Book Review Essay: On Infertility (Barnes, Bell, Wilson)

Conceiving Masculinity: Male Infertility, Medicine, and Identity. Liberty Walther Barnes. Philadelphia: Temple University Press, 2014, 211 pp. Misconception: Social Class and Infertility in America. Ann V. Bell. New Brunswick: Rutgers University Press, 2014, 166 pp. Not Trying: Infertility, Childlessness, and Ambivalence. Kristin J. Wilson. Nashville: Vanderbilt University Press, 2014, 203 pp.

Men, women of color, poor women, and women who are not seeking medical treatment—these are the individuals whose experiences of infertility seldom become considered in scholarly or popular discussion of childlessness in the contemporary United States. By drawing attention to the overlooked and unseen, the three books discussed here complicate our understanding not only of who is infertile, but also what infertility is.

In all three works, the expectations of gender shape the experiences of infertility. This is not so surprising, but readers of Conceiving Masculinity might be startled to learn about (or be reminded of) the extent to which the medical treatment of male infertility is defined and practiced in terms of female reproduction. Based on ethnographic research at five male infertility clinics and interviews with 24 couples (who were interviewed separately), Barnes’s book is an especially welcome contribution to cultural and social studies of reproduction and medicine. The first two chapters detail the ways in which infertility is always female—even when it is marked as male—in the institutionalized practices and ideas of medicine. “Essentially, male infertility gets repaired in female bodies,” Barnes writes, “and many male infertility treatments require women’s willingness to undergo medical interventions” (p. 29).

Notably, in vitro fertilization, intended originally to assist conception for women with reproductive health complications like blocked fallopian tubes, is used now in cases of men with low sperm counts. Couples seeking treatment for infertility generally go to specialists who are board certified in obstetrics and gynecology and reproductive endocrinology. However, there is no counterpart in andrology or male reproductive health, and when male factor infertility is diagnosed, men may be referred to urologists whose additional training in male infertility can vary from highly specialized fellowships to workshops or continuing education courses.

Given the rapid and revolutionary developments in assisted reproductive technologies, some doctors question whether there is even a need for a specialty in male infertility. In response, Barnes, a medical sociologist, points out that fertile women needlessly subject themselves to procedures that are invasive and costly in terms of both money and time. Moreover, harm can be caused to infertile men, such as when doctors mistakenly prescribed testosterone based on their assumption that the hormone raises their sperm counts. (In fact, it has the opposite effect.)

One of the male infertility doctors whom Barnes interviewed describes “IBF” or “in bed fertilization” as the aim of his practice—i.e., the medical treatment of male infertility should enable his patients to conceive pregnancies that they consider “naturally” through sexual intercourse. The doctor’s remark and the preference of his patients underscore both the role that doctors themselves play in “doing gender” and the adherence to gender ideologies that conflate fertility, sexuality, and masculinity. Barnes notes that most of the couples in her study preferred male treatments to female treatments and that 20 of the 24 couples expressed a wish to pursue medical treatment “to whatever extent necessary.”

Although all the men interviewed for the study matched the clinical definition of “infertile,” the majority did not use the term to describe themselves. Rather, they defined infertility as the inability to conceive a pregnancy even with medical assistance, a finding that Barnes considers in the second half of the book. These men did not identify as infertile because they still had options available from a range of reproductive technologies. Male infertility patients were willing to submit their own bodies to exploratory surgeries and procedures in the spirit of supporting and protecting wives who wished for children, and toughing out the pain and taking one for the team like “real men” should. If these male treatments failed, then IVF and other female treatments still remained as options.

Men’s understanding of infertility and particularly their investment in medical ideas and practices complicate the assumption that women’s desire for the bodily experience of pregnancy and for motherhood drive a never-ending quest for conception, involving more intensive (and more expensive) medical interventions. Bell and Wilson further undermine this notion. Both books describe women who cannot and will not pursue fertility treatments. While there are overlapping aims and analyses between the two books—indeed, they tread much of the same ground in their opening chapters—they also display the distinct approaches and concerns of the disciplines of their authors: Bell, a sociologist, explores how race and class shape infertility in the United States and Wilson, an anthropologist, examines the making of meanings, roles, and opportunities as women without children.

Misconception is based on 58 interviews with U.S. women who identified themselves as having been “involuntarily childless” for at least 12 months, which is the clinical definition of infertility. However, it also raises questions about what defines voluntary and involuntary childlessness as well as planned or unplanned and intended or unintended pregnancy. Drawing on the framework of stratified reproduction, Bell compares the experiences of white and black women of low socioeconomic status (SES) with those of white women of high SES. Explaining that an initial aim of her study had been to also include black women of high SES, she suggests the continuing marginalization of women of color in conversations about infertility might have discouraged them from participating in the research. Infertile women, as portrayed in U.S. popular culture, are white and rich. Women of color and poor women are perceived as having too much fertility and too many babies, which is revealing not of their biological reality but of the social value that is placed (or not placed) on their and their children’s lives.

The lower SES women in Bell’s study did not pursue fertility treatment in part because they assumed (in general, correctly) that they could not afford it, which also shaped their interactions with doctors who seemed unhelpful and uncaring about the women’s difficulties with conception. The lower SES women also did not have the same access to information that higher SES women shared in their formal and informal networks. The lower SES women assumed that unprotected intercourse would result naturally in pregnancy. In general, they were unaware of the various mechanisms that higher SES women used to plan their pregnancies, such as monitoring their basal body temperatures to time intercourse to coincide with peak fertility. In general, women of lower SES have children at younger ages than women of higher SES, but Bell finds also that they were slower to consider whether infertility as a medical condition might explain their childlessness. “And then it probably was like three years into it,” one woman recalled to Bell, “‘Whoa. Wait a minute. We ain’t got no kid yet’” (p. 49).

Both Bell and Wilson describe women who find themselves caught between what feminist scholars have called the motherhood mandate and intensive mothering. In Bell’s study, women are marginalized both for not having children in a culture that assumes women ought to be mothers—and for wanting children in a society that does not regard women of color and especially poor women to be good mothers. The women in Wilson’s study face accusations of being selfish because they are childless. Worse, they are not even trying to become mothers. Significantly, these women assert themselves as less selfish because they are not having children merely to satisfy their own whims and wishes and because they understand that good mothering is not about having money, but about “being there” for a child.

Not Trying is based on interviews with 25 women in a range of occupations and class statuses who identify themselves as members of socially marginalized groups based on race, ethnicity, sexual identity, or marital status and as “off course” in terms of the expectation that they should be mothers. While the authors of the three books discussed here all contended with the difficulties of identifying infertile individuals to include in their studies, Wilson is especially forthright in discussing the challenges of seeking entry into what she calls a “hidden population”—i.e., the majority of women with infertility who do not seek medical treatment. Thus, she points out that most of the scholarship on infertility is based on research that represents a minority perspective.

The terms “voluntary” and “involuntary,” as well as “childlessness” and “childfree,” carry almost no meaning for the women whom Wilson interviews. Being childless was neither a choice that women actively made, nor was it merely coping and settling for one’s lot in life. Instead, Wilson finds that there are multiple pathways to what we commonly call involuntary childlessness or infertility. Although some women described themselves as childfree by choice, others said it “just happened.” For some women, this resulted from intentionally delaying pregnancy, either for education and career, while others described being committed to the idea that having children ought to happen in the context of a marriage or relationship with the kind of partner that did not materialize. Moreover, childless is not a description that the women in Wilson’s study find entirely accurate. Half of them also identified themselves as aunties or godmothers.

Taking seriously how women understand their life stories allows for the acknowledgment of ambivalence, which is arguably underappreciated in both the lived experiences of and the scholarship on infertility and childlessness. It also enables us to see the hold on U.S. women that intensive mothering particularly has. These women both articulated an idealized vision of mothers as patient, loving, forgiving, selfless, and comforting—and emphasized the responsibility, effort, and time required for mothering children. From their perspective, women who failed to uphold such standards were mothers in name only, or nominal mothers. One of the women in Wilson’s study remarked on the unfairness of having been unable to have children when there were others “that didn’t deserve children,” but still did. Many shared a disdain and even hostility for teen mothers that is expressed openly in U.S. society. Two-thirds of the women who identified as aunties and godmothers described nurturing, enjoying, providing for, and loving unconditionally their nieces, nephews, and godchildren. Attributing their ability to do so directly to not having their own children, these women revalue their childlessness as even better mothering.

All three works shed light on the overlooked and unseen experiences of infertility. Barnes’s book ought to be included on the reading lists of anthropologists interested in reproduction and men; it should also be considered for courses in medical anthropology. Both Bell and Wilson will be accessible even for advanced undergraduate students in sociology, anthropology, and gender studies. Readers will find both Barnes and Wilson particularly engaging as the writing is clear and the lively quotes from men and women participating in the studies illustrate a range of responses. The insights in these three books are well worth teaching and learning.

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