Laura Mamo is Assistant Professor of Sociology and Affiliate Assistant Professor of Women’s Studies and Lesbian and Gay Studies at the University of Maryland.

Queering Reproduction

DUKE UNIVERSITY PRESS

Contents

Chapter One

IN 1994 ESTHER CALDWELL attended a Women's Action Coalition meeting and heard about a new program called "Lesbians Considering Parenthood," which would soon be offered at a San Francisco feminist health center. As an out lesbian, Esther wasn't sure that children would be part of her future, but she had always wanted kids. She decided to attend the eight-week workshop as well as an instructional class on how to self-inseminate. There were eight women in the class. Each was given a small speculum and advised to hold a mirror between her legs and look inside to find her cervix. Each was then given a little syringe with water to squirt into herself as close to the cervix as possible. Esther thus learned the very simple procedure of alternative insemination. Just as important, Esther met a group of women she would see with regularity over the next ten years. After the workshop concluded, Esther immediately purchased semen from a local sperm bank and performed inseminations at home. Eight months later, she still had not gotten pregnant. Although she planned to continue trying, her plans were derailed by life events-a car accident, a change of living situation, and a break-up.

In 1998 she decided to again attempt pregnancy. This time, everything was different. She had to re-register, for a fee, at the sperm bank that she was using to purchase donor semen. In addition, the sperm bank now required all clients to have a complete "fertility work-up," as well as an intake interview and signed authorization from a designated physician. As a member of a health maintenance organization (HMO), Esther scheduled an appointment with her Ob-Gyn, who, during the exam, told her about their new "infertility clinic." Immediately referred to the clinic, Esther met with a provider who suggested she use a technology called intrauterine insemination (IUI). With IUI, Esther could not inseminate at home, as she had four years earlier, but would have to attend a clinic and have the procedure performed by a nurse.

Esther's story illuminates a key trend of recent decades. As do-it-yourself alternative insemination has evolved (unevenly, but along with women's and lesbians health movements), so, too, has Fertility Inc., a large-scale biomedical service sector so powerful that it threatens to displace the low-tech options often used by lesbians. Esther's personal experience reflects two forces examined in this book: first, the expanded sense of possibility and self-empowerment in the realm of reproduction that emerged in the last decades of the twentieth century, supported by major social movements, including the women's health, gay rights, and lesbian and feminist movements; second, the medicalization of reproduction, facilitated by the emergence of assisted-reproduction technologies. There would seem to be tension-if not outright opposition-between these forces. And yet, as Esther's story illustrates, the recent history of lesbian reproductive practice encompasses both these and a great deal of acceptance.

What explains this shift from self-empowerment and low-tech practices (self-insemination at home) to reliance on high-tech methods (requiring medical intervention in clinics and doctors offices)? To be sure, one might expect medical intervention in cases where pregnancy has been impeded by an individual's health conditions, risk factors, or age. But how did biomedical services come into play in lesbian reproductive practice despite the absence of a medical diagnosis? How can we understand lesbians' decisions to become "patients," that is, to turn to biomedical services and professionals to address a problem that is social rather than medical-a lack of access to sperm? To explore these issues, it is necessary to trace two intertwined strands of medical history: the evolving relationship between medicine and reproduction, and the evolving relationship between medicine and homosexuality.

Looking Back at Medicine and Reproduction

The practice of assisting reproduction is centuries old. It first developed as an efficient method for breeding animals. The earliest reported use of artificial insemination (AI) occurred among Arab horse-breeders in the fourteenth century (Herman 1981, 2). There were frequent and well-known experiments with AI in animals. The first documented success of AI in animals came in 1742 when Ludwig Jacobi, a German natural philosopher and fisherman, artificially fertilized salmon eggs (documented in 1765) (Poynter 1968; Finegold 1976). In 1773 Abbe Lazzaro Spallanzani, an Italian priest and professor, fertilized frog spawn, silk worms, and salamanders (Zorgniotti 1975) and was said to have produced an offspring by inseminating a female dog in 1780 (Herman 1981, 2; Poynter 1968; Guttmacher 1938).

The idea of assisting human conception appeared as early as 1550, when Bartholomeus Eustacus recommended that a husband guide his semen toward his wife's cervix with his finger to enhance the chances of conception (Rohleder 1934). However, for most of human history, sterility was viewed primarily as a social or moral issue, not as a medical problem requiring treatment. Sterility was defined as an inability to conceive due either to "natural" circumstances such as one's age and length of marriage or to more personal matters such as one's mental, moral, and sexual habits. Childlessness was often believed to denote a barren mind and body. For women, external signs of masculinity, old age, and fatness were all suggestive of disordered sexual health and were considered potential causes of sterility. Idleness, abundant sensuality, eating rich food, sexualized and sexually active behaviors, depression and melancholia, drinking alcohol and/or using drugs were also considered "self-induced immorality leading to childlessness" (Pfeffer 1993). Prior to the late nineteenth century, women did not turn to medical professionals to understand, let alone solve, their inability to conceive; instead, they looked to god and the clergy.

Medicalizing Infertility

Over the course of the eighteenth and nineteenth centuries, childlessness was recast as biological pathology, rather than as moral degeneracy. The context was significant. The sciences, including biology, genetics, and medicine, developed into male-dominated academic disciplines in the eighteenth century (Schiebinger 1989, 1993). In the absence of women's voices, "men ... increasingly tightened the reins on what was recognized as legitimate knowledge and who could produce that knowledge" (Schiebinger 1993, 142). Nineteenth-century medical practices consolidated professional jurisdiction over medical "problems" and profoundly altered where and to whom people could turn to understand and make meaning out of their bodily and social experiences (Starr 1982). Women's bodies and their reproductive processes were central sites of such medicalization (see especially Riessman 1983).

Not until the late nineteenth century was a medical classification, sterility, assigned to those unable to conceive or carry a pregnancy to viability. Women's bodies were placed under the medical gaze for "treatment" and "cure." The speculum, a diagnostic tool introduced in the early nineteenth century, allowed doctors to survey the internal landscape of women's genitalia and create new bases for theorizing the biological causes of childlessness. The "abnormal" size, appearance, and disposition of women's internal genitalia all became factors thought to contribute to sterility (Pfeffer 1993). By the late nineteenth century, surgeons were performing surgeries to "restore fertility." To be sure, over the course of the eighteenth and nineteenth centuries, medical science produced new insights into male and female reproductive processes and their mutual contribution to fertility (e.g., the spermatozoon theory of reproduction, or the meeting of the egg and sperm) (Zorgniotti 1975). However, this new knowledge did little to dispel the belief in character as the key to fertility, and most medical practitioners continued to view "barrenness" as primarily a malady of women and largely an expression of women's moral condition (May 1995). The continuing focus on women's moral fiber was exemplified by Francis Galton, the founder of eugenics (the use of scientific knowledge to influence genetics), who believed childlessness to be a result of degeneracy, a failing race, or the deleterious influences of civilization (Kevles 1985). This moralistic interpretation of childlessness continued into the nineteenth century but was soon joined by biological models.

At the beginning of the twentieth century, concomitant with ongoing moral inflections, advances in biology, medicine, and agriculture began to consolidate (Clarke 1998), leading to new, "scientifically based" approaches to assisted reproduction. The first reported "cure" for sterility appeared in 1909, as reported by the physician Addison Davis Hard, who had witnessed an experiment that William Pancoast, a prominent Philadelphia physician, conducted while treating a sterile couple. In his examination of the woman Pancoast found no known physical abnormality. He then inspected the husband's ejaculate under a microscope and found no signs of spermatozoon (sperm). After several months of using the husband's semen without achieving results, Pancoast selected the "best looking member of the [medical] class" to provide semen for the experiment. (It has been suggested that it may have been Hard himself who donated the sperm.) While the woman was under anesthesia, he inseminated her with the donor sperm using a needleless syringe. She conceived, and it is alleged that neither Pancoast nor her husband informed her that a donor had been used. This experiment was groundbreaking, not only expanding the focus of sterility research and treatment from women to men but also initiating the use of sperm donors in assisted reproduction (Hard 1909).

Hard's report unleashed controversy over the practice of "artificial impregnation" (May 1995), its consequences for the sanctity and naturalness of reproduction coming into question. Critics expressed alarm, concerned that the practice would harm the nation by destabilizing the presumed naturalness of heterosexual married intercourse as the foundation of moral social life and American kinship. They warned that the use of donated sperm might disrupt the bonds between husband, wife, and children as legally sanctioned and secured by heterosexual sex and the biological link of parents to children. Other opponents argued that artificial impregnation would lead to the "bastardization" and "illegitimacy" of children and, by extension, the stigmatization of the entire social (family) unit. In short, some objected to its presumed unnaturalness, others to its assumed anti-natalism (in not promoting biological reproduction), and others to its eugenic implications.

Expanding "Scientific" Medical Authority

Early objections to donor insemination are central to understanding the gradual legitimacy of assisted reproduction for most women and men. One strongly held belief was that having another man's semen in a woman's vagina was, even when inserted by artificial means, akin to adultery. Marital intercourse was not only constructed as natural but also granted the power (symbolic and legal) to bind together man, woman, and child (Pfeffer 1993). Heterosexual intercourse that resulted in conception was considered a measure of a man's potency and masculinity, an assurance of his biological fatherhood, a preservation of "true" fatherhood (privileging the biological definition of fatherhood), and an escape from any signs of unnaturalness or immorality associated with infertility. These constructions signaled a necessity to create a rhetoric whereby medical treatments for sterility would be understood as "assistance" of the "natural," and therefore not as "intervention" into the "unnatural" or pathological.

Despite ongoing resistance to assisted reproduction as expressed in these controversial perspectives, "scientific medicine" continued to expand its understanding of human reproduction and to devise new technologies for overcoming obstacles to conception as well as unwanted childlessness. Beyond basic knowledge of fertilization, the most significant scientific developments for assisted-reproduction technologies occurred in three areas that together led to a new specialty-infertility medicine-and its associated technical and pharmaceutical innovations.

The first area was the study of the menstrual cycle. Understanding the menstrual cycle and hormonal changes in women's fertility allowed doctors and women themselves to track ovulation through various means. Charting the menstrual cycle was and remains an important development for infertility medicine. Ovulation prediction has long been in existence as a method to both prevent and assist conception. In its most simple form, women simply chart their menstrual cycle based on experiential knowledge about their bodies: changes in vaginal mucus, skin and mood changes, timing of menstruation, and so on.

Charting basal body temperature in order to predict the timing of ovulation produced the knowledge needed to diagnose anovulation (infertility based on an inability to ovulate) and set the groundwork for the medical "treatment" of this new disease classification. Resulting from this knowledge were pharmaceutical therapies for anovulation-the second area of technoscientific discovery that contributed to infertility medicine as a large-scale specialty.

In the 1960s clomiphene citrate was introduced and was found to be a convenient and effective treatment for ovulation "problems." In 1966, ten years after its initial development and following six years of clinical trials, clomiphene citrate received approval from the Food and Drug Administration, was released under the brand name Clomid by the pharmaceutical company Merrell (Gruhn and Kazer 1989), and became widely available as a treatment option for infertile women diagnosed with anovulation (Pfeffer 1993). The development of clomiphene citrate facilitated the now close relationship between pharmaceutical companies that develop, manufacture, and market hormonal treatments for infertility and the doctors who prescribe them. This association was made possible by laboratory science, by the mass-production of drugs, and by the placement of these drugs in doctor's hands not only as patient-treatment options but also as justifications for what became a large-scale procreative service delivery system.

The third area that helped launch infertility as a medical specialty was the study of spermatozoa, including semen storage, semen analysis, and cryopreservation (freezing and thawing sperm). The development of techniques for cryopreservation of human sperm specifically for use in human reproduction is attributed to Jerome K. Sherman's and Raymond G. Bunge's work during the mid-1950s (Sherman 1954; Bunge and Sherman 1954). Medical cryopreservation was first used for helping men with low sperm counts to consolidate sperm in their semen and for banking small supplies of donor sperm to facilitate the coordination of artificial insemination by donor. Cryopreservation, which most commonly involves the immersion of semen in liquid nitrogen, was developed in the 1950s and for a decade or more was practiced on a small scale by private physicians, often as "fertility insurance" for men who were to undergo a vasectomy but might later desire to have a child. In the last decades of the twentieth century these advances drove the formation of a large-scale commercial sperm-bank industry. To make this procedure commercially viable, scientists had to develop methods for washing, concentrating, freezing, storing, and transporting sperm, as well as techniques for delivering sperm into the female body.

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Excerpted from Queering Reproductionby Laura Mamo Copyright © 2007 by Duke University Press. Excerpted by permission.
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