Conceiving Normalcy: Rhetoric, Law, and the Double Binds of Infertility / Edition 2

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This ground-breaking rhetorical analysis examines a 1987 Massachusetts law affecting infertility treatment and the cultural context that makes such a law possible.

Elizabeth C. Britt uses a Massachusetts statute requiring insurance coverage for infertility as a lens through which the work of rhetoric in complex cultural processes can be better understood. Countering the commonsensical notion that mandatory insurance coverage functions primarily to relieve the problem of infertility, Britt argues instead that the coverage serves to expose its contours.

Britt finds that the mandate, operating as a technology of normalization, helps to identify the abnormal (the infertile) and to create procedures by which the abnormal can be subjected to reform. In its role in normalizing processes, the mandate is more successful when it sustains, rather than resolves, the distinction between the normal and the abnormal. This distinction is achieved in part by the rhetorical mechanism of the double bind. For the middle-class white women who are primarily served by the mandate, these double binds are created both by the desire for success, control, and order and by adherence to medical models that often frustrate these same desires. The resulting double binds help to create and sustain the tension between fertility and infertility, order and discontinuity, control and chaos, success and failure, tensions that are essential for the process of normalization to continue.

Britt uses extensive interviews with women undergoing fertility treatments to provide the foundation for her detailed analysis. While her study focuses on the example of infertility, it is also more broadly a commentary on the power of definition to frame experience, on the burdens and responsibilities of belonging to social collectives, and on the ability of rhetorical criticism to interrogate cultural formations.

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Editorial Reviews

From the Publisher
"There is a rapidly growing literature on topics related to family building in traditional and nontraditional ways. This is the first I am aware of that undertakes a rhetorical analysis of the discourse surrounding infertility and its resolution."
—Lisa Cuklanz, Boston University
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Product Details

  • ISBN-13: 9780817310981
  • Publisher: University of Alabama Press
  • Publication date: 7/28/2001
  • Series: Albma Rhetoric Cult & Soc Crit Series
  • Edition description: 1
  • Edition number: 2
  • Pages: 222
  • Product dimensions: 6.00 (w) x 9.00 (h) x 0.90 (d)

Meet the Author

Elizabeth C. Britt is Assistant Professor in the Department of English at Northeastern University.

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Conceiving Normalcy

Rhetoric, Law, and the Double Binds of Infertility

By Elizabeth C. Britt

The University of Alabama Press

Copyright © 2001 the University of Alabama Press
All rights reserved.
ISBN: 978-0-8173-1098-1


Defining Infertility

Socrates: ... Well then, my dearest, what the subject is, about which we are to take counsel, has been said and defined, and now let us continue, keeping our attention fixed upon that definition. —Plato, Phaedrus

The Massachusetts mandate defines infertility as "the condition of a presumably healthy individual who is unable to conceive or produce conception during a period of one year." For members of RESOLVE, the advocacy organization for the infertile, defining infertility as a medical condition was fundamental to their goal of mandatory insurance coverage. It would not be adequate for a statute to specify a range of procedures that insurers were required to cover, as new techniques are constantly being developed and would require new legislation. Pinpointing the nature of infertility as a medical problem with medical solutions would compel insurers to cover all procedures as soon as they ceased to be considered experimental.

The advocates in RESOLVE also had other reasons for wanting to define infertility as a medical condition. Doing so, they hoped, would help reduce blame (usually directed toward women) and the associated stigma and would identify the condition as a serious one deserving serious professional attention. Locating the problem of infertility within the realm of medical science was therefore more than a strategic move designed to help pass the proposed legislation; it was also an opportunity to educate the public on the "real" nature of infertility.

This move, situated within the Platonic ontological tradition, sought to arrive at a fundamental truth (in this case, about infertility) that could serve as a foundation for further discussion (in this case, about the remedies that the law should provide). Once legislators understood what infertility is, the advocates reasoned, they would be more inclined to agree on how the problem should be treated. This philosophy guides RESOLVE's activities in a larger sense. With a stated mission of education, support, and advocacy, RESOLVE's goals are to help individuals to make decisions while changing perceptions of the situations and needs of this group.

Reaching consensus on terminology and definitions in this way is essential for technical normalization, which requires a common language by which all participants in the process can communicate (Ewald 151). Among physicians, common definitions and terminology allow for standards of observation, measurement, and intervention. They allow patients to be able to compare diagnoses and treatment regimens and to observe themselves, and they allow insurers to categorize claims consistently. Common definitions and terminologies also allow groups of individuals to communicate with other groups—physicians with patients, patients with insurers, insurers with physicians. They permit the routinization of practices and the creation of subsequent assumptions about standards of care. A woman diagnosed in the late 1990s with anovulation, for example, might have expected to be prescribed a drug to induce ovulation, a practice considered to be a contemporary standard in infertility care.

Privileging certain definitions requires ignoring or subordinating others. This chapter presupposes that a definition, as a social construction, is less about the true nature of the definition's object than it is about the context of its production. In other words, how a culture defines infertility says as much about that culture as it does about the condition itself. The Nayars of South India, for example, believe that infertility is a disruption in a divine energy that women possess in greater amounts than men. In this matrilineal society, both the infertile woman and her matrilineal kin are held responsible for her inability to conceive, and both take part in rituals designed to appease family fertility gods (Neff).

Among the Egyptian poor, infertility is sometimes attributed to "pollution" of a reproductively vulnerable woman (those who have been recently circumcised or married or who have recently given birth or had a miscarriage) by a liminal person, usually a woman. Women determined to have been polluted undergo rituals involving the sharing of bodily fluids, which are thought to reverse the pollution and thus the infertility (Inhorn 487). In America, middle- and upper-class women, who regard infertility as a medical problem, believe that they have a right to take medical risks to remedy infertility (Becker and Nachtigall, "Born").

In this chapter I provide a brief history of involuntary childlessness in America. I use the term "involuntary childlessness" to distinguish it from the condition as it has been medicalized (that is, "infertility"). I then outline the medical model of infertility treatment in contemporary America, showing through stories how the model is experienced by those defined as infertile. I end the chapter with a discussion of the role of RESOLVE in advocating for the infertile.

A Brief History of Involuntary Childlessness in America

The deeply ingrained ideology of the family has proven difficult to denaturalize because its demands and rhythms seem intimately connected with biology (Thorne 10). Like other social institutions, however, the American family that is today seen as natural (that is, a heterosexual married couple, with children, residing in an individualized space, and connected by love or mutual concern) is the product of a particular space and time.

To take one example, the anthropologist Bronislaw Malinowski advanced the theory that the family unit is universal, a theory that Collier, Rosaldo, and Yanagisako have refuted by describing cultures in which no language exists for defining parents and children, in which living arrangements are not organized around biological kinship, and in which no "loving sentiments" (35) are expected to bind those who are biologically related. They argue that the contemporary family unit is not a given but "rooted in a set of processes that link our intimate experiences and bonds to public politics" (41). In particular, the form of the modern industrialized state has helped to create the family unit as an intimate space (marked in the American family by the ideology of nurturance) in opposition to the public sphere (marked by the ideology of competition).

Two recent book-length histories of infertility and childlessness in America illustrate how ideas about the value of children in the family and the meanings of childlessness have shifted over the centuries. The Empty Cradle: Infertility in America from Colonial Times to the Present, by Margaret Marsh and Wanda Ronner, and Barren in the Promised Land: Childless Americans and the Pursuit of Happiness, by Elaine Tyler May, both dispel the popular notion that the inability to have children is a recent phenomenon and show that the experience has not remained constant. These histories suggest that the experience of childlessness cannot be separated from its historical, cultural, economic, and political contexts and that its medicalization, rather than being the inevitable outcome of scientific progress, is but one way of framing reproductive choices. A complete summary falls beyond the scope of this chapter or this book, but the following section highlights some of the key features of these accounts.

Both accounts argue that the meaning of childlessness in America has changed with the structure of the family. As the family unit became more privatized and focused on the marital couple, the value of biological children born to that couple increased. In colonial America, the family unit was the flexible and changing household, which might include children and stepchildren as well as related and unrelated dependents. The ideal household included many children, as they were needed to sustain the demands of a largely rural life. May notes that the average colonial woman had eight live births (and even more pregnancies, as they often ended in stillbirth or miscarriage) and lost at least one child in infancy (25). Households might gain even more children through remarriage, by taking in children of relatives after the death of one or both parents or by taking in apprentices to learn a trade.

Those who could not conceive probably attributed the fact to God's will and accordingly addressed the problem through prayer. While neither May nor Marsh and Ronner denies that colonists who were unable to have children felt loss, they agree that the nature of communal life made it relatively easy—and sometimes expected—to participate in the raising of other people's children. Like those with biological children, those without children participated in rearing and disciplining the offspring of other members of the community, took in the orphans of relatives, received children as apprentices, and "adopted" children of living relatives without the biological parents' completely giving them up (Marsh and Ronner 17).

Beginning near the end of the eighteenth century, when the family came more and more to be defined as nuclear and separate from the community, the absence of biological children was felt more acutely. As Manifest Destiny compelled the people of the new republic to expand westward, "men were the builders of the nation, women the vessels of propagation, and children the hope of the future" (May 37). As this expansion occurred, the household ceased to be the center of the economy. Men, going out to the commercial centers, created an apparent distinction between the "public" world of business and government and the "private" world of the home.

The new ideology of domesticity positioned women—especially middle-class, white, nonimmigrant women—as contributing to the new republic through their roles as guardians of the home and moral educators of their children. Children, no longer valued primarily for their labor in the middle-class household, became objects of attention and devotion as their parents strove to mold them into good citizens. Among the immigrant poor, children both were needed to contribute to income and sometimes became a financial burden. Parents determined to be "unworthy" (especially those who were immigrants or poor) were encouraged to give up their children so that others could raise them "properly" (May 42). As children's value as individuals increased, as Victorian ideas about sex encouraged restraint, and as slavery (and white interest in black fertility) ended, overall fertility rates dropped (especially among the white urban middle class) from an average of seven children per couple in 1800 to three or four children in 1900 (May 44, 57).

Several factors—the increased privatization of the family, the contradictory messages of Manifest Destiny both to populate the republic and to nurture each of its new citizens individually, the limitation of women's roles accompanying the ideology of domesticity, and the introduction of adoption laws beginning at midcentury—contributed to the discomfort felt by nineteenth-century Americans, especially women, who were unable to have children. While significant numbers of Americans chose to remain both single and childless (May 48), and while evidence suggests a good number of nonlegalized adoptions (Marsh and Ronner 104), married couples who wanted children but could not have them enjoyed fewer social options for bringing children into their lives.

At the same time, medical activity designed to alleviate childlessness increased in the nineteenth century. While in the colonial period the inability to reproduce was seen as reflecting God's will, infertility during the nineteenth century came to be seen more and more as a disease. As the century wore on, women continued to rely on prayer and self- help (for example, by taking herbs and tonics, changing diet or exercise, or applying compresses) but increasingly sought out physicians.

Middle-class white women—who were increasingly resorting to abortion and contraception as they made greater forays into the world beyond the home—were widely understood to be weaker and in poorer health than their mothers and grandmothers, a "fact" that boded ill for their ability to have as many children as, or more children than, their immigrant sisters (Marsh and Ronner 31). In the first half of the century, physicians, uncredentialed healers, and social commentators alike often advised women to improve their general health through devotion to the private sphere, for the sake of their own reproductive capacities as well as for the sake of the nation. In the last decades of the nineteenth century, however, new medical instruments—including the speculum—made it possible for physicians both to observe and to alter women's reproductive systems to address what was now being called "sterility" (Marsh and Ronner 42). Surgeons made cervical incisions and repositioned the uterus in order to correct malformations. Ovariotomy—removal of the ovaries—became a standard gynecological procedure for addressing a range of conditions, not only reproductive problems. Surgeons, believing that a woman's entire physical, mental, and emotional health depended on her reproductive system, removed women's ovaries in order to cure supposed disorders such as hysteria and nymphomania; thousands of women underwent such unnecessary procedures before the turn of the century (Marsh and Ronner 83). By the end of the century, however, at least some gynecologists began to question whether sterility was related to women's willingness to assume traditional roles. These physicians focused their attention instead on the reproductive organs themselves, especially the ovaries and the fallopian tubes. More conservative doctors advocated less invasive surgeries that left the reproductive organs essentially intact but that removed pelvic adhesions or ovarian cysts or that opened the fallopian tubes (Marsh and Ronner 96).

At the same time, investigations into the possible role of gonorrhea, which was thought to be curable but would not in fact be so until penicillin was introduced in the 1940s, revealed that husbands were bringing home the disease after having sex with prostitutes. While the husbands might be asymptomatic, the disease often rendered their wives sterile. These investigations brought with them an attention to the related issue of male sterility. Physicians were discovering that the husbands of "sterile" wives often had no sperm, a diagnosis that was attributed to causes ranging from disease to masturbation. While some men followed advice to undergo surgery, take tonics, or exercise, physicians assumed that some cases could not be cured. The practice of inseminating a woman with the sperm of a donor occurred but with unknown frequency (Marsh and Ronner 94).

In the early twentieth century, surgery continued to be a preferred method of treating sterility, although with little success, but the emerging science of reproductive endocrinology eventually changed the approach in ways that are still evident today. The discovery of estrogen in the 1920s, which led to both the birth control pill and contemporary hormonal therapies, created a role for scientists and pharmacologists in the newly emerging discipline. Marsh and Ronner characterize the 1920s through the 1940s as a time of rapid changes as a collective of physicians, scientists, pharmaceutical companies, and others, well funded by research institutes, sought to understand the nature of female reproduction and to create synthetic hormones (Marsh and Ronner 139). Physicians, eager to put the new scientific knowledge into practice even without firm evidence about either the efficacy or the possible dangers of hormones, argued that the increase in voluntary childlessness (which according to some historians reflected economic pressures from the Great Depression more than an inherent desire not to have children) made it all the more important to help those who did want to have children (Marsh and Ronner 143).

While treatment in the first part of the century was generally limited to urban centers and was not seen as hopeful, the introduction of hormonal therapies and nonsurgical means of diagnosing and treating blocked fallopian tubes (including the hysterosalpingogram) led to new confidence and a surge of information in the popular press. Nevertheless, success rates remained very low. By the late 1930s, the inability to have children had come to be understood as a condition that resulted from problems associated with both the man and the woman, a condition that demanded treatment through a series of diagnostic tests and planned interventions. The ideal diagnostic regimen included tests to determine the shape, quantity, and motility of sperm as well as the condition of the fallopian tubes. Some physicians began asking their female patients to take their temperatures daily and to record them on charts as a way to determine when ovulation was occurring. In short, physicians were coming to believe not that one partner was absolutely "sterile" but that the couple was "infertile" (Marsh and Ronner 152).


Excerpted from Conceiving Normalcy by Elizabeth C. Britt. Copyright © 2001 the University of Alabama Press. Excerpted by permission of The University of Alabama Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents


Introduction: Pursuing Normalcy,
1. Defining Infertility,
2. Insuring (In)Fertility,
3. Success and Failure,
4. Order and Discontinuity,
5. Control and Constraint,
Epilogue: The Cultural Work of the Double Bind,
Appendix A: Text of the Massachusetts Infertility Insurance Mandate,
Appendix B: Legislative Information,
Appendix C: Research Methods,
Appendix D: Interview Participants,
Works Cited,

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