Bioethics and gender in the case of in vitro fertilization in Bulgaria

Assia Assenova


Infertility is an important topic to bring forth, since it elicits multiple themes and cultural values having to do with the path take, with gender roles and definitions of femininity and masculinity, as well as moral and legal issues. ‘IVF is a shifting cultural artifact, as imbricated as any other in contemporary discourses and the struggles they articulate.’ [1] Reproduction is turning into a zone where gender, sexuality, economic development, public and private family life and public policies, biotechnology and the ethical dilemmas it causes, interact in a very delicate and specific way.

For a long time in most public discussions about the ethical issues of IVF, only the status of the embryo seems to have accounted. Most opponents of ART (Assisted Reproductive Technologies) and embryonic stem cell technologies base their arguments on the twin assertions that the embryo is either a human being or a potential human being, and that it is wrong to destroy a human being or potential human being. What unites the two warring sides in the discussion is that women are equally invisible to both: ‘he lady vanishes’. In new biotechnologies, we are witnessing the fear of feminization of all bodies, whether biologically male or female: all now appear to risk being reduced to the status of objects, just as women’s bodies have as long been objectified [2].

I proceed from the basic concepts of Donna Dickenson, who defines women as being out of sight as the lady who vanishes or is totally missing in the bioethical debate about the embryo’s moral status [3]. It is because of the need to study women in bioethical perspective that I focus on oral histories of women who have suffered or are suffering from infertility in Bulgaria over the past decade with the purpose of identifying the social construction of infertility a national context. Putting the accent on two different discourses (bioethical and gender), which in this particular case are based on personal experience, I attempt to demonstrate the nature of the matter regarding social problems of infertility and the application of in vitro methods in Bulgaria. My focus is on the way in which culturally available discourses of the expected transition to motherhood and of femininity play out in women’s narratives of living.

I follow the meaning that the situation holds for these women, and ways in which they creatively appropriate, transform, and resist culturally available meaning in the process of constructing their narratives and identities. In these women’s histories I explicate some social aspects of infertility in the Bulgarian context.

In my work, I am also motivated by the conviction that breaking the silence surrounding infertility experiences in Bulgaria. The lack of talking about the incapability to have a child is a very substantial moral problem in Bulgaria. On the one hand, this represents a difficulty because sexuality and reproduction in Bulgaria were taboo almost until the end of the  twentieth century. On the other hand, infertility is a delicate subject to share, since it is a very personal and innermost problem. The stereotyped attitudes formed and established in society impose a social pressure and make every woman feel obliged to experience motherhood at least once in her life. An additional difficulty for identifying and talking about the problem is the impossibility of exercising the original right and unique ability of women to conceive and reproduce their kind. In this case, the selected criteria will also demonstrate all practically marginalized groups, secondarily stigmatized in their essence and difference. Silence surrounding infertility is visible: in schools, in families, and the media are more discourses that normalize unproblematic pregnancies, constructing infertility as an extraordinary expectation and as deviant. It is these constructions that make these women feel separated from the rest of society.

Traditional construction of childless women as embodying an active and even harmful influence, with a dependency and passive inability to change her situation, can still be discovered in present day cultural meaning and medical constructions of infertility in Bulgaria. The extent of stigmatization and social ostracism of childless women in Bulgaria has certainly significantly tempered a century later such obvious forms of exclusion, including exclusion from the public and medical discourses and the media. Responsibility and thus blame for the inability to conceive is attributed mainly to women, both through social interactions and through the social sciences and medical literature on the topic – a victimization that seems to exist in different forms across many national and cultural boundaries. Stigmatization and blame regarding childlessness are local discursive phenomena, supported by cultural constructions of ‘true’ masculinity and femininity, as well as by culturally taken for granted expectations of life cycles and what constitutes a meaningful life [4].


In order to reveal the multi-language aspect of the moral and social world and with a view to the complexity of the problem, preference was given to oral history as a basic methodological approach in three particular aspects: 1) oral history as contemporary history, 2) oral history as gender history, 3) oral history as verbal text. On invitation was addressed to women to participate in the forum ‘Zachatie/Conception’. Eleven women participated in the study, three of whom wrote detailed narratives in Skype conversation. Histories of life told under the form of semi-structural interviews by different types of women. Their interweaving gives opportunity to study the process in its full dynamics in Bulgaria during the last ten years.

I carry out a linguistic analysis, motivated by the way, wish, duration and readiness to present personal experience, giving the opportunity to reveal the differences in the ‘similarity’ of perceiving, experiencing and talking about infertility. The communication situations, strategies for maintaining a conversation, thematic set and narration scheme, extralinguistic factors, are different and specific for each story. The formation of an individual profile of each woman enables the illustration of the difference between women with identical problem, since the ways of perceiving, experiencing and coping with the problems are strictly individual.

Constructing an identity within motherhood

For most of the women becoming a mother was ‘an event taken for granted’ in their life path. They had seen their future as including children and the identity of motherhood as part of their female identity. The menstrual periods were dramatic events, symbolizing the ‘destruction of hope’.

At the semantic level I treat the nominations, definitions and meanings implied by the women suffering from infertility themselves – self-identification and specifying the infertility related conditions, as well as its definition of infertility. The women identified as ‘other’ and different. The inability to conceive immediately was seen as abnormal and was fear provoking. Perceptions of abnormality, defectiveness, and incompleteness entered into the constructions of their identities. The sense of lack and emptiness, the perceiving of infertility as a tragedy and drama, the treatment as a fight and a struggle for happiness, the achieved parenthood as heaven and indescribable happiness – all these confirm the indispensable biological motherhood without the right to choose at a formal verbal level as well.

The inability to have children had a strong effect on the women’s social identities. The women perceived themselves as excluded additionally because the topic of infertility is silenced in society. They stressed that the extent of silencing depends on the size of the city – with the absence of children being much more obvious in smaller towns, while at the same time the efforts to avoid it as a topic also being more pronounced. When the question is posed directly a couple feels that they have to give an explanation, they say that they are postponing having children because of poor living conditions, economic insecurity and other external factors.

Blame and Self-Blame

The medical and social discourses of blame are pivotal to the construction of the infertility experience of the Bulgarian women. Their histories always included a position relative to the discourses blaming women’s bodies, behavior, and psyches. For example, in presenting her explanations of the couple’s infertility, most of women started that she had not had abortions.

Self-blame is a key theme in the histories. It included the speculation that infertility is a punishment from God. Another prominent theme of self-blame had to do with the women’s decision about treatment. Many women saw themselves as being responsible for making the wrong medical choices for not correctly assessing their symptoms, for not seeking treatment which ultimately would have provided them with care after the procedures.

Self-Exclusion in social and professional interactions

The women that I talked to rarely experienced direct exclusion and stigmatization in their family and community contexts. The extent of stigmatization, however, was different according to their location – women who came from smaller towns and villages expressed much more intensely negative experiences as a result of the attitudes of family and social contacts.

In family context the women did not experience pressure or blame from their partners. Rather, they usually felt supported by them. By this, the women meant that the husbands did not blame them, did not impose a solution on them and ‘let me do what I want’, or in rare cases, accompanied them to the tests and procedures. Thus, support was defined both in terms of their efforts to embark on infertility treatment. The husbands were actually more willing to discontinue infertility treatment, while the women were the ones who were determined to persist indefinitely to ‘endure any pain’. Multiple egg extraction has become the norm for IVF because it increase the chances of success. Asking a women undergoing IVF to submit to intensive ovarian stimulation for multiple egg extraction does at least lessen the likelihood that she will have to return for treatment again and again.

In several cases, the relationships between the partners has deteriorated because of the stress of the inability to conceive and the pressure of the demanding medical treatments, mechanical sexual relations, etc. Some marriages were dissolved as a direct consequence of infertility. These, however, were the exceptions, in most cases the women felt strongly supported by their partners. Since many newly married couples lived in the same household as the husband’s parents, the presence or absence of a pregnancy were much more closely monitored.

Basic topics in women’s individual stories

There is the (over-)medication of the reproductives process and the lack of reflexivity, which predetermine the thematic selection. As basic in the personal stories appeared the topics about purely medical interventions and those about reasons and decisions regarding in vitro attempts, the fear of another or eventual attempt, the wandering in the vicious circle of different clinics (a bad experience), and finding the right doctor. As an alternative and secondary topic in the personal stories appeared social contacts, the partner’s role, the parents’ place, the access to information.

Where do moral problems occur in your everyday life?

The idea of morality of and moral problems of in vitro fertilization remains strange to women, suffering from and fighting infertility, since the problem is perceived as deeply personal and limited in the private sphere and is entirely missing in the everyday personal discourse. ‘When it comes to being unable to have a child and there is only one way, the word ‘moral’ is out of place.’

Despite the alleged reproductive freedom of women, motherhood is perceived as intrinsically inherent, genetically preset role a biological instinct which is manifested at a certain stage of life. The embryo’s moral status is identified with the value of the child and the embryo is thought of and perceived as an unborn child. The child gives meaning to the relationship between two people, not their relations. ‘It’s a little bit frightening.  Why do you get together with someone? What’s the point?’

Real moral problems declared in the personal histories are 1) the financial (defined as the main and only), 2) the equal access to the ART services and 3) the doctor-patient relations where they actually comment on many moral problems involuntarily and without considering them as such. The problems outlined in these stories are identical to the ones present in public debate and the public sphere.

The lack of sensitivity to the moral problems, the not finding of place for the word ‘moral’ in their ‘fight’, the incomplete feminine identity and the confirmation of the stereotyped model of indispensable and compulsory biological parenthood, is manifested both at a linguistic and semantic level as a projection of their own Ego, understanding and primary attitudes of the world around them.

The Causes

1. Regulation.

Until 2009 Bulgaria and Albania were the only countries in Europe where the state or health insurance funds did not cover even partially the treatment of sterility. In most European countries, at least three IVF cycles are reimbursed. Until 2004 the National Health Insurance Fund did not cover any part of the treatment. In Bulgaria the struggle was for covering at least one cycle and part of the cost of medicines and it was not before the beginning of 2009 that the ‘Assisted Reproduction’ Fund began working.

2. Bulgarian public discourses.

Despite the numerous dilemmas related to reproduction and contemporary ART, ethics and gender studies remains outside the public sphere in Bulgaria, as well as drastically out of sight for concrete ART users. Funding, access, and age of women, as well as the medical interventions, are the main subjects discussed in Bulgaria, whereas in Europe the discussions focus on the rights of homosexuals and HIV-positive people, surrogate mothers, etc. The access of homosexuals, HIV-positive and sick people, widely discussed in the West, is absent from the public discourse in Bulgaria.

3. Biotechnologies vs. Stereotypes

It turns out that ART actually confirm and impose deeply rooted patriarchate  models and cultural stereotypes, as in the first place they oblige the woman to accept motherhood at any price, without raising the question of life without children or alternative options like adoption or host parenthood. In the second place, in this way compulsory genetically related parenthood is actually once again imposed.

Reproduction (sexual or otherwise) is often sentimentally considered to be on of the main activity and fundamental characteristics of life. Biotechnologies are quickly entering human reproduction: a woman can carry a fetus from another woman’s egg and so motherhood becomes too movable, and so is fatherhood. However, the right to a family and offspring is a basic human right. On the one hand, the concepts of parenthood, motherhood and fatherhood are blurred and are hard to define. At the same time, traditional practices are getting more solid. The introduction of reproductive technologies shakes the traditional nuclear family model, yet on the other hand, their application and the desire of many families to achieve it, makes it even more solid. Surrogacy is a classic example of entering a new, yet completely old identity.

Without even realizing it, the infertile woman is actually left with no personal choice. Biotechnological opportunities turn out to be too little, the most desirable of them being in vitro with genetic material from both partners. Determined to become mothers of their own children, women fall victims at numerous and diverse levels – victims of social pressure and cultural stereotypes, of strictly established moral practices in society, of the healthcare system, economics and finances, politics, medicine, of the biotechnological studies and experiments, of the commercialization of medical services, etc., where categories like gender and morality interfere continuously, but remain equally hidden and unnoticed to them.

Limiting the moral problems of infertility and the applying of in vitro procedures only to access and funding (in the personal, as well as in the public discourse) leads to hiding the symbolic power whose manifestations turn out to be modified, covered, even more hidden and therefore invisible. It turns out that ART actually confirm and impose deeply rooted patriarchate models and cultural stereotypes, as in the first place they oblige the women to accept motherhood at any rate, without raising the question of life without children or alternative options like adoption or host parenthood. In the second place, in this way compulsory genetically related parenthood is actually once again imposed.


  1. Farquhar Dion 1996. The Other Machine. Discourse and Reproductive Technologies. London, Routledge
  2. Dickenson Donna 2007. Property in the body: Feminist perspectives. Cambridge University Press
  3. Dickenson Donna 2006. The Lady Vanishes: What’s Missing from the Stem Cell Debate. In Journal of Bioethical Inquiry, Vol. 3, pp. 43 – 54
  4. Todorova Irina, Kotzeva Tatyana 2003. Social Discourse, Women’s resistive voices: Facing involuntary Childlessness in Bulgaria. In Women’s Studies Forum, Vol. 26, № 2, pp. 139 – 151


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