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UNIVERSITY OF CALIFORNIA, SAN DIEGO Preconceived Notions: The Social Construction of Male Infertility A dissertation submitted in partial satisfaction of the requirements for the degree Doctor of Philosophy in Sociology by Liberty Elizabeth Walther Barnes Committee in Charge: Professor Rebecca Klatch, Chair Professor Lisa Cartwright Professor Steven Epstein Professor Christena Turner Professor Deborah Wingard 2011 The dissertation of Liberty Elizabeth Walther Barnes is approved, and it is acceptable in quality and form for publication on microfilm and electronically: Chair University of California, San Diego 2011 iii TABLE OF CONTENTS Signature Page…………………………………………………………………….iii Table of Contents………………………………………………………………….iv List of Figures………………………………………………………………………v List of Tables………………………………………………………………………..vi Vita…………………………………………………………………………………..vii Abstract of the Dissertation………………..……………………………………..viii Chapter One: CONSTRUCTING GENDER AND DISEASE: Making Room for Male Infertility within the Sociological Imagination………..1 Chapter Two: CLAIMING JURISDICTION: The History of Urology and the Practice of Male Infertility Medicine……...…62 Chapter Three: MASCULINITY IN CULTURE AND PRACTICE: How Institutions Take Part in Constructing Popular Notions of Gender…....112 Chapter Four: INFERTILITY AND IDENTITY: How Men Redefine Their Masculinity in Light of Their Fertility Status……...145 Chapter Five: MEN AND TECHNOLOGY: How Infertile Men Construct Masculine Narrative around Medical Interventions……………....196 Chapter Six: CONCLUSION…………………………………………………….243 Appendix I: Interview Guide……………………………………………………..261 Appendix II: Table 1. List of Research Subjects………………………………264 Works Cited……………………………………………………………………….265 iv LIST OF FIGURES Figure 2.1: Diagram entitled “Male Reproductive System.” Source: U.S. Government………………………………………………………………………79 v LIST OF TABLES Table 1. List of the twenty-four male subjects in this study, including their ages, professions, diagnoses, and race. All names have been changed…..65 vi VITA 1999 Bachelor of Arts, Brigham Young University 2002-05 Teaching Assistant, Department of Sociology, University of California, San Diego 2004 Master of Arts, University of California, San Diego 2006 Candidate of Philosophy, University of California, San Diego 2006-09 Instructor, Sociology Program, Portland Community College 2006-07 Graduate Intern, Domestic Designs and Technology Research Group, Intel Corporation 2007 Graduate Intern, Health Practices Research Group, Intel Corporation 2008 Associate-In Professor, Department of Sociology, University of California, San Diego 2009 Instructor, Department of Sociology, Brigham Young University 2011 Doctor of Philosophy, University of California, San Diego vii ABSTRACT OF THE DISSERTATION Preconceived Notions: The Social Construction of Male Infertility By Liberty Elizabeth Walther Barnes Doctor of Philosophy in Sociology University of California, San Diego, 2011 Rebecca Klatch, Chair Gender scholars argue that in Western culture hegemonic gender beliefs are widespread and stable, and individuals’ access to resources and power are contingent upon their ability to conform to these ideals (Ridgeway and Correll 2004; West and Zimmerman 2002). However, they also argue that gender is a fluid and dynamic aspect of identity, as demonstrated by viii individuals’ ability to revise personal notions of gender based on other salient features of identity, including, race, class, age, sexual orientation or physical (dis)abilities (Connell 1995; Fenstermaker and West 2002; Kimmel 2006; Ridgeway and Correll 2004; West and Zimmerman 2002). This dissertation uses male infertility as a case study for exploring what happens when the perceived foundations of masculinity are destabilized in the lives of heterosexual married men. Male factor infertility is a clinical condition that affects nearly half of the more than seven million infertile couples in the United States. For this original research study, I employed mixed qualitative research methods, including ethnographic observation in male infertility clinics, in-depth interviews with male infertility specialists, clinic staff, infertile men and their wives, and content analysis of medical texts and conference addresses, in order to examine how medical institutions and individuals socially construct male infertility. I argue that the social processes of constructing gender and negotiating masculinity are tightly intertwined with the process of constructing disease. Early in this dissertation I show that preconceived notions regarding women’s responsibility for all aspects of reproduction have historically shaped popular understandings of male infertility and hindered the development and organization of male infertility as a medical specialty. I describe how medical practices are designed around preconceived notions of men as sexually knowledgeable and experienced, yet all the while strive to protect presumably fragile masculine identities. I detail the various ways infertile men work to ix redefine their condition in terms that downplay infertility’s threat to masculinity. Throughout this dissertation I argue that gender-constructing and disease- constructing processes are inextricable, because notions of gender inform understandings of disease. When disease presents a threat to gender identities, individuals create new understandings of disease in order to negotiate and stabilize their personal gender identities. x Chapter One: CONSTRUCTING GENDER & DISEASE: Making Room for Male Infertility within the Sociological Imagination Chapter outline: Introduction Male Infertility in the ‘Reproductive Imaginary’ Literature Review Infertility and Assisted Reproductive Technologies Male Infertility Gender Theories Contributions of this Study Methods Research Questions Mapping Out the Infertility Industry Research Design: Mixed Qualitative Methods Challenges to Research: Performance of Subjects, IRB Protocols, and My Role as Researcher The Trouble with Masculinities Dissertation Chapter Outline 1 2 Gender scholars argue that in Western culture hegemonic gender beliefs are widespread and stable, and individuals’ access to resources and power are contingent upon their ability to conform to these ideals (Ridgeway and Correll 2004; West and Zimmerman 2002). However, they also argue that gender is a fluid and dynamic aspect of identity, as demonstrated by individuals’ ability to revise personal notions of gender based on other salient features of identity, including, race, class and age (Connell 1995; Fenstermaker and West 2002; Kimmel 2006; Ridgeway and Correll 2004; West and Zimmerman 2002). This dissertation investigates how individuals respond when they realize they do not measure up to culturally dominant gender ideals. Concisely put, how do men deal with a crisis of masculinity? This research study uses male infertility as a case study for exploring what happens when the perceived foundations of masculinity are destabilized in individuals’ lives. As I discuss throughout this dissertation, cultural norms dictate a fundamental and fixed understanding about men and reproduction, specifically, that fertility is closely tied to virility. A man’s masculinity is evidenced by his ability to impregnate his wife. Over the next several chapters, I describe how infertile men engage in ‘gender work’ to maintain their masculine identities when they cannot live up to the social expectations of their roles as men and husbands. The American Society for Reproductive Medicine (ASRM) reports that 30% of infertile couples suffer from male factor infertility. While 30% are due to female factor infertility, 20% are due to both male and female factors, and 3 20% of couples have unexplained infertility. 1 In other words, men are responsible for heterosexual couples’ inability to conceive in about 40% of all infertility cases. Internet sites, books, and magazines devoted to helping couples combat infertility provide long checklists for women: fertility signs she should watch for throughout her menstrual cycle, diets and vitamins that will improve her fertility, questions she should ask her doctor. Articles and books by psychologists, social workers and sociologists detail the grief, frustration, and depression suffered by infertile women. Infertility is an estimated three billion dollar industry, in which specialists who treat women dominate the business (Spar 2006). Despite statistics that indicate men are equally responsible for infertility, the notion that women are primarily responsible for infertility still prevails in contemporary society’s collective consciousness. Have infertile men escaped the medical gaze and social scrutiny? Why, in light of scientific evidence showing that men are just as likely to be infertile, do women bear the brunt of reproduction and infertility treatments? Are infertile men invisible? According to the National Center for Health Statistics (NCHS), there are 2.1 million infertile women in the United States of reproductive age, and 7.3 million American women have used infertility services. 2 The NCHS has closely monitored fertility rates, fertility status, and use of infertility services among women in the U.S. for the past several decades. No such statistics 1 ASRM web-site: http://www.asrm.org/Patients/faqs.html#Q2: 2 NCHS web-site: http://www.cdc.gov/nchs/fastats/fertile.htm 4 exist for men. Where are all of the infertile men? Who are they? How do they cope? Where do they find help and support? The goal of this research project is to better understand