The Fertility Landscape for LGBTQ+ Communities: Barriers and Considerations

The latest PET event – 'The Fertility Landscape for LGBTQ+ Communities: Barriers and Considerations' – brought together figures from medicine, activism, policy, research and law to discuss assisted conception as experienced by LGBTQ+ people. Historically, LGBTQ+ people have often had negative experiences when dealing with healthcare professionals, and have faced particular barriers to accessing fertility treatment (see BioNews 1267). This event explored a complex landscape involving legal and policy barriers, and also barriers that stem from misinformation and mistreatment.

The first speaker was Dr Carole Gilling-Smith – founder, medical director and chief executive of the Agora Clinic. There has been a marked rise in LGBTQ+ people in the UK seeking to have children via surrogacy, and Dr Gilling-Smith discussed what people – particularly couples where both prospective parents produce sperm – can expect, and should think about, when considering surrogacy as an option.

Due to regulations requiring that sperm or embryos must be frozen and quarantined before they can be placed in a surrogate, one consideration is whether the surrogate will be providing the egg, or whether a donor egg will be sought. Creating an embryo for surrogacy requires IVF, and this entails additional expense. A further consideration is the requirement for people providing sperm or eggs in the context of surrogacy to be screened for certain sexually transmitted infections, because a positive test during the quarantine will lead to the samples having to be discarded. These requirements have only recently been relaxed, to enable people with non-transmissible HIV to provide sperm or eggs in the context of surrogacy (see BioNews 1213, 1239 and 1262).

Next, we heard from Professor Nick Macklon, medical director of the London Women's Clinic. He first reflected on how much change has occurred in the fertility treatment space over the years, remembering a time in the UK when it was normal to turn away same-sex couples and single women seeking sperm donation. Professor Macklon framed fertility treatment as not just what will help a couple get pregnant, but also will best support quality of life or a sense of kinship. He added that there is a lot of work to do in combatting misinformation.

Professor Macklon used the example of intra-partner IVF treatment allowing for shared motherhood, where one partner provides an egg to create an embryo, and that embryo is then transferred to the other partner who carries the pregnancy (see BioNews 928). Despite having a successful live birth rate, this procedure is not as widely available as other fertility treatments in the UK. Research also shows that fertility treatment can be successful in the context of surrogacy and fertility treatments for transgender patients. He ended with the message 'It takes courage to lead' and urged attendees to be boldly inclusive and active in calling out misinformation, referring to a recent BioNews comment piece (see BioNews 1275) that he said was exemplary in this respect.

The next two speakers were Nancy Kelley and Laura-Rose Thorogood, both of whom discussed the ongoing Fertility Justice Campaign in which they are involved. Kelley is former chief executive of Stonewall and current executive director of Diva magazine, and Thorogood is the founder of LGBT Mummies and Proud Foundations. Kelley began by introducing attendees to the core message of the Fertility Justice Campaign – that queer people should have equal access to fertility support. Kelley's perspective dug deeper into how queer people themselves experience starting a family.

Historically, queer people have had to battle pervasive myths that children are inherently unsafe around us, and have been at risk of children being taken away after a divorce following a coming out. We have also been historically excluded from many forms of medical care, including fertility care. All of this coalesces into a deep-seated existential question for queer folk seeking fertility treatment – will we be supported in the kinds of families we want to have?

Kelley outlined many of the present-day barriers that the Fertility Justice Campaign aims to address. It is still difficult for many people to access IVF, due to limited NHS coverage and the procedure itself costing thousands of pounds. Some GPs don't know anything about family-planning options for queer people, particularly when it comes to services for trans people. The current process for birth registration does not work for many queer families, particularly platonic coparents and trans people. Kelley finished with a call to action for people to write to MPs, and shared a template that can be found on the Fertility Network UK website.

Thorogood then walked us through the specific aims of the Fertility Justice Campaign's manifesto. First, she outlined how this campaign is not aiming for 'quick wins' but rather for long-term change, not just for same-sex couples but for all members of the LGBTQ+ community including transgender, non-binary, intersex and asexual people. The LGBTQ+ community has a lower birth rate compared to the rest of the population, and queer people are not being given the same chance to contribute to society as our peers. The manifesto centres on fair and equal access to information, fertility testing, fertility preservation and assisted conception, together legal recognition of LGBTQIA+ families, and offers practical steps for each. Thorogood ended with the call to 'raise and amplify the voices of queer people' in the process of working together for fertility justice.

Next, we heard from Dr Marcin Śmietana, a research fellow at Ca' Foscari University of Venice and lecturer at the University of Cambridge. He presented findings from his qualitative research concerning gay men and their use of surrogacy in the UK, drawing upon interviews with 30 families in England and Wales who had children via surrogacy (in most case this was domestic surrogacy, but in some cases it was overseas surrogacy).

Dr Śmietana's research highlighted some of the ways in which the parenting journeys of gay men are distinct from those of their heterosexual counterparts. Some research participants described experiencing a change in 'reproductive consciousness', having believed earlier in their lives that being gay excluded them from parenthood, and only realising later that parenthood was actually a possibility for them. Another phenomenon described was the careful projecting and tracking of expenses, resulting in 'spreadsheet fertility', where reproduction is experienced as something that needs to be planned and carefully managed.

Lastly, Dr Śmietana noted that in light of gaps in NHS funding for IVF and in the availability of voluntary surrogates in the UK, it was hardly surprising that none of those who participated in research had incomes below the average household income in the UK. Summarising the situation, he said: 'If you are gay in the UK, you are lucky to be a parent.'

Next, we heard from Jacob Stokoe – founder of Transparent Change, a nonprofit organisation fighting misinformation and disinformation in relation to transgender people and gender identity. He began by addressing the assumption that not many trans people give birth, pointing out that this number has been increasing, and that available statistics only count birthing parents and don't take account of the transgender partners of birthing parents.

Stokoe described some of the barriers that exist that can make trans people more hesitant to access perinatal care. Transphobia or direct misgendering from clinic staff will certainly make a trans person feel unsafe in a given space. Additionally, paperwork that fails to use inclusive language, doctors who don't understand the basics of trans identity and indirect misgendering (such as through materials or signage directed toward only one gender) can make people feel that they are not welcome.

Stokoe is himself a transgender birthing parent, and shared some specific examples of how he had experienced these barriers personally. He argued that such access issues are important, because trans people are likely to have to access fertility treatment, and medical professionals who aren't equipped to know about fertility care for transgender patients will be hard-pushed to provide appropriate guidance.

Finally, we heard from Natalie Gamble, director of NGA Law and founder of the nonprofit surrogacy agency Brilliant Beginnings. She provided a deeper legal and policy perspective, including key policy decisions that had shaped the current landscape. We began in 2008, when updates to the UK's Human Fertilisation and Embryology Act included the removal of the requirement to consider a child's 'need for a father' (see BioNews 673). This made sperm donation a more legitimate and practical option for single women and women in same-sex partnerships.

However, Gamble argued that the law as it now stands does not go far enough in recognising or protecting LGBTQ+ people. For one thing, it is drafted in a very gendered way that creates challenges for transgender parents, forcing trans men who give birth to be registered as the 'mother' on birth certificates (see BioNews 1017, 1062 and 1073). A child in the UK can also only have two legal parents, thereby excluding multi-parent families (see BioNews 742).

For all of the above, the way forward may be an approach that considers the intentions of parenthood rather than the family structure. Gamble concluded by challenging the belief that respecting queer parenting relationships prioritises the desires of adults over the needs of the children, pointing to research that shows that children in queer families are not at greater risk of harm.

The chair of the event, PET director Sarah Norcross, then moderated a discussion which included questions and comments from attendees. Some questions were legal and medical, for example concerning how the recent legal change concerning HIV+ donors has impacted the field. Dr Gilling-Smith and Professor Macklon affirmed that allowing people with non-transmissible HIV to donate has had a huge impact, opening up possibilities for people who previously had fewer options for starting families. Dr Śmietana added that prior to the change, men in the UK who were HIV+ had resorted to travelling abroad for fertility treatment.

Another set of questions concerned personal advice, such as what to do after inadvertently misgendering someone. Stokoe responded by emphasising the importance of avoiding the 'sorry spiral', which puts the onus on the misgendered person to reassure or soothe the person who made the slip-up. Instead, say a quick 'sorry' or 'thank you' and move on.

The last category of questions concerned the future in relation to an increasingly conservative atmosphere, both in the UK and abroad. How likely are we to achieve fertility equality anytime soon? Gamble offered the hope that any backlash is just a reaction to the progress we are making. Stokoe acknowledged that we are in scary times, but that it's important to not get stuck in thinking about likelihoods, and to remain focused on ways of pursuing real change, as with the Fertility Justice Campaign.

This event not only provided an overview of the current landscape, but also inspired the audience to think about how to shape the landscape going forward. We heard about the many changes that had occurred to bring us to where we are today, and were helped to see all of the opportunities that exist to create an even better future.

PET is grateful to Merck and Born Donor Bank for supporting this event.

The next free-to-attend PET events will be:

• Is Fertility Treatment a Solution to Population Decline?, taking place online on Wednesday 26 March 2025 – register here.
• Fertility in Flux: What Can State-Funded IVF Do for Population Growth?, taking place online on Wednesday 9 April 2025 – register here.
• Our Future Health, UK BioBank, Genomics England: Exploring the Impact, taking place online on Wednesday 30 April 2025 – register here.
• IVF and Miscarriage: Reducing Risks, Providing Support, taking place online on Wednesday 21 May 2025 – register here.
• Lifestyle, Obesity, Diabetes: Optimising IVF Outcomes for Patients, taking place in person in Edinburgh on Wednesday 28 May 2025 – register here.
• Diversity in Health Data: Achieving Benefit for All, taking place online on Wednesday 4 June 2025 – register here.
• Rare Disease Genomic Testing: How Do We Make Access Equitable and Timely?, taking place online on Wednesday 18 June 2025 – register here.
• 40 Years of the Surrogacy Arrangements Act: What Next for Surrogacy?, taking place online on Wednesday 16 July 2025 – register here.