An internet forum analysis of stigma power perceptions among women seeking fertility treatment in the United States

An internet forum analysis of stigma power perceptions among women seeking fertility treatment in the United States

Social Science & Medicine 147 (2015) 184e189 Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/...

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Social Science & Medicine 147 (2015) 184e189

Contents lists available at ScienceDirect

Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed

An internet forum analysis of stigma power perceptions among women seeking fertility treatment in the United States* Natalie Anne Jansen a, *, Jarron M. Saint Onge b a b

Department of Sociology, University of Kansas, USA Department of Sociology, Department of Health Policy and Management, University of Kansas, USA

a r t i c l e i n f o

a b s t r a c t

Article history: Received 5 June 2015 Received in revised form 31 October 2015 Accepted 2 November 2015 Available online 5 November 2015

Infertility is a condition that affects nearly 30 percent of women aged 25e44 in the United States. Though past research has addressed the stigmatization of infertility, few have done so in the context of stigma management between fertile and infertile women. In order to assess evidence of felt and enacted stigma, we employed a thematic content analysis of felt and enacted stigma in an online infertility forum, Fertile Thoughts, to analyze 432 initial threads by women in various stages of the treatment-seeking process. We showed that infertile women are frequently stigmatized for their infertility or childlessness and coped through a variety of mechanisms including backstage joshing and social withdrawal. We also found that infertile women appeared to challenge and stigmatize pregnant women for perceived immoral behaviors or lower social status. We argue that while the effects of stigma power are frequently perceived and felt in relationships between infertile women and their fertile peers, the direction of the enacted stigma is related to social standing and feelings of fairness and reinforces perceived expressions of deserved motherhood in the United States. © 2015 Elsevier Ltd. All rights reserved.

Keywords: United States Infertility Stigma Stigma power

A great deal of research finds that the stigma of infertility can have negative health implications (Slauson-Blevins et al., 2013; Clark et al., 2006; Goffman, 1963; Kimani and Olenja, 2001; Nachtigall et al., 1992; Greil, 1997), including long-term depression (Schwerdtfeger and Shreffler, 2009), lower life satisfaction (Greil et al., 2011), or social isolation (Miles et al., 2009). Infertility serves as both a visible and invisible stigma e infertile individuals decide both when and to whom they disclose the details of their condition while childlessness remains highly visible and stigmatized. In order to better understand the impact and implications of stigma faced by infertile women, we focused on how infertile women seeking fertility treatment perceived and expressed discontent with fertile women in their lives.

* A previous version of this research was presented at the Midwest Sociological Society. The authors wish to thank Mehrangiz Najafizadeh and David Smith for comments on a previous draft. This manuscript benefitted immensely from detailed and insightful comments from the editor and anonymous reviewers. We also thank the Fertile Thoughts forum for providing this service and most importantly, the women who posted on the forum for sharing their intimate and painful struggles with infertility. * Corresponding author. Department of Sociology, 716 Fraser Hall, 1415 Jayhawk Blvd, Lawrence, KS 66045, USA. E-mail address: [email protected] (N.A. Jansen).

http://dx.doi.org/10.1016/j.socscimed.2015.11.002 0277-9536/© 2015 Elsevier Ltd. All rights reserved.

According to Goffman (1963), stigmatization occurs after an individual's undesirable condition is acknowledged by “the normals” e those who do not depart negatively from society's expectations (p. 5) e who attach negative associations or attitudes to an individual and his or her condition (Crocker and Major, 1989; Berger et al., 2011; Joachim and Acorn, 2000). The frequent conflation of motherhood with womanhood (Hird, 2007; Rich et al., 2011; Peterson and Engwall, 2013) and cultural expectations of completed fertility (Musick et al., 2009; Sweeney and Raley, 2014) are among the factors that set the “national context” for infertilityrelated stigma (Pescosolido et al., 2008). However, as Lekas et al. (2011) argue, a generalized description of stigma “obscures the delineation between sources and targets of stigmatization” (p. 1206), with social expectations pertaining to motherhood not limited to fertile women. Research on stigma often differentiates between the perceptions of others' discrediting actions of “felt stigma” and the actual discriminatory behaviors against a stigmatizing condition of “enacted stigma” (Jacoby, 1995; Brewis et al., 2011; Scambler, 2004). Felt stigma and internalized blame lead individuals to frequently respond to everyday social interactions as if they were enacted stigma (Barlӧsius and Philipps, 2015), whether or not the actual intent of individuals in their social networks are known (Brewis et al., 2011). Both actual and felt

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stigma can reinforce the internalization of stigma by infertile women and lead to decreased self-esteem (Corrigan et al., 2006), marginalization, or feelings of social isolation (Ferland and Caron, 2013) that may potentially compromise relationships (Pescosolido et al., 2008). Contextualizing infertility in a framework of felt versus enacted stigma sheds light on stigma responses by infertile women by socially situating women within hierarchical relationships. Maintaining positive social relationships throughout struggles with infertility can be critical to the maintenance of infertilityinduced anxiety and stress, especially because most women wish to discuss their infertility with others (Schmidt et al., 2005; Peterson et al., 2006) but frequently complain about difficulties in finding adequate social support (Domar, 1997; Lechner et al., 2007; Verhofstadt et al., 2007). Johansson and Berg (2005) studied involuntarily childless women two years after unsuccessfully completing infertility treatment and highlighted their difficulty in relating to peers with children and found that women socially withdrew at gatherings of family and friends as a result of feeling marginalized. Remennick (2000) emphasized that the infertile women in her study intentionally avoided conversation topics related to family or children, and many admitted to selectively disclosing the truth or simply telling lies to avoid uncomfortable conversations. Miall (1986) found that nearly all of the infertile female respondents she interviewed were concerned that others would view them in a “new and damaging light” if made aware of their infertility problems (p. 271). While friends and family members may aim to be supportive, social networks of infertile women are often inexperienced or ill-equipped to provide the emotional support infertile women desire. For example, High and Steuber (2014) found that women often received unwelcome advice and information from friends and family, suggesting that friends and family often overwhelmed infertile women rather than offering meaningful forms of desired social support or empathy. While the consequences and struggles with infertility are well documented, less is known about stigma-related power differentials within relationships. As Parker and Aggleton (2003) describe, stigma must be understood at the intersections of culture, power, and difference in order to contextualize its influence on social order. Stigma power is frequently conceptualized as uni-directional, where the “normals” have access to the power and avenues for exclusionary and discriminatory behavior to prevent status gains (keeping people down), to maintain social norms (keeping people in), or to present social barriers (keeping people away) (Phelan et al., 2008; Hatzenbuehler et al., 2013; Link and Phelan, 2001). Alternatively stated, stigma power maintains the public stigma of infertility and reinforces the potentially damaging effects of power differentials within presumably supportive networks. Stigma power potentially works in three ways. First, stigma power may be exclusively enacted by the non-stigmatized group. Link and Phelan (2001) suggested that while “stigmatized groups often engage in similar types of stigma-related processes in their thinking about individuals who are not in their stigmatized group” they do not have the “social, cultural, economic, and political power to imbue their cognitions” thereby resulting in no serious discriminatory or stigmatizing consequences to their processes (p. 376). Second, unequal relative social standings of individuals in a relationship may serve as a buffer to felt stigma. Access to resources and protective social factors may reduce the felt effects of stigma power. Indeed, women seeking treatment are more likely to be middle- and upper-class, highly educated, employed, and part of the ethnic majorities in their communities (Green et al., 2001). In a quantitative study of women seeking treatment, Donkor and Sandall (2007) found that tertiary education and higher social

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status were mediating factors in reducing a woman's perceived stigma. Third, the active resistance or negotiation of felt stigma may serve as an active challenge to stigma power and the corresponding social hierarchies (Parker and Aggleton, 2003). As evidenced, women frequently take action to mask (i.e., passing) or hide their infertility. While passing or hiding is a frequent stigma management strategy, this ability to remain invisible may be more readily available to individuals with higher social standing. Thus, increased access to social resources may actually reverse the direction from “stigmatized” to “stigmatizer” in terms of moral judgments of “deserving” motherhood. We extend previous research on the unique stigma challenges facing women seeking fertility treatment. Specifically, we analyzed the content of initial threads on the infertility forum Fertile Thoughts, the largest infertility forum available online, to explore perceptions of power within socially situated stigma experiences. Timmermans (2013) suggested that, “[inter-situational research] helps to contextualize health issues within other pressures of living and within biographies across the life course” (p. 5). Forum analysis allows for an assessment of statements written from the personal spaces of infertile women without the probing or questioning frequently present in other methodologies. Furthermore, online forum participation offers a support system that is both convenient and affordable, and communication amongst members provides aid when other types of support may be unavailable (Malik and Coulson, 2008, 2010). Accessibility facilitates relationships between infertile women and provides “a new reference group capable of validating their feelings and restoring their sense of normalcy” (Greil, 1991, p. 151). Importantly, online forums present an outlet for expressing intimate thoughts on perceptions of felt stigma and perceived power dynamics and provides the advantage of total anonymity if so desired. Analyzing a space where individuals can readily access support and post anonymously minimizes social desirability biases in discourse e a particularly important quality for understanding stigma power dynamics. As such, our central aim was to analyze the relationship dynamics between infertile and pregnant women and assess the evidence of felt and enacted stigma in an online forum setting. Accordingly, our results highlight the role of perceptions of felt and enacted stigma in infertile/non-infertile relationships, and examine the role of expressed responses to perceived stigma power. 1. Methods We selected two infertility forums on the website Fertile Thoughts, the largest social networking site dedicated to fertility and infertility (Fertile Thoughts, 2014). We chose Fertile Thoughts due to its high usage and reputation for fostering a strong community. Using a Google search for “infertility forum,” Fertile Thoughts is the top search result out of 1.9 million. The website was launched in 1996 and has provided a space for infertile individuals for 19 years. The forums have over 87,000 members and over 4.8 million posts to the site on an array of forums about parenthood. In the infertility section of the website alone, there are 59 unique infertility-related forums. Specifically, we selected a forum exclusive to women attempting to conceive and coping with other women's pregnancies, TTC and Coping with Other Women's Pregnancies, which included 432 posts. We chose to analyze the initial post on each thread as a thematic analysis in order to best understand what prompted users to access the forum. We did this for two reasons. First, approximately onethird of the users visited the site for one year or less, with many only posting once. Second, the majority of the posts on the forum did not lead to dialog between users; most posts either (1) did not

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have any responses, or (2) had responses that merely demonstrated that someone had viewed the post. Demographic information came from the post, if provided; from the individual profiles of the posters (which often included additional information such as profession, current treatment, and location); and from the signature (an optional inclusion) that frequently includes the poster's age, spouse's age, the length of time trying to conceive (TTC), and details of past procedures. Because each individual can provide as much or as little information as they choose, the amount of information for each poster varied. In order to determine the average length of stay on Fertile Thoughts, we averaged the length of stay for the 100 users with the oldest posts between the two forums. The length of time was calculated by finding the difference between the date the user joined the site and the date of her last post to the site. Upon completing the analysis, we analyzed an additional forum with 53 posts called the Pain of Infertility as a measure of reliability in order to confirm that similar stigma themes and power differentials are present elsewhere in the forums. Seven months after completing the analysis, we re-analyzed a random sample of 10 percent of the original forum posts to ensure coding reliability. While Eysenbach and Till (2001) maintain that informed consent of participants should always be obtained, the anonymous nature and sporadic participation of members made obtaining such consent impossible. However, all of the data used is accessible without website membership, and the website archives all of its forums, therefore making the forum explicitly public. To ensure the protection of women posting to the site, the project was approved by the University of Kansas Institutional Review Board in April 2014. 2. Procedure This study employed a qualitative, inductive thematic analysis to identify common themes within the infertility forums (Malik and Coulson, 2008; Van Hoof et al., 2013), as per the guidelines outlined by Braun and Clarke (2006). Prior to beginning the analysis, we followed the forums of interest for several weeks to gain insight regarding the content of the posts. Upon beginning analysis, first, we read each of the forum posts several times in order to familiarize ourselves with the data. Second, we coded emerging patterns and grouped these codes into prospective themes. We created eight codes to categorize women's accounts: positivity toward pregnant women/young families/small children; hostility toward pregnant women/young families/small children; frustrations with friends/ family not understanding; desires to be a parent; psychological distress; uncertainty of the future; social isolation; and expressions of disdain for a “dysfunctional” body. Upon coding the comments into these eight categories, themes of stigma emerged across the forums. 3. Results and discussion 3.1. Characteristics of forum posters Of the 257 unique users between the two forums, we excluded the one man, resulting in a total sample of 256 female users. In calculating the average time spent on Fertile Thoughts, three users were excluded because they were still active on the site at the time demographic information was collected. Six percent of the women used the site for three weeks or less, with 18 percent on the site for 7 or more years. The average length of stay was 3.33 years (SD ¼ ±2.69). The forum was primarily used by women living in the United States (85.43%). The average age of those who reported age (n ¼ 157) was 30.43 (SD ¼ ±4.74), and the average number of years

who reported TTC was 3.58 (SD ¼ ±2.77). After comparing the randomly sampled analysis to the formal analysis, we determined a coding reliability of 90.7 percent. 3.2. Stigma toward fertile women Two primary trends regarding perceived stigma and stigma power emerged on the forums, demonstrating the complexities of stigma power dynamics situated in the lives of women struggling with infertility. First, the inability to get pregnant, experience pregnancy, and experience motherhood was perceived as stigma. For example, an infertile woman from Missouri discussed her experiences with baby showers, stating that “unnecessary attention” is often paid to women without children. After other women at the shower started “asking too many questions”, she expressed her strategy to redirect attention to the mother-to-be after receiving comments about “sex positions and herbal this, that, and the others, relaxing, and ‘don't think about it and it'll happen soon.” She went on to say, “It seems, no matter where I go, I find a woman who finds nothing wrong with ‘laying hands’ on my belly and saying a prayer.” Though some infertile women on the forum discussed instances of intentional enactment of stigma, more often than not, stigmatizing actions were reported as unintentional. This may be due to the majority of perceived stigma comments in our analysis coming from close contacts (e.g., friends and family), as found in previous research (Brewis et al., 2011). Misplaced sympathy, insensitivity, or a general lack of understanding were given as reasons for painful remarks or actions, which was interpretable as felt stigma by the women on the infertility forum. For example, one woman wrote: They may know about our infertility, but they don't know what hurts someone with infertility. They kvetch about their morning sickness and get sympathy from others while we just want to scream, I'd do anything to have morning sickness you stupid cow! … but I'm not sure if we are always wise to see the commenter as rude or mean e I think there is a lot of not realizing how delicate our feelings on the matter are. Second, many forum posts appeared to be clear challenges to stigma power. While past analyses indicate that a stigmatized individual cannot enact stigma, our forum analyses indicated that an infertile woman is capable of stigmatizing a fertile woman. We found that infertile women frequently appeared to stigmatize fertile friends and family. Words and phrases used to describe fertile women included: fat cows, ferts, the fertiles, or momzillas-tobe. For example, a 40-year-old woman wrote about discovering a fellow church-goer's pregnancy, “I smiled, congratulated her and wished that I was on a remote tropical island where no fertiles walked around. Short of staying held up in my house, how in the heck can I avoid all these Fertile-Myrtles?? UGH!!” Goffman described these types of interactions as “behindscenes joshing,” where a stigmatized individual “jokingly enacts scenes of degradation with one of his kind” and participates in language usage that would typically be construed as taboo in daily life (p. 134). These behind-scenes actions, in the safety of an anonymous forum, were likely used to cope with their own disappointments in their inability to become pregnant themselves (Goffman, 1963). But, they may also be interpreted as challenges to the social hierarchies existent within public stigma. For example, an English professor wrote: If I could choose my mutant power, I would choose to be able to cure infertility e my own as well as others'. And for good measure, I might throw in the ability to make it harder for some

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women to conceive e especially the cows who sit around talking about getting pregnant like they were ordering from a fast food menu.

While these remarks resemble stigmatizing behaviors, they do not necessarily demonstrate stigma power held by infertile women over fertile women. However, the idea that these women were just “joshing” may also be an unfair assessment. While their comments may not clearly be stigmatizing, they have the potential to be damaging e more malicious than mere joking. These behaviors are comparable to those found in the mental health patients surveyed by Link and Phelan (2001), who antagonistically regarded their doctors and nurses as “pill-pushers.” While infertile women's minority group status and relative powerlessness may minimize the stigmatizing consequences from their comments and actions, the challenges to the existing power structure likely affect their relationships, regardless of whether they are enacted. Our analysis also showed several instances of infertile women presenting derogatory remarks toward a fertile woman's social position. Often, these comments were contextualized within constructions of a “just world”, and specifically commented on the role God plays in the determination of who does or does not become a mother. For example, women questioned “how there could be a God that would give children to such a terrible person?”, or “Why would God give her and her cheating hubby a baby and not me?” The use of theodicy was frequently used to rationalize suffering and fairness and was contextualized within an existing public stigma discourse that adjudicates between “undeserving” and “deserving” motherhood. In some cases, this may have provided infertile women with a template for comprehending suffering within a rational worldview (Simko, 2012), that in turn may have justified stigmatizing behaviors towards fertile women. The forums consistently showed that being pregnant and on welfare were perceived as less acceptable than being pregnant with more financial stability (a near requisite for fertility treatments). In this way, women on the forum appeared to actively stigmatize fertile women in situations when they deemed the fertile woman as “undeserving” of motherhood. Propagating comments about low-income mothers led to common definitions of acceptable and unacceptable behavior. By equating low socioeconomic status with undeserving motherhood, infertile women appeared to rectify feelings of unfairness through stigma power. Whereas Link and Phelan (2001) noted the lack of power within mental health patients to publicize their thoughts, this select group of infertile women posting to the forums was largely middle- and upper-class employed white women. The invisible stigma of infertility does not appear to limit the social power through which infertile women reinforced cultural norms of “deserving” versus “undeserving” motherhood in a public forum. Infertile women frequently used socioeconomic status and/or moral record as a measure for deservingness. One woman left infertile after a battle with cancer wrote, “Several of these girls are unmarried and can barely afford the child they have already had previous to their new addition.” As Gilens (1999) points out, “welfare has been viewed by the public as a long-term substitute for economic self-reliance” (p. 37). As such, misconceptions about ‘welfare mothers’ and ‘babies having babies’ are fueled in part by an incongruous understanding of the realities of poor mothers and the preconceived notions of them. Another woman, a 30-year-old bank manager, posted about an unmarried pregnant employee with no interest in getting married because her boyfriend's income would disqualify them from federal assistance programs such as the Special Nutrition Program for Women, Infants, and Children (WIC) and Medicaid. She wrote, “Doesn't [my employee] realize that WE are paying for her to cheat

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the system when they can more than afford to pay for their child!” And another woman wrote that she does not understand why she cannot be happy for her pregnant friend and her husband because “they are not losers or on welfare or anything.” Many women also defined unplanned pregnancies as undeserving. For example, a 25year-old woman who had been TTC for one year posted, “I … feel like I'm the only one not being given my ‘turn’ at motherhood, especially since my brother and his girlfriend … accidentally got pregnant recently!” Another woman stated, “Why is it that others have something they take for granted when we would give anything to have what they don't want?” Each expressed disapproval through non-adherence to the cultural expectation of “normal” paths to motherhood. Further, the emphasis on deserving versus undeserving appeared to reinforce and reify the decisions to actively stigmatize fertile women for immoral behaviors. For example, “My husband's 19-year-old brother announced he accidentally got his girlfriend pregnant. I was devastated! I cried, yelled, screamed, I totally decided then and there that I would have no part in their life or the life of that child.” Moral judgments allow for social distancing, a key component of stigma power (Link and Phelan, 2014). Infertile women also posted to the site when fertile women used drugs or alcohol. For example, a stay-at-home mom from Louisiana expressed concern about a close relative who is “addicted to crack and other drugs” and is “already being watched by child welfare after being caught driving while high and half passed out.” The forum poster appeared to use her relative's drug habits to suggest that she is more deserving of parenthood because she would adhere to the morally acceptable behaviors expected of mothers. Another example was written by a 31-year-old preschool teacher who discussed her step-sister and wrote, “[My pregnant] step-sister is smoking and finished off [her] boyfriend's mojito also, but was at least making an attempt at not drinking.” Another forum poster from Canada wrote about her best friend and said, “I hate her for getting her healthy baby when she was drinking and smoking before she took a home pregnancy test, knowing she didn't have a period.” Consequently, infertile women seeking treatment frequently expressed displeasure with being exposed to both less deserving and inadequate mothers. Other social factors were expressed as undeserving of motherhood. For example, a number of posts discussed pregnant teenagers or couples who got pregnant outside of marriage: “My 17-year-old cousin, who is a senior in high school, is pregnant. The baby's father is a high school drop-out who doesn't work and does drugs … How unfair is this?” As previously shown, others discussed parents who have affairs. Still others discussed parents who were undocumented immigrants or possessed criminal records: “Her boyfriend is an illegal alien from England. His visa has expired and he won't renew it, going on several years now.” Other women discussed less educated couples: “She married a guy who didn't graduate high school, and they've been on welfare ever since.” And finally, many women stigmatized multiple groups simultaneously: My lil sis is 6 months pregnant by some guy she has been seeing on and off for like 2 years. She is 19, he is 18. He is a horrible guy … drugs, jail, abuse, other children, cheats, etc … I would love to have been able to have the 1st grandchild … [My husband] deserves to be a DADDY!! Not your criminal, player, wannabe thug, baby's daddy jack a$$!! … The findings from this study suggest that felt stigma, enacted stigma, and stigma power, are invaluable to the discussion of infertility stigma. We argue that the definition of stigma power should be more inclusive; it appears that stigmatized groups can and do stigmatize other groups, when they possess alternative

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forms of social status. While the stigma of infertility may be invisible, the enacted stigma towards pregnant and new mothers were visible (at least as expressed on the forums), which demonstrated an individual's ability to simultaneously assume the role of both stigmatized and normal. While fertile women typically hold stigma power over infertile women in a physiological sense, infertile women who have the material privileges of seeking treatment may hold power over fertile women in other meaningful ways through education, finances, or social standing. 4. Conclusion Postings on the infertility forum, Fertile Thoughts, demonstrated that stigma is perceived and manifested through a variety of actions by the fertile women in their lives, with perceived power distinctions favoring the fertile over their infertile counterparts. Findings from the forum echo past findings that demonstrated the challenges of finding adequate social support (Lechner et al., 2007; Verhofstadt et al., 2007). Similar to work by High and Steuber's (2014), the forum highlights how fertile women may unintentionally stigmatize and are perceived to provide insufficient support. Because infertility affects 30 percent of women aged 25e44 in the United States (Schwerdtfeger and Shreffler, 2009) and about 80 million women worldwide (WHO, 2002), a mutual understanding of infertility needs between friends and family are essential to decreasing the potential negative psychosocial consequences of infertility. Second, many of the forum posts indicated an attempted reversal of stigma power, when available. Moving beyond hiding stigma or passing as fertile, infertile women appeared to stigmatize others whom they perceived as overly-fertile and actively participated in behind-scenes joshing with others in similar situations on a public anonymous forum. It appeared that this serves as a means of coping with infertility (Goffman, 1963), as well as a way to deal with unmet expectations of fairness within a public discourse of deserving motherhood. Whether these comments materialize as enacted stigma toward their fertile counterparts or not, women struggling with infertility appeared to use the forum to cope with their own expressed disappointments in their inability to become pregnant. Enacted stigma behaviors or negative attributes were frequently directed towards vulnerable populations of fertile women (i.e., welfare recipients, teen mothers, and substance users) that reinforced middle-class beliefs of pregnancy and motherhood (Edin and Kefalas, 2005; Luker, 1996). Therefore, while infertile women clearly perceived stigmatization for their infertility and childlessness, it became evident that infertile women could also potentially stigmatize, or at least express and highlight their elevated status over other women. It may be that status and/or invisible stigma allows infertile women the opportunity to enact stigma on groups that hold less social, socioeconomic, and political power, or who are pregnant under ‘less-than-ideal’ circumstances. Many of the infertile women using Fertile Thoughts used the forum as an outlet for stigmatizing comments toward women in their lives who they deemed less deserving of motherhood. As Goffman (1963) wrote, “the normal and the stigmatized are not persons but perspectives” and “it should come as no surprise that in many cases he who is stigmatized in one regard nicely exhibits all the normal prejudices held toward those who are stigmatized in another regard” (p. 138). In this way, they enacted stereotypes and appeared to stigmatize women who did not fit the socially acceptable mold of who should be pregnant. In other words, the infertile women often made remarks articulating the importance of having socially desirable traits, and they used an individual's bad moral record as a reason to publicly scorn them. Further, they reinforced the middle-class understanding of the “proper” ways to

experience motherhood (Edin and Kefalas, 2005). There are several limitations in this study that warrant mention. First, demographic information for the posters to the forum was limited by anonymity. Additional demographic information could underscore stigma power dynamics by providing content based on occupation, socioeconomic status, or level of education. However, most instances of enacted stigma on the forums were performed by women who had provided a measure of their social status e whether that was occupation or education. We were limited by having to rely on a select group of infertile women: women who were seeking fertility treatment and women who found reason to post to a forum. Also, little is also known about how the role of treatment-seeking may influence the responses and receptions to perceived insults or stigmatization. Future work would benefit from including a wider demographic range (e.g., comparing higher to lower socioeconomic women) or more generalizable infertile women and to consider perceptions from women who opt for pregnancy alternatives such as adoption or surrogacy. A second limitation was a lack of access to private messages or other forms of communication within the forums. The analyses of the first post on a thread rather than the entire conversation minimized this limitation. Third and most importantly, it is difficult to discern how and why perceptions of stigmatization may be manifested or enacted in daily life. We recognize that we were unable to truly capture the unique psychosocial or cultural circumstances of infertile women through postings on a forum. For example, it would be interesting to further explore why infertile women frequently perceive stigma as unintentional. Unfortunately, we were unable to determine whether negative postings served as attempts to buffer felt stigma or existed as an active challenge to public stigma and social hierarchies. Indeed, it is unlikely that these posts truly reflect opinions articulated outside of the safety of an anonymous online community. Nonetheless, evidence from other studies that utilize forums suggests that data presented in the forums are meaningful with real-life implications (Malik and Coulson, 2008, 2010; BehmMorawitz, 2013), and we would expect that harboring these feelings would negatively influence peer relationships to varying degrees. In conclusion, we find that the pressure to have children is continuously validated and renewed through relationships with fertile women. Perceptions of stigma and the challenging conceptualizations of “normal” are deeply rooted in convictions about who is “deserving” and “undeserving” of pregnancy opportunities, and more specifically, motherhood. The women posting to the forums tended to be financially stable, part of the ethnic or racial majority, well-educated, and were willing to undergo expensive infertility treatments. While these women clearly fell into the category of felt stigma, they were also “normal” in terms of social status and appeared to rely on this status to cope with infertility. Stigma was perceived or felt through insensitive remarks and actions, but these can go both ways, with infertile women drawing upon their social status, interpretations of fairness, and public discourses of deservedness to potentially challenge the status of fertile women. The implications of expressed power are multiple, with reinforced perceptions of “deserving mothers” potentially impacting both the stigmatized and stigmatizer in terms of their relationship. Future consideration should be given to determine effective strategies for discussing infertility and exploring whether this stigma reversal is truly enacted, or simply expressed. Additionally, strategies to better consider the meaning of motherhood outside of the context of middle-class norms could potentially shift damaging power dynamics beyond a simple deserving-undeserving dichotomy to reduce stigmatizing behaviors or harmful fertility policy recommendations.

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