Constructions of “Infertility” and Some Lived Experiences of Involuntary Childlessness

Abstract

This article draws on data from a feminist, qualitative social work research project on women’s experiences of involuntary childlessness in the context of assisted reproduction. It argues that the dominant construction of “infertility” is partial, biased, and inaccurate and that it serves to maintain infertility as a “woman’s problem” to be addressed ideally via biomedicine and individualized approaches to the delivery of services. With reference to the background literature, women’s lived experiences of involuntary childlessness are explored. An alternative, multidimensional construction of involuntary childlessness is proposed and implications for social work in reproductive health and directions for further research are presented.

This article presents some of the findings from a larger qualitative research project on women’s experiences of and need for support in relation to assisted reproduction. Specifically, it explores the lived experiences of 28 Australian women in relation to “infertility” and proposes an alternative, more inclusive, and arguably more accurate construction of “involuntary childlessness.” In this article, I argue that the dominant construction of infertility comes from a typically biomedical perspective, rather than from a biopsychosocial, human rights perspective. Using a phenomenological, feminist, grounded theory approach, I explore the experiential knowledge of women who have used reproductive technology to attempt to redress infertility in order to construct an alternative view and to recognize their epistemic agency. The implications of this alternative construction for social work practice in this field are discussed along with directions for further research. Before the participants’ lived experiences of involuntary childlessness are explored, a brief, contextual review of the literature is presented to indicate some of the dominant constructions and some competing constructions of infertility.

Review of the Literature

Many people who experience “infertility” choose to use reproductive technology in the hope of achieving a successful pregnancy culminating in the birth of a child. Since the first successful “IVF (in vitro fertilization) baby” was born in the United Kingdom in 1978, the use of assisted reproduction has increased around the world (Hammons, 2008). Reproductive technology presents a range of possibilities for people with fertility challenges, but it also raises a wide range of complex concerns about health, well-being, social justice, and human rights (Moss, 1988).

Worldwide, social workers and other human service professionals often provide psychosocial support in this field of reproductive health practice (Alzate, 2009; Bell, 2012a). The dominant discourse in assisted reproduction is biomedical, and infertility is typically constructed within this dominant paradigm (Seguin, 2001). There is a need to use careful, accurate terminology when referring to people who are involuntarily childless; not all involuntarily childless people are infertile, and fertility appears to be a continuum, rather than a fixed, definitive state. The definition of infertility has indeed been contested. The definition that is most often used by the general public and by service providers of assisted reproduction services constructs infertility as the inability to achieve a pregnancy over a 1-year period via sexual intercourse despite regular attempts (Daniluk, 2001; Van Horn & Reed, 2001).

According to the World Health Organization (WHO, 2012; see also Gaard, 2010), definitions of medical infertility typically use a 1-year baseline, and infertility is often regarded as “a predominantly female disorder” even though half the “infertile couples” fail to reproduce because of problems with men’s fertility. However, the literature indicates that a 2- to 3-year period is a more accurate time frame. For example, Palmer (2004) stated that most people (85%) naturally achieve a pregnancy via sexual intercourse after 1 year and 94% do so after 2 years, with the overall average “trying time” being 4 months. The Australian Reproductive Technologies Review Committee (ARTRC, 2006, p. 23) found that after 3 years of unassisted attempts, only 5% of people remain involuntarily childless. WHO prefers a 2-year baseline because it is more accurate than the usual 1-year baseline definition in most cases.

Estimates vary somewhat as to the etiology of infertility, with male factor–only infertility accounting for 40–50% of situations, according to some sources (Research Centre for Reproductive Health [RCRH], 2007; Van Horn & Reed, 2001; WHO, 2012). Other sources (e.g., ARTRC, 2006, p. 24; Wang, Macaldowie, Chambers, & Sullivan, 2011) reported a more conservative estimate of male factor–only infertility at 30% of all cases, with female factor–only infertility accounting for 37% of all cases, combined factors accounting for 20–25% of all cases, and unexplained infertility accounting for 5–15% of all cases. Yet in most cultures worldwide, infertility is viewed as predominantly a “woman’s problem” (WHO, 2012; see also Dyer, Abrahams, Mokoena, & Van Der Spuy, 2004; Inhorn, 2003). This cultural attribution is also reflected in the realm of assisted reproduction in which the “patient” is the woman, regardless of the etiology of the infertility.

This focus on female fertility obscures the existence and impacts of male factor–only infertility. The bias is curious, given the relatively even incidence of diagnosed female-only and male-only infertility. Indeed, the RCRH (2007, p. 14) described a “growing concern” with the increase in male factor–only infertility and expressed alarm that in 60% of the cases, conventional diagnostic measures often fail to assess and diagnose male-factor problems adequately. Thus, the data on infertility do not support a gender-biased definition as the one that is commonly used and indicate the need for a broader, more accurate, and gender-inclusive definition of infertility.

Regardless of how infertility is defined and whatever the underlying assumptions of the definition are, there is a consensus in the literature that infertility is stigmatizing (Blyth & Moore, 2001) and that it is one of the most distressing life crises for most people who experience it (Fekkes et al., 2003; Kirkman & Rosenthal, 1999; Koonin & Napier, 2000; WHO, 2012). The inability to bear a child when that is the preference represents for most families an “intergenerational developmental crisis affecting extended family members and family relationships” (Hammer-Burns, 1999, p. 97). Campagne (2006, p. 1651) advocated for early and concurrent psychosocial support during the use of assisted reproduction services. Lechner, Bolman, and Van Dalen (2007, p. 288) also advocated for ongoing psychosocial support and referred to the “complicated grief” brought about by infertility. Several other studies have also identified the need for similar support because of the social exclusion that people with fertility issues, guilt, stress, and relationship tension of infertility often experience (Baker, 2003; Bell, 2012a; Verhaak, Smeenk, Nahuis, Kremer, & Braat, 2007; Wirtberg, Moller, Hogstrom, Tronstad, & Lalos, 2007).

Baker (2003) discussed the social exclusion, guilt, and relationship tension that those who are affected by infertility often feel. Schmidt, Christensen, and Holstein (2005, p. 1050) also argued that women are more likely to be constantly confronted by involuntary childlessness and that men have more “pain-free zones” at their disposal. Roach-Anleu (1999, p. 203) also discussed men’s and women’s patterns of coping with infertility. She argued that men perceive infertility as “disappointing but not devastating,” in comparison with women “so long as it remains assumed that the cause of the problem is the female partner.” Toward this end, she also said that women sometimes adopt a “courtesy stigma” to protect their male partners when the partners have been diagnosed as infertile. Furthermore, Roach-Anleu argued, infertility is regarded as a deviation from social norms and that the stigma attached to this deviation is particularly potent for women who are much more bound by societal expectations with regard to family and motherhood.

In summary, the literature indicates that the dominant construction of infertility is still predominantly biomedical in perspective and still predominantly seen as a woman’s problem. An alternative, inclusive perspective is that infertility, or involuntary childlessness, can be seen from a biopsychosocial perspective as a human issue that affects people in multidimensional ways: at the individual (micro) level, at the family and local community (mezzo) level, and at the societal (macro) level. Persuasive sources (e.g., WHO, 2012) have also recommended that in the absence of obvious, diagnosable medical conditions, the normal time frame for attempting to become pregnant should generally be extended from 1 year to 2 or 3 years before couples resort to diagnostic investigations to determine the causes of infertility and interventions, such as assisted reproduction.

The Study

Method

Using data from a larger (doctoral) qualitative research project exploring women’s experiences of and need for psychosocial support in relation to the use of assisted reproduction services, this article explores the participants’ experiences of involuntary childlessness using a phenomenological, feminist, grounded theory approach. Seeking women’s experiential knowledge of infertility contributes to an alternative, validating construction of involuntary childlessness and in recognizing women’s self-determination and epistemic agency.

Recruitment

The participants were recruited via newspaper advertisements and notices at health services and on community notice boards at several locations. The most successful method of recruitment was newspaper advertisements, with 73% of the participants recruited in this way and 27% recruited via notice boards at health services and community centers. The eligibility criteria for participation included past or present use of Australian-assisted reproduction services. Twenty-eight Australian women volunteered to participate in individual in-depth interviews about their experiences and need for support in relation to the use of assisted reproduction services. The research was conducted with the approval of the university’s Ethics in Human Research Committee. Before each interview, the participants received an information sheet about the project and signed a consent form.

Data Gathering, Storage, and Analysis

Of the 28 women, 27 chose to be interviewed in their own homes, and 1 chose to be interviewed at her workplace. Most interviews were 90 min in duration, with a range of 65–130 min. A semistructured interview schedule was used and contained key words and prompts to maintain the focus of the research interview and yet encourage the participants to be as self-directed as possible in what to disclose to me (the researcher). Key words and prompts from the interview schedule that were relevant to involuntary childlessness included the “nature of involvement with assisted reproduction,” “stages of assisted reproduction,” “preparation of self/partner,” “benefits/costs,” and “recommendations to others.”

The interviews were digitally recorded and later transcribed into text documents. Each participant was given a pseudonym to preserve her anonymity. I thematically coded the transcripts and developed 30 analytic codes from the 80 tentative thematic codes (Denzin & Lincoln, 2000). The transcripts and analytic codes were uploaded into a qualitative data management system (Richards, 2005; NVivo 7) to assist me in organizing the data for analysis. The analytic code “experiences of infertility” is the focus of this article.

Limitations

The participants’ experiential knowledge is not presented as a universal truth or as necessarily generalizable; given the number of participants and the methodology, there was no intention to seek a representative sample. However, the data provide in-depth, phenomenological information directly from those with lived experience of involuntary childlessness. This information helps to build a richer understanding of involuntary childlessness and is a validation of the women’s epistemic agency. As Kirkman and Rosenthal (1999) and Gaard (2010) noted, women’s knowledge deserves attention and greater epistemological value in the discourse on infertility.

The interviews were in depth, and the participants were given opportunities to contact me to provide follow-up information and to comment on the initial data analysis; however, most of the data came from the interviews. Data obtained from a series of interviews with opportunities for reflection in between could arguably have been even richer.

The participants all identified as heterosexual and were homogeneous in terms of ethnicity, and all identified as Anglo-Celtic in ethnic origin. Thus, experiential knowledge from same-sex couples, culturally diverse people, sole parents, and men was not obtained. This was a clear limitation of this project, and I acknowledge that information from a wider range of sources would have contributed to an even broader construction of involuntary childlessness and would therefore be a fruitful area for future research.

Most participants at the time of the interviews had resolved their involuntary childlessness either by assisted or unassisted conception and childbirth or via substitute care of children (adoption or foster care). Thus, the views of women who experienced ongoing, unresolved involuntary childlessness are underrepresented. This underrepresentation does not diminish the usefulness of the findings from the participants, since involuntary childlessness is not a fixed state. However, additional research using the purposive recruitment of participants is needed to explore ongoing involuntary childlessness fully.

Findings and Discussion

Participants’ Pathways to Involuntary Childlessness

Most of the participants (approximately 80%) were not aware of any fertility issues before they attempted to become pregnant, although a few (approximately 20%) were aware that conception might be difficult to achieve because of previous gynecological issues or their partners’ known fertility issues. Nearly one third of the participants tried for natural conception for approximately 2 years before they sought further medical assessment. A little under one third tried for 12–18 months, and approximately 10% tried for 3–5 years. Some participants did not definitively state how long they had tried for natural conception before they sought medical help.

All the women initially consulted their usual family doctors, and those who commented on this experience reported a range of initial recommendations varying from “wait another year” to being told that in vitro fertilization (IVF) was “the only way to go.” Some women were asked to keep basal body temperature charts to track their natural cycles, and some, because of other symptoms, underwent exploratory surgery (laparoscopy) to determine the cause of infertility.

Reasons for Infertility

Most (71%) of the participants were given a medical reason for their childlessness, 39% were told it was female-factor infertility only, 14% were told that it was male-factor infertility only, and 18% were told that a combination of male and female factors contributed to the inability to conceive naturally. For 18%, no explanation was given for their infertility because there appeared to be no diagnosable issues with either them or their partners. Eleven percent of the participants did not definitively state the reasons for their involuntary childlessness. The rates of reported female-only infertility, combined male–female infertility, and unexplained infertility are fairly consistent with the data from ARTRC (2006), RCRH (2007), and Wang, Macaldowie, Chambers, and Sullivan (2011), but the rate of male-only infertility reported by the participants in my study represents a smaller proportion of the reasons for childlessness than the national data. The relatively large proportion of participants (3 of the 28 women; 11%) who did not definitively state the reasons for their childlessness could account for some discrepancies in these figures.

For the women who had been given a reason or reasons for infertility, there was comfort at least in having some information as to why natural conception was proving elusive. For those with “unexplained” infertility, the cause of their situation remained “a big mystery” (Lily), which made it somewhat more difficult to initiate clear problem-solving strategies: “We never actually could find a cause; we never had a diagnosis, … and I think even to this day that has been the most frustrating thing” (Vikki). Some women even felt that although they were not given a diagnosable reason for their infertility that it must still be their “fault” and that it was not “natural” for a woman not to be able to become pregnant naturally: “I always felt it was my fault; … even though it was unexplained, it was just like somebody grinding a knife into your back or into your heart and saying, ‘well it is your fault, what are you doing about it, why haven’t you?’ You know? Why haven’t you? What’s wrong with you?” (Sharon).

Experiencing a “Woman’s Problem”

Despite the data presented in the literature review on the sources of infertility indicating that it is a shared issue across humankind, many women spoke of the “courtesy stigma” they adopted (Roach-Anleu, 1999, p. 203) and of gender-biased assumptions—sometimes their own and often others’—that if there are fertility issues, then it must be the woman’s “fault.” For example, Belinda said, they automatically assumed that the problem was with me,” and Judith stated, “I seem to have blamed myself, the 1950s notion that the women always think it’s their problem with fertility, but it wasn’t.”

Like Judith, several other women also expressed feelings of guilt about not being able to have a child naturally. Some stated that they had contemplated leaving their partners, so that their partners would find someone else with whom to have children. Still others spoke of being thankful that they knew of their fertility challenges before they entered the relationships with their partners. They felt that this prior knowledge meant that their partners were then fully informed of the choice they were making in terms of possible long-term childlessness. These women thought that this prior knowledge was preferable to their partners finding out after partnering and the possibility that their partners would feel “trapped” in a childless relationship: “Sometimes I felt like leaving because I used to think that he’ll meet someone else and probably end up having children” (Lindi), and “I have been grateful that I knew it would be a problem so that when Fred and I were talking about getting married, he knew there might be a problem because I think I would always have felt really guilty otherwise if we’d married and he’d found out later. I would have felt I had cheated him” (Felicity).

Partners’ Reactions

Some women spoke about how their male partners had reacted to infertility. One woman’s first marriage ended in violence and divorce, which she attributed in large part to her infertility. Another woman spoke of how her husband “deep down feels it’s his fault, … but it makes no difference to me at all” (Sue). Others also spoke of their partners’ feelings and societal attitudes toward male infertility and masculinity:

I think it is a manly thing as well, going and getting tested to make sure, you know, he is good enough. He didn’t know he was never tested before. He couldn’t stand having a low sperm count; he would be devastated. (Elle)

I think it might be harder for a man actually because they’re brought up to be, you know, virile and all that …. I think in our society men really like to think that they can produce the goods. (Jacquie)

Elle’s and Jacquie’s comments identify how traditional constructions of masculinity rely on notions of virility and productivity, with women more likely to be seen as “faulty” (Klein, 1989). There is a clear need to gain more insights into men’s experiential knowledge of infertility in order to validate men’s experiences and to contribute to a more inclusive construction of involuntary childlessness.

Impacts of Involuntary Childlessness on Self-Concept

Almost without exception, the participants spoke of their involuntary childlessness as one of the most significant life crises they had experienced, which has certainly been supported by previous research (e.g., Blyth & Moore, 2001). Most spoke of being “devastated” or “crying for days,” and many spoke of anger and frustration at not being able to conceive naturally. And almost without exception, the women spoke of the decision to have children as a conscious choice, rather than a feeling of obligation or as an inevitable part of being a woman. As Amber commented, “I was never getting married or having kids …. Having kids wasn’t desperately on my hit list of things I wanted in life until I couldn’t have them; all of a sudden, I did really want them.” This comment highlights an issue that affected several other women—the feeling of disempowerment that came from involuntary childlessness. Many said that they felt a lack of control because of infertility and a need to “fix” the issue as soon as possible. For example, Anne said, “Once the choice had been taken away from me, it was hard to deal with because then I thought, well, there’s really no choice any more.”

Some participants spoke of their motivation to have children as a long-standing life wish—of having “always dreamed of having children” (Lily). Many had actively envisaged how many children they would produce, and Sarah had decided that if she had not partnered by the time she was 35, she would “have a baby anyhow …. I was always very determined to have babies …. I was one of those women who would do anything to have a baby.”

Impacts of Pronatalism

Although some participants spoke of choice and self-determination, others identified strong, basic, almost visceral urges and society’s pronatalism as powerful forces: “Society just expects you to have a child” (Sue), and “it’s an incredible urge to have children …. It’s society …. It’s just a natural desire and a natural instinct to reproduce oneself” (Judith).

This pronatalism also emerged as a major point of contention in first-wave (and subsequent) feminists’ reactions to assisted reproduction, and it also clearly underpins the unhelpful and insensitive comments that other people directed at these women and their partners about their childlessness (Thompson, 2005). Almost without exception, the participants had been asked directly about the absence of offspring, and some women felt that people had assumed they were voluntarily childless. And while voluntary childlessness should be recognized as a legitimate choice in any case, many thought that the implication was that the women in particular were being selfish and choosing their careers and/or material wealth over childbearing, indicating that childlessness, whether by choice or not, is still not a readily accepted way of life, especially for women:

There was a bit of pressure, why hadn’t we fallen pregnant? Was it a choice thing? You know, people seemed to think we were being mean; … it was almost like a criticism (Vikki).

This woman said to a friend of mine, “Isn’t it a shame Jacquie is so selfish; Jim would make such a lovely father, and all she’s doing is off having a career, and I think that’s very selfish.” My friend said, “You’ve got no idea; they’ve been on IVF.” … And she said it really upset her to think that people might be thinking we were really selfish when it wasn’t the case at all (Jacquie).

One person said to me that I was being selfish spending my money on a big house and that I would have been better off buying a smaller house and concentrating on a family (Amber).

Some women had tried to dismiss these types of questions using humor to defuse the lines of inquiry about childlessness: Josie said: “They’d ask, ‘When are you going to have a baby?’ and I’d just say practice makes perfect,” and Felicity said, “Often I would make a joke of it; otherwise I probably would have cried.” Some women had feigned indifference: “People used to ask, and I’d just go, ‘Oh it will happen when it happens’” (Josie); “I’d just say no, I wasn’t interested in kids, and people thought that was true and they’d leave me alone” (Felicity). Some had tried the direct approach:

My husband starting saying we are actually having trouble falling pregnant, and it would really shut people up …. You are quite raw, … you know, when every fiber of your being wants to be pregnant, so yes, it was awful. I would often say yes, we would really like a baby and just always hope that was enough. (Sarah)

I actually said once, “What if we can’t have any?” That usually stops them in their tracks. But then I feel guilty and awful …. But people can be very nasty and cruel (Amber).

Others had much more positive reactions from friends and family members, and some mentioned the unsolicited advice they had received from others. Sue said: “The family was very loving and understanding, but the anticipation was there as well; … they were wanting this child as much as we were,” and Jacquie noted, “People knew we were trying to have a baby on IVF, you know, [they’d give] lots of advice, ‘Tell her mother to give her parsley” or some old wives’ tales …. Everyone’s an expert!” Regardless of the responses to inquiries from others, most participants found these types of questions “hurtful” and said that they added to the stress of involuntary childlessness. Many said they were offended that others, even if they were only minor acquaintances, thought that they had permission to ask such questions. As Anne said, “It annoys me when people keep hounding people about why they haven’t got children; obviously, it’s either a choice or it’s not.”

Perhaps the issue that seemed to irritate many of the participants the most was being labeled infertile. Many women spoke of not wanting to be identified in such a way, of not wanting to be “one of those ‘poor women’ who can’t have children” (Sarah). Sarah’s comment indicates her agency and her resistance to the notion that womanhood—or femininity—hinges on motherhood and that childless women are somehow faulty, deviant, or pitiable. Many participants also acknowledged that some people wanted to be helpful or to be sympathetic but lacked the knowledge of how to respond in a constructive manner. There were quite a few comments about how some people seemed to minimize the impacts of involuntary childlessness and tried to be helpful by suggesting substitutes like overseas holidays and material possessions to compensate for childlessness.

Coping Strategies

Several women spoke of trying to use avoidance strategies to cope with situations in which women with babies might be. Shopping centers were identified as decidedly difficult places, and celebrations like Mother’s Day also featured in the participants’ comments. Some women had experienced being in waiting rooms at assisted reproduction clinics with women and their children, and most found this situation particularly challenging. Many had also experienced the hypersensitivity and awkwardness of family members and friends, particularly at times when a new pregnancy was announced.

One participant spoke of how she kept her secondary infertility and use of assisted reproduction private, with only her partner and one other person knowing. She spoke of her withdrawal from her usual activities; avoidance of friends and social situations; and the ongoing, long-term effects this coping strategy was still having: “I found [that] I withdrew. You don’t emotionally attach yourself to people or their children to a certain extent, [so] it can’t touch you …. I think I did emotionally withdraw” (Vikki).

Loss and Grief

Most participants spoke in some detail of their grief in relation to involuntary childlessness. Many identified feeling initial shock and disbelief—“I shouldn’t have to do this [assisted reproduction]; I should be able to conceive naturally; why can’t I have a kid?” (Toni) to tearfulness—“I cried for days” (Jan) to anger and depression. Some described how they had moved on to try to integrate the experience and take action to attempt to remediate the situation: “I just kept saying, ‘I can’t have children, I can’t have children,’ and Mum said, ‘You can have children; you just have to go through [it] a different way. She was really supportive; … she helped me deal with that” (Elle).

To compound feelings of loss, many described moving through phases of grief and loss as like moving in a seemingly endless loop of hope, despair, repair, and back to hope again with each menstrual cycle—the “complicated grief and loss” of involuntary childlessness (Lechner, Bolman, & Van Dalen, 2007, p. 288). Several women described this cyclical pattern of grief and loss and how each month could be a disappointment and how involuntary childlessness is constant, “something you can’t get away from” (Jane).

Some women directed their feelings of anger and injustice at other people with children, especially those they perceived were ungrateful or unkind to their children (“How come she gets a baby and I don’t?”—Jacquie). Many described feeling angry and upset if they witnessed negative behavior toward children, such as verbal abuse, physical punishment, or perceived neglect. Many commented on seeing young mothers and babies and feeling resentful toward them for the ease with which these young women had produced babies. Most also recognized the source of their feelings as resentment about their own situations as opposed to being judgmental about others:

I used to walk down the street and would see these little 17 year olds with babies, … and [I] would reckon there were a million of them all lined up just to torment [me]. I used to get really resentful. I used to think it’s not fair, and then I would think well, yes, it is; that’s life. (Lindi)

Why us when there [are] so many kids out there that are born to parents that really don’t want them? That was hard to deal with …. Why us? Why did it happen to us? …. That was just kind of a selfish moment, trying to justify what happened, but then it was, well, this is how it’s going to be, so just kind of deal with it. (Belinda)

Accepting or Resolving Involuntary Childlessness

For most who participated in the research, the acceptance or resolution of their situation came via the eventual birth of children either by assisted reproduction or natural conception (more than 90%). Some participants said that in hindsight, they “had the best of both worlds” (Jacquie) and that their experience of involuntary childlessness had brought positives, such as a heightened appreciation of the children they eventually had and/or opportunities to travel and/or acquire material possessions and/or to advance their careers and acquire additional qualifications: “As much as we enjoyed all that, it’s a poor substitute” (Carmen).

Those who did not experience successful pregnancies described acceptance as a much more difficult task and the use of assisted reproduction was, at the least, a way of coming to terms with the situation: “We’re going to have to accept the future of a barren nest, so to speak …. At least we gave it a go. They say you haven’t got children; I can now turn around and say well, I gave it a go; we just didn’t have success …. You just grab these opportunities and chances you have” (Judith). Judith’s comment also highlights the importance of assisted reproduction as an option for people who desire a child but face fertility challenges, albeit an imperfect option with no guarantees of it being fail proof. Her comment indicates that not only did assisted reproduction aid her problem-solving approach to involuntary childlessness, but it gave her a level of protection or “insurance” as well as evidence of her maximized effort to procreate (Kirkman & Rosenthal, 1999, p. 26) against what she perceived as persistent negative community attitudes toward childlessness. Many researchers have discussed the importance of active choice in assisted reproduction, of assisted reproduction providing some hope and a degree of empowerment, and of reproductive technology as the basis for a strategy of action, a rational choice for people who are faced with involuntary childlessness (Bell, 2012a; Gupta & Richters, 2008; Kirkman & Rosenthal, 1999; Koch, 1990; Porter & Bhattacharya, 2008; Roach-Anleu, 1999).

Conclusion

The participants’ experiential knowledge of involuntary childlessness indicated that there are still significant issues regarding how infertility is commonly perceived. The dominant construction influences the nature of psychosocial support offered to users of assisted reproduction services. If the dominance of a biomedical approach to infertility is maintained, approaches to psychosocial support could tend to be individualized and largely confined to microlevel practice. Social work, as a profession with social justice and empowerment at its heart, ideally promotes a multidimensional, human rights focus in the delivery of services. Thus, the need for social workers to be aware of and to resist narrow, individualizing constructions of social phenomena, such as involuntary childlessness, is reinforced.

The term involuntary childlessness is indeed preferable to infertility, especially in the context of the use of assisted reproduction services because many women who use assisted reproduction services are not infertile at all; some have partners who are medically infertile, some are in social situations in which conventional conception is not possible, and some are not definitively infertile because there is no diagnosable reason for their childlessness. Thus, the term involuntary childlessness more accurately captures this range of situations. The term is also preferable at the macrolevel because it implies a broader range of possibilities and roles for women (and men) in society and largely avoids pronatalism, in that it recognizes that some people make a voluntary choice to remain childless, reinforcing that this is a legitimate option that is available to all people.

The lived experiences of relatively underresearched groups, such as same-sex couples, single people, men, and people from culturally diverse backgrounds, would contribute to an even more inclusive construction of involuntary childlessness. Likewise, the experiences of those who experience long-term failure in natural and assisted conception deserve further attention and validation.

The use of accurate terminology like involuntary childlessness instead of infertility along with resisting medical language to describe assisted reproduction (e.g., treatment and patient) are important steps in the poststructuralist endeavor to disrupt the dominant discourse and contribute to the reenvisioning of a more accurate, inclusive discourse and knowledge base related to involuntary childlessness and the choice to use reproductive technology in an attempt to redress involuntary childlessness. As Alzate (2009), Blyth (2010), Dominelli (2002), Bell (2012b), and others suggested, the social work profession’s framework for ethical, holistic practice is well placed to disrupt the dominant discourse of assisted reproduction and to reclaim reproductive rights from the silencing and disempowering effects of biomedicine. A human rights framework would serve to emphasize the need for foundational assumptions about wholeness, interdependence, interconnectedness, diversity, and the broader community context to be reinforced, not to be overrun by an individualized, biomedical paradigm that often denies women’s epistemic agency.