The answers to an innocent question asked 10 years ago have led Emory anthropologist Marcia Inhorn to her dissertation, two books, a major national award, several research projects, and down the initial stretch of a promising academic career.
In 1985, Inhorn, then a graduate student at the University of California/Berkeley, was part of a multidisciplinary team in Egypt studying the blinding eye disease trachoma. As she visited rural villages and observed families, Inhorn often asked married couples whether or not they had children.
The answers she received seemed unusual and far from straightforward. Childless couples were much more uncomfortable with this simple question than most western couples would be, and they almost always expressed the expectation of better fortune in the future.
Intrigued by this awkward reaction, Inhorn pursued the subject and learned that not only was childlessness almost never a conscious choice of Egyptian couples, but also that infertility was in fact a grave social problem for women.
In 1988 she returned to Egypt to work and conduct research in an Alexandria infertility clinic. Information garnered through personal interviews in the clinic and in homes and small villages led to her dissertation and later to two books: Quest for Conception: Gender, Infertility, and Egyptian Medical Traditions and Infertility and Patriarchy: The Cultural Politics of Gender and Family Life in Egypt.
In November 1995, the Society for Medical Anthropology of the American Anthropological Association named Quest for Conception the best book of the year on gender and health and presented Inhorn with the Eileen Basker Award. The book describes the multiple ways in which Egyptian women seek a cure for infertility. Inhorn's second book, Infertility and Patriarchy, confronts the gender issue in infertility, the role of patriarchy and the social dilemmas of infertility from a feminist context.
Egypt sits just above the "infertility belt" of Central Africa, which begins in Sudan and stretches into West Africa, explained Inhorn. Although Egypt's infertility rate is not one of the highest, the causes of infertility are the same throughout the region. Sexually transmitted diseases are common, often leading to infection and occlusion of the fallopian tubes. This kind of infertility is one of the hardest to treat, and in vitro fertilization offers the best hope. While doing her research, Inhorn found that as many as one-third of all patients in some gynecology practices were seeking health care due to infertility.
Medical practice in Egypt lags far behind the West; in fact, a common cause of infertility in Egypt is iatrogenesis, or medically induced harm. In trying to correct problems of infertility, many physicians in private practice still commonly use outdated procedures that lead to infection and irreparable reproductive problems.
"This is not done with malicious intent," Inhorn pointed out, "but because physicians believe that doing something is better than doing nothing at all. Some of these practices date back 50 years. There is no continuing education requirement, and the procedures generate income in a competitive medical environment. Although many university physicians are critical of these outdated practices, in the absence of a national protocol for reproductive care, things are unlikely to change."
Most national initiatives in medicine in developing countries come from international agencies such as the World Health Organization, which encourages improvements in public health practices. Population reduction is such an established priority, however, that infertility usually is overlooked as a problem in Egypt as in most of Africa. Inhorn believes it deserves much more respect.
"I have always had detractors who wonder why I want to study infertility in a place with an overpopulation problem," she said. "But in a high fertility society like Egypt, which is very pronatalist, both culturally and religiously, infertility causes significant social problems and often drives women on a desperate therapeutic quest." This quest includes not only visits to medical physicians, but also ethnogynecologists, including midwives, spiritual healers and herbalists.
In her second book, Infertility and Patriarchy, Inhorn noted that in a patriarchal society such as Egypt women usually are blamed for infertility problems, even though statistically at least 40 percent of all infertility problems are attributable solely to the male. In Egypt, even when men are recognized to have an infertility problem, women still usually are the solution seekers.
Many times pressure to do so comes from the husband's family. Although Inhorn found that men in loving, committed marriages usually are happy with their wives despite childlessness, the problem comes from the husband's female relatives, who can be very cruel and insulting.
"In Egypt adults often continue to live with their extended families, where they are enmeshed in loving, connected relationships," said Inhorn. "Children are an important addition to the family line, especially to the husband. When couples can't have children, their families become very involved. Although the wife's family wants the marriage to work, the husband's family often tries to influence the husband to divorce."
Infertile women also are stigmatized because of the danger they might pose to other people's children. A major cultural belief in Egypt, said Inhorn, is that children fall ill because an infertile woman may be so envious that she gives a child the evil eye.
Inhorn will return to Egypt this summer under a Fulbright-Hays grant to study in vitro fertilization and the growing Islamic reaction to reproductive technologies.
"There are an estimated 27 million infertile Muslim women worldwide," she said. "We need to broaden the scope of what we consider to be women's health issues."
-- Holly Korschun