The charity Fertility Network UK has recently published results from a survey they commissioned on the psychological, financial and relational impacts of sub-fertility and fertility treatment (see BioNews 1165).
The survey was conducted between April and July 2022 and received over 1200 responses, of which 98 percent were women, 93 percent white and 90 percent in heterosexual relationships. In this short piece, I canvass the demographics of the respondents, and the results of the survey.
It is unsurprising that the vast majority of the survey respondents were women, white and in heterosexual relationships. While for most forms of fertility treatment it takes the gametes, financial and emotional investment, and time of two people, women tend to discharge the majority of the labour associated with accessing and managing treatment, and experience adverse mental health outcomes as a result of their inability to conceive. Gender socialisation may partially explain this. Even if women increasingly opt not to have children, they are still largely associated with the social role of mothers. Fertility treatment may thus be perceived to be, and experienced as, a woman's remit and responsibility. Relatedly, the inability to conceive can be particularly distressing for women because it represents a failure to fulfil a prescribed social role.
Users of fertility treatment are mostly white (and middle class). That ethnicity is largely a predictor of sub-fertile people's likelihood of accessing fertility treatment can be partially explained by a correlation between ethnicity and socio-economic status. But this only tells part of the story. More likely, a multiplicity of factors contribute to this phenomenon, some of which generate claims of justice. Poor health outcomes, racism and other forms of exclusion seem to influence the degree to which ethnic minorities are likely to seek fertility treatment and its success rates.
The UK government has recently unveiled plans to remove the requirement for same-sex couples to 'prove their fertility status' by privately paying for up to 12 rounds of artificial insemination to be eligible for treatment on the NHS (see BioNews 1152). While this removes one of the barriers to accessing treatment, in many parts of the UK same-sex couples continue to struggle to access state-funded fertility treatment (see BioNews 1100).
The inability to conceive for same-sex couples, single women, older women, and transgender people cannot be traced back to biological or other kinds of (statistically coherent) abnormalities. Insisting on the disease-status of infertility weakens their claims for assistance. In my work, I argue that it is important to appreciate that biological or congenital abnormalities are not what is at stake with respect to people's inability to conceive. After all, a woman whose fallopian tubes have been removed and who does not want to have children would not be offered fertility treatment as a cure.
Rather, what is at stake for people who are unable to conceive is the absence of a desired state: they are involuntary childless. A woman in a same-sex relationship and a woman whose fallopian tubes have been removed who want to have children should be both considered involuntarily childless and offered treatment, for they both cannot achieve genetic parenthood unassisted.
NICE recommends offering three cycles of IVF to women up to 40 years old, one cycle for women aged between 40 and 42, and for referrals to be made after couples have unsuccessfully tried to conceive for a year. However, fertility treatment provision in the UK differs markedly from these guidelines (see BioNews 1120, 1003, 983 and 973). In several parts of the UK, women older than 35 are excluded from accessing treatment; and referrals are sometimes only accepted after couples have been trying to conceive for two years. Moreover, if a woman's partner already has a child from a previous relationship, they are also not eligible for treatment on the NHS – something captured by the survey's results. These restrictions, together with waiting times and additional discrimination criteria such as women's BMI and other lifestyle factors, significantly curtail access to state-funded treatment.
Fertility treatment allows patients a chance to have genetically related children, which is seen as problematic by those who argue that the preference for genetic relatedness is the product of norms that unjustifiably prize genetic relatedness over other kinds of familial relationships (see here and here). For women, the pursuit of motherhood through harmful, burdensome and costly forms of fertility treatment is sometimes constructed as an instance of complicity with oppressive gendered socialisation. This partially explains some feminist theorists' critical stance on fertility treatment and its provision.
As the survey results show, the impact of sub-fertility, and of the corresponding frustration of reproductive preferences has wide-reaching effects on people's well-being. It might be true that the emergence and consolidation of the preference for genetic relatedness can be partially explained by social norms. Relatedly, it would be desirable for adoption to be considered within these norms.
At the same time, in my work, I argue that pursuing social reform 'on the backs of' sub-fertile people is an approach that privileges political agendas and desirable social reforms over the fulfilment of people's stated preferences. Critiques of fertility treatment and its provision often fail to account for the costs of frustrating reproductive preferences in terms of women's flourishing and well-being within a given socio-political and cultural environment. In dismissing women's (reproductive) preferences, they risk overlooking the effects of this specifically for women. The 'solution' to oppressive norms and their entrenchment should not be to castigate preferences and place the costs of social reforms on a small group of people, who are already disadvantaged due to their fertility status. Relatedly, as Dr James Fletcher and I argue elsewhere, the construction of (certain forms of) fertility treatment as a 'lifestyle choice for careerist women' renders it unlikely to receive the public funding necessary to expand its provision.
As a society, we have several options. We can try to satisfy reproductive preferences, and expand fertility treatment's provision. We can also try to challenge social norms that prize genetic relatedness and that construct motherhood as women's only reasonable path in life. But doing so by leaving treatment provision at its current levels, or even reducing its reach, will inevitably have substantial impacts on people's well-being. This should give us pause. There are good reasons in favour of considering expanding fertility treatment provision and doing so in more egalitarian ways.
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