Discussion
Numerous requirements and prohibitions in Islam regarding ART make it very complicated for Islamic couples receiving fertility treatment to make the relevant decisions. Their position as migrants living in a Western country results in extra problems. The available methods in Western countries do not comply with religious dictates and go beyond what is acceptable for Muslims. Doctors in the countries of origin are able to advise on the basis of Islamic structures, giving the couples a sense of security. The data from our study show that many migrants have doubts about their medical treatment and that they are unsure whether it complies with Islamic fatwas. This raises the question of the extent to which religion is a factor in the answers of the Turkish and Moroccan respondents.
Dutch doctors think they know what is permitted by Islam but it is not clear whether they sometimes adapt their treatment accordingly by not offering forbidden methods. However, although the doctors we interviewed were aware of Islamic rules about the third-party donation of gametes, they still offer these “forbidden” methods to their patients and as such accept “agency” of their patients. In Van Rooij’s study, several Turkish people expressed dissatisfaction about their doctors proposing the semen or egg donation (van Rooij, Korfker 2009). However, others complained that the doctor did not allow them to make their own decision about whether or not to use donor eggs or donor semen, and that the doctor made assumptions about their behaviour on the basis of their stated religious beliefs (Atighetchi 1994, Serour, Dickens 2001, Yeprem 2007, Inhorn 2006d, van Rooij, Korfker 2009, van Rooij, van Balen & Hermanns 2009). Although Sunni Islam does not allow egg or semen donation, a couple may nevertheless decide to avail themselves of this option. By not proposing the possibility of gamete donation, the doctor denies the agency of the patients and effectively precludes them from taking their only chance of achieving a pregnancy (van Rooij, Korfker 2009). In Van Rooij’s study of help-seeking patterns and decision-making, she finds that 21 per cent of women and 5 per cent of men mentioned that they would accept male donor semen if this was necessary to have a child. The acceptance of egg donation is higher in both groups: 27 per cent of women and 20 per cent of men (van Rooij, Korfker 2009). A Turkish survey of the opinions of infertile Turkish women about gamete donation found that some infertility patients approve of gamete donation: 23 per cent were for accepting oocytes and 3.4 per cent were for accepting sperm (Baykal et al. 2008). Another Turkish study focused on oocyte donation. Only 15 per cent of the respondents were completely opposed to oocyte donation and more men were in favour than women (Isikoglu et al. 2006). These are examples of women and men who explore their own agency in a society dominated by Islam by negotiating the structure that prohibits the third-party donation of gametes. However, Khalili describes a study from Iran and Turkey where the majority thought that oocyte donation was allowed by their religion (Khalili et al. 2008). In our study, women mentioned the reluctance of their husbands to accept donor semen, while they themselves seemed to be in favour. Just as in the examples of Van Rooij and Baykal, the agency of women seem to negotiate with the prevailing structure, while the agency of men looks to comply with this structure in accordance with their religion. Simpson describes this process in a study among Pakistani in England as:
“a complex navigation through demands placed on couples by religion, community, the medical profession and by husbands and wives themselves upon each other.” (Simpson, Hampshire & Blell 2012). They use the notion of “moral pioneering” first put forward by the anthropologist Rayna Rapp as an explanatory model for the efforts of couples to work out an optimal social and cultural position in relation to infertility.
The data in our study also show a mismatch between men and women with respect to the acceptance of gamete donation: women said their husbands did not accept gamete donation while they themselves seem to see it as a last-chance option. They did not openly say that they were in favour of donor insemination, but by saying only that their husbands were opposed, they seemed to suggest that they themselves were not. Women’s strong wish to have a child, amplified by the social norms about procreation, means they adopt a more flexible approach to the prohibitions of their religion and therefore explore their agency to fulfil their serious desire for offspring child. According to the information from the doctors, some couples choose to challenge structures by breaking the rules relating to third-party donor gametes and decide to accept donor gametes while keeping this a secret from their families. People did not admit openly in our study that they accepted donor gametes, except for one woman who admitted third-party donation. Secrecy about gamete donation seems to be one way Islamic couples extend their agency. We do not know whether men use the structural reason of religious regulation as an opportunity to escape the burden of being seen as infertile and to evade the corresponding questioning of their virility. Further research is needed to answer this question.
Inhorn investigated the attitudes of childless Muslim men in Lebanon towards both adoption and gamete donation (Inhorn 2006a). Most Muslim men continue to resist both, arguing that such a child “won’t be my son”. However, some Muslim men are adopting these alternatives as ways of preserving their loving marriages, of satisfying their desires to be fathers, and of challenging religious dictates (Inhorn 2006a). Men in our study did not admit that they were considering gamete donation: the topic was never mentioned by men.
Several studies indicate that patients’ Islamic beliefs may also play a role in women’s preference for a female doctor (Atighetchi 2000b); (Lafta 2006); (Yanikkerem et al. 2009). Our study found a preference for female doctors among Moroccan women and men that was less pronounced among Turks. Van Rooij also found in her study that Turks seldom raise the issue of gender-matched doctors (van Rooij, Korfker 2009). In our study, we did not enquire explicitly about the reasons for gender preference and so it may be that non-religious reasons also played a role. Indeed, the Dutch reference group also had a gender preference. However, the strong preference for a woman doctor in the Moroccan group, which even extended to the refusal of a male doctor by some husbands, suggests that religion is very important for Moroccan men in their preference for a female doctor for their wives. This preference for gender matching therefore seems necessary to maintain the dominant religious structure, especially for Moroccan men and to a lesser extent for Moroccan women.
Men were hesitant about the production of semen by masturbation because of the assumed prohibition in Islam on masturbation in general. They had to consult the imam for permission, and to avoid masturbation, some couples provided semen by making use of a condom during intercourse. Inhorn has provided an extensive description of the ambivalence toward semen as simultaneously life-giving and polluting and toward masturbation as a defiling and repugnant in Muslim societies (Inhorn 2007);(Khuri 2001). Furthermore, the act is surrounded by guilt and sometimes men assume that their infertility is a result of masturbating as a child (Inhorn 2007). A Moroccan population-based epidemiological study of women’s sexual behaviour found that 90 per cent of the women thought masturbation was forbidden, and that 83 per cent associated it with guilt and shame, but 15 per cent thought that it was authorised by religion as a means of calming the effects of abstinence (Kadri et al. 2007).
There were several limitations in our study. More than half of the interviewees were recruited by the interviewers, and this may have led to some bias in the answers. The interviewers convinced people to participate by telling them that being interviewed was an opportunity to express the problems they experienced. The number of Turkish men who participated in the study fell short of the target. Interviewers from the individual ethnic communities on the one hand may have created a better understanding during the interview, but on the other hand this also may have limited participant openness because of a fear of gossiping in the community. This raises the question of the extent to which religion is a factor in the answers of the Turkish and Moroccan respondents.
Conclusion
Many migrants have problems with infertility treatments because a large group feels insecure about what is allowed by their religion. This is particularly true of Moroccan men. They doubt whether doctors are sufficiently acquainted with Islam. Moroccans therefore go to Morocco for information and advice. Moroccan doctors confirm these facts and would like to advise European doctors on the subject.
Doctors assume they take the religion of their patients into account, but are not always aware of the importance of religious prohibitions for fertility treatment. Others take the rules too literally and do not take the agency of their patients into account.
Men cling to the rules and their agency is to comply with what structure prescribes; women may prefer to adapt the rules and navigate their agency, and even disregard the preferences of their husbands. The situation in a new country challenges couples to shape their own agency. This may result in the acceptance of more gamete donations. Doctors need to be educated in cultural competency so that they are aware of these dynamics and can help their migrant patients.
Acknowledgements
We thank the Netherlands Organisation for Health Research and Development for financing this study.
Survey forms (in Dutch) can be obtained by sending an email to the author dineke.korfker@tno.nl
Note
* In the Netherlands, the first successful IVF treatment was in 1983 (Hardon 2003). Three IVF attempts are paid by the health insurance.
** Dutch definition of migrant (allochtoon): anyone who had at least one parent born outside the Netherlands. If a person is born in the Netherlands he/she is second generation migrant. Non-western countries are countries in Africa, Latin America, Asia (except Japan and Indonesia) and Turkey (Statistics Netherlands).
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