounds that embraces a multiple masculinities framework. Further research is required in every advancement presented to explore the changing responsibility of men and the diversity of masculine identities present within the various biosociocultural contexts and environments. This can be supported by not only developing theory and models alongside rigorous empirical research but also by placing these developments back within the global and cultural understanding of the movement towards engaging men in family planning behaviours.

Integrating Men, Family Planning and Technological Advancements Into Theory and Health Psychology Models The previous section looked at how the constructs of masculinities and biological essentialism informed the development of male reproductive technologies. This section focuses on how masculine identities can inform the development of behavioural theory. It starts by explaining each theory and then moves on to discuss how these theories could be applied with men in mind to update the models used by health psychologists and others.

Subjective Expected Utility Theory Using principles of experimental psychology and economics, Edwards (1954) defines decision-making as a case of choice A and choice B, in which the choice an individual will make can be predicted. This approach focuses on the subjective utility of the cost of the alternative choices. Adapting the Subjective Expected Utility (SEU) Theory for family planning is attributed to Luker’s (1975, 1997) work on abortion, contraceptive choices and contraceptive risk taking in California. In the studies, Luker assigned utilities to contraceptive decision-making (in this case, the decision not to use contraception). The utility of the alternative choices considered the cost of contraception within social and cultural means, access to contraceptive maintenance, access to medical appointments, biological reactions, cost of pregnancy and abortion when deciding choice A contraceptive use or choice B non-use. Furthermore, probabilities were then explored and assigned to individuals, in this case women, to predict the various aforementioned cost variables. Implications included that greater involvement was needed from unmarried and married men using condoms, as they are half of the unwanted pregnancy population and often ignored in the equation. Luker further argued that if contraceptive use or non-use is a decision believed to be women-centric then men may not do their own cost accounting when making contraceptive decisions. She encouraged outreach services to engage men in cost accounting in

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order to promote individual responsibility. Luker’s theory has been tested empirically and refuted; however further replication is needed as the tested sample was biased to University students (Crosbie & Bitte, 1982). Extending Luker’s SEU Theory to men and family planning, deciding choice A (use) and choice B (non-use) of using a condom, alternative choices of size (such as fit and feel), cost, accesses and cost of pregnancy would be assigned various probabilities based on the assessment of individuals. Similarly for vasectomy, deciding choice A (to have) and choice B (to not have) would involve alternative choices of cost of procedure, cost of follow up, cost of potential complications and cost of a pregnancy, which would be assigned various probabilities to be accounted for and assessed. Withdrawal/natural family planning would have the least set of costs for choice A (to withdraw the penis) and choice B (to not withdraw the penis), which would include cost of a pregnancy. Withdrawal has the least set of probabilities assigned, with lack of awareness of the cost of child support being found in a qualitative study with UK men (Wilson, 2018a). While these SEUs need further experimental research to test these proposed predictions, the decreased probabilities assigned to withdrawal, largely due to lack of awareness of the cost of pregnancy, could explain why choice B is the option preferred by a majority (but not all) men in the United Kingdom at present. As technology advances and more male options are released on the market, the simplicity of the SEU Theory would become more complex, as the transdermal gel would need its own separate SEU model; then integration of the separate models would be required to predict which contraceptive option, A or B, that a man would choose. Arguably this is already the case for women, with the many choices they have available. Furthermore, SEU Theory fails to account for male sexual enhancement products and how the use of these may change over the life course. Without clear guidance on how to integrate SEUs, it is therefore logical to progress the other theoretical models health psychologists use to see how their extensions would fare.

Theory of Planned Behaviour Many theories have been combined with, or emerged from the Health Belief Model (HBM), including SEU. Building off of HBM and SEU, to understand both direct and indirect cognitions, research by Sheeran and Abraham (1996) argue for the use of the Theory of Planned Behaviour (TPB), which they applied to HIV risk (Sheeran & Abraham, 1994). Later Sheeran and collaborators applied both the Theory of Reasoned Action (TRA) and TPB to predict the intention to use a condom. Variables included gender (no difference found), age (older less likely than younger), time between intention and use (not significant), intention versus expectation (no difference found) and casual/new or steady partner (more likely with casual/new) (Sheeran & Orbell, 1998). Furthermore, psychosocial variables were used to explain condom use including: attitudes, social norms, previous condom use and a third unidentified variable that may be acting as an influence. From the psychosocial study, it was determined that the TPB could better account for self-efficacy and expand the understanding of social influences

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(Sheeran, Abraham, & Orbell, 1999). In a comparison of the HBM, TRA and TPB by Sheeran and Taylor (1999) a medium to strong correlation was found for both TRA and TPB, suggesting these models hold more validity than the HBM or SEU. When testing these models, a small gender difference was found where women were more likely to intend to insist on the use of a condom than men. There were three forms of evidence that suggested that the TPB was a superior model by the authors. One, the model better explained the variance in behavioural intentions. Two, using self-efficacy in the regression equation had a higher return of statistically significant results. Three, the change from including self-efficacy was significant. In further experimental testing, it was found that behavioural intention benefited from the inclusion of anticipated regret and descriptive norms, suggesting the need for adaption of the model (Sheeran & Orbell, 1999). Another study suggested again self-efficacy was important, and that confidence of use, carrying a condom, and the perception of protection be the focus rather than the intercourse itself (Abraham et al., 1999). Further testing has not been done, and after the 1990s Sheeran and colleagues ceased looking at heterosex and condom use, though they continued to suggest further adaptions to the TPB. Criticisms of Sheeran and colleagues’ models of condom use include the lack of data on men and pregnancy prevention to predict the behavioural intention to use a condom (Wilson, 2020). It is easy enough to factor in pregnancy prevention as an intention to use a condom using TPB. However, beginning to extend the TPB is no easy feat, given the various psychosocial factors raised in both the historical background, particularly around culture, and in the literature in the United Kingdom. A literature search shows the lack of quantitative descriptive statistics and qualitative social factors largely ignored both in present contraceptive methods and in the technological advancements discussed. Support for the TPB modelling includes that it allows for the attitudes of different male methods that are reaching the market to be considered in comparison and for the introduction of social norms that facilitate the integration of sexual enhancement products and changes over the life course. An exhaustive list of attitudes, social norms and previous contraceptive use would lead to a complex model though, increasing the margin for error, even with the acceptance made for a third unidentified variable that may be acting as an influence.

Developmental and Decision-Making Contraceptive Models in Health Psychology Ogden (2012) argues for the integration of both developmental (see Lindemann, 1977; Rains, 1971) and decision-making models (see above and Albarracin, Johnson, Fishbein, & Muellerleile, 2001; Herold & McNamee, 1982; Lowe & Radius, 1987) to understand contraceptive use. This allows for the combination of both the end stages of decision-making and psychological factors that influence this. The factors that best comprise a combined model are: background factors, intrapersonal factors, interpersonal factors and situational factors. Background includes demographic variables like ethnicity; intrapersonal includes knowledge,

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attitudes, personality; interpersonal includes partner, parents, peers and situational includes spontaneity, substance use and accessibility of contraception. Wilson (2018a, 2018b, 2020) and Wilson et al. (2018) argue for a fourth interpersonal factor, health professionals, to highlight the role health professionals have in facilitating engagement or marginalising men, which impacts on their decision-making ability of whether to engage in family planning behaviours such as contraceptive use or not. This integrated model would best explain the factors raised by new male contraceptive technology within the intrapersonal factors, partners and other individuals within the interpersonal and allowing for situational factors such as male sexual enhancement products, fertility/infertility and other life course factors. However, the main criticism is, do we have enough literature globally and in the United Kingdom to truly understand these factors without exploring the irrational variable further and allowing ourselves the humility to accept and except that our understanding may change exponentially? Looking to the future of models used to predict contraceptive use by health psychologists and other social scientists alike, there are several areas of consideration. Firstly, the theoretical implications of Luker and Sheeran and colleagues need to be replicated and undergo further empirical testing, to update our understanding. This could be done using methods such as meta-analysis (though to note there are few studies on heterosexual men and contraceptives) and experimentation. Criticisms made by Luker still resonate today, where there is an unmet need for greater involvement in research from both unmarried and married men who are using contraception. Researchers also still make the mistake of focusing solely on men, with a burgeoning area of literature globally around men and reproduction, but not the complex factors influencing men’s decision-making. Connell (2012), a leading expert in multiple masculinities theory, makes this argument more generally, calling for a relational approach to gender (rather than a categorical binary approach of men versus women) in order to better understand the lasting impact of colonialism, the structural violence of globalisation and systemic institutional biases on a global scale. It is further argued by Connell that reproduction is a result of an active gendered socialisation, where reproductive bodies are shaped by agency and status, and that the act of reproduction is one where femininities and masculinities are not only defined but also associated and enacted. Historically reproduction has been considered categorically, where men are masculine and women are feminine, ignoring that women’s identities can be more masculine than feminine and vice versa. Furthermore, this binary approach ignores that the theoretical standpoint puts both men and women in contrasting and competing roles, where feminism has rightly argued against male control of the reproductive body, but literature on men either limits men placing them as strictly biological agents of reproduction and/or shapes them as disengaged accessories. However, as Luker and others have stated, men are half of the reproductive equation, and this should be considered in future research by placing men within a larger theoretical relational context of gender, which allows for complexities of decision-making to be rigorously explored. My own theoretical advancement of masculinities theory also looks across the life course, adapting a systems theory approach to identify psychological development, where

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men have a core gendered identity that they may display to say partners, and this could be a different identity for when with friends and yet another identity for when acting as a member of society. This theoretical standpoint suggests that identity is not fixed and allows for change across the trajectory of the lifecourse. (Wilson, 2015). Furthermore, beyond theoretical development, there is key information missing from our research on men’s family planning behaviours, where men’s roles and responsibilities need to be understood within the context of when couples form and when couples separate. Research is still lacking on heterosexual men and contraceptive use and the role intention of preventing pregnancy plays in predicting male contraceptive use. There is also little consideration as to how factors of fertility or infertility predict contraceptive use and how contraceptive use may change over the life course based on this. Extension of the integrated developmental and decision-making model are further required to account for these criticisms and provide further theoretical development.

Conclusion In conclusion, researchers within critical men’s studies have begun to improve the lack of representation of men within reproductive research and technologies. Initial studies have aimed to celebrate male participation and to encourage their involvement and engagement in reproduction, though often framing men’s engagement in family planning as ‘heroic’ and tied to the hegemonic masculine gender norm. While men are now encompassing an active role, moving beyond the notion of men as passive recipients, the studies have for the most part exclusively focused on men and reproduction, often removing any consideration of women as partners, or people with wombs, in the process. This fails to account for women’s and people with wombs’ physical contributions in reproduction and removes them from a traditionally dominant space, of which few exist. Therefore, the male engagement agenda of family planning that has been presented earlier using a range of reproductive technologies that relate to new contraceptives, sexual enhancement products and reproductive wellbeing apps are entrenched in biased gendered norms. Recognising the contributions of men is important but this should not stop the empowerment of women or people with wombs within reproductive research, especially if we truly are aiming to facilitate reproductive justice. This is why we are at a turning point for focusing on men. When looking at how men are and should be engaged, it is important that women and people with wombs are still recognised and that research on reproduction and family planning is conducted without removing either perspective, but in a relational way. This is particularly true for health psychology theories and models, which often miss key factors and are based on the decision-making of one partner, rather than capturing how a decision is made within a couple. Research should recognise and be driven by an understanding of the interactions between partners and advancements in technology, and how this shapes and restricts men’s reproductive responsibility and masculine identities, constructing them as irrational variables who cannot be allies in the fight towards achieving reproductive rights.

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Reflection As mentioned a psychological systems theory approach to men’s identity development could be a more effective approach to build upon the critical studies in masculinities. This has been a theoretical standpoint I have been developing since 2015, all be it after 10 years researching men’s engagement in family planning in England I still feel the paucity of research limits my ability to come to a grand theory. To elaborate, in a systematic approach, men’s differing masculine and feminine positions could be understood in relation to the individual’s multiple identities and then looked at in relation to their reproductive partner’s own identity development also using systems theory. There are different levels in a systematic approach; these levels could be understood as the different positions an individual man could place himself within, with the inner level being most reflective of a man’s central identity and the outer levels reflective of positions men may use less frequently or in certain situations, but that they may not believe in. This is not to say that all men would have the same central identity (the levels presented in the following could vary based on identity differences), neither would the same identities expected to be found as positions available to all men. Some positions may give men masculine capital, where they say may not identify with hegemonic masculinity, but still benefit from it if it is a dominant identity in society in general. The above example could be visual represented as follows to present identity more fluidly: Central reproductive identity (relational gender of femininities and masculinities) Equal Partners (desire)

Supportive Partners (reality)

Lad (friendship groups)

Men in general society/ Hegemonic Masculinity

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Why a grand theory cannot be developed at this stage is largely due to the difficulties in recruiting men for reproductive research, something Law (2019) has begun to explore. Often large grants are needed to provide men incentives to participate in order to understand why they are participating to begin with, placing us in a catch22 scenario, which came first, the incentive or the desire to participate. The competition of grants has increased in the last few years, and when applying it must be considered in a relational capacity as to not take funds away from women’s and people with a wombs’ health, if we are truly acting within a reproductive justice framework. Furthermore, incentives are often limited by ethic committees to the living wage rate per hour, and this would mean for an hour interview men would only receive around £10, failing to recognise the incentive may not be in line with the wealth of information that can be gathered by the researcher(s) who are already in a power position. For quantitative research this power position still stands and often surveys or psychological scales take less than 20 minutes to participate, and large numbers are needed to be statistically relevant. This would require less than £5 per participant, in line with ethics committees’ living wage standard, but for around 384 participants (to be reflective of the United Kingdom) this amounts to around £1,500 for participant payment, something most researchers in the field of men and reproduction do not have access to. If a prize draw is used instead, though ethics and data controllers do not like this approach as it comes with extensive requirements, there is less incentive to participate as you are not guaranteed to receive compensation for your time and you have to forgo your anonymity if you want a chance to be compensated by providing an email address. Furthermore, the dominance of qualitative literature has led to an over-confidence on these methods’ findings, which provide little validity and reliability as a small pool of potential participants leads to difficulties with statistical power or the use of advanced psychometrics. So how do we then come up with a grand theory for men and family planning if we have poor theoretical advancements, ethical limitations that often ignore or minimise the difficulties recruiting men and the valuable contributions men can make, data protection obligations, over reliance on qualitative findings, and limited funding? I feel we must move towards Open Science (something promoted by both the American Psychological Association [APA], the British Psychological Society [BPS] and myself), which allows researchers to pre-register studies, combine already existing data sets with citation to the original data (either with our own data or combining the pre-existing data of others to form a larger data set) or materials and coding can be shared. However, to do so academia must move in the direction of collegiality versus individualistic gains that often are shrouded in secretiveness and lacking transparency. If reproductive researchers around the world committed to Open Science I feel we would see real progress in understanding men’s engagement in family planning behaviours. To learn more about open science see: https://www.apa.org/pubs/journals/resources/open-science; https://thepsychologist.bps.org.uk/tags/open-science and https://www.cos.io/. To access my own Open Science Forum account and re-use any aspect of my studies see: osf.io/yhb4g.

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Chapter 13

Inclusion, Exclusion, Anticipation: How the Politics of Intimate Relationships Structure Innovation Ryan Whitacre

Abstract The politics of intimate relationships structure innovation for sexual and reproductive health technologies. In this chapter I present three case studies that explore how national political concerns surrounding maternal intentions and the race of sexual women shape the production of sexual and reproductive health technologies. The products I examine are: GONAL-F, a subcutaneous injection of follitropin alpha for ovulation induction; Evra, a transdermal patch containing norelgestromin (NGM) and ethinyl estradiol (EE) for hormonal contraception; and zidovudine (ZDV) for HIV therapy, including the prevention of mother-to-child transmission. Together, these case studies illustrate how the politics of intimate relationships, which are deeply engrained in societies, structure clinical innovation, through conditions of inclusion, exclusion and anticipation. Keywords: Intimacy; innovation; biomedicine; HIV; contraception; reproduction; clinical labour; medical anthropology

Introduction The politics of intimate relationships structure innovation for sexual and reproductive health technologies. The intimate elements of these interventions are

Technologies of Reproduction Across the Lifecourse, 247–259 Copyright © 2022 Ryan Whitacre Published under exclusive licence by Emerald Publishing Limited doi:10.1108/978-1-80071-733-620221021

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evident at the point of use, as women use assisted reproductive technologies (ARTs) to conceive children or prevent pregnancies, and soon-to-be mothers take antiretrovirals (ARVs) with hope their children will not inherit illness, and thus these technologies become wrapped up in assumptions about sex and reproduction and their many moralities (Gammeltoft & Wahlberg, 2014; Rapp, 2004). However, the politics of intimate relationships also shape the very invention of ARTs and ARVs. Early in clinical research studies, as experimental therapies first enter human bodies, they become shot through with political and economic expectations about gender, sex, race and the family. In the very process of research and development, new therapies become stitched to regimes of social inclusion and exclusion in societies (Petryna, 2009), which determine who should be granted access to experimental therapies (Fisher, 2008). Meanwhile, the measures of efficacy that support their chances of commercial approval are structured through successive moments of anticipation (Adams, Clarke, & Murphy, 2009), opening a range of possible outcomes about how life will be, which allow for things to turn out unexpectedly – and thus, manifest in that inevitable condition of disappointment that Lauren Berlant has referred to as the ‘secret epitaph of intimacy’ (Berlant, 2000). In this chapter I read through a series of clinical research histories for sexual and reproductive health technologies to analyse how the politics of intimate relationships have structured clinical research for biomedical innovation. Specifically, I identify how the politics of the intimate have become essential to the very design and conduct of clinical research, structuring the criteria for inclusion in research participation and calibrating measures of efficacy for experimental therapies. The politics of intimacy are local and specific to the contemporary conditions within countries, and yet become embedded within the supposedly universal methods for evaluating efficacy of new therapies, supporting regulatory approval and commercial potential in global markets. As an anthropologist of biomedicine and markets for new therapies, I aim to weave together scholarship in the anthropology of biomedicine and clinical research with critical Black feminist science and technologies studies (STS). Thus, I examine how biomedical innovation has been pieced together by processes of ‘co-productive’ wherein political and economic elements of societies jointly shape the scientific enterprise (Jasanoff, 2004), and I am attentive to the ways market-based economies overdetermine the experimental work of clinical research, pushing human subject clinical trials to distant shores, where experimental subjects are pharmaceutically naive and labour is expensive (Petryna, 2009), or launch trials in post-Fordist economies that have created new opportunities for entrepreneurial labour, including for people in precarious positions (Cooper & Waldby, 2014; Fisher, 2008). I also think with scholars in critical, Black and feminist STS who have interrogated the White assumptions of the discipline (Mascarenhas, 2018), re-centering race and racism as critical social issues in reproduction (Valdez & Deomampo, 2019). Drawing on Dorothy Robert’s contention that reproductive politics ‘inevitably involve racial politics’ (1997, p. 9), these scholars have examined how pregnancy has been transformed

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into a site of racialisation (Bridges, 2011), and traced the impact on present-day clinical outcomes (Davis, 2019), as ‘all politics become reproductive politics’ (Briggs, 2018). However, whereas these scholars have shown how the politics of reproduction structure uses of technologies and clinical outcomes, I aim to show how the politics of intimate relationships, including systemic forms of racial exclusion, are integrated into biomedicine, including in the very invention of new technologies. My research thus advances both of these bodies of scholarship: reconceptualising the stakes of human subject research participation in research to support the development of new biomedical technologies and shining new light on the politics of intimacy within innovation. In this chapter I examine the clinical research histories of specific sexual and reproductive health technologies, including for ovulation induction, hormonal contraception and the prevention of mother-to-child HIV transmission, and reconstitute the clinical histories of specific technologies developed for each type of therapy, drawing on clinical trial data made publicly available by national health organisations and situating experimental histories within their contemporary political and economic contexts. I focus on first product to be approved for commercial use in Europe, based on the records of the European Medicines Association (EMA). These products are: GONAL-F, a subcutaneous injection of follitropin alpha for ovulation induction; Evra, a transdermal patch containing norelgestromin (NGM) and ethinyl estradiol (EE) for hormonal contraception; and zidovudine (ZDV) for HIV therapy, including the prevention of mother-tochild transmission. For each individual product, I gathered information about the clinical research supporting its regulatory approval from a central database hosted by the US National Library of Medicine (clinicaltrials.gov), including basic information about the trials (dates, locations, investigators); detailed information on the clinical protocols (recruitment and enrolment criteria, including sex, gender, age; numbers of participants retained over the course of research) and measures of efficacy; through subsequent queries using the central database of published articles within the US National Library of Medicine (PubMed), I also sourced publications associated with the pivotal clinical trials that supported regulatory approval and the commercialisation of products. My analysis has also been informed by 10 years of ethnographic research on the development and implementation of biomedical technologies, including interviews and participant observation with clinical research investigators, public health practitioners, research participants and people who use these technologies in their everyday lives (Whitacre, 2018, 2021). This chapter is organised across three empirical sections: each section examines how the politics of intimate relationships structure biomedical innovation for sexual and reproductive health technologies. I aim to contribute to scholarship on the ‘integrative approach’ by reinvigorating the clinical research histories of these technologies and demonstrating how they have been structured by the politics of intimacy.

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Inclusion: The Politics of Maternal Intent The politics of intimate relationships structure maternal intentions and thus also shape the conditions of participation for studies evaluating the efficacy of infertility technologies, including by shaping trial design, defining inclusion criteria, and determining the measures of efficacy. Consider the 12 randomized controlled trials (RCTs) that generated evidence about the safety and efficacy of GONAL-F, the first ovulation induction therapy approved for use in Europe. Beginning in 2003 a series of studies evaluating GONAL-F were held across several European countries, including in Austria, Belgium, France, Hungary, Spain and Switzerland. Investigators recruited relatively small cohorts of women across a wide range (18 and 40 years old), offered them the experimental therapy and monitored participants for approximately two years to evaluate differences in pregnancy and birth rates between the experimental and control groups. The trials went according to plan: most participants (more than 90%) completed the studies; each trial showed the experimental therapy increased pregnancy rates among women in the experimental arm. This set of European studies not only supported the commercialisation of the therapy, but they also set the bar which all future open-label studies and international trials could be measured against, and in many subsequent studies evaluating GONAL-F, trial designs and participant retention rates varied in significant ways, reflecting differences in local maternal expectations, and the ways they were shaped by political and economic conditions. The way the politics of intimate relationships structured innovation for this ovulation induction technology became clear in the open-label studies evaluating how GONAL-F was being used by would-be mothers, including its convenience as a clinical intervention (NCT01183143). The first open-label trial was conducted in Germany. After enrolling 215 women, investigators discovered that many women did not complete the course of therapy – in fact, of the 215 women enrolled, only 65 continued long enough to be included in the reported findings. While birth rates were relatively high among these 65 women – as 41 gave births – it also became quickly apparent these women represented only a minority of women who were intent enough on maternity to complete the study that had begun two years earlier. The maternal intentions reflected in this low rate of retention reflected a more general trend toward decreasing fertility among European women, which has steadily declined for several decades, leading up to and following the study – between 1990 and 2015, the number of live births decreased from 5 to 4 for the average individual woman in Europe (ec.europa.eu); and in Germany, fertility rates had dipped well below 1.5 live births for women shortly before the study began. The decline in maternal intentions among women in Europe were reflected in the clinical intervention. The ways maternal intentions affected clinical interventions were also evident as trials evaluating GONAL-F began to expand around the world. After this initial period of intensive experimentation in Europe, investigators began to conduct clinical trials in other countries, including in Russia, China and the United States. In the process, national policies presiding over intimate

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relationships became interwoven with local socioeconomic conditions; and in turn, local conditions of maternal intentions structured participant recruitment and retention, as well as outcome measures that determined the efficacy of the intervention. Thus, the globalising clinical research began to demonstrate how the intention to become a mother was at once shaped by political conditions and was becoming embedded in experiments. Take the example of the trial conducted in the United States, where in 2013, investigators launched the first clinical trial evaluating the efficacy of the GONAL-F for increasing pregnancy rates among an older cohort of women (Nyboe et al., 2017). Whereas previous trials conducted in European countries had opened recruitment for women in a relatively wide age range (e.g. 20–40 years of age), the US trial focused specifically on evaluating the efficacy of GONAL-F among women between 35 and 42 years of age – a life-stage in which it was becoming increasingly common to give birth for women living in the country. The age of pregnancy had recently increased by nearly a year and a half across the country since the year 2000; however, women over 35 still only made up 9.1% of total births (Mathews & Hamilton, 2016). The experiment was thus responsive to local maternal intentions – fit for women with careers, who wanted to children ‘later in life’ (Kost & Lindberg, 2015). Targeting this older cohort of women in the United States afforded a market advantage – few previous therapies were approved specifically for women of this age group. Consider also the example of the Russian trial, which began in February 2017 (NCT03296527). Like the US study, the Russian study was conducted in a highly competitive market, where several other products were already commercially available, thus investigators were obliged to compare GONAL-F to another brand-name therapy – in this case, Primapur. The Russian study was striking in its relatively small size, enrolling just 110 women across three sites – a hospital, clinic and IVF site, all in Moscow – and conducted in a political environment where the government was actively incentivising maternal intent. In 2006, Putin had introduced explicit incentives to have children in a ‘cash for babies’ programme, which as Michelle Rivkin-Fish has observed, reinforced a particularly Slavic form of ‘maternity capital’ (2010). During the time the GONAL-F study was being conducted, maternal intent became further infused with capital incentives as the Putin-led government began to provide a new round of cash payouts, tax breaks and even mortgage relief for families with young children (Courthouse News, 2020). Given these state incentives and clear market demand, it may then come as little surprise that all women who were enrolled in the study also completed the year-long monitoring and zero participants deviated from the protocol – at least according to the official reports – making the Russian study the only study with such high participant retention. By December 2017 yet another clinical trial testing GONAL-F had begun in China. This trial was initiated almost exactly one year after the One-Child policy had ended in the country (Gietel-Basten, Han, & Cheng, 2019) – during a time when maternal intentions were allowed to shift. As in the Russian study, the most striking element of the Chinese study was the retention of participants. While Chinese investigators did not report 100% participant retention, as the Russian

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investigators had, the Chinese study recruited a much larger cohort of women – 500 in all, and maintained high participant retention over two years. The number and endurance of women intent on motherhood was significant – it far outpaced observed intentions among would-be mothers observed in open-label studies conducted in Europe over a dozen years earlier, which had shown that only 40% of women continued therapy over the course of a two-year study. The clinical trial history of GONAL-F is instructive for understanding how the politics of intimate relationships shape clinical interventions. Just as local political and economic conditions structure maternal intent, the contemporary prospects of motherhood manifest in participant retention rates. Indeed, local maternal intentions manifest in the outcomes of experiments, and in this case, also supported regulatory approval of GONAL-f in global markets.

Exclusion: The Race of Sexual Women The politics of intimate relationships also structure experimental trials for contraceptive technologies, including the demographics of participants who are included in clinical studies. In this case, the politics of intimate relationships manifests in disparities in representation of racial demographics among participant groups. The participants included in studies evaluating the efficacy of hormonal contraception technologies have been overwhelmingly white – far whiter than the racial demographics of resident populations in the places where the trials have been conducted. The clinical trials evaluating the efficacy of Evra, the first hormonal contraceptive approved by the EMA (2002), were conducted in several countries where racial demographics vary significantly, and yet across the participant groups in these three large-scale RCTs, the vast majority of women were white (Zandvliet et al., 2016). The percentage of white women who participated in the studies was far greater than the average population in all countries, including the United States and Europe. However, disparities in racial inclusion were most striking in the multinational studies for which participants were recruited in countries with non-white majorities, such as South Africa, and yet the groups of women who were included in the studies were overwhelmingly white – in fact, white women made up 91.1% of the total participant population (Fig. 1). The racial demographics of women included in the Evra study offer another example of the ways the politics of intimacy structure innovation. As the demographic chart provided by the investigators exhibits, women who want to have vaginal sex without becoming pregnant encounter systemic forms of racial exclusion, and are thus not included in clinical research evaluating experimental therapies. Whereas the example of participant recruitment and retention in ovulation induction studies demonstrated how local political and economic conditions structure maternal intentions, the racial demographics of the contraceptive studies offer insights into forms of inclusions and exclusion in societies. The racial make-up of studies is masked by the regulatory review process – at least, historically, racial demography has not been a factor that regulatory

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Table 1: Evra Users (All-Subjects Treated) in Studies 2004, 2003, 2002.

agencies consider when they review new drug applications. Regulators instead focus only the measures of efficacy among participants who were included – the group of 4,766 mostly-white women who wanted to have sex without having children. They evaluate the experimental design, including the study objectives, inclusion criteria and evaluation schedules, which were similar across all three of these clinical trials. Enrolment had been limited to women between the ages of 18 and 45 years, who were not pregnant, and reported regular menses in a range of 25–35 days. Investigators had assigned the participants to the experimental arm and asked them to use the Evra patch on the first day of menses. The patch was applied for a full week for three consecutive weeks (days 1–7, days 8–14, days 15–21 of each cycle; days 22–28 were patch free). Meanwhile, participants in the control arm were asked to take a tablet of a combined oral contraceptive on the first day of menses, and to take one tablet per day for 21 days, followed by 7 days of no treatment or inactive treatment, depending on the study (CONT-003/004). When the studies were complete the scientific team at Janssen cobbled together measures of efficacy across all three studies, pooled the results and sent them off to the EMA in a new drug application for Evra (Center for Drug Evaluation Research, 2001). Upon receipt of the application, EMA regulators were presented with evidence about the use of Evra in 22,160 on-therapy cycles for more than 3,319 women. Among all of these women, the number of pregnancies amounted to just 15. In a series of summary tables, efficacy outcomes were analysed relative to indices for the expected number of pregnancies among this large group of

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Fig. 2. Table 3: Phase III Efficacy/Safety Studies. Submitted to the European Medicines Association in the New Drug Application for Evra.

women over these many cycles. In review of the evidence, EMA officials agreed: the Evra patch reduced the probability of pregnancies, and was thus marketed broadly across Europe (Fig. 2). This way of evaluating clinical research ignores and disguises the forms of intimate exclusion that are embedded within societies, and the ways they manifest as limitations to access for experimental therapies. Experimental research proceeds without addressing local concerns for health equity – benefiting from research participation among privileged demographics that are thought to be more compliant with study protocols, and more likely to already have access to clinical care. Inclusion in clinical research would not by itself remedy the forms of exclusion that people face in societies, and thus increasing the racial diversity of clinical research alone would be an under-powered form of social justice (Epstein, 2009). Yet, experimental trials that recruit human subjects can also offer avenues of access to therapies; and hold the potential to advance health equity – as an important site where systemic forms of social exclusion are explicit and documented.

Anticipation: Is It Worth the Wait? The politics of intimate relationships also structure clinical research evaluating novel biomedical methods to prevent HIV. In this case, the very condition of waiting and wanting to know is an integral aspect of participation in experimental research to evaluate the efficacy of antiviral therapy, including clinical interventions for the ‘prevention of mother-to-child transmission’ or ‘PMTCT’. Anticipation calibrates our knowledge of and interest in the results, as antivirals are

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used to reduce the chances that pregnant women might pass the virus on to their babies, and would-be mothers wait in suspense – have they passed the virus on to the next generation, or did HIV therapy effectively prevent HIV? Clinical research for PMTCT began in April 1991, with a clinical trial evaluating the efficacy of an HIV therapy for PMTCT. The trial was staged across France and the United States, managed by the AIDS Clinical Trial Group (ACTG) and known as ‘ACTG 076’. Anticipation structured the intervention, beginning with criteria for participation. To be eligible, women had to be pregnant (between 14 and 34 gestation weeks), living with HIV and not receiving HIV therapy. This inclusion criteria specified a very particular kind of intimate relation between one’s self and one’s foetus – over this gestational period, the foetus experiences tremendous growth, the baby’s head and body grow in proportion, a sleep pattern begins to develop and the head points downwards toward the birth canal. Anticipation also calibrated the measures of efficacy: women were assigned to one of two participants groups, an experimental group that would receive AZT or a control group that would receive a placebo. The investigators would determine the efficacy of the intervention by monitoring the number of babies born living with HIV and compare outcomes between the two groups. The study ran for nearly three years, until February 1994, when the anticipatory elements of experimentation were transformed into clinical realities, as the investigative team conducted an interim efficacy analysis evaluating outcomes. There had been 364 births: 180 in the AZT group and 184 in the placebo group. 53 babies had been born with HIV: 13 were in the experimental group; meanwhile, 40 new cases were confirmed in the placebo group. The difference was statistically significant – investigators calculated the experimental therapy reduced the risk of transmission by 67.5%, and soon published the results, offering clear evidence that AZT could be efficacious for use in PMTCT (Connor et al., 1994). For the majority of women who were assigned to the experimental arm of the study, and gave birth, these hopes came true – their babies were born free of HIV. However, for the 40 women who were assigned to the placebo arm, and gave birth, things turned out differently – thus, reinforcing ‘the secret epitaph of intimacy’ (Berlant, 1998, p. 281). The politics of anticipation only intensify after results of efficacy are reported. At the same time as results were published, a series of closely related studies were also evaluating the efficacy of AZT for PMTCT in several African countries. In the African studies, as in ACTG 076, investigators had enrolled women in two arms of the trials – offering AZT to participants in the experimental arm AZT, and placebo to women in the control group. However, once results from ACTG 076 were announced, the ethics of the trial were thrown into question. Was it morally acceptable to continue the experiment knowing that AZT works for PMTCT? Or should the study be unblinded, so that all participants could receive the therapy, and thus reduce the chances that women would not pass HIV onto their babies? These questions sparked international controversy: bioethicists drew tight boundaries around access and the experimental intervention – they privileged the imperatives of ‘scientific progress’ and thus promoted the integrity of the experiment above and beyond the well-being of women who participated;

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meanwhile, advocacy groups campaigned to unblind the study and provide access (Wendland, 2008) – advocates determined it was no longer morally acceptable to anticipate efficacy (McIntyre, 1998). The women simply could not wait. Indeed, anticipation structured the AZT controversy – both buttressing the interests of biomedicine and justifying disparities in access to life-saving therapy.

Conclusion The politics of intimate relationships structure biomedical innovation and preconfigure the very possibility of producing biomedical technologies, including by shaping the conditions of participation, calibrating measurements of efficacy and justifying disparities in access to life-changing therapies. To trace the impact on the politics of intimacy on the innovative, we must break open the common-sense logics of biomedicine and look more carefully at the human aspects of clinical research supporting the production of new products. From this perspective, it is clear that the political dimensions of intimacy are a precondition for the development of biomedical therapies, and political interests in the intimate have been built into science. National policies structure maternal intentions and set the stage to increase fertility through the development of ovulation induction technologies, as evident in the case of GONAL-F. When the Chinese government allowed women to have more than one child, investigators launched large-scale studies evaluating the efficacy of the novel therapy. Likewise, when the Russian government incentivised women to have more children, investigators enrolled large groups of women to test the same product. And in both cases, retention in clinical research was high – nearly 100%. Conversely, in countries where governments were not actively promoting nor limiting fertility rates, investigators running trials testing the same product recorded much lower retention rates. In each case, the national politics of intimate relationships had discernible effects on the experimental intervention. When national governments systematically exclude non-white women from accessing benefits in societies, the consequences of racial exclusion are evident in experimental settings, as made clear by the demographics of women in studies evaluating the Evra patch. Disparities in racial demographics represented in clinical research are shaped by systems of exclusion in societies and manifest as difference in enrolment and access to experimental therapies. In this case, racialised exclusion limit access to social institutions, not only for care but also for pleasure – inhibiting the ability of non-white women to enjoy the very act of having vaginal sex without becoming pregnant. When the ethics of biomedicine favour the integrity of clinical research over the well-being of participants, access to life-saving therapies may remain limited, and women are asked to wait and see if their babies will be born with HIV, as made clear in case of AZT for PMTCT. Indeed, the politics of intimacy are wrapped up in measures of efficacy as well as the right to access for experimental therapies. The politics of intimacy are deeply material, yet also always affective

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and anticipatory – they configure futures in which babies will be born with or without a virus, and medications will be made available or will not. These case studies show how the politics of intimate relationships, which are deeply engrained in societies, structure the biomedical enterprise. The case studies also show how politics of intimacy are specific to contemporary conditions within societies, and thus impact interventions differently. However, in review of all the cases, the impact of intimate politics is most clear by contrast: in the ways different government policies shape clinical outcomes, as systemic exclusion operates within several societies, and the ethics of anticipation are negotiated across borders, wherein disparities in access are stark and women wait to know if their children will inherit a life-changing diagnosis. I hope this chapter offers helpful perspectives for social scientific enquiry about biomedical technologies for sexual and reproductive health and deepens our collective understanding of the ways the politics of intimate relationships structure biomedical innovation – through inclusion, exclusion and anticipation.

References Adams, V., Murphy, M., & Clarke, A. E. (2009, September 1). Anticipation: Technoscience, life, affect, temporality. Subjectivity, 28(1), 246–265. doi:10.1057/sub. 2009.18 Berlant, L. (1998). Intimacy: A special issue. Critical Inquiry, 24(2), 281–288. Berlant, L. (Ed.). (2000). Intimacy. A critical inquiry book. Chicago, IL: University of Chicago Press. Retrieved from https://press.uchicago.edu/ucp/books/book/ distributed/I/bo3644687.html Bridges, K. (2011). Reproducing race: An ethnography of pregnancy as a site of racialization. Oakland, CA: UC Press. Briggs, L. (2018). How all politics became reproductive politics: From welfare reform to foreclosure to Trump. Oakland, CA: UC Press. Center for Drug Evaluation Research. (2001, November 20). New drug application 21-180, ORTHO EVRA. U.S. Department of Health and Human Services. Connor, E. M., Sperling, R. S., Gelber, R., Kiselev, P., Scott, G., O’Sullivan, M. J., … et al. (1994, November 3). Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. New England Journal of Medicine, 331(18), 1173–1180. doi:10.1056/NEJM199411033311801 Cooper, M., & Waldby, C. (2014). Clinical labor: Tissue donors and research subjects in the global bioeconomy. Durham: Duke University Press Books. Courthouse News. Putin extends cash payouts for babies to counter population slump. Retrieved from https://www.courthousenews.com/putin-extends-cash-payouts-forbabies-to- counter-population-slump/. Accessed on February 23, 2022. Davis, D. A. (2019). Reproductive injustice: Racism, pregnancy, and premature birth. New York, NY: NYU Press. Retrieved from https://nyupress.org/9781479853571/ reproductive-injustice Epstein, S. (2009). Inclusion: The politics of difference in medical research. In Chicago studies in practices of meaning. Chicago, IL: University of Chicago Press. Retrieved from https://press.uchicago.edu/ucp/books/book/chicago/I/bo5414954.html

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European Medicines Agency. (2002). “Medicines.” European Medicines agency. Retrieved from https://www.ema.europa.eu/en/medicines. Accessed on March 24, 2021. Fisher, J. A. (2008). Medical research for hire: The political economy of pharmaceutical clinical trials. New Brunswick, NJ: Rutgers University Press. Gammeltoft, T. M., & Wahlberg, A. (2014). Selective reproductive technologies. Annual Review of Anthropology, 43(1), 201–216. doi:10.1146/annurev-anthro102313-030424 Gietel-Basten, S., Han, X., & Cheng, Y. (2019, November 6). Assessing the impact of the ‘one-child policy’ in China: A synthetic control approach. PLoS One, 14(11), e0220170. doi:10.1371/journal.pone.0220170 Jasanoff, S. (Ed.). (2004). States of knowledge: The Co-production of science and the social order (1 New edition). London: Routledge. Kost, K., & Lindberg, L. (2015, January 9). Pregnancy intentions, maternal behaviors, and infant health: Investigating relationships with new measures and propensity score analysis. Demography, 52(1), 83–111. doi:10.1007/s13524-014-0359-9 Mascarenhas, M. (2018, March 1). White space and dark matter: Prying open the Black Box of STS. Science, Technology & Human Values, 43(2), 151–170. doi:10. 1177/0162243918754672 Mathews, T. J., & Hamilton, B. E. (2016). Mean age of mothers is on the rise: United States, 2000-2014. NCHS Data Brief, no. 232 (January), 1–8. McIntyre, J. (1998). AZT trials to reduce perinatal HIV transmission: A debate about science, ethics and resources. Reproductive Health Matters, 6(11), 129–130. doi:10. 1016/S0968-8080(98)90090-8 Nyboe, A. A., Nelson, S. M., Fauser, B. C. J. M., Garc´ıa-Velasco, J. A., Klein, B. M., Arce, J.-C., ESTHER-1 study group. (2017, February 1). Individualized versus conventional ovarian stimulation for in vitro fertilization: A multicenter, randomized, controlled, assessor-blinded, Phase 3 noninferiority trial. Fertility and Sterility, 107(2). 387–396.e4 doi:10.1016/j.fertnstert.2016.10.033 Petryna, A. (2009). When experiments travel: Clinical trials and the global search for human subjects (1st ed.). Princeton, NJ: Princeton University Press. Rapp, R. (2004). Testing women, testing the fetus: The social impact of amniocentesis in America. Oxfordshire: Routledge. Rivkin-Fish, M. (2010). Pronatalism, gender politics, and the renewal of family support in Russia: Toward a feminist anthropology of ‘maternity capital’. Slavic Review, 69(3), 701–724. doi:10.1017/S0037677900012201 US National Library of Medicine . ClinicalTrials.Gov. Retrieved from https:// clinicaltrials.gov/. Accessed on March 24, 2021. Valdez, N., & Deomampo, D. (2019, October 3). Centering race and racism in reproduction. Medical Anthropology, 38(7), 551–559. doi:10.1080/01459740.2019. 1643855 Wendland, C. L. (2008). Research, therapy, and bioethical hegemony: The controversy over perinatal AZT trials in Africa. African Studies Review, 51(3), 1–23. Whitacre, R. (2018). Intimate innovation: Subjectivity, political economy, and a novel method to prevent HIV. Ph.D. University of California, San Francisco. Retrieved from https://search.proquest.com/pqdt/docview/2124411373/abstract/EAA52A CEB03045C7PQ/1

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Whitacre, R. (2021). Revealing truth through diagnostics: From disclosure laws to clinical research for novel drug development. Medicine Anthropology Theory, 8(2), 1–23. doi:10.17157/mat.8.2.5135 Zandvliet, A. S., Prohn, M., de Greef, R., van Aarle, F., Sisk, C. McC., & Stegmann, B. J. (2016). Impact of patient characteristics on the pharmacokinetics of corifollitropin alfa during controlled ovarian stimulation. British Journal of Clinical Pharmacology, 82(1), 74–82. doi:10.1111/bcp.12939 Zhang, J. (2017). The evolution of China’s one-child policy and its effects on family outcomes. The Journal of Economic Perspectives, 31(1), 141–159.

Chapter 14

Integrating Reproductive and Nonreproductive Technologies: Egg Freezing and Medical Abortion Lucy van de Wiel

Abstract Although research on reproductive technologies such as IVF and egg freezing has traditionally been rather separated from the work on contraceptives and abortion, analysing reproductive and nonreproductive technologies together, as this volume proposes, can provide the basis for a broader contemporary politics of reproductive control. This chapter analyses this politics of integrating reproductive and nonreproductive technologies by focusing specifically on IVF-based fertility (preservation) treatments and (medical) abortion. More specifically, it explores both technologies’ interrelated research trajectories and the financial and platformised dimensions of their clinical implementation. With a dual focus on egg freezing and medical abortion, this project seeks to explore how processes of platformisation and financialisation shape the clinical and commercial infrastructures that govern twenty-first-century reproduction. The chapter’s broadened analytic scope that incorporates both reproductive and nonreproductive technologies highlights how a contemporary biopolitics of reproductive control may be expressed through these technologies’ interrelated regulatory practices, shared politicised reference points (e.g. the embryo), opposite investment practices and mutually reinforcing social effects. Keywords: Egg freezing; abortion; medical abortion; IVF; US; reproductive politics; fertility sector; platformisation; financialisation Although research on reproductive technologies such as IVF and egg freezing has traditionally been rather separated from the work on contraceptives and abortion, analysing reproductive and nonreproductive technologies together, as this volume

Technologies of Reproduction Across the Lifecourse, 261–283 Copyright © 2022 Lucy van de Wiel Published under exclusive licence by Emerald Publishing Limited doi:10.1108/978-1-80071-733-620221022

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proposes, can provide the basis for a broader contemporary politics of reproductive control. This chapter focuses on the integrated politics of reproductive and nonreproductive technologies, focusing specifically on IVF as fertility (preservation) treatment and (medical) abortion. While Dow and Boydell highlight the relevance of different reproductive technologies within an individual’s life course in the introduction to this edited volume, the life courses of the technologies themselves also integrate – whether through their research and development, regulation or clinical implementation. This chapter focuses on these forms of integration, in relation to the technologies’ interrelated research trajectories, regulatory genealogies and the financial and platformised dimensions of their clinical implementation. By approaching reproductive and nonreproductive technologies as a lens onto one another, we may be able to articulate a shared logic underlying their regulation and commercialisation. In order to address these biopolitical and biocapital dimensions of reproductive and nonreproductive technologies, I will zoom in on the cases of egg freezing and medical abortion. Both egg freezing and medical abortion are relatively recent (non)reproductive technologies that have been politicised for expanding the scope of reproductive control. After the birth of Louise Brown in 1978, IVF has grown to a thriving global industry and enabled the birth of over 8 million babies. In the twenty-first century, an influential new variation of IVF is egg freezing. This technology which has become more popular in the last decade, particularly after the American Society for Reproductive Medicine (ASRM) lifted its experimental label in 2012. Egg freezing has introduced the possibility – if not always the reality – of extending the reproductive life course later in life with frozen eggs, while also introducing concerns and potential treatment of future infertility earlier in life. Egg freezing is effectively an IVF procedure, which requires a course of injections to stimulate the ovaries to mature eggs and surgery to collect those eggs from the body. Whereas in IVF the eggs are subsequently fertilised, incubated and implanted into the womb, they remain in the freezer in fertility preservation procedures. When a pregnancy is desired, the frozen eggs can be thawed, fertilised and used in an attempt to conceive. In the introduction to this edited volume, Boydell and Dow highlight the importance of integrating reproductive and nonreproductive technologies, given that many people experience multiple reproductive technologies throughout their lifetimes. They suggest we should not approach the use of reproductive technologies as discrete events, but as part of a longer-term engagement with different technologies throughout the life course. This particularly rings true in the case of egg freezing, which allows fertile and infertile life phases to overlap. Women who do not want to have children at present may at once take measures to prevent (or end) a pregnancy and act to preserve fertility for the future. Beyond a single freezing cycle, egg freezing is typically preceded by fertility tests and education initiatives that reframe fertility in relation to the possibility of cryopreservation. After the egg freezing cycle, multi-cycle norms and discount packages can provide a pathway for further cycles. Storage and subscription fees likewise present a continued, long-term engagement in which reproductive and financial value is exchanged. In these ways, egg freezing is less a single moment of fertility

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preservation and more part of a long-term and ongoing technologised management of fertility. When egg freezing is presented as a means to ‘have a child when you are ready’ it is implicitly linked up with contraceptive and nonreproductive technologies that ensure that this child does not arrive before you are ready, while frozen gametes are suggested to enable an extension to the time of readiness by preserving a cryopreserved form of fertility. In this way, it is possible to be at once too fertile and not fertile enough. While egg freezing has been politicised in relation to new norms of ageing and fertility, abortion is undoubtedly one of the most politicised nonreproductive technologies. Twenty-first-century abortion has been transformed by the use of medical abortion pills, especially in combination with telemedicine. Medical abortion with pills – specifically misoprostol and mifepristone – has enabled women and people with ovaries to safely end their pregnancies in a variety of settings. Whereas surgical abortions require the presence of a doctor and medical equipment, medical abortion with pills has disruptive potential because can also be self-administered and taken at home. Although abortion pills are often (legally required to be) provided in person by a healthcare provider or taken in a clinic setting, the nature of the procedure also lends itself to other set-ups, including telehealth approaches, in which patients consult with medical professionals via the internet and have the pills sent directly to them by mail. This approach is offered by organisations such as Women on Web and Aid Access, which offer online consultations and prescriptions by qualified doctors and send pills to women who need them in countries where abortion is not legal. This approach has enabled more women to access safe abortions across the world regardless of local laws and medical infrastructures, thereby shifting the scope of reproductive control in important and politically relevant ways. This chapter engages with the integration of reproductive and nonreproductive technologies by focusing on their mutual influence during the research and development stages and after their clinical implementation. Accordingly, the chapter consists of two parts; first, I will address the integration of reproductive and nonreproductive technologies in the politics of embryo research. The politics of assisted reproduction and abortion are frequently articulated through one another; their mutual effects become particularly clear in the regulation of the research that underlies the development of these technologies. Focusing on the patenting of embryo development, egg vitrification research and the 14-day rule, this discussion analyses how the politics of abortion affects assisted reproduction and, vice versa, how the organisation of IVF – and the embryo research underlying it – affects reproductive rights. The second part zooms in the promotion and practice of fertility preservation by new Silicon Valley–based start-ups alongside the current politicisation of abortion rights in the US context – focusing specifically on the case of Aid Access and its provision of medical abortion through telemedicine. Both technologies exemplify the increasing clinical and political importance of digital reproductive health in the United States. I will discuss how the specific business models developed in the tech-focused context of Silicon Valley are adopted by egg freezing companies in ways that expand the indication for (in)fertility treatment

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across the life course. I contrast this with Aid Access’ business model and the restrictions that underlie its emergence to highlight how the transnational reach enabled by telemedicine is shifting the landscape of reproductive politics at large. The central role of online platforms in mediating these digital reproductive technologies is moreover respatialising reproductive practice. Through the dual focus on egg freezing and medical abortion as contrasting examples of digital reproductive health, this analysis reveals the intersecting and politicised regimes of capital accumulation, reproductive control and risk production at the intersection of technologised reproduction and nonreproduction.

(Non)Reproductive Technologies and the Politics of Embryo Research The integration of reproductive and nonreproductive technologies is particularly pronounced at the stage of research and development. Abortion politics has long affected the development of reproductive technologies – including the influence of anti-abortion legislation on scientists’ research areas, the relation between academic and industry in research funding and the intertwined politics of abortion and embryo research regulations. Vice versa, new developments in reproductive biomedicine also have consequences for established reproductive rights and the organisation of abortion practices. Given that reproductive and nonreproductive technologies share the reference point of the embryo, we may consider how the biological substances involved in the former become politicised through the latter – and vice versa.

Anti-Abortion Politics and the Privatisation of Embryo Research Starting with the influence of abortion politics on the research and development of reproductive technologies, the institutional genealogy of the leading fertility (and egg freezing) benefits company Progyny provides an interesting case study. Progyny provides company-sponsored fertility benefits that currently cover over 2.9 million US employees. The company entered the NASDAQ stock market in 2019 and works with Fortune 500 employers such as Google, Microsoft and Unilever to offer its fertility benefits packages (Van de Wiel, 2022). Prior to this focus on fertility benefits, however, Progyny’s focus was more diffuse. The company was formed in 2008 from a merger of Fertility Authority, a popular online platform with fertility information, and Auxogyn, a biotechnology company offering time-lapse embryo imaging systems. These systems film IVF embryos while they grow in the incubator and use the temporal and visual information to select which embryo to implant in the womb. The latter company, Auxogyn, was at the heart of an international scientific controversy about the patenting of embryonic development that illustrates the close link between the politics of abortion and reproductive research. Auxogyn’s embryo selection technology (EEVA – Early Embryo Viability Assessment) aimed to predict which embryos would be viable and should be

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implanted first in an IVF cycle. These predictions were based on calculations of the timing of embryo development observed in the incubator. Between 2011 and 2013, the European and US patent offices issued patents with exclusively licensing to Auxogyn that claimed ownership over the timing of embryo development, i.e. the average time between cell divisions (Van de Wiel, 2019). These patents caused controversy in the reproductive biomedicine community, in which influential figures objected to this patenting of ‘natural phenomena’. For example, Jacques Cohen, chief editor of Reproductive BioMedicine Online, argued against the ‘unlikely proposition’ of ‘patenting time and other natural phenomena’ in this journal (2013, p. 109). In response, the lead scientist behind Auxogyn’s patent, Rene Reijo Pera, argued that this patent referred to a method rather than a natural phenomenon. However, interestingly, Reijo Pera also explains the patent application followed the Republican 1996 Dickey–Wicker Amendment, which ceased US federal funding for human embryo research that resulted in the destruction of embryos, including those donated by IVF patients (Reijo Pera, 2013).1 Reflecting Republican anti-abortion ideologies, the Amendment was a response to the 1994 recommendations of the National Institutes of Health Human Embryo Research Panel, which proposed research on so-called leftover gametes and embryos from IVF treatments should be allowed with the consent of the donor(s) (Kearl, 2010). The Dickey–Wicker Amendment’s long-lasting restriction of federal funding for embryo research has resulted in scientists such as Reijo Pera searching non-federal research funding from for-profit partners, who would invest private capital in embryo research that could be translated into clinical applications. She states that ‘without patents to protect the inventions made in this process, it would be nearly impossible to attract the investment finance needed to move a technology from the research and development phase, through clinical trials, through the regulatory process, and ultimately to commercialization’ (Reijo Pera, 2013, pp. 113–114). Conservative politics, informed by a widespread anti-abortion sentiment in the United States, thus played a key role in enlisting embryo research within a capitalist logic that requires a redefinition of embryo development as patentable invention.

Vatican and Vitrification: Abortion Politics and the Development of Egg Freezing While the time-lapse embryo imaging case highlights how abortion regulation can affect patenting and scientific reliance on industry partners in embryo research, the technology of egg freezing itself has also been developed in tandem with restrictions on nonreproductive technologies. In fact, the geographies of the development of egg freezing are linked to anti-abortion sentiments. A case in point is vitrification: one of the key technologies that made egg freezing and thawing more successful and more widely indicated. As opposed to slow freezing, the very fast freezing (vitrification) of eggs allowed significantly larger numbers of cells to survive the procedure. It was this improvement in freezing techniques and

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concomitant egg survival rates that rendered egg freezing attractive to a new group of presumably fertile patients. Italy was home to some of the key research into this vitrification technique. In the 1990s, Italy was recognised as one of the ‘most cutting-edge’ fertility industries globally and came to be known as the ‘Wild West’ of IVF in Europe, particularly for helping relatively older women reproduce (Inhorn, Patrizio, & Serour, 2010, p. 850). In keeping with this focus on age-related infertility, researchers in Bologna started working with frozen eggs as early as 1997 (Gosden, 2011, p. 266).2 This research focus also anticipated the legal restrictions on assisted reproduction that were subject of heated political debate and resulted in Italy’s draconian 2004 IVF law, which banned embryo freezing and left egg freezing as the only legal alternative (Benagiano & Gianaroli, 2004, p. 118; Gook, 2011, p. 284; Martin, 2010, p. 527). The 2004 law obliged intended parents to implant all embryos produced in an IVF cycle (up to three) and prohibited the cryopreservation of excess embryos. This both decreased the chances of women becoming pregnant and increased the likelihood of medically complicated multiple pregnancies (Benagiano & Gianaroli, 2004, p. 117). Widely condemned for ‘its excessive concern with the status of embryos and disregard for the interests of women and infertile couples’ and described as ‘a disaster for women [and] utterly deplorable’ by the chair of the European Society of Human Reproduction and Embryology (ESHRE) (Robertson, 2004, p. 1693), the Italian IVF law’s prohibition of both creating more than three embryos and freezing any embryos provided the impetus for developing egg freezing technologies in order to save eggs that could otherwise have been fertilised. Reflecting this focus on egg freezing, the first live birth with the – currently dominant – vitrification technique for egg freezing occurred in Italy: on 20 June 1999, a girl was born to a 47-year-old mother who had used vitrified donor eggs (Kuleshova, Gianaroli, Magli, Ferraretti, & Trounson, 1999; Van de Wiel, 2020, p. 244n19). The debate leading up to the 2004 IVF law exemplifies the integration of the politics of abortion and assisted reproduction. While Italy had long legalised abortion when the regulatory debate on IVF was initiated in the 1990s, the political debate on assisted reproduction allowed anti-abortion political agendas to re-emerge. Whereas the earlier abortion debate started in civil society and was subsequently discussed in parliament, the IVF debate was initiated with a government bill that later became subject of public debate (Calloni, 2001, p. 195). A bill on the ‘norms about artificial insemination, in vitro fertilisation and transferring of gametes and embryos’ was introduced in parliament on 20 June 1996. For a coalition of Catholic and conservative abortion opponents, this IVF bill provided the occasion to push back against the legalisation of abortion (Calloni, 2001, p. 195).3 In March 1997, female pro-choice MP Marida Bolognesi became chairwoman of the commission preparing the IVF bill. She eventually resigned in protest because the Chamber of Deputies voted to only allow gametes belonging to heterosexual married couples to be used in IVF. She was replaced by a male pro-life conservative MP Alessandro Ce, who was in favour of restrictions. The result was a very restrictive IVF law, which was adopted by the Chamber of Deputies in May 1999, reflecting its pro-life majority, but failed in the Senate

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(Calloni, 2001, p. 196). In response, women’s activists appealed the proposed law and opposed the ‘new patriarchal’ intention ‘to dominate once again the female body and to control all reproductive processes’, writing ‘No to the law! No to any reductive and restrictive revision of the law no. 194’ (Calloni, 2001, p. 197). Indeed the political debate reflected the influence of the cross-party alliance between Catholics and conservatives in the Chamber of Deputies as well as individual attempts to attack the existing abortion law, for example through Irene Pivetti’s proposed – but failed – 1999 amendment to deny the right to abort a foetus produced by IVF (Calloni, 2001, pp. 197–201). In these ways, the adoption of the restrictive law reflected the political power of the pro-life presence in the law-making process, while also revealing how the threat of IVF legislation to established abortion rights was at the forefront of this debate. When the Italian IVF law was eventually passed, it existed alongside a law passed 25 years prior that liberalised terminations of pregnancies in the first trimester. In the IVF law, it states that ‘embryo cryoconservation and suppression are forbidden; however, the provisions of the Law of 22 May 1978, No. 194 stand valid’. This 194/78 law gives women the right to terminate their pregnancy within 90 days since her last menstrual period. As a result, the Italian law forbids the ‘suppression’ of in vitro embryos in IVF, but not in vivo ones in early pregnancy (Benagiano & Gianaroli, 2004, pp. 117–118). This was particularly problematic for couples who carried a heritable disease, who were allowed to biopsy their embryos with pre-implantation genetic diagnosis (PGD), but were still obliged to implant them. Yet during pregnancy, they could have prenatal diagnosis and terminate the pregnancy if the foetus was affected (Robertson, 2004, p. 1695). The obligation to implant affected embryos after PGD was withdrawn in 2009 (Riezzo, Neri, Bello, Pomara, & Turillazzi, 2016, p. 2), yet the obligation to implant embryos free from genetic disorders remained. A case illustrating the continued draconian effects of this revised approach was brought to the UN Committee on Economic, Social and Cultural Rights in April 2019. An unnamed couple affected by a hereditary bone disorder underwent IVF treatment in 2009 and only one of their six embryos tested was unaffected. This embryo was of ‘average’ quality and unlikely to form a successful pregnancy. Yet when the woman wanted to withdraw her consent for the implantation of this embryo for fear of a miscarriage, she was denied. The clinic threatened to sue her if she refused, citing the IVF law’s prohibition of withdrawing consent to implant an embryo after fertilisation has occurred. The woman eventually had the embryo transferred and indeed suffered a miscarriage. The UN committee recognised this course of events ‘violated [the couple’s] right to health and to form a family’ (Wolfe, 2019). In this way, it is IVF law, rather than abortion law, that imposes women experience forced pregnancies. Through the shared reference point of the embryo, the Italian case illustrates how IVF and its regulation can become a vehicle for mobilising anti-abortion political forces and legislating the control of reproduction in ways that enforce pregnancies. Besides such forced pregnancies, ironically, the intended protection of prenatal life and ‘the sanctity of human life from its inception’ in this legislation resulted in the reduction of cumulative pregnancy rates per oocyte retrieval,

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primarily because embryos could no longer be frozen for implantation in future cycles (Benagiano & Gianaroli, 2004, p. 117; Ragni et al., 2005, p. 2227). The 2004 IVF law has been revised over the years. In 2009, the Constitutional Court declared the maximum limit of producing three embryos to be constitutionally illegitimate; in 2014, the ban on donor insemination was declared unconstitutional; and in 2015, the Constitutional Court granted the right to access PGD for couples who were fertile but carriers of genetic diseases (Riezzo et al., 2016). Yet restrictions remain, particularly against same-sex couples, single women and older intended parents. The Italian case thus shows how a restrictive climate can provide an impetus for researching alternative reproductive technologies, as was the case for vitrification for egg freezing in the face of an embryo freezing ban. At the same time, the case of the Italian IVF law also highlights how the regulation of assisted reproduction can provide an opportunity for existing rights to abortion to be threatened and revised.

Abortion Politics, Embryo Research and the 14-Day Rule It is precisely this concern that Mary Warnock raised in another national context in which the regulation of reproductive biotechnologies could affect the right to abortion. In the United Kingdom, embryo research is governed by the HFEA Act that followed from the Warnock Committee, which was formed after the birth of IVF-baby Louise Brown in 1978. One key outcome of the Committee’s work on regulating embryo research was the 14-day rule, which permitted embryos to be cultured in vitro up to 14 days. The rule was enacted into UK law in 1990 and was legally adopted in over a dozen countries; across the world, it is recognised as a regulatory standard (Hurlbut et al., 2017, p. 1040). The formation of the Warnock Committee directly followed a decade in which the constitutional courts of various countries, especially in the United States and Europe, brought the embryo into law through the legalisation of abortion. While these courts were concerned with the in vivo embryo within the body, the emergence of in vitro embryos that could result in the birth of children such as Louise Brown led to the need for new regulations in the wake of the preceding abortion debates (Piciocchi & Martinelli, 2016, p. 511). Indeed, as Sarah Franklin and Michael Mulkay note, the Warnock Committee was appointed against the backdrop of an anti-abortion backlash in the 1970s. Conservative campaigns to ‘reassert moral conservatism’ and ‘restore the traditional family as a centrepiece of modern life’ gained popular and political momentum in the 1970s (Franklin, 2019, pp. 748–749). In this context, similar to the aforementioned Italian case, conservative pressure groups ‘targeted the regulation of assisted conception as an opportunity to overturn the 1967 Abortion Act’ (Franklin, 2019, p. 749). The challenge for the Warnock Committee was to avoid the polarising abortion debate; Mary Warnock and biologist Anne McLaren persuaded their colleagues to back the 14-day rule through a complex social process of translating of ‘biological “landmarks” in the development of human embryos’ into law and policy (Franklin, 2019, pp. 750, 771). The Warnock recommendations had to be

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passed by a conservative Parliament that was strongly associated with the anti-abortion lobby and overwhelmingly opposed to embryo research. The approval process took over six years – a period during which Parliament accepted that research would be limited to the first 14 days, had the potential to avoid passing on genetic disorders and would be regulated by a licensing authority (what would become the HFEA). In this context, parliamentary support grew, while religious opposition was limited and the scientific community was well organised in their backing of the Warnock recommendations (Belew, 2004, p. 491). While the anti-abortion sentiments that provided the context for the Warnock Committee were less influential in the eventual enactment of its recommendations into UK law, the political opposition to abortion in the United States has dramatically influenced the regulation of both assisted reproduction and embryo research. In the same year that the Roe vs Wade decision that legalised abortion in the United States in 1973, the US government placed a moratorium on embryo research. Strangely, this prohibition was in part motivated by the concern that research on embryos could motivate women to have abortions (Wertz, 2002, p. 674). An Ethics Advisory Board (EAB) was established to create and review ethical guidelines for research on embryos. The EAB also adopted the 14-day rule and concluded in their 1979 report that ‘no embryos will be sustained in vitro beyond the stage normally associated with the completion of implantation (14 days after fertilization)’ (EAB, 1979, p. 107; Piciocchi & Martinelli, 2016, p. 512).4 However, the Department of Health and Human Services (DHHS) rejected the EAB’s recommendations. Conveniently, EAB’s funding expired the following year and the body was never replaced. After the National Institutes of Health requested funding for Parkinson’s research using neural cells in 1987, the DHHS withheld approval and argued that ‘this research would induce women ambivalent about abortion to have one’ (Wertz, 2002, pp. 674–675). Opponents of abortion claimed that ‘use of embryonic tissue will make women feel less guilty than they should and will further increase society’s approval of abortion’ (Wertz, 2002, p. 676). In 1995, Congress banned federal funding for research on embryos, including all infertility and IVF research – a prohibition that remains to this day. As was also clear in the above-mentioned time-lapse embryo imaging case, US anti-abortion politics has the effect of not so much banning embryo research, but relegating it to the relatively unregulated private sector. In the absence of both government funding and an outright ban, US embryo research has primarily taken place in private clinics and labs in the fertility and biotechnology sectors. Obstetrician-gynaecologist Lisa Harris has highlighted how this has affected the development of IVF specifically, given that, as a result of the federal funding ban, US fertility research became more reliant on clinical IVF cycles that were often paid for by patients themselves. Consequently, market rationales became increasingly influential in shaping both IVF research and clinical practice, reflecting the demands of those patients who could afford to undergo fertility treatment. These patients were primarily relatively older women, who were ‘often professionals, disproportionately white, […] delayed childbearing and had the best odds of affording IVF care’ (Harris, 2013, p. 201). By contrast, low-income women without higher education degrees,

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who were disproportionately women of colour, had almost twice the infertility rates – often due to tubal infertility – compared to their affluent, highly educated white counterparts. Yet, in spite of this, IVF has primarily focused on the age-related infertility of the women who can afford treatment (Harris, 2013, p. 201). In this way, the anti-abortion regulations curtail reproductive justice not only by directly limiting access to treatment or research funding but also by intensifying the market logic within the sector, which exacerbates existing reproductive stratifications and inequalities.

Revisiting Warnock While these examples point to the effect of anti-abortion politics on assisted reproduction and research in reproductive biomedicine, the reverse also holds true in cases where the regulation of embryo research can disrupt a pre-existing consensus on abortion rights. A prominent recent example is the revisiting of the aforementioned 14-day rule. In August 2016, researchers at the Magdalena Zernicka-Goetz lab at the University of Cambridge managed to keep embryos alive up until 13 days, just below the legal 14-day limit (Shahbazi et al., 2016). Up until this point, scientists were only able to culture embryos until about seven days (Cavaliere, 2017). In the wake of this extended-culture discovery, the question of whether the 14-day rule should be adjusted was revived. As was the case in the original Warnock deliberations, the politics of abortion was once again prominent in this discussion. I remember how, at a public debate on this topic at the British Library, the late Mary Warnock warned against changing this regulation because she feared it may result in a backlash fuelled by anti-abortion sentiments. In her account of the Warnock Committee’s work, Sarah Franklin notes that a key challenge for the committee was the ‘the difficulty of avoiding the highly polarised abortion its political terrain dominated by anti-progressive moral causes’ (Franklin, 2019, p. 749). Given that conservative moral pressure groups approached the regulation of assisted reproduction as a possibility for overturning the 1967 Abortion Act (Franklin, 2019, p. 749), it is no surprise that Mary Warnock raised these concerns when she was asked about the potential revision of the 14-day rule. In an interview for Nature Biotechnology, Warnock stated that she was ‘personally rather unwilling to see the limit changed, at least until a good deal of research has taken place in the additional days [of embryo culture in vitro] now available’. She explained that she ‘fear[s] that those who oppose research using human embryos would triumphantly marshal their forces, and say that the limit has been adhered to only because technically it had proved impossible to do otherwise’ and also wishes that ‘in the US, especially it would be helpful if ethical issues could cease to be the preserve (as they are sometimes seen to be) of fanatics, such as the anti-abortion lobby’ (qtd. in Hurlbut, 2017, p. 1041). She was worried that ‘pro-life people, who do not seem to realise how intensely pro-life IVF itself has always been, are waiting in the wings and marshalling their forces to make an assault on what they regard as immoral legislation all over again’ (Warnock, 2017). Therefore, as Kate Williams and Martin Johnson surmise, a new debate on

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the 14-day rule carries the large risk of providing the opportunity to encourage opposition to embryo research as well as ‘abortion and other issues regarding embryo protection’ (2020, p. 5). Whereas in the United Kingdom embryo research is currently less politicised – in part because the ‘opinions about reproductive technologies cross party political lines’ and therefore ‘legislation is not dependent on which party is in power’ – this issue is at the heart of political divisions in the United States (Murdoch qtd. in Hurlbut, 2017, p. 1039). As the extended embryo culture was announced during the Trump presidency, ethicist Laurie Zoloth argued that ‘the prudent course of action would be to wait’ for a different administration before proposing any regulatory changes in order to limit the risk of a political backlash against embryo research and assisted conception (Hurlbut, 2017, p. 1038). Raising the issue under a hostile administration could risk ‘opening the door to a policy change that leads to more restrictive, rather than a more permissive, research policy’ (Levine, qtd. in Hurlbut, 2017, p. 1038). Likewise, Robin Lovell-Badge states that ‘if the timing is wrong, then it could indeed have negative consequences not just for research, but for the clinical practice of IVF’ and concerns were raised that ‘raising the question of the 14-day rule will reinvigorate debates on other contested aspects of assisted conception’. Abortion rights could likewise be part of these ‘collateral consequences’ (Hurlbut, 2017, p. 1039).5 Whether in relation to the 14-day rule, vitrification research or embryo patenting, these cases all point to the ways in which the politicisation of nonreproductive technologies also affects the development, clinical introduction and commercialisation of reproductive technologies. While anti-abortion sentiments can play a key role in curtailing assisted reproduction and embryo research, new developments in reproductive biomedicine can also provide the occasion to reopen public debates on established reproductive rights. The mutual influence of the politics of reproduction and nonreproduction indicates how the technologies enabling them are integrated from the earliest stages of their own conception and development.

Opposite Investments: Egg Freezing and Medical Abortion Having established the intertwining politics of assisted reproduction and abortion at the stage of the research and development, I now turn to the clinical practice of both reproductive and nonreproductive technologies. Thus far, the discussion has focused on government regulations of these reproductive technologies; this section also includes the market and financial dimension of these (non)reproductive technologies. By approaching reproductive and nonreproductive technologies as a lens onto one another, it will be possible to articulate a shared logic underlying their regulation and commercialisation. In order to do so, I will zoom in on the cases of egg freezing and medical abortion.

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IVF Investments In the US context, reproductive technologies, such as IVF and egg freezing, are currently the subject of an investment boom, while nonreproductive technologies, such as misoprostol and mifepristone abortion pills, are increasingly curtailed through both regulatory and financial means. The first aspect of this, the increased investment in assisted reproduction, is particularly pronounced in the case of egg freezing. The emergence of egg freezing is situated in a global fertility sector that has experienced consistent growth and is projected to continue expanding from an estimated $20.4 billion in 2020 to $25.7 billion in 2027 at a compound annual growth rate of almost 16% (Sherkar, Srivastava, & Sumant, 2021). In keeping with this trend, the total number of IVF cycles has steadily grown every consecutive year, but the number of egg freezing cycles – albeit only a small percentage of total IVF – grows even more rapidly year on year. Numbers from the Society for Assisted Reproductive Technology (SART) show that, in 2009, just 475 US women froze their eggs, and by 2018, 13,275 women did so: an increase of 2,695%. At the time of the COVID-19 pandemic, more women still have frozen their eggs as they have more open schedules and more time to reflect – as well as fewer opportunities to find a partner or have a child. Some major clinics report a 50% increase in women freezing their eggs in 2020 compared to the year prior (Dockterman, 2021). Although the number of women freezing their eggs remains relatively small, financial investments in the technology abound and hundreds of millions of dollars of venture capital and private equity have been allocated to new egg freezing start-ups. Some of these start-ups have quickly become influential players in the fertility market. Prelude, for example, used its $200 million initial investment to buy dozens of traditional clinics, as well as a fertility pharmacy and frozen egg bank, to become the largest fertility group in the United States only two years after its founding. In this way, the rise of egg freezing companies does not only reflect the popularity of fertility preservation, but is shifting the organisation of assisted reproduction at large. Other start-ups promote egg freezing through employer insurance, which garnered widespread media attention in 2014 when the Apple and Facebook first started offering fertility preservation as a ‘perk’ for their employees. Progyny, market leader in egg freezing insurance, covers over 2.7 million people, and an estimated 20% of US Fortune 500 companies have signed up to its plan (Progyny, 2021).6 Since its founding in 2015, Progyny has raised almost $100 million in investment capital and has had doubling revenues for several years in a row. Following a strategic alliance with Mercer, the world’s largest HR consultancy firm with $4.6 billion revenue, Progyny floated on the NASDAQ stock market in 2019 (Javeed, 2019). Thus broadening its reach to more potential patients, Progyny’s online, platformised organisation of fertility treatment centralises the discursive framing of egg freezing as, on the one hand, a tool for employees to self-invest in future fertility to both extend and speed up the time to pregnancy and, on the other, a tool for employers to increase return on investment on health benefits.

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Buoyed by this capital, these new egg freezing companies have a widespread reach; they manage relations and affiliations with nation-wide networks of fertility clinics as well as influential online platforms, and its innovations receive widespread media and academic commentary. Underlying the logic of equity and venture capital investments is a drive towards growth. Each round of funding sets up a set of performance metrics which must be met in order to reach the threshold to receive another, larger round of funding. These investments are typically made with an exit strategy in mind; from the investor’s perspective the point is not so much the profit that is made with each egg freezing cycle, but the possibility of selling the fertility company itself at a profit – prospects of future or continued growth aid in this process. These financial investments thus at once enable the current emergence of new egg freezing enterprises, signal the valuation of the promissory value of fertility preservation and materialise the speculation of further growth of this practice in the foreseeable future.

Curtailed Reproductive Rights The rise of egg freezing – its promotion and its different forms of financialisation through investments, insurance and lending – coincides with the severe curtailing of abortion rights in the United States. Increasingly restrictive state regulations all but outlaw abortion, while – as we will see below – the FDA attempts to prevent women from accessing medical abortion on politically motivated ‘safety’ grounds (Dyer, 2019). During its 2017–2021 term, the Trump administration politicised reproductive rights with renewed vigour to mobilise the conservative Christian electorate – whether with Trump’s prayers for ‘the unborn child’ as a ‘sacred gift from God’ in front of the White House or through the appointment of three anti-abortion judges to the Supreme Court. While the US fertility industry remains relatively unconstrained and unregulated amid continued growth, US state and federal governments are selectively limiting access to abortion services. Although the right to abortion has been retained for almost 50 years in the United States, an increasing number of regulations and bills chipping away at abortion provision have been introduced in the last decade. For example, since 2011, 483 abortion restrictions have been passed as part of ‘a nationwide strategy to push abortion care out of reach’ (ACLU, 2020). And, as of 2019, 22 states had introduced 62 bills that sought to completely ban, or ban with limited exceptions, all abortions (Boys & Harris, 2019, p. 521). Reproductive rights organisations and activists have resisted this trend. For instance, in recent years, a coalition of healthcare providers, ACLU, Planned Parenthood and SisterSong Collective for Reproductive Justice blocked laws that would ban abortion from the earliest weeks of pregnancy in Georgia, Alabama, Kentucky, Mississippi, Missouri and Ohio (ACLU, 2019). After Roe v Wade, bills completely outlawing abortion continue to be unconstitutional, in spite of legislative attempts to ban abortion (Boys & Harris, 2019, p. 521). Yet various states have passed laws that define life ‘to begin at conception’ that would go into effect should Roe v Wade be overturned. With the 2020 appointment of Amy Coney Barrett to the Supreme Court,

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Trump’s third Republican anti-abortion appointment, and the publication of the initial draft majority opinion written by Justice Samuel Alito in May 2022, concerns about over turning Roe v Wade (1973) have intensified. Alongside the obvious threat to abortion rights, the IVF community has also raised questions about the potential effects and unintended consequences of a regulatory anti-abortion backlash on the cost, availability, safety and efficacy of IVF (Boys & Harris, 2019, p. 518). For example, for the first time in its 70-year existence, the influential Fertility and Sterility journal raised concern that ‘women’s constitutional rights are in jeopardy’ with the seating of a new Supreme Court Justice after the vacancy left by Justice Ruth Bader Ginsburg. Niederberger and colleagues wrote that ‘the seating of Amy Coney Barrett to the US Supreme Court threatens those who seek to build a family through IVF’. Barrett signed a letter by the Becket Fund opposing access to contraception and supported ‘HR 586, the Sanctity of Human Life Act (115th Cong [2017–2018]), a so-called personhood bill’. This bill ascribes to a cell ‘all the legal and constitutional attributes and privileges of personhood’ (Niederberger, Feinberg, & Pellicer, 2020). The Fertility and Sterility authors highlight that such a position would put physicians at risk for criminal violation, create greater health risks and lower pregnancy rates for women undergoing IVF and halt scientific advances in the field. They conclude that they ‘fear that reproductive health care would be set back many decades, endangering the families for which we care’ with this appointment (Niederberger et al., 2020). In the face of the threat to Roe v Wade, Stephanie Boys and Evan Harris also propose that the potential impact of overturning this ruling – and the concomitant enactment of life at conception bills – on IVF could be used strategically in lobbying against anti-abortion legislation (2019). This intervention in Fertility and Sterility may be an example of such a strategy. Both the curtailing of abortion access and the growth of the fertility industry has pronounced class-, race- and gender-specific effects that further stratified reproduction. The above-mentioned new fertility benefits covering the high costs of fertility treatment are primarily offered by wealthy Fortune 500 companies and are used as a HR measure to attract highly-educated female employees, rather than increase increase access to reproductive technologies in a more equitable way. Instead, it links access to reproductive healthcare more explicitly to a particular segment of the labour market that is only accessible for some. On a more structural level, Lisa Harris’ work has revealed that although poor women and women of colour suffer more frequently from precisely the infertility problems that IVF was developed for – particularly blocked fallopian tubes – lack of finances often precludes their access to assisted reproduction. In keeping with this, the number of people of colour using IVF is disproportionately low compared to their white counterparts (Harris, 2013). Where fertility loans are made available to people who cannot afford treatment, the financing of IVF increases household debts and results in a situation in which the people who can afford it the least, pay the most. Likewise, the curtailing of abortion access also disproportionately affects underprivileged women, for whom it is harder to afford travel, childcare and the

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procedure itself. As US states are severely restricting or effectively banning abortion provisions, strict regulations on abortion clinics have forced many to close. The restrictions particularly affect women who cannot pay for the significant treatment fees, do not have the means to travel the increased distances to clinics that are still open, have care or labour obligations that prevent them from receiving treatment or are victims of domestic violence. Economic hardship often represents a key reason for seeking an abortion and being denied one results in further economic insecurity for women and their families; US women who carried a pregnancy to term after being unable to access a termination experience a fourfold increase in odds that her household income is below the Federal Poverty level compared to women who did receive an abortion (ANSIRH, 2018).

Telemedical Abortion In the face of the significant costs and access issues associated with a clinic-based abortion, medical abortion with misoprostol and mifepristone are providing an alternative. Misoprostol is also used for stomach ulcers and, in combination with mifepristone, it is 99% effective in ending a pregnancy before 9 weeks. This combination of drugs has been marketed together as ‘Mifeprex’ to induce early abortions in the United States since 2000. FDA only approved Mifeprex under a highly restricted distribution system called REMS, or risk evaluation and mitigation strategy, which restricts distribution of this medication to certified providers and prohibits pharmacies from dispensing this medication. Many have argued that REMS poses an ‘undue burden’ on the rights of US women to end their unwanted early pregnancies. Because of the high costs of clinical abortions and the restrictions on medication abortions, many American women have turned to the internet to obtain abortion pills.7 One of the new abortion telemedicine providers that US women may turn to is Aid Access. Aid Access was founded in early 2018 and incorporated in Austria by a Dutch doctor called Rebecca Gomperts. She is best known for founding Women on Waves (1999) and Women on Web (2005), which also provides support to women living in countries where safe abortion is not available through online telemedicine. Women on Web answers 120,000 emails annually. Aid Access received over 37,000 requests for assistance with unwanted pregnancies between March 2018 and August 2019. Telemedicine consultations through Aid Access are assessed by medical doctors and women have access to a helpdesk that supports the process of the abortion with practical and medical advice. A doctor prescribes the pills to qualifying women, who can order a shipment of the pills from an exporter in India. Aid Access shipped over 7,000 packets of medicines to the United States in 2018 and 2019. In contrast to the investor-funded growth rationale underlying the contemporary fertility sector, Aid Access operates through a pay-it-forward business model, in which proceeds are used to offer free treatment to women who can’t afford to pay for the donation. As opposed to a drive for growth, its financial model instead is a vehicle for solidarity in access and communicating trust. Yet Aid Access has also been subject to the strict anti-abortion regime in the contemporary United States. On International Women’s Day, 8 March 2019, the

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FDA sent a letter to the organisation that ordered to cease activities. Aid Access complied and stopped consultations and shipments for almost two months. 108 Congressmen (of whom 92% were male) wrote to the FDA to approve of their warning letter. In May, Rebecca Gomperts publicly responded to the FDA with a letter in which she stated she would not be deterred from offering support. If a woman requested her help, she would continue to provide it. Attached to the letter were 12 pages of testimonies by her patients, who explained why they required a medical abortion. The FDA did not respond to the letter. In September, Gomperts decided to sue the FDA instead stating in the legal complaint that: As a licensed physician providing medical abortions to women in the United States, Dr Gomperts brings this case on behalf of all her present and future pregnant patients seeking a medical abortion prior to viability who reside in the United States. (Hearn, 2019, p. 4) It states that after opening up the service in May 2019, Gomperts believes that the FDA has seized between 3 and 10 packages for between 3 and 10 of her patients, based on tracking information and communication of her patients. In this case, financial flows once again shape reproductive politics. The legal complaint brought against the FDA suggests that the Agency has tried to stop Aid Access’ work by stopping its means of receiving money. Aid Access claims that two money-transfer businesses – WorldRemit and TransferWise – have refused to continue working with them. Patients were moreover blocked from using MoneyGram, Xoom, Ria Money Transfer and XE to make payments to Aid Access. In this way, governmental power was instead exerted through its influence on international flows of money. The legal complaint asks the court to declare that these actions indeed violate the rights of Dr Gomperts and her US patients and prohibit the FDA from any further actions barring Aid Access’ work. While this case highlights the difficulties of providing abortion care in (certain parts of) the United States, it also shows that medical and self-managed abortions create new ways of ending a pregnancy that less reliant on traditional medical infrastructures – and may instead be reshaped through online infrastructures that respatialise the provision of reproductive technologies. At the same time, Gomperts’ experience with the FDA also illustrates how the curtailing of abortion occurs not only through regulations, but through the obstructions of financial flows. So, on the one hand, new reproductive technologies like egg freezing are booming, fertility start-ups are receiving capital investment and are reaching a wider group of women who may be considered candidates for fertility preservation through marketing and insurance packages, and, on the other, the provision of nonreproductive technology of medical abortion through telemedicine is providing new ways of accessing abortion as provision is increasingly curtailed. While these two cases are different in nature, there are some shared concerns and connections, including the role of anti-abortion sentiments in shaping the current and future landscape of assisted reproduction, the politics of safety in

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reproductive care, the role of hidden financial flows in organising the availability of reproductive care and the significance of online platforms in disrupting fertility in the twenty-first century.

Platformisation The US egg freezing start-ups and Aid Access’ telemedical abortion provision are both respatialising reproduction through their online platforms. Egg freezing start-ups like Progyny and Prelude use online platforms to centralise marketing efforts, streamline practices between different branches within the network and share patient information. Aid Access uses its platform for education, patient communication and services provision that would otherwise not be accessible. The platform is central to the larger egg freezing start-ups because they are typically geographically dispersed organisations, with a widespread network of affiliate partners. Prelude has bought over 50 clinics while Progyny works with over 100 companies offering fertility insurance. As these fertility start-ups operate through widely dispersed networks, online platforms become a key instrument in centralising marketing and streamlining practices between distant locations. In order to reach a new group of potential patients, consolidated fertility start-ups can also concentrate marketing budgets to reframe IVF as a tool for comprehensive, pro-active fertility management. Investors in egg freezing start-ups have made it clear that they intend for these fertility (preservation) companies to consolidate marketing efforts to promote fertility preservation among a wider audience. For example, Prelude’s investor Lee Equity states that they seek to transform the fertility industry with their investment through a ‘broader adoption of vitrification services’. Collins Ward, a principal at Lee Equity, claims that ‘the combined resources and leadership at Prelude provide a powerful mix of medical innovation and marketing expertise that will drive consumer education and enable millions of people to plan and grow their families’ (Dorbian, 2016). As part of these marketing initiatives is a drive to encourage younger egg freezing among a larger group of fertile women. As the key point of information and service provision for any of the 2.7 million people covered by Progyny fertility insurance, or patients of the IVF clinics acquired by Prelude, the online platform has a widespread reach and potential influence in reframing fertility as benefitting from early, proactive and ongoing technologised management (Van de Wiel, 2022). These platforms moreover take on functions previously covered by the clinic. Ongoing medical and emotional support is offered through concierge services and wellness apps, which provide a centralised discursive framing of the ‘entire fertility journey’. Fertility company Kindbody takes this one step further through its patient portal, which provides the foundation for ‘building a centralized data platform, allowing for standardized decision-making, and building predictive protocols to define and scale best practices’ (Kindbody, 2018). The equity-backed fertility start-ups can thus affect IVF’s broader provision through the centralisation of marketing and patient support through online platforms and the

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adoption of cloud-based services that enable standardisation and streamlining across the network – in ways that reflect and reconfigure intersecting regimes of capital accumulation, reproductive control and risk management. Aid Access likewise relies on the online platform as the key organising principle for its care provision. Unlike the egg freezing platforms, here the platform displaces the clinic and the medical consultation as it occurs online. As the service spans three continents, the online platform allows for a reconfiguration of the locus of care in a way that dodges existing regulations and operates in a legal grey zone. The platform enables multiple ambiguities pertaining to the locus of care, the separation between healthcare and activism as well as online and offline regulatory structures. This raises questions about how the platformisation of reproductive care can create new ways in which reproductive technologies are linked up with one another or further separated out. The platformisation of fertility and its insurance present a mode of streamlining with more technologies, but only selectively so – abortion and more low-tech contraceptive technologies are not included on the platforms, for example.8 Aid Access is specialised in medical abortion but also provides contraception and advice on follow-up care after the abortion. In their use of the platform, there appears to be an opposite movement: Progyny and Prelude centralise formerly decentralised care through a single platform that organises marketing, concierge and data services. Aid Access, by contrast, decentralises formerly more centralised care by moving away from a clinic model that may be strictly regulated to a much more dispersed, transnational mode of organising care which is not easily captured within a single regulatory framework. Both share a decentring of the clinic, thereby offering alternative organisation of the reproductive landscape that does not fit conventional, clinic-based regulatory and financial models. While this offers a means to circumvent restrictive regulations, it also creates new ways in which in/fertilities may be capitalised. As Uber and Airbnb have fundamentally altered the taxi and hotel industries, so the turn to digital care in reproduction is disrupting the fertility sector. In order to assess whether the move towards digital reproductive health risks monopolising care or enables more reproductive freedom, it is important to consider not only the movement of care, but the movement of money – and consider the flows of capital underlying these developments.

Conclusion This discussion explores the integration of reproductive and nonreproductive technologies both during research and development and following their clinical implementation. This broadened scope highlights how (anti-)abortion politics affects the research and regulation of assisted reproduction, while new developments in reproductive biomedicine can provide the occasion for revisiting established reproductive rights. Focusing on IVF and egg freezing on the one hand and (medical) abortion on the other, these (non)reproductive technologies also

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reproduce comparable social stratifications. Barriers to access follow a similar logic along lines of marginalisation – if at different price points and in different circumstances – resulting in situations in which people don’t have children when they want them (no access to ART) and have children when they don’t want them (no access to abortion). At the stage of research and development, the shared reference point of the embryo integrates some of the political and regulatory approaches to reproductive and nonreproductive technologies. I have highlighted some of the ways in which anti-abortion ideologies shape the scientific development and clinical implementation of reproductive technologies. Vice versa, the regulations – and their revisions – of assisted reproduction and embryo research can pose a threat to established access to abortion. Cases from Italy, the United States and the United Kingdom showed how opposition to one technology can thus be expressed through the regulation and politicisation of another. In the US context, anti-abortion politics also materialised in the curtailing of federal funding for embryo research, rendering it more dependent on private funding. Ironically, the ban on federal funding has resulted in less government control over embryo research, as it is relegated to a relatively underregulated private sector. Attention to the commercial infrastructures and financial flows that underlie the introduction and availability of reproductive and nonreproductive technologies provides another approach to considering their integration and the new forms of digital reproductive health they introduce. Financial flows play a key role in determining which technologies are promoted, curtailed or integrated with one another. The egg freezing start-ups show how a set of different reproductive technologies are integrated when they align new reproductive values of ‘proactive fertility management’ with a capital logic that presents opportunities for growth and profit. Conversely, nonreproductive technologies may not only be curtailed by regulations and a politicised notion of safety but also through less transparent means of blocking financial flows, as was the case for Aid Access’ provision of medical abortion in the United States. In other words, beyond a biocapitalist frame, the case of Aid Access also showed how governmental organisations can exert power through the control of capital flows. Both reproductive and nonreproductive practices are currently disrupted by online platforms, which function as a means for normalising new visions of fertility and reorganising local practices in relation to a broader network. Yet while platforms can function as a centralising and monopolising force, which may render certain norms and practices more influential through central management decisions, they may also function as a decentralising and subversive structure that enables dodging conventional regulations of nonreproductive technologies. Egg freezing and medical abortion platforms draw attention to the role of platforms in centralising or decentralising reproductive practice and in consolidating or disrupting reproductive power structures. A broadened analytic scope that incorporates both reproductive and nonreproductive technologies can highlight how a contemporary biopolitics of reproductive control may be expressed through these technologies’ reciprocal influence, shared politicised reference points (e.g. the embryo), opposite investment practices and mutually reinforcing social effects.

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Notes 1. Although it was signed into law by President Clinton, the amendment was authored and sponsored by Republican Representatives and quickly passed in the House and the Senate – both of which were Republican-controlled at the time (Kearl, 2010). 2. The first frozen egg babies were born much earlier, in 1986, in Australia (Chen, 1986). 3. The Vatican’s original stance was to oppose all forms of assisted reproduction and Pope John Paul II’s concern was with the ‘absolute protection of the human life from conception’ (Calloni, 2001, p. 195; Robertson, 2004, p. 1693). 4. The report also drew on public opinion polls conducted in 1978 after the birth of Louise Brown, in which the majority of respondents favoured IVF and thought further testing was prudent, but opposed federal funding of research on IVF (EAB, 1979, p. 88). 5. Hedging against the abortion discussion, proponents of the 14-day rule extension argue that it is precisely a means to avoid abortion, given that additional research on embryo development beyond this time limit ‘may be able to reduce the frequency of selective abortion and thus reduce embryo and fetal wastage’ (McCully, 2021, p. 3). 6. In addition to egg freezing, Goldman-Sachs also offers women $20,000 to buy donor eggs in case their own eggs don’t work (Makortoff, 2019). 7. On 12 April 2021, in the context of the COVID-19 pandemic, the FDA has decided to allow Mifeprex to be dispensed through mail, either by or under the supervision of a certified prescriber (Aidaccess 2021; FDA, 2021). 8. Kindbody is an exception and has recently broadened the scope of its services to include nonreproductive technologies.

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Afterword Victoria Boydell and Katharine Dow

Abstract Here we provide a short reflection on the persistent themes from the volume and relate it to wider reproductive studies. Keywords: Technologies of reproduction; discipline formation; lived experience; comparative methods; biological citizenship; reproductive justice

This book project has been in the making over many years. The idea first germinated when we were working on our respective PhD dissertations. Katie examined people’s perceptions of assisted reproductive technologies in rural Scotland, and Vicky was tracing the social life of the oral contraceptive pill in London. We were regularly struck by the parallels in our ethnographic accounts of different reproductive phenomena in our many joint supervision sessions. For example, Marilyn Strathern’s (1992) ‘merographic connections’ surrounding ideas of nature echoed in the logic of how people imagine surrogacy or weigh up their contraceptive options. This led to our first joint endeavour on nature and ethics (Dow & Boydell, 2017). Nevertheless, the relatedness we found in our work on different technologies of reproduction continued over time and led to a more general observation of the relatedness of technologies in people’s lives that has inspired this book. In a bid to test our observations, we brought both scholars and practitioners from different areas of reproductive health and technologies into conversation to examine whether and how technologies of reproduction relate to each other. This edited collection has emerged from these conversations, and the underlying precepts and principles are drawn from all the authors’ collaborative intellectual labour. The colleagues and conversations that generated this collection have far exceeded the expectations of the initial workshop, particularly given that much of this work was completed under the constraints of the COVID-19 pandemic. The relatedness of technologies across the life-course makes intuitive sense. As the proceeding chapters attest, this idea has real analytical purchase in understanding reproductive lives and engagement with technologies of

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reproduction. Yet this begs a broader question, particularly given the wide recognition of relationality and of complexity thinking, why this relatedness between technologies has gone unmarked or unrecognised. One possible reason is the blinkers created by the conventions of our intellectual traditions. In the tradition of science and technology studies (STS), Adele Clarke’s (1998) seminal work on disciplining reproduction provides us with insights into how reproduction became a scientific and medical speciality. Drawing on studies of discipline formation, Clarke painstakingly details how reproduction transformed into a scientific field and a profession with associations, meetings and forums, funding streams and set out conditions for knowledge production. She illustrates that this is not a coherent and premeditated process, but is shaped by collaborations, conflicts, hierarchies and differences. We draw inspiration from Clarke’s insights on discipline formation and apply these to the social scientific study of reproductive technologies to better understand the under-elaboration of the relatedness of technologies. In recent years, there have been some initial forays into documenting the field of the social scientific study of reproductive technologies. Rene Almeling’s (2015) review paper on the sociology of reproduction usefully canvasses the field, and outlines the core texts of the discipline and the key concepts of this particular intellectual tradition. For instance, one such core and defining concept is that of ‘stratified reproduction’ (Colen, 1995), how the fertility and reproduction of some people are valued over others, and this has become almost a defining analytical feature of the field, or Charis Thompson’s (2005) analysis of the ‘ontological choreography’ provoked by encounters with RTs. In her review paper, Almeling outlines how social scientists have conceptualised reproduction as a series of events associated with specific technologies. She then suggests that we should see reproduction as a biological and social process, much in the spirit underlying this volume. Building on this and other convening initiatives, Rene Almeling went on to bring together over 200 scholars working on reproduction research as part of the 2020 Repro Scholars Mentoring Meetup that started with a reflection by Faye Ginsburg and Rayna Rapp on the past and future of reproduction research. These moments indicate an emerging speciality of the social scientific study of reproductive technologies, much like the formation of other disciplines. As an emergent field, some methodological and analytical conventions have come to inform the conditions of knowledge production. One such convention is that a specific technology of reproduction is treated as the object of study. The object is traced across different domains – within clinics, families, historical moments, and even within and between markets. This focus on a specific technology, Clarke argues, draws on the STS tradition of examining the ‘social construction of technology’ (Clarke, 1998) we can also see this in the biographic approach. There are clear analytical advantages to ‘following the technology’ – take, for example, the works of Charis Thompson (2005) and Sarah Franklin (1997) on assisted reproductive

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technologies that trace a technology and its associated constructs over time and through different spaces. More recent examples include Daisy Deomampo’s (2016) work on neo-colonial surrogacy in India and Lucy van de Weil’s (2020) study of egg freezing in the context of broader reproductive politics. Both of these recent monographs have followed a specific technology of reproduction to learn about how power works at particular socio-cultural junctures. Moreover, the focus on ‘new reproductive technologies’ in the earlier social scientific study of reproductive technologies parallels the boundary work noted by Clarke in the formation of reproductive science. Clarke provides a powerful example: …the boundary between reproductive sciences and genetics is publicly construed by most geneticists as absolute and never to be crossed. While prenatal genetic screening and diagnostics, gene therapy, and fetal surgery are all predicated on the availability of abortion and other reproductive science interventions, these necessities must not be mentioned. (1998, p. 271)

The creation of silos in reproductive sciences is paralleled in the social analysis of reproduction (Boydell & Dow, 2021). There are, of course, notable exceptions, such as Emily Martin’s (1987) The Woman in the Body that purposefully looked across different reproductive events to capture how the cross-cutting market logic underpinning reproductive medicine conceptualises bodies. These unspoken conventions were reflected in how the authors in this collection introduced themselves and their papers in our inaugural meeting. Almost all revealed how they appreciated the opportunity to write their paper because they had similar observations, which had remained underdeveloped as there was no space or place to pursue the thought. Like so many conventions, there are benefits and some inevitable drawbacks. One such limitation of studies that trace a specific technology means the focus is on experiences of a specific technology, usually at a particular juncture in an individual’s life, rather than on how a technology figures in wider lived experience. The snapshot of a particular technology, people and settings runs the risk of losing the complexity of lived experiences and other perspectives. People do not experience a technology in isolation but as part of a broader context. A more contextualised analysis of reproduction recognises that we see technologies of reproduction as a part of life, tracing the imaginaries, values and principles that structure reproduction, as well as how reproductive experiences shape other parts of social, political and ethical life (Dow, 2016). Here we look to colleagues in clinical practice who are shifting to a more person-centred approach in reproductive health care where the focus is on

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considering people’s desires, values, family situations, social circumstances and lifestyles to find appropriate solutions (Constand, MacDermid, Dal Bello-Haas, & Law, 2014; Dehlendorf et al., 2021). The empirical cases included in the preceding chapters illustrate how it is useful to ‘make explicit’ some of our implicit assumptions in how we study technologies of reproduction. This should not preclude studies that focus on technologies but complement and enhance them. The comparative approach is a common feature of the chapters shared in this volume. A comparative approach here refers to comparing something across space and/or across time. This could be comparing several time points in a person’s life (see Boydell and Mackenzie in this collection), comparing two technologies (see Nandagiri, Wilson, van de Weil, Whitacre, Han and Hudson and Law in this collection), comparing a technology over points in time (see Hamper and Pickard in this collection) or two populations (see Kasstan and Appleton in this collection). Writing about the advantages of comparative ethnography, Simmons and Rush Smith (2019) argue that comparison extends in-depth research methods and insights across different sites, objects and actors, with the aim of tracking similarities and differences to map change, question existing categories, propose novel concepts and generate theoretical insights. Comparison allows for attention to meaning-making and lived experiences, through an understanding that all knowledge is situated in power relationships. It can bring to the fore dynamics that might be missed through focusing on a single site, offering ways to investigate the complexity, ambiguity and even incoherence that characterise lived experience. We are not unique in our proposition; feminist postcolonial STS scholars (Pollock & Subramaniam, 2016) and others show the benefits of comparative approaches, whether it be looking at racial injustice across technologies (Valdez & Deomampo, 2019) or how imperatives of contemporary parenting manifest in decisions around childbearing and childrearing (Faircloth & Gurtin, 2017). The chapters in this book show that such comparative approaches can help us create new possibilities and explore different angles that expand our thinking and analysis. Such an approach moves us away from narratives that reflect singular experiences toward accounting for how multiple dimensions intersect and interlock, in order to capture the breadth and complexity of lived experience. Tracing experiences, constructs and logics across populations, times, places and technologies also reveals the stickiness and power of certain logics, legacies and ideologies that circulate and shape biological engagements. The chapters here illustrate how technologies of reproduction travel across all aspects of life and how these biological engagements are deeply biopolitical projects (Pollock & Subramaniam, 2016). The breadth of technologies covered speaks to the intensification of biopower more generally but also the application of biotechnologies to all bodies, not only those with a particular medical condition or disease (Wehling, 2010). People are actively re-envisioning their bodies, situations and biological destinies through

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biotechnologies. New responsibilities, duties, obligations and burdens for people about their biologies accompany these possibilities. Focusing on the intersections and interplay between technologies of reproduction tell us that using biotechnologies to shape bodies and biologies has become a central part of neoliberal governance practices (Charles, 2013; Lock & Nguyen, 2018). As outlined by Rose and Novas (2004), these engagements are forms of biological citizenship, engaging biotechnologies that shape and affect subjectivities, beliefs and biological presuppositions of disease and are linked to ideas of citizenship. Rose and Novas (2004) adopt the term biological citizenship to refer to …all those citizenship projects that have linked their conceptions of citizens to beliefs about the biological existence of human beings, as individuals, as families and lineages, as communities, as population and races, and as a species. (p. 440)

These chapters can be seen as accounts of biological citizenship. Each depicts how citizens relate to technologies to inform themselves and self-regulate and how these relationships facilitate engagement within a particular mode of governance and neoliberal rationalities. For Rose (2007), individuals act and think positively about their biologies which they know and improve with biotechnologies, and therefore biological citizenship operates within an economy of hope. However, others argue that engaging with the technology can be equally driven by fear, burden, despair, guilt and exclusion (Charles, 2013). In these chapters that compare the ¨ intersections between reproductive technologies (see Buhler, Hamper and Hudson and Law in this volume), we can see how both hope and risk promote biological citizenship as the relationship between the individual, the state and biomedical technologies. Citizenship projects are driven not only by individuals who organise biomedical classifications but also by ‘incentives and recommendations from the state and other authoritative channels’ (Charles, 2013). Nicole Charles (2013) argues that biological citizenship is a biopolitical tool within more extensive governmentality processes. It does not promote new rights but reconfigures a certain gendered and responsible citizenship based on rights and obligations. Several of the citizenship projects shared in this collection illustrate the ‘incentives and recommendations from the state’ (see Appleton and Mackenzie in the collection), and others include examples of the ‘incentives’ of commercial forces (de Weil, Whitacre, Han, Pickard and Hamper). With these new citizenship projects come new forms of discrimination, injustices and inequalities in accessing new biotechnologies and how obligations, duties and rights are unevenly distributed with differential implications for citizens. Speaking to a long history of technoscience and

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feminism that points out how science and its subjects are gendered and imbricated in the circuits of power, Pande and Moll’s (2018) account of egg donors in South Africa and Charles’s (2013) analysis of the promotional materials for HPV in Canada show how the expansion and normalisation of biomedical technologies places a disproportionate obligation on women. From the beginning of this project, we have sought to reflect seriously on the myriad ways in which the lessons of the reproductive justice movement might help shape the future of the study of technologies of reproduction. Once again, we are reminded that the phrase ‘reproductive technologies’ is so often assumed to be referring to high-tech techniques aimed at particular bodies – i.e. IVF or egg freezing for older, richer, white women in the Global North. One lesson of the study of technologies of reproduction/reproductive technologies has been the importance of attending to the ways in which these technologies are represented, in popular and public discourse, and where and how these representations diverge from personal experiences. Social scientists are, of course, well placed to capture and analyse both personal experiences and representations, as well as try and demystify both through empirical data. This is one reason we have emphasised the importance of both temporality and relationality in this volume, as well as the methodological and theoretical imperative to take what we know about reproductive technologies and bring them into conversation through comparative methods. This project began with the simple and, in many ways obvious, – yet strangely under-theorised – observation that, not only do increasing numbers of people across the world encounter and (refuse to) engage with RTs during their lives, but they do so in plural ways. Different technologies of reproduction become salient at different ages and life stages, within different relationships, in different life circumstances and in different medical, legal and economic contexts. We hope that this book has put some empirical meat on the bones of this observation, as well as suggesting ways in which we might attend to this point within reproductive studies. Undoubtedly, the principles of reproductive justice can help us in this task, as they encourage a vision of reproduction in the round, that takes in all those who have been marginalised from previous studies of RTs and which takes a long view of reproduction and RTs. This approach can also offer fresh perspectives on long-standing precepts within both popular and scholarly (mis)conceptions about RTs and their users. For example, let’s return briefly to Sharmila Rudrappa’s study of surrogacy in India mentioned in the Introduction. For many years, we heard that people travelled to India for surrogacy because it had a good medical system but was cheaper than other locations in North America or Europe. Rudrappa’s empirically informed account of Indian surrogacy provides a more complex rendering of this situation, as well as inviting us to step back and wonder about the assumptions that inform a judgement of India as a place that is cheap, but good enough. As Rudrappa shows, medical provision in India is both high standard and low-cost because of very particular

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colonial and postcolonial policies of medical education and population control, as well as broader inequalities that make acting as surrogates a reasonable option for lower-income women (and training as an obstetrician an attractive choice for others with the opportunities and privileges to pursue it). Another instructive example is D´ana-Ain Davis’s (2019) account of reproductive injustice against black middle-class women in the United States. Once again, we could start with a popular and well-meaning assumption – that African-American women are more likely to experience maternal morbidity and mortality because they are more likely to have lower incomes. By focusing on middle-class black women, Davis explodes this neat assumption and all it can do to sidestep racism and injustice, showing that even those who are better off and who should therefore benefit from some of the privileges of class still experience disproportionately poor outcomes. As she shows, this demonstrates the necessity of a better understanding of the causes of maternal morbidity and mortality amongst black mothers that does not shy away from medical racism and the real effects it has on patient care. These examples are cautionary tales about treating technologies of reproductive in a singular way or isolating accounts of their use that can reproduce a privileged interpretation that is blind to the experiences of those who are subject to reproductive injustice. Reproductive justice reminds us to take account of the complex contexts in which reproduction does and does not take place and the part that technologies play in upholding and/or circumventing those contexts.

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