Sociology of Health & Illness Vol. xx No. xx 2017 ISSN 0141-9889, pp.

1–16
doi: 10.1111/1467-9566.12607

The gas that fuels the engine: Individuals’ motivations

for medicalisation
Ann V. Bell
Department of Sociology, University of Delaware, USA

Abstract It is well established that the drivers of medicalisation have shifted alongside
changes in the institution of medicine. The process of medicalisation is no longer
incited by macro processes of institutional prestige or control; rather, individual
patients/consumers are pushing the process forward. The present study complicates
this neat transition and examines the relationship between structure and agency
using the case of assisted reproductive technology (ART), specifically the
medicalisation of lesbian reproduction in the US. I explore individuals’ influence
on and motivations towards medicalisation through 24 in-depth interviews with
women in same-sex relationships who had ever attempted to become pregnant. In
centring on their experiences, I find that while individual consumers may now
propel medicalisation forward, oftentimes consumers’ motivations for doing so
reside in the prestige and control of medicine. In other words, consumers now
seek medicalisation precisely because of the process’s previous institutional
drivers. In exploring what fuels the engine of medicalisation, the findings reveal its
nuance and complexity.

Keywords: medicalisation, reproductive health, reproductive technology

Introduction

It is well established that medicalisation1 is no longer driven by the macro processes of medi-
cine’s institutional dominance, prestige, or social control. Rather, as scholars argue, ‘the engi-
nes have shifted’, and medicalisation is now a market-based enterprise, propelled by patients/
consumers seeking medical products to fulfil their needs (Clarke et al. 2003, Conrad 2005,
2007, Conrad and Leiter 2004). In other words, there has been a ‘move to the micro- and
meso-level’ in our understanding of medicalisation and what drives it forward (Figert 2011:
293). Yet, as I argue in this article, such a move is still informed by the more macro, profes-
sional mechanisms of medicine. So, while consumers may now be the impetus behind medi-
calisation, such a pursuit is still rooted in the professionalisation of medicine and its
ideological repercussions. Put simply, consumers now seek medicalisation precisely because of
the process’s previous drivers of medical dominance, prestige, and control.
To make such an argument, I examine the case of assisted reproductive technology (ART),
specifically the medicalisation of lesbian reproduction. Situated in a private medical market,
insurance companies often do not cover ARTs, with less than a third of states in the US hav-
ing some form of benefits for the technology (Centers for Disease Control and Prevention
2013). Coverage is even more limited for lesbian women and single heterosexual women who
© 2017 Foundation for the Sociology of Health & Illness.
Published by John Wiley & Sons Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA
2 Ann V. Bell

are not diagnosed with medical ‘infertility’, per se. As a result, attaining medical treatment to
assist in conception, whether medically infertile and especially if not, is particularly expensive.
Given the absence of coverage, there is little direct-to-consumer advertising and corporate
manoeuvring around ARTs. This is especially true for lesbian women, with few clinics explic-
itly advertising their services for that population (Johnson 2012).
Coupled with the high cost and limited promotion of ARTs, lesbian women face marginali-
sation in both the institutions of motherhood and medicine. They are outside the realm of
‘good’ motherhood and excluded from heteronormative medical treatment (Glenn 1994,
Hequembourg and Farrell 1999, Mamo 2007a, Padavic and Butterfield 2011). Unlike other
medical procedures such as cosmetic surgery in which women attempt to adhere to social ide-
als, lesbian women trying to conceive go against dominant norms. Moreover, there are alterna-
tives to assist in conception that are less clinical, such as the infamous ‘turkey baster’
technique2 (Mamo 2007b). Given such factors, including its high cost, social exclusion, and
available alternatives, why do lesbian women pursue medical treatment to become pregnant?
Past literature has not fully answered such a question. While research, such as that of
Becker and Nachtigall (1992), demonstrates individuals’ desires for medical intervention of
reproductive processes, it does not fully interrogate why those desires exist in the first place
(Figert 2011). Exploring individuals’ motivations for medical treatment reveals the interplay
between micro and macro, structure and agency, demonstrating the complexity behind the pro-
cess of medicalisation beyond simple binaries. Indeed, medicalisation today, and the individu-
als behind the wheel, rely upon rather than refute the process’s paternalistic drivers of the
past.
In exploring such interplay, I initially review the literature on the trajectory of medicalisa-
tion, generally, followed by a discussion of the medicalisation of infertility and lesbian fertil-
ity, specifically. Next, through US lesbian women’s narratives, I examine their motivations for
medicalising their reproduction. While the findings are limited to a specific population and
topic, they still begin the conversation around the how and why of individuals’ pursuits of
medicalised solutions. In other words, in centring individuals’ experiences, I reveal the gas that
fuels the engine of medicalisation.

Literature review

The trajectory of medicalisation

Medicalisation is ‘a process by which non-medical problems become defined and treated as
medical problems’ (Conrad et al. 2010: 1943). Much of the research on medicalisation centres
around the factors behind such a process. Literature in the 1970s emphasised the power and
authority of the medical field, arguing that professional dominance and control propelled medi-
calisation forward (Conrad 2007). Beginning in the mid-1980s, however, the medicalisation
process itself began to change alongside shifts in the institution of medicine (Clarke et al.
2003). Biotechnology, consumers, and managed care all transformed biomedicine from the
inside out into a commodified form of healthcare. In turn, the push behind medicalisation
shifted to the hands of individuals and corporations buying and selling medical goods and ser-
vices (Ballard and Elston 2005, Conrad 2005).
As a result of these shifts, it became clear that individuals are not passive victims of ‘medi-
cal ascendancy’ (Lock 2004: 118, Martin 1987). Rather, they are agents actively pursuing (or
rejecting) medicalisation (Ballard and Elston 2005, Conrad 2007). This agency is particularly
apparent in private medical markets in which consumers drive medicalisation. Without direct
to consumer advertising or insurance coverage that are present in a corporate-driven mediated
© 2017 Foundation for the Sociology of Health & Illness
 Individuals’ motivations for medicalisation 3

market, consumers themselves pursue the expansion and development of medicalised entities
in a private market.
This market-based structure of medicine led to the ‘emergence of the “expert patient”’ (Fig-
ert 2011, Fox et al. 2005). As consumers, individuals now take on the expectation of having a
heightened self-knowledge and a kind of ‘lay expertise’ regarding the medical product they are
purchasing, just as they would for any other good or service (Figert 2011). For instance,
patients now go to physicians with hypotheses of diagnoses and treatment ideas. Despite the
clear presence and development of the agentic, expert patient, it is necessary to avoid conflat-
ing expert patients and consumers, as is often done (Fox et al. 2005). As Lupton (1997)
demonstrated, even well-informed consumers desire guidance and advice from an ‘expert’
physician in a clinical encounter. This ‘paradox of consumerism’ in which individuals are
simultaneously both independent consumers and dependent, anxious patients reveals the need
to recognise the ‘double edged character of consumerism’ (Figert 2011: 298, Henderson and
Petersen 2002, Lupton 1997). Indeed, as Figert (2011: 298) argues, researchers often ‘fail to
acknowledge the ambivalent nature of the feelings and opinions that many people have in rela-
tion to medicine or the ways that patients willingly participate in medical dominance and may
indeed seek medicalisation’.

ARTs: the medicalisation of infertility and lesbian reproduction

The medicalisation of infertility demonstrates this shift to commodified medicine with con-
sumers in the driver’s seat. Before the advent of assisted reproductive technologies in the
1970s and 1980s, infertility was considered an unfortunate natural part of life with which to
be coped (Becker and Nachtigall 1992, Quiroga 2007, Remennick 2000). Since then, the use
of ARTs has proliferated in the US to the extent that ‘the treatment has become the illness’,
and the medicalisation of infertility is now ‘hegemonic’ (Sandelowski 1993: 41, see also Greil
et al. 2010). This normalisation of medicalised infertility is so profound that alternative solu-
tions and low-technology treatments to address the condition have significantly declined in the
US (Becker and Nachtigall 1992, Inhorn et al. 2009).
Treating infertility medically, however, is a costly process. As a ‘commercial activity’, med-
icalised infertility is situated in a private market in which insurance companies do not often
cover services (Conrad and Leiter 2004). Only 15 states in the US mandate some type of cov-
erage for the condition, leaving most treatment costs out-of-pocket (Centers for Disease Con-
trol and Prevention 2013). In turn, only the wealthy can afford the average $13,000 expense
of one round of in vitro fertilisation (IVF) (American Society for Reproductive Medicine
2013). This exclusivity results in what scholars have deemed a form of ‘social engineering’ or
‘stratified reproduction’ rooted in ideologies about who should reproduce and parent (Colen
1995, Quiroga 2007, Thompson 2005).
Notwithstanding its exclusion of certain groups, the market-basis of medicalised infertility
has opened up the treatment to new populations, including lesbian and single women (Agigian
2004). Creating new groups for whom to provide their services allows providers to increase
both their profit margins as well as the expanse of medicalised reproduction. ARTs are no
longer the singular solution to medicalised infertility; they are now the answer to medicalised
conception as well. As Foucault (1977) described it, medicine’s ‘disciplines of surveillance’
have seeped into other areas of social life. This market-based strategy succeeded, resulting in
what many call a ‘lesbian baby boom’ occurring in the early twenty-first century (Arnup 1998,
Nordqvist 2008). More lesbian women are having biological children via ARTs now than ever
before (Daar 2013). As Agigian (2004: x) relays, most lesbian women now ‘use the full gamut
of infertility industry resources, from boutique sperm to IVF’.

© 2017 Foundation for the Sociology of Health & Illness

4 Ann V. Bell

Despite the recent normalisation of medicalised lesbian reproduction, there are alternatives
and constraints to these medical solutions. While lesbian women are considered ‘structurally
infertile’ due to their inability to reproduce through sexual intercourse because of the structure
(i.e., same-sex desire) in which they identify, they are not necessarily ‘functionally infertile’
with a physical reproductive impairment (Daar 2013). Thus, there are ways they may achieve
biological parenthood through means other than medical treatments. For instance, the collo-
quial ‘turkey baster’ method is, in reality, a demedicalised form of artificial insemination (AI),
without the cost or side effects of many medical treatments (Conrad 1992; Wikler and Wikler
1991). Additionally, lesbian women confront ideological barriers to seeking motherhood that
are replicated in the medical system since it ‘reflects the same value system at work through-
out society’ (Becker and Nachtigall 1992: 467; Mamo 2007a). With a heteronormative under-
standing around parenting, medical clinics often (unconsciously) marginalise lesbian women
from their services. For instance, many clinics do not explicitly advertise or promote their ser-
vices to lesbian women, and they often prescribe their standardised infertility treatments to les-
bian women who are not physically/functionally infertile (Bell 2016; Johnson 2012). Given
the non-clinical alternatives and significant barriers faced by lesbian women seeking parenting,
why do they seek medical solutions for their reproduction?
There is little exploration of this question in the literature. While there is a plethora of
research examining individuals’ experiences of infertility and how medicalisation has shaped
such experience (e.g. Becker and Nachtigall 1992; Bell 2014; Greil 1991), there is little
exploring why individuals pursue medical treatments to resolve their reproductive struggles in
the first place. For instance, Becker and Nachtigall (1992) demonstrate how women are ‘eager
for medicalisation’ of their reproductive problems oftentimes due to a desire to regain control,
yet the authors focus on the implications of medicalisation on that desire rather than the desire
itself. Taking a step back and exploring what motivates such desire widens the camera lens,
exposing the complex give and take of upstream and downstream mechanisms, structure and
agency, and individuals and institutions (House 2002).
Moreover, there is minimal research on lesbian reproduction, specifically. Importantly,
Mamo’s (2007a) work is an exception. In her insightful study, Mamo (2007a: 3) demonstrates
the ‘queering of reproduction’ and the implications of ‘medicalising a simple process’. She
begins to examine women’s motivations for medical treatment, oftentimes highlighting the
‘progression’ to medicine after failed conception attempts at home. For instance, she exposes
the array of ‘choices’ lesbian women face in becoming pregnant. Interestingly, Mamo’s partici-
pants still conceived of them as ‘choices’, as her data gathering took place at the turn of the
twenty-first century when medical clinics were beginning to open their doors to same-sex cou-
ples. Now that medicalisation of lesbian reproduction is normalised and the ‘progression’ has
all but disappeared, this study is able to further interrogate those ‘choices’ (indeed, as the find-
ings below demonstrate, nearly 90 per cent of participants sought medical solutions straight-
away). While Mamo understandably used biomedicine as a way to further our understanding
of lesbian reproduction, in this study, I use lesbian reproduction as a way to further our under-
standing of biomedicine. Doing so allows this article to extend and expand on medicalisation
as a process, including its historical constructs.

Methods

To gain insight on women’s/consumers’ motivations for medicalised reproduction, I inter-

viewed 24 women in same-sex relationships (including 6 couples) who had ever attempted to
become pregnant. To participate in the study, the women had to be between the ages of 18
© 2017 Foundation for the Sociology of Health & Illness
 Individuals’ motivations for medicalisation 5

and 44. I recruited participants via flyers posted at public venues and organisations affiliated
with same-sex couples. I also recruited through snowball sampling.
The study sample largely reflects the national US demographics of women in same-sex rela-
tionships seeking medical treatment to assist in pregnancy (Centers for Disease Control and
Prevention 2013). All of the women in the study are white and two-thirds (67%) have at least
a college degree. On average, the participants were 36-years-old with an age range of 28-44.
All of the women had private health insurance. Four (17%) of the women self-identified as
bisexual, while the remaining 83 per cent identified as lesbian.3 Twenty-one (88%) of the par-
ticipants sought medical treatment for conception immediately, while three did so after initial,
unsuccessful attempts at home.
I conducted the majority (75%) of semi-structured interviews in-person, often in study
rooms of public libraries or the participant’s home. For logistical reasons as well as difficulty
recruiting such a specific population, I also conducted six interviews (25%) by phone. The
length of the interviews as well as their substantive content did not vary between methods.
Within the interviews, I asked women about a variety of topics including their desires for med-
icine, attitudes about medical treatment, and their experiences of reproduction. On average,
interviews lasted approximately 75 minutes. The participants received a $10 grocery store gift
card after completing the interview. They also filled out a demographic questionnaire prior to
our conversation.
All interviews were transcribed verbatim. I generated the majority of the analysis from the
data and created the codes inductively as I read the transcripts, similar to a grounded theory
approach (Charmaz 2014). Once all of the codes were created and entered into a qualitative
research software program, I began analysis by creating reports of codes of interest and then
refining those codes into hierarchical coding schemes. After analysing those initial reports, I
formed a more formal, detailed and thematic analytical approach, ultimately identifying pat-
terns and variations in responses. From those reports and for the purposes of this article, I
parse out the motivations for medicalised reproduction among lesbian women. I report how
the simple acknowledgement that consumers are now the drivers of medicalisation does not
reveal its complexity. Individuals may drive the medicalisation process forward, yet they are
fuelled by the medical profession’s institutional prestige and expertise.

Findings

In the findings that follow, I explore why lesbian women seek medical assistance for their
reproduction. I outline two overarching reasons for such medicalisation. First, the hegemony
and normalisation of medical solutions drowns out less clinical alternatives. Second, the valori-
sation of medicine in which the institution’s prestige, objectivity, and expertise are assumed
motivate the women to seek its services.

‘There’s not really that many options’: the normalisation of medicalisation

While three of the participants sought medicine only after numerous unsuccessful attempts at
home, the majority of women did not even consider (or know about) alternative options. Medi-
cal treatment for infertility, whether the infertility is structural or functional, has become the
norm. As Greil and colleagues (2010: 146) state, ‘in developed societies, acceptance of the
biomedical model is virtually hegemonic’. The hegemony and embeddedness of medicalisation
are evinced through the women’s automatic pursuit of its services. For instance, in asking the
participants if they ever considered trying to get pregnant without medicine, they frequently
responded as Susan did with a, ‘no, not at all’. Or, as Shannon described it, she
© 2017 Foundation for the Sociology of Health & Illness
6 Ann V. Bell

‘automatically’ went to a clinic once she decided to have kids. Indeed, to Jenny, seeking medi-
cal assistance was the immediate next step after deciding to have children. She told me, ‘So
we said, ‘okay, let’s go for it [having kids]’. Um, and then it was, you know, visit the fertility
doctor and figure out how to get it done’.
Many women in the study were unaware of non-clinical alternatives to becoming pregnant,
which reveals the deep-seated embeddedness of its medicalisation. Erin relayed how ‘there’s
not really that many options’ for lesbians to become pregnant. Jill concurs when she told me:

We weren’t really, um, considering any options. We just were told that [medical treatment]
is how it could be done and we said, ‘Okay, then we’ll do it’. So it wasn’t, um, it wasn’t
really an option.

To Jill, Erin, and many of the other participants, medicine was the only method to assist them
in becoming pregnant. In other words, not considering medical treatment ‘was not really an
option’ for the women. Much like other medicalised ailments (e.g. childbirth), medical solu-
tions have overshadowed and diminished alternatives and have become the normalised as well
as naturalised way of addressing individuals’ needs and desires (Becker and Nachtigall 1992,
Pierret 2003).
The medicalisation of reproduction, broadly, has allowed medical treatments to infiltrate
other aspects within that realm, including infertility and lesbian conception. As Zola (1972)
described in his theory of medicalisation as an agent of social control, much of the power of
medicalisation resides in its ‘expansion into life’. Susan’s experience demonstrates such expan-
sion through the referral process:

We finally just said, ‘Yep, this is it. We’re not getting any younger and we really wanted to
[have kids] anyway’. So we just called and made an appointment and checked it all out,
talked to the gynecologist first and she referred us to somebody. So it worked out well . . .
And then from there we were – were set and had a consultation and I feel like I haven’t left
the office since (both laughing).

As Susan’s experience reveals, one reason lesbian women’s conception is medicalised is

because reproduction itself is considered a medical entity. Susan did not necessarily purpose-
fully and actively seek a medical solution to her conception specifically, but in speaking with
a gynecologist about having children (given the embeddedness of medicalised reproduction),
Susan was set on a moving track that was difficult to get off of. The highly specialised, refer-
ral-based medical system enables the expansion and spread of medicalised reproduction.
Such a spread is evident in the high prevalence of knowing others who have pursued medi-
cal solutions to reproduce. The ‘lesbian baby boom’ has resulted in not only more lesbian cou-
ples having biological children, but also more (higher income) lesbian couples having children
via medical means (Arnup 1998, Ryan and Berkowitz 2009). Indeed, as Nordqvist (2008: 274)
relays, ‘reproductive technologies . . . can now be understood to have an established place in
lesbian reproductive practices’. Having children is becoming a family norm for lesbian women,
but so is the medical process for doing so. These trends are evident in the women’s experi-
ences. Most learned about medical solutions from others they know in their situation. This
was the case for Melissa who told me:

Um, there was a girl at my work that was going through fertility treatment and she told me
about this place in New Jersey. And, um, she was like, ‘Why don’t you call and find out
what they, you know, they can do for you guys?’ And that’s how it started.
© 2017 Foundation for the Sociology of Health & Illness
 Individuals’ motivations for medicalisation 7

Shannon similarly states:

Uh, anoth–another friend of ours, they, um, actually did IVF. Uh, so they recommended
Fertility Center Inc. So when I looked online at them and other ones, I’m like, ‘Okay,
they’re close. They’re, you know, they’re good’. And, you know, so we went and just
checked it out and so we decided that that one was fine.

Many women, like Shannon and Melissa, sought medical solutions to assist with pregnancy
because they learnt about them from their peers. Such transfer of knowledge is founded upon
and reifying of the normalisation of medicalised conception.
These more ‘informal’ processes of normalisation that motivate women to pursue medical
treatment are accompanied by more ‘formal’ processes of normalisation as well. Beyond ideol-
ogy, medical expansion, and word of mouth, the embeddedness of the medicalisation of les-
bian reproduction is also instigated through institutional mechanisms. For instance, only four
out of the 11 sperm banks and clinics in the United States ship to an individual’s home. One
of those four still requires women to ‘work with a physician’ in the handling of the sperm and
another requires written consent of a medical professional. Additionally, in many states, if a
doctor does not conduct the insemination, the parental rights of a sperm donor may not be ter-
minated. Regulations such as these implicitly ‘force’ lesbian women to attain medical assis-
tance for their conception. As Lana’s experience demonstrates this contradiction:

Well, [the sperm] can come to you, which was kind of unique with this, um, this, uh, sperm
bank. It can come to you, but you have to get doctor’s consent and prove that you’re
healthy enough. And I’m like, ‘Straight bitches don’t have to do any of this’ . . . So, I was
aggravated.

Lana did not set out to have a medicalised pregnancy, however, the sperm bank’s requirements
led her to this approach. In having to seek a physician’s consent to use the sperm, Lana con-
tinued with the medical treatments to become pregnant. Lana was ‘aggravated’ by this process
not only because it caused her to become pregnant in ways she did not desire, but also because
such requirements are only applied to those using sperm donors, oftentimes lesbian women.
In addition to sperm banks’ regulations restricting lesbians’ conception to medical means,
insurance companies’ policies are similarly limiting. By requiring lesbian women to have offi-
cial documentation of their insemination attempts, insurance companies implicitly force women
to inseminate medically rather than at home. Leigh explains:

One of the really interesting piece – parts for us was the fact that – that insurance didn’t
cover it at all and in order for it to be deemed infertility, you had to have like received
show receipts – and I’m adlibbing here. I don’t know if they need to have – show receipts –
but you need proof that you have tried to inseminate a certain number of times. I think 12
times is, uh, was what my provider, uh, had at the time. Twelve times so over the course of
a year, 12 times and then it would kick in. So, um, we kind of geared up – we geared up
for the cost at that point. We tried to, you know, able – on top of savings, save extra to put
aside for this for – for quite some time . . . [We] put it in the hands of a professional who
knows what they’re doing, um, especially because if we did it ourselves, it wouldn’t show –
it wouldn’t count towards the 12 times.

Many insurance companies will only cover fertility treatments if a woman is diagnosed with
medical/functional infertility. Unlike heterosexual women who can just report that they have
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8 Ann V. Bell

tried unsuccessfully for 12 months at home in order to be deemed functionally infertile, lesbian
women need ‘proof’ of such attempts through documented inseminations and only then, as in
Leigh’s case, would insurance cover any future fertility treatments. In turn, insurance compa-
nies not only force medicalisation (by requiring documentation), but they also prevent accessi-
bility to such medicalised treatments due to the excessive cost of 12, medically-assisted
inseminations (Bell 2016). In essence, as Conrad (2007: 141) argues, despite being a recent
driver of medicalisation alongside consumers and biotechnology, managed care is oftentimes a
‘double edged sword’ for the process since it can both instigate and constrain medicalisation
simultaneously. Insurance companies bolster the medicalisation of lesbian conception through
the necessity of a diagnosis and/or documentation of attained ‘medical’ infertility (and igno-
rance around less clinical means of conception). Yet they also constrain medicalisation through
such requirements which limit insurance coverage and increase costs, ultimately pushing con-
sumers towards private medical markets.
Andrea’s experience reveals the unique dilemma that such costly, medicalised requirements
have for her family:

And I’m a pretty private person, so [medical treatment is] just uncomfortable. Um, and then
just insurance, you know, it’s – we are in a situation where we can’t just try to get pregnant
at home. And the way that our insurance works is if you try six times unsuccessfully, then
you are fully covered for IVF. But to try six times unsuccessfully for us costs so much
money out of pocket . . . And so that’s just really hard, you know, because we literally have
to think, ‘Okay, do we want to keep trying for another child or do we want to buy a
house?’ And that’s just – seems not fair when other couples can just be monitoring what
they’re doing at home and it’s not costing them anything.

The medicalisation of lesbian conception is so embedded, that even insurance companies fail
to acknowledge and validate alternative methods such as at-home inseminations. Insurance
companies do not question straight couples’ ‘natural’ attempts at home, yet they do not recog-
nise such attempts by lesbian women; it is assumed that lesbian women have to and can only
conceive via medical means. In other words, the double edged nature of medicalised lesbian
reproduction is rooted in insurance companies’ heteronormative notions of fertility. Lesbian
women in this study are purposeful and agentic in seeking medical treatment for conception;
they are an ‘engine’ of medicalisation. However, such a pursuit is rooted in the normalisation
of such a practice, to the extent that women do not think about the choices they are making
and/or are forced to make such a choice because the normalisation has become institution-
alised.

‘I’m not qualified’: the valorisation of medicalisation

Much of this normalisation is based in the high esteem placed on medicine. As Barker (2008:
29) purports, ‘the strong desire to frame one’s suffering within scientific medicine’s core
assumptions demonstrates that medical discourse still garners significant cultural authority’.
Indeed, it is precisely this valorisation of medicine that causes the participants to seek out
medicalised solutions for their childbearing desires. While patients may be considered ‘expert
consumers’ in the market-based age of medicine, they still rely on and pursue the expertise of
physicians (Figert 2011, Lupton 1997). Such is the paradox of consumerism. Individuals desire
to be informed, agentic patients, yet also yearn for and become passive to the expertise and
authority of physicians (Henderson and Petersen 2002). As Zadoroznyj (2001: 119) argues,
‘constructing the patient qua consumer has gone too far . . . the adoption of a dependent,

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 Individuals’ motivations for medicalisation 9

passive patient stance has therapeutic value, [and] is one that ought to be maintained in con-
siderations regarding consumerism in health’.
Placing their confidence and trust in the hands of physicians causes many consumers to seek
out professional assistance. Dylan, whose partner is the one hoping to get pregnant, feels that
the insemination procedure falls on her shoulders. Dylan reflects on this ‘burden’ when she
tells me:

Plus I feel like I would mess it up. Like because I would probably be the one putting it in
. . . They give you that long like syringe thing and I’m like, ‘What if I poke something in
her?’ Like do you know what I mean (laughing)? . . . I was like, ‘What if I’m coming over
to you and I trip and it just like sh-h-h and that’s like $740 (laughing) worth of sperm?’ So
I mean I make jokes of things, but it’s serious. Like I’d probably be all nervous and like
fumbling with stuff.

Dylan does not trust her own skills to successfully conduct such a procedure and believes she
‘would mess it up’. Because of the scientific basis and ‘societal faith’ of medicine, individuals
come to believe that medicalised processes are complicated and require expert skill (Ballard
and Elston 2005, Sandelowski 1991). As Wikler and Wikler (1991: 10) argue, ‘medical hege-
mony over artificial insemination was sustained in part because both physicians and patients
continued to believe that medical skills were essential for the technique’s success’. Leigh
relays this belief:

And we were like, ‘Um, [insemination] seems really complicated’. And then if – if – if, you
know, we didn’t get pregnant the first time, I didn’t want that to fall on anybody’s shoul-
ders. I didn’t want to look at her and be like, ‘You didn’t do it right’ or her worry if she
did it right. I didn’t – I wanted to take that very heavy responsibility off of our amateur
shoulders because we had not done anything like that before. And put it in the hands of a
professional who knows what they’re doing.

Women’s embodied knowledge has been subordinated to the extent that they believe they are
‘amateurs’ in understanding their selves. Instead, they ‘conform to somebody else’s agenda’,
who, as Leigh states, ‘knows what they’re doing’ (Purkis 2003: 109). Ironically, the women
are agentic in pushing for and pursuing medicalised solutions, but such a push is founded
upon and reifying of giving up such agency.
Similarly ironic, the participants believe that seeking medical solutions for their reproduction
will simplify the process, when in reality it makes the experience more complex. Andrea’s
experience of intrauterine insemination (IUI) demonstrates:

Um, they really take care of everything for you. So you would just call them, um, on the
day you ovulate. You just do the ovulation test, you call them on the day you ovulate and
then they tell you what day and what time to come in and that’s it. You don’t have to do
anything else. Whereas if you’re doing it at home, you have to think about, ‘Well, what
time should we do it and how does this work? And are we doing it correctly?’ And to them,
it’s just – it’s second nature so we didn’t have to have any of those concerns. We just drove
there, got it done, and left.

Reminiscent of women’s attempts to seek medical solutions for their infertility in order to
regain control all the while relinquishing their control to medicine, lesbian women in this
study seek what one participant calls a ‘one stop shop’ to simplify the pregnancy process, but
© 2017 Foundation for the Sociology of Health & Illness
10 Ann V. Bell

in doing so make it more complex (Becker and Nachtigall 1992). While Andrea’s quote makes
it seem that ‘you don’t have to do anything’, she does not relay the entirety of her experience.
For instance, Andrea does not describe the medicines she had to take to get her ovulation
cycle aligned with the other patients in the clinic, the orientation that the clinic required of her
and her partner before they began the process, her ovarian hyperstimulation to produce multi-
ple eggs for the procedure, etc . . . The professionalisation of medicine and its accompanying
expertise (i.e., ‘it’s second nature’) overshadow these other complexities, to where Andrea has
simplified her medicalised experience to ‘we just drove there, got it done, and left’.
Embedded within this expertise and simplification is the participants’ assumption that medi-
cine would be more successful at yielding conception than if they were to do it themselves.
The hope and optimism that medicine incites along with the belief that physicians can ‘pro-
vide miracle cures’ have endured through time (Earle and Letherby 2007: 245). As Susan told
me, she had ‘never, ever, ever, ever thought of doing it [herself] anyway . . . But thought
[medicine] was the most easily insured way of getting pregnant’. Similarly, Helen believed
that medicine ‘is going to give you the best chance’. Indeed, women in the study yearned for
even more medical intervention than was necessary in order to increase their chances of suc-
cess. For instance, due to its standardisation and foundation in heteronormative assumptions,
medical clinics provide infertility tests and treatments to lesbian women even though the
women are not functionally infertile. The participants, however, welcomed such overtreatment
and medicalisation because they believed it would increase their odds of pregnancy. Jamie
relays:

Um, and they had said that, that basically the way that [the clinic] works is that they want
to get all the testing done up front so that basically you have the best chance possible of
getting pregnant, which we really liked.

Jamie and her partner ‘really liked’ receiving infertility blood work and tests (e.g. sonohystero-
grams) because, to them, it gave them ‘the best chance possible of getting pregnant’.
Cathy also welcomed the medical testing because it revealed that her partner was a ‘prime
candidate’ for pregnancy:

I think anything that [the clinic] would do [testing] for anybody going in. Um, so I – I don’t
know all the names of this, but like really kind of checked to make sure your fallopian
tubes are open, make sure you don’t have any diseases, make sure you are ovulating, make
sure that all – okay – just – I think just kind of like the basic groundwork. Everything is
like perfect. [My partner] is healthy, like doesn’t drink, doesn’t smoke, doesn’t have caf-
feine, she eats healthy, she exercises. So like she’s got kind of everything on her side. Um,
and the doctors were like, ‘You know, you are the prime candidate for someone who can
get pregnant’.

As in the case of medicalised childbirth, women’s faith and belief in medicine cause them to
not only medicalise their reproduction, but extend such medicalisation to anticipated risk (e.g.
infertility) as well. In doing so, they unconsciously reinforce heteronormative standards of care
and the normalisation of medicalised lesbian conception.
The participants seek medical solutions for their pregnancies not only due to their assump-
tions surrounding the knowledge and success of medicine, but also because they consider med-
ical treatment the ‘right’, or appropriate way of conceiving for lesbian women. Medicalisation
has often been considered a status characteristic – it serves as a signifier of women’s social
positions as modern mothers (Litt 1997), allows teens to avoid stigma and normalise their
© 2017 Foundation for the Sociology of Health & Illness
 Individuals’ motivations for medicalisation 11

pregnancies (Brubaker 2007), and validates the childlessness of infertile women (Throsby
2004). As a status symbol, individuals conceive of medicine as clean, objective, and safe
(Franklin 1992). In contrast, alternatives to medicine are often considered dirty, subjective, and
risky. For instance, through the medicalisation of childbirth in the US in which doctors dis-
placed midwives much more rapidly and completely than its European counterparts, midwifery
came to be seen as ‘ignorant, dirty, and . . . unsafe’, while physicians were viewed as civil and
scientific (Fisher 1986: 138, Wertz and Wertz 1989). This mentality is reflected in the partici-
pants’ motivations for medicalised conception despite shifting attitudes about midwifery and a
rising natural childbirth movement. This may be because medicalised childbirth still reigns
dominant in the US and, as such, ‘while some women may feel comfortable rejecting domi-
nant cultural norms, most individuals are oriented towards adhering to pre-established,
accepted social behaviors’ (Brubaker and Dillaway 2009: 36). As Melissa told me, she and her
partner selected medical treatment to conceive because ‘we wanted it done right . . . let’s do it
the right way’. In their case, the ‘right’ way was medicine, implying that there is a ‘wrong’
way of doing so. Jenny has similar sentiments about medicine and its alternatives. She relays:

[We chose to go to the] fertility clinic. Didn’t want to do any messy (laughs), you know,
try to do it ourselves or anything like that. Yeah, we went right for that. Went to the doctor,
you know, took all the tests, figured out what had to be done, and then just went to the fer-
tility treatments.

Jenny and her partner ‘went right for’ medical solutions to conceive. In their minds, trying to
conceive at home would be a ‘messy’ enterprise. As the women’s impressions relay, solutions
to lesbian reproduction have been reduced to a binary: medicalisation is now considered the
normal way of conceiving, while alternative methods are marginalised and rebuked.
Because medical treatments are deemed ‘cleaner’ than alternative techniques for conception,
many women in the study pursue such treatments for safety reasons. Rooted in the AIDS dis-
course around sexuality and safety, lesbian participants’ choices were often driven by health
concerns. For instance, Chelsea contends, ‘that’s my concern is just the whole safety thing’.
Deb echoes this sentiment. In asking her whether she ever considered trying to get pregnant
without medicine and without going to a clinic, Deb told me:

No, that scares me . . . I don’t know. There’s so many people with so many diseases out
there and then you have to get somebody tested and it just seemed like – I mean I would
have – I know enough people that would totally, you know, do whatever I needed but it
was like it just wasn’t an option for me. It just not in my – I’m too paranoid.

Not seeking medical treatment to conceive was ‘scary’ to many participants. Much of this fear
resides in the sperm donor and women’s desires to use an anonymous, tested donor from a
sperm bank. The assumption (and often the institutional reality) that an individual must go
through a physician to use such a donor motivates the women’s medicalisation. For instance,
Melissa elaborates that ‘[At the clinic] everything is done professionally, and they test and
make sure there’s no diseases’.
While the participants are agentic consumers in pursuing medical treatment, they do so in
order to defer such agency to the clinicians whom they believe are more knowledgeable, trust-
worthy, successful and efficient in achieving pregnancy for patients than the patients are
themselves. In other words, the valorisation of medicine, including its assumed prestige and
expertise, motivate the women in this study to seek medicalised solutions for their
reproduction.
© 2017 Foundation for the Sociology of Health & Illness
12 Ann V. Bell

Discussion

As Plechner (2000: 90) argues, we ‘need to examine the process of medicalisation from the
point of view of the women who are experiencing it’. In doing so, this article reveals the
nuance and complexity of the engines of medicalisation. While individual consumers may now
propel medicalisation forward, oftentimes consumers’ motivations for doing so reside in the
institutional prestige and control of medicine.
Becker and Nachtigall (1992) set the stage for revealing the medicalisation of infertility, yet
focused more on the consequences of such medicalisation rather than the reasons behind
women’s pursuit of medical solutions. Examining such a pursuit among lesbian women is par-
ticularly revealing. With available alternatives, a marginalised status, and limited insurance
options, lesbian women seeking medical treatment for pregnancy expose aspects of medi-
calised motivations unattainable from other groups. Situated in a private medical market with
consumers at the helm, lesbian reproduction explicitly reveals women’s drive to drive toward
medical solutions. In contrast to Mamo’s (2007a) research conducted at the turn of the century
when the lesbian ‘baby boom’ was just commencing, the findings in this study reveal the tran-
sition from women’s ‘progression’ to medicine after failed attempts at home to one in which
medicalisation is embedded and normalised (Nordqvist 2008). Most women in the study did
not consider or have knowledge of alternatives. Indeed, as Erin said, ‘there were no other
options’. The extent of the embeddedness of medicalised reproduction is evident in its institu-
tionalisation through clinic, sperm bank, and insurance company policies.
The normalcy of medicalised reproduction including childbirth, infertility, and now lesbian
conception not only overshadows less clinical treatments, but also marginalises them as an
‘other’, dangerous and messy alternative. In turn, while Mamo (2007a: 188) revealed that ‘in the
biomedical era there is no choice but to exercise choice’, the current medicalised context deems
that there is not just a choice, but a ‘right’ choice for resolving lesbian reproduction. Consumers
certainly have agency, but they are swayed by ideological norms and institutionalised mecha-
nisms. The literature itself has infrequently challenged medicine as the legitimate provider of
reproductive technologies (Agigian 2004). Unquestioningly studying medicalised reproduction
without interrogating the why or how behind the process unconsciously reinforces its primacy.
Understanding individuals’ motivations for medical solutions allows for a more comprehen-
sive understanding of the medicalisation thesis in relation to patients/consumers. Importantly,
it demonstrates that such normalisation is spurred on by structural, professional forces of the
medical institution. It is not simply that individuals are now one driver of medicalised pro-
cesses (Conrad 2005, Figert 2011). Rather, as the findings demonstrate, why individuals are
driving those processes forward is shaped by larger, social, cultural, and ideological forces.
The institution of medicine encompasses many of those forces, including its assumed status,
expertise, success, and safety (Freidson 1974, Parsons 1951, Zola 1972). In effect, the medical
institution, its mechanism of social control and its expanse of prestige, is the gas that fuels the
engine (i.e., individuals) of medicalisation. In other words, macro vs micro, patient-consumer
vs profession, structure vs agency, are not mutually exclusive. Each side of the binary informs
and drives the other to the ultimate effect of medicalising reproduction.
Individuals are certainly agentic and knowledgeable in their pursuit of medical treatments.
However, ignoring what drives their agency forward and assuming a universality and confla-
tion around medical consumers and expert patients is misleading (Figert 2011, Fox et al.
2005). Henderson and Petersen’s (2002) notion of the ‘paradox of consumerism’ is fully evi-
dent in the women’s experiences (Lupton 1997). While many of them extensively researched
their reproductive options and selected medical treatment on their own accord, the women
often did so in an effort to relinquish their agency and have the ‘professionals’ take over.
© 2017 Foundation for the Sociology of Health & Illness
 Individuals’ motivations for medicalisation 13

Indeed, they are expert patients, yet desire to be patients precisely to hand over such expertise.
Like other medicalised solutions, ARTs have constructed the impression that reproduction is a
complex process, only to be handled by professionals. In turn, lesbian women in this study
‘automatically’ seek medical solutions when considering pregnancy and believe that such solu-
tions provide the ‘best chance’ of a positive outcome. Moreover, oftentimes the patient con-
sumers have no choice in selecting medical treatment for conception; their agency is restricted.
The institutionalisation of medicine through sperm banks and insurance companies implicitly
force women to seek medical services.
As Ikemoto (1996: 12) argues, this ‘technological imperative’ has turned into a ‘family forma-
tion imperative’. ARTs and medical solutions for reproduction are naturalised and go unques-
tioned, shifting the focus from a previously considered ‘unnatural’ method of family formation to
the ‘unnaturalness’ of childlessness. Lesbian women now confront many of the same expecta-
tions of motherhood that straight women have historically faced (Hertz and Nelson 2015; Mamo
2013). Now they are not only pressured to be parents, but how they become parents is also
socially dictated. Lesbian women learn about medical treatments from their peers and reinforce
its normality in choosing to pursue such treatments themselves (Agigian 2004).
Importantly, normalising medicalised conception has the effect of also normalising reproduc-
tive inequalities. The current reliance on experts and high-tech treatment results in higher costs.
In turn, as Quiroga (2007: 149) notes, this ‘bolsters a system of class- and race-stratified repro-
duction in which some people are empowered to nurture and reproduce while others are disem-
powered’. So, while the women who participated in this study could all afford medical
treatments, many women and families are unable to do so (Bell 2014). Moreover, the findings
in this study are framed from a specific class and race perspective. For instance, the high preva-
lence of knowing others who have pursued medical solutions to reproduce is present for the
high socioeconomic status white women in this study, but may not be true for less advantaged
women. Future studies should examine the race and class dimensions of lesbian conception.
While the lesbian population offers unique insight into choices and agency around medicali-
sation, the findings are restricted to this demographic. Consumer motivations for medicine
may differ among women and men of diverse backgrounds. The study does, however, provide
initial exploration of individuals’ experiences and desires for medicalisation. Future research
may continue to expand upon our understanding of the patient consumer.
In centring on individuals’ experiences, this study exposes the complexity, nuance, and
depth of their motivations, role, and agency in medicalisation processes. Medicalisation is
fuelled by both macro and micro forces working together to inform consumer choices.

Address for correspondence: Ann V. Bell, 325 Smith Hall, Department of Sociology, Univer-
sity of Delaware, Newark, DE 19716. E-mail: avbell@udel.edu

Acknowledgments

Thank you to the anonymous reviewers for their helpful feedback, and thank you to Tammy Anderson
for her assistance and support.

Notes

1 Throughout the article I use the term ‘medicalisation’ rather than Clarke and colleagues’ (2003) term
‘biomedicalisation’. In alignment with Conrad’s (2007: 14) interpretation of the terms,
© 2017 Foundation for the Sociology of Health & Illness
14 Ann V. Bell

biomedicalisation is a broader concept highlighting ‘a more extensive set of changes than is usually
meant by medicalisation’. Concentrating on change through the shifting engines of medicalisation
maintains the focus on medicalisation, which is at the centre of this study.
2 The turkey baster technique is a colloquial phrase to denote the ‘simple, low-tech process that could
be performed at home with materials you already have around the house (e.g. turkey baster and
mason jar)’ (Agigian 2004: x).
3 For the purposes of this article, I use the term lesbian throughout for ease of readability and conversa-
tion with other academic literature, but it is important to note the diversity of sexuality among the
sample.

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