Infertility and non-traditional families.

This issue’s Feature Article and accompanying commentaries focus on the issue of uterine transplantation (UTx). Stephen Wilkinson and Nicola Jane Williams consider, in the Feature Article, whether there is any good reason why publicly funded healthcare systems such as the UK’s National Health Service (NHS) should not fund UTx in the event that it becomes sufficiently safe and efficacious. They argue that public funding for UTx should not be denied on the ground that creating more people would contribute to climate change problems, nor on the ground that infertility might be better viewed as a social problem rather than a disease. They then question whether systems like the NHS might decline to fund UTx on the ground that there exist sufficiently good, cheaper alternatives to the problem of absolute uterine factor infertility (AUFI), such as adoption and surrogacy. Both of these alternative options offer the possibility of ‘social parenthood’ (rearing children), which the authors note is the most powerful reason for the state to fund fertility treatment. However, neither of these alternatives is quite satisfactory. Prospective parents typically do not merely want social parenthood, they also want genetic and gestational parenthood (parenting a child to whom one is genetically related, and whom one parent has gestated). Adoption offers neither genetic nor gestational parenthood, and surrogacy offers at most only genetic parenthood. Wilkinson and Williams argue that while genetic and gestational parenthood are not the strongest reasons for the state to fund fertility treatment, neither are they so insignificant that they can plausibly regarded as mere ‘frills’ or ‘optional extras’. The authors concede that surrogacy might become a sufficiently good alternative to safe and efficacious UTx if the law surrounding it were reformed; until then, the case for refusing state funding for UTx is weak. THE HARM OF INFERTILITY AND CULTURAL ATTITUDES Wilkinson and Williams’s article is accompanied by commentaries by Amel Aghrani, Jacques Balayla, and Mianna Lotz. Aghrani and Balayla are broadly in agreement with Wilkinson and Williams. Lotz focuses her argument on the role played by social and cultural attitudes in the harmfulness of infertility. As she notes, Wilkinson and Williams concede that in many societies including the UK, people—especially women—who do not become parents are discriminated against, and this likely exacerbates the extent to which infertility is viewed as a harm. In particular, our socio-cultural attitudes encourage the view that it is important to become genetic and gestational parents. Were such attitudes not widespread in society, not having children at all, or parenting children to whom one is not genetically or gestationally related, might be more widely accepted as worthwhile alternatives to the traditional model of parenthood. Wilkinson and Williams argue that, until our society’s attitudes change, the preference for genetic and gestational parenthood warrants viewing safe and efficacious UTx as sufficiently superior to adoption and surrogacy as to prioritise it for public funding over those alternatives. Lotz, in response, argues that Wilkinson and Williams underestimate both the likelihood of being able to change society’s emphasis on genetic and gestational parenthood, and the extent to which prioritising fertility treatments that ensure genetic and gestational parenthood risks reinforcing that emphasis. According to Lotz, the possibility of implementing societal efforts to undermine this emphasis, along with the possibility of reforming surrogacy and adoption law, weaken the case for publicly funding UTx. In their response to the commentaries, Wilkinson and Williams welcome Lotz’s suggestion of societal efforts to reduce the emphasis on genetic and gestational parenthood, but they argue that such efforts could complement, rather than substitute, publicly funding UTx. Indeed, offering publicly funded UTx alongside educational efforts is preferable since it takes seriously and responds to the real distress of infertile couples. HETEROSEXUALITY, HOMOSEXUALITY, TRANSGENDER, AND (IN)FERTILITY The discussion in the Feature Article and the commentaries applies to the traditional model of starting a family in the context of a heterosexual relationship. However, these arguments are not quite satisfactory when we consider issues associated with starting families in the homosexual and transgender communities. Before considering why, let me introduce a few terms that have entered the public discourse, yet which are perhaps not so ubiquitous that they can be used without confusion. The term ‘cisgender’ refers to people who identify with the gender they were assigned at birth. ‘Transgender’ refers to people who do not identify with their gender assigned at birth. Some transgender people are trans men or trans women; that is, the gender with which they identify is different to the one assigned at birth. Some, but not all, trans men and trans women seek medical help to transition physically to the sex associated with the gender with which they identify. ‘Transgender’ also includes people who do not identify with any one gender; these include non-binary individuals who do not identify with any one gender, and gender fluid people who identify as both male and female at different times.