Making families: Organizational boundary work in US egg and sperm donation

Social Science & Medicine 99 (2013) 64e71

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Making families: Organizational boundary work in US egg and sperm donation Katherine M. Johnson* Dept. of Sociology, Tulane University, 220E Newcomb Hall, New Orleans, LA 70118

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 28 October 2013

Egg and sperm donation can create distinct issues for designating family boundaries. These issues come to the forefront as relations between donors, recipients, and donor-conceived children have been shifting from anonymous to more open arrangements in the US and other western countries. In this study, I address US organizational practices and family boundary construction. Fertility clinics, egg donation agencies, and sperm banks are central providers of US gamete donation services. Given the disruptive potential of gamete donation, how do they manage relationships between parties? Through a content analysis of materials from twenty fertility clinics, twenty egg donation agencies, and thirty-one sperm banks, I address three major strategies of organizational boundary work: 1) creating identity categories, 2) managing information, and 3) managing interaction. I ultimately argue that even as many organizations offer opportunities for connections between parties, they exercise social control over donation arrangements through bounded relationships. Ó 2013 Elsevier Ltd. All rights reserved.

Keywords: United States New reproductive technologies Gamete donation Family boundaries Boundary work Organizations

Introduction Gamete donationdthe donation of eggs or sperm to help conceive a childdfrequently has been framed as socially disruptive technology (Michelle, 2006), especially for designating family boundaries (Cohen, 1996). Surrogacy raises similar issues, but it is arguably more complex than gamete donation, so it is excluded in this analysis. Historically, US gamete donation has been under medical jurisdiction, characterized by strict professional control over the process and anonymity of all parties, although boundaries between donors and recipients were differentially enforced for egg versus sperm donation (Becker, 2000; Braverman, 2010). Since the early 1980s, however, growing international attention has been paid to more open arrangements (Greenfeld, 2002), including disclosure to children about their conception and use of donors willing to release their identities. Various countries have enacted policies, such as legislation that makes all donor identities available for donor-conceived children upon reaching adulthood, a ‘doubletrack’ model where both anonymous and identity-release options coexist, and explicit legislation that all donations are anonymous, or that anonymous options are outlawed (Frith, 2001; Greenfeld, 2002; Pennings, 1997). There are no official US policies, although * Present address: Dept. of Sociology, Tulane University, 220 Newcomb Hall, New Orleans, LA 70115, USA. Fax: þ1 504 865 5544. E-mail address: [email protected]. 0277-9536/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.socscimed.2013.10.015

the American Society for Reproductive Medicine (ASRM)dthe major professional association in the industrydhas typically advocated for anonymity (Greenfeld, 2002) until recently (ASRM, 2008, 2009). In the US, donor-shared sibling families have started connecting through online registries, potentially creating alternative kinship arrangements (Hertz & Mattes, 2011). Additionally, newer considerations for donors’ rights, obligations, and interests (ASRM, 2009) make donor personhood more difficult to ignore. Such transformations raise questions about how US donation arrangements are currently managed. More broadly, this offers a site to explore issues in constructing family boundaries that are taken for granted when reproduction occurs ‘normally.’ Although gamete recipients can independently search for donors, they are encouraged to use fertility clinics, egg donation agencies, and sperm banks to minimize medical, psychological, and legal risks (ASRM, 2006). Yet there has been little sociological analysis of how these organizations shape donation arrangements (although see Almeling (2010)). A recent theoretical article (Rauscher & Fine, 2012) called for more sociological research on family privacy in assisted reproduction, but focused primarily on disclosure between parents, children, and others such as extended family. The current study focuses specifically on organizations providing donation services. Given the disruptive potential of gamete donation, how do these organizations manage relationships between donors, recipients, and children? How do they demarcate families out of these different parties?

K.M. Johnson / Social Science & Medicine 99 (2013) 64e71

Conceptual framework The growing calls for openness in gamete donation are situated within the context of a changing fertility industry as well as gendered expectations and technological differences for egg versus sperm donation. I address each of these briefly below. Then I conceptualize openness more broadly as a question of family boundary construction. Patient to consumer? Like other US healthcare services, gamete donation has largely transformed from a medical service to a commercial product (Holster, 2008). Beginning in the late 19th century, the traditional medical model, at least for sperm donation, relied on secrecy and anonymity between donors, recipients, and donor-conceived children (Marsh & Ronner, 1996). This reflected professional anxiety about medical, legal, and moral boundaries between parties. Addressing potential legal controversies, Hager (1960, p. 223) described how physicians controlled sperm donation, by making sure the donor was “anonymous to everyone except the doctor” and that he “racially and physically resembles the husband.” Hager further acknowledged that although the infertile couple’s “fancies and wishes” would be considered, “in the end it will probably be necessary for [the doctor] to use his own best judgment” to select a donor. US egg donation has a different story. First successfully used in the early 1980s, initially many recipients identified their own donors, such as a friend or family member (Thompson, 2005) or received eggs from another woman in the clinic’s patient population (Sauer & Paulson, 1995). As such, donor options were quite limited, and the procedure was not subject to the same norms of anonymity as sperm donation. Donor choice increased as clinics began to offer pools of anonymous dedicated donors (Sauer & Paulson, 1995) and egg donation agencies came onto the scene (Spar, 2006), promoting a movement toward anonymous arrangements (Cohen, 1996). In the early 21st century, US gamete donation looks quite different. Donors are advertised online, their gametes available at the click of a button (Holster, 2008; Schmidt & Moore, 1998). Egg donation has particularly become a high-demand, high-priced sector in the fertility industry (Spar, 2006). Patients have become “patient-consumers” and the market in reproductive medicine has broadened to include not only the medically-defined infertile couple, but also “parents-in-waiting” such as single, gay, and lesbian prospective parents (Mamo, 2013). These changes in the patient-consumer population have also impacted donor, recipient, and child relationships, particularly for sperm donation. The traditional medical model reinforced the hetero-patriarchal family by appearing as if reproduction had occurred ‘naturally’ within the family unit. As demand for donor sperm came increasingly from lesbian and single women in the 1970s and 1980s, anonymity remained desirable to keep donors from exerting parental rights (Scheib, Riordan, & Rubin, 2003), but disclosure to children also became more relevant as peers, family members, and others inevitably commented that “everybody’s got a dad” (Haimes & Weiner, 2000). Many requests for identity-release sperm donors came initially from lesbian and single women; although, heterosexual couples are also increasingly using identityrelease donors as part of growing concern that donor-conceived children have a right to know about their genetic origins, among other factors (Scheib et al., 2003). A more consumer-oriented model of gamete donation has also produced different types of organizations specializing in different products and services (Spar, 2006). Here I focus on fertility clinics,

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egg donation agencies, and sperm banks. Fertility clinics are staffed and directed by medical professionals such as reproductive endocrinologists and andrologists. Egg donation is one of many infertility services they offer. Clinics conduct the medical aspects of the donation: screening donors; training them to inject fertility drugs; providing informed consent consultations; and conducting the egg retrieval and embryo transfer for in-vitro fertilization. Clinics may also run in-house donation programs, recruiting and matching donors with recipients. Egg donation agencies are staffed and directed by various personnel, including previous donors/recipients, nurses, and even former modeling agency CEOs (author’s data collection). They act as “intimate intermediaries” (Spar, 2006) e their primary purpose is to recruit donors, match donors and recipients, and connect parties with other services (e.g., reproductive lawyers). They partner with fertility clinics for medical services. Because agencies are solely focused on creating arrangements between donors and recipients, they are considered more responsive to client desires than clinics (Treiser, n.d.). Sperm donor recruiting, screening, and donations all occur through sperm banks. The sperm donation sector is significantly smaller and more consolidated than egg donation because federal regulations to quarantine and freeze sperm for six months are costly. However, cryo-preservation creates the capacity to ship sperm across the country, so a smaller number of large sperm banks dominate this sector (Spar, 2006). Gender, biology, and donation Gender norms and biological aspects of donating interact to produce different expectations for egg versus sperm donation. Egg donation is often framed as a ‘gift’, emphasizing emotional labor that egg donors are expected to engage in, whereas sperm donation is often framed as a ‘job’ (Almeling, 2010; Ragone, 1999). Egg donation is also noted for being a more open process between donors and recipients, the acceptability of which is reinforced by cultural norms of femininity (Becker, 2000). Rather paradoxically, there are also reasons to view open egg donation as more threatening to family boundaries because women are perceived as more invested in their gametes as potential children than men (Almeling, 2010). There are also technological differences that create closer connections between parties in egg donation compared to sperm donation: donor sperm is cryopreserved and quarantined for six months (ASRM, n.d.), but egg donation is usually “fresh” because of the lagging capability to freeze and thaw human eggs without damage (Rodriguez-Wallberg & Oktay, 2012). The two women’s cycles are coordinated, prepping the donor for egg retrieval and the recipient for embryo transfer within a few days from each other (ASRM, 2006). Family boundaries and boundary work Questions about openness in gamete donation explicitly invoke family boundaries. Gamete donation involves disclosure of personal information and the transfer of bodily products symbolizing highly intimate aspects of human relationshipsdsexuality and reproduction (Becker, 2000). During the exchange there is both a need and a desire to permeate boundaries through disclosing relevant health and social information, coupled with maintaining boundaries to protect each party from unwanted intrusion by the other (Burr, 2009; Cohen, 1996). Symbolic boundaries, which refer to conceptual distinctions that separate “people into groups and generate feelings of similarity and group membership” (Lamont & Molnar, 2002, p. 168), are particularly crucial to understanding family creation processes. Symbolic boundaries serve important social, legal, and political functions by acknowledging “who, when, and how, members participate in family life” and distinguishing “members of a family from one

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another and from other groups” (Carroll, Olson, & Buckmiller, 2007, pp. 210e211). The process of demarcating boundaries is referred to as boundary work (Gieryn, 1983). In family research, boundary work is often described as a task that family members engage in through such acts as controlling access to parental rights and responsibilities (Nelson, 2006); designating ability to claim emotional, financial, and social support (Ihinger-Tallman, 1988); and controlling access to intimate family knowledge (Serovich & Greene, 1993). Yet, boundary work can also be done at various levels (interpersonal, institutional, societal) and by various actors (individuals, organizations, social institutions) (Lamont & Molnar, 2002). Indeed, boundary creation is a primary reason why fertility clinics, egg donation agencies, and sperm banks exist: designating who is an ‘acceptable’ patient and what is an ‘acceptable’ form of treatment (Ehrich, Williams, Scott, Sandall, & Farsides, 2006), designating ‘good’ donor candidates from ‘bad’ ones, and designating ‘safe’ sperm from ‘unsafe’ sperm (Schmidt & Moore, 1998). Boundaries conceptually include privacy. Altman (1976) explicitly described privacy as an “interpersonal boundary control process” by which an individual limits access to oneself or one’s group. Newer theorizing on families and privacy acknowledges that privacy is not simply an individual issue. Rather, there are various tensions at its core including individual versus collective privacy in families, and the “juxtaposition of needing both privacy and openness simultaneously” (Petronio, 2010, p. 176). These come to the forefront in assisted reproduction (Rauscher & Fine, 2012). Laufer and Wolfe (1977) identified two dimensions of privacy that are relevant here: information management and interaction management. Information management is the ability to control access to information about oneself or one’s significant others. Interaction management is the ability to control physical interaction with others, such as who participates and the length, frequency, and content (Leino-Kilpi et al., 2001). In donation arrangements, these management strategies become relevant through deciding what information to share and whether/how parties should interact. In gamete donation, family boundary work is conducted along various fronts such as between donors, recipients, and donorconceived children, and between the families and extended relatives, friends, or others (Becker, 2000; Haimes & Weiner, 2000). For example, Thompson (2005) discussed the “kinship work” in fertility clinics to “establish and disambiguate kin relations” (p. 145), focusing on strategies used by women who were infertility patients and their known/familial egg donors and surrogates. Yet, this interpersonal emphasis overlooks broader organizational and institutional processes. Here I broaden the scope of boundary work to include the reproductive organizations that set policies and shape expectations for donor, recipient, and child relations. Haimes (1993) explicitly called for examining clinicians’ perspectives, arguing that, historically, clinicians conducted anonymous donations to avoid social stigma of being “an accomplice to adultery” and illegitimacy (p. 1519). Anonymity also helped to “avoid detailed scrutiny” (p. 1519) of physicians’ (in)ability to deal with both the medical and social aspects of gamete donation. As such, practitioners and other organizational actors provide expectations for donor, recipient, and donor-conceived child relationships and have particular interests in managing these relations. Method Data Data came from a larger project addressing US fertility industry practices with primary data collection (2009e2010) from three main reproductive organizations: fertility clinics, egg donation

agencies, and sperm banks. The research design was a content analysis of organizational materials including websites, brochures, and donor/recipient applications or profiles. These materials are part of organizational routines (Levitt & March, 1988) that organizations construct and operate through, expressing both organizational and broader cultural norms about families, gender, and reproduction in conveying information to potential donors and recipients. There are limitations to this type of data because representations of organizational policies may not adequately portray how these are enacted; however, this approach minimizes intrusiveness of in-person observation and captures a larger sample of organizations across the country. The latter is important because some practices differ by region, such as clinic acceptance of lesbian and single women (Johnson, 2012). Most data came from organizational websites, which are more dynamic data sources (McMillan, 2000), so I downloaded and archived copies. After coding all publicly available materials, I attempted three contacts through mail, email, or phone with each organization to gain (more) information. Although this study did not include a formal interview component, I frequently relied on staff and physician communication to fill in the gaps if there was not enough detail in the organizational materials supplied. A research assistant later made follow-up phone calls to organizations with missing data, identifying herself as a potential egg donor to increase the likelihood of response. We did not re-contact any organizations that refused during open contact attempts. All contact and data collection methods were deemed exempt through Institutional Review. The sample for the larger project included 227 clinics, 101 agencies, and 31 sperm banks. I drew a random, stratified subsample of twenty clinics and twenty agencies for more in-depth analysis here. Several staff mentioned regional differences in attitudes about egg donation openness versus anonymity, so I stratified by region (Northeast, South, Midwest, West) before randomly selecting within each strata. I included all commercial sperm banks because the original sample was relatively small. Coding In my review of the literature on gamete donation, I identified four main topics: use of photographs, anonymity, cycle outcome disclosure, and post-cycle contact. I used these as a priori codes during initial or first cycle coding (Saldana, 2009, p. 45), coding organizations as having (¼1) or not having (¼0) a particular policy/ practice, as well as coding any passages related to these practices. I also coded any references to social, emotional, psychological, or legal relationships between donors, recipients, and donorconceived children. I noted that organizational terminology differed for donors and recipients; so I systematically coded up to five descriptive terms from each organization, privileging any referring to families or parental status. In this coding phase, ‘boundaries’ between parties were noticeably relevant if not explicitly stated by organizations. During second cycle coding, which emphasizes more conceptual, as opposed to descriptive, analysis and identifying relationships between analytic categories (Saldana, 2009, p. 149), I used boundaries as a sensitizing concept (Bowen, 2006). Drawing explicitly on boundary and privacy concepts, I further identified three components of organizational boundary work in gamete donation: 1) creating identity categories, 2) managing information, and 3) managing interactions. The quantitative results derived from first cycle coding were analyzed separately and published for a clinical audience (Johnson, 2011). The current study addresses the qualitative results developed from more in-depth analysis.

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Findings Creating identity categories Terminology used for gamete donors and recipients is a key site for organizations to construct symbolic boundaries of family membership (Lamont & Molnar, 2002). “Donor” is typically used to describe those who provide their gametes to recipients, although most US donors are compensated. Donation language helps to soften the idea that gametes are ultimately being exchanged in an economy (Ragone, 1999). Yet, the donor language also creates an identity category, signifying that the person donating gametes will not be a parent to the resulting child. “Donor” and “recipient” are provided by reproductive organizations as mutually exclusive identity options in relation to the imagined child. Donors were also referred to as “candidates,” “[third] parties,” and generous or special people who could give the “gift of life” to those wanting a child. One agency described their egg donors as “fertility helpers” [Agency #64], assisting recipients in their familybuilding journey. Another agency noted that their egg donors were “triple proven” because many had previously donated, had been surrogates, and were mothers themselves [Agency #111]. While this implied a more successful donation, an underlying implication was that these women were used to relinquishing parental claim in third party situations or they would be less likely to exert it since they had their ‘own’ children and had therefore fulfilled their maternal desires. Recipients were frequently referred to as “intended” or “prospective” parents, “couples,” “clients,” and “patients.” Ninety-five percent of agencies used intended or prospective parent to describe recipients and more than half of clinics (55%) and sperm banks (58%) referred to recipients’ future parental status or parental desire. In contrast, minimal references were made to donors’ parental status. One sperm bank used “biological father” when referring to a donor-conceived person learning about the donor upon reaching adulthood. A second bank described single women as using donor sperm to avoid having a relationship with the biological father. In both cases, the parental link was weakened by describing the donor as an absent party during childrearing. Another bank used “father,” in quotes, to indicate that this was not the intended social relationship, but that there was not a better word available. Egg donors’ maternity was also infrequently referenced: when it was, donors were described as being already mothers or the impact of donating on their future fertility was discussed. This explicitly framed donating as an act where donors were specifically not seeking maternity. Indeed, although these organizations may draw on gender norms about maternity and paternity, they do not want donors to view themselves as parents in any way (Almeling, 2010). To this end, one agency noted that donors would undergo a psychological evaluation to be sure they understood their role as assisting a “couple build a family without your retaining any parental rights” [Agency #60, my emphasis]. There were also clearly gendered discussions of parental rights and responsibilities. Sperm banks more frequently referred to donors as being protected from parental responsibility; clinics and agencies more frequently emphasized egg donors needing to relinquish parental claims. This reinforced cultural perceptions that women are more invested in their gametes than men. Given the different terminology used for donors versus recipients, I argue that organizations strategically deployed future parental status and intentions to position donors and recipients visa-vis the donor-conceived child. Gamete donation and other third party options such as surrogacy have complicated definitions of parenthood, particularly motherhood, which traditionally defined the woman who gave birth as the biological, legal, and social

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mother (Anderson, 2009). After parentage disputes arose in a gestational surrogacy arrangement, the California Supreme Court used the concept of parental intent to determine legal and social parentage (Douglas, 1994). Because the commissioning parents intended to bring about the child and initiated the process, they were the “fundamental cause of [the child’s] creation” (Douglas, 1994, p. 637). Parental intention has gained broader use in reproductive contracts as evidence of parties’ motives even if the contract itself is not legally recognized (Vorzimer, 1999). By describing recipients in this way, organizations conceptually distinguished between clients who were intending to become parents and donors, who were helping others fulfill their parental goals. Clinics and sperm banks were less likely to reference parental intent than agencies, frequently describing recipients as patients, clients, and infertile couples. The legal demarcation of parentage in US sperm donation is relatively solidified compared to egg donation (Crockin & Jones, 2010, pp. 188e208). Physician involvement and spousal consent are more integral to removing the parental rights and obligations of sperm donors, so evidence of parental intention is less relevant. The difference between agency and clinic language likely reflects how the medical versus consumer-oriented models of gamete donation are differentially employed by clinics and agencies. As a result of their responsive to consumer desires for more open arrangements (Treiser, n.d.), agencies may also have greater rationale to symbolically designate roles. Agencies also tended to rely on legal contracts mediated through reproductive attorneys to clarify parental rights, whereas clinics frequently included clauses about relinquishing parental rights in donors’ informed consent forms for the egg retrieval procedure. As such, referring to the recipient as a patient, client, or infertile couple is sufficient in the medical context of informed consent as opposed to a legal context looking for parental intent. Managing information exchange A second major boundary work strategy was visible through organizational policies and practices regarding degree and type of information to present to each party. There are different expectations about what should be disclosed about donors versus recipients (Broderick & Walker, 2001). Donors typically shared extensive personal information and received little to no information about recipients. Sharing donor information Donor profiles are a primary method of presenting information to prospective recipients. Donors fill out extensive applications, which are translated into briefer, more aesthetically pleasing, profiles for client viewing (Holster, 2008). These profiles give organizations control over how individual donors and gamete donation more broadly are constructed. Donor profiles frequently convey gendered, cultural expectations as well as reinforce social difference and hierarchy by race, ethnicity, and social class (Almeling, 2010; Daniels & Heidt-Forsythe, 2012; Schmidt & Moore, 1998). They are also mechanisms to control personal information flow between parties. Recipients have access to profiles in-house or through online databasesdmany of which require registration and passwords to access. In transitioning from the application to the profile, certain information is filtered by the organization, marking applications to distinguish confidential information for organizational use only (e.g., full names, addresses, workplaces) from information that could be shown to prospective recipients. Organizations also frequently assigned donor identification codes, pseudonyms, or only allowed first names in online, searchable databases. Profiles provide extensive personal information, down

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to intimate details about a donor’s sexual, reproductive, and medical history, but organizations controlled access to what they deemed as the most private information: that which could lead to a donor being personally identified outside of the organization. Organizations also controlled access to donor photographs. Photographs can be integral to donor selection, because physical resemblance is an important aspect of family legitimation in Western societies (Becker, 2000; Thompson, 2005). Although most organizations requested donor photographs, these were not always freely given to prospective recipients. Agencies were most likely to provide any photographs (95% compared to 85% of clinics and half of sperm banks), often through online donor databases. Decisions to offer childhood but not adult photos were often justified to maintain donor confidentiality while giving recipients some impression of how the donor’s physical features fit in with their own family and what their child might look like: We do not reveal your identity to recipients [.]. Sometimes, with the donor’s permission, we show the recipient a baby picture [.] but never an adult photo [Clinic #20050223]. A few organizations allowed adult photographs to be viewed on location under staff supervision. Others offered “photo matching” services: recipients could submit photos with characteristics they desired and physicians or staff would suggest donors based on how well they physically matched the photos. This was more commonly offered by sperm banks: approximately 16% had this option for purchase. Photo matching helped preserve boundaries and strictly manage information transfer as physicians and staff literally examined donor photographs on behalf of recipients. Several organizations referred to staff members’ personal knowledge of both the donors and recipients as valuable insight for helping to match parties: [D]oing our own pre-screening [.] gives us the opportunity to get to know the donor better, enabling us to provide more knowledgeable information to you [the recipient] [Agency #125]. The donor egg team gets to know both donors and recipients prior to the matching process [Clinic #20050223]. Our bank is small enough that we have the opportunity to get to know our donors. Phone counselors can provide you with personal impressions of donors [Bank #90033]. This helped preserve anonymity while creating a means to transfer more subjective information between parties. One agency mentioned that by getting to know their egg donors, staff could better assess their commitment to donating. This soft knowledge cannot be easily captured in donor profiles. Staff knowledge was also regularly institutionalized in sperm donor profiles, labeled as “staff impressions.” Approximately one-third of sperm banks offered this feature. Staff impressions provided quality assurance to recipients, bolstering the credibility of how the donor presented himself in his profile. Although staff knowledge created a means to convey different types of information about a donor, it also symbolized that this was not an opportunity for donors and recipients to develop personal relationships, but rather, to preserve distance and anonymity by having the staff act as intimate intermediaries (Spar, 2006). Sharing recipients’ information Changes in the recognition of gamete donor interests and rights have raised issues of whether donors should be informed about

recipients and the outcome of the donation cycle (ASRM, 2009; Cohen, 1996). Many organizations had recipients fill out brief profiles about themselves, and then “wish lists” of what they were looking for in a donor. Some organizations shared this information with potential donors, though this was relatively infrequent and only done by agencies in my sample. Sharing recipient information with donors was framed as an opportunity to establish a closer, more informed relationship between parties. As one agency noted on their website, it was an “opportunity to have the donor care almost as much about a positive outcome as you do” [Agency #58, my emphasis]. This also clearly reflects the emotional labor expected of egg donors (Almeling, 2010). It could also give the egg donor an opportunity to learn about the recipients’ lifestyle and “help her identify with the intended parents” [Agency #13]. This might prevent any future legal claims if the donor had been unaware of and opposed to whom she was donating (e.g., a gay or unmarried couple or recipients with a different religious background). One agency described their “informed donor” policydas a “unique standard” where they were committed to only working with parties who could equally assess one another [Agency #60]. Similar to donor profiles, recipients’ identifying information was heavily guarded to preserve anonymity when desired. Additionally, sharing recipient information was not a symmetric practice: donors provided more extensive information about themselves than recipients. These justifications for sharing recipient information, however, were significant because they indicated a shift away from the typically uni-directional, minimal information exchange of the traditional medical model (Braverman, 2010; Cohen, 1996). A second, more widely discussed, issue is whether to disclose the cycle outcome to donors. Donors have expressed particular interest in knowing donation outcomes (Broderick & Walker, 2001; Kalfoglou & Geller, 2000). Major arguments against informing donors include the analogy of gamete donation to blood donation where donors do not expect to learn, and are not informed of, transfusions; the possibility of donor distress due to reasons such as an unsuccessful cycle (ASRM, 2009); and the recipients’ medical privacy (Zweifel et al., 2007). Other discussions imply that informing donors of a successful pregnancy could increase their emotional or psychological attachment to the child, leading to unwanted intrusion in the new family’s life (Baetens, Devroey, Camus, Van Steirteghem, & Ponjaert-Kristoffersen, 2000). Arguments for informing the donor include the donor’s psychological ‘need to know’, preparation for possible future contact by donorconceived children (ASRM, 2009), and that the donor has a moral stake in knowing (Cohen, 1996). Outcome disclosure policies, then, were another main mechanism through which organizations managed expectations and information exchange between donors and recipients. While some organizations saw outcome disclosure as negotiable within individual donation arrangements, others implemented stricter policies, preserving the recipient’s right to privacy or the donor’s right to know: Will I know if a baby is born? [.] [N]o, you will not. You will however, walk away knowing that you have a given a couple a chance [.] to help make their dreams of parenthood come true [Agency #63]. There was also considerable variation in what information was actually disclosed to donors: the number and quality of eggs retrieved, information about the pregnancy and delivery, or only the overall pregnancies achieved. This latter approach was more commonly practiced at sperm banks, where donors usually have multiple vials stocked and available simultaneously. Overall, organizations had to make decisions about whether and how to convey

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information to donors, but also to protect recipients and children from any socially transgressive outcomes, if donors were given ‘too much’ information. Managing interactions Organizations also set expectations for whether or how parties interacted with one another. Interactions can take place before parties agree to a donation cycle together, during the cycle, or after. Before or during the cycle interactions focus on donorerecipient relations, but post-cycle contact typically emphasizes donorechild relations. Before/during cycle contact Because most sperm banks use quarantined, cryopreserved specimen, sperm donors and recipients are less likely to meet before or during a cycle. In contrast, egg donation often has possibilities for meeting one’s donor, but this is also more likely to happen at agencies rather than fertility clinics (Treiser, n.d.). In my sample, 20% of clinics and 10% of sperm banks had options for donorerecipient meetings, compared to 60% of agencies. For those organizations that allowed meetings, donors and recipients did not typically initiate contact. Personnel managed interactions, taking responsibility for defining the terms of contact. For instance, some organizations noted that any contact would involve supervisiondat least initially: Personal meetings are only arranged and conducted by our President who must be present for the introduction and meeting. You cannot meet on your own unless you’ve have [sic] one initial meeting [Agency #111, my emphasis]. In other instances, supervision was not explicit, but organizations emphasized their role in facilitating and mediating the contact: [T]here are some cases when both parties e egg donor and intended parent e choose to meet one another. We will work to maintain everyone’s privacy to the extent they wish [.] [Agency #39, my emphasis]. One organization appeared at first to leave discretion to donors and recipients, yet a closer look showed that they still maintained control over the exchange: Your Level of Privacy is Up to You [.] During and after that [donation] process, the level of disclosure you wish to have with the recipient is entirely up to you. Most donors choose to remain anonymous [.]Some donors may be willing to meet with the recipient in the presence of a [organization name] representative, but even then any information that would lead to your identity is kept confidential [Agency #2, my emphasis]. As such, even in more open arrangements donorerecipient contact was supervised and facilitated by organizations to manage the terms and extent of interpersonal interaction. This implicitly reinforced the need for boundaries between parties, even when purportedly fostering connectedness. Post-cycle contact After completing a donation cycle, there are several possibilities for contact between parties. Some organizations acknowledged

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that recipients might desire to express gratitude to donors and offered to deliver messages or gifts on their behalf. A more commonly addressed form of post-cycle contact was the future relationship a donor might have with a donor-conceived child. This relationship included both institutionalized and negotiable options. Sperm banks were more likely to have institutionalized options, frequently referred to as “identity-release” donors (50% of banks offered this). Agencies tended to have more negotiable options, letting parties work out the terms through a reproductive lawyer. Clinics were more likely to have explicit policies against any postcycle contactdreflecting the more traditional medical model of gamete donationdbut not all had clearly stated policies. Because sperm banks had more institutionalized options, they were more likely to detail these than clinics and agencies, so below I focus on this subsample. Identity-release programs allow for the provision of more personal information about a sperm donor when a donor-conceived child reaches adulthood. Identity-release donors explicitly agree to this when they donate and typically receive higher compensation. For example, one bank offered $500 per accepted sample for “Open ID” donors compared to $100 for anonymous donors [Bank #90040]. Most sperm banks specified that identity-release donors’ personal information would only be made available to the donorconceived child. They also typically controlled the type and extent of information given and under what conditions it would be released. For instance, one bank required all donor-conceived persons to attend a psycho-educational session on location prior to receiving any information about their donor [Bank #90050]. Even as many sperm banks recognized the importance of identity-release, several were explicit that this was not meant to redraw family boundaries to include the donor: This [.] give[s] adults conceived through donor insemination the option of learning their donor’s identity in case they have unanswered questions about their genetic background. It is not designed to create parental or family relationships between donors and their offspring [Bank #90033, my emphasis]. Several sperm banks set expectations that they might not be able to contact the donor, and that not all identity-release donors were obligated to actually meet with donor-conceived persons. One required only one meeting; others left the level of contact solely to the donor’s discretion whether it was through a phone call, email, or in-person [Bank #90025]. As such, organizations tried to downplay the possibility of establishing a close connection between the donor and donor-conceived child. Institutionalized identity-release options particularly highlight the difficulty of negotiating family boundaries and privacy. Policies such as releasing the donor’s identity only when the donorconceived child reached adulthood were aimed at protecting the integrity of the recipient/child’s family boundaries and protecting the donor from being defined as a parent. Allowing access to donor information was framed as a balance between the child’s “right to know” and the donor’s privacy. These are also paradoxical positions: seeing the donor as a potential intruder on the family as well as seeing the recipient or child as intruding on the donor’s privacy (Cohen, 1996). Only one sperm bank followed a noticeably different model for identity-release. Their philosophydas stated on their websitedwas to create connections and enduring relationships between the donor, birth mother, and child as well as the local gay and lesbian community from which they received many donors and recipients [Bank #90039]. Their policy was to release the donor’s identity to the mother when the child was three months old. If the mother had not contacted the donor by the child’s first birthday,

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the program released the mother’s information to the donor to initiate contact. In contrast to other organizations, they explicitly envisioned possibilities for donors, recipients and children to form lasting and meaningful relationships: Your child will grow up without secrets. [.] Your child will know that their donor is a regular guy who they will meet and maybe become friends with. [.] [T]he donor, who is not the legal parent of the child, will be known to the child while they grow up. This is similar in concept to open adoption, where the birth mother is known to the child although she is not the child’s legal parent [Bank #90039, my emphasis]. Even as they were clearly differentiated from other organizations, they still distinctly marked family boundaries, stating that donors would have no legal parental rights or responsibilities. To reinforce this, they constructed donors as filling an “uncle-type” role, strategically side-stepping parental status. Conclusion Assisted reproduction techniques such as gamete donation are rife with social, ethical, and legal controversy. Discussions are divided over the social problems they create versus the creative reproductive opportunities they bring. In this analysis, I addressed issues of family boundary construction, focusing on the boundary work engaged in by organizations providing donation services. Although prior research has shown that fertility clinics and sperm banks are key sites where ethical boundary work occurs, kinship relations are sorted out, and ‘acceptable’ patients and ‘safe’ sperm are designated ( Ehrich et al., 2006; Schmidt & Moore, 1998; Thompson, 2005), there has been little analysis of how reproductive organizations mediate donor, recipient, and donor-conceived child relationships. I identified three major strategies that organizations used to construct family boundaries: 1) creating identity categories to symbolically delineate family membership; 2) managing personal information exchange between donors, recipients, and donorconceived children; and 3) managing interactions between parties. Following Haimes’ (1993) call to investigate clinician interests in maintaining anonymous gamete donation, my analysis shows that reproductive organizations actively shape expectations and manage relationships between donors, recipients, and donorconceived children. Even as the industry purportedly moves toward more open donations in the contemporary US (Scheib et al., 2003), organizations still constrained these relationships. Analyzing emotional boundary work in nurseepatient relationships, Allan and Barber (2005) used the concept bounded relationships to address how nurses can create emotional connections and care for patients without overstepping professional boundaries. Bounded relationships create “a feeling of closeness, but at the same time maintains a distance” (p. 392). I argue that organizations involved in donation arrangements strategically use such an idea to both appear more responsive to consumer and donor desires for openness and to maintain both social and jurisdictional control over gamete donation. By responding to patient-consumer demands through offering various services such as donorerecipient meetings, identity-release, and photographs, reproductive organizations were both (re)creating demand for these services as well as reinforcing their own necessary existence as intermediaries to safeguard the medical and social processes of gamete donation. The variation in the degrees of openness among organizations and the different ways in which practices were enacted further reflects

multiple tensions within reproductive medicine and the fertility industry: the tension in transitioning from the traditional medical to consumer-oriented models of gamete donation (Braverman, 2010; Holster, 2008), which has clearly not occurred uniformly across the industry; and the tension from newly arising ethical dilemmas for children to know their genetic origins, donors to be morally recognized in the donation process, and families to have a right to privacy and family integrity (ASRM, 2009; Scheib et al., 2003). More broadly, the very existence of these boundary work practices, for clinics and sperm banks at least, reflects the notion that practitioners in reproductive medicine are both professionally and socially accountable: viewing their work as not solely medical, but also engaging with broader social and moral questions (Ehrich et al., 2006). Finally, it is important to recognize that not all organizations acted similarly. Broad patterns emerged across clinics, agencies, and sperm banks, and egg versus sperm donation. Clinics appeared at times more conservative about donation arrangements than both agencies and banks, although there was variation as some have adopted more consumer-oriented practices. Egg donation agencies were most flexible in providing channels for parties to share information and negotiate terms of present and future contact. This is intuitive given that the primary impetus for agencies was to create more consumer choice (Spar, 2006; Treiser, n.d.). Compared to both agencies and clinics, sperm banks were more institutionalized in what they provided: opportunities for contact or additional donor information were typically ‘add-ons’, available for a fee. Donor sperm recipients were often described as “clients” entering into transactions with sperm banks, as opposed to “prospective parents” creating a collaborative relationship with a donor. As such, the consumer oriented transition in gamete donation (Braverman, 2010; Holster, 2008) has taken different trajectories for egg versus sperm donation. There were also clearly gender differences at work, especially in discussions of donors’ (lack of) parental rights and responsibility. This reinforced the perception that women are more connected to their gametes as potential children. Sperm donors were more frequently positioned as not desiring the burden of parental responsibility, whereas clinics and agencies were more likely to emphasize that egg donors would need to relinquish parental claimsdimplying that they were more likely to seek maternity. This, rather paradoxically, complicates the greater acceptability of openness in egg donation and the fact that egg donors are expected to be more emotionally invested than sperm donors (Almeling, 2010). Organizational differences are further complicated by organizational mission and structure. For instance, the sperm bank that emphasized ongoing connections between donors and recipients from the local gay and lesbian community was clearly founded with this mission. The existing ties between the bank and the local community helped to foster a model of donorerecipientechild relationships that would likely not be feasible for larger, corporate sperm banks attempting to serve clients across the country, or internationally as some of the banks advertised. This invokes a similar question for clinics and agenciesdif they broaden from small, local facilities to serving national or international client populations, as some have started to do, will there be the same emphasis on altruism and emotional labor from egg donors? A related issue is: how much of these differences are due to gender norms, differences in target patient populations, and technological differences in egg and sperm donation? This is clearly difficult to answer, but the technological aspects of sperm donation (cryopreservation and six month quarantine) and the ability to virtually search for donors, purchase a sample, and have a vial of cryopreserved semen shipped to you creates more psychological and physical distance between donors and recipients than the “fresh”

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transfer typically used in egg donation. Disentangling this will likely be more fruitful as the use of frozen eggs moves from “experimental” to normalized in the industry (Rodriguez-Wallberg & Oktay, 2012). Acknowledgments This material is based upon work supported by the National Science Foundation under Grant No. 0927836 and The Pennsylvania State University College of Liberal Arts RGSO Dissertation Support Grant. I would like to thank Pat Rafail for reading and commenting on drafts of this paper. An earlier version, titled “Making Families: Managing Donor, Recipient, and Child Relations in Gamete Donation,” was presented at the 2011 SWS Winter Meeting, San Antonio, TX. References Allan, H., & Barber, D. (2005). Emotional boundary work in advanced fertility nursing roles. Nursing Ethics, 12(4), 391e400. Almeling, R. (2010). Sex cells: The medical market for eggs and sperm. Berkeley: University of California Press. Altman, I. (1976). Privacy: a conceptual analysis. Environment and Behavior, 8(1), 7e30. American Society for Reproductive Medicine (ASRM). (2006). Third party reproduction (sperm, egg and embryo donation and surrogacy): A guide for patients. Retrieved from http://www.asrm.org/Patients/topics/eggdonation.html. American Society for Reproductive Medicine (ASRM). (2008). Gamete donation: Deciding whether to tell. Retrieved from http://www.asrm.org/Gamete_ Donation_Deciding_Whether_To_Tell/. American Society for Reproductive Medicine (ASRM). (2009). Interests, obligations, and rights of the donor in gamete donation. Fertility & Sterility, 91(1), 22e27. American Society for Reproductive Medicine (ASRM). (n.d.). Summary of “Eligibility determination for donors of human cells, tissues, and cellular and tissue-based products”. Retrieved from http://www.asrm.org/Media/FDA/donoreligibilityruling05. html. Anderson, L. S. (2009). Adding players to the game: parentage determinations when assisted reproductive technology is used to create families. Arkansas Law Review, 62, 29e56. Baetens, P., Devroey, P., Camus, M., Van Steirteghem, A. C., & PonjaertKristoffersen, I. (2000). Counseling couples and donors for oocyte donation: the decision to use either known or anonymous oocytes. Human Reproduction, 15(2), 476e484. Becker, G. (2000). The elusive embryo: How women and men approach new reproductive technologies. Berkeley: University of California Press. Bowen, G. A. (2006). Grounded theory and sensitizing concepts. International Journal of Qualitative Methods, 5(3), 12e23. Braverman, A. M. (2010). How the Internet is reshaping assisted reproduction: from donor offspring registries to direct-to-consumer genetic testing. Minnesota Journal of Law, Science & Technology, 11(2), 477e496. Broderick, P., & Walker, I. (2001). Donor gametes and embryos: who wants to know what about whom, and why? Politics and the Life Sciences, 20(1), 29e42. Burr, J. (2009). Fear, fascination and the sperm donor as “abjection” in interviews with heterosexual recipients of donor insemination. Sociology of Health & Illness, 31(5), 705e718. Carroll, J. S., Olson, C. D., & Buckmiller, N. (2007). Family boundary ambiguity: a 30 year review of theory, research, and measurement. Family Relations, 56(2), 210e230. Cohen, C. (1996). Parents anonymous. In C. Cohen (Ed.), New ways of making babies: The case of egg donation (pp. 88e105). Bloomington: Indiana University Press. Crockin, S., & Jones, H. (2010). Maternity and egg donation. In Legal conceptions: The evolving law and policy of assisted reproductive technologies. Baltimore: The Johns Hopkins University Press. Daniels, C. R., & Heidt-Forsythe, E. (2012). Gendered eugenics and the problematic of free market reproductive technologies: Sperm and egg donation in the United States. Signs, 37(3), 719e747. Douglas, G. (1994). The intention to be a parent and the making of mothers. The Modern Law Review, 57(4), 636e641. Ehrich, K., Williams, C., Scott, R., Sandall, J., & Farsides, B. (2006). Social welfare, genetic welfare? Boundary-work in the IVF/PGD clinic. Social Science & Medicine, 63, 1213e1224. Frith, L. (2001). Gamete donation and anonymity. Human Reproduction, 16(5), 818e824. Gieryn, T. F. (1983). Boundary-work and the demarcation of science from nonscience: strains and interests in professional ideologies of scientists. American Sociological Review, 48(6), 781e795. Greenfeld, D. A. (2002). Changing attitudes towards third-party reproductive techniques. Current Opinion in Obstetrics and Gynecology, 14(3), 289.

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