JOURNAL ISSUE 4
2001/2002

table of contents | abstracts

Involuntary Childlessness in Israel: The Need to Cope with Discriminating Family Policies

Zmira Laufer, Ph.D.
Ron Laufer, M.D., M.P.H.

 



ABSTRACT

Involuntary childlessness is a social problem shared by different societies and cultures. The twentieth century has witnessed advanced fertility treatments being added to more traditional solutions such as foster care and adoption. In Israel, childless people are presented with a variety of welfare and medical solutions, which are offered under an inconsistent social policy. This policy, which reflects the complex social and professional environment in Israel, engenders various professional dilemmas among different disciplines, including the social work profession.
Among the issues that the social work community must address are the built-in inequalities in policies intended to provide assistance to childless people and securing the best interest of children. These biases point to new directions for professional intervention not just on the previously studied clinical level but more importantly, on the macro policy level.

INTRODUCTION

One of the most complex struggles which can be seen recurring throughout human history is the pursuit of couples and singles to achieve the status and fulfill the role of a parent. This struggle has been propelled primarily by two basic motivational forces: first, existential physical needs, as parenthood guarantees a "next generation" that can supply for individuals the food and protection they need in their old age. Second, the individual's emotional need to belong to society through parenthood, which means belonging to the normative club of parents and preventing the need to cope with the stigma of being childless (Miall, 1989), or through motherhood in a social environment in which social norms dictate that women are fulfilled only by motherhood (Shalev, 1989a; Blyth, 1993; Yishai, 1998).

It is no wonder that this very important human struggle has been documented in every era. Among the oldest and most well-known experiences of coping with the inability to become a parent is in the Biblical story of Abram, Sarai and Hagar: "Now Sarai Abram's wife bore him no children; and she has a handmaid, an Egyptian, whose name was Hagar. And Sarai said unto Abram: 'Behold now, the Lord hath restrained me from bearing; go in, I pray thee, unto my handmaid; it may that I shall be builded up through her.' And Abram hearkened to the voice of Sarai. And Sarai Abram's wife took Hagar the Egyptian, her handmaid, after Abram had dwelt ten years in the land of Canaan, and gave her to Abram her husband to be his wife" (Genesis 16:1-3). Even today, certain cases of childlessness have received international attention, especially those involving surrogate mothers as in the stories of "Baby Cotton" in England (1) (Cotton and Winn, 1985) and "Baby M" (2) in the US.

At the close of the twentieth century, the world of childless people has become more and more complex in the presence of rapid social and medical developments which have provoked a series of ethical, professional, theological, philosophical, judicial and economic dilemmas. Because of its complexity, the issue is still very much in the public eye and has awakened the need for more activism among the relevant disciplines.

The first part of the paper is a short overview designed to clarify the essence of the problem on involuntary childlessness (IC) and provide an acquaintance with the available social and medical solutions to the problem. Next, we present the current social policy regarding IC in Israel, which raises a range of dilemmas among different disciplines. The discussion focuses on the unique status and commitment of the social work profession in relation to this social problem and in particular, to aspects of intervention on the macro level.

 

INVOLUNTARY CHILDLESSNESS IN AN ERA OF CHANGE

Involuntary childlessness (IC) may be defined as a situation in which individuals or couples desire to become parents and have difficulties realizing it.

This definition emphasizes two basic elements of this paper's ideational perception. First, the problem affects couples and single persons alike, and second, couples and singles may be perceived as involuntarily childless only if they desire to change the situation.

Present policies on IC are the outcome of two major processes of change that took place in the second half of the twentieth century. The first process, of a social nature, is characterized by a sharp decrease in the number of children available for both foster care and adoption - two traditional, acceptable and common ways for dealing with childlessness. Today, statistics show a continued increase in the number of couples registered at adoption agencies as well as in the number of years these people must wait (Miall, 1989; Jaffe, 1995). This significant decrease can be seen to be the result of:

  1. the development of effective means of birth control (e.g., the pill) and their widespread use;
  2. liberalization of abortion laws to allow more women to decide for themselves or with the assistance of health and welfare practitioners to stop unwanted pregnancies; and
  3. the creation of openness and support for nontraditional parental patterns such as unmarried single mothers, or single-sex parents. It should be noted that the latter development may act in two directions. On the one hand, it may reduce the number of children available for adoption since women will be raising their children by themselves rather than giving them up for adoption. Yet on the other hand, same-sex couples may put pressure on the available children by demanding the right to adopt a child themselves, since they may also suffer from the general population's infertility problems or because the couple's gender makes procreation an impossibility.

The second process of change, scientific by nature, has to do with the treatment of infertility problems. The medical options offered to infertile persons are the result of significant scientific progress, both in the understanding of different pathologies that may cause infertility and in the diagnostic and therapeutic techniques for these pathologies.

The scope of possible therapies offered to men and women range from hormonal medication up to assisted reproductive techniques (ART). The most well-known ART is "in vitro" fertilization (IVF) in which the oocyte is fertilized by sperm in the lab and is then implanted back in the woman's body.

The new medical technologies available today enable doctors to expend greater efforts in order to help specific people express their potential to give birth, by either manipulating sperm or ovum. These abilities also permit other people to participate in the birth process, by donating sperm, ovum or even a womb, if surrogate motherhood is needed.

At present, the possible solutions for IC can be divided into three groups: non-biological, biological which do not require an additional partner and biological which do require an additional partner (Table 1).

Table 1: Solutions for childless couples and individuals (3)

  1. Non-biological options
    1. Short-term foster care
    2. Long-term foster care
    3. Open adoption
    4. Confidential adoption
  2. Biological options
    1. Hormone therapy requiring another party
    2. Assisted fertilization
  3. Biological options - requiring another party
    1. Sperm donation
    2. Ovum donation
    3. Sperm and ovum donation
    4. Ovum donation and surrogacy
    5. Sperm donation and surrogacy
    6. Sperm and ovum donation and surrogacy

It can be argued that in purchasing a pregnancy, sperm and ovum are essentially identical to the biological process that occurs in adoption except for the fact that this is a type of "reservation ahead of time" of the child to be adopted. However, due to the lack of data about the frequency of people opting for this solution, and since massive biological interventions are required, this solution was included in the group of biological options.

 

INVOLUNTARY CHILDLESSNESS IN ISRAEL

Israel is a state with two prominent social features. First, it is a society of immigrants, having absorbed massive waves of immigration of different cultural groups from developed and developing countries. Second, modernity and tradition co-exist in Israel. On the one hand, Israel is an industrialized, urbanized country, yet on the other hand, religious and traditional values play a central role in it (Shalev, 1989b; Kurazim, 1997).

Today, the pluralistic and diverse Israeli population has before it a wide range of social and medical alternatives and the complexity of the Israeli society have transformed the country into a living laboratory for all these alternatives.

 

INVOLUNTARY CHILDLESSNESS AS A SOCIAL PROBLEM IN ISRAEL

A sociological definition states that a social problem is "an alleged situation that is incompatible with the values of a significant number of people who agree that action is needed to alter the situation" Rubington and Weinberg, 1989, p.4). Examining the problem of IC in Israeli society shows that all four characteristics exist and hence we can speak of this issue as a social problem.

a.) An alleged situation - It seems that the problem of IC is unable to disappear from the public agenda in Israel. In the mass media (newspapers, television, cinema and radio), the problem has been widely reviewed. The combination of family issues, ethical dilemmas and biotechnology, together with dramatic personal stories make the topic an "all-time favorite."

The problem also continues to be a "burning topic" on professional levels. The medical developments, which occur with such high frequency, engender situations requiring extended efforts to resolve contradictions between these developments and ethical codes. These efforts can be seen by the quantity of publications in professional journals relating to different aspects of childlessness.

b.) Incompatibility with the values - Different sociological studies have established that Israel is characterized by being a "family society" in which children are highly valued, not only by their families but also by the community, and which the children's welfare considered to be the responsibility of society as a whole (Peres-Katz, 1981, 1990; Shamgar-Handelman, 1986, 1990).

The last Declaration of Intentions published by the Ministry of Labor and Social Affaires (LASA) complements these findings. The Ministry's declaration, which is characteristic of social positions that have appeared consistently since the 1920s, states that "the Ministry of LASA believes that a strong and modern society is obligated not only on a moral level to protect, nurture and strengthen its child population. A strong society perceives its children as its most important resource and places the area of children in a central place on its national priority list" (Korazim, 1997, p. 12).

This background explains why childlessness in Israeli society is considered incompatible with its values.

c.) The scope of childlessness - The problem of childlessness in Israel, as in other Western countries, has become in the last few decades the concern of a large section of the population.
As has been found in surveys conducted throughout the world, about 15 percent of the population that is of fertile age suffers from fertility problems (Zigler, 1998). It has been estimated that in the U.S. alone, every sixth couple encounters difficulties in reproducing (Greenfield, 1997).

In Israel there is available data only on married women. 19 percent reported difficulties in becoming pregnant and one percent reported an inability to conceive even after fertility treatments. It can be assumed that similar figures apply to unmarried women.

d.) A need for an organized intervention by society - The existence of a demand for change in a situation is the fourth condition for a social problem. As Rubington and Weinberg (1989) explain, the actual absence of the public's satisfaction with a certain situation does not transform a situation into a social problem. Only a clear demand to find a solution indicates a social problem.

The call for change in Israel comes from three directions at the same time. First, there are the childless people who demand help. Second, there is the general population, which is publicly pressing for "something to be done." The third source of pressure comes from the professional disciplines dealing with different aspects of the situation that are petitioning for changes that would resolve their professional dilemmas. Their dilemmas arise from having to resolve complex issues such as the rights of the embryo as a patient, the ownership of sperm or ovum which belonged to people who died or couples that separated, the ethics of removing fetuses (embryo reduction) in a multi-fetal pregnancy (Vilichek, 1987; Shamgar, 1989; Shenkar, 1990; Daor, 1993; Davis, 1995).

 

AVAILABLE SOLUTIONS FOR CHILDLESS PEOPLE IN ISRAEL

A. Non-Biological Options
Short and Long-Term Foster Care
Foster care is a monopoly, held by the Ministry of LASA, executed only by social workers. It is implemented selectively both among childless couples and among couples and singles who already have children. All candidates go through a process of recruitment and training. The selection of candidates focuses on parental skills and the ability to cope with a diversity of biological parents. The economic, education and health status requirements for foster parenthood are lower than those demanded from people who are interested to adopt a child confidentially.

In a retrospective survey of 4,500 former foster care children, it was found that 50 percent of them continued in foster or residential care until they were adopted by either their foster parents or by other families (Segev, 1997).

At the moment there are about 1,600 foster families in Israel caring for approximately 3,600 children. The procedures for operating this system are based on regulations established by the Ministry of LASA, and in addition to some of the laws regarding placement in residential care. At present the Knesset (Israeli parliament) has before it for first reading a Foster Family Law which that will determine the legal framework of the issue (Laufer, 1997).

The average cost of keeping a child in foster care is NIS 3,550 per month (about $905 US). Special expenses such as psychological care, participation in enrichment programs, etc. are paid for separately. The Ministry of Labor and Welfare generally bears the expense of raising foster children (in rare instances birth parents also contribute).

Confidential Adoption
a.) Intracountry adoption - In this option, children are given selectively according to the principle of the child's best interest. Potential parents must go through a strict recruitment process in which they are required to prove an above average economic, educational and health status as well as the ability to be parents. This policy takes advantage of the fact that demand exceeds supply. As fewer children are available for adoption, the standards of prospective parents become higher.

The process of adoption has its own specific law and its procedure is fixed in defined regulations (Law of Adoption of Children 1981). This law gives the Ministry of LASA the monopoly for all adoptions of Israeli children.

According to the latest data, 893 children were adopted between 1992 and 1995. This group of children included 362 infants, 513 children defined as having special needs and 18 children with Downs' syndrome (Ben-Asher & Zionism, 1996).

According to informal estimates, the Ministry of LASA has today a waiting list of 1,500 couples. The average waiting period for a couple is approximately six years. Due to this long waiting period, it happens that couples who are approved for adoption are later disqualified and taken off the list because they are over the age limit for adoption (Jaffe, 1994).

There is no available data regarding the cost of the adoption process, not of the cost of caring for children until they are adopted. All these costs were covered by the Ministry of LASA.

b.) Intercountry adoption - Up until 1997, and Israeli citizen with the necessary financial means could acquire a child for adoption outside of the state. This situation created religious and legal problems. It was a threat to the principle of "the child's best interest" and to the Israeli society's ability to take responsibility for the welfare of these children. As a result, the Law of Adoption (Law of Adoption, Amendment) was amended to state that intercounty adoption can take place only through a nonprofit association or through the designated service in the Ministry of LASA. Only candidates who were assessed and approved by the association as being able to fulfill a parental role may adopt a child.

Unfortunately, the current situation is that people who want to adopt are caught in a trap. One on side, they cannot carry out independent adoption arrangements. On the other side, there is as yet no nonprofit association that has been authorized to provide adoption services, and the Ministry of Labor and Welfare does not provide adoption services at the moment. In practice, couples and individuals continue to adopt children from abroad, thereby becoming lawbreakers.
Official data regarding the extent of intercountry adoption is unavailable, as is information about its costs.

Open Adoption
This alternative is relatively new in Israel. There are no figures regarding its extent or its cost. The legal basis for this adoption, at the moment, is the existing Law of Adoption. The unique judicial aspects of this option have not as yet been addressed.

B.) Biological Options
Medical treatment is given in the framework of the National Health Insurance Law which guarantees every citizen a basic "health package," and for which every paycheck is taxed. The actual services are given by any of the four sick funds, which also provide a complementary health package paid for privately and separately by their clients. The Israeli Ministry of Health supervises the medical services that are provided to the public, but also provides services itself as a subcontractor for the sick funds through a net of government hospitals and clinics.

Many medical centers maintain fertility units and of these, 22 units provide IVF treatments. The ratio of IVF units per population is about four times that of the UK or the US, and the ratio of treatment cycles which they provide is about four times that of the UK and about ten times that of the US (Seidman & Lotan, 1998). These treatments, which began in Israel in 1982, are responsible today for about two percent of all the births in Israel.

Most of the treatments for childless people are covered by the National Health Insurance. Fertility treatments are given, up to two births, for couples or single women who do not have children of their own. An attending doctor who has suspicions about the ability of the prospective parents to raise children, whether due to psychiatric disturbances or mental retardation, is entitled to ask for a social worker's evaluation prior to beginning treatment at one medical center is able to apply at another one which may give the treatment and not ask for such an evaluation.

Medical insurance covers up to six therapy cycles. Additional attempts are given in accordance to the different rules of each sick fund, with the client having to cover some of the costs herself. The cost of fertility therapy varies greatly from case to case and may range from less than $1,500 to over $13,000 (in US dollars).

C.) Biological Options Requiring Another Party
Donation of Sperm and/or Ovum
Donations of sperm and ovum are regulated through laws and regulations which determine who is allowed to be a donor, how many times a donor may donate (for example, a man is allowed to donate sperm up to three times) and who may receive a donation.

The regulations do not mandate central registration of donors and recipients. This is in order to prevent the stigmatization of people involved, taking advantage of the low probable risk for future marriage between siblings (Shalev, 1996; Korinaldi, 1996). At present, there is no data about the extent of the use of sperm and ovum donations.

Surrogacy
Fertility treatments involving a surrogate mother are new in Israel and a special procedure has been developed for them under the "Law of Agreements for Carrying Fetuses." The Israeli Ministry of Health established a committee designed to specifically supervise this procedure and authorize each case. In order to be eligible to be helped by a surrogate mother, the woman must prove that she is medically incapable of becoming pregnant or maintaining a pregnancy.

The National Health Insurance covers the costs of medical treatments involved in the procedure, as if the surrogate mother were a patient requiring IVF treatments, through the surrogate mother's sick fund. The expenses that are not covered by the insurance are covered by the prospective parents. These would be the treatments involved in an ovum donation (if the prospective mother is unable to supply one), medical and psychological evaluations of the prospective parents required by the supervising committee and psychological counseling for the surrogate mother which is required by law.

A monetary agreement between the expected parents and the surrogate mother is allowed by law, but the committee has to approve the agreement, making sure that the payments are reasonable and that the rights and needs of the surrogate mother are not compromised.
The new procedure of surrogacy can still be considered experimental and will most likely change in the future. Up until today, two cases of surrogate pregnancies have been successfully concluded. It must be noted that each of the two pregnancies received an unprecedented amount of media attention, and the first one even reached the courts when the surrogate mother claimed that her rights had been infringed upon.

 

INEQUALITIES AND DISCRIMINATION IN THE POLICIES RELATED TO INVOLUNTARY CHILDLESSNESS

Analysis of the policies described previously clearly points out a consistent priority given to certain population groups and specific solutions for childless people. This preference is most prominent when it comes to financial coverage and criteria definition.

 

INEQUALITIES IN FINANCIAL COVERAGE

Analysis of the welfare policy reveals an inequality in resource allocation for the different types of adoption. Full funding is provided for the adoption of Israeli children, while none is given for intercountry adoptions. Bearing in mind that the requirements from candidates for intracountry adoption include an above average economic status, both adoption options discriminate. People of lesser economic status who are interested in adopting a child, although not proven to be less suited for parenthood, are at a major disadvantage.

The existing medical policy also creates inequalities in resource allocation. Sperm and ovum donations are not covered, even though their actual costs may be less expensive than some of the sophisticated fertility treatments that are fully covered by the national health insurance. Furthermore, in the case of surrogacy and health care coverage, the state released itself from any financial obligation beyond IVF procedure (Shifman, 1991).

 

INEQUALITIES IN SELECTION CRITERIA

Analysis of the current policies reveals inequalities between different population groups through the practiced criteria for parenthood. Such inequality is the result of using familial status for selecting parents for confidential adoption. For example, single mothers are at a disadvantage when compared to couples with the same economic, educational and health characteristics. These women are generally offered children with special needs and not infants, who are in much greater demand (Jaffe, 1994). Single-sex couples or homosexual singles may find themselves at an even greater disadvantage, though such cases are still too few for a verifiable statement to be made.

Another inequality has to do with screening for parental abilities. Medical treatments are given to anyone who demands them. The responsibility for testing the parental ability of the candidates for treatment falls on the attending doctor. In other words, the responsibility is in the hands of personnel whose specialty is fertilization and not parenting. Furthermore, in past cases in which fertility treatments were provided for people whose inability to be parents was patently obvious, the doctors involved were not taken before a board of ethics or any other public body for having gone ahead with the fertilization. In contrast, in nonmedical solutions as well as in surrogacy, prospective parents must, by law, prove their ability to be parents (Law of Adoption, Foster Care Regulation and the Law for Carrying Fetuses).

 

DISCUSSION

An attempt to examine the issue of IC in Israel from a general perspective reveals a noncomprehensive policy, both on the theoretical and practical levels.

Professional debates that have not been resolved yet include issues such as the right for parenthood. Should Israeli society assist any couple or single to become a parent, not just by providing a legal right, but by committing adequate funds for this purpose (Korinaldi, 1996)? Another such issue has to do with the state's right to intervene in the process of becoming a parent. Does a financial investment give the state the right to impose public norms and perceptions on prospective parents (Shifman, 1991)? An additional issue involves the possible use of the Law of Adoption of Children, with its developed legal principles, for other solutions to childlessness.

On the practical level, IC is a social problem that is being addressed by two very different medical establishments. This difference between the medical and social work establishments can explain a large part of the inequalities and discriminations that were described previously. Each establishment has a different approach for intervention. While the focus of the medical approach is the infertile patient, the focus of the social work establishment is the child who needs adequate parenting. The result of these opposing approaches can explain the inconsistent criteria for candidacy for different parenthood options.

The reality in which government ministries provide the funds for different parenthood options can explain the existing economic inequalities. However, the problem of unequal budgeting has to do with more than just the simple fact that the two ministries have different resources. An important factor is the different public image and appeal that the options have. The medical options are perceived to be doctors who give children to childless people while using exciting innovative technology (in spite of the low success rate of 11 percent). The nonmedical options are perceived to be social workers who take children away from their biological families and place them in old-fashioned arrangements.

In view of the current situation in Israel, the social work profession has a commitment to take a public stand on the issue of IC, followed by active intervention on the macro level. This professional commitment is based on two elements. The first one is inalienably part of the code of ethics upon which the profession rests, which demands that it work for the reduction of cases of discrimination (Association of Social Workers, 1994). The second is the monopoly that the profession has on dispensing nonbiological solutions to the problem of IC and on the social aspects of biological treatments.

It appears that there are two directions for action in which social workers must take the initiative. One direction would be to focus more attention on childless people in the framework of nonmedical options, not as a means of helping children, but as a way to answer clients seeking help. This can be done by initiating and encouraging the establishment of pressure groups of clients and a social lobby to demand equal assistance for people choosing or needing the solution of intercountry adoption. It should be mentioned that today social workers in the public adoption service are the ones implementing the discriminatory policy, and so have the highest accessibility to the discriminated segment of the applicant population.

The other direction for action would be to implement the biological options under the principle of "the best interest of the child." This can be achieved by creating pressure groups and a social lobby that would help settle the differences between the policies guiding the adoption services and fertility units. As social workers are committed to the welfare of children at risk due to parental dysfunction, intervention at the fertility clinic level should be an important preventative goal.

It can be summarized that the social work profession has a unique obligation to the problem of childlessness. The social mandate given to the profession, as well as its ability to respond rapidly to social change requires social work practitioners, educators, researchers and policy makers to form the professional leadership that would mediate the changing medical and social reality and those seeking to become parents.


FOOTNOTES


1.) The first publicized case in England in which a surrogate contract was drawn up and signed. In this case, Ms. Cotton, the surrogate mother, was paid in installments by the childless couple. In addition, she also received £20,000 by an English newspaper for the sole rights to publish her story. Public argument centered on the degree of fairness shown by the courts to the surrogate mother when they had the baby turned over to the prospective couple immediately after birth and thereafter allowed them to leave the country.

2.) In this case, a childless couple, S., contracted with a surrogate mother through the services of an agency. Everything was fine up to right after the birth. At this point the surrogate mother declared that she regretted her previous decision and decided that she was not prepared to give up the baby to the couple. The matter reached the courts.

3.) It should be emphasized that the scope of this paper is limited to involuntary childlessness. However, these options may also serve people who are fertile: women who desire to become mothers but are not willing to go through a pregnancy, men who ask to freeze their own sperm before starting a job that may jeopardize their fertility, etc.

 

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