Infertility is a biological condition.
It’s hard to get beyond the World Health Organization’s woke, but an article in the New England Journal of Medicine manages that task. The question involves the definition of “infertility.” To the NEJM authors’ consternation, the WHO has embraced an objective, scientifically based approach to diagnosing the condition. From “Who Counts as Infertile: A Missed Opportunity” (citations omitted):
In 2017, the WHO collaborated with international reproductive-medicine groups on an edition of a glossary related to infertility and fertility care. That document defined infertility as “a disease characterized by the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or due to an impairment of a person’s capacity to reproduce.” The WHO has emphasized the importance of equitable access to fertility care globally, but its formal definition of infertility continues to exclude same-sex couples and to rely on intercourse-based framing.
Infertility is a biological condition. The WHO’s approach seems a good way to identify the inability to have children without expensive tests.
The authors grouse that LGBT people and others are not included:
The guidelines acknowledge that “a wide variety of people, including individuals who are single or who are in same-sex or gender-diverse relationships, may need services to fulfil their fertility preferences” and that “providers of fertility care should consider the needs of, and provide equal care to, all individuals.”
The authors support a sociological definition of “infertility” propounded by the American Society of Reproductive Medicine:
The American Society for Reproductive Medicine (ASRM) is more expansive and covers the need for medical intervention, including the use of donor gametes or embryos, to achieve a successful pregnancy for both single people and those with a partner.
Of course the ASRM favors such a subjective and expansive definition! Fertility companies stand to make a lot of money if “infertile” includes people in same-sex relations and celibate individuals, because that diagnosis often opens the door to bounteous insurance or government benefits that pay for expensive reproductive medical services.
The authors acknowledge the goal:
Although the ASRM’s definition includes single people and same-sex couples, eligibility requirements for coverage of fertility care in the United States still often disadvantage LGBTQ+ and single people. Of insurance plans that cover fertility treatments, many continue to define infertility as the inability to conceive after 6 to 12 months of unprotected heterosexual intercourse. Such policies effectively exclude many same-sex couples, single people, and some transgender people. LGBTQ+ and single people must often pay thousands of dollars out of pocket for multiple donor-insemination cycles before becoming eligible for insurance coverage, whereas people in heterosexual relationships who have infertility can qualify for coverage immediately. Insurance coverage for fertility care is particularly inconsistent for transgender patients. For example, coverage for fertility preservation before gonadotoxic therapy often doesn’t include gender-affirming care.
There’s a disturbing irony here. If society accepts the NEJM authors’ desired approach, heterosexual couples will have to demonstrate a factual inability to conceive before benefits would be payable. But gay people would be immediately eligible — even if biologically they are perfectly capable of reproducing — because, by definition, their intimate relations cannot result in a baby. Women beyond childbearing age and celibate individuals would also, it seems, be eligible for benefits if necessary to “fulfill their fertility preferences.”
The authors argue that reproductive technologies should be essentially universally available to anyone who wants a baby:
Some scholars have used the term “socially infertile” to describe single people and LGBTQ+ couples who wish to conceive biologic children. The moral relevance of distinguishing between medical and social infertility for the purposes of professional recommendations and insurance-related policies is questionable, however. For one thing, some LGBTQ+ and single people might face medical infertility in addition to social infertility, which complicates attempts at simple categorization. More important, the modern understanding of the goal of fertility medicine is to enable family formation, not to narrowly cure a particular medical dysfunction. The ASRM’s ethics committee has stated that “interest in having and rearing children exists for individuals and couples regardless of marital status, sexual orientation, or gender identity.” LGBTQ+ and single people may require the same types of services as people with solely medical infertility, and their needs are just as pressing.
No, they may want it, not “require” it because of a pathology. There’s a difference.
Whether to cover reproductive interventions for anyone wanting a baby — whether because of a pathology or life choices — is a policy issue. (For example, California passed such a law some time ago.) This is a science issue. Redefining objective and accurate medical terminology to enable particular subjective policy objectives undermines the scientific foundation of medicine, which is the last thing the New England Journal of Medicine should promote.
Moreover, creating a right for essentially anyone to have a baby by whatever means are required — which is what the desired redefinition of “infertility” seeks to enable — exemplifies why we will never control health-care costs.