By Layla McLeod, an undergraduate candidate reading Human Sciences at Hertford College, University of Oxford. All opinions are her own.
For anyone struggling with fertility, pursuing treatment and testing can be a challenging and emotionally taxing process. People who identify as LGBTQ+, however, often face unique struggles that make accessing fertility services even more difficult. In honour of Pride Month, I feel it is fitting to reflect on how navigating the fertility care landscape differs for queer people.
What does ‘Access to Healthcare’ Really Mean?
Although ‘access’ to healthcare is commonly understood in terms of service availability, it is important to remember that an individual’s likelihood of using a healthcare service also depends on their personal attitudes, experiences, and perception of their needs, alongside financial and organisational barriers. Therefore, to better understand the inequalities LGBTQ+ individuals face when accessing fertility testing and treatment, it is important to consider how these factors influence their experiences during this process.
Queer Fertility in Context
As I began researching queer [in]fertility, I was surprised at the lack of research and data that addresses LGBTQ+ individuals’ utilisation of fertility services in the UK. Even the NHS definition of infertility, “when a couple cannot get pregnant (conceive) despite having regular unprotected sex”, assumes that patients are in a heterosexual couple. This is commonplace within medical documentation; the World Health Organisation similarly defines infertility as “the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse” leaving both queer and single people unable to fit the clinical definition.
However, you do not have to be in a heterosexual relationship to display physiological indicators of poor fertility such as disrupted hormonal levels or suboptimal sperm health.
Anyone can struggle with infertility regardless of their relationship status, gender identity or sexual orientation. Therefore, anyone might want to pursue fertility testing or treatment.
To better understand the barriers that queer people face in the context of reproductive healthcare, it is worth noting the broader health inequality affecting queer populations. Research suggests that health outcomes are generally worse for people identifying as LGBTQ+. According to the 2017 National LGBTQ survey, at least 16% of respondents who sought public health services reported negative experiences due to their sexual orientation, and roughly 38% reported negative experiences due to their gender identity.
Additionally, in terms of wider determinants of health, on average LGBTQ+ individuals report higher rates of smoking, alcohol consumption, and drug use and are 2 to 3 times more likely to report a mental health issue than those identifying as heterosexual. Considering these overarching health inequalities, there is reason to expect substantial disparities when it comes to reproductive health and fertility treatment.
In fact, given the stigma surrounding queer people becoming parents, reproductive health may be an aspect of health where disparities are even more pronounced. Indeed, 79% of lesbian, gay and bisexual people believe that societal attitudes to gay parenting are a barrier to becoming a parent. This reminds us that queer reproduction should be viewed alongside a broader picture of evolving social perspectives and UK law concerning LGBTQ+ family planning. After all, same-sex couples have only been legally allowed to be full and equal parents of their children for just over two decades.
Granted, since the introduction of the 2002 Adoption and Children Act, substantial progress towards equality has been made, particularly in terms of legislative changes concerning who is allowed to be the legal parent/s of a child born through IVF or surrogacy. Nonetheless, with a recent history of such stark inequality, it is perhaps unsurprising that queer people are concerned that their decision to become parents might be met with judgement. In addition, considering infertility is already a taboo subject, especially for men or people with sperm, this fear of judgement might compound with existing stigma, making [in]fertility testing and treatment particularly daunting.
That said, the challenges of accessing fertility services are by no means limited to stigma. Learning about and seeking care for infertility is generally less straightforward for people who identify as LGBTQ+. Thinking back to the NHS’s definition of infertility, it can be difficult for LGBTQ+ individuals to “prove” that they are in need of fertility testing or treatment. While the NHS website does provide valuable information on the pathways LGBTQ+ individuals and couples can take to have a child, it seems that this information on IVF, artificial insemination, surrogacy and adoption overlooks that queer people may also suffer from suboptimal reproductive health. Having a fertility test could provide peace of mind before pursuing these options and help to inform what might be the best route to take to have a child. For instance, starting a surrogacy journey confident in your sperm health may help to ease anxieties throughout the process.
Access to Information
The information available online tends to provide quite a biased picture of who fertility services, such as fertility testing are ‘intended for’. As it stands, discussions of infertility are disproportionately centred around cisgender women. Advice on infertility aimed at cisgender, heterosexual men is comparatively harder to find, let alone advice for transgender people or those in non-heterosexual relationships. The NHS website page on Infertility advises heterosexual couples to visit a GP if they have not conceived within a year of trying, but does not offer any explicit information directed at same-sex couples enquiring about fertility testing. If looking elsewhere, a quick Google search of “LGBTQ fertility testing” does retrieve an array of private fertility clinic websites. Although these are helpful, they may be financially inaccessible for many. In addition, they are mostly aimed at lesbian couples meaning support for LGBTQ+ people with sperm is even harder to find.
Inside the Clinic
Fertility clinics are often tailored to cisgender, heterosexual couples and therefore can (even if unintentionally) make queer people feel as though they do not belong. Whether it be through pictures of heterosexual couples on the walls, or documentation that pigeonholes patients into categories of “male” or “female” and “mother” or “father”, these spaces are populated with reminders of who is expected to enter a fertility clinic, pursue fertility treatment, and raise a child.
Ivy Taylor, a transgender woman who began considering having children after starting her transition, describes the clinic atmosphere as “strangely hostile” and compares the experience to entering an alien world. Similarly, in the US, Epstein reports how Sam and Rob, who both identify as Black, transgender men had their referral questioned as the clinic struggled to comprehend why two men would be seeking insemination. Sam additionally highlights how at times he was unable to pinpoint why exactly why medical staff seemed so uncomfortable treating him, asking himself “Is it because I’m black? Is it the trans thing? Is it because I’m fat? Is it my shaved head?”
Intersectionality
Sam’s experience reminds us of the importance of intersectionality, that individuals experience discrimination and inequality in various ways due to their overlapping social identities. In the context of fertility testing and treatment, alongside their sexual and gender identity, an individual might experience their own unique set of challenges due to their racial/ethnic identity, their socioeconomic status, or having a disability. Indeed, research suggests there are disparities in the outcome of fertility treatment between ethnic groups in the UK: the HFEA reports that Black patients aged 18-37 have lower IVF birth rates (23 per cent) compared to their White counterparts (32 per cent). Furthermore, in an Access Fertility article, Nia, who is partially blind, anecdotally shares how her disability led to struggles with transportation to the clinic and administering her own medicine. Minority groups often face barriers when accessing fertility treatment, and for those who identify with multiple minority groups, these challenges can compound making it even harder.
Another significant barrier to access is the cost of fertility treatment, which in many cases is disproportionately higher for people who identify as LGBTQ+. For instance, surrogacy is not covered by the NHS meaning that for same-sex male couples and people for whom IVF is not an option, might be required to spend thousands of pounds on having a biological child. Furthermore, to qualify for NHS-funded IVF, female same-sex couples were, until recently, first required to self-fund 12 cycles of artificial insemination. Meanwhile, heterosexual couples could qualify after having 2 years of unprotected sex which is, of course, free. In 2022, following legal action pursued by influencers Megan and Whitney Bacon-Evans, this guideline was revised and the UK Government has pledged to remove these financial barriers. However, the change is yet to be implemented in many areas of the UK.
This is ultimately due to another major hurdle when it comes to fertility treatment in Britain, the well-documented “postcode lottery”. Despite national guidelines provided by the National Institute for Health and Care Excellence (NICE), in reality, the funding for healthcare services is determined at a regional level by Integrated Care Boards (IBCs). This means that some areas have far better fertility support for LGBTQ+ people that comes at a much lower cost.
Beyond the Barriers
Although much of what I have discussed highlights the challenges queer people face when accessing fertility services, I do not intend to paint an overly pessimistic picture. All things considered, there are plenty of queer parents who have successfully embarked on the fertility journey to raise happy families. In addition, progress is being made: in 2020, the Scottish couple Ross and Chris Muller became the first gay couple in the UK to have a baby through NHS-funded IVF. The media also a powerful tool to raise awareness and could be vital for taking further steps towards equal access.
Social media platforms are home to community groups such as @bristolqueerparents or @queerparentsbtn (Brighton) which provide support for LGBTQ+ people who are parents or considering becoming parents. Moreover, news articles are becoming increasingly populated with queer celebrities’ success stories such as those of Sir Elton John and David Furnish, or Tom Daley and Dustin Lance Black, who have both grown their families through surrogacy. This representation can play a key role in changing societal attitudes and educating more people on the LGBTQ+ fertility journey. In fact, Dustin Lance Black went on to create a podcast that shares stories of the surrogacy process.
While more research is needed to address these inequalities, there is reason to believe that access to fertility services for all, regardless of sexuality or gender identitry, will improve in the future. With continued advocacy and representation, and efforts on behalf of fertility service providers, the landscape of fertility care can become more inclusive and supportive for everyone.
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