Changing Global Fertilities: a third demographic transition?
More than 30 years of ethnographic research on IVF has demonstrated two contrasting worldwide trends. One is the enormous variation in the governance and regulation of assisted reproductive technologies (ARTs), including striking divergences between otherwise similar adjacent countries, such as Norway and Sweden, or Canada and the USA (Mohr in press, Thompson in press). Dramatic policy zig-zags within a single country are also common (as in Italy, Bonacorrso 2009), as are bold U-turns, for example in the cases of Turkey (Gurtin in press, Goknar 2015) and Germany (see Hermann 2009). This highly varied pattern of regulation and ethical governance contrasts with the equally striking consistency of people’s reasons for choosing to pursue technologies like IVF or PGD, and their descriptions of their experiences of doing so, which reveal remarkably constant and predictable patterns across the globe and over time (Franklin and Inhorn, in press). As the ethnographic literature has vividly shown time and again, the ethical governance of assisted conception is often defined by powerful religious forces mixed with complex symbolic expressions of national aspiration (Inhorn and Tremayne 2012, Roberts 2012 and in press). Indeed it is the well-worn utility of reproduction, gender and technology as powerful symbolic idioms for nation, religion and ethnicity that largely accounts for the enormous variety in cultural framings of ART regulation (Jasanoff 2005). Government policy on reproduction in many countries functions as a kind of dog-whistle political siren call, expressing an apparent meaning on the surface that conceals a more subtly coded message for specific audiences of listeners, who hear and interpret a specific enactment or prohibition as confirmation of underlying political allegiances or loyalties. The highly symbolic role of ARTs as markers of modernity, tests of religious conviction, or proofs national scientific achievement all but guarantees that legislation in this area is never simply (or even primarily) practical or administrative. It is for these same reasons that national debates about ARTs are highly emotionally charged, frequently linked to a sense of moral crisis, and often the source of severe social conflict (Petchesky 1987) – although also potentially of enduring consensus (Mulkay 1997). Tellingly, neither the consensual outcomes of national debate over ARTs, nor the social divisions and tensions that they inevitably reveal, map neatly onto traditional political parties, religious affiliations, or parliamentary procedures -- or even conventional definitions of politics, religion or morality.
Ethnographic scholarship on IVF and other ARTs has long been attuned to precisely these sorts of complexities (for an overview see Inhorn and Birenbaum-Carmeli 2008). As Susan Kahn memorably demonstrated in her influential ethnographic study Reproducing Jews (2000), an entire portrait of Israeli society could be drawn from the highly complex and multiply stratified process of ethically monitoring IVF embryos in a single lab (see also Birnbaum-Carmeli in press). Marilyn Strathern’s elegant analyses of English kinship and British society have for many years made deft use of debates over surrogacy, egg donation, and the Human Fertilization and Embryology Act to illustrate a distinct set of changes to the very idea of national belonging (1992a & b, 2005, and see Franklin 1997), while Marcia Inhorn’s research on assisted conception in Dubai similarly demonstrates how a changing sense of Emerati identity can clearly be traced through its recent turn away from a cosmopolitian medical model to prioritising the fertility needs of its indigenous population (Inhorn, 2015 and in press).
At the conference we organised together at Yale last year entitled ‘IVF: Global Histories’ Marcia Inhorn and I were joined by 14 ethnographers from around the world researching IVF and ARTs from Mali and Thailand to Mexico and Sri Lanka. Comparing case studies from a range of countries in the Middle East, Europe, Central and South America, as well as India and China, led us to experiment with the term ‘repronationalism’ to describe how each country uses reproductive policy to shape its national identity, while similarly expressing its national identity through its reproductive policy. China’s one-child policy, for instance, expresses both a practical national concern about population, the food supply and economic growth, but also a more complex message about the extent to which government can legitimately control the behaviour of its subjects (Wahlberg in press). The recent change in this policy is equally multi-faceted: on the one hand it signifies a more relaxed approach to population size, but beneath this confident general message is a more subtle suggestion concerning China’s relationship to human rights and its role on the international political stage.
Based on her comprehensive and pioneering early studies of assisted conception in Denmark in the 1990s, the anthropologist Tine Tjørnhøj-Thomsen (1999a and b)described assisted conception technologies not only as symbols of national values, but as ‘technologies of social belonging’ and indeed as forms of ‘social contract’. This fascinating argument, which proposes that the social and political organisation of fertility services is never purely administrative, but always expresses additional meanings about whose reproduction is valued and how, implicitly suggests that ART global histories should be understood in terms of how they make citizens and define social norms, as well as how they make parents and miracle babies. The case of Denmark is interesting because although it is a small, progressive and wealthy Scandinavian country, which initially followed a relatively progressive path of lightly-regulated ART provision in the 1980s, it reversed many of its liberal policies in the 1990s under a more conservative government. It later resumed a more inclusive practice of ART provision following an economic assessment that confirmed the cost to the nation of the ‘lost’ ART babies not being born as a result of tighter restrictions on access to fertility services (Mohr in press). With over 6% of Denmark’s population now being born through ARTs, this repronational strategy takes on ever greater significance as a model of changing global fertilities in the future.
Denmark’s zig-zagging path toward more mainstreamingof ARTs is not atypical – even in countries with historically conservative policies. Germany has always regulated IVF in a manner that is deliberately intended to convey a strong and highly visible message about the nation’s commitment to the principle of human dignity. The German ban on embryo storage and freezing expresses a commitment to historical memory as well as the doctrines of the Catholic Church, and is accompanied by tight restrictions on the number of embryos that can be produced during IVF treatment (3) and the requirement that all embryos, even non-viable ones, are transferred back into the uterus. However, in 2011 Germany famously reversed this longstanding embryo protection policy in order to allow couples at risk of giving birth to offspring with severe genetic disease to undergo preimplantation genetic diagnosis – a procedure that involves both manipulating and potentially discarding viable human embryos. Again, this legislative change was both pragmatic and expressive: it brought relief to German couples who would otherwise have had to travel outside Germany to seek treatment, but it also articulated a more nuanced interpretation of ‘human dignity’ and an altered relationship to the painful national memories linked to the national eugenic programme implemented under the Nazi racial hygiene policies.
Against the backdrop of these contrasting cases of highly varied, inconsistent and changeable national ART policies are the consistent ethnographic findings of strikingly similar emotions, motivations and experiences described by patients and couples seeking and undergoing fertility services – seemingly no matter which country they are from. Whereas the differences in national regulatory policy concerning IVF in the UK and Germany could hardly be more different either practically or symbolically, the words used by individuals and couples attending fertility fairs in both countries would likely be almost identical if they were not in different languages. Indeed it was precisely the similarity of the feelings and experiences described by German couples seeking PGD to their European neighbours that eventually led the German Parliament to conclude that subjecting their citizens to such a harshly prohibitive legal system was unsupportable. Just like parents at risk of passing on terminal genetic pathology to their children in London, Manchester or New York, German couples who tested positive for Tay Sachs, Lesch-Nyan syndrome or Spinal Muscular Atrophy in Berlin, Frankfurt and Munich were most likely to describe their desire for treatment in terms of a deeply felt moral obligation to prevent harm, and a profound reluctance to initiate a pregnancy that had no chance of producing viable offspring.
As governments around the world continue to wrestle with the moral, ethical and religious issues at stake in the regulation of ARTs, and as an increasing range of distinctive repronational strategies emerge out of these struggles, another set of questions arises in the context of what might be called the demotechnics – or demographic management -- of the population question in the twenty-first century. In a US study published in 2008 (Connolly et al), the medical cost of producing one IVF baby was calculated to generate a 700% net return to the US government, deriving from that individual’s lifetime contribution to the economy. This new calculation of the economic effect of ARTs on national economies exemplifies an emergent demo-technical apparatus of planning that we could compare to Foucault’s model of biopolitics, except that it in many crucial respects it is rather different. Whereas Foucault investigated the means by which individuals internalise the disciplining forces of modern social control, today’s fertility assistance seekers are largely seeking to have children for reasons that are neither quintessentially modern, nor particularly closely linked to the ‘disciplining’ powers of the nation state. The desire for children is made up of many things: a desire for social belonging, the wish to emulate a peer group, a sense of obligation to others, as well as an individual need to achieve an adult identity or fulfil a gender role. People want to have children to make their partners, spouses, or parents happy, and some feel they cannot be complete without children of their own. Whatever we may call these commonly expressed desires to become parents, they are neither particularly new nor do they appear to be the product of modern power knowledge or the nation state.
Becoming a parent has rapidly become much more diverse over the past two decades. Probably one of the most visible and surprising forms of social change in the early twenty-first century has been the speed with which attitudes toward gay and lesbian parenthood have changed globally. Jasbir Puar (2007) coined the useful phrase ‘homonationalism’ to describe the new phenomenon whereby nations now compete to claim pride in their progressive policies toward gay marriage and gay parenthood, which have become for many nations not only markers of political emancipation but symbols of advanced national consciousness, sophistication and modernity. This too is a new ‘demotechnical’ phenomenon to the extent that is represents a very distinctive form of representing, managing and calculating the nation’s population and its fertility.
The first so-called demographic transition associated with the eighteenth and nineteenth centuries in Europe has long been understood to have involved a cyclical response to declining infant mortality and longer projected lifespan (Davis 1945, Notestein 1945, Thompson 1929). The security engendered by this shift is argued to have enabled people to plan their families more deliberately, opting to have fewer children, in whom they could invest greater resources, and thus reducing the rate of population increase. Demographic transition theory has proven a popular (although contested, see Sretzer 1993) model with which to analyse population changes, such as decreasing family size over time, and it is often used to explain changes in terms of a presumed intensification of the positive relationship between fertility and planning. A second demographic transition is associated with the latter end of the twentieth century, which saw an increasing diversity of family forms resulting from higher rates of divorce, increased access to abortion and birth control, less stigma attached to single motherhood and children born to unwed couples, and higher visibility of these ‘alternative’ family forms alongside further declines in fertility. As the ethnographic literature on IVF and ARTs around the world increasingly suggests, a third demographic transition may now be underway. In this new cycle, the increasing diversity of family forms is accompanied by a larger proportion of parents both imagining and enacting their parental aspirations not only in terms of planning, but in terms of technological planning. As before, this turn to technology is changing how people understand fertility, parenthood, reproduction and family. It is also changing our perception of ‘planning’ and its relationship to fertility, as the relationship between technology, planning and fertility becomes both more prominent and more ambiguous simultaneously. Elsewhere I have described IVF as the epitome of this process, and increasing ambivalence about the ability of technology to make fertility planning easier as one of its results (Franklin 2013). We can see, for example in the context of the current egg freezing debate, that neither forward planning nor technological assistance necessarily make fertility decisions easier (see www.time-less.org). At the same time, governments must make complex choices about how to plan fertility care for their populations, especially as the most highly educated women in many of the world’s wealthiest societies contribute an ever smaller share of the total birth-rate. Characterising the third demographictransition will require traditional demographic skills alongside the kind of rich, small-scale qualitative description ethnography is best at providing. As fewer of the old models, presumed correlations or past correlations seem to apply to the mixed bag of baby-making strategies occurring in the context of rapidly changing family forms, increased global fertility services, ever newer reproductive technologies, and more visibility for all of these through the Internet and social media, Susan Greenhalgh’s call more than 20 years ago for a more nuanced approach to ‘situating fertility’ in order to explain falling birthrates seems increasingly apt (1995). This call is complemented by Alison Bashford’s persuasive recent deconstruction of the ‘population problem’ in which she demonstrates the global politics that defined responses even to seemingly local, regional and national programmes of reproductive planning throughout the twentieth century (Bashford 2014). In our newly globalised, virtualised and personalised world of ‘iVF’ as I have called it (Franklin 2013), both the means and the motivations for having children are significantly affected by a combination of new technologies, and premodern conventions that are reshaping parenting and kinship in ways that have not yet been adequately charted. The dual task of capturing the local-global dynamics of increasing use of ARTs, and translating these findings into more generalisable models of global fertility change, is one of the most exciting challenges facing ReproSoc and other similar research groups around the globe. It is also a challenge that is more likely to draw on longstanding feminist concerns with the politics of reproduction, technologies of gender, kinship and the family, the ongoing influence of patriarchy, and the sexual division of labour than on Foucault or biopolitics. It is a challenge that has the potential to release the powerful synergies between small scale, highly qualitative ethnographic research and more accurate quantitative modelling. And last but not least it is a challenge that returns us to some of the oldest and foundational questions of social science.
List of References
Bashford, Alison (2014) Global Population: History, Geopolitics and Life on Earth New York: Columbia University Press
Bharadwaj, Adi (in press) ‘The Indian IVF Saga: A Contested History’ Reproductive Biomedicine and Society Special Symposium on ‘IVF Global Histories’ co-edited by Sarah Franklin and Marcia Inhorn, Volume 2, Issue 1, forthcoming 2016
Birenbaum-Carmeli (in press) ‘Thirty years of ART in Israel’ Reproductive Biomedicine and Society Special Symposium on ‘IVF Global Histories’ co-edited by Sarah Franklin and Marcia Inhorn, Volume 2, Issue 1, forthcoming 2016
Bonacorrso, Monica M. E. (2009) Conceiving Kinship: Assisted Conception, Procreation and Family in Southern Europe New York and Oxford: Berghahn Books
Connolly, Mark P., Pollard, Micahel S., Hoorens, Stijn, Kaplan, Brian, Oskowitz, Selwyn and Silber, Sherman (2008) ‘Long-term Economic benefits Attributed to IVF-Conceived Children: a Lifetime Tax Calculation’ The American Journal of Managed Care 14:9:598-604
Davis, Kingsley (1945) ‘The World Demographic Transition’ Annals of the American Academy of Political and Social Science 237:1-11
Franklin Sarah (1997) Embodied Progress: A Cultural Account of Assisted Conception London and New York: Routledge
Franklin Sarah (2013) Biological Relatives: IVF, Stem Cells, and the Future of KinshipDurham, NC: Duke University Press
Franklin, Sarah and Inhorn, Marcia (in press) ‘IVF: Global Histories’ Reproductive Biomedicine and Society Special Symposium on ‘IVF Global Histories’ co-edited by Sarah Franklin and Marcia Inhorn, Volume 2, Issue 1, forthcoming 2016
Gerrits, Trudi (in press) ‘ARTs in Ghana: Transnational Undertakings, Local Practices, and More Affordable IVF’ Reproductive Biomedicine and Society Special Symposium on ‘IVF Global Histories’ co-edited by Sarah Franklin and Marcia Inhorn, Volume 2, Issue 1, forthcoming 2016
Goknar, Merve (2015) Achieving Procreation: Childlessness and IVF in Turkey Oxford and New York: Berghahn
Gonzales-Santos, Sandra (in press) ‘From Esterilogia to Reproductive Biology: the Development of IVF in Mexico’ Reproductive Biomedicine and Society Special Symposium on ‘IVF Global Histories’ co-edited by Sarah Franklin and Marcia Inhorn, Volume 2, Issue 1, forthcoming 2016
Greenhalgh, Susan, ed. (1995) Situating Fertility: Anthropology and Demographic InquiryCambridge: Cambridge University Press
Gurtin, Zeynep (in press) ‘Patriarchal Pronatalism: Islam, Secularlism and the Conjugal Confines of Turkey’s IVF Boom’ Reproductive Biomedicine and Society Special Symposium on ‘IVF Global Histories’ co-edited by Sarah Franklin and Marcia Inhorn, Volume 2, Issue 1, forthcoming 2016
Herrmann, Sven L., 2009. Policy Debates on Reprogenetics: The Problematization of New Research in Great Britain and Germany. Campus, Frankfurt am Main & New York
Horbst, Viola (in press) ‘”You cannot do IVF in Africa as in Europe": IVF in Mali and Uganda’ Reproductive Biomedicine and Society Special Symposium on ‘IVF Global Histories’ co-edited by Sarah Franklin and Marcia Inhorn, Volume 2Inhorn, Mohr, , Issue 1, forthcoming 2016
Jasanoff, Sheila (2005) Designs on Nature. Science and Democracy in Europe and the United States Princeton: Princeton University Press
Inhorn, Marcia (in press) ‘Cosmopolitan Conceptions in Global Dubai: the Emiratization of IVF and its Consequences?’ Reproductive Biomedicine and Society Special Symposium on ‘IVF Global Histories’ co-edited by Sarah Franklin and Marcia Inhorn, Volume 2, Issue 1, forthcoming 2016
Inhorn Marcia (2015) Cosmopolitan Conceptions: IVF Sojourns in Global Dubai. Durham, NC: Duke University Press.
Inhorn Marcia and Birenbaum-Carmeli, Daphna (2008) Assisted reproductive technologies and culture change. Annual Review of Anthropology 37 (2008):177-196.
Inhorn Marcia, and Tremayne, Soraya, eds. (2012) Islam and Assisted Reproductive Technologies: Sunni and Shia Perspectives Oxford and New York: Berghahn.
Mohr, Sebastian (in press) ‘Transforming social contracts: the social and cultural history of IVF in Denmark’ Reproductive Biomedicine and Society Special Symposium on ‘IVF Global Histories’ co-edited by Sarah Franklin and Marcia Inhorn, Volume 2, Issue 1, forthcoming 2016
Mulkay, Michael (1997) The Embryo Research Debate: Science and the Politics of Reproduction. Cambridge: Cambridge University Press
Notestein, Frank W (1945) ‘Population – The Long View’ in Theodore W. Schultz (ed.) Food for the World, Chicago: University of Chicago Press, pp. 36-57.
Puar, Jasbir (2007) Terrorist Assemblages: Homonationalism in Queer Times Durham, NC: Duke University Press
Roberts, Elizabeth (2012) God’s Laboratory: Assisted Reproduction in the Andes Berkeley: University of California Press
Roberts, Elizabeth (in press) ‘Resources and Race: Assisted Reproduction in Ecuador’Reproductive Biomedicine and Society Special Symposium on ‘IVF Global Histories’ co-edited by Sarah Franklin and Marcia Inhorn, Volume 2, Issue 1, forthcoming 2016
Simpson, Bob (2016) ‘IVF in Sri Lanka: a Concise History of Regulatory Impasse’
Sretzer, Simon (1993) ‘The Idea of Demographic Transition and the Study of fertility Change: a Critical Intellectual History’ Population and Development Review 19:4:659-701
Strathern Marilyn (1992a) Reproducing the Future: Anthropology, Kinship, and the New Reproductive Technologies. London and New York: Routledge.
Strathern, Marilyn (1992b) After Nature: English Kinship in the Late-Twentieth CenturyCambridge: Univerity of Cambridge press
Strathern, Marilyn 2005) Kinship, Law and the Unexpected: Relatives are Always a Surprise Cambridge University Press, Cambridge.
Tremayne, Soraya (in press) ‘Conceiving IVF in Iran’ Reproductive Biomedicine and SocietySpecial Symposium on ‘IVF Global Histories’ co-edited by Sarah Franklin and Marcia Inhorn, Volume 2, Issue 1, forthcoming 2016
Thompson, Charis (in press) ‘IVF Global histories, USA’ Reproductive Biomedicine and Society Special Symposium on ‘IVF Global Histories’ co-edited by Sarah Franklin and Marcia Inhorn, Volume 2, Issue 1, forthcoming 2016
Thompson, Warren S. (1929) ‘Population’ American Journal of Sociology 34:6:959-975
Tjørnhøj-Thomsen,Tine (1999a) ‘”Det føles ikke-mandigt på en måde": mænd og infertilitet’ Kvinder, Køn og Forskning :71-89
Tjørnhøj-Thomsen,Tine (1999b) Tilblivelseshistorier. Barnløshed, slægtskab og forplantningsteknologi i Danmark København, Insitut for Antropologi, Københavns Universitet
Wahlberg, Ayo (in press) ‘The Birth and Routinisation of IVF in China’ Reproductive Biomedicine and Society Special Symposium on ‘IVF Global Histories’ co-edited by Sarah Franklin and Marcia Inhorn, Volume 2, Issue 1, forthcoming 2016
Whittaker A (2015) Thai In Vitro: Gender, Culture, and Assisted Reproduction Oxford and New York: Berghahn.