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ExpectantIsraeliFathersandtheMedicalizedPregnancy:Power,PragmatismandResistance.Culture...

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ORI GIN AL PA PER

Expectant Israeli Fathers and the MedicalizedPregnancy: Ambivalent Compliance and CriticalPragmatism

Tsipy Ivry Æ Elly Teman

Published online: 17 June 2008

� Springer Science+Business Media, LLC 2008

Abstract This article addresses the medicalization of pregnancy in Israel and its

effects on the experiences of Jewish-Israeli men who participated in various stages

of their female partners’ prenatal care. The highly medicalized arena of Israeli

prenatal care, with its strong emphasis on prenatal diagnostic testing, provided the

context in which the men’s accounts of their interactions with reproductive bio-

medical authority, practitioners and knowledge were understood. It is suggested that

the anthropological scholarship on reproduction assumes that men benefit from the

medicalization of pregnancy and birth and comply with medicalization. Women, on

the other hand, are often depicted as being subjected to harmful medical surveil-

lance and responding to it in degrees, ranging from compliance to resistance, and

mediated by pragmatism. Data derived from participant observation in multiple

arenas and from 16 in-depth interviews with Israeli men whose female partners were

pregnant or had recently given birth suggest that although some Israeli men regard

the biomedicalization of pregnancy positively, most tend toward varying degrees of

criticism. It is suggested that men’s responses to reproductive biomedicine are far

more complex than portrayed to date in the existing scholarship and that men’s

responses to biomedicalization reveal complex power negotiations.

Keywords Medicalization � Pregnancy � Men � Israel � Biomedicine

T. Ivry (&)

Department of Sociology and Anthropology, University of Haifa, Mount Carmel,

Haifa 31905, Israel

e-mail: tsipy.ivry@gmail.com

E. Teman

Science, Technology and Society Center and Beatrice M. Bain Research Group,

University of California, Berkeley, Berkeley, CA 94720, USA

123

Cult Med Psychiatry (2008) 32:358–385

DOI 10.1007/s11013-008-9099-x

Introduction

While many women who gave birth 30 years ago or more may describe pregnancy

and childbirth as lonely experiences, both medical practitioners and pregnant

women in Israel today would agree that Israeli expectant fathers, much like their

American and European counterparts (Draper 2002, 2003; Sandelowski 1994), are

now participating in these processes as never before. When prenatal care is highly

medicalized, as it is in Israel, it means that ‘‘participation’’ entails men repeatedly

encountering the technology, practitioners, knowledge and authority of reproductive

biomedicine as they accompany their female partners to prenatal care checkups,

sonograms, prenatal diagnostic testing (PND), and hospital birth.

Men’s participation brings up important questions regarding men’s responses to

biomedical authority and their role within the negotiations of power that are part and

parcel of the biomedicalization of reproduction. Men’s experiences and attitudes

toward reproduction have become increasingly central to our understanding of the

complexities of pregnancy and birth from a sociocultural perspective. In the

following, we examine how men navigate their participation in biomedicalized

pregnancies.

Expectant Fathers in the Anthropological Literature

It is only recently that ethnographic research exploring the experiences of expectant

fathers has begun to emerge in anthropological literature. Anthropologists of

reproduction have primarily concentrated on women’s navigations of the nexus

of gendered power structures that Ginsburg and Rapp (1995) term ‘‘the politics of

reproduction.’’ After all, it is women and not men in whose bodies gestation and

birth literally occur, and it is often the female body that becomes the site in which

medical interventions are practiced to resolve problems of ‘‘other’’ patients or quasi-

patients, such as medical interventions due to male-factor fertility problems (Lorber

1989) or fetal surgery (Casper 1998).

When men are addressed in this literature, it is usually in the context of their

involvement in pregnancy-related medical activities, typically obstetrical ultrasound

scans (Draper 2002; Georges 1997; Sandelowski 1994). Men are also discussed in

the context of their participation in the dramas of decision-making surrounding the

option to undergo amniocentesis (Browner and Preloran 1999; Rapp 1999), in birth

education courses (Reed 2005; Sargent and Stark 1989) and in the birth event itself

(Draper 2003; Jordan 1993, 1997; Reed 2005). Yet, most scholars tend to analyze

the attitudes, positions and interactions of expectant fathers with biomedicine in a

direction that is strikingly different from that in the women-centered literature.

Specifically, many of the major works on women and reproduction examine the

way in which medicalization, the process by which human experiences are redefined

as medical problems (Friese et al. 2006; Zola 1972), subjugates women to

biomedical scrutiny in assorted reproductive contexts, from infertility to pregnancy

and birth (Becker 2000; Davis-Floyd 2004; Franklin 1997; Martin 2001; Rothman

1993, 2000; Thompson 2002). Whereas medicalization is overwhelmingly

Cult Med Psychiatry (2008) 32:358–385 359

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conceptualized as being harmful to women in much of this literature, studies that

focus on expectant fathers seem to group men and biomedicine on the same side of

the patriarchal divide. Consequently, men are depicted as considerably less

threatened by reproductive biomedical practices.

Moreover, while paying close attention to the nexus of power within which they

maneuver, anthropologists of reproduction have accounted for women’s varied

responses to medicalization. The complex negotiations documented in these studies

are best conceptualized in the concept of ‘‘biomedicalization,’’ a reframing of the

prior term to account for the interactive nature of the medicalization process and the

intricate power relations between biomedicine and its consumers (Clarke et al.

2003; Friese et al. 2006). Women’s responses to biomedicalization are theorized in

such accounts as ranging in degrees from acceptance to resistance (Davis-Floyd

2004; Martin 2001; Root and Browner 2001). In lieu of the complexity and range of

these accounts of women’s encounters with biomedicine, studies that focus on

expectant fathers tend to see male partners as generally benefiting from the

medicalization of pregnancy and birth.

Men and Reproductive Biomedicine

The relative benefits that male partners can obtain from the medicalization of

pregnancy are particularly emphasized in ethnographic accounts of expectant

fathers’ participation in sonograms and hospital birth. Much like in the psycho-

logical literature, in which men are often depicted referring to their peripheral role

in pregnancy and birth as a source of feelings of inadequacy, fear, jealousy and

uselessness (Coltrane 1996; Linton 2000), the anthropological literature portrays

men as suffering a ‘‘reproductive deficit’’ (Sandelowski 1994, p. 234) in their lack of

access to the direct embodied experience of the fetus. Representing a potentially

helpful compensation for this discrepancy, it is suggested that reproductive

technologies, particularly the sonogram, can function as ‘‘proxies’’ of embodiment

for men (Draper 2002, p. 779). Ultrasound, Draper claims, gives the expectant father

‘‘the potential . . . to have the same visual access to the baby as his partner, thus

equalizing their respective positions as knowers of the baby’’ (p. 782).

Sandelowski’s account of American men during ultrasound scans goes a step

farther in describing the ‘‘equality’’ achieved by epistemologically privileging

visual access over embodied experience. She shows how the circumstances of fetal

ultrasonography ‘‘tend to preserve a certain patriarchal arrangement of power and

authority’’ (Sandelowski 1994, p. 239). Ultrasound itself, she claims, serves to

exclude women by making them more and more invisible while the ‘‘independent

fetus floating in space’’ (Petchesky 1987) takes center stage. Sandelowski (1994)

suggests that this exclusion of the pregnant woman, who often lies in the supine

position without a direct view of the sonogram while her male partner is imparted

information by the doctor, sometimes makes the woman herself feel ‘‘left out’’

(p. 238). Keeping in mind the empowerment ultrasonography seems to afford men,

Draper’s (2002, p. 790) suggestion that men use the scans as rituals to help them

360 Cult Med Psychiatry (2008) 32:358–385

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‘‘make and mark their transition to Western fatherhood’’ may not come as a

surprise.

Browner and Preloran’s (1999) study of the role of men in the amniocentesis

decisions of Latinas in California adds to this picture. Their study shows a striking

correlation between Latina patients’ acceptance of amniocentesis and the presence

of their male partners during consultations with a genetic counselor. They observed

that men who attended consultations with their wives were ‘‘less openly fearful than

the women and appeared much more comfortable in the situation’’ (Browner and

Preloran 1999, p. 101). Men’s concerns were ‘‘informational’’ and they tended to

explain biomedical concepts to their partners, serving as a ‘‘bridge between the

world of medicine and their wives’’ (p. 101). This was exemplified in one man’s

encouraging his wife to ‘‘see the truth of science’’ (p. 101).

Last but not least, Draper’s (2003) study indirectly suggests that men may benefit

from the medicalization of childbirth. She suggests that the birthing body, with its

leakages and unstable boundaries, threatens to ‘‘pollute’’ the men present at the

birthing scene. The biomedical control of birth, in Draper’s view, is a series of

procedures that symbolically restores the woman’s body to a less-threatening form.

‘‘The restoration was completed,’’ Draper writes, ‘‘when the mother and baby were

separated, umbilical cords cut, episiotomies repaired and cesarean section wounds

closed’’ (p. 62). Biomedicine, consequently, plays a role in helping men cope

securely with the threats posed by the birthing body.

At the same time, there is evidence in the anthropological literature in each of the

aforementioned arenas of less enthusiastic approaches that men may have to

reproductive biomedicine. Draper (2002) briefly acknowledges the potential of

ultrasound to alert men to its diagnostic abilities and make them aware of the

possibility of fetal anomalies. Rapp (1999) accounts for how African American men

refuse amniocentesis, associating it with instances in American history when black

patients became ‘‘guinea pigs’’ of experimental biomedical interventions. Browner

and Preloran (1999) report that some of the Latino men in their study did not attend

genetic counseling sessions because they were apprehensive towards medical

institutions. Finally, Jordan’s (1993) ethnographic account depicts one husband of a

woman in labor who ‘‘appears intimidated by the scene. He comes to the woman’s

bedside when she calls him but gets out of the way when the medical team moves

in.’’ However, these accounts remain anecdotal within these scholars’ general

arguments and are not analyzed separately for what they may teach us about men’s

interactions with biomedicine during their partners’ pregnancies.

To our knowledge, Reed’s (2005) study, entitled ‘‘birthing fathers,’’ is the first to

draw attention to the ambivalence that expectant fathers may feel toward

medicalized reproductive events. Based on in-depth interviews with men, Reed

suggests that birth education classes contribute to confusion about men’s expected

role in birthing. While course instructors tend to emphasize how much men matter

to women’s birthing processes, men discover during the actual birth event that they

are trapped between the conflicting needs and expectations of their wives and those

of the medical professionals in charge. Consequently, many male partners walk out

of the birthing room feeling ambivalent and disillusioned toward the birthing

experience and their role in it.

Cult Med Psychiatry (2008) 32:358–385 361

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Whereas Reed’s study makes an important step toward understanding men’s

experiences of reproduction and of partnership in relation to reproductive medicine,

his study also highlights important issues that require further investigation. First,

Reed’s focus is concentrated around birth-related practices. While he allows

ethnographic breadth to men’s narratives of birthing and, to a much lesser extent, to

a description of one birth education class, the long-term experience of pregnancy is

described as if from afar. As a result, we can learn relatively little from his

ethnography on men’s experiences of pregnancy. Second, Reed does not discuss his

findings in relation to the elaborate concepts that anthropologists of reproduction

have developed to theorize the encounters of obstetrical patients with biomedicine.

By contrasting his data against the large body of literature on women’s reproductive

experiences, Reed could have sharpened our understanding of the workings of

gender within reproductive encounters with biomedicine.

It is precisely these ethnographic and theoretical gaps that this article attempts to

fill. We propose that men’s negotiations with reproductive biomedicine are much

more complex than the existing literature has accounted for. In recollections of their

encounters with biomedicine in the course of their partners’ pregnancies, some

Israeli expectant fathers did show acceptance of biomedicine and gratitude for its

benefits and were even empowered by it in various ways. However, the majority’s

responses leaned toward degrees of criticism, cynicism and even resistance. The

present data suggest that men’s responses to biomedicine, in comparison to those of

women, stem from their different positioning vs. biotechnologies. We view this

tremendously varied range of responses, with its bent toward powerful criticism, as

being directly related to the local version of medicalization that characterizes Israeli

prenatal care.

Prenatal Care in Israel

As recent publications have clearly shown, becoming pregnant in Israeli society

means a high degree of exposure to medical care (Ivry forthcoming a, b; Teman

2001, 2003a, b; Benjamin and Ha’elyon 2002; Hashiloni-Dolev 2007; Morgenstern-

Leissner 2006). This is particularly true for Jewish Israeli women who do not define

themselves as ultraorthodox (Sher et al. 2003). Israeli legislation, recognized by

many scholars as explicitly pronatal (Birenbaum-Carmeli 2004; Hashiloni-Dolev

2007; Kahn 2000; Remennick 2000, 2006), also formally and openly encourages the

medical management of pregnancy and birth by making prenatal care accessible and

virtually expense-free. Israeli law permits women to miss up to 40 h of work for

medical appointments during pregnancy, and prenatal care and hospital birth are

covered by Israel’s mandatory national health insurance, thus making them

available to all Israeli women. The state rewards women for giving birth in a

hospital, rather than at home, with a special monetary birth grant (Morgenstern-

Leissner 2006). This policy is reflected in the rate of hospital births: according to the

Israeli Association of Obstetrics and Gynecology, more than 99% of all births occur

in hospitals (Kupermintz 2005).

362 Cult Med Psychiatry (2008) 32:358–385

123

The high degree of medicalization of reproduction in Israel is also evident in

Israel’s ranking as one of the countries with the highest rates of cesarean operations

in the world,1 and in the government subsidization of conceptive technologies,

which has led Israel to have the highest rate of fertility clinics per capita in the world

(Kahn 2000; Remennick 2000). Although alternatives to conventional hospital birth

are increasingly marketed to Israeli women by hospitals offering ‘‘natural birth’’ and

‘‘hospitalized homebirth’’ options, very few alternatives are available to medical

care during pregnancy. Routine prenatal care in Israel emphasizes the necessity for

prenatal diagnostic screening tests. A partial list for a ‘‘low-risk’’ pregnancy

currently in the standard health basket are a second-trimester scan and a second-

trimester alpha-fetoprotein maternal blood test for the probability of a child with a

chromosomal or genetic anomaly; in the case of any indication of the latter, state-

funded amniocentesis is offered.

Compliance with the medical management of pregnancy has become an implicit

expectation of Israeli women, including a minimum of six prenatal care checkups

and basic PND screening. Noncompliance with the norm is rare among women who

do not define themselves as ultraorthodox.2 Consequently, most Jewish women who

are not ultraorthodox embark on a similar route during pregnancy. This route of

biomedical ‘‘stations’’ exposes them to medical technologies, professionals and

‘‘authoritative knowledge’’ (Jordan 1997). Dating their pregnancies in weeks, most

pregnant women who embark on this route will do a blood test to confirm the

pregnancy and a scan at eight weeks to confirm a heartbeat. They will attend at least

six prenatal checkups and their blood pressure and urine will be regularly

monitored. Their doctor will usually refer them for diagnostic tests including a

nuchal translucency scan and blood test at 11–12 weeks, a ‘‘checklist’’ scan at

16 weeks, the triple-marker test at 17 weeks, a second checklist scan at 24 weeks

and a scan to measure fetal weight at 32 weeks. Many will have scans at each

prenatal checkup if their physician has a sonogram in the office, and most will be

referred for thrice-weekly monitor and scan when their pregnancies pass the 40-

week mark. Finally, many will face the decision of whether or not to undergo

amniocentesis, especially if their pregnancies are ‘‘high-risk.’’

It is on the background of this highly medicalized route of pregnancy that we

now turn to the accounts of male partners in pregnancy. In the following, we

examine the relationships between men and reproductive biomedicine as they

develop along this trajectory. The next section of the article defines the extent of

actual involvement that ‘‘participation’’ encapsulates for male partners of pregnant

1 Steadily increasing since 1973, when it averaged 5%, Israel’s cesarean rate reached 11% in 1994, then

jumped to 16% in 2000 and 18.3% in 2004 (Kupermintz 2005). Heightened medicalization is also

exemplified in other statistics from the Israel Association for Obstetrics and Gynecology for the year

2004, reported by Kupermintz (2005), including high rates of vacuum-enabled births (5%), use of forceps

(0.3%), epidural use during labor (41.8%) and elective cesarean operations (4%).2 See, for example, Sher et al. (2003) about the noncompliance of the ultraorthodox population to alpha-

fetoprotein test or amniocentesis. As an example of the institutional intolerance of the rare instances of

noncompliance with standardized prenatal care, several Jerusalem-based ultraorthodox women told us, in

the framework of a separate study, that they were chastised by midwives upon admittance to the delivery

ward if their prenatal care card was not filled with the appropriate number of appointments (Ivry and

Teman 2006).

Cult Med Psychiatry (2008) 32:358–385 363

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women. We continue from there with men’s descriptions of their encounters with

the authoritative experts and technology-based knowledge produced from ultra-

sound scans. Next, we turn to their accounts of the triple-marker test and

amniocentesis. Finally, we discuss the experiences of those men whose partners

were given high-risk results from PND. The article ends with a typology of men’s

responses to medical technologies, medical authorities and medical knowledge and

a discussion of this gendered range of responses in light of comparative accounts of

women and biomedicine.

Methods

The findings reported in this article are based on ethnographic materials collected by

the first author and analyzed together with the second author. The materials are also

partially drawn from a larger comparative study of the social management of

pregnancy in Japan and in Israel that the first author conducted between 1999 and

2003 (Ivry forthcoming a), in which she used a wide range of methodologies,

including in-depth interviews with ob-gyns and pregnant women in each country,

textual analysis of pregnancy guides, medical forms, and medical literature in each

language and participant observation in local prenatal clinics, maternity- and birth-

education courses and clinics that perform prenatal tests.

This study also draws on the first author’s additional participant observations in

birth-education courses in 2003 and 2006. Particular weight, however, is given to

the findings from 16 in-depth interviews with Jewish-Israeli men conducted during

the summer of 2006. Thirteen interviews were conducted by the first author, and

three interviews by a male research assistant.3 The interviewees ranged in age from

mid-20s to early 30s, all but one was married, and all were first-time fathers. During

the semistructured interviews, which lasted between 1 and 2 h, the men were asked

to openly describe their day-to-day experience of their partner’s pregnancy,

particularly their experience of the medical events they participated in related to the

pregnancy. As their narratives unfolded, the men were prompted to give further

detail on their interactions with medical practitioners, their attitudes toward medical

technologies such as ultrasound and genetic testing and their assessment of the

impact of medical knowledge, particularly risk-based medicine, on their experience

of their partner’s pregnancy.

Interviewees were recruited for the study primarily through snowballing

techniques. The remaining informants were approached by the first author for

interviews after they had participated in the birth-education courses in which she

had conducted participant observation. Most interviews with these men took place

in cafes and not in the presence of their women partners. Two interviews were

conducted by phone (one because of scheduling problems and one because the

3 Interviews by the male research assistant were conducted according to the same format as those carried

out by the first author. Upon hearing the audio recordings of the interviews and reading the transcriptions,

we did not identify any differences in the depth of insights, or in the quality of openness, shared by the

men with the male research assistant and with the first author, who is female. The authors would like to

thank Niv Gal for his assistance in conducting these three interviews.

364 Cult Med Psychiatry (2008) 32:358–385

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interviewee preferred it to a face-to-face interview). All of the interviews were

recorded with the agreement of the informant, transcribed verbatim and translated

from Hebrew to English. Names of informants were changed in order to protect

their anonymity.

The men lived in central and northern Israel, were primarily of middle-class

upbringing, and had diverse professions. Aside from two participants, all of the men

were born and raised in Israel. They identified themselves in terms of ethnicity as of

Eastern European, Moroccan, Indian, Spanish, and Yemenite descent. They were all

Jewish, their religiosity ranging from secular to traditional. In a separate research

project (Ivry and Teman n.d.), we have begun to study the reproductive experiences

of ultraorthodox and modern-orthodox Jewish Israeli men and women, which

require analytical effort in and of themselves.

Prenatal Participation as an Index of Commitment

Since the establishment of the discourse of ‘‘new fatherhood’’ in the 1960s, men in

many Western countries are increasingly encouraged and expected to be more active

participants in child rearing and more intensely involved in their partners’

pregnancy, labor and birth (Draper 2003; Mitchell 2001). Pregnant partnership is

heralded in the psychosocial scholarship as largely beneficial for both members of

the couple and for their relationship. It has been suggested that increasing

involvement of fathers during childbirth can reduce the pain suffered by women

(Hennenborn and Cogan 1975) and help couples negotiate the transition to

parenthood while preserving their relationship as a couple (Diemer 1997).

Israeli legislation encourages fathers to become more involved in child rearing by

giving men the theoretical possibility of taking half of their partner’s 12-week

maternity leave. Nearly all Israeli hospitals allow expectant fathers to be present

during the birth of their children. The idea of the ‘‘shared pregnancy’’ has become

part of the local discourse on pregnancy as well (Ivry 2008, forthcoming a), and was

reiterated by all of the men we encountered in our observations and interviews. Yet

while the Israeli men in our study did indeed participate in their partners’

pregnancies, their participation was never taken for granted, and there was not a

strong consensus among them on what ‘‘participation’’ actually meant. Although it

was clear from the start to some men that they would accompany their wife to all

medical activities, they nevertheless commended themselves for their commitment

and for being ‘‘excellent’’ partners because of their participation. Lior, 28, an

engineering student who was determined to take part in all pregnancy-related

medical activities, expressed this idea explicitly.

The first author first met Lior when he and his wife attended a birth-education

course in the midst of the second Lebanon war during the summer of 2006. Lior,

who had missed the previous class because of reserve duty, smiled at the birth

educator as he entered and said, ‘‘See what a dedicated partner [mashkian] I am? I

came straight here from reserves duty [miluim]. My father, all of his children were

born when he was away in the army. He received a letter saying, ’Mazal Tov, you

have a boy, you have a girl.’ And here I am coming directly from miluim.’’ The birth

Cult Med Psychiatry (2008) 32:358–385 365

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education teacher responded with a warm ‘‘Well done [kol hakavod],’’ and Lior’s

wife looked at him proudly.

Later, when the first author asked Lior about this incident, he explained how he

had felt resentful as a child of the way his father treated his mother. ‘‘The truth is,’’

he said, ‘‘my father is not as primitive anymore, but maybe I am this way because of

what I used to see at home.’’ Being acutely aware of his position in an era of social

transition to a new model of partnership, Lior derives a deep sense of satisfaction

about his role as a new father from his choice to become a devoted participant in

pregnancy events, to the extent that he speaks about himself in evolutionary terms,

as a higher ‘‘breed’’ of father than his ‘‘primitive’’ predecessor.

Whereas Lior was applauded for overcoming the fatigue of military service to

participate, other men the first author met in birth-education classes and elsewhere

were applauded for significantly less heroic acts of devotion, such as giving up a

football game on TV or missing a meeting with friends (Ivry 2008). These cases are

illustrations of a state of affairs in which men are expected to participate but their

participation is never taken for granted and is often applauded by wives, birth

educators, relatives and friends. Clearly, participating in all medical activities was

collectively understood as the ultimate expression of commitment to their pregnant

female partners. In general, then, more men today may be pregnancy participants,

but our findings show that men’s participation is often under negotiation between

them and their pregnant partners. These negotiations varied in content and

emotional intensity but they were always present.

Omri, 29, a technician in a startup company, boasted with self-satisfaction that he

had hardly participated in any medical checkups since his partner had exempted him

from most of them: ‘‘She said, listen, there is no point in your coming with me to the

ob-gyn; they do nothing special there, only routine tests. So I said ‘cool’ [all hakefack].’’ Likewise, Hillel, a copy editor at a publishing company, explained that

although he is ‘‘very thrifty’’ [kamtzan] with his time, pregnancy was ‘‘without

question ... our first priority.’’ Nevertheless, he later admitted, ‘‘Yesterday she

underwent a third ultrasound scan and I felt that it was not critical that I accompany

her, but I assured her that if she ever feels that is important for me to be there, I will

attend.’’

Both of these stories reveal that the urgency expressed by female partners plays a

major role in men’s motivations to participate. Individual pregnant women expect

different degrees of participation from their male partners and put different amounts

of pressure on their partners to take part. Omri’s wife indeed exempted him from

routine checkups and even from major ultrasound scans, however, Omri reported

that she was upset when he announced that he did not intend to be present at the

birth of their daughter, a relatively rare decision in contemporary Israel. It was not

rare for men to express feeling unnecessarily ‘‘forced’’ into a medical activity by

their female partner. Sometimes men reported being angrily reproached by their

partners for not attending a prenatal test. Shaul, 30, an accountant, described these

tensions:

She comes complaining to me that I am not as excited as she is, she says: ‘‘I

feel that I am going through this alone.’’ For example, there was some test that

366 Cult Med Psychiatry (2008) 32:358–385

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I could not attend because I had a lot of work, and I also was not overly upset

about missing it. I said to her: ‘‘I came to the ultrasound scans, but I do not feel

the need to come to a routine check up.’’ So she got really upset [hitkomema].

She said: ‘‘Don’t you feel the need to come, aren’t you excited to hear the

pulse?...’’ I told her: ‘‘I already accompanied you to the important tests....’’

Shaul’s words illustrate how emotionally charged the issue of men’s attendance

of medical tests can become for some couples. Moreover, it reveals an unwritten

hierarchy of importance among different biomedical activities that might feed into

men’s considerations. The order of priority reflected in Shaul’s narrative echoes that

of other male partners in this study and even in comparative cases in the

anthropological literature (Draper 2002, 2003). Top priority goes to ultrasound

scans, which seem to bring even the most resentful of men into the clinic. However,

as Shaul’s story illustrates, such hierarchies are not always found acceptable by

female partners as legitimate excuses for nonparticipation.

If most men considered scans ‘‘mandatory,’’ then they are closely followed on the

unwritten list of participation priorities by ‘‘emergency’’ consultations with

physicians and genetic counselors related to indications of fetal anomalies in

which the option of pregnancy termination is discussed. The observations and

interviews show that such consultations manage to attract even those men who are

most uninterested in participation. For example, even the above-quoted Omri, who

celebrated being exempted by his wife from participating in most prenatal tests,

initiated a consultation with his wife’s ob-gyn soon after she had informed him

about the worrying result of her triple-marker test. He explained, ‘‘I didn’t

understand what this triple marker was about, and she could not give me the

information, so I went to the doctor to find out what this test meant.’’

It is also in the context of such emergency decisions that the friction between

partners becomes most intense. Especially in cases when the couple turned to

genetic counseling, the first author’s participant observation findings revealed

women openly expressing their discontent when their partners failed to live up to

their expectations. Even with the genetic counselor and the anthropologist present in

the room, Talya, 32, a special education teacher, raged at her partner for being late

to the appointment and missing the introductory conversation and movie about

amniocentesis that they were to be shown in preparation for the consultation.

Throughout the meeting with the genetic counselor, Talya reminded her husband

that his lateness was the cause of his lack of knowledge about the options being

discussed. To judge from his gestures, the husband was ashamed, and although he

repeatedly apologized for his lateness and for ‘‘coming unprepared,’’ his wife

continued to reject whatever he said during the consultation on the basis of his late

arrival. Especially significant in this exchange is that Talya interpreted her

husband’s late arrival as indifference on his part during a stressful and disturbing

time for her and as a sign of his lack of commitment to the pregnancy and to their

partnership.

This variety of cases tells us about the multiple tensions, frictions and modes of

power relations that emerge between men and their pregnant partners. Here,

however, it is biomedical activities—an organized system of practices and

Cult Med Psychiatry (2008) 32:358–385 367

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technologies imbued with expert authority—that serves as the substrate of these

bilateral power struggles. Men and their partners alike perceive participation in

medical activities as the ultimate index of commitment to each other and to the

pregnancy, and biomedicine lends itself well to this indexical role by producing the

sense of importance and often urgency that is so powerful and crucial in drawing

men into its spheres. The array of medical checkups, with their unwritten hierarchy

of importance, become the blackboard on which absence and presence can be

marked and counted, excellence awarded prizes, mediocrity criticized and

commitment and emotional involvement assessed. It is no wonder that some of

the men in this study developed forms of resistance to the authoritative system that

was used as a crucial measure in their wives’ evaluation of them as participants,

partners and fathers-to-be.

The First Ultrasound as Wife-Lending

The attendance of ultrasound screenings—a rarely disputed priority on the

participation ‘‘checklist’’ of Israeli pregnant partnership—has become one of the

most common rituals of Israeli pregnancy, much as Mitchell (2001, p. 3) describes

in the case of late-20th-century urban North America. The benefits of this ritual

have been heralded in the psycho-social scholarship as enhancing men’s experience

of pregnancy and enhancing their transition to parenthood by making the fetus more

‘‘real’’ (Georges 1997). Sandelowski (1994) conceptualizes the fetal ultrasound as a

‘‘prosthetic device’’ for expectant fathers, suggesting that ‘‘expectant fathers’

experience of the fetus is always enhanced’’ by the technology. She suggests that for

men, ultrasound is an enabling mechanism that helps them overcome their pregnant

partner’s privileged embodied access to the fetus and become more ‘‘equal’’

partners in relation to it. As an additional benefit, Sandelowski suggests that some

male partners even gain privileged knowledge of the fetus by forming a type of male

camaraderie with the male obstetrician.

In the 13 years since Sandelowski published her findings, fetal ultrasonography

has evolved from a technique in which a transducer was moved across the pregnant

woman’s gel-covered belly to its current form, in which a vaginal transducer is used

in first-trimester scans. Usually at eight weeks, the transducer is covered with a

condom and inserted into the woman’s vagina, enabling a clearer view of the

embryo than is possible through the relatively thick fat and muscles of the abdomen.

The vaginal ultrasound associates the notion of ultrasound as a ‘‘prosthetic device’’

with more sexually oriented connotations. The men commented on how unprepared

they had been to witness a stranger physically penetrating their partner’s vagina

with what they described as a ‘‘stick-like’’ or a ‘‘penis-like’’ apparatus in a situation

they saw as more of a ‘‘peep show’’ than a medical event.

Indeed, the men seemed much more concerned with the sexual overtones of early

scanning than their pregnant wives, who had previously learned from pregnancy

guides or friends of the possibility that their first scan might be performed vaginally.

The women were also more equipped to deal with the boundary transgressions that

such medical encounters involve because of prior experience with gynecological

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examinations, in which intimate clinical interactions are ‘‘ungendered,’’ neutralized

and desexualized in the name of medical science (Galasinski and Ziolkowska 2007;

Henslin and Biggs 1971). However, the expectant fathers were unrehearsed in the

cultural scripts that enable the woman and sonographer to leave sexuality at the

clinic door and were shocked to witness the silent collaboration between their

pregnant partner and the sonographer, who touched and even penetrated their

partner’s body as they watched from the sidelines. A far cry from the male bonding

among expectant father and sonographer described by Sandelowski, sometimes

experienced by the pregnant woman as leaving her out, the men in our study

experienced this transgression of normative boundaries of sexuality and intimacy as

a source of uneasiness and embarrassment, and even as a threat to their exclusive

access to their partners’ bodies.

The men expressed their embarrassment in various ways. Oren, 25, a checkout

clerk, said: ‘‘I didn’t believe that such a test existed ... well, maybe I knew but I

didn’t internalize it.’’ Yakir, 29, a soundman, recalled the situation as an

‘‘unpleasant surprise,’’ and Lior described the procedure as an invasive test that

he felt shy about witnessing. Unsure that his partner would feel comfortable with his

presence, he entered the room only after the doctor(!!) had assured him that his wife

felt okay with it. Finally, Lotan, 32, an elementary-school teacher, admitted that he

was completely shocked by the procedure.

Other men clearly engaged in significant ‘‘emotion work’’ (Hochschild 1983) in

order to neutralize and normalize the intimate connotations of this highly sexually

suggestive act. Tamir noted how excited he was to see his son on the ultrasound

screen, but also commented that he ‘‘felt a little uneasy. It was as if it is some kind

of intimate situation between her and him [the doctor]. A stranger is doing

something like that to my wife. It always somehow disturbed me throughout [the

pregnancy]. But gradually it faded away because somehow I feel that I am in

control, because you see, it is purely a medical act.’’ Later, Tamir added that the

doctor’s professional attitude and ‘‘clean’’ expertise helped him to feel more at ease

with the situation. Other men demonstrated additional variations of emotion work to

process the situation. Samson, 34, a gardener, responded by joking about it:

Samson: My first encounter with [the reality of the fetus] was when they put this

stick covered with a condom into her [laughing].

Interviewer: Did you know it was going to be vaginal?

Samson: I did not know exactly, but whenever I go to the hospital ... I know that

you have to be prepared for all sorts of unexpected things, let’s say, all sorts of

things that do not stimulate your appetite.

Laughing as he recalled the scene, Samson added: ‘‘It was very funny. It did not

threaten me. It was very funny, not a big deal.... We made a joke that it was like a

dildo or something.’’ Whether by ‘‘purifying’’ the sexually suggestive act as

‘‘professional’’ or ‘‘medical,’’ or by coping with embarrassment through humor, the

men find ways to settle the tensions inherent in circumstances in which medical

authorities transgress sexual mores. These tensions are vividly summarized in the

definition of an ob-gyn that Oren includes in a humorous book he wrote about his

experiences of pregnancy and birth. He writes, ‘‘Ob-Gyn [definition]—Like God,

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but His commandments are always kept piously. Every two months he will

shamelessly feel up [yemashesh] your wife and you will encourage it and support

it.’’

Oren’s definition of an ob-gyn poignantly conceptualizes the paradoxical

situation of vaginal ultrasound for the expectant father, who is socially expected

to differentiate between professionals and laypersons in allowing access to his

partner’s body. Ironically, while their female partners may not feel comfortable with

their bodies being penetrated, the men in this study seem more sensitive to such

transgressions, more concerned about invasive medical interventions, especially

when they deal with their partners’ intimate organs, and less prepared to take such

interventions for granted; they are surprised, shocked, and sometimes horrified by a

practice that has become a routine part of prenatal care. What is at stake for the men

is, of course, quite different from the feminist concern: they are concerned with the

threat posed to their exclusive accessibility to their female partner’s body.

Consequently, some of the men in this study felt virtually disabled by the social

expectation that, upon entering the medical theater, they would ‘‘lend’’ their

exclusive rights of accessibility to their partner’s intimate body parts, when in fact

nobody asked their permission. For men, participating in pregnancy-related medical

events therefore means actively ‘‘lending,’’ permitting and purifying the handling of

their partners by medical professionals, who are often other men. Nevertheless, at

least some of the men do emotion work in order to temporarily and literally hand

over their wife’s body into the hands of another man or woman who will handle her

genitals.

Ultrasound Scans and the Performance of Fatherhood

If the expectation to participate in the pregnancy and in medical ‘‘wife-lending’’ was

not enough, the men in this study encountered yet another challenge to being

pregnant partners: the expectation that they would exhibit excitement and

heightened interest in the ultrasonic image of ‘‘their’’ fetus. This expectation

follows the ultrasonic medium’s implicit aim of strengthening prenatal ‘‘bonding’’

by helping the expectant parents to visualize their baby (Georges 1997; Mitchell

2001; Taylor 1998). Couples can now take home a souvenir photograph or DVD of

the fetus to be cherished as ‘‘baby’s first picture’’ (Mitchell 2001) or view their

future offspring through three-dimensional (3D) and 4D scanners, which produce

even more easily distinguishable baby-like images than the 2D ultrasound, which

requires the sonographer’s help in ‘‘translating’’ the blurred image into a

recognizable ‘‘baby.’’

Scholars based in Euro-American societies point out that fetal ultrasonography is

believed by many to help expectant fathers realize the ‘‘reality’’ of the pregnancy

and to facilitate their transition to fatherhood (Draper 2002). As a result of

ultrasound’s assumed transformative power, men are now routinely expected to

perform the scripted postures of reacting in excitement while viewing their child’s

image on screen. As Mitchell (2001) relays in her ethnography of fetal

ultrasonography in Canada, the contemporary ritual of ultrasound viewing involves

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the expectant parents smiling, laughing and pointing at the image they are being

shown while the sonographer ‘‘observes the couple closely to see if they like the

blur and show signs of ‘bonding’ with it’’ (p. 3). Yet while some of the Jewish-

Israeli men in this study did express their excitement at seeing their fetus through

this technology, many of them also noted their uneasiness and ambiguous feelings

about the images produced and the situational expectations of them.

First, the Israeli men seemed relatively less adept than their partners at accepting

the sonographer’s attempts to translate the blurry images into an animated ‘‘fetus.’’

While their female partners displayed some familiarity with and acceptance of this

translation work, a number of men in this study admitted that they could not figure

out what they were seeing. Ron, 28, an electronics technician whose wife was soon

to give birth, explained: ‘‘I sat there and the doctor explained and I said, ‘Yes, yes’

as if I understood what he was doing....’’ Significantly, even more technologically

advanced devices, which are supposed to bypass the problem of blurry images by

presenting a more realistic 3D image, do not always seem to solve the problem.

Some men were indeed enthusiastic about this technology, but many expressed fear

and even disgust at the 3D image. For example, Lior said:

Lior: No, I didn’t like at all the three-dimensional scan, I think it is completely

unnecessary, it also does not look good, it only frightens the parents, and I didn’t

like it.

Interviewer: What specifically did you not like?

Lior: This [type of] scan images the tissues, doesn’t it? So it gives rise to

distortions in the face and the body, all sorts of these ... like mountains on the

skin. I prefer observing the green monitor and that’s it [referring to the 2D

ultrasound].

Similarly, Eli, 34, a lawyer, described the 3D image as a ‘‘wax figure’’ or a

‘‘mummy,’’ and Kobi, 30, a literature student, said that the 16-week-old fetus he saw

during the sonogram looked like a bat. This hesitation to accept the 3D image as a

‘‘cute baby’’ made ‘‘bonding’’ with the fetal image a difficult task. Again, whereas

some of the men dutifully accepted this discourse and spoke about their

‘‘excitement’’ and ‘‘unprecedented feelings’’ at seeing the ‘‘little peanut [heart]

beating,’’ others expressed dismay. Shaul spoke about his general frustration with

ultrasound scans. Comparing himself to his friend who was excitedly ‘‘walking

around with sparkles in his eyes,’’ and taking heed of his wife, who expected him to

respond excitedly to the sight of his ‘‘daughter’s’’ sonographic image, Shaul felt

disappointedly disconnected. During his half-hour-long ‘‘confession,’’ he repeatedly

reiterated his inability to ‘‘connect’’ to the image of his child:

I saw the baby on the ultrasound, I saw her, I saw something there, I saw a

child. This child seems to be fully composed: all things [organs] are in place,

but I still feel disconnected.

Shaul’s words shed light on Sandelowski’s (1994, pp. 240–242) suggestion that

ultrasound has ‘‘democratized the access to the baby by privileging the status of

visual knowledge over embodied experience,’’ for it reveals that this democrati-

zation does not necessarily benefit men in every case. Instead, men like Shaul

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experience such ‘‘new opportunities to bond’’ as significant pressure imposed on

him to display a specific emotion. In addition, a minority of the men expressed

apprehension over the safety of repeat scanning. Eli articulated this sentiment: ‘‘It

might be nice and pleasant to go together and see the fetus, but proportions should

be maintained. I am also not so sure that pouring all of that [radiation] energy onto

the fetus is healthy.... Who says that it does not harm it?’’

The men’s narratives reveal a somewhat shifted version of the relations of

subjection between women’s bodies and biomedicine. Whether the men experience

scientific ‘‘incompetence’’ when they are unable to ‘‘translate’’ ultrasonic images,

feel emotionally inept for not being able to ‘‘bond’’ with the fetal image or feel

embarrassed or shocked while witnessing medical professionals penetrate the sexual

organs of their female partners, it is clear that such unsettling, ambivalent and

emotionally charged experiences open up the floor to a set of tensions and power

relations between men and the medical professionals who treat their pregnant

partners. These tensions are amplified when the couple is forced to make tough

decisions after ultrasound or other tests produce ambiguous, ‘‘high-risk’’ or positive

results.

Prenatal Diagnostic Testing: Suspicious Technologies and Medical Knowledge

Ultrasound may challenge men with embarrassment raised by disrupted norms of

intimacy, frustrations related to prenatal bonding and difficulties interpreting

ultrasound pictures, but the biggest challenges of all emerge from their diagnostic

capabilities. Throughout these scans, medical practitioners are busy searching for

indications of fetal anomalies. Taylor (1998) addresses this contradictory use of

ultrasound in the United States in simultaneous ‘‘bonding’’ and diagnostic

capacities. Yet whereas in cultures such as Japan (Ivry 2006, 2007, forthcoming

a) the doctors reveal hardly any of the diagnostic purposes of obstetrical ultrasound

scans, and tend to be exceedingly cautious when mentioning the possibility of other

more invasive diagnostic tests for fear that they will upset the already ‘‘bonded’’

pregnant mother, in Israel the diagnostic screening for fetal anomalies intensifies as

the pregnancy develops and becomes the main concern of pregnant women and

physicians alike. In fact, the most comprehensive diagnostic scan offered as part

of the standard health basket—in which the fetus is scanned against a ‘‘checklist’’

of the internal and external fetal organs for deformations and indications of

abnormality—takes place only in the second trimester, sometimes as late as

26 weeks.

Screening for fetal anomalies through ultrasound becomes one aspect of a

medicalized pregnancy route that has been called ‘‘obsessed’’ with PND for the

purposes of selecting ‘‘perfect’’ babies (Remennick 2006) and ‘‘chosen’’ bodies

(Weiss 2002). In addition to scans, other diagnostic tests are offered, such as the

triple-marker blood test, general genetic tests and amniocentesis. Statistically, the

high use of PND in Israel is exemplified in the numbers reported by Sher et al.

(2003, p. 420), that is, that 96% of secular Israeli women and 94% of traditional

women take the triple-marker test and 94.4% of secular women and 62.5% of

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traditional women over age 35 undergo amniocentesis. Many Israeli women under

age 35 also undergo amniocentesis, with or without an indication of abnormality

and often at their own expense, after they are made aware that amniocentesis is the

only test, other than the less available chorionic villus sampling, which can give a

diagnostic result of 95% accuracy.

This cultural fervor over PND was strongly evident in the first author’s earlier

research among pregnant Israeli women and their doctors, for whom the fetus

represented a ‘‘suspect’’ under investigation for possible defects and for whom

pregnancy was guided by a ‘‘worst-case scenario’’ mindset. Yet despite their female

partners being caught up in the local PND fervor and consuming every diagnostic

test they were offered, the men that we spoke to were generally more critical of

PND. Men repeatedly commented on the zeal surrounding PND and critiqued its

necessity, trustworthiness and implications. They deconstructed the very nature of

the biomedical knowledge produced through PND, the role of biomedical

practitioners and the commercial industry that has cropped up together with the

cultural frenzy. They also noted the newness of prenatal testing and that people once

survived without it. As Omri put it:

Throughout this process I asked myself why they are doing all this. People

bore children before this and they bear children today. What is the percentage

of abnormalities in the population? One percent? Half a percent? If it were

more the world would not have survived. This whole business looked too

exaggerated to me.

In the same vein, Shai said that he had developed a technique for calming his wife

down during the pregnancy by reminding her to ‘‘look around us, everyone that you

see was once born, all of them were born.’’ Shai’s comment portrays his wife’s

preoccupation with the results of PND, as opposed to his more relaxed ability to put

PND into context. The men also compared their perspectives to their female partners’

ideas about ‘‘risk-based’’ diagnostic tests, such as the second-trimester triple-marker

maternal blood test that is part of the standard health basket. In her study of pregnant

Israeli women, Ivry (forthcoming a) found that the women were extremely nervous

and pessimistic interpreters of the probability-based results of this specific test. Even

if the probability was 1 in 10,000 that their children would have Down’s syndrome,

they tended to view the result as 100% for the person who ends up with a disabled

child. The men in our study were less worried about how the risks would affect their

lives and, instead, formed strong sentiments about the risk-based technology itself,

expressing doubt and even antagonism. The men’s critiques of the triple-marker test

focused primarily on its limitations and on its basis in numbers and probabilities,

with nothing ‘‘certain’’ in its results. Gonen, for instance, said:

You come and they give you a printed form with statistics: one in 4000 that

your child can be this and one in 2000 that your child can be that, and they tell

you what the normal is. If you are slightly above the normal then start

panicking.

This tendency toward optimism was also evident in the men’s ideas about the

possible consequences of the actual discovery of a fetal anomaly. Lior noted that his

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wife tended to listen to the doctor more than he did, and to interpret statistical

results pessimistically, and was generally overcome by fear. He, on the other hand,

was skeptical about the undisputed authority of doctors and medical technology

alike, and was not sure that the choice to abort an anomalous fetus could be made

based on this knowledge:

Let’s say in the worst case scenario she [the fetus] will have an anomaly.

What, we should kill her because she has an anomaly? Still, deep inside me, I

want to believe there is no anomaly, that she’ll be okay, doctors aren’t always

correct, tests aren’t always right either. What, we won’t kill her. I don’t want

to believe that we’ll kill her.... Oshrat was afraid. She didn’t know what to do.

She was in shock, but she tended to listen to the doctor more....

Lior’s attitude toward ‘‘therapeutic’’ abortion stands out as a highly male-

gendered response to this issue within the local cultural climate. Indeed, studies of

Israeli women’s decisions following abnormal PND results show an intense matrix

of pressures on women to abort after the discovery of fetal anomalies—coming from

genetic counselors, physicians and society as a whole, which offers little economic

and institutional support for mothers of disabled children (Ivry forthcoming a;

Hashiloni-Dolev 2007; Remennick 2006; Weiss 2002). Israel’s abortion law does

not set a time limit on ‘‘therapeutic’’ pregnancy terminations and permits the

abortion of ‘‘defective’’ fetuses without specifying the kind of anomaly (Amir and

Benjamin 1997), thus making abortion a viable option in a wide range of cases. The

majority of secular Israeli Jewish women thus make the ‘‘forced choice’’ (Rothman

1993) to abort after diagnosis of fetal anomalies; it has been reported that Israelis

terminate pregnancies after the discovery of fetal anomalies at rates that are

significantly higher than those for Europeans and Americans, and at extremely late

stages of pregnancy, especially in cases following diagnosis of relatively minor

defects, such as harelip, chronic sinusitis, and deformed foot, or following unclear

results of amniocentesis (Sagi et al. 2001).

Yet like Lior, the men in our study had a significantly different attitude toward

‘‘therapeutic’’ abortion, which they expressed in commentaries that effectively

deconstructed the consequences of the Israeli PND fervor. It was common for the

men to cautiously note that the panic surrounding fetal anomalies can lead to

diagnostic mistakes. Several spoke heatedly about ‘‘people who were told to

terminate the pregnancy, went to the high abortion committee, and the committee

did not agree [to grant them an abortion] and [in the end] they bore a healthy child

[yeled takin].’’ As this type of commentary alleges, the men’s critiques of the

biomedical knowledge itself were more often than not accompanied by their

sentiments about the conduct and knowledge of biomedical practitioners as well.

Profitable Technologies, Greedy Doctors and Suspicious Patients

The men in our study developed a particular appreciation of the ob-gyns and

sonographers they encountered along the medicalized route of pregnancy. However,

this appreciation veered far from the gratefulness and near-camaraderie that

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Sandelowski (1994) has described. Instead, the men were highly critical of the

profitability of PND for doctors offering extra, expert scans in their private

practices. Their wives may have been busy searching for the most qualified expert to

perform PND, but the men were busy deconstructing the PND industry, which

consists of local specialists who offer their services at exorbitant prices. These

experts even market ‘‘package deals’’ to women of lower socioeconomic

backgrounds. These include tests not currently covered by health funds, such as

the nuchal translucency test—a scan measuring the width of the fetus’ neck at

12 weeks as an earlier indication of Down’s syndrome—as well as two second-

trimester scans around the 16th and 24th weeks, and private amniocentesis for

women who are not eligible for state-subsidized amniocentesis or are hesitant to

have a random doctor perform the test.

Israeli women who are not content with the tests financed by the state tend to

consume the private medical expertise offered by these specialists, often regardless

of their financial condition. In fact, the costs played only a minor role in the

considerations of the women interviewed by Ivry (forthcoming a,), and most of her

interviewees were willing to pay as much as the expert asked for while explaining

that it was worth paying in order to have their ‘‘peace of mind.’’ In contrast, the men

we interviewed remained acutely aware of the financial interests of prenatal

screening professionals. Omri described the dynamics of the testing ‘‘market’’

cynically: ‘‘In the world of gynecology it works like this: you send [your patients] to

your friend and your friend sends to you.’’ When their pregnant partners considered

being tested at a costly clinic, men often voiced doubts about the necessity and cost

of a private expert. In most cases they went along with it just to make their partners

feel better. Samson’s description of the ultrasound expert who fit them into his

packed schedule after midnight is a vivid example of this sensitivity to the business

skills and financial motivations of the medical expert:

He is like a money making machine. He is a professional, he is good and he is

doing a lucrative business, but it is a good business to make money in, because

99 percent are happy. Maybe only one percent is problematic.... He has the

newest equipment and he is using it as an incentive for the customers. He is

cheaper but he also offers 3D, what else can you say? Come to me.

Taking this criticism of the biomedical expert and his expertise one degree

farther, Gonen made fun of the lucrative offers couples are subject to from the PND

industry:

And we have two new tests that are not part of the health basket that you better

do. It would be worth your while to do them ... it is like a market [shuk]. We

have two new tests that are not part of the health basket but maybe you might

want to do them: it checks whether your child will have gray horns.

Among their criticisms of the PND experts, the men often commented on the

doctor’s unfriendly personality and egocentric manner or, on the contrary, the

doctor’s superficial friendliness for the purpose of soliciting recommendations and

further business. Nevertheless, even as they criticized it bitterly, all of these men

used biomedicine pragmatically. Gonen, for instance, whose mockery of the PND

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industry is quoted above, still pragmatically described his desire to remain in the

doctor’s favor:

After the ultrasound scan you sit with the doctor and he has a list of things that

can happen to your child and he marks them off with a checkmark, this is ok,

that is ok, and he gives you the information and ... mainly he is telling you

things that you don’t understand and you say to him, wait a minute, is this

normal or not?... Once in a while I inserted cynical comments, you know,

gently, because despite it all [bechol zot] I still want him to be on my side [not

against me], I want him to check well. He likes to tell jokes. His jokes do not

make me laugh, but I laugh. Actually his jokes make me nervous.... I laugh,

what can I say to him? That this is not funny? The truth is that he has good

intentions, he is aware of the stress people come to him with and he is trying to

improve the atmosphere.

Gonen’s account illuminates the simultaneously ambivalent and pragmatic

attitudes that men often develop toward biomedical practitioners and the knowledge

they offer. He laughs at the doctor’s jokes for the pragmatic purposes of winning his

favor and ensuring that he does his job properly, thus showing his acceptance of the

privileged status of biomedical knowledge. Yet at the same time he criticizes,

resents and even rejects this knowledge. Likewise, Omri, who fervently sought out

any information available to help him interpret the puzzling results of the triple-

marker test, now says retrospectively that he does not consider medical knowledge

an adequate source of information. In most cases, this dual position was expressed

by the men voicing their criticisms only after they had left the clinic. One man

explained: ‘‘I do not argue with doctors. I leave the discussions for us to have

afterwards.’’

The men’s dual attitude toward biomedical knowledge and professionals

contrasted starkly with the approach to biomedicine of their female partners.

Unlike the men’s skeptical attitude toward the financial motivations and risk-based

results that were part and parcel of the PND industry, their wives expressed their

willingness to pay as much as the doctors charge in order to keep their peace of

mind. Yet our findings show that as long as PND successfully serves this calming

function by expertly reassuring their wives of fetal health, the men continue to

straddle this pragmatic yet critical position vis-a-vis reproductive biomedicine. It is

when couples were faced with anomalous PND results and doctors who were

hesitant to take responsibility for the test results that the men displayed more

antagonistic positions, viewing PND as threatening their own feelings, their wives’

sanity and their marital partnerships.

Pregnancy as an Ordeal: False Alarms and Defensive Medicine

The aspect of the physicians’ conduct that was most upsetting and angering to the

men was their practice of ‘‘defensive medicine,’’ which often separated the

pragmatic/critical men from those who were more strongly antagonistic toward

reproductive biomedicine. The practice of defensive medicine has inflated in

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response to the growing number of lawsuits against gynecologists who are held

responsible by childbearing couples for ‘‘wrongful births’’ (Ivry forthcoming a, b;

Hashiloni-Dolev 2007). At present, a woman making an initial prenatal visit to an

ob-gyn may be presented with an integrated list of 30 or more prenatal tests, some of

which are subsidized by her health fund (under specific conditions), and others that

she can only do privately. Some ob-gyns may take the legal precaution of asking

patients to sign a declaration that they have been made aware of the existence of all

of these tests, and most ultrasound experts will have patients sign a declaration that

they are aware that the results of the scan are true to the time of scanning and that

ultrasound cannot detect all possible anomalies. Omri described the connection

between the profitable PND industry and the practice of defensive medicine as a

‘‘circle’’ within which

One test leads to another test leads to another test and the money flows. The

gynecologist recommends (the tests) because he won’t take responsibility for

these things, for these dangers in percentages, and the person will pay for the

test ... not because it gives a definite answer but because it gives a relative

answer.

With the force of defensive medicine, PND often leads to amniocentesis. This

invasive test, with a local 1-in-200 rate of pregnancy loss following it, may be

recommended after indications of fetal anomalies appear on the ultrasound or

following abnormal triple-marker test results. Maternal age and other high-risk

circumstances also lead to this recommendation. If the triple marker predicts a

probability above 1:370 of chromosomal anomaly, the woman is referred for

amniocentesis. Women over 35 years old are referred for amniocentesis regardless

of other indications. In some cases, defensive medicine leads ‘‘low-risk’’ women to

amniocentesis because doctors recommend it as a self-protective measure against a

potential ‘‘wrongful birth’’ lawsuit.

This means that many circumstances can lead to a couple’s being recommended

to undergo an amniocentesis procedure funded by the state and that an

unprecedented number of couples pass through the ordeals of decision-making

regarding this procedure and its potential outcomes. Even in our sample of

interviews, 6 of 16 couples were offered amniocentesis following some indication of

fetal anomaly. All but one couple underwent the test. In all six cases, a healthy child

was born a few months later; the five couples who were tested received negative

results, ruling out the predicted anomaly at a statistical rate of 95%. All six couples

went through an extremely turbulent period of negotiating the meaning, value and

necessity of the technologies with one another as well as with various biomedical

professionals.

A feeling of emotional turbulence colors the accounts of all six men who

underwent the ordeal of fearing that something might be wrong with the fetus.

However, only one interviewee described himself straightforwardly as anxious: the

other five depicted their pregnant partners as ‘‘hysterical’’ or ‘‘in a state of panic’’

and themselves as trying to alleviate their anxiety. This division echoes gender

stereotypes about feminine irrationality and emotionality versus masculine ratio-

nality and self-control. The only man who admitted his own anxiety, Lior, recalled

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his reaction to the urgent phone call from the lab telling his wife that the triple-test

result was ‘‘not good’’ and recommending amniocentesis:

When Oshrat called me [to tell me about the problematic results of the triple

marker] I felt that darkness fell upon me. I didn’t know what to do. I ran strait

to the internet, books, started reading what this meant. Chances for abortion

1:200. I told her we should not do the test. [She said] yes we should, we

shouldn’t, we should. I said ‘let’s give up.’ She said ‘the doctor said don’t give

up.’ After the test I didn’t let her move from the bed. It ended up just being

unnecessary stress [stam malhits].

Just like Lior, who had avoided reading about pregnancy from any of the sources

of information his wife had collected, other men also found themselves searching

for information as fervently as their wives when faced with tangible doubts about

fetal health. Samson became an expert on ultrasound equipment, Benny—an

accountant with no prior medical education—read original medical articles about

the triple-marker test and Yoni searched the Internet and approached doctors with

specific questions. These are only a few examples of the information fever that

struck the men and made them acutely involved in the emotionally tiring process of

decision-making. However, becoming more familiar with the medical knowledge

did not at all make it more acceptable to the men. Quite to the contrary, the result of

the PND ordeal for all of the men was that they became bitterly critical of the

reliability of biomedical knowledge and the motivations of its practitioners. The

majority criticized the ways in which medical practitioners communicated this

knowledge to them. Samson was upset when he accused the genetic counselors of

trying to frighten couples when they were in fact supposed to help them understand

what the results of the ‘‘suspicious’’ triple marker mean:

Interviewer: How does it work, how did they try to frighten you?

Samson: This is how it works: We recommend, but we are not responsible, if you

don’t undergo [amniocentesis] ... they would not take any responsibility, they use

all kinds of terminologies, do not explain to you precisely, I had to research the

internet to check about the triple marker, what the chances are, what are all these

statistics.... Let’s just say we had other resources to give us a critical perspective

on what they told us. And when they spoke to us, they did not speak to the point

[tachles] about the results.... They said, ‘‘With such results we recommend

undergoing amniocentesis,’’ and threw us out like this, this I call frightening.

...[As a result] she [his wife] was hysterical and I told her ‘‘We should decide.

They are doing everything to cover their asses. [Kastah—initials of kisui tahat:

covering one’s ass meaning making sure that one is not taken as responsible.]

Everyone is defending themselves from lawsuits. What do they care, they don’t

want to be sued, but we have to be smart. We have to take our fate in our hands,

to make decisions.... We cannot count on these guys.

Samson and his wife were the only couple of six who decided to resist the

medical recommendation to undergo amniocentesis. They underwent an extremely

detailed ultrasound scan by a distinguished expert to help them decide what to do

about the results of the triple marker. However, when even this expert was not

378 Cult Med Psychiatry (2008) 32:358–385

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willing to reassure them with a direct, explicit statement about the health of their

fetus, they eventually realized that the wealth of numbers, statistics and medical

indications that their consultations with medical experts had yielded were in fact

illustrations of uncertainty rather than decision-making aids. Thus, as Samson said,

they took their fate into their own hands. Like Samson, other men who became

increasingly involved in the medical monitoring of their partners’ pregnancies

because of an ‘‘alarming’’ indication might find themselves increasingly antago-

nistic and doubtful about the reliability of medical knowledge and practitioners.

They increasingly come to associate biomedicine with threats to their wife’s sanity

and to their partnership. Such men might become protective, fed up, and resentful

because of the unnecessary ordeals they have been through.

Regardless of any major decision-making ordeal, by the time the birth is

approaching most first-time expectant fathers have experienced some degree of

biomedical practices. They have also acquired a certain amount of medical

information and learned to use some biomedical terms. Finally, they have already

encountered some of the ambiguous aspects of biomedical knowledge and have

already expressed a certain degree of criticism toward reproductive medicine, the

nature of its knowledge and the motivations of its practitioners. Within this

ambivalent and often critical state of mind, the majority of men prepare for

accompanying their partners to give birth in a hospital setting.

It is beyond the scope of this article to account for Israeli men’s experiences of

the dramatic event of birth. However, we suggest that it is with men’s experiences of

pregnancy partnership in mind that men’s experiences of birth ought to be

approached. It is only after understanding men’s experiences, interpretations and

attitudes toward reproductive medicine as these develop during their partners’

pregnancies that a full understanding of their position during birth can be

comprehended. It was precisely this process we have attempted to illuminate here.

We discuss its theoretical implications below.

Skeptical Compliance and Critical Pragmatism: Toward a Typology of Men’sResponses to the Medicalization of Pregnancy

In the above, we have explored men’s experiences of the route of medicalized

pregnancy. For first-time expectant fathers, their partner’s pregnancy is often their

first major encounter with reproductive biomedicine and its myriad paradoxes,

contradictions and consequences. The first of these tensions is raised during the first

trimester of their partner’s pregnancy, when issues of intimacy, commitment and

partnership take center stage. Gradually, as the pregnancy proceeds, additional

tensions are added to the picture as PND introduces speculations about fetal

anomalies, decisions about invasive procedures and even highly emotional ordeals

to the pregnancy experience. Throughout, the role of biomedicine in creating a

standard route of medical events that Israeli couples pass through during pregnancy

emerges as that of supplier of measurement criteria and investigative apparatus.

Whereas the anthropology of reproduction scholarship has justly shown how

biomedicine serves as a mechanism of surveillance of pregnant women’s conduct

Cult Med Psychiatry (2008) 32:358–385 379

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and a tool for personifying the fetus as a visual subject and investigating the ‘‘fetal

suspect’’ for possible anomalies, our findings show that reproductive biomedicine

also plays an increasingly central role in diagnosing ‘‘good’’ partnership and ‘‘good’’

fatherhood, and provides a stage on which expectant fathers are tested in these

respective roles. The men in our study experienced biomedicine as diagnosing and

investigating them: whether they are good enough husbands who are committed to

their wives, whether they are good enough fathers who bond with the images of

their children-to-be and whether they are hip enough modern men that they

‘‘participate’’ in their wives’ pregnancies. As in the case of any testing apparatus,

some are bound to fail.

Ultimate success in this test would be to fulfill the gospel that biomedical

technologies can make it possible to bond, to grasp the ‘‘realness’’ of the fetus as a

person, to equalize the couple’s positions during pregnancy and to strengthen the

couple’s partnership and transition to parenthood. However, our findings suggest

that it was usually after they had overcome their PND ordeals and had made the

conscious choice to resist the terrifying predictions and procedures that biomedical

technologies and authorities had offered them that men and their pregnant partners

openly expressed pleasure in the possibilities of biotechnology, such as excited

responses to the fetal image produced by a 3D scan.

We suggest that in the local Israeli medicalized route of pregnancy, the relations

among the fetal image, the biomedical institution and the couple make these

possibilities of the technology a very difficult thing to achieve. Our analysis shows

that technology in many cases threatens the men: it makes them feel like defective

fathers even before their children are born because it is hard for them to ‘‘bond’’

with the electronic image of the fetus. Moreover, it makes them feel like threatened

husbands because they are forced to comply with ‘‘lending’’ their wife’s body to a

stranger who performs intimate acts on the body under the auspices of ‘‘medical

procedures.’’

Third, it makes them feel judged as bad husbands who are not committed enough

participants, and this often leads to confrontations and negative sentiments between

them and their wives instead of harmoniously bringing them together. Fourth,

instead of medical knowledge reassuring them, the local PND craze makes them

feel confused and even helpless in face of the terrifying suggestions PND holds

for their fetus. Later, it may also make them feel deceived when the whole

technological ordeal is exposed as a false alarm, and then make them suspicious,

and even highly critical, of medical professionals and the authoritative knowledge

they market. This is a far cry from biotechnology smoothing their transition to

fatherhood, as Draper (2002) might suggest, or diffusing their problems vis-a-vis

their wife’s unpredictable body and saving the situation, as Draper (2003) discusses

in the context of birth in British hospitals.

It is no wonder that the range of responses toward biomedical knowledge, the

authority of biomedical practitioners and the institution of biomedicine itself tends

far more toward the critical and cynical than the grateful, empowered and positive

sentiments that prior studies suggest. Yet to fully grasp the meaning of this range of

responses, it should be stressed that the majority of men, even the most critical and

antagonistic, continue to follow their partners to further medical monitoring

380 Cult Med Psychiatry (2008) 32:358–385

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procedures and eventually to hospital birth while typically explaining that ‘‘after all,

this is her body and it is she who is carrying.’’ At times, men might end up

participating in medical procedures despite the most explicit resistance they voice.

The medicalized route of pregnancy harbors the potential for men to experience

themselves as being pushed aside to the point of being undermined—a state in

which their own opinions and feelings carry significantly less weight compared to

their female partners’, not to mention medical authorities’. Medicalized reproduc-

tion turns out to be an important arena to study the social setting and practices of

men’s disempowerment. Specifically, the findings here also invite further research

in the area of Israeli masculinities. While the anthropological literature has long

emphasized the dominance of men in Israeli society and explored various

mechanisms through which this dominance is achieved, the experiences of men

in the arena of reproductive medicine present an opportunity to investigate male

experiences of disempowerment by women and medical authority figures. An

exploration of such experiences, we propose, will enrich our understanding of the

range of Israeli masculinities and the experiences of men that are forged vis-a-vis

these masculinities within domestic as well as medical circumstances.

At the same time, such reconsideration encourages a reappraisal of women’s

experiences. From the perspective of male partners, at several points along the

medicalized route of pregnancy, female partners come to fit neatly into widely

prescribed gender stereotypes. Nevertheless, while occupying these gendered

niches, they are depicted as exceedingly powerful agents whose emotional fervor

threatens the stability of the men’s lives. We suggest that metaphorically, from a

male perspective, women come to occupy more space during pregnancy, not only as

their bodies expand, but also as their voices become more and more dominant. Still,

the analysis also reveals that men’s responses to this threat, so closely associated

with biomedicine, is an important component of tension in the pregnancy

experiences of women. When men continue to take part in pregnancy while

constantly muttering critical comments in the background, the experience of the

‘‘shared [medicalized] pregnancy’’ can become far from romantic.

Finally, we suggest that the duality, ambivalence and inconsistency between

men’s feelings toward reproductive medicine and its practitioners and their actions

add to the growing corpus of theorizations of gendered responses to biomedicine in

reproduction, the majority of which concentrate on women’s complex negotiations

with biomedical knowledge, authority and control. In studies focusing on birth, in

particular, responses are categorized between full acceptance and holistic resistance

(Davis-Floyd 2004). Martin’s (2001, pp. 184–187) categories add five additional

positions in between, including lament, nonaction, sabotage, resistance and

rebellion. Further writings emphasize women’s strategies for maneuvering within

the biomedical system and surviving, using and overcoming its control, including

pragmatism (Lock and Kaufert 1998), postbiomedical resistance (Klassen 2001),

‘‘working the system’’ (Greil 2001) and ‘‘agency through objectification’’

(Thompson 2002; Teman 2001). Our study of men adds to this picture, with its

emphasis on criticism and loss of faith in biomedicine, while at the same time

adhering to its dictates to quite a stunning degree.

Cult Med Psychiatry (2008) 32:358–385 381

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It is understandable that men find biomedicine difficult to actively resist because

it acts on their partners’ bodies (and not their own) with the latter’s informed

consent. However, we propose that if biomedical rites would not have been so

closely associated with the performance of responsible expectant fatherhood, men

might have found it more feasible to resist. Within such a complex nexus of social

and emotional constraints, we suggest that ‘‘ambivalent compliance’’ and ‘‘critical

pragmatism’’ best encompass Israeli men’s attitudes. They may become compliant

users of the technologies while feeling ambivalence and skepticism; they might feel

strongly opposed to medicalization and criticize its privileged access to their

partner’s body as well as to her mind, yet pragmatically accompany their partners to

further scrutiny while avoiding confrontations with doctors so that the latter do their

job properly. These responses, we believe, can be used more as ‘‘a diagnostics of

power’’—to follow Abu-Lughod’s (1990, p. 42) suggestion—informing us about the

registers of biomedical power within which these men are enmeshed, rather than as

a testimony about their own ability to stand up and fight the system.

Whether and how the stances men arrive at vis-a-vis biomedicine during

gestation apply to their experiences of later pregnancies or of the birth event itself is

a topic that deserves further research and analysis.

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