What Is Racial Difference?

Race, Racism, and Infertility

In our second article of the Racism in Science series, Vital editor Lesley Curtis interviewed researchers Bethany Johnson and Margaret M. Quinlan concerning the connection between racism and infertility.

Your research focuses on how perceptions involving race influence women’s health and the care they receive. Since race is a socially constructed category, let’s begin by noting the actual statistics about infertility and women of color in the US.

Sure. In the US, we have an inaccurate, wide-reaching, offensive stereotype of the “welfare queen” with numerous children. This stereotype is often racialized to support the idea that African-American women are somehow more fertile or more likely to need government assistance. This is, of course, not true. Yet, it often informs thinking about fertility.

Research suggests people of color, particularly African-American women, are as likely or sometimes more likely to be infertile than white women. Moreover, fewer infertile women of color seek testing and treatment for infertility. “According to data from the Department of Health and Human Services and from the National Center for Health Statistics, fifteen percent of white women ages 25 through 44 have received medical help like fertility treatments in order to become pregnant while only eight percent of black women have” (Hardy, 2016). It is possible that our ideas about who is and who should be fertile influence how and if women of color seek treatment for infertility.

Your research focuses on cultural myths or stereotypes that assume women of color are somehow more fertile. Could you give us an example of this stereotype in American history?

Women of color, particularly enslaved African or African-American women were long portrayed as hyperfertile and hypersexual. As Miah Hardy argued in a blog post at The Odyssey, “Fertility is not a widely discussed topic within the black community due in part to the stigma that black women actually have no problem popping out babies like bunnies, which is very offensive, racist, and not true at all” (Hardy, 2016). In fact, we ensconced these stereotypes in some of our early governmental documents, such as Thomas Jefferson’s Notes on Virginia (from 1781). The late 19th-century obsession with the “hottentot venus” and other hyper-sexualized foreign bodies at World Fairs, traveling exhibits, and circuses paired darker skin with claims of inexhaustible sexual desire, love of sexual attention, and incredible virility. Audience members felt they could access these bodies when they pleased, pulling, touching, and fondling–behavior exhibitionists sometimes even encouraged. Today, individuals (even complete strangers) often ask inappropriate questions about when someone will have children or sometimes touch pregnant bellies and babies in public. The public touching of pregnant women, infants, and young children forefronts the ways women and pregnant bodies are still very much considered public property.

How does the experience of infertility differ for women of color in the US?

As individuals who identify as white and cis-gender, we have found The Broken Brown Egg and Fertility for Colored Girls useful in helping us to understand how white privilege has influenced our understanding of the issue of fertility. Both of these organizations address the specific issues faced by women of color, particularly African-American women. For example, the topic is often considered taboo, which is rooted in historical injustice and racist attitudes about sex, sexuality, and fecundity. Yet, more troublingly, African-American women can receive inaccurate diagnoses that are also influenced by myths we believe about race and sexuality.

There is research, for example, examining the rates at which African-American women are misdiagnosed with pelvic inflammatory disease and STIs instead of fibroids or endometriosis during ER visits. These misdiagnoses can result from the assumption that any reproductive health problems result from sexual behavior and not from reproductive issues. In fact, there is evidence that African-American women can suffer from higher rates of both endometriosis and fibroids, yet these issues might go undiagnoised. Moreover, researchers are still considering what role social stress (like experiencing racism) and environmental issues play in impacting individual fertility. Shockingly, until the 1960s, gynecologists didn’t even think women of color could contract endometriosis (it was a “white women’s disease”). We think it’s safe to say racist attitudes about what could impact patients of color have narrowed and truncated research for a long time. As a field of specialty, Reproductive Endocrinology and Infertility (REI) has a lot of work to do to examine inaccurate assumptions that might still negatively influence patient care and patient outcomes.

Consider, for example, the impact of a doctor who insinuates that sexual activity caused any or all of one’s unrelated health problems. This could prevent someone from even seeking out testing and treatment. As researchers, we’ve heard stories at group gatherings about such problems, but it is unclear to us how widespread the experience is. Mia Hardy’s comment comes to mind again here—if you are dehumanized and perceived as a “bunny,” do you want to go to a fertility doctor at all? Unfortunately, this often sets African-American women up for a dual shame if they struggle with infertility. Not only are they not hyper-fertile (as they stereotype goes), they aren’t even “normally” fertile. It’s an extra burden on women who are already struggling with infertility.

How do you think that the history of the enslavement of people of African descent in the Americas has influenced perceptions about women of color and fertility?

When enslaved, the bodies of women of childbearing age became literal producers and reproducers of profitable labor, particularly if the child resulted from an (inherently non-consensual) union with a master or another male family member. Today, many of us have yet to consider the legacy of a history that viewed women’s bodies as property useful for reproduction. For example, it is astonishing after our archival work and the work available by scores of talented scholars, that media outlets recently referred to Sally Hemings as Thomas Jefferson’s “mistress.” Since Jefferson and many of his contemporaries thought raping a “Negress” wasn’t actually possible given their “inherent” sexual appetite, and given that he owned Hemings’ physical body (legally speaking), it is crucial to remember that Hemings was not in fact able to consent freely or fully to any sexual interaction. There is speculation the two had six children together, yet we can no more call Hemings Jefferson’s mistress than we can call Jefferson Hemings’ partner. Recognizing this longstanding imbalance of power might allow us to rethink how women have and have not been able to manage the fate of their own bodies.

In addition to this history of owning women’s bodies, hundreds of years of documented, racist medicine negatively impacted women of color disproportionately, including Dr. J Marion Sims’ non-medicated, surgical, gynecological experiments on enslaved women, which eventually led to the surgical repair of the fistula.[1] During our research, we’ve found that many are resistant to engage with this history, as it brings up intense feelings and calls into question many of the foundational beliefs we may have about the US and American history. It is certainly something we’ve been stretched and challenged by personally, but it can be beneficial to examine what assumptions and stereotypes we have inherited from past sources.

Could you give an example of recent media portrayals that seem to support or continue the false idea that women of color are somehow more fertile?

We argue most of what we see in media sources (including television and films) confirms entrenched stereotypes—certain types of women can’t get pregnant, and certain types of women can’t stop getting pregnant. Children of Men (2006) had one fertile human being on an infertile planet—a black woman. It’s a science fiction movie that asks the audience to imagine another world while presenting a common, false stereotype. There are recent examples as well. The Emmy-award winning series The Handmaid’s Tale (2017) also leans on mythical connections between race and fertility. In Margaret Atwood’s (1998) text, “the Children of Ham” (people of color) are all sent to the colonies. In the television reboot, people of color exist and are more complex, nuanced characters, but they are still ultimately breeders, enslaved because of their rare fertility in a barren world (Berlatsky, 2017). The barren women in the ruling class all seem to be white. But this is not reflective of reality.

Consider some of the celebrities and public figures known to speak publically about their infertility journeys—Amy Smart, Emma Thompson, Giuliana Rancic, Maria Menounos, Jamie King, Brooke Shields—all are white women who used Assisted Reproductive Technology (ARTs). Recently, Chrissy Tiegan, married to John Legend, went public about their struggle to conceive their daughter. A number of women, including Sarah Jessica Parker, Nicole Kidman, Elizabeth Banks, and African-American actors Angela Bassett and Tyra Banks, carried via surrogate. Gabrielle Union also began her IVF treatments in her 40s—there are agencies around the U.S. that require an egg donor for IVF cycles involving patients that are over 40, to ensure a significantly higher chance of success. It is unclear if those in this cohort (famous; of means) fell under the same restrictions. Kim Kardashian struggled with secondary infertility, while her sister Khloe has been outspoken about her infertility treatments. Mariah Carey leaned on progesterone treatments to avoid early miscarriage (see Klinefelter & Lippo, 2017). There are also some whispers about early pregnancy loss and ART treatment for Beyoncé; she did confirm an early pregnant loss but the ART treatments comprise unconfirmed rumors. Alternatively, we see Halle Barry getting pregnant in her 40s and Janet Jackson in her 50s. Given the statistical chance of getting pregnant each cycle after 40 years of age, it is likely ARTs were involved, though this is often not addressed in media reports.

Of course, these individuals do not owe us an explanation of their personal choices. It strikes us, however, that there are some missed opportunities here—the public is not hearing a counter-narrative. For example, non-white women do need and use ARTs, for age-related and non-age-related reasons.

Hyperfertility myths harm real women’s health; how can we counter their effects?

As white women, we believe that self-reflexivity is a great starting point. In the spirit of full disclosure, I (Johnson) also struggled with infertility, and my experiences are the catalyst for much of my research with Quinlan over the past three years. I (Johnson) conceived my daughter, but first endured four years of unsuccessful treatments. So, our suggestions here are supported by research findings from a number of studies (including our own qualitative work) and our personal experiences. Supporting our infertile friends and family becomes harder when we aren’t working on our own internalized assumptions and incorrect information (e.g., not knowing accurate infertility rates). Practitioners can also be more effective when they become aware of historical and longstanding cultural stereotypes that often influence our beliefs and behaviors.

We’ve created this resource guide for family, friends, and practitioners.

 

 

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Footnotes

[1] Ample scholarship exists for those interested in studying this history. Harriet Washington’s (2007) Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present is an excellent place to begin and looks closely Sims’ practices.

Further Reading

Ariyabuddhiphongs, K., Bates, C., Brockmeyer, D., Catalanotti, J., Potter, Weinstein, A. (2008, Apr 10). Teaching the pelvic exam: A patient-centered and evidence-based approach to training medical residents. Presentation given at Society of General Internal Medicine, annual meeting.

Atwood, M. (1998). The handmaid’s tale. New York, NY: Anchor Books.

Baile, W. F., Buckman, R., Lenzi, R., Glober, G., Beale, E. A., & Kudelka, A. P. (2000). SPIKES-A six-step protocol for delivering bad news: Application to the patient with cancer. The Oncologist, 5, 302-311.

Barrow, R. Y., Berkel, C., Brooks, L. C., Groseclose, S. L., Johnson, D. B., & Valentine, J. A. (2008). Traditional sexually transmitted disease prevention and control strategies: tailoring for African American communities. Sexually transmitted diseases35(12 Suppl), S30-S39.

Bowser, R. (2001). Racial profiling in health care: An institutional analysis of medical treatment disparities. Michigan Journal of Race & Law, 79, 115-122.

Bute, J. J. (2009). “Nobody thinks twice about asking”: Women with a fertility problem and requests for information. Health Communication, 24, 752-763.

Centers for Disease Control and Prevention (2000). 2000 STD prevention conference-African Americans disproportionately affected by STDS.

Danielle, B. (2017, July 7). Sally Hemings wasn’t Thomas Jefferson’s mistress. She was his property.

Fabien, V. (2017, Apr 16). My body, my pain: Listen to me and all black women.

Fassler, J. (2015, Oct 15). How doctors take women’s pain less seriously.

Gaines, T. (2011, May 4). Chronic pelvic pain often misdiagnosed in black women study finds.

Hardy, M. (2016, Feb 1). Tyra Banks revisits issue of infertility in the Black community.

Hoberman, J. M. (2012). Black and blue: The origins and consequences of medical racism. Berkeley, CA: University of California Press.

Hoberman, J. (2014a, Oct 14). Recognizing racially motivated diagnosis and treatment. UT Southwestern Medical School Ethics Grand Rounds lecture, Dallas, Texas.

Hoberman, J. (2014b, Aug 4). Medical racism and how we can rise above it. Presented at the Annual Convention & Scientific Assembly of the National Medical Association, Honolulu, Hawaii.

Hoberman, J. (2005). The primitive pelvis: The role of racial folklore in Obstetrics and Gynecology during the twentieth century. In C. E. Forth & I. Crozier (Eds.), Body parts: Critical explorations in corporeality (pp. 85-104), Lanham, MD: Lexington Books.

Hoberman, J. (2001, Feb 27). How do doctors think about race? Presented at the Georgetown University School of Medicine, Washington, D.C., September 17, 2007. “Pain and Ethnicity.” Sponsored by the Criss Cole Rehabilitation Center, Austin, Texas.

Jefferson, T. (1781/1995). Writings: Autobiography, a summary view of the rights of British America, notes on the State of Virginia, public papers, addresses, messages, and replies, miscellany, letters. London: Fitzroy Dearborn Literary Classics of the United States.

Johnson, B. (2016). Personal, interpersonal, biomedical, textual: Vignettes on infertility and fertility privilege. Departures in Critical Qualitative Research, 5, 76-100. doi: 10.1525/dcqr.2016.5.2.7.6.

Johnson, B., & Quinlan, M. M. (2016). Insiders and outsiders and insider(s) again in the (in)fertility world. Health Communication, 32, 381-385. doi: 10.1080/10410236.2016.1138384

Johnson, B., Quinlan, M. M., & Marsh, J. S. (2017). Telenursing and nurse-patient communication within Fertility, Inc. Journal of Holistic Nursing. 089801011668546

Johnson, B., Quinlan, M. M., & Myers, J. (2017). Commerce, industry, and security: Biomedicalization theory and the use of metaphor to describe practitioner-patient communication within Fertility, Inc. Women’s Reproductive Health, 4, 89-105. doi: 10.1080/23293691.2017.1326250

Klinefelter, M., & Lippo, C. (2017, Feb 13). 24 celebrities who have spoken out about their fertility problems.

Kuligowska, E., Deeds III, L., & Lu III, K. (2005). Pelvic pain: Overlooked and underdiagnosed gynecologic conditions. Radiographics25, 3-20.

Mackintosh, N., Rance, S. Carter, W., & Sandall, J. (2017). Working for patient safety: A qualitative study of women’s help-seeking during acute perinatal events. BioMed Central Pregnancy and Childbirth, 17, 1-13. doi:10.1186/s12884-017-1401-x

Monden, K. R., Gentry, L., & Cox, T. R. (2016). Delivering bad news to patients. Proceedings (Baylor University Medical Center), 29, 101-102.

Tracy, B. (2017, Oct 4). Gabrielle Union’s heartbreaking struggle with infertility: ‘I’ve had eight or nine miscarriages’.

Racial bias skews medical diagnosis and treatment for African Americans, research shows. (2012, Apr 23).

Reproductive Health Access Project (2015, Feb 10). Trauma-informed pelvic exams.

“Unconscious” racial bias among doctors linked to poor communication with patients, dissatisfaction with care (2012, Mar 16).

Wang, L. (2003). Race as proxy: Situational racism and self-fulfilling stereotypes. De Paul Law Review, 53, 1013-1110.

Washington, H. A. (2006). Medical apartheid: The dark history of medical experimentation on black Americans from colonial times to the present. New York, NY: Doubleday.

Werner A., & Malterud, K. (2003). It is hard work behaving as a credible patient: Encounters between women with chronic pain and their doctors. Social Science & Medicine, 57, 1409–1419. doi: 10.1016/S0277-9536(02)00520-8.

Whaley, A. L. (1998). Racism in the provision of mental health services: A social-cognitive analysis. American Journal of Orthopsychiatry, 68, 47-57.

Williams, A. A., & Williams, M. (2013). A guide to performing pelvic speculum exams: A patient-centered approach to reducing iatrogenic effects. Teaching and Learning in Medicine, 25, 4, 383-391.

Willer, E. K. (2014). Healthcare-provider compassionate love and women’s infertility stressors. Communication Monographs, 81, 407-438.

Yanikkerem, E., Ozdemir, M., Bingol, H., Tatar, A., & Karadeniz, G. (2009). Women’s attitudes and expectations regarding gynaecological examination. Midwifery, 25, 500-508.