Patriarchal pronatalism: Islam, secularism and the conjugal confines of Turkey’s IVF boom

Abstract

This article constructs an explanatory history of the introduction, growth and social regulation of IVF in Turkey, labelling it a form of ‘patriarchal pronatalism’. Based on sociological research between 2006 and 2010, including analysis of regulatory and media materials as well as an in-depth clinical ethnography and interviews with IVF patients and practitioners, the paper contextualizes Turkey’s ‘IVF boom’ within the wider and governmental contexts of reproductive politics. Examining both the legal framework and the surrounding rhetoric, it highlights how the nationally pertinent tensions between Islam and secularism unfold in this particular field, and traces how the rise of neo-conservatism and the expansion of the role of religious organizations and discourses has led to the promotion and development of assisted reproduction, but only within strictly enforced conjugal confines. This work contributes not only to the significant sociological and anthropological scholarship on the globalization, localization and repro-national character of assisted reproductive technologies around the world, but also to the growing scholarship examining the contours of reproductive citizenship, gender relations and family formation in contemporary Turkey.

Introduction

Turkey’s first tüp bebek (literally ‘tube baby’), Ece Çokar, was born on 18 April 1989, 11 years after the birth of Louise Brown heralded the dawn of a new era in assisted reproduction. Following the creation of a pre-emptive legal structure by the Ministry of Health – and the Germany-based training of Turkish doctors entrusted with importing the latest medical technologies back to Turkey – her parents were one of 10 couples recruited to undergo IVF treatment at Izmir’s Ege University Hospital. Despite early successes, however, the development of IVF in Turkey was slow and tentative. In the late 1990s, a review of assisted reproduction practice across Europe (Schenker, 1997) showed Turkey to be one of the countries with fewest fertility clinics per capita, ahead only of Poland, Russia and Ukraine. Yet, a decade later, the situation had completely changed. By 2008, the national press was celebrating Turkey as ‘the world’s seventh biggest IVF market’ (behind Israel, France, Spain, England, the USA and Germany), and reflexively referring to the country as a ‘tüp bebek paradise’. Indeed, today, having gripped medical ambitions and the public imagination, tüp bebek is a large and lucrative industry dedicated to the art of making babies (Gürtin, 2013). As one of the most rapidly growing IVF markets in the developing world (Urman and Yakin, 2010), assisted reproduction in Turkey has not only changed the lives of countless involuntarily childless couples, but also impacted local notions about reproduction, infertility and modernity (Aciksoz, 2015, Demircioğlu Göknar, 2015, Gürtin, 2014).

Based on sociological research in Turkey between 2006 and 2010, including analysis of regulatory and media materials, in-depth clinical ethnography, and interviews with IVF patients and practitioners, this article constructs an explanatory history of the introduction, growth and social regulation of IVF in Turkey. Examining both the legal framework and the rhetorical debates surrounding IVF, I highlight how the nationally pertinent tensions between Islam and secularism unfold in this particular context. I also explore the role of the Justice and Development Party (AKP) government, with its neo-conservative and pronatalist agenda, and the growing influence of the Ministry of Religious Affairs to explain both the boom of the Turkish IVF industry on the one hand, and the construction of firm access restrictions on the other. I label the particular ‘repro-national’ character that emerges in this hybrid state, with its precarious relations between secular principles and Sunni morality, a form of ‘patriarchal pronatalism’ promoting and funding IVF but only within strict ‘conjugal confines’, justified with reference not only to religious but also to moral, social and scientific rhetoric.

The growth of IVF

After almost 15 years of slow growth, Turkey’s ‘tüp bebek sector’ experienced a marked and accelerated development in a very short period. The introduction of state and social security funding for IVF treatment in February 2005 not only widened access but also provided an unparallelled opportunity for the expansion of the assisted reproduction industry. Clinic numbers rose dramatically from 66 (20 state, 46 private) in 2005 to 91 (19 state, 72 private) in 2007, with private clinics opening in nine additional cities, extending coverage to 22 of Turkey’s 81 cities (Ministry of Health figures, http://www.saglik.gov.tr). Even more markedly, the number of annual treatment cycles doubled from approximately 20,000 to 40,000 (Turkish Society of Reproductive Medicine, https://www.tsrm.org.tr), amassing a total turnover in excess of 300 million euros. Moreover, in 2008, Professor Bülent Tıraş, then president of the Turkish Society for Obstetrics and Gynecology (TSOG), estimated that, in order to properly meet demand, the sector would need to perform 150,000 IVF cycles per year (Aktüel, 07.04.2008), while some newspaper reports claimed as many as ‘2 million women waiting for tüp bebek’ (Radikal, 13.08.2007) across the nation. Although in more recent years, clinic numbers have continued to rise, reaching 120 centres in 2014 (located variously in private clinics, private hospitals and state institutions), growth has become much slower as various legislations have made it more difficult for doctors to open their own private practices. Hence, my fieldwork, conducted between April 2006 and December 2009, coincided perfectly with the extraordinary ‘boom’ period of the Turkish IVF industry enabling me to witness both the opportunities (particularly in terms of access) and challenges engendered by such rapid growth of the industry.

Today, there are approximately 120 IVF clinics operating in Turkey. Although many are concentrated in the large urban centres of Istanbul, Ankara and Izmir, clinics have also opened in the farthest corners of the country. The locally welcomed establishment and successful operation of IVF clinics in what are often considered traditional and conservative areas of the country are a testament to the widespread acceptability and desirability of high-tech fertility treatments as IVF becomes ‘normalized’ (Thompson, 2005) in Turkey as it has been elsewhere (Demircioğlu Göknar, 2015). Moreover, the spread of assisted reproductive technologies is often interpreted by practitioners and the popular media as an indication of progressing social mores and national scientific advancement, with newspaper reports representing infertility as ‘a battle that must be fought until the end’ (Görgülü, 2007), with IVF designated as the modern weapon of choice.

Islam and secularism

In 1923, Turkey became the first secular democratic nation with a predominantly Muslim population, a fact that has arguably been more influential on the national character than any other (for discussions see Bozdoğan and Kasaba, 1997, Kandiyoti and Saktanber, 2002). It is still the case that the most interesting and heated public debates in contemporary Turkey concern and question the rhetorical and actual mobilization of secularism and Islamism as the basis for binary identities and identifications in both public and private imaginaries. Such processes of dialogical identity formation, in relation and reference to an ‘othered’ opposite, on the part of both Islamists and secularists, have been recently noted, described and analysed by anthropologists Ayşe Saktanber (2002), Esra Özyürek (2006), Yael Navaro-Yashin (2002) and Jenny White (2002), as part of their ethnographic enquiries. Despite White’s pertinent description of a continuum of identities, however, over the past decade, polarized thinking and oppositional self-definitions have increased among Turks who identify as ‘secular’ (laik) or ‘Muslim’ (Müslüman), amounting to what some have called a ‘conflict between two Turkeys’ (Yavuz, 2009: 144).

The AKP, which entered its third term with a strong majority in 2011, has been variously referred to in both the national and international press as ‘fundamentalist’, ‘Islamist’ and a ‘party with Islamic roots’. Although they define themselves as ‘conservative democratic’ and deny an Islamic agenda, critics, such as political scientist Hakan Yavuz, 2006, Yavuz, 2009, accuse the party of a ‘politics of camouflage’, claiming that, although ‘the AKP never uses the explicit language of political Islam, and indeed often feels compelled to stress that it is not an Islamic party’, its ‘repressed identity occasionally re-emerges’ (2009: 3). Acar and Altunok add that even when the political rhetoric of the government is not explicitly religious, its ‘messages are often traceable to Islamic stances of its leaders’ and are aimed at ‘the selective stigmatization of practices that religion denounces’ (2013: 14–15). Indeed, regardless of one’s view of the AKP, the current political atmosphere in Turkey is both indicative and constitutive of important social and religious change. For example, the AKP has transformed the Presidency of Religious Affairs (Diyanet) into a central agency with an annual budget of $1.6 billion – more than the combined budgets of Turkey’s European Union, Foreign, Energy and Environment ministries. And, according to an article by Daniel Steinvorth (2012) in der Spiegel, there is now one mosque for every 350 people in Turkey, in contrast to one hospital for every 60,000. The conservatism of the government has also impacted gender relations and the role of women in particular ways, reigniting existing debates about women, modernity and Islam in Turkish society (e.g. Acar, 1995, Arat, 1997, Kandiyoti, 1997, Tekeli, 1995). Indeed, there are many indications that the social opportunities available to women have receded and that women’s rights have been regressing over the past decade, as the AKP has sought to advance a traditionalist and neo-conservative family values agenda through gendered governmental logics. Reviewing ‘the politics of the intimate’ in Turkey, Acar and Altunok (2013: 14) explain that the interaction between the two political rationalities of neo-liberalism and neo-conservatism have come to play important roles in the shaping or regulation of private and public domains in the last decade, and argue that, ‘given the intermesh of [these] rationalities, the notion of gender equality loses its significance, leaving disadvantaged groups open to the detrimental effects of power relations’.

‘No home will be left childless!’

As Steinvorth (2012) notes, ‘[t]here is no doubt that the Turkish premier is a deeply conservative man. His view of women is traditional and his notions about family policy are patriarchal’. Particularly since 2007, patriarchal and moral notions, often framed by religion, have become increasingly dominant in AKP rhetoric (Acar and Altunok, 2013). The party’s brand of neo-conservatism is, as Yavuz convincingly demonstrates, a ‘social attitude rather than a political one [...] filtered through tradition (read Islam)’, with ‘the first critical element [...] its stress on the family as an institution and on a particular set of values surrounding the family’ (2009: 94). The emphasis on this ‘first critical element’ is loud and clear in a speech made by President Erdoğan on 8 December 2008:

If our family institution is strong, then we are strong as a nation. If the institution of the family is eroding, then also as a nation we are facing collapse. Because of this I insist upon the family! […] For it will aid in solving many of our problems if the family structure is strong. (Author’s translation; see the news agency website http://www.netbarcilik.com for the full Turkish text of this speech)

The AKP’s neo-conservative and pronatal family focus is striking, not only because of its overt nature, but also because it represents a distinct shift in the political position on population policy and family planning, ‘[abandoning] the state’s decades-long anti-natalist population policies in favour of a pro-natalist approach to population’ (Aciksoz, 2015). This shift is also evidenced in the government’s provision of financial incentives for early marriage and childbearing, anti-abortion rhetoric, and negativity towards Caesarian section delivery (on the questionable grounds that it limits the number of healthy pregnancies a woman can carry) (Acar and Altunok, 2013, Aciksoz, 2015, Shafak, 2012). Speaking during celebrations to mark International Women’s Day on 8 March 2008 in Uşak (an Aegean city), Erdoğan delivered what has subsequently been coined his ‘three children for everyone’ speech:

The West is now crying. Do not fall into the same traps! If it continues like this, by 2030, most of Turkey’s population will be over 60. My dear sisters, I am not speaking as a Prime Minister, I am speaking as your troubled brother. Please do not fall into this trap. We must protect our young population. […] If you do not want your population to decline, then each family should have three children. […] I speak from experience: a child is a blessing, you should know this. I have four children, I am happy, I wish I had more. Each came with their own blessings. (Author’s translation; original Turkish and news item available at: https://ntvmsnbc.com/news/438418asp)

This message was not only based on unfounded fears, according to demographic projections from the Turkish Statistical Institute, but it also immediately drew strong reactions from national women’s groups, feminists and female Members of Parliament from opposition parties as inappropriate and backwardly patriarchal (as reported, for example, in Vatan, 09.03.2008). The statement was seen as indicative of the AKP’s views on women’s role in society, and reflective of its attitudes on family life and reproduction, clearly demonstrating the government’s strong pro-natalist attitudes and its commitment to pursue a neo-conservative family values agenda through intervention in reproductive rights and policies. In light of this, it is perhaps not surprising that the AKP has been a strong supporter of extending access to assisted reproduction, as long as it is used exclusively within strict heteronormative parameters, to aid only the creation of traditional families in which a married mother and father conceive and nurture their genetically related offspring (Gürtin, 2011, Gürtin, 2012a, Gürtin, 2012b). It is these parameters, not only reliant on the marital form and contract, but also containing strong implications of exclusivity, boundedness, and both moral and sexual piety, that I label as the ‘conjugal confines’ which define the character of Turkish IVF. Moreover, they are clearly part and parcel of a broader agenda of patriarchal pronatalism, not only with regard to how families are created and what kinds of reproduction are sanctioned, but also with regard to women’s role in society, which according to such priorities is fundamentally equated with mothering.

Indeed, it was the AKP government that introduced funding for IVF through all three social security institutions (the SSK, The Retirement Fund and Bağ-kur, covering different types of workers) in its 2005 Budget Implementation Directive (Official Gazette no. 25722, 09.02.2005; item 10.3 is titled ‘Tüp Bebek’, and provides details of the funding protocol and outlines eligibility criteria), streamlining and broadening coverage further with the 2008 Annual Social Security Health Application Statute (Official Gazette no. 27012, 29.10.2008). These decisions proved extremely popular in Turkey and were celebrated by much of the media as humanist and progressive government acts indicative of medico-scientific modernity, with headlines such as ‘Tüp bebek boost from social security! Everyone should be a mum or dad – All hopes have sprouted as tüp bebek is reclassified as a compulsory health expenditure’ (Günaydın, 17.04.2006). Moreover, the recategorization of IVF treatment as ‘therapeutic’ and ‘compulsory’, rather than an ‘elective’ health intervention or expenditure, was not only of great practical significance (in extending access), but also reflective of a shift in attitudes, transforming involuntary childlessness into a medical condition for which the seeking of biomedical treatment is anticipated and supported. Indeed, funding coverage was credited throughout the country, both for enabling much wider sectors of the population to access IVF, and for destigmatizing assisted reproduction and increasing its popularity. Enthusiastic newspaper reports exclaimed ‘Rush to Tüp Bebek’ (Radikal, 22.05.2005), ‘Social Security Bargains for Tüp Bebek’ (Sabah, 27.04.2006) and ‘New Era in Tüp Bebek’ (Hürriyet, 08.02.2007), making hyperbolic and utopian promises like ‘No home will be left childless (Çocuksuz ev kalmayacak)!’ (Takvim, 17.08.2008), to feed what one of my ‘expert’ interviewees referred to (at the time) as ‘an IVF frenzy’.

The budget directive specified eligibility for IVF treatment funding to include involuntarily childless couples who had been married for a minimum of 3 years, in which the wife was between 23 and 39 years old. Couples fulfilling these requirements could receive three cycles of intrauterine insemination (IUI) (where deemed medically appropriate) and two partially-funded cycles of IVF treatment (with patients contributing 30% to their first, and 25% to their second, treatment cycle). The state-defined cost of an IVF cycle was 1240 YTL (excluding the cost of drugs), and patients could choose either to receive treatment at a public hospital or to use funding as partial payment for (more expensive) treatment in a private clinic. As I began my fieldwork in spring 2006, even private clinics had long waiting lists of couples keen to use their funding ‘entitlements’. However, because much of the bureaucratic details remained unclear, many patients and clinics were caught up in ‘chaos’, unsure of when and how they would receive reimbursement. The ability for private clinics to act as ‘funded IVF providers’, after contractual agreements with the Ministry of Health, was encouraged as a means to ameliorate some of the overcrowding in public hospitals, and considered a preferential arrangement by many patients. By 2007, social security-funded couples comprised at least 60% of all IVF patients in Turkey, and waiting lists were growing (Radikal, 13.08.2007).

Regulating reproduction

In Turkey, a regulatory framework for assisted reproduction was introduced in 1987 by a designated body within the Ministry of Health (Elcioğlu and Yildirim, 2004). Preceding the birth of Turkey’s first IVF baby by 2 years, this pre-emptive legislation, titled ‘By-law on Centres for Assisted Procreation’ (Official Gazette no. 19551; translation by Elcioğlu and Yildirim, 2004) determined how assisted reproduction could be initiated and practised, and appointed the Ministry of Health responsible for licensing, registering, regulating and overseeing all forms of assisted reproductive practice. As assisted reproductive technology developed, the legislation was superseded by a more detailed ‘By-Law Concerning Treatment Centres for Assisted Procreation’ on 19 November 1996 (Official Gazette no. 22822; translation ibid.). This more comprehensive statute, detailing definitions, prohibitions and all necessary requirements (including building and physical environment specifications, equipment, materials and personnel) for assisted reproductive practice (Arda, 2007), was subsequently updated four times – twice in January 1998 (Official Gazette no. 23227 and Official Gazette no. 23244), once in March 2001 (Official Gazette no. 24359) and once in July 2005 (Official Gazette no. 25869) – in order to reflect advances and technological developments, but retained essentially the same character. The 2005 version of the statute was operational when I conducted my fieldwork in Turkey, from 2006 to 2009, and it is this version that is cited below. Subsequently, in March 2010, the AKP government introduced a new version of the regulations, the ‘Legislation Concerning Assisted Reproduction Treatment Practices and Centres’ (Official Gazette no. 27613; author’s translation). This latest version instigates novel restrictions to the way assisted reproductive technology is practised in Turkey, including the introduction of mandatory single-embryo transfer for all women under the age of 35 in their first or second cycle of IVF treatment (Kutlu et al., 2011, Urman and Yakin, 2010) and, more significantly for the current discussion, emphasis on the prohibition of any third-party involvement in reproduction (Gürtin, 2010, Gürtin, 2011). I explore this further below.

At its outset, Turkey’s assisted reproduction legislation (in the 2005 version) provided the following definition for ‘Assisted Reproduction Treatments’:

Procedures, accepted as treatment methods by modern medicine, which involve assisting the fertilization of the prospective mother’s egg with her husband’s sperm in various ways, enabling them to fertilize outside of the body when necessary, and transferring the gametes or the embryo back to the prospective mother’s genital organs. (Official Gazette no. 25869, item 4f; author’s translation and emphasis)

Such a definition is extremely important, not just semantically or symbolically, but for its actual regulatory implication. By referring to the ‘prospective mother’ and her ‘husband’ (rather than a socially or relationally indeterminate ‘man’ and ‘woman’), the legislation places the marital unit as legally central and clinically indispensable for assisted reproductive practice. Moreover, by providing this as a definition of assisted reproduction (rather than more explicitly as a definition of their legal application), it collapses the distinction between what is scientifically possible and what is socially acceptable (Gürtin, 2011, Gürtin, 2012a). Of course, such an interpretation of assisted reproduction is not unique to Turkey; reproductive technologies lend themselves well to the perpetuation of a traditional patriarchal agenda, where women must become biological mothers to their husband’s children, as pointed out by many feminist critiques (for a review of these, see Thompson, 2005). However, what is extraordinary here is the level of selective erasure evident in the Turkish legislation; by contextualizing assisted reproduction as squarely equivalent with the heteronormative reproductive unit, and setting legal marriage as an access requirement, the statute limits the use of assisted reproductive technology within conjugal confines. Thus while, globally, assisted reproduction has been associated with the ‘creation of family types that would not otherwise have existed’ (Fasouliotis and Schenker, 1999: 26; my emphasis), including gay and lesbian families, single mothers by choice and myriad family types formed with third-party assistance, within Turkey, assisted reproduction has been used exclusively to aid the propagation of traditional families (Gürtin, 2011) framed by a patriarchal pronatalist agenda.

These conjugal confines for assisted reproductive practice, limiting treatment provision to married couples using their own gametes, are also reiterated at the start of Section Five (‘Prohibitions’):

The use of the eggs and sperm or the embryo of applicants undergoing ART [(assisted reproductive technology)] for any other purpose, or in the treatment of other applicants, or the use of those [sperm, eggs or embryos] obtained from anyone other than the applicants in the treatment of the applicants, or the storage, use, transfer, and sale [of sperm, eggs or embryos] for any sort of purpose falling outside the definitions of this legislation, are prohibited. (Ibid.: item 17; author’s translation)

Until the 2010 amendments, the above was the only regulatory reference to the prohibition of third-party assisted reproduction. Apart from this statement, there were no other items in this or any other Turkish legislation that specifically addressed the use of donor gametes or surrogacy. There were, however, plentiful media reports circulating by 2009 claiming that involuntarily childless Turkish couples who could not find a solution to their infertility through IVF were willing to use donor gametes and engage in ‘reproductive tourism’ to nearby Cyprus or Greece for this purpose (Gürtin, 2011, Urman and Yakin, 2010).

As I conducted interviews with IVF practitioners in 2008 and 2009, there was a growing awareness of the covert cross-border choreographies facilitated by Turkish clinics and their Cypriot ‘branches’ (Gürtin, 2011). Although some practitioners complained about or criticized this state of affairs, they were mostly disapproving of the financial aspects of this practice, particularly ‘fee splitting’ between clinics. In general, the facilitation of cross-border reproductive care (CBRC) for patients willing or wishing to access third-party assisted reproduction was considered a ‘solution’ rather than a ‘problem’, as expressed in this quote from a senior practitioner:

It is not yet time to discuss the legalisation of donor gametes here in Turkey. Individuals may accept this of course, we live in a secular (laik) country; but it would be very difficult for a government to raise this openly, it would create a huge scandal. So, as you must have noticed, it [treatment using donor gametes] happens in alternative ways, and [the government] would rather turn a blind eye to it. (Senior IVF practitioner; Expert Interview no. 6)

It thus came as a surprise when, with very little warning and seemingly minimal consultation, the AKP government introduced a set of amendments to the regulation of assisted reproduction in March 2010 (Gürtin, 2010, Gürtin, 2011). In this latest version, following item 18.4, which outlines prohibitions on all third-party reproductive assistance (as per item 17 from the 2005 version, discussed above), there is a new item setting out the legal ramifications that will result if third-party assisted reproduction is practised by a Turkish clinic:

In the event of a discovery at any stage of a pregnancy achieved against any of these prohibitions [on third-party reproductive assistance], the [ART practice] certificates of the involved persons will be nullified, the centre will be closed indefinitely, and all personnel will be indefinitely barred from working at ART centres. (Official Gazette no. 27513, item 18.5; author’s translation)

Furthermore, items 18.6 and 18.7 stipulate the consequences for CBRC involving third-party assisted reproduction, including financial penalties, centre closures and the reporting of involved persons to the state prosecutor (see Gürtin, 2011 for details). These additions take the nationally enforced conjugal confines of assisted reproductive practice and extend them with extraterritorial relevance. Notably, this represents the first instance of a country legislating against the reproductive travel of its citizens in order to access donor gametes (Gürtin, 2010, Gürtin, 2011). Unsurprisingly, with this move the government came under heavy criticism, particularly from Turkish feminists and women’s rights campaigners, not only for infringing reproductive rights and discriminating against single women and gay couples (Acar and Altunok, 2013), but also for failing to publicly debate the ban before its swift introduction; Pinar Ilkkaracan, a prominent women’s rights campaigner, chided, ‘[t]his government has slipped this regulation without any debate in parliament’ (Head, 2010, Zorlu, 2010). Irfan Şencan, Director of the Ministry of Health’s Treatment Services department, explained the new regulations as necessitated by the growth of CBRC in recent years: ‘It is a way of breaking Turkish law abroad’ (Hürriyet Daily News, 15.03.2010), he argued. Şencan further clarified to Hurriyet Daily News that the prohibitions against CBRC will ‘protect ancestry [and] make the newborn’s mother and father known’ in alignment with the existing Article 231 of the Turkish Penal Code, which makes it illegal to obscure or conceal the lineage of a child. It is interesting that, although the desire to protect children’s lineage (nesep) is articulated with reference to an existing secular law, and indeed reflects what has been a guiding principle in the legal governance of the Turkish family even during the radical secularist period, it also noticeably echoes the Islamic imperative to conserve genealogy. Indeed, Şencan’s interpretation of the penal code and his reasoning is assessed by Ilkkaracan as a complete misinterpretation of the spirit of the law: ‘This is completely against the philosophy of the reformed penal code’, she argues, maintaining that its proper intention is to protect the inheritance rights of children, not to constrain family formation. Thus, while on the one hand, the prohibition of CBRC can be seen (and is explained by some members of the Ministry of Health) as a logical extension of the existing prohibition on third-party assisted reproduction, Ilkkaracan and other commentators – including several IVF professionals I interviewed in the aftermath of the legislation – provide an alternative explanation of the prohibitions as emblematic of the strong traditional family values espoused by the neo-conservative AKP, and indicative of its agenda to ‘smuggle’ Islam into government.

Conjugal confines

The conjugal confines I describe for assisted reproductive practice in Turkey clearly echo the ‘Sunni Islamic approach’ to assisted reproduction throughout much of the Muslim Middle East (Gürtin et al., 2015; also see Inhorn, 2003, Inhorn, 2004). However, whereas the parameters of assisted reproductive practice across the Muslim Middle East are justified with direct reference to religion – namely the rulings of Islam (Inhorn and Tremayne, 2012) – in Turkey, the same parameters are characterized as ‘secular’ and justified as ‘bioethical’ and ‘moral’, rather than religious (e.g. Arda, 2007). Several Turkish commentators have advanced (at international conferences, for example) the view that Turkey, where ‘98% of the population is Muslim, represents an ideal model country in which the legal framework [of assisted reproduction] is being shaped according to the secular governmental protocols, established socio-cultural values, as well as contemporary medical advances’ (Kahraman, 2007: 105), and entered heated debates with ‘foreign’ scholars who view Turkey’s assisted reproduction legislation as ‘religious’ or ‘Islamic’ (see debates from the 2006 Ethics, Law and Moral Philosophy of Reproductive Biomedicine conference, as printed in Edwards, 2007a, Edwards, 2007b). Indeed, the extent to which Islam exerts an influence on Turkey’s assisted reproduction regulation is a controversial topic without an easy answer, and I explore these competing – and heavily charged – characterizations in detail elsewhere (Gürtin, 2012a). While on the one hand Turkey is a secular country, on the other, it has a predominantly (Sunni) Muslim population whose views on such fundamental and ethical matters are undoubtedly shaped by their religious affiliation and the broader aspects of a Muslim culture. Indeed, the two elements have been integral to defining how assisted reproduction is practised in Turkey.

Turkey’s highest religious authority, the Presidency of Religious Affairs (Diyanet), is the official body charged with providing information about religious rulings, prohibitions and morality to the country’s religious leaders (imams), as well as to the general public. Despite the overt secularism of Turkish government and legislation and the rhetoric of secular assisted reproduction regulations (see Gürtin, 2012a), Diyanet plays a very active role in discussions about assisted reproduction. The regular presence of statements from Diyanet in popular media coverage of assisted reproductive technology, internet patient forums and even the websites of some Turkish IVF clinics, suggests that (at least some) Turkish men and women, and some institutions, are concerned with abiding by Islamic parameters and teachings.

Diyanet’s rulings on assisted reproduction (e.g. ‘Tüp Bebek’, May 2002 and ‘Islamic assessment of today’s medical developments in tüp bebek and stem-cell research’, March 2006, both available through www.divanet.gov.tr) replicate the rulings of Sunni authorities from around the world, asserting that assisted reproduction should receive encouragement, as long as the procedures do not damage the sanctity of the family or threaten the four central concerns of protecting inheritance, preventing incest, prohibiting adulterous relations and preserving lineage. Thus, although Diyanet’s fetva clearly states that IVF ‘is no longer permissible if a foreign element is included, meaning if the sperm, eggs or womb belong to a person outside of the husband-wife couple; because according to the general principles of the religion of Islam, there is an imperative for a legitimate child to belong, whether by sperm or egg or womb, to a wedded husband-wife couple’ (Presidency of Religious Affairs, 2006; author’s translation), within the bounds of marriage the use of IVF is both supported and encouraged. As articulated by Saim Yeprem, theologian and member of Diyanet’s Higher Council, ‘since children (as blessings) are Allah’s endowment, the treatment seeking of involuntarily childless couples does not contradict a sense of fate or destiny’. He adds:

Islam neither considers scientific research an intervention in God’s job, nor does it encumber freedom of research. It rather regards scientific research as discovering laws of nature to figure out the works of God (which is called al-sunnatullah in Islamic literature) in the universe. (2007: 47)

Indeed, as well as explicitly supporting the practice of assisted reproductive techniques within conjugal confines, Diyanet has even opened its own hospital with an IVF clinic in Istanbul. Asked to comment on the IVF clinic at the opening ceremony, Professor Ali Bardakoğlu, Diyanet’s president, explained: ‘We will support all treatments within the framework of our religion. […] The aims of religion and medicine are the same: to make people happier on this earth’ (Akşam, 29.12.2005). Sometime later, when twins conceived after treatment at the clinic were born to a 42-year-old imam and his wife from Samsun, newspapers reported the birth as ‘Diyanet’s first tüp bebekleri (tube babies)’, and quoted the imam as saying, ‘[w]e were comforted by Diyanet’s statements, and we came to this hospital with a clear conscience’ (Sabah, 11.02.2007). Indeed, more generally, practitioners credit Diyanet’s support for IVF with not only alleviating concerns, but also with actively and influentially promoting treatment-seeking among couples ‘who in the past did not come for tüp bebek for fear of religion’ (Star Gazete, 24.11.2007). Some IVF clinics, such as the Maya Clinic in Ankara, for example, even provide summaries and direct links to Diyanet’s fetva on their websites’ information pages.

It would, however, be over-simplistic to stipulate a homogenous position against third-party assisted reproduction among Turkish men and women informed solely by Muslim morality and culture, because individuals do not always care about, follow, or even have an accurate knowledge of the teachings of their religion. Moreover, although the AKP may represent and publicly proclaim a morality derived from and reflecting Sunni Islamic principles, Turks comprise a heterogeneous group, including Sunnis, Alevis, minorities from other religions and the non-religious. While it is generally true that third-party reproductive assistance (particularly the use of donor spermatozoa) is a stigmatized taboo in Turkey, the available research evidence on public and patient opinions about third-party assisted reproduction certainly suggests a diversity of opinions among Turkish people (Baykal et al., 2008, Isikoglu et al., 2006, Kilic et al., 2009) and warrants further exploration of the multiplicity of attitudes regarding reproduction and sexuality.

Concluding remarks

This article has sought to describe and explain the particularities of IVF and assisted reproduction practice in Turkey, a hybrid context where secular laws and a modernist approach to medicine intersect with a Sunni Muslim culture and neo-conservative government policies. Concentrating particularly on the years 2006 to 2010, during which I conducted fieldwork, and which coincided not only with the boom period of Turkish IVF, when clinic numbers, treatment cycles and the public visibility of IVF rose dramatically, but also with the introduction of certain regulatory and attitudinal changes, I have provided a repro-national portrait of this specific context. Situated within the broad Islam versus secularism tensions that permeate this society on many levels, the field of IVF too displays a complicated negotiation between what are at times conflicting and competing ideological positions regarding the country’s present and its future. In this particular arena, we see the vying of medical modernity and advancing technological capabilities of reproduction, as well as globalization, international travel, and changing social attitudes on the one hand, with religious institutions, traditional mores and the regulatory and symbolic pronouncements of a neo-conservative government on the other. The pronatalism of the AKP government is evident not only in the overt calls by Erdogan for ‘each family [to] have three children’, but also in its broader involvement in reproductive health and politics, of which the control of assisted reproduction is just one quintessential example.

Indeed, with its introduction of funding for assisted reproductive treatments, and its willingness to enable a prominent rhetorical role for the Ministry of Religious Affairs, the AKP has on the one hand enabled the rapid growth and accessibility of IVF throughout Turkey, while on the other curtailed its practice within strict conjugal confines. The fact that the conjugal confines for assisted reproduction practice have not only been asserted through regulatory, ideological and financial means within the country, but have also been extraterritorially extended (in law, if not in practice) is both striking and indicative of the centrality of reproductive politics for this government. As Acar and Altunok (2013: 20) remind us, ‘family is crucial to the functioning of the neo-conservative mentality’ not just as the only legitimate domain for experiencing sexual and reproductive capabilities, but also because it plays ‘a crucial role in producing and sustaining the desired moral order’. Heteronormative conjugality, as the legal and social parameters delineating not just the use of assisted reproductive technology but more broadly the acceptable family unit then, is the cornerstone of the AKP’s patriarchal pronatalism. It is, thus, the pronatalist rhetoric of the neo-conservative government, tensions between Islamic and secular principles, and a commitment to medico-scientific modernity that comprise the repro-national character of Turkey at the start of the 21st century. Future research may productively examine how the contours of reproductive citizenship are affected by the growing polarization of political identities, privatization of healthcare under the neo-liberal rule of the AKP, or Turkey’s developing links with the European Union. Situating these findings within the growing sociological and anthropological scholarship on the localization of IVF and assisted reproduction, as is the case in this Symposium issue of Reproductive BioMedicine and Society, demonstrates all the more vividly the extent to which personal reproductive choices and decisions are intimately entangled with the social and national contexts of reproductive governance.

Biography

Dr Zeynep Gürtin is a Research Associate at the Reproductive Sociology Research Group (ReproSoc), University of Cambridge. Her academic interests concern the social and ethical aspects of the globalization and localization of assisted reproductive technologies, particularly in Turkey and the Middle East, egg donation, and cross-border reproductive care. Zeynep teaches both undergraduate and graduate students at the University of Cambridge. This article was written while Zeynep was a Visiting Researcher at UCLA's Institute for Society and Genetics during the spring semester of 2015.