Defining Infertility in History
The first step towards providing these answers is to unpick some of the difficulties facing historians of infertility. It makes sense to start with some fundamental questions. If infertility is a multidimensional experience, then what constitutes its essence? How should it be defined? In the contemporary world, such questions hold urgent importance for many. The issue of how infertility is defined has repercussions for the status of sufferers and their ability to access social support and medical treatment. In healthcare systems regulated according to free-market principles, governments or insurers will only subsidize treatment when infertility is defined as a medical condition rather than as an unfulfilled desire.28 These medical and legal systems affect how individuals define their own experience of involuntary childlessness. For example, in recent years, in order to achieve equal access to the financial resources to attain treatment, some women have argued that infertility constitutes a disability under the terms of the Americans with Disabilities Act (1990). Although disability is often perceived as stigmatizing in and of itself, these women perceive the disabled identity as providing not only financial benefits, but ‘evidence of an authentic medical condition to present to those who questioned, blamed, or advised them otherwise’.29 Definitions of infertility are complex, contested, and can be used and abused in many different ways, by many different agencies and individuals.
The World Health Organization (WHO) currently defines infertility as ‘a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse’.30 This clinical definition, or its earlier equivalents, has often been adopted by social scientists in their own research on infertility. In part, this reflects the fact that researchers need some kind of simple and widely accepted definition in order to proceed with research, and for their findings to be meaningful to other scholars. But it also indicates that medical models and aims can have disproportionate, and often unrecognized, influence on other fields. Indeed, in some Western countries, most psychological studies of infertility aim at answering medically oriented questions, because the main driver for such research is the perceived need to improve the success rates of IVF treatment.31 Although scholars may not intend their research to directly contribute to medical agendas, the unthinking adoption of a medicalized definition reveals certain underlying assumptions in approaches to infertility, shapes the research process, and therefore has important consequences for the outcomes of research.
Assumptions inherent in medicalized definitions can operate to hide political and structural issues that affect both the experience of infertility, and how it is researched. Deborah Lynn Steinberg argues that subsuming idiopathic (unexplained), environmentally induced and iatrogenic (medically induced) infertility into a medicalized framework has the end result of constituting infertility as an individualized and pathological diagnosis. The medical model of infertility therefore ‘eclipses or precludes social and political questions about medical (mal)practice and environmental pollution’.32 Moreover, in her view, medicalized definitions are ‘covertly gendered’ because it is assumed that women take greater responsibility for tackling infertility and that they are more distressed at the diagnosis (whether in themselves or in their partners). Crucially, women also bear the brunt of investigations and treatment, which are more invasive than the procedures applied to male bodies.33 Adopting a medical model of infertility can thus prevent researchers from locating the experience of involuntary childlessness within wider systems of power, privilege, and suffering.
A similar point has been made by Arthur L. Greil and Julia McQuillan, who argue that because social science research on infertility is usually conducted on easily accessible clinic populations, researchers ‘implicitly and inadvertently’ define their subjects as ‘people who ask for and receive infertility treatment’. This specific subgroup comes to stand for all who are involuntarily childless, even though the very fact of motivated health-seeking behaviour differentiates in important ways this population from those who do not or cannot access medical systems. Moreover, standardized definitions of infertility as the failure to achieve pregnancy after a specified period of unprotected intercourse implicitly assumes that infertility is closely related to the intention to conceive, and therefore reinforces the perception of infertile individuals as help-seekers. Greil and McQuillan’s research uncovered a substantial subset of women who had experienced 12 months of unprotected sex, but answered ‘no’ when asked if they were trying to get pregnant. The existence of these women highlighted prominent assumptions about ‘planfulness’ that divide individuals into two categories - those who do not wish to become pregnant, and are actively taking measures to prevent conception, and those who actively wish to become pregnant. Women, often less privileged, who do not fit into either of these categories occupy a liminal status.34
The women in this study did not necessarily define themselves as ‘infertile’. Similarly, research on women’s experiences of infertility in New Zealand suggests that some women resent the perception that infertility has a ‘clear fixed and stable meaning’, and emphasize instead that involuntary childlessness is not ‘a black and white issue’.35 Greil and McQuillan conclude from their research that focusing
on those who visit infertility clinics renders invisible the experiences of women who have not sought treatment, either because they do not identify as infertile or do not see their situation in medicalized terms. A focus on treatment seekers not only ignores the experiences of half of U.S. women who are infertile by the medical definition, but it takes for granted the biomedical concept of ‘infertility’ without subjecting that concept to a close examination.
Researchers must therefore trade ‘a spurious definitional certainty for complexity, ambiguity, and questions about intentionality’.36
The same argument has been made by those researching infertility in different local and global contexts. Frank van Balen and Marcia C. Inhorn argue that while standardized definitions can be useful in Western clinical settings, ‘subjective meanings and experiences of infertility are culturally variable’: a woman may define herself as infertile if she does not become pregnant within a month or two of marriage; in some societies, bearing no sons may be perceived as the equivalent of having no children at all, making the parents socially infertile; and in places where cultural norms dictate that women bear seven or eight children, having only one or two babies may be seen as evidence of reproductive abnormality.37 In Chinese medicine, the concept of infertility as a pathological condition barely exists. Instead, buyn zheng (‘failure to become pregnant’) is perceived as ‘a failure to achieve a desired bodily state, rather than an undesired change that must be brought under control’.38 There is no reason to assume that Westernized definitions apply to the rest of the world, and making this assumption can severely limit understandings of how infertility is perceived and understood in different contexts.
Although these warnings were issued with social science researchers in mind, they are equally applicable to historians. Historians rarely if ever explicitly define infertility; the contributors to this volume use a range of unarticulated working definitions, and in itself this illustrates the variety of potential approaches to its study. This lack of definitional clarity or consensus is primarily an outcome of gaps in the historical record (to be discussed further in the following section) and the constraints these impose on researchers. Most often, historians are able to track infertility through history only when it has been perceived as pathological, whether by states, physicians, sufferers, or other interested commentators: it is under these circumstances that substantial discourse on infertility has been generated, resulting in the raw material from which historians build their narratives. It is therefore easier to write the history of infertility from the top-down than from the bottom-up, from the perspective of those concerned with regulation and rectification than from those whose lives and futures were disrupted by involuntary childlessness. However, it also means that historians usually adopt a de facto definition of infertility as describing the condition of people who experienced difficulties either in conceiving, or, less frequently, in having as many children as they wanted. The evidence is weighted towards those who sought help for this condition, because they left material traces of this aspect of their lives. Consequently, our historical knowledge is inevitably skewed towards the construction of infertility as a medica- lized condition, even though scholars are aware that this constitutes at best only one aspect of the experience of infertility.
While it is not possible to fully resolve these issues, historians may be able to produce richer histories of infertility if they pay more attention to questions of definition, and interrogate their own assumptions about what exactly they intend to research. First, it is clear that different understandings of infertility have operated in different past societies. For example, in contrast to the assumptions of contemporary medicalized definitions, the intention to procreate played no part in ancient Greek terminology. Instead, the word atokos was employed ‘to denote a woman who has not yet borne a child, regardless of whether or not she has tried; that is, it signifies a current physical state, with an open future’. Likewise, there is no noun directly equivalent to ‘infertility’, ‘sterility’, or ‘barrenness’ in ancient Greek. Instead, it is insisted ‘through adjectives, participles, and periphrases, that it is infertile, sterile, or barren, individuals, bodies, and pairings, that are being described, explained, and treated’.39 Explaining these linguistic differences is essential to historicizing infertility.
Second, we do not only need to shake off medical definitions of infertility when looking at past societies. We also need to consider how dramatic changes in the landscape of reproductive technology have altered our working assumptions about how the body is experienced and understood. Since the 1930s, it has been possible to establish pregnancy with some certainty in its earliest stages by measuring the level of progesterone in the urine. The test was expensive to carry out at that time, but in the late 1960s the home pregnancy testing-kit was invented, and is now easily accessible in the West.40 In the 1950s, ultrasound was developed, and by the 1970s obstetricians were recommending use of the technique on all pregnant women.41 This ability to visualize the foetus in the womb has had important consequences for the politics of reproduction.42 These developments mean that we are now likely to perceive pregnancy as a positive and unmistakeable state of being. However, Cathy McClive points out that the modern interpretation of pregnancy as ‘a linear progression from conception to delivery’ contrasts starkly with the corporeal uncertainty that was ‘an intrinsic and accepted part of the early modern understanding of the process of conception’. It was difficult to detect pregnancy, or to distinguish between ‘true’ and ‘false’ pregnancies, and pregnant women and medical practitioners often disagreed over their equally subjective interpretations of the proper signs of the condition.43 To understand past experiences of infertility, we need to realize just how radically quite recent changes in medicine and technology have altered our perceptions and experiences of the body.
Finally, in order to move beyond medical approaches to the history of infertility, it is necessary to start looking for evidence - no matter how fragmentary or dispersed - in different places. It seems likely that historians have been unwittingly influenced not only by medicalized approaches to infertility, but by dominant cultural constructions of infertility as equivalent to childlessness. If primary infertility (the inability to achieve pregnancy despite regular unprotected sex) is difficult to locate in the historical record, then, perhaps perversely, secondary infertility (the inability to become pregnant or carry a pregnancy to term following the birth of one or more children without use of ARTs) is even more likely to remain hidden. For the modern era, demographic data tells us how many couples remained childless; while we do not know how many of these couples chose this status, it is reasonable to assume that in intensely pronatalist societies, and in the absence of effective forms of birth control, childlessness was more often involuntary than chosen. What we cannot know is how many of those who did have children were unable to achieve their desired family size, although evidence from the mid-twentieth century suggests that this figure may be surprisingly high.44 If historians start asking different questions about how infertility was defined, then they are likely to come up with some different answers as to how it was perceived and experienced.