The influence of social and cultural factors on infertility and new reproductive technologies

Frank van Balen is a member of the editorial board of The Journal of Psychosomatic Obstetrics and Gynecology (JPOG) and associate professor at the Faculty of Behavioural and Social Sciences, University of Amsterdam. Over the years, Frank has developed a strong research line on such topics as childlessness, reasons for having children and families in which parenthood resulted from the use of a new reproductive technology.

Frank has approached these topics from various disciplines – such as pedagogics, psychology, cultural anthropology, sociology, ethics, public health, women's studies, and gay and lesbian studies – and always with a strong focus on cultural diversity. In 2003, the Council on the Anthropology of Reproduction (CAR) awarded a prize to a book Frank edited together with Marcia Inhorn: Infertility around the Globe: New Thinking on Childlessness, Gender and Reproductive Technologies[1]. This prize was the crowning glory on his work. Frank will leave our department during the next academic year. Although we hope he will still be involved in scientific research at our department, for us – two of his ‘scientific children’ – his imminent departure was reason to surprise him with a special issue on some of ‘his’ topics written by people with whom he has worked during his career.

As a result of new reproductive technology, the routes to parenthood are increasingly diverse and are expanding the ways in which individuals become parents. New reproductive technology has led to the birth of more than 300,000 babies since 1977 [2]. Within the social sciences, however, interest in new reproductive technologies is a recent phenomenon [3]. For many years, research in this area was mainly dominated by the medical sciences. There are several reasons why such important issues as infertility, new reproductive technologies and involuntary childlessness were neglected for so long by the social sciences [4].

In the past, infertility was mainly seen as a medical condition and the interest was in how to rectify the problem. Consequently, infertility was associated with new reproductive technologies and less attention was paid to how the people/couples involved experienced this. When attention was paid to infertility and involuntary childlessness outside the medical sciences, it was mainly within bioethics, where there was a strong philosophical focus on such questions as whether or not to use new reproductive technologies and which methods are acceptable. At the moment, there is still a strong focus on ethical issues [5-7], as can be seen in the recent debate on several issues, such as sex selection [8],[9].

Another reason why the subject of infertility was neglected in the social sciences might be linked to the fact that for a long time it was taboo to talk about infertility and involuntary childlessness, perhaps because it was seen as a ‘failure’. As a consequence, infertility was a subject that was not easily discussed with others, even with researchers. In most non-Western countries, people who do not have children are still regarded as ‘failures’[10-13].

Nowadays, there are several reasons why scientists are interested in the issue of new reproductive technologies from a social-scientific perspective [3]. First, a better understanding of several new techniques is needed as a guide to legal and public policy decisions. Countries within the EU, for example, have different laws about such techniques as surrogacy, egg donation, sex selection and lesbian couples' access to artificial insemination of sperm donor. A second reason for studying issues related to new reproductive technologies and infertility in the social sciences is a theoretical one. With the development of new reproductive technologies, both new and old theoretical questions are being raised. For example, what are the consequences for parenting roles and child development of having children with the help of new reproductive technologies? What are the attitudes of immigrant communities towards infertility, new reproductive technologies and the importance of having children? What effects do genetic relationships and same-sex parenthood arrangements have on child-rearing and child development?

Third, a better understanding of the cultural aspects of how people deal with infertility, infertility treatments, the value of children, etc. could increase the ability of health-care providers to take the context into account in their approaches, treatments and solutions [14].

For most people, having children is an essential part of their life, and all societies put a great value on having children. However, many millions of couples are confronted with the problem of childlessness caused by infertility, and childlessness – whether voluntary or involuntary – profoundly influences the life course of childless couples. However, societies differ as regards the reasons for having children, the ideal number of children, the importance of sons and daughters, and the issue of childlessness [1]. In the West, for example, involuntary childlessness is associated with new reproductive technologies, such as IVF, ICSI and full surrogacy. These new techniques are developing rapidly. Although also in the West involuntary infertility leads to much suffering, the new reproductive technologies open up prospects for would-be parents. Couples who would probably have remained childless in earlier times, or who would remain childless if they lived in another part of the world, now have the opportunity to become parents. In non-Western countries (which, of course, are the poorer parts of the world), the situation is very different: couples do not count if they do not have children, and especially women are often treated badly if they do not have children, and especially if they do not have sons. In these parts of the world, effective infertility treatments and the new reproductive technologies are scarce and available only to the upper class. Also within a given society, people hold many different views on these issues. In addition, the meaning of childlessness varies within a society and might be moderated by sociocultural and religious factors [15].

This special issue contains papers about what it means for people to be infertile, how they cope with it and what kind of new reproductive technologies they choose. All the articles are written from the perspective of the value of having children and the meaning of parenthood and parenting relationships. The focus is on both Western and non-Western societies and on differences within Western societies, especially minority groups in the Western world, such as immigrants and lesbian mothers.

The first contribution is on the value of children, parenthood motives, and the meaning of parenthood and infertility in a non-Western part of the world: Africa. Studies on the value of children among infertile couples or among couples who became parents following the use of new reproductive technologies are rare [16],[17].

Recently, the value of having children has received attention in studies on infertile immigrants [18]. Although there is a relatively strong tradition of research into the reasons for having children in non-Western countries [19-21], much less is known about the motives to have children among infertile people in non-Western countries. Dyer reviewed in her contribution several studies that had been carried out on this topic in Africa. Most of the studies were based on qualitative research methods, such as focus-group discussions, in-depth interviews and life histories. In previous studies on parenthood motives among native couples in Western societies, it was found that motives that are part of the realm of an expression of personal development and involve notions of the unique parent-child relationship are more important, and that motives that express the interest of the group, social pressure, continuity or heredity are less important. In contradiction, Dyer found that the social-related reasons for having children are very important in African society.

The second contribution is also about the value of having children. Purewal and van den Akker are fascinated by the contextual aspects (e.g., age, gender and culture) of why people want to become parents. Their study is interesting especially because they also interviewed people in the UK with a South Asian cultural background. They found that sociocultural identity influenced the meaning of parenthood. For South Asian people living in the UK, such aspects as continuation of the family name are still very important reasons to have a child. From a Western perspective, such values are viewed as traditional motives of having children.

In the third contribution, by van Rooij, van Balen and Hermanns, the focus shifts to another immigrant group in another country: Turkish immigrant couples in the Netherlands. This study is exceptional because it compares these immigrant couples with Dutch infertile couples and with infertile couples in western Turkey. It appeared that stress is less severe among Dutch couples. There were also some different patterns between Turkish immigrants and couples from western Turkey, in that feelings of guilt about and blame for being childless were strongest among the latter. The authors' conclusion that Turkish immigrants' experience of infertility is more similar to that of Turkish people (in western Turkey) than to that of Dutch people, underscores the importance of a sociocultural perspective on childlessness and infertility. Health-care providers, clinicians and GPs who work with infertile Turkish immigrants should appreciate the role of culture in their approach to these patients.

There is an ongoing debate in several Western countries about new reproductive methods: which methods are acceptable, for whom and in what circumstances? In their contribution, van Berkel and Pijffers focus on one of the new and much discussed reproductive methods, viz. egg cell donation. As the title of their paper shows, they were especially interested in establishing the relationship between egg donors and recipients, how they perceive their relationship with their children, how the egg recipient mothers deal with the missing genetic link, how non-anonymous egg donation mothers handle secrecy, etc.

Secrecy is also an important issue in the contribution by Sundby and colleagues, who collected data among a group of 66 women ten years after they had undergone IVF treatment. They questioned these women about several topics related to the consequences of the treatment. Most of the respondents had become mothers since the treatment, some as a direct result of it. Although the women stated that in the past they perceived the treatment period as very emotional and painful, they also said that it had not permanently affected their lives in a damaging way. However, most of the women who had become parents through IVF had not told their children that they had been conceived with the help of this technology, nor did they have the intention to tell them in the future.

A relatively new field in social scientific research into infertility, involuntary childlessness and new reproductive technologies is to study these topics from the perspective of infertile men. This lack of empirical social scientific research on male infertility is surprising, especially because in more than half of all infertile couples men are the sole cause of, or at least a contributing factor to, the couple's infertility [22],[23]. It might be that men with male factor infertility suffer more emotional problems because they perceive infertility as synonymous with a crisis of masculinity in which their manhood is shaken to its deepest core [10],[24]. However, as Peronace, Boivin and Schmidt report in their contribution, their study of 256 infertile Danish men revealed that most of the infertile men who had been unsuccessfully treated exhibited an increased level of stress, independent of whether the infertility was due to male factor infertility or another cause.

The final contribution to this issue is about planned lesbian families, that is, families headed by two lesbians who have opted for motherhood within their lesbian relationship. Frank van Balen is the principal investigator of a longitudinal study that is being carried out at the University of Amsterdam on this relatively new family type [25-27]. Most investigations show that there is no reason for concern regarding lesbian parenting and the development of children within lesbian families. However, there is an ongoing social, religious and political debate over whether lesbian women are fit to parent children and should have the right to do so. This debate is current even in the Netherlands, which has a relatively positive climate regarding homosexuality and same-sex parenting [28]. In their contribution, Bos and Hakvoort discuss the differences between lesbian families with a known donor and those with an as-yet unknown donor on child-rearing and child development.

This special issue is a Liber Amicorum for all the work that Frank van Balen has done on infertility, involuntary childlessness and non-traditional families in which parenthood resulted from the use of new reproductive technology. Frank, we thank you for all the wise lessons and inspiration you have given us over the years, and hope that we will continue to work together in the years to come.