The Biomedicalization of Social Egg Freezing

Introduction

In 2012, a major professional society representing Europe and another representing the United States released influential statements that would propel a commercial market for social egg freezing (SEF), a practice that involves women paying hefty sums to retrieve and bank their own oocytes for later use in order to avoid compromised fertility that comes with age. In light of advances in the effective cryopreservation of human eggs through vitrification (a fast freezing technology), publicized in prominent studies between 2008 and 2011, the European Society of Human Reproduction and Embryology (ESHRE) reversed an earlier statement from 2004 that had discouraged the practice. Their new statement considered that the procedure ought to be made available to women who, facing “the threat of time,” desire to cryopreserve their own eggs in order to “give them more breathing space” (ESHRE 2012, 1231). The European statement exclusively focused on the case of egg freezing (EF) for “age-related fertility loss,” providing an in-depth analysis in relation to core bioethical principles such as beneficence, nonmaleficence, respect for reproductive autonomy, and justice. Several months later, the American Society for Reproductive Medicine (ASRM) reacted to the same scientific improvements by lifting the experimental label on EF and recommending the technique for a number of “medical indications,” most prominent among them the case of cancer patients whose toxic treatments compromise their gametes and impair their ability to have genetically related children. However, the statement cautioned, “there are not yet sufficient data to recommend [egg freezing] for the sole purpose of circumventing reproductive aging in healthy women” (The Practice Committees 2013, 42). It further stated, “Marketing this technology for the purpose of deferring childbearing may give women false hope and encourage women to delay childbearing. In particular, there is concern regarding the success rates in women in the late reproductive years who may be the most interested in this application” (p. 41). Although the ASRM statement did not endorse SEF, it actually had the effect of unleashing unrestrained commercialization of SEF as the distilled version of its message, “egg freezing is no longer experimental,” overtook any cautionary recommendations discouraging nonmedical applications of the technique in mainstream news and popular media. Despite their opposed positions on SEF, we juxtapose the ESHRE and ASRM statements from 2012 to highlight how they both mark the beginning of state or public engagement with selective feminist scripts on gender, work, and family formation in support of SEF. These processes raised the acceptability of EF as a biomedical practice designed to address social anxieties and problems rather than exclusively medical ones.

In this article, we analyze the social and discursive processes by which SEF biomedicalized. In their influential paper on biomedicalization, published in 2003, Clarke and her coauthors expanded Irving Zola’s term “medicalization,” put forth in the 1970s to mean “the extension of medical jurisdiction, authority, and practices into increasingly broader areas of people’s lives,” or a process by which previously social issues come under a medical gaze (p. 164). Clarke et al. argued that medicalization could no longer fully explain new social forms and organizational changes in the practice of medicine by the late twentieth century. They employed biomedicalization to illuminate shifts that had occurred in politicoeconomic, technoscientific, and sociocultural processes as they relate to biomedical practice. For example, they highlighted a new focus on “treatment of risks and commodification of health and lifestyles” rather than creating ever more diagnostic categories of illness (p. 168). A key difference between medicalization and biomedicalization, signaled by the prefix bio, is that these processes no longer require the construction of pathologies and illness identities. Rather, they proceed through the goal of optimization of health or life itself. We argue that the biomedicalization of SEF occurred through significant interventions made by leading professional bioethical authorities in Europe and the United States, noted above, as well as through shifts in discourse occurring in popular and news media. It involved a two-step process. The first step identified and pathologized a side effect (the future impaired fertility that results from cancer treatments), so that it became a new indication for more medical intervention. Upon the completion of this more classic form of medicalization, signaled by approval of ESHRE and the ASRM in 2012, the processes readjusted to the priorities of life itself (bio) to optimize fertility for a woman so as to influence her life course toward ensuring an imagined future with children. This occurred via a particular feminist script, what we call a Lean In efficiency model of feminism that socially sanctioned SEF for women with careers (Sandberg 2013). In this article, we map the contexts and discursive moves by which the biomedicalization of SEF post 2012 proceeded.

Prior to the ASRM announcement in 2012, sociologist Lauren Jade Martin revealed the earliest processes by which “anticipated infertility,” which she defines as “a sociological descriptor for the condition in which one believes one may be infertile in the future” became medically treatable (2010, 529). She studied representations of potential users of EF in biomedical literature as well as in news articles and marketing. We follow her approach in the period after the ASRM announcement, but in our case, we conduct a close reading of the ASRM and ESHRE statements released in 2012 to analyze the claims made by these major bioethical authorities. Despite the ASRM’s recommendation against SEF, its use in the United States has grown dramatically, in part because it is largely unregulated, private, and for-profit. To better understand the tension between ASRM’s position on SEF and the seemingly cultural acceptance of SEF, as well as to gain a deeper appreciation of the social and economic factors at play in the burgeoning SEF market, we examine the construction of users in US news and popular media. Our review covers 138 articles collected from Lexus Nexus, Proquest, Google News, and individual newspaper and magazine archives between October 2012 and June 2015. We compare professional bioethical arguments that made the case to approve SEF in Europe with the popular discourse that formed and shaped the commercial marketization of SEF in the United States despite the recommendation of the ASRM. While a statist pronatalist perspective drove the former, a distinctly private labor market recruitment strategy utilizing a Lean In efficiency model of feminism accompanied the latter.

The ASRM, Self-regulation, and the Clinical Treatment of “Anticipated Infertility”

Prior to 2012, Martin discerned three separate narratives running through mainstream media, medical literature, and marketing materials that constructed social egg freezers as victims, selfish, or liberated. As victims “vulnerable to exploitation,” the narrative highlighted a number of potential risks including physical complications, costs, empty and misleading claims about the assurance of fertility preservation and a lack of data about safety and effectiveness. The selfish narrative most prevalent in popular media derived from a long-standing conservative view that careerist young women cared more about themselves and their social lives than about starting and caring for families. This narrative created a dichotomy between cancer patients and social egg freezers by driving a wedge between altruistic and selfish motivations. Again, according to Martin, “The selfish/altruistic dichotomy represents two sides of the same gender ideology of motherhood as role fulfillment. In the first instance, freezing eggs is selfish because it delays motherhood, whereas in the second freezing eggs is altruistic because it enables it” (p. 537). Finally, the third narrative, promoted mostly in marketing literature, emphasized egg freezing as a means for women to control their bodies, fertility, lives, and to “level the playing field” with men in careers. It is important to remember that these three narratives circulated at a time when the medicalization of the future impaired fertility of the cancer patient or “oncofertility” was still incomplete. Because reproductive medicine is often not recognized as “real” medicine, fertility preservation for cancer patients was, and sometimes still is, not seen as an essential part of cancer care. One clear example of this is insurance coverage: while other iatrogenic, quality of life treatments are covered, such as breast reconstructive surgery following mastectomy, it is often difficult, or at least not standardized, for patients to receive oncofertility coverage (Campo-Engelstein 2010).

Published in 2010, Martin’s research provides us with important clues as to how medicalization and biomedicalization processes occurred concurrently. In her review of biomedical literature, Martin unveils a technique of contrast, which she calls the “dichotomous portrayal.” This narrative compares young women cancer patients to women undergoing “social” EF. The former is seen as sympathetic users of EF, who in their pursuit to become well must unjustly bear the “tragic consequence” of impaired functionality of their eggs, including the social stigma of childlessness. By undergoing egg freezing, including the rigors of “hormone injections, surgery, and possibly delaying cancer treatment,” young women cancer patients were construed as making an “embodied sacrifice for the sake of the family” (p. 534). Martin reveals how both clinical literature and a 2008 ASRM statement succeed in their portrayal of cancer patients as “worthy” candidates for the procedure in part through a contrast to a less deserving countersubject–healthy, young women who desire to bank their younger eggs in order to delay reproduction. She writes:

By limiting access to egg freezing technologies to a particular population, professional organizations enact a gatekeeping function. This gatekeeping marks cancer patients as more deserving of treatment than healthy young women and exposes the socially constructed nature of egg freezing, the elusive parameters of what constitutes necessary treatment, and the power of clinicians to judge which patients are deserving of their services. (pp. 534-35)

Likely motivated by the bioethical principle of nonmaleficence (to do no harm), the ASRM position on SEF, which was rearticulated in 2012, assumes that the bar of acceptable risks and burdens that women must face when undergoing EF would have to be raised for those who are healthy. The 2008 ASRM statement devoted solely to “elective oocyte preservation” at a time when the technique was still considered experimental laid out the detailed information required in counseling to ensure that the candidate for SEF could give “valid consent.” It concluded, “Women with cancer or other illnesses requiring immediate treatments that seriously threaten their future fertility who are considering oocyte preservation should receive the same thorough counseling. However, unlike healthy women, they may have no viable options and therefore may be appropriate candidates for such treatment despite its experimental status” (emphasis added, The Practice Committee of SART and the ASRM 2008, S135). This contrast between “elective” users and those who presumably have no other “options” to achieve the social obligation of motherhood does much work toward the justification of EF as a medical treatment for cancer patients. We agree that the portrayal of an ethically less deserving candidate for EF made a medical application of EF for cancer patients all the more palatable. Yet, in spite of its not uncertain characterization of SEF as something that “should not be offered or marketed,” we would argue that the statement also does important preemptive work toward the biomedicalization of SEF (S134). It provides the literal guide by which physicians can ethically offer this treatment, which presumes at the same time as it ensures that individual autonomy can and will prevail in the context of a competitive, for-profit, and relatively unregulated market for assisted reproductive technology (ART)—or what some writers now refer to as “Fertility, Inc.” (Mamo 2010, 178). In 2012, even though the ASRM reiterated a stance of not encouraging SEF, it recognized “elective cryopreservation to defer childbearing” (p. 41) as a medical indication among several other categories of use for a technique it no longer viewed experimental. The practice thereby assumed medical meaning in spite of its classification as “social,” “elective,” or even paradoxically, “nonmedical.”

ESHRE’s Assertion of Selective Feminist Claims and the Statist, Pro-natalist Case for SEF

Unlike the ASRM, ESHRE took a different tack by specifically advising fertility physicians against “a paternalistic attitude” that would decide for a potential patient how “the importance of keeping open the prospect of having children later in their lives…weighs up to the burdens and risks of repeated stimulation and oocyte-pick up” (p. 1233). The reference to paternalism here resurrects a historical argument made within the late twentieth-century women’s health movements, when the concerns of women patients were routinely disregarded by primarily men physicians at a time when “doctors know best” attitudes prevailed culturally. ESHRE ignores the equally relevant interventions made by these movements to raise concerns for women’s safety in the now well-known and recognized unethical promotion of inadequately tested or formulated forms of birth control (such as the oral contraceptive pill and Dalkon Shield intrauterine device) or synthetic estrogen (DES) use during pregnancy (Morgen 2002, 26-31; Zimmerman 1987, 460-61). The ESHRE statement asserts the relative importance of respecting the bioethical principle of reproductive autonomy over nonmaleficence in this case, even though a feminist case in favor of the latter could be made just as strongly. ESHRE goes further by questioning the imposition of physician attitudes that may construct some women (e.g., those who remain childless because they have no partner) over others (“career women”) as potentially more deserving of sympathy. Positing that sick women obviously are worthy candidates for EF, ESHRE then designates women without partners also as worthy because their childlessness could result from conditions that are similarly “beyond their own control.”

Fertility preservation for women at risk of disease-related or iatrogenic premature menopause clearly falls within the scope of reproductive medicine. The same can arguably be said of fertility preservation for women who want to have children and are still without a partner at the age of 35. Their request is understandable, given that there is a reasonable chance beyond their own control that they will remain childless. But what about requests from women who deliberately choose to postpone childbearing while giving temporary priority to other life goals such as buildup of a career (ESHRE 2012, 1232)?

Here, the statement employs the familiar strategy of the “dichotomous portrayal.” The existence of the “career woman,” now as the outlier or countersubject, allows for a more immediate extension of sympathy from the worthy cancer patient to the “partnerless woman.” The statement then goes on to question the very dichotomy it set up by arguing that these two nonmedical situations of EF involve categories of women that are, in fact, not necessarily mutually exclusive. “The postponing ‘career woman,’” the statement argues, “is not so deviant a character as many seem to think” (p. 1233). In this two-step process, ESHRE advances a claim for respecting reproductive autonomy, thereby enclosing ever broader categories of potential “nonmedical” users. Finally, ESHRE also employs the bioethical principle of justice. In this case, justice is presented as an explicitly feminist claim:

For men, the combination of fatherhood with other life plans is not as difficult. Not only do they tend to leave most of the burdens of daily care to their partners, but they also have the opportunity to reproduce until much later in their lives. Moreover, men already can have their sperm cryopreserved. This is done for medical reasons, but sperm banking is also commercially available as a means of preserving reproductive capacity to men in jobs or sports that pose a possible threat to their fertility. From a feminist perspective, therefore, the availability of options for female fertility preservation can be regarded as an important step towards greater reproductive justice. (emphasis added, 1234)

The empowerment narrative that Martin documented as primarily occurring in marketing literature prior to 2010 is operationalized in this instance by ESHRE as a bioethical claim.

ESHRE appeals to a specifically feminist notion of justice to raise sympathy for the deviant career women, retrieving her from the status of countersubject to become a full biocitizen subject.

ESHRE’s support of a bioethical claim to “reproductive justice” is made on behalf of a very generalized category of women against a similarly unmarked category of men. This hides the means by which SEF secures for the state the selective reproduction of privileged racialized and classed groups, those ESHRE euphemistically characterizes as “women who are socially, economically and physically able to give [a child] a good start in life” (p. 1235). We think it is important to highlight the peculiarity of this approach, especially in relation to the meaning of reproductive justice originally advanced by socially marginalized groups in the United States in the late twentieth century. They specifically challenged a reproductive rights framework that had become libertarian, abortion-centric and focused on market-driven notions of choice and autonomy. Reproductive justice in this sense takes as its central concern experiences of oppression and the consistently devalued reproduction of disadvantaged groups. The movement exposed the wide differences of experiences with reproduction among women and put forth claims foregrounding notions of justice based on the social and political recognition of particular subgroups, the “other” women, which sociologists Luna and Luker (2013) specifically define as “often poor people, people of color, people with disabilities, and people with non-normative gender expression and sexualities” (p. 345). That the ESHRE statement asserts the ethics of SEF on the basis of a reproductive justice claim made on behalf of all women is not only highly peculiar but counterintuitive, given that the provision of SEF depends in part on its exclusivity—the idea that it must be unavailable to most women. The SEF market functions because it banks objects that are not exchangeable in transactions precisely because they are viewed as priceless and unique by clients who receive customized care. Waldby makes these processes visible in her analysis of egg banking as a singularities market ¹ (2015). Yet, apart from reliably inaccessible market mechanisms, ESHRE’s case for supporting SEF is motivated by a distinct, statist pronatalism.

During the 1990s, fertility rates in Europe dipped to new lows. New anxieties arose around the twin phenomena of aging and shrinking populations. In Germany, for example, Schultz documents what she calls “the revival of demographic rationalities” in the mid-1990s onward when think tanks, private foundations, and research institutes joined political parties and government ministries to formulate a range of policy measures to combat population decline (Schultz 2015, 338). These included state subsidies for in vitro fertilization (IVF) treatments and for parents when they give birth to a child. Explicit pronatalist rhetoric and policy resonate in Europe in ways that do not apply to the United States, and we contend that the largely optimistic assessment of SEF by ESHRE must be viewed against this background. For example, the European statement acknowledges that in addition to benefiting individuals, “societal benefits include the birth of additional children at a time of declining birth rates in developed countries” and that “in many western societies, there are demographic reasons for welcoming the birth of any extra child born to women who are socially, economically, and physically able to give it a good start in life” (ESHRE 2012, 1234, 1235). Among eleven final recommendations, ESHRE urges “policy-makers in countries where IVF is (partly) covered within the healthcare system” to “consider how women whose stored oocytes are eventually used for reproduction can be compensated” (p. 1236). Here, subsidizing SEF expenses contingent upon the application of banked eggs toward reproduction calls states to action to incentivize SEF as a way of addressing population decline.

In contrast, appeals for federal or state government promotion of SEF would not work in the US context. Not only are there no comparably overt statist pronatalist interests, the field of assisted reproductive medicine is characterized by a mostly private, competitive, for-profit market which operates not only with minimal state interference but also minimal state support. The prompt, in the US case, had to come from another powerful source.

Lean In and the Narrative Shift from Selfish to Brave

Since 2012, social egg freezers are now repositioned, taking the place of former cancer patients as the new sympathetic subjects. Lost is the selfish narrative and in its place, social egg freezers are reconstructed through a selective feminist script, this time as victims in a male-dominated society and labor market. They are no longer viewed as potential victims of an exploitative, for-profit, fertility industrial complex that reinforces women’s anxieties about aging along with their desires for genetically related children just as much as it exploits them. Rather than despised as self-centered, women’s brave efforts to succeed in the workplace against the reality of gender-based discrimination and inequality are depicted as understandable and in need of support. We suggest that the shifting narratives on social egg freezers, while prompted by the 2012 ASRM decision to lift the experimental label on EF for medical purposes, have been indirectly assisted by the recently mainstreamed feminist messages of leaning in.

Chief operating officer of Facebook, Sheryl Sandberg’s widely popular bestseller Lean In: Women, Work and the Will to Lead appeared at the same time as her nonprofit organization by the same name in March 2013. The book and organization have flooded mediascapes with advice to encourage graduate students and working women to Lean In to leadership positions and combat societal and internalized barriers to climbing career ladders and breaking the glass ceiling. The organization provides tips to graduate students such as “Adopt the Mantra, ‘Proceed and Be Bold,’” and “Make your Partner a Real Partner” (which is advice on choosing a supportive, presumed to be male, life partner who will help with housework). Lean In has brought widespread attention to social issues that hold women back such as the negative correlation of likeability with their success in the workplace. A Lean In-related campaign called Ban Bossy brings attention to the ways that girls who show leadership on the school playground are often derided as bossy. Lean In has brought ongoing conversations about women’s position in the labor force to broader audiences in a way that engenders greater understanding for the difficulties of work–family balance and the challenges of getting ahead in male-dominated leadership positions. Sandberg’s intervention may have helped to shift the popular discursive field related to young women professionals away from the selfish to an expanded and revised empowerment narrative, in which young, fertile women are portrayed as justly taking all needed measures to Lean In and take control of their careers as well as their reproductive futures.

While it may seem like the rhetoric of Lean In can only be tangentially associated with the biomedicalization processes of SEF, Sandberg’s Facebook took a much more concrete step in October 2014, when alongside Apple it began to offer up to US$20,000 of coverage for EF costs as a workplace benefit to its employees. Intel followed a year later (Bellstrom 2015). A possible connection to the Lean In movement was not lost in some news coverage of this decision. An Associated Press newswire article reported, “Freezing their eggs gives women an option to focus on their career or education first, the “leaning in” that Facebook Chief Operating Officer Sheryl Sandberg champions.” The Boston Globe’s Joanna Weiss wrote in a similar vein, “The perk is nice (if a little ‘Brave New World’), but the message is clear: Lean In now, and save the kids for later” (October 17, 2014). Asked by Emily Chan in a Bloomberg Television interview to address such criticism of Facebook’s EF benefit, Sandberg chuckles as her co-interviewee, Richard Branson, founder of the Virgin Group, defends the policy, asking incredulously, “How could anybody criticize them for doing that? It’s a woman’s choice. If they want to carry on working they can carry on working.” Sandberg then responds first by emphasizing the generous leave and cash benefits the company offers to employees who have a new child. In her explanation of how her company initiated the EF benefit, Sandberg echoes the two-step biomedicalization process we discussed earlier by forefronting an anecdote about an employee with cancer.

There’s a young woman working at Facebook who had got cancer, and I knew her and she came to me and said, “I’m going to go through the treatment, and that means I won’t be able to have children unless I can freeze my eggs, and I can’t afford it, but our medical care doesn’t cover it.” She was coming to me for advice and help and I talked about it with our head of HR, and said, “God we should cover this.” And then we looked at each other and said, “Why would we only cover this for women with cancer, why wouldn’t we cover this more broadly?” And that is where that benefit came from and we think it’s great! (Bloomberg 2015)

The Discursive Shift in Popular and News Media—Lean In and the Social Sanctioning of Elective Egg Freezing

We now turn to the mainstream popular and news media in the United States to highlight how the themes raised by professional medical organizations, like ASRM and ESHRE, and discussed in the academic literature were portrayed in this medium. Overall, newspaper articles framed SEF according to the Lean In model of feminism and upheld a consumeristic approach to women’s reproductive health. The overwhelming focus of the articles was on the economic considerations of SEF, specifically SEF as a workplace benefit given its high cost. This economic focus placed professional career women as the key players in SEF and as the primary subjects of the biomedicalization process. Professional women were portrayed sympathetically in the news and popular media as women who were trying to balance pursuing a career and having a heterosexual relationship with biological children. Newspapers suggested, as did ESHRE, that professional women who are considering using SEF should not be blamed if they have not been able to find a partner and/or try to balance their career with having children. Not surprisingly, the empowerment narrative discernible in SEF marketing before 2012 (when ASRM lifted the experimental label on EF) subsequently became the dominant narrative in the news and popular media. SEF was promoted as a technological solution for these women as a way to enhance their choices and autonomy. While some concerns about SEF were raised in newspaper articles, they were often minimized or framed as just another obstacle for the superhero career woman to overcome. The price of SEF, one of the main obstacles mentioned, was often declared an unfair burden, and many of the articles were supportive of SEF as a workplace benefit. In prioritizing women’s autonomy above all other considerations regarding SEF, newspaper articles made a similar move as ESHRE. In this section, we tease apart some of our main findings from the newspaper content analysis and connect it to our previous sections.

Conclusion

Medicalization and biomedicalization processes related to EF occurred concurrently prior to 2012. However, in their influential statements issued that year, professional bioethics committees in Europe and the United States recognized EF as no longer experimental, thereby sealing the medicalization of EF and opening the door for expanded, nonmedical applications of EF. Shifts in both professional bioethics and mass media discourses that catalyzed these processes employed a distinctive feminist script for support of statist pronatalism in Europe and a Lean In vision of gender equality in the corporate workplace in the United States. We chose to focus on popular discourse in the United States in order to identify the discursive means by which SEF became socially acceptable in the United States in spite of professional opinion within reproductive medicine that recommends against its provision and marketing. Although our methodological choices are premised on a broad distinction in the organization of fertility medicine between a regulated/public/Europe and an unregulated/private/United States, we realize that there is far more complexity in both locations, which warrants further study that might include a content analysis of news and popular media discourse in Europe. The decision in early 2016 by the Department of Defense to offer EF benefits to women in the US military, for example, complicates the public/private boundary we have taken for granted here.

Medicalization and biomedicalization processes construct counter subjects or illegitimate users just as much as validated subjects of SEF. The growing acceptability of SEF relies upon a particularly classist, heteronormative feminist script in both contexts, which excludes working-class women, lesbians, transgender individuals, and other devalued or deviant reproducers. The narrative shift from depicting SEF users as brave rather than selfish touts SEF as a means for women to redeem lost or “wasted” precious time devoted to careers instead of starting families. Ironically, this exclusive and selective feminist script in support of SEF operates as a way for women to redeem “lost” femininity by performing legitimized desires for the heteronormative family ideal with genetically related children and the self-sacrifice needed to do all in one’s power to obtain that version of feminine maternal identity. While many issues related to SEF practices remain that require feminist questioning, including whether valid informed consent actually takes place in clinical settings, in this article, we have prioritized a critique of the overly simplistic gender empowerment promise, which we view as primarily a market formation available to few women through purchase and use of SEF. Apart from its inaccessibility, the gender empowerment promise of SEF depends on a Lean In efficiency model of feminism, which contributes to the very social anxieties that SEF is set up to treat.