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Department of Sociology and Anthropology The Hebrew University of Jerusalem
The Medicalization of "Nature" in the "Artificial Body": Surrogate Motherhood in Israel
In this article, I draw on anthropological and feminist scholarship on the body and the nature/culture divide as a framework for understanding the place of surrogate mothers in a conceptual ideology that connects motherhood with nature. I explore links between the medicalization of childbirth in Israel and the personal agency of surrogate mothers as relayed through interviews. Taking the patriarchal context of the Israeli surrogacy law of 1996 into consideration, I underscore surrogates' imaginative use of medical metaphors as tools for the subversion of surrogacy's threatening social connotations. By redefining the surrogate body as "artificial" and locating "nature" in the commissioning mother's body, surrogates adopt medical rhetoric to transform surrogacy from a transgressive act into an alternative route toward achieving normative Israeli national reproductive goals, [surrogate motherhood, medicalization, nature, body, agency, Israel]
he theorization of the body in sociology and anthropology has become increasingly popular over the last two decades. Although the body has historically been located on the "nature" side of the nature/culture divide (Bordo 1993), it has become clear to students of culture and society that there is no "natural" perception of the body that is free from the social dimension (Douglas 1970). The body is no longer regarded as "instinctual" or "natural" (Foucault 1972) but, rather, as already and always inscribed by culture and anchored in a particular historical moment (Scheper-Hughes and Lock 1987). As a result, contemporary scholars are forced to consider the body as constructed in unison with the discourses and artifacts of science and technology (Haraway 1991). In the literature on motherhood, however, the assumption remains that women's bodies are deeply rooted in nature, their reproductive biology serving as a harness to their freedom. From Simone de Beauvoir's (1957) first protest that the female body "trapped within the web of nature" was the root cause of men's control of women's lives to Ortner's (1974) distinction between women as nature and men as culture, feminist scholars have theorized women's natural and cultural conditioning
Medical Anthropology Quarterly 17(1 ):78-98. Copyright © 2003, American Anthropological Association.
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into the maternal role. Echoing the view that women are enslaved to men because of their "natural" reproductive bodies, Shulamith Firestone (1970) proposed the "artificial womb" as a possible way to free women from the bonds of their bodies. A second group of feminist theorists took a different approach, seeing possibilities for women to exert their agency through the strength and pride exhibited in their mothering practices (seeChodorow 1978; Dinnerstein 1976; Ruddick 1980). Their views yet again reflected a belief in the rootedness of the maternal role in nature, as they grounded their claims in the idea that every woman has a deeply rooted, natural, biologically determined desire to become a mother. Considering childbirth to be a "natural" process that creates an immediate, instinctive "maternal bond" between mother and child, these theorists not only implied that motherhood is the core of womanhood but also that only women who are mothers can truly exercise their agency and reach full empowerment (Burner 1993). Romanticizing childbirth and pregnancy, these theories only strengthen the nature/culture divide in the discussion of maternal "nature." A number of female anthropologists have taken a critical look at these theories and stressed just how rooted in culture motherhood really is. Nancy ScheperHughes's (1992) account of poor women in a Brazilian shantytown, who guardedly delay "bonding" with their newborn until the child has proven its will to survive, and Meira Weiss's (1994) analysis of Israeli parents' astonishingly high rate of rejection of physically impaired newborns paved the way toward the rupture of the motherhood myth. Today, prominent anthropologists such as Marylin Strathern argue that "if nature has not disappeared, its grounding function has" (1992:195). Susan Kahn develops this idea, claiming that oppositions between "nature" and "artifice" are "profoundly destabilized by the advent of the new reproductive technologies, which have eclipsed "nature" and its ability to serve as a field of metaphors for culture" (1997:24). Other anthropologists who study reproduction, such as Sarah Franklin (1995,1998) and Rayna Rapp (1997), continue to challenge the nature/culture dichotomy in the sphere of the new reproductive technologies and genetic testing, showing that "nature," now constructed by science, has essentially "become" culture.
Dynamic Models of "Natural" Kinship Despite these convincing attempts to discredit the nature/motherhood continuum, the connection between motherhood and nature persists in the popular imagination in many cultures (Lewin 1995). A large body of work on the anthropology of reproduction has been devoted to elucidating the ways that infertile women draw the line between nature and culture in their personal encounters with assisted conception. Studies conducted in the United States by Sandelowski (1993) on in vitro fertilization (TVF) patients and by Lewin (1998) on lesbian mothers using donor insemination document different ways that women "naturalize" such technologies to make their own culturally assisted maternity more "natural." Comparing the naturalization techniques used by IVF patients and parents through surrogacy, Cussins (1998b) has shown how the same technology can be oppositely "naturalized" according to different agendas. Whereas IVF patients using donor eggs dismissed
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genetics and claimed maternity through gestation, parents through surrogacy negated the importance of gestation in favor of a genetic kinship model. Ragone* (1998) has also described the act of selectively defining "natural kinship" in the context of surrogate motherhood. She presents cases of women who begin the process of gestational surrogacy but become traditional surrogates after IVF treatment fails. This change from gestating a nongenetically related fetus to providing the female gamete brings about an explicit shift in the way such women describe their role. As gestational surrogates, they attribute their lack of maternal feelings for the fetus to the fact that it is not genetically related to them. When this genetic kinship model no longer serves their purpose, however, they shift to a social model in which desiring and nurturing a child is more significant than gestation or genetics. Whereas in all of these studies, women draw on different kinship models to make technologically assisted kinship more "natural," the women in my study negotiate the meanings of nature and artifice in a way that aligns them both with their own personal systems of meaning and with the reproductive goals of Israeli society and the nation-state. This study thus presents another perspective on the "ontological choreographies" (Cussins 1996) of technologically assisted maternity, because Israeli surrogates face the challenge of reconciling their actions not only with their personal ideas regarding maternity but also with their pronatalist national culture. It is therefore important to outline the connection between maternity, nature, and nationalism in Israel. "Nature," Motherhood, and Surrogacy in Israel The dominant ideologies surrounding maternity in many countries focus on the "natural" role of women as mothers with special bonds to the children they bear (see, e.g., Gailey 2000; Inhorn 1994; Pashigian 2002). In Israel, however, this "natural" role is nationalized and deeply embedded in Israeli culture. Israeli women participate in what has been described as a "cult of fertility" underlain by a pronatalist ideology of compulsory motherhood (Rappaport and Elor 1997). The Israeli reproductive impulse is rooted in a variety of factors, including the biblical directive of Jewish tradition to "be fruitful and multiply" and the emotional needs of a people in a permanent state of war (Yuval Davis 1989). In a country that situates the family as the cornerstone of the nation's construction, it comes as no surprise that women enter into symbolic relations with the state specifically through their roles as wives and mothers (Rappaport and Elor 1997). Reproduction is celebrated as the Jewish-Israeli woman's "national mission," a notion that has been explored both as a product of social pressure and of explicit encouragement by the Israeli government (Amir and Benjamin 1997; Berkovitch 1997; Morgenstern-Leissner 2002). This pronatalist focus is symbolically expressed in the laws and regulations relating both to abortion and the new reproductive technologies. The cultural reproductive imperative is so strong that Israeli legislation actively encourages Israeli women to pursue technologically assisted reproduction. In contrast to other countries, where IVF and donor insemination are illegal, limited lo married couples, or privatized and extremely expensive, in Israel such procedures are both legal and funded by the state. The National Insurance Law ensures full funding of artificial
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insemination for both married and unmarried Israeli women as well as up to seven rounds of in vitro fertilization per child for up to two live births. In contrast, one round of IVF in the United States costs from $5,000 to $20,000 (Kahn 2000). It comes as no surprise that Israel has more fertility clinics per capita than any other country in the world and that Israeli women participate in state-sponsored prenatal genetic screening at exceptionally high rates (Ivry 2001) in an attempt to ensure the perfect "chosen bodies" of their offspring (Weiss 2002). The surrogacy law of 1996 brought the "cult of fertility" to a new height, providing Israeli women with even more options to populate the nation. Through her contractual relationship with a childless couple, for whom she carries a child to term in exchange for payment, an Israeli surrogate deviates from the "normal" and "natural" life course. Because it is opposed to the "naturalness" of motherhood in the popular Israeli imagination, surrogacy is associated with violations of the natural order, much like lesbian motherhood in the United States (see Lewin 1995). Surrogacy is transgressive because it places women in unique relationships with "nature." Commissioning mothers see themselves as having failed to heed their "natural" and national calling, whereas surrogates risk doing something "against their maternal nature," that is, relinquishing the children they bear to the custody of others. In gestational surrogacy, where the embryo is formed from the commissioning couple's genetic substance, surrogacy is seen as a medium for the commissioning mother to achieve her natural, national duty and to realize her womanhood. At the same time, it places the surrogate in the problematic position of violating her "natural" procreative urges and denying her maternal instincts, her gendered national duty, and her cultural role. Surrogacy is thus a practice that simultaneously reifies and subverts the national and natural orders. Given the mandate of motherhood in Israel, how do women retain their cultural role and their national and personal identities when they take part in a procreative process that does not result in their own motherhood? I argue that the medical arena emerges as a site through which Israeli surrogates negotiate this careful paradox. Medicalized reproduction becomes a field of potent metaphors that surrogate mothers draw on in their efforts to align "nature," "maternity," and national reproductive goals with their role as surrogates. In this light, it is important that we consider how "nature" and "culture" are understood in the context of medicalized childbirth in Israel. Processing "Nature": The Medicalization of Childbirth in Israel In accordance with the popular belief in maternal "nature," feminist authors have critically attacked the medicalization of childbirth specifically because it has led to the transformation of birth from a "natural" to an unnatural process requiring medical control. Linking "nature" with women's agency, feminists view medical intervention in childbirth as decreasing women's control of birthing and as alienating them from a potentially empowering experience (Fox and Worts 1999). Medicalization is seen as so fully disruptive of women's "natural" control during childbirth that it has even been considered a cause of postpartum depression (Oakley 1980). Some feminists have argued for a return to midwifery, wherein birth occurs as a natural process with minimal medical intervention. This return to "nature" is
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seen as empowering women to control their own processes of pregnancy and birth (Turkel 1995). The effects of medicalization on women's lives have been explored in various contexts, from hospital rituals to medical rhetoric. Anthropologist Robbie DavisFloyd (1992) claims that obstetric rituals surrounding childbirth in U.S. hospitals communicate culturally specific messages about the necessity of culturally controlling natural processes and about the untrustworthiness of nature. She suggests that these rituals also communicate the weakness and inferiority of the female body and the validity of patriarchy. Likewise, Emily Martin (1992) has shown that descriptions of human reproduction in medical textbooks reflect similar themes, attributing negative, feminine characteristics to the "fragile" human egg and positive, masculine characteristics to the "macho" sperm under the guise of "natural facts." Whereas Davis-Floyd's and Martin's research reflects postindustrial, capitalistic forces in the United States, the medicalization of childbirth in Israel mediates interactions between pregnant Israeli women and the state. Israeli reproductive legislation entitles Israeli women to miss 40 hours of work without a salary cut for medical appointments during pregnancy. The state not only funds a woman's medical care during pregnancy and her hospital expenses but it also rewards her with a special monetary grant for giving birth in a hospital rather than at home (Ivry 2001; Morgenstern-Leissner 2002). In surrogate pregnancies, the state's implicit desire to gain control reaches an apex. Whereas all of the benefits mentioned above are extended to both the surrogate and the commissioning mother, the surrogacy law of 1996 directs that surrogacy births be carried out exclusively in Israeli hospitals and only in those units approved within the context of the law. The "Law of Agreements for the Carrying of Fetuses," as it is called, made Israel the only country in the world besides the United Kingdom to allow state-controlled surrogacy (Benshushan and Schenker 1997) and the only country where all surrogacy contracts are legislated by a government-appointed committee (Kahn 2000). The members of the committee, who are chosen by the national Health Minister, must approve every surrogacy contract carried out under the law.' Although the law is a fascinating patriarchal artifact eagerly calling for an indepth anthropological analysis, here I will focus on its effect on the medicalization of Israeli women's bodies. In order to qualify for surrogacy, medical and genetic histories of the surrogate and both members of the commissioning couple must be supplied to the committee. In addition, they must provide proof from the rabbinate of their Judaism and a statement from the police pertaining to any criminal records. Furthermore, all three are examined for disease and mental deviance through a series of blood tests, psychological examinations, and social aptitude tests. The law limits surrogacy to couples in which the woman is unable to become pregnant or to carry a pregnancy to term. Often such women are forced to prove their barrenness to the committee.2 "Traditional" surrogacy, in which the surrogate herself provides the female gamete, entails simple artificial insemination. The Israeli surrogacy law, however, limits the surrogacy option to the gestational variant only, which is necessarily dependent on IVF technology. The female gamete can be supplied either by the commissioning mother or by an anonymous donor, but the law specifies that the commissioning father must provide the sperm.
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The medicalization of the surrogate's body is written into the surrogacy contract itself in the form of her agreement to refrain from the use of alcohol, cigarettes, and all drugs during the pregnancy.3 Her body is harnessed by her signed agreement to refrain from sexual contact and to stop her regular work during part or all of the pregnancy; to receive daily injections, undergo periodic blood tests, and ingest all medicines and vitamins vital for fetal growth. She must also agree to any prenatal screening or diagnostic procedures, such as amniocentesis, and to abort the fetus or undergo selective reduction, cesarean section, or intrauterine fetal surgery, according to doctors' recommendations. The surrogacy law thus emerges as an extreme example of medical, legal, and state intervention in Israeli women's bodies and lives. • As a result of these strictures, surrogacy in Israel is shaped into a locus where "culture" controls procreation with the help of powerful state institutions. It is within this web of power controlled by legislation, state representatives, and doctors that Israeli surrogates maneuver. Despite the encompassing reach of this power nexus, however, surrogacy is also a locus where women creatively exercise personal agency. The "Nature" of Paradox: Medicalization and Women's Agency The line between compliance and subversion is always a fine one and difficult to draw. Men and women are not rendered passive and compliant by virtue of their entanglement in various networks of power, nor do such networks render women more subject to corporeal production than men. Whereas Foucault (1973) saw the body as a medium on which power operates and through which it functions, others (e.g., Grosz 1994) have pointed to the possibility of resistance inherent in the body. The majority of anthropological and feminist literature on medicalization has been informed primarily by Foucauldian thought, which views medicalization as necessarily hostile to female subjectivity (Klassen 2001). If we focus only on the power imbalance that causes the birthing woman's loss of control and disempowerment in relation to the doctor, however, we overlook the agency of women who accept medical management of their births and their use of medical intervention toward their own ends (Fox and Worts 1999). Studies have, in fact, shown that many women are not alienated by the medicalization of birth but actually welcome medical intervention into their pregnancies (Fox and Worts 1999). Sargent and Stark (1989; see also Ivry 2001) found that birthing women's definitions of control and participation in the birth process included medical intervention as a prerequisite. In order to participate fully in birth, the women they studied wanted to be wide awake and pain free. Thus, 78 percent willingly chose epidural injections even before contractions became unbearable. Mitchell and Georges (1997) have also uncovered fascinating empirical evidence that women in Canada and in Greece choose ultrasound willingly, often "bonding" with their fetus through the medical medium before they ever "feel" the fetus move within them. In fact, even women who opted for nonmedicalized birth at home have been shown to make this choice against a backdrop of biomedical support (Klassen 2001). Klassen has found that some reliance on the biomedical approaches they had purportedly foresworn was critical in empowering her informants to choose
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home birth. Fox and Worts (1999) similarly found that some of the women they interviewed perceived medicalized birth as more empowering than nonmedicalized birth. Whereas many women welcomed medical intervention because it promised to leave them in better shape to assume their maternal responsibilities, other women complained of a lack of control because of the hospital staffs failure to intervene quickly enough in response to their requests for pain relief. Surrogate Mothers and Medical Metaphors As Greil (2002) reminds us, much of the anthropological literature on women's responses to the medicalization of childbirth draws too sharp a line between acquiescence and resistance. He argues that we should pay closer attention to the creativity and agency of women working within medical frameworks to achieve their own ends. It is through this lens that Cussins (1996) describes IVF patients who manifest personal agency through their objectification during such medical procedures as pelvic examinations, ultrasound, and laporascopic surgery. The technological objectification of their bodies does not harness these women's agency but, instead, serves as an avenue through which they actively pursue and negotiate control over their reproductive futures. Taking Cussins's understandings one step further, Greil (2002) claims that the infertile women he interviewed lived in several metaphoric worlds at once, calling on different vocabularies to express the way that infertility had affected them. As I have demonstrated, Israeli surrogate mothers also draw on medical, commodity, and technological metaphors to shape their pregnancy experience according to their own terms (Teman 2001). Here I focus specifically on Israeli surrogates' use of medical rhetoric as an expression of personal agency. The data I present are derived from a larger research project that examines various facets of the Israeli experience of surrogacy. As I have noted, surrogates draw on multiple metaphoric worlds in their narratives as a means of distancing themselves from their pregnancies (Teman 2001). Their use of medical rhetoric, however, is especially prominent. Medical metaphors appeared in all of the surrogates' narratives I recorded, most likely because of the central role that reproductive medicine plays in the gestational surrogacy process.4 Ethnographic studies have revealed that when pregnancies are medically managed, most women learn to describe their bodily changes through the language of medical technology rather than experientially (Martin 1987). Accordingly, the gestational surrogates I interviewed used medical metaphors in an imaginative way, with a strong sense of familiarity and confidence, not far removed from the language of the medical professionals from which they were adapted. Taking metaphors from mainstream biomedical discourse, surrogates claim that their "artificial" surrogate pregnancy has no connection to "nature," to their "natural body," or to the "natural" maternal instincts that they had while carrying their "own" children. It is to the way that Israeli surrogate mothers use medical metaphors to create the "artificial body" that I now turn.
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Methods The research described in this article is based on in-depth, open-format interviews and many hours of participant-observation with eight Israeli surrogates and 11 Israeli commissioning mothers. Typically, the interviews took a narrative form, with the woman responding to my request to "tell your surrogacy story from wherever it begins." Most interviews were conducted in women's homes and lasted an average of two hours. The interviews were tape recorded and transcribed verbatim, then translated from Hebrew to English. Surrogates and commissioning mothers ranged in age from 34 to 42. Geographically, they were drawn from the entire length of the country, from south of Be'er Sheva to north of Haifa. Three of the commissioning mothers held bachelor's degrees, and eight held steady jobs. Only one surrogate had a bachelor's degree, and she and the other surrogates all worked in temporary jobs. All of the women interviewed were Jewish, and all but one had been born in Israel. Still, they associated themselves with a wide variety of ethnic heritages, including Russian, Georgian, Yemenite, Moroccan, Egyptian, and Kurdish. The "Artificial" Body Surrogates referred to their bodies during surrogacy as "artificial," creating a distinction between the "medically managed" body of surrogacy and the individual, "natural body" that they inhabit regularly. One surrogate, Sima, distinguished between her own body and the "artificial" body in terms of her own system being "suppressed" through medical management: "Before that you get ten days of injections, every day, in order to suppress your system . . . your biological system. To suppress it and prepare your womb for absorption of something else, (something) strange, in an artificial way." Sima draws a clear line between her own "biological system" and the "artificial" system that temporarily replaces it during surrogacy. The medical management of the pregnancy then becomes a tool with which she formulates her personal conceptual logic of surrogacy. She endows the hormone injections with powerful agency capable of temporarily pushing "nature" out of her body to make room for "something else." However, the clear division between nature and artifice that the hormones enable subsequently give her the opportunity to disclaim the connotations of "natural" pregnancy. In this way, Sima and other surrogates drew on its unnaturalness to establish that the surrogate pregnancy was not predestined to give rise to the "natural" maternal feelings that they normally associated with pregnancy. Orna explained how the hormone-injected artifice neutralized her body so that such "normal" emotional attachment does not occur: It is not mine. It is all artificial The hormones do it all instead of me. My brain doesn't even know that I am pregnant. My brain is suppressed with the shots that they give me. It turns my brain back to zero. Then all that is needed is given through pills. Through hormones . . . the brain is the injections. Instead of the brain ordering one, two, three, the hormones need to go up, need to go down, and then the injections do everything.
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In her narrative, Orna clearly outlines the relations among her mind, body, and personal self. So firmly set on consciously disembodying the pregnancy, Orna claims that her "brain doesn't even know" that she is pregnant. Like Sima, she projects conscious determination on the hormones that enter her system, replace any traces of "nature" in her body, and "do it all instead" of her. The injections become her brain, with her body an artificial entity that is "other" to her and over which she has resigned all control. In this way, Orna established how all personal aspects of her being are clearly divided from the mind and body that she has partitioned off for involvement in the surrogacy process. This rhetorically enabled division subsequently allows her to "medically prove" that this pregnancy is not her own. Like Orna, Rinat also embraces the medical manipulation of her body to establish that the surrogate pregnancy is outside of "nature." She too claims that the hormones regulate the surrogate body: It isn't regular. You have to take their hormones, because the hormones aren't yours. And you start to get bloated.... In the beginning I got a bit round... and I am usually very small in my pregnancies! See, now [pointing to her stomach, currently pregnant with her own child], from the beginning of this pregnancy, mine, till now, I've gained one kilo or so. With them [pointing to her two youngest children playing on the floor], I lost weight during the pregnancy.... But here [pointing to a photo of herself pregnant, with her arm around the commissioning mother] I weighed seventy something kilo from the injections and the hormones that they gave m e . . . suddenly I got a bottom, I got a tummy, I got thighs... from the hormones. The hormones change your body. And my hair fell out. I would go like this [scrunches her hair] and it fell... because of the hormones. They aren't yours. The hormones that enter your body are strangers. They give them to you in injections. It is hormones for the baby to develop well. Rinat compares her "natural" body during her own pregnancy with the "artificial" body that the hormones created during surrogacy. She details how signs of her own body's naturalness fell away during surrogacy and how her body changed shape as "proof of its "otherness": her hair fell out in bunches, her stomach and bottom grew round. Like Sima and Orna, Rinat has not only willingly relinquished control of her body to medical management, but she also seems to encourage the hormones to enter her body and relieve her of responsibility for this pregnancy.5 It is she, however, who remains ultimately in control. She welcomes these "strangers" into her system in order to use them as conceptual pawns to help her disembody and depersonalize the pregnancy. As active participants in the medical manipulation of their bodies (Teman 2001), these women partake in a Goffman-like exercise in intentional submission, subordinating their will to the structural power of the medical practitioner to achieve their own purpose (Cussins 1996). Their compliance thus overturns any arguments that have been made in the past regarding the control of women's bodies by medical technology (see Corea 1985). What could be seen simply as a classic example of women willingly accepting the medicalization of their bodies thus becomes a lesson in the clever strategies that they use to subvert external control of their bodies from within the system. If medical technology is an implicit part of gestational surrogacy, then these surrogates make sure that they are the ones to shape its course. As a result, they view themselves as powerful agents who allocate
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control over their bodies to the artificial substance that best suits their own conceptual boundaries of body, self, and nature. Genetics and the Relocation of Nature Furthering this conceptual model of nature and artifice, surrogates were also quick to separate their own bodies from the fetus, often through the employment of a genetics discourse. One Israeli surrogate, quoted by Kahn, expressed surprise that the first questions many potential couples asked her concerned her height and ethnic affiliation. Interpreting surrogacy through her understanding of human genetics, she asserts that her own characteristics and those of the fetus she carries are mutually exclusive: "What does it matter (referring to the inquiry regarding her height)? I have no effect on the kid. It is their genes" (Kahn 1997:153; emphasis added). She goes on to say that she is particularly disturbed by couples who ask her to donate her egg, because doing so would mean giving up her child. The metaphor of genetic kinship is repeatedly engaged by surrogates to emphasize their disconnection from the fetus and to emphasize the "natural" genetic connection between the commissioning couple and the child. This emphasis allows surrogates to safely locate "nature," now actively suppressed in their own bodies through injected artifice, in the commissioning mother's body.6 Another surrogate repeatedly stressed that because the commissioning couple provided the genetic substance, the child is their product, not hers:
I saw her [the surrogate child she bore] two months ago and she has grown and looks very much like her parents. There is no resemblance between us. You must understand that all of the genes are hers [the commissioning mother's] and her husband's, and therefore the girl resembles her [the commissioning mother's] husband very closely.
The excerpts above add another layer to the interconnected map that joins nature, medical technology, and maternity for these surrogates. Whereas hormones created artificial, impersonal relationships, here we see that kinship and nature are rooted in the genes. Whereas Ragone' (1998) and Cussins (1998b) both found that U.S. gestational surrogates drew on genetic models of kinship instrumentally— discarding them in favor of social kinship models when they no longer served the surrogate's purpose—Israeli surrogates used this model of genes, maternity, and nature consistently as their central explanatory model.7 Drawing from media accounts of Israeli surrogates, Kahn (2000) suggests that these particular beliefs about the biogenetic origins of motherhood are essential to Israeli women's willingness to become surrogates. Her argument suggests that without the medical knowledge that they have no genetic connection to the child, these women might not have chosen to become surrogates at all—a hypothesis that is impossible to test in the Israeli case because traditional surrogacy is prohibited by law.8 Kahn also points out (2000:152) that the biogenetic understanding of relatedness professed by Israeli surrogates directly contrasts with the Halakhic understandings of relatedness that are at the core of the surrogacy law. In other words, although Jewish law determines kinship through gestation rather than genetics, surrogates dismiss the importance of gestation in favor of a genetic kinship model.9
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By juxtaposing the determined devotion of Israeli surrogates to a genetic model of relatedness against the dynamic shifting among diverse kinship models by U.S. surrogates, it is possible to begin to outline a particular logic behind Israeli women's understandings of maternity—a logic contrary to the Halakhic perception: when the genes are "hers," then "nature," gestation, and maternity are personalized for a woman. When the genes are not "hers," then nature, gestation, and maternity are foreign to her.10 Nature thus appears as a personal, durable "substance" that begins in the genes but can be embodied and disembodied at will. A woman's "nature" is removed from her during a surrogate pregnancy to make room for the commissioning mother's maternal "nature" to develop in the "artificial" womb without interference.1 l Maternity simply follows "nature's" path, as evident in Rinat's words:
Some [neighbors] said, "Oy vey, she is giving away her children." They just couldn't digest that it wasn't mine. Nothing of mine is there. Nothing, nothing is mine here. It is only theirs [the couple's]... nothing of him, not my blood. No. It is all theirs . . . what was put into me is a whole baby. It is ready. A baby that is formed from the sperm and egg together and was created as a baby and only then inserted into my stomach. And then what is attached to me is just in the placenta and the umbilical cord. But nothing else is mine. Nothing, nothing is mine.... And that is why I am telling you, that you don't have feelings [for the fetus] like you would expect.
Rinat links nature with maternity in a way that allows her to refute the taunts of her neighbors, who see her actions as transgressive. Whereas her own children are "naturally" her responsibility because they share a common biogenetic substance with her, Rinat has no maternal connection to the surrogate fetus because she shares "nothing" (repeated six times) with him. Rinat's preteen daughter has adopted her mother's interpretation and uses it to explain her mother's actions to her friends: "He is not related to us. His blood isn't our blood. Nothing is ours. It is the blood of the commissioning mother, of the parents. I would like to have him as a brother, but he isn't ours." Rinat's daughter adds the element of blood to the conceptual model of nature and motherhood. Nature not only exists in the genes and selectively in the womb, but it also resides in the blood of genetically related kin. Parents and children share the same blood, according to this model, whereas those who are not genetically related, even if they are gestated in the same womb, share "nothing." As reflected in Rinat's daughter's words, surrogates use the nature/maternity model to explain to their children where their familial blood boundary ends and the commissioning couple's blood and genes begin. Another surrogate takes the idea of blood/nature even further, using it to explain how her own natural biological system has remained untouched by the biogenetic substance of the commissioning couple, even as they coexisted in her body. She embraces scientific discourse to explain her "biological" distance from the fetus in an assured, didactic manner:
The egg and the sperm aren't mine, right? There are cells, I just develop those cells. I mean, the cells divide with his genes. For instance: when you get a blood transfusion, you don't change all of your blood.... The blood that they give you, it helps you make more of your own blood. It has to be the same type of blood, because you can't mix two different types of blood, but it just helps your own body
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recover by itself. It is the same thing here. You have a cell, an embryo, and it just needs a little help from outside in order to develop into a fetus. The genes of the child aren't mine . . . I feed him, develop his genes. But not mine. My genes are something else. His looks, his personality, he takes nothing from me. It is all there in four little cells, eight cells, thefirstcells, everything is already there. Even the shape of his nose is in those two cells.... I have nothing to do with this embryo. I have no genetic connection to him I have no connection to him. By imagining the child as a whole unit simply transferred into her body for the length of the pregnancy, this surrogate concretizes the separation between the fetal body and her own. She repeatedly refers to the hormones as "injections that neutralized my natural cycle" and to the*medicines that stopped her "natural" ovulation cycle "so that the doctor could control my body." She imagines an "other" residing in her body without becoming part of it. The fetus exists in a separate blood/kinship system that does not disrupt or mix with her own "blood," even while developing within her. From the conceptual constellation that has been mapped out so far, it appears that surrogates view their own and the commissioning mother's biological systems as naturally imbued with genetic substance, blood, and bodily reflexes that give rise to traditional maternal feelings. These natural properties, however, can be stripped away temporarily or suppressed by the introduction of an "artificial" substance into the body. Whereas informants never mention the hormones the commissioning mother receives to increase her egg supply, they describe those injected into the surrogate as having the potential of erasing any "natural," maternal feelings that may reside in the surrogate's unmedicated body. Calling on different definitions of what is natural and maternal and what is not, these women engage in serial moves of embodiment and disembodiment, personalization and depersonalization, through which they ultimately create a personalized logic of maternity: of what constitutes it and to whom it belongs (Cussins 1996). The constructed nature of this model comes to light when compared with the narratives of IVF patients, who receive similar hormone treatments but view them as bringing "nature" back to the body (Cussins 1996; Franklin 1998; Sandelowski 1993) rather than replacing it with artifice. Why are Israeli surrogates so determined to prove that "nature" has no part in the surrogate pregnancy? And to what lengths do they go to prove this point? Fooling Nature At the height of their navigation of the nature/culture paradox, Israeli surrogate mothers see themselves as "conquering" or "fooling" nature. This notion can best be summed up in the words of a surrogate named Sarah, who whispered to me: You know what I said to Danit? [her commissioning mother]. I said, "It is kind of like we are fooling G-d!" I mean, I believe in G-d and I know that it is a horrible thing to say... I hope that I don't get punished for saying it, but it is kind of true. I mean, maybe we're not fooling G-d, but we're definitely fooling nature. Yes, I guess that G-d is the one who helped us find one another and the doctor, of course— so G-d is helping us fool nature.
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Sarah's comments underscore the degree of power surrogates see themselves as possessing within the surrogacy process. Sarah plays with the idea that she and her commissioning mother are "fooling G-d," an idea she quickly retracts, revealing the importance she attaches to this almighty being against whom she positions herself. Still, she tempers her statement without detracting from her own authority. In the end she claims that G-d and the doctor are there to help her and the commissioning mother, the main actors on this reproductive stage, "fool nature." In a similar light, Orna describes how she orchestrated the medical management of her body to gain control over and manipulate the pregnancy herself. She excitedly relates how she "fooled" the doctor by intentionally maximizing her hormone levels without his knowledge: I took, on my own, twice the [amount of] hormones, twice the injections, and the doctor almost wanted, I don't know, to kill me, that I took them without asking. Like instead of him telling me to take two pills, I took four pills. And he told me to take two injections—I took four injections. I said [that] this small one [pats her stomach], he needs to grow in a bed [matsa] of whipped cream. Not just any womb. He needs something special! Once again invoking metaphors of nature and artifice, Orna takes the idea of mother's milk associated with nature and maternity and turns it inside out, imagining her womb as processed milk or a bed of whipped cream. Although feminists have long seen medical practitioners as dominating women, forcing medical technology on them, here we witness the opposite scenario. Orna embraces medical technologies of discipline and control (Foucault 1973) and personally, actively exercises "bio-power" on herself, to the point that she enforces the supposed "exploitation" of her body without the doctor's knowledge and in direct opposition to his instructions. Consequently, Orna undermines what would commonly be perceived as her own interests by subversively "tricking" the doctor—and putting her body in danger. Her blind faith in the medical system enables her to usurp its power over her body, manipulating its established regimens and "truth" regime, all the while reassuring herself that she can get away with this precisely because there are doctors close by who can "save" her, if necessary: When I did the blood tests he [the doctor] went crazy. "What a high level of hormones! You can't, what, you did something! What did you do?" I said to him, "No. No. I didn't do anything." I am surrounded by doctors. I work with them [at a medical clinic]. I said, worse comes to worse, something happens to me, all of the doctors are around me. What more do I need? I won't die! Worse comes to worse, there is a hospital right here, all of the doctors are with me. He said, "What is this here!" Only when all of the hormone levels were over the roof, he said to me, "Come here. What are you taking? This isn't hormones." When I interviewed Orna's doctor, he explained that he had been hesitant to subject Orna to the possibility of a multiple pregnancy, which he described as "more dangerous in many ways: more defects, more miscarriages, more physiological difficulty/exertion for the [carrying] mother; more danger of a cesarean section, [and of] early delivery." He explained that he had 'Veturned" too few embryos to Orna's womb during the first two transfers out of concern that "triplets or quadruplets might occur, and then we have to think about selective reduction."
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In the rhetoric of radical feminists and ecofeminists, women-hating, wombenvying medical terrorist, male techno-docs control women's desires and make them submit to invasive, risky, and costly procedures (Faquhar 1996). In this case, the situation is exactly the opposite: a male doctor hesitates to subject a woman to a potentially risky procedure, while the woman insists on his intervention. In spite of the doctor's concern for her safety, Orna herself demanded that her body be maximally manipulated during their final attempt at embryo transfer, to serve her own nearly obsessive interest to "succeed in my mission," as she termed it. Success, for Orna, appears to have been to achieve pregnancy while keeping her body, the doctor, and "nature" all under her control:
Orna: I said to him, "What's the matter? For the last treatment I want to do the maximum! I want it to be the best it can be. I want twice the amount when you return the embryos." Usually for each return they put back between three and four embryos, no more... but in the last treatment they returned to me eight embryos! Elly: You insisted? Orna: Yes! I want eight! The doctor said no! I said yes! You will do two returns [transfers] for me. I mean, two days after [the egg retrieval] the first prick [dikur] and five days after [do] the second one. The same treatment. I am not interested [mimics a gesture of shutting off her attention with her hands to her ears]. Four, four. I want eight. If I have triplets, all the better! I am not prepared [for any other option].... So he said okay. And they returned eight embryos, andfromthe eight, one remained.
Earlier I described surrogates as not only willingly accepting technomedical intervention but also actively participating in the process. Orna's case provides an extreme example of how surrogates use the doctor's control of their bodies to direct the process themselves to achieve their own goals and interests. Orna does not simply allow the doctor to manipulate her body; she tricks him into manipulating it so that she can attain the much-desired pregnancy. Whereas Orna is unable to control "natural processes" in what she knows as her personal, biological body, she has the power to make her body serve her intended purposes once it has been rendered "artificial" and manipulable through the doctor's regimens. The redefinition of nature gives Orna and other surrogates the opportunity to exercise personal agency more freely than ever before. As Cussins (1996) observed in the case of IVF patients, Israeli surrogates emphasize the medical control of their bodies by outside agents as a strategic tactic through which they are able to frame their surrogacy experience in accordance with their own understandings of the "nature" of maternity. They ultimately reformulate the medically managed, pregnant female body as a site of specifically female power and ability directly facilitated by external medical control (Klassen 2001). The surrogate sees herself as the one with the ultimate control: she not only tells the doctor what to do, but she and the commissioning mother also use him to help them "fool" G-d, nature, and everyone else. Discussion: Nature, Nation, and Personal Agency I have demonstrated how Israeli surrogates align nature and culture in accordance with their own personalized system of meaning. Narrative excerpts convey how surrogates participate in an extreme form of chosen medicalization, strategically
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using medical metaphors to control the location of "nature" and maternity during surrogate pregnancy. Carefully mapping "nature" and maternity onto the appropriate body, they engineer medical intervention in their bodies to "conquer," "fool," and force "nature" into complying with their reproductive quest Their clever manipulation of language reunites motherhood and nature through the subversive reversal of the very discourse that separates reproduction and motherhood (Martin 1992). Consequently, instead of emerging as passive victims of the medicalization of their bodies, Israeli surrogates use scientific language to exercise personal agency (Teman 2001). The question, however, remains: What ends does this agency serve? Why do Israeli surrogates need a conceptual model that locates genes, blood, and nature so explicitly? And why do they go to such lengths to prove where they "end" and the surrogate pregnancy begins? These strategies appear extreme in comparison with those employed by U.S. surrogates (see Cussins 1998a, 1998b; Goslinga-Roy 2000; Ragon^ 1994, 1998, 2000; Roberts 1998). Accordingly, the Jewish-Israeli experience of surrogacy may be read as a product of the Israeli cultural context. The strategic negotiation of nature and artifice thus may be a method of survival in a complex cultural terrain wherein these women are forced to "work the system" (Greil 2002) on a larger scale to get ahead. As single mothers in a familyoriented society, women who become surrogates are already in a socially marginal position and have limited access to financial resources (Kahn 2000). In fact, it is precisely their status as unmarried women with children that places them in the stringently defined group permitted to be surrogates under Israeli law. Although all of the surrogates I interviewed assured me that "there are other ways to make money," surrogacy appealed to them because it promised a financial jump that would be impossible for them through traditional avenues. They saw it as an opportunity to acquire a significant monetary gain, US$20,000-30,000, in a relatively short time. The great cultural significance given to motherhood in the Israeli context, however, makes surrogacy explosive terrain to navigate, especially because it is carried out directly under the eyes of the state. As a result, surrogates not only juggle the meanings of nature and maternity but also the meanings of gender role fulfillment and national belonging. Motherhood is not only socially venerated and of national significance in Israel, but it is also a significant determinant of inclusion in the Jewish-Israeli collective. Susan Kahn (2000) has shown how unmarried women in Israel use motherhood as a channel of status enhancement, because the stigma against single women in Israel is far greater than that against single mothers. Nevertheless, just as becoming a mother moves a single woman from marginal status to a more "natural" or normative status (Kahn 2000), denial of motherhood can also make a Jewish-Israeli woman "other." It is this reverse path that Amir and Benjamin (1997) illustrate in their discussion of women who decide to terminate their pregnancies because of personal concerns. They argue that Israeli abortion committees ritually and symbolically distance such women from the collective because they have Dejected their expected "natural'Vnational role. Amir and Benjamin conclude that the normative Israeli female subject is a mother who wants and is instinctively attached to her children,
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whereas women who give up their children or refuse to reproduce are labeled deviant. Under these circumstances, agreeing to give birth to a child and then relinquish custody in exchange for money is a major social risk. Paradoxically, Israeli surrogates find themselves participating in a reproductive act wherein they are simultaneously creating and denying motherhood. In this light, the surrogates' careful management of the meanings of maternity and nature can be seen as strategies for aligning their actions with cultural and national understandings of maternity, shaping surrogacy into a status-enhancing experience personally and dismissing the threat of their further marginalization. By designating the surrogate pregnancy "artificial" and distinct from the "natural" mothering of their own children, they avoid the stigma attached to denying their "maternal natures." Moreover, by emphasizing how unnatural surrogate pregnancy is for them and how natural it is for the commissioning mother, they are able to align their actions with the reproductive goals of the state. Surrogates establish themselves as conformist Israeli women who have heeded their "natural" and national reproductive calling in the past and are now continuing their missions as good national subjects by helping childless women achieve their own "natural'Vnational goal. To this effect, they are not denying but facilitating motherhood and thus are not acting against society's interests but, rather, are fulfilling them. The surrogates' conceptual logic even protects the state's interests because they so vehemently protect maternity's rootedness in nature—an ideological tenet that is in conformity with the patriarchal interests of the state. Within this context, Israeli surrogates' firm attempt to control meanings associated with the surrogate pregnancy raises further questions: Do they go to such lengths to subvert medical control of the pregnancy only to make their actions compatible with the pronatalist, patriarchal ideology of the Israeli nation-state? Could they be partaking in this extreme form of medicalized self-abnegation all in the service of ensuring national belonging? Moreover, does their crusade act to strengthen traditional gender categories that associate women with nature and motherhood? As single women rendering themselves "artificial" to produce "natural" families for married, heterosexual couples, are they reaffirming a patriarchal view of the family that only serves to further marginalize single women (Kahn 2000)? The answers, as Greil (2002) suggests, lie in the middle ground between acquiescence and resistance. Indeed, the actions of Israeli surrogates have not altered any of the cultural definitions attached to gender roles that would signal a change in the power structure (Lcwin 1995). In fact, their need to comply with national, social, and cultural dictates of Israeli society is part of what motivates them to exercise agency in the first place. However, surrogates emerge as "problem solvers operating creatively within a system that they do not control" (Greil 2002:103), working the system to make it fulfill their needs. Ultimately, they work within "culture" to shape "nature" to facilitate personal, national, and cultural aims all at once.
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Acknowledgments. An earlier version of this article was chosen as the winning essay of The Council on Anthropology of Reproduction's Second Annual Graduate Student Paper Prize. I thank Gail Landsman and the members of the CAR prize committee for this honor. I would like to extend my thanks to my dissertation advisors and mentors Meira Weiss, Eyal Ben-Ari, and Don Seeman for their helpful comments on earlier drafts of this article and for their support at all stages of this research. I would also like to thank Susan Kahn and Aviva Dautch for their insightful comments on later drafts of this article and for taking the time to discuss it with me at length. I am also indebted to Shulamit Reinharz for her helpful suggestions, Rhisa Teman and Avi Solomon for their editing help, and the anonymous MAQ reviewers for their suggestions. Finally, a heartfelt thanks to the women who shared their surrogacy stories with me. This research was funded by grants from the Hebrew University Social Sciences Department, the Minerva Center for Human Rights, the Lafer Center for Gender Studies, the Shaine Center for Social Research, and the Israeli Society of Academic Women. Correspondence may be addressed to the author at the Department of Sociology and Anthropology, Hebrew University, Mt. Scopus, Jerusalem, 91905, Israel; e-mail: mslula® mscc.huji.ac.il. 1. The committee comprises seven members: two gynecologists, an internal specialist, a clinical psychologist, a social worker, a lawyer, and a religious representative (Benshushan and Schenker 1997). Surrogacy arrangements carried out within Israel without the committee's approval are illegal, and participation in them is a punishable crime. 2. Most of the women seeking a surrogate either have no womb or have attempted IVF up to 23 times at the expense of the state. The committee informed one participant in this study that she must undergo IVF an eleventh time to prove her inability to bear a child. Following her subsequent pregnancy and miscarriage, her surrogacy petition was approved. 3. The surrogate must seek a doctor's and the commissioning couple's approval before taking even such common drugs as aspirin. 4. Although medical metaphors appeared in the narratives of all eight of the surrogates' discussed here, I draw heavily from the richly layered, yet representative narratives of Rinat and Orna. 5. It is important to point out that, like Rinat, all of the surrogates interviewed strongly differentiated between the surrogate pregnancy and pregnancies with their "own" children. Just as they stressed the "artificial" nature of the surrogate pregnancy, they also stressed how immediate and "natural" their maternal feelings were during their own pregnancies (see Teman 2001 for examples of this). As Ragone* (1994) has described in the case of U.S. surrogates, they prided themselves on being "good mothers" and evenframedthe payment receivedfromsurrogacy as an act of maternal love aimed at providing a better future for their children. 6. Although the secretary of the surrogacy committee estimated that roughly half of all surrogacy agreements in Israel involved the use of eggs from anonymous donors, none of the women I interviewed admitted that the eggs were not the commissioning mothers'. Because frozen embryos were often used, the surrogate may not have been aware that the commissioning mother had not provided the female gamete. Conversely, this information simply may not have fit into their conceptual scheme and, therefore, was disregarded. 7. Ragone* (1998) shows that women who begin as gestational surrogates but become traditional surrogates later in the process are forced to discard the claim that the child is not theirs because it is not genetically related to them and to adopt a different interpretation. This is because in traditional surrogacy the woman is genetically linked to the child. Traditional surrogates, then, replace the genetic kinship model with a kinship model based on intention, in which they claim that the child was "conceived in the heart" of the commissioning mother, making her the "real" mother of the child. In the Israeli case, the genes are always the deciding factor in the surrogate's ideas about maternity.
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8. Traditional surrogacy, whereby the surrogate provides the female gamete, is not allowed in Israel, whereas it is permitted in the United States. Thus Israeli surrogates do not face the possibility of being the gamete provider themselves, and they can thus consistently maintain the genetic model. 9. The surrogacy law requires that the surrogate and commissioning mother be of the same religion. This is to ensure that the child will be considered Halakhically Jewish. Jewishness is determined matrilineally. Therefore, a child is considered to be Jewish if it is gestated in a Jewish woman's womb. Gestation can thus pass on Jewishness, but genetic material cannot: If an embryo formed from non-Jewish genetic material is gestated in a "Jewish womb," the child is considered Halakhically Jewish. If a Jewish couple's genetic material is gestated in a "non-Jewish womb," however, the child is not considered Halakhically Jewish (Kahn 2000). 10. It will be interesting to see how this maternal logic is negotiated in other reproductive spheres, such as egg donation and local and international adoption. 11. See Teman (in press) for a discussion of the ways that the commissioning mother's maternal "nature" develops during the pregnancy and how she comes to intuitively "know" and sympathetically embody the pregnancy.
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Acceptedfor publication May 26, 2002.
Birthing a Mother
The Surrogate Body and the Pregnant Self
Birthing a Mother is the first ethnography to probe the intimate experience of gestational surrogate motherhood. In this beautifully written and insightful book, Elly Teman shows how surrogates and intended mothers carefully negotiate their cooperative endeavor. Drawing on anthropological fieldwork among Jewish Israeli women, interspersed with cross-cultural perspectives of surrogacy in the global context, Teman traces the processes by which surrogates relinquish any maternal claim to the baby even as intended mothers accomplish a complicated transition to motherhood. Teman’s groundbreaking analysis reveals that as surrogates psychologically and emotionally disengage from the fetus they carry, they develop a profound and lasting bond with the intended mother. elly Teman is a Research Fellow at the Penn Center for the Integration of Genetic Healthcare Technologies at the University of Pennsylvania.
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Illustration from Yedioth Aharonot newspaper. Courtesy of the artist, Rutu modan.
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