The Child Yet-to-be-Born
by Anna Velychko
In this paper, the author explores the topic of Assisted Reproductive Technology (ART) along with its pre- and post-procedural medical and psychological effects. The paper offers a new perspective on ART that looks at fertility clinics as a holding environment for potential parents and as the first holding environment for the yet-to-be-born child. The aim of the paper is fourfold: (a) to encourage a broader discussion among fertility clinic coordinators, medical staff, and social workers who work with the lesbian population about the intricacies of the ART procedures; (b) to advocate for the de-medicalization of fertility procedures so as to make them less traumatizing for both the mother and the child; (c) to raise more awareness about fertility treatment in institutional entities (e.g., medical industry, insurance companies) so they might extend medical coverage of ART to lesbian women and couples; (d) to create dialogue about the experiences of underrepresented clients, such as the lesbian population, with ART.
Keywords: assisted reproductive technology, conception, trauma, lesbian, gay women, mental health, psychotherapy, attachment, holding environment
The Child Yet-to-be-Born
Couples with infertility issues, biological clock-challenged career women, and the gay community can now achieve what has previously been considered inconceivable due to rapid technological advances in Assisted Reproductive Technology (ART). However, the vulnerabilities of these populations and the health and psychological risks of ART are often not considered. Little pause for thought is given on behalf of the patients. In particular, lesbian couples already trying to navigate the heterosexism in American culture can pay a high price of potential health and psychological risks at the mercy of medical specialists and drug companies. The progressive private clinics in the USA providing ART neither advertise the risks, nor do they conduct longitudinal research on the occurrence of cancer, ovarian hyperstimulation, and traumatization throughout resulting from ART and post-ART treatment procedures.
Within the context of a pronatalist society there is an evident pressure to have children. Utilization of ART becomes a “neoliberal trope to imagine a life without limits” (Gentile, 2013, p. 255). ART includes in-vitro fertilization (IVF), intra-cytoplasmic sperm injection (ICSI), cryopreservation, and intra-uterine insemination (IUI) (Mann, 2014). IVF, which was first offered in the United States in 1981, is perhaps the most well known method of assisted reproduction. It has resulted in the birth of more than 500,000 children between the years of 1985 and 2006. More than 5 million babies total have been born through ART to date, representing up to 4% of all births worldwide (Asch & Marmor, 2008).
When the decision to have a child with the help of ART has been made, an individual or a couple has yet to encounter and navigate through another set of the demands from the medicalization of reproduction (Mamo, 2007). Biomedical services came into play in lesbian reproductive practice despite the absence of medical diagnosis, and they address the social issues of reproduction through the medical lenses (Mamo, 2007). The charting basal body temperature and menstrual cycle to diagnose anovulation, as well as the careful timing of insemination set the groundwork for the need for advanced technology. The measurement criteria and precise technology set up new standards for people against which to judge themselves. The reproduction process, which usually happens under natural circumstances, is now under the purview of science.
According to the literature (Roberts, 1996; Daar, 2008), most of the individuals assisted through IVF clinics are married heterosexual couples. Daar (2008) states that a woman’s inclination to access ART is directly related to the availability and access to insurance to cover a costly procedure (an average of $10-20K per procedure). Economic hardship constrains choice. Roberts (1996), shares that insurance companies cover only certain procedures (e.g., wife’s eggs fertilization with her husband’s sperm), which creates barriers for lesbian couples to receive assistance on a legislative level and becomes a health equity issue.
Reproductive clinics offering ART procedures thrive on their reputation, which is directly correlated with the “success rates.” Success rate refers to attempts to induce pregnancy and deliver a child. While the medical industry mainly operates with the incentive to increase its profits, it creates a procreative limbo (i.e., not yet pregnant) and “a symbolic liminal space between not-pregnant and soon-to-be-pregnant” (Mamo, 2007, p. 30). The space of not knowing could manifest in a state of uncertainty, which if prolonged could be experienced as traumatic. There is not enough space left for processing the physical and psychological demands of the fertility procedures, which might be dissociative as the woman becomes preoccupied with the outcome of such procedures. Thus, infertility can bring about feelings of shame, grief, loss, emptiness, and anxiety (Mann, 2014). For the individuals and couples seeking medical or psychological assistance, the fertility treatment could serve as another affirmation of not being able to reproduce.
Given the poor understanding of connections within the triad of trauma, sexual identity, and ART, certain groups of individuals are disproportionally put into a double jeopardy. Assuming that ART services will be at even higher demand, there will also be a greater demand for additional supportive services to assist people on both individual and systemic levels. To improve ART, there needs to be a focus on the inclusion of LGBTQI and trauma-informed social services, a re-evaluation of the role of medical providers and social workers within fertility clinics, and a push to expand insurance policy coverage for a growing population (e.g., lesbian couples). Advances with all these facets could improve fertility procedures in way that they would remain lucrative, yet become more humane and patient-centered.
Cultural imagination and idea of “normalcy” to have a child are central in today’s society. The stigmatization and taboo around the topic of individual’s choices about conceiving the child and using ART facilitate further silencing and marginalization from the health care system. A universalism approach or the acceptance of the standard of “The American Family of the Future” (Carter & McGoldrick, 1999, p. 19) blinds individuals to the common welfare of the whole society. The nature of political power in the hands of whites, the affluent, men, and heterosexuals needs to be acknowledged to develop a pluralistic service approaches to assisting diverse clientele (e.g., gay and lesbian). ART could be seen as sentimentality of belonging to society (Mamo & Alston-Stepnitz, 2015) and adapting to heteronormative mainstream (Harrington, 2019).
The power differential manifests on multiple levels within the domain of ART procedures. The medical provider is in a position of power for disseminating information (e.g., what the procedure entails, potential risks and harms related to the procedure, availability of the resources and support services) to the clients and monitoring their bodies. When assisting gay and lesbian clients, the providers need to be aware of society’s homophobia and social stigma, which also persists within medical institutions. The social stress could become a family conflict, especially for populations that tend to be isolated. To increase the contextual supports and enhance the options available for change, the medical providers as well as social workers must use their essential common sense awareness and professional ethics to inform patients about the pros and cons of ART and provide a continuous support for pre-, throughout, and post-fertility assistance procedures.
The Hippocratic Oath is oath taken by physicians to uphold specific ethical standards. It states, “I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing.” The managerialism, privatization and the shift from environmental and patient-centered practice toward medical models has become more prevalent in the field of health and mental health service delivery. An inevitable tension arises – the tension of navigating between the work within the medical private companies while also utilizing professional training and professional judgment in respect of potential physical complications and mental distress of the clients. The service providers need to serve as mitigating agents who facilitate opportunities for women to make informed choices about their decision to conceive the child with the aid of ART (Ross, Steele, & Epstein, 2006).
What is perceived to be a natural process (i.e., conceiving a child) involves medicalization. Some of the side effects of the hormone medication (e.g., Clomid, Serophene, and Pergonal) are cyclothymic symptoms, ovarian hyperstimulation, abnormal vaginal bleeding, vomiting, seizures, stroke, cancer, or even death. Medical responses range from noninvasive to highly invasive. All carry significant risks for both the mother and fetus – about 17% of pregnancies result in miscarriage, stillbirth, abortion, or maternal death prior to birth (Asch & Marmor, 2008). ART could be seen as a treatment that furthers the impersonalized power that medical procedures exert over individuals. Some literature (Gentile, 2013) points out that usually families wait in crowded waiting rooms, with a long wait time, in order to meet with a doctor who will most likely be different each visit.
The entry of a third party – medical provider or a donor – could result in recreating more mistrust toward medical institutions (Daar, 2008; Gentile, 2013), or create a sense of crisis within a couple (Mann, 2014). Women’s bodies are being monitored according to the menstrual cycles and hormonal procedures, which further objectify and take away the control over their own bodies. The lack of control, and close to no time to reflect in between procedures could be particularly re-traumatizing for individuals with a history of sexual abuse. According to Mann (2014), “the infertility can turn into a monthly assault on feelings of masculinity or femininity and can provoke a sense of identity crisis.” As a result, the individual may experience lack of control and confidence in decision-making, social alienation, self-blame, lack of trust, and dissociation of the body (Gentile, 2013).
It could be speculated that historically marginalized and stigmatized population, such as gay women, would be more likely to experience barriers invisible to the external eye, and they will less likely be seeking assistance in cases of psychological distress. Bowen’s concept of differentiation concerning lesbian couples, specifically the responses in a form of fusion or emotional cut-off, depicts a picture of lower self-acceptance and a lesser ability to self-disclose to others (Spencer & Brown, 2007). Given that ART procedures are inherently invasive to the body and the mind, the impersonalization of the process only adds to patients’ emotional distress. This distress needs to be addressed in the clinics where ART services are offered. It is the service providers’ professional obligation to cause no harm. Thus, they need to be trauma-informed and perceptive to the nuances of one’s sexual identity.
Providing emotional assistance to lesbian women after the symptoms begin to surface is not nearly enough. It could be argued that fertility clinics must incorporate an ongoing emotional support to their clients, including screening prior to the start of the procedures as a preventative measure to identify any potential risk factors (e.g., history of sexual trauma). The fertility support services need to be provided within the clinics and not solely in a form of referrals to the LGBTQI-friendly community services. Outside referrals instead of providing an onsite emotional care could indicate further divisiveness of the dominant heteronormativity and the ones who do not conform to the traditional ideas.
Use of modern reproductive technology could lead to experiencing physical and emotional pain, including psychological distress for lesbian couples in the form of internalized homophobia that impacts the bonds between parents and children (Mamo, 2007), as well as traumatization (Chochovski, Moss, & Charman, 2013; Daar, 2008; Gentile, 2013; Mann, 2014; Roberts, 1996). Internalized homophobia could be expressed in directing negative social attitudes about one’s sexuality toward the self, which adversely impacts the self-concept, and then could be transmitted to one’s children. Limited research attention was directed toward repetition compulsion that is the core of ART trials, which manifests in self-induced trauma (Mann, 2014), as well as re-traumatization (Gentile, 2013). Compulsion, for individuals who experienced trauma, is the notion of repeating the repressed material, instead of accepting it as a part of their past (Mann, 2014). Thus, for people who are more resilient in accepting their infertility, or who receive proper and timely support, they will have fewer psychological complications. Otherwise, the trauma could result in narcissistic injury, change in self-representation and the body image perception (Mann, 2014). The repetition of the trauma results in inducing guilt, helplessness, evoked control over other, as well as self-directed aggression (Mann, 2014).
The nature of repetition compulsion resides in the idea of the forgotten impressions (Freud, 1914) that needed to be repressed in order to be less painful. The forgotten material could be understood as forgotten consciously, but it remains alive in individual’s implicit memory (i.e., the unconscious). Painful or traumatic experiences should not be negated simply because there is no language to describe them. In repression it is not the idea so much that is repressed, but the affect associated with the experience. One can re-experience the terror, rage, and helplessness, even though such experiences could be impossible to articulate through words (van der Kolk, 2014). Freud (1914) stated that certain behaviors and the characteristics of one’s personality is the result of experiences of the past.
The therapeutic task consists in translating the experience back to the past and allowing the individual to tell their story; “without stories, memory becomes frozen” (van der Kolk, 2014, p. 221). Creating a safe space for individuals to be able to share and reflect on their stories becomes increasingly important in the realm of ART. Freud (1914) pointed out, “the transference is only a piece of repetition, and that the repetition is a transference of the forgotten past not only on to the doctor but also on to all the other aspects of the current situation.”
The percentage of cycles resulting in term normal weight live births is about 24% for women under 35 years; this number decreases to 4% for women 43 years and older (National Center for Chronic Disease and Prevention, 2019). The fact that ART procedures need to be compulsively repeated multiple times to be effective to conceive, while leaving no time for reflection, resemble the situation similar to the one of sexual trauma. To help the client feel protected and elicit a sense of trust the therapist needs to show the patient that they will be loved and accepted no matter what. It is possible through reparative attachment transference to help unearth the memories of the “forgotten past.” Providing interpretations could help the client to reconcile the repressed material and, hopefully, stop the loop of the repetition compulsion allowing new forms of relating and being to take place.
The individual learns to anticipate rejection or withdrawal in instances of learned negligence and coldness of their caregiver. To cope with a parental hostility the child acts as if nothing happened, while the body remains in high alert. In such state an individual experiences a profound confusion. As van der Kolk remarks, “Dissociation means simultaneously knowing and not knowing” (2014, p. 123). To translate this phenomenon into the context of assisted reproduction, the service provider could be interpreted as a caregiver, and the patient ¬a delicate child. If the former ignores or disavows the patient’s psychological distress it could contribute to dissociation of the latter. Dissociation will further lead to emotional shutdown and not feeling real inside (van der Kolk, 2014).
The creation of therapeutic holding environment serves as a fertile soil for healing to take place. There is little to be said about fertility clinics providing psychological screening or collecting social-historical information about their clients. Ross, Steele, & Epstein (2006) conducted focus groups consisting of 17 lesbian women and offered recommendations pertaining to the participants’ experiences with ART. Women described their fertility clinic’s staff as unwelcoming; the workers were perceived as not being attentive to clients’ life histories and relationships. The responders felt uncomfortable revealing their personal information or asking questions at their clinics. For people to feel accepted and understood, regardless of their sexual identity, there is an evident need to create a more welcoming and accepting environment in clinics, both at the level of the physical space and in the psychological terms of a “holding environment.”
Fertility treatment should not be based on medical procedures only. The sensitive nature of conceiving a child needs to be reproduced in the caregiving atmosphere of fertility clinics; instead many of these clinics seem to create a sense of alienation and confusion. Welcoming and acceptant environment at fertility clinics could be seen as holding environment (Winnicott, 1960). Positive and trusting relationships are central in helping clients to become more connected to their feelings, better engage in fertility treatment procedures, and be more equipped in addressing any potential health or mental health challenges. Also, it is important not to assume that women who use ART have a support system and people who are familiar with the effects of such procedures on person’s body and their psyche. Advocacy around availability and affordability of psychological services needs to take place to supplement women undergoing ART procedures.
With consideration of the nurturing and accepting aspects of the therapeutic work with lesbian women could also supplement the quality of the relationship with their partners. As Sussal (1993) remarks, “Sexuality is grounded in the psychosomatic partnership of mother and infant, and is central as an expression of the emotional commitment made by the partners” (p. 314). Mutual holding relationships perform a reciprocal function of supporting between the partners, as well as their children. The strong therapeutic alliance between mother and therapist positively reflects on the bond between the mother and the child, and it furthers the mother’s understanding of her baby (Sherman, 2003). In contrast, if the therapeutic relationships are not established, it could manifest in intergenerational transmission of trauma and the lack of affective connection and reciprocity between the parents and the child.
It could be argued that the psychological assistance is important not only throughout, but also after the completion of fertility procedures. For instance, the tripartite treatment (between the mother, infant and therapist) could further the mother’s understanding of her child, who might present with anaclitic depression or disorganized attachment style (Sherman, 2003). To circle back to the idea of intergenerational transmission of psychological distress, the mother’s ambivalence about having a child could be expected, due to the stressors associated with ART procedures. As Slade (2000) pointed out, “…just as parents develop representations of their own parents, so do they develop representations of their children, which begin to form long before conception, and evolve substantially during pregnancy” (p. 1155). Having such understanding allows empathy to enter the therapeutic space and engage the mother in ways that induce reflective capacity and a sense of safety, instead of blaming the parent for being unavailable or aggressive (i.e., the term “schizophrenogenic mother” used in the 1950s). The fertility clinic itself is like the first holding environment for the yet-to-be-born child – not just the potential parents. In this sense, the beginnings of attachment (and representations of attachment) are already forming, even if the child is yet-to-be conceived.
Object Relations and Sense of Self
Shifting the societal blame from inability or difficulty to conceive from individuals (especially women) to the expectations of the idealistic neoliberal pressures could assist individuals undergoing fertility treatment in finding a capacity to reflect and make appropriate choices to avoid traumatization. Heterosexual culture and what constitutes a “normal” family shapes one’s ideas about what it means to be a parent. Lesbian individuals could experience guilt and internalized homophobia, as they could not uphold these standards. Internalized homophobia can become layered in the dynamics of each partner’s antilibidinal ego, in recursive fashion creating and recreating greater experience of danger (Sussal, 1993), which could sabotage their intimate relationship. Alleviating guilt could happen when the service providers will begin to interact and support their clients by acknowledging the societal pressures around reproduction, instead of letting the internalized homophobia adversely impact women sense of self.
Fairbairn’s (1943) work provides in-depth understanding of the process of identification and the way in which early object experiences are based upon identification. The idea that identification and internalization vary in severity embraces a broader scope in understanding of trauma. The developmental trauma that results from invalidation by a caregiver, for instance, could be just as detrimental as other traumatic event (e.g., sexual abuse). Trauma and its aftermath shatter the mind, creating self-states that harden and split into separate parts of the self, which Fairbairn (1943) elaborately described as “emotional life of internal objects,” the elements of which are interconnected and constitute the internal object world. The internalized bad objects and unrecognized aspects of one’s self need to be correctly and timely identified by the therapist. To translate Fairbairn’s concept into the domain of assisted reproduction, the medical industry in face of fertility clinics could be understood as bad objects. Thus, it becomes the professional task of the mediators (i.e., service) to become and be perceived as a good object that the client needs. The psychological outcome of fertility procedures could be attributed to some extent to the quality of the real relationships. To assist lesbian women on their journey of becoming a parent the service provides also need to connect to the moral and caring aspects within themselves.
The ideas about procreation and parenting could be perceived as playing central importance to an individual’s identity and life choices. If that is to be true, then the fertility clinics should be regarding their clients as people who bring their unique histories and vulnerabilities, not as just mere consumers of their services. Thus, further involvement of the service providers needs to be the one of expanding individuals’ choices instead of limiting them, despite of the sex, sexual identity, family constellation, and socioeconomic status. With proper resource allocation, such as insurance policies coverage on expanding the lesbian population, it would lessen the institutional barriers in accessing ART treatment. While technologies continue to evolve and the demand for treatment continues to grow, it is more important than ever to conduct rigorous and timely research to help guide policies that are effective and inclusive, as well as and safe clinical practices, and that minimize potential short- and long-term adverse outcomes to individuals involved in treatment. The need for nuanced psychological thinking is paramount in helping people to become aware of their inner state while undergoing or discontinuing ART treatment.
The focus of the paper is to provide insight into the current state of affairs of medicalization of reproductive procedures and their outcomes on the physical and mental health of individuals. Exploring the interconnectedness of the systemic pressures and psychological effects on lesbian individuals who are trying to conceive with the aid of ART can better formulate relevant ways of assisting. There is a higher chance to inform the practice on individual and systemic levels by tapping into tacit understandings of these individuals. Revisiting and improving the existing ART procedures and employed practices will help generate abundant psychological understanding sensitive to the individual’s lived knowledge and experience. Encouraging and making psychological assistance accessible for people may lead to a more positive and healthy experience for everyone involved with ART.
By examining the effects of ARTs within the individual and systemic contexts, there is hope to create preventative measures to emotionally and financially support individuals undergoing infertility treatment. Providing client-centered care and affordable psychotherapy could also help to re-evaluate neoliberal pressures and expectations from individuals (especially women) in order to assist people in finding a capacity to reflect and make appropriate choices to avoid further traumatization. Trauma-informed and perceptive to the nuances of the individual’s sexual identity fertility clinics’ staff would help to destigmatize and engage a diverse population that wishes to pursue fertility treatment. The value of researching the interconnectedness of trauma, sexual identity, and ART lays in deepening our understanding of how reproductive technologies disproportionally impact individuals’ health with the account for diversity.
The intent of this paper is to help begin a broader discussion among fertility clinics coordinators, medical staff, and social workers who are involved in working with the lesbian population in being conscious of the intricacies of the ART procedures, as well as their pre- and post-procedural psychological effects. Development of a greater awareness around fertility treatment could allow for the greater engagement of higher institutional entities (e.g., medical industry, insurance companies), in appropriating informational resources and advancing medical coverage beyond profiling based on sexual identity or sexual orientation all to support the fulfillment of individual’s desires and promote healthy choices. Researchers and therapists in examining current practices and exploring relevant relational therapeutic interventions could then support underrepresented clients, such as lesbian population, in ways that provide space to reflect on their experiences, and make informed choices about interventions that are consistent with the known fertility.
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