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We know that family is something we build. We, as LGBTQ+ people, have been redefining the heterosexist and heteronormative assumptions of what family means for generations. More recently, scientific developments have allowed for radical improvements in fertility medicine over the last half century, and many couples (both straight and queer) who were not able to biologically conceive a child without assistance, can now do so. But while fertility technology and social opinions of queer and trans family planning have evolved, the standard medical definitions of infertility haven’t.
What is the standard medical definition of infertility?
According to The Centers for Disease Control and Prevention, “infertility is defined as an inability to get pregnant (or conceive) after one year (or longer) of unprotected sex.” To echo this, the World Health Organization (WHO) defines infertility as “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.” Some medical providers will treat and diagnose infertility if you are 35 years old and meet the definition of infertility, due to declining fertility with age.
You will notice that both of these definitions rely on unprotected sexual activity as a prerequisite to determining infertility. However, what isn’t made explicit is the body parts and reproductive systems in this definition. A diagnosis of infertility can only be made after an egg and a sperm are exposed to each other for a year without conception. And while there might be some LGBTQ+ couples who could receive a medical diagnosis of infertility—for example, a cisgender man and a transgender man, a transgender woman and cisgender woman, or even a trans masc and trans femme couple—this rigid definition of infertility, by and large, excludes many LGBTQ+ couples and parents-to-be.
Does insurance cover LGBTQ+ infertility treatment?
Without an infertility diagnosis, most insurers won’t cover infertility treatment. Many insurers base coverage on one of the following: 12 months of unprotected penis-in-vagina intercourse without pregnancy or conception or six months of failed IUIs (intrauterine inseminations). This timeline can be reduced if you are over the age of 35. The first requirement excludes many queer and transgender couples from IVF or other fertility treatments, as well as other cisgender gay and lesbian couples, who are unable to get pregnant from unprotected sex with each other, while the second may require people to pay out of pocket for IUIs performed either at home or in a clinic by a healthcare provider before they can get an infertility diagnosis and get insurance to cover the cost of care.
Despite the need for fertility services, the cost of fertility care is inaccessible for many people in the United States. Insurance coverage for infertility varies widely from state to state. Many fertility treatments are not considered “medically necessary” by insurance companies and therefore aren’t covered by private insurance plans or Medicaid programs, and most states do not cover it broadly. Only 20 mandated states require insurance companies to offer coverage for infertility diagnosis and treatment, but—even in states with coverage laws—not all insurers cover it, not all treatments are covered, and not all patients are eligible for infertility treatment.
In many states with infertility coverage mandates, there is no included language for LGBTQ+ people. This means that queer and transgender couples often aren’t able to access coverage without a diagnosis of infertility. And couples who aren’t having “unprotected sexual intercourse” (a.k.a. vaginal penile sex) are excluded from definitions of infertility unless they undergo multiple failed rounds of IUI. These stipulations also deny coverage to both heterosexual and queer single parents who are looking to pursue biological family building, as a diagnosis of infertility typically refers to “couples,” excluding most single parents-to-be. This lack of specificity can lead to legal and political wormholes when it comes to understanding which identities and types of relationships are eligible for infertility coverage.
On top of this, some adoption agencies won’t work with prospective parents who don’t already have an infertility diagnosis. These agencies often prioritize those who are “unable to get pregnant due to infertility,” which can technically create a workaround for some adoption agencies to actively discriminate against LGBTQ+ couples and families hoping to adopt outright.
These exclusionary insurance policies create an enormous financial burden for many LGBTQ+ people and single parents-to-be who want to start families but can’t afford them, not to mention people who do not have insurance. Infertility treatment can be extremely expensive, especially within the United States (with IUI usually costing between $500 to 4,000, a single IVF and Reciprocal-IVF cycle costing up to $30,000 (excluding the cost of donor sperm or eggs), and surrogacy costing between $100,000 to $200,000). Furthermore, most employer benefits don’t cover infertility costs outside the standard medical definition of fertility, unless they supplement insurance coverage with fertility-benefits-focused companies such as Progyny, Kindbody, or Carrot.
What does the future of fertility benefits look like for LGBTQ+ couples and families?
This is where fertility and family-building resources and organizations come in. Some medical practitioners and bioethics scholars have begun arguing for a broader definition of infertility, called “fertility by different means” or “social infertility.” These definitions of infertility would expand upon the physiological ability to get pregnant or conceive and consider a range of factors including sexual orientation, relationships, life choices, and circumstances to determine whether or not assisted reproductive technology is needed. However, there is some fear that expanding the definition of infertility could lead to backlash, further pathologizing LGBTQ+ relationships and families as having “medical limitations”.
Meanwhile, the Biden Administration is considering requiring, through a pending update under the Affordable Care Act, that some health plans (under Obamacare and some other group health plans) cover fertility care for policyholders regardless of their gender identity or sexual orientation. While some doctors and healthcare providers will currently give LGBTQ+ couples and families an infertility diagnosis (even if they don’t meet the medical definition), they currently risk putting their own license at risk for the good of helping their patients.
In January 2022, a new definition of infertility was made into law in Illinois stating that there are two ways that someone could be infertile: “A person’s inability to reproduce either as a single individual or with a partner without medical intervention; or a licensed physician’s findings based on a patient’s medical, sexual, and reproductive history, age, physical findings, or diagnostic testing.” For the future of queer and trans rights and LGBTQ+ inclusivity, a new definition of fertility based on identities and intentions is critical to expanding access to fertility care. This is based on the fact that reproduction and the right to build a family should be a basic human right for all.
What is FOLX doing to help provide family-building access to the LGBTQ+ community?
As a healthcare company focused on providing joyful and affirming care for the LGBTQ+ community, FOLX is expanding the scope of services we offer to include clinical support, education, and community building to assist people on their fertility and family-forming journeys. FOLX offers clinical guidance and support for a range of fertility needs from going through IVF or RIVF at an in-person clinic, to education on possible paths of achieving conception through fewer interventions at home, to adoption and surrogacy. Our expert-led fertility and family-building support groups and individual virtual healthcare visits are available to any LGBTQ+ folks who are looking to find support and build community with us.
If you are interested in learning more about LGBTQ+ fertility and family-building services, make sure to sign up for our new offering here. If you would like to speak directly with a FOLX clinician about fertility and family-building options, schedule a virtual healthcare visit to get all your questions answered, or drop us a line at firstname.lastname@example.org.