More Than a Biological Condition: The Heteronormative Framing of Infertility

More abstract Infertility is often framed from the perspective of heterosexual couples, the dominant patient group using reproductive technologies. However, there are many types of patients availing of fertility treatments and those patients are often overlooked in policy, planning, service provision, and research. This commentary demonstrates the need for further research into LGBT subgroups, who frequently fall outside of infertility discourses, and are therefore especially disadvantaged by current policy and fertility service structures. Abstract L’infertilité est souvent abordée du point de vue des couples hétérosexuels, le groupe de patients utilisant majoritairement les technologies de reproduction. Cependant, il existe de nombreux types de patients qui bénéficient de traitements de fertilité et ces patients sont souvent négligés dans les politiques, la planification, la prestation de services et la recherche. Ce commentaire démontre la nécessité d’approfondir la recherche sur les sous-groupes LGBT, lesquels se situent souvent en dehors des discours sur l’infertilité et sont donc particulièrement désavantagés par les structures actuelles des politiques et des services de fécondité. Infertility is often framed from the perspective of heterosexual couples, the dominant patient group using reproductive technologies. However, there are many types of patients availing of fertility treatments and those patients are often overlooked in policy, planning, service provision, and research. This commentary demonstrates the need for further research into LGBT subgroups, who frequently fall outside of infertility discourses, and are therefore especially disadvantaged by current policy and fertility service structures. Mots clés

Les éditeurs suivront les recommandations et les procédures décrites dans le Code of Conduct and Best Practice Guidelines for Journal Editors de COPE. Plus précisément, ils travaillent pour s'assurer des plus hautes normes éthiques de la publication, y compris l'identification et la gestion des conflits d'intérêts (pour les éditeurs et pour les auteurs), la juste évaluation des manuscrits et la publication de manuscrits qui répondent aux normes d'excellence de la revue.
The editors follow the recommendations and procedures outlined in the COPE Code of Conduct and Best Practice Guidelines for Journal Editors. Specifically, the editors will work to ensure the highest ethical standards of publication, including: the identification and management of conflicts of interest (for editors and for authors), the fair evaluation of manuscripts, and the publication of manuscripts that meet the journal's standards of excellence.

More Than a Biological Condition: The Heteronormative Framing of Infertility
Erika Maxwell 1 , Maria Mathews 1 , Shree Mulay 1

Résumé
Abstract L'infertilité est souvent abordée du point de vue des couples hétérosexuels, le groupe de patients utilisant majoritairement les technologies de reproduction. Cependant, il existe de nombreux types de patients qui bénéficient de traitements de fertilité et ces patients sont souvent négligés dans les politiques, la planification, la prestation de services et la recherche. Ce commentaire démontre la nécessité d'approfondir la recherche sur les sous-groupes LGBT, lesquels se situent souvent en dehors des discours sur l'infertilité et sont donc particulièrement désavantagés par les structures actuelles des politiques et des services de fécondité.
Infertility is often framed from the perspective of heterosexual couples, the dominant patient group using reproductive technologies. However, there are many types of patients availing of fertility treatments and those patients are often overlooked in policy, planning, service provision, and research. This commentary demonstrates the need for further research into LGBT subgroups, who frequently fall outside of infertility discourses, and are therefore especially disadvantaged by current policy and fertility service structures.

Introduction
When it comes to infertility and the right to reproduce, financially stable, heterosexual couples often have the loudest voices [1], resulting in the heteronormative framing of infertility research. This heteronormativity obscures the experiences of people using fertility services who fall outside the traditional infertility definition, such as lesbian, gay, bisexual, transgender (LGBT), and other sexual and gender minorities [1,2]. Using a critical theory lens, we can examine political, economic, social, and cultural factors to gain insight into the reasons for inequality [3]. We argue that the definition of infertility, and its social construction, leads to an exclusion and oppression of LGBT individuals and call for more research on LGBT experiences with infertility and fertility services to inform services and policy.

Definition
Infertility can be defined as both a medical and social condition. The increased availability of fertility services has contributed to the perception that infertility, a natural part of life for some people, is a medical condition requiring medical treatment [1]. In fact, the World Health Organization defines infertility as "a disease of the reproductive system defined by the failure to achieve a clinical pregnancy [(diagnosed by ultrasonographic visualization of one or more gestational sacs or definitive clinical signs of pregnancy)] after 12 months or more of regular unprotected sexual intercourse" [4]. This definition is inarguably framed in heteronormative terms. Many studies frame infertility from the perspective of heterosexual couples [5][6][7][8][9] and neglect other groups. The heteronormative definition is restrictive and means that the concerns and therapeutic goals of other patient groups are often overlooked. This definition should be broadened to include more perspectives, specifically those from LGBT subgroups experiencing social infertility (or involuntary childlessness).

Social Construction of Infertility
The belief that the right to reproduce is inalienable is influenced, to some extent, by the social construction of motherhood and the importance of biological parenting. Although infertility is most commonly defined and recognized as a medical condition, it can be argued that it is also a social condition, as women often feel societal pressure to be mothers [8,10]. This pressure is derived from the social construction of gender and gender roles [11]. For women, motherhood is a role perpetuated by social, cultural, and patriarchal values [11]. In some cultures, women may be ostracized because of their inability to conceive [8]. Interviews with Indian women found that women experienced social exclusion for not being able to have children, even if it was the result of their husband's infertility [8]. In an American study, questionnaires used to assess perceived infertility-related stress amongst male and female patients found that women experienced greater stress than men from infertility-related social concerns, sexual concerns, and the need for parenthood [9]. Nonetheless, men also experience pressure to become fathers and similarly feel stress from infertility and societal expectations of fatherhood [9,12]. Their experiences may be hidden and stigmatized, particularly when fertility is equated with masculinity [13]. The need for parenthood described above demonstrates the constructed ideals surrounding parenting, as society defines parenthood in terms of the "biological parent" and assigns value to individuals based on their ability to have biological children. Biological parents are considered more legitimate than step or adoptive parents [14]. The nature of infertility as a social condition (and the social obligation to be a parent) means that it is not only experienced by heterosexual couples, but also by LGBT individuals and couples. The social constructions of infertility, motherhood, and biological parenting are important concepts to understanding how policy-makers, health care teams, and fertility patients define infertility. Research needs to explore how LGBT subgroups perceive and experience these infertility related issues.

Exclusion from Research
LGBT individuals are under-represented in infertility-related research. Although infertility research is beginning to examine this population, several studies noted that heterosexual couples are generally thought of as the main, if not the only, group using fertility services [1,15]. One researcher interviewed 17 heterosexual women of high socioeconomic status and 95 individuals from non-dominant groups using fertility services, including women of low socio-economic status, men, and women in same-sex relationships, to gain a better understanding of the medicalization of infertility [1]. The study found that the medicalization of infertility contributes to the misconception that infertility disproportionately affects white, wealthy, heterosexual women and excludes other individuals from proper access to reproductive care [1]. When LGBT subgroups are included in research, key information is lacking. For example, in studies that have examined the experiences of transgender individuals, there seem to be issues with the low level of service uptake, but little discussion of why this might be the case. Retrospective chart reviews of all transgender patients who had been seen for fertility preservation consultations at a Canadian clinic between November 2011 and March 2014 showed that nine of 11 male-tofemale transgender patients and zero of three female-to-male transgender patients used cryopreservation services [16]. For transgender patients, fertility preservation services seem to be underutilized [17], especially for female-to-male patients [16,18], who must undergo more expensive and invasive procedures. It must be noted, however, that the underutilization of services by female-to-male patients may be a consequence of these patients not identifying with typical gender roles attributed to women, like motherhood [11]. Additionally, the limited service uptake by transgender patients may be associated with the substantial difficulties faced by LGBT subgroups, including limited financial resources, discrimination, and poorly-educated health professionals [1,2,15,19,20]. Further research is needed to examine utilization of fertility services in LGBT subgroups, specifically transgender individuals, to substantiate these deductions.

Exclusion from Service
LGBT individuals regularly face exclusion from fertility services. For example, a review of fertility centre websites found that patient education was heavily focused on heterosexual couples and did not provide similar information for same-sex couples [15]. Moreover, lesbian mothers and lesbians attempting to become mothers experience stigma and discrimination [19,21,22], in addition to the typical challenges associated with infertility and motherhood [2]. In England, lesbians using donor insemination were subjected to heteronormatively structured protocols and underwent additional screening to ensure suitability as parents [19]. Australian lesbian mothers who had used fertility services also experienced various forms of discrimination when accessing health services and by health professionals, including inappropriate questioning, heterosexual assumption, and refusal to provide care [2]. In the Australian study, researchers called for equitable access to service through more inclusive policy, sensitive to non-heteronormatively structured families, such as the use of gender inclusive language, health promotional materials, and health assessment forms, as well as staff education on the specific needs of this patient population [2]. These patient experiences demonstrate the subtle micro-inequities that exist due to the heteronormative framing of infertility, such as health assessment forms catering to heterosexual couples, as well as more blatant acts of discrimination like refusal of care.

Exclusion from Policy
When discussing policies related to reproductive technologies and procreation, it is important to be aware that they have been, and still are, largely designed from a heteronormative perspective [20,23]. An example of this can be seen through the discriminatory federal tax incentive for procreation offered by the Internal Revenue Service in the U.S., which allows a tax deduction for medical expenses, including IVF and other assisted reproductive technologies [20]. The way the law is written may result in heterosexual couples and same-sex couples being treated differently in qualifying for the deduction. The deduction may not be available to same-sex couples, even if one or both partners are infertile, because the law stipulates that it is only available to (medically diagnosed) infertile couples who would otherwise be able to reproduce naturally (i.e., heterosexual couples) [20]. Policies such as these reinforce systemic discrimination that perpetuates heteronormativity, and thus contributes to the further disadvantage of LGBT individuals.

Conclusion
This commentary demonstrates that there is a need for a body of evidence related to infertility issues experienced by LGBT subgroups. Research on fertility care for the LGBT community offers an opportunity to gain a better understanding of infertility, as well as the social, political, and economic factors that surround it. Among other topics, research must explore the social construction of fertility from the LGBT perspective, develop a more inclusive definition of fertility, and describe barriers (and facilitators) experienced by LGBT individuals who seek fertility services. Research and the ensuing evidence base are needed to support inclusive policy and patient-centred models of care.

Conflit d'intérêts
Conflicts of Interest Aucun déclaré None to declare
Reviewer evaluations are given serious consideration by the editors and authors in the preparation of manuscripts for publication. Nonetheless, being named as a reviewer does not necessarily denote approval of a manuscript; the editors of Canadian Journal of Bioethics take full responsibility for final acceptance and publication of an article.