(Queer) Family Values and “Reciprocal IVF”: What Difference Does Sexual Identity Make?
In this paper I employ the case of “reciprocal IVF” (R-IVF)—in which a female–female couple uses in vitro fertilization to allow one woman to be the genetic mother and the other the gestational mother of their child(ren)—to illuminate the role sexual identity might productively play in bioethics. Bioethicists who have taken up this issue have largely focused on the moral permissibility and availability of the technology, and so defend R-IVF through analogy to commonly accepted different-sex uses of IVF. In this way, they position sexual identity as largely irrelevant to the primary bioethical questions raised by R-IVF. My approach diverges on these counts as I focus on the ethics of R-IVF through the lens of queer family values specifically. I ask what the practice of R-IVF as an option might mean for the queer community at large, and so view sexual identity as integral to a full bioethical evaluation of the practice.
Lesbian, gay, bisexual, and queer (lgbq) family-making has exploded in many western nations in the past few decades in the midst of growing social acceptance and legal recognition of queer families, as well as increasing options for same-sex reproduction.1 Philosophers and bioethicists have perhaps been late in taking up these issues compared to scholars in other fields concerned with politics, justice, and cultural criticism. And where philosophers and bioethics have taken up these topics, often the moral issues at stake are framed in a manner that implicitly or explicitly holds heterosexual reproduction through intercourse in a committed relationship to be the normal, natural, and morally unquestioned paradigm of “family.”
With some exceptions, pro-lgbq positions in the literature then often take what might be characterized as a defensive stance—leaving largely unquestioned the goodness of the traditional biologically-intact heterosexual family and arguing only that same-sex families and typical [End Page 443] modes of queer reproduction are equally good or can similarly instantiate the values that make traditional families worthy of dignity, social protection, and promotion. Thus, as Timothy Murphy (2014b) points out, the bioethics literature on lgbq reproduction often relitigates debates over the morality of same-sex parenting in itself.2 Where sexuality has been taken to make a difference in bioethical debates, too often the presumed difference falls out of assumptions or views that take lgbq reproduction and/or the resulting families to be morally inferior.
Murphy’s suggestion is that contra this tendency, bioethics ought to “assume in an axiomatic way” the legitimacy of lgbq parents just as it does straight parents (2014b, 765); in other words, sexual identity ought not make much of a difference in bioethics. For, presumably to the extent that a particular practice or technology involved in same-sex reproduction raises legitimate ethical questions, these questions will hold equally for different-sex couples’ use of the technology or participation in the practice as well. It begins to look, then, for those who affirm the inherent dignity of lgbq people and view lgbq parents as the presumptive equals of straight parents, that there is almost no room for sexuality to make any legitimate difference in bioethics.3
While I certainly share Murphy’s impatience with continued questioning of the appropriateness of lgbq family-making, I will here offer an alternative approach to thinking about what difference sexual identity might make. The position I offer takes on board Murphy’s axiomatic presupposition of the legitimacy of lgbq parenthood, yet also insists that sexuality might still make a significant difference in bioethics even with this presumption in place—particularly with regard to specifically ethical evaluations of various reproductive practices and family-making more generally.4
In what follows I illuminate this perspective by taking up the case of “reciprocal” in vitro fertilization (IVF), a practice in which coupled cisgender women can both be biologically related to their child(ren), one as the gestational mother and one as the genetic mother.5 A number of papers in the past decade have taken up this topic and defended the permissibility of “reciprocal IVF” (R-IVF) by comparing it to similar uncontroversial technologies—particularly IVF with intracytoplasmic sperm injection (ICSI) and IVF with egg donation—aimed at heterosexual couples (Woodward and Norton 2006; Marina et al. 2010; Dondorp et al. 2010; Zeiler and Malmquist 2014).6 Thus, like Murphy, the authors in question seem to hold that the sexual identities of those employing a given practice/technology are irrelevant to the morality of the practice/technology. [End Page 444]
I want to suggest, in contrast, that sexual identity is relevant to the ethical evaluation of these sorts of practices—an evaluation that goes beyond the question of mere permissibility. In the particular case of R-IVF, I will argue that attention should be aimed at the question of whether this practice and others like it cohere with specifically queer family values. Thus the primary question motivating my discussion is this: is R-IVF good for the queer community? (Though, I will try to show how taking up this question with lgbq people centrally in mind can also shed light on the more general ethical complexity of reproductive technologies like IVF for communities of any sexual identity.)
In Section 1, I summarize the conclusions of previous bioethical work on R-IVF, with emphasis on the analogizing of the practice to other more common uses of IVF in different-sex couples. In Section 2, I consider whether R-IVF might raise fewer moral concerns than other forms of reproductive technology. I then go on to make the case, in Section 3, that we have good reason to be suspicious of the practice of R-IVF from the perspective of the queer community by evaluating R-IVF in light of three queer family values: do-it-yourself (DIY), anti-bionormativity, and parental egalitarianism. I suggest, in concluding, that sexual identity does matter in bioethics and that taking up distinctively queer values in this case can help to show what is missing from previous evaluations of R-IVF.
1. BIOETHICISTS ON THE MORAL PERMISSIBILITY OF R-IVF
I begin by considering what other scholars have said about the morality of R-IVF. IVF in all forms involves stimulating the ovaries, oocyte removal, fertilization outside of the body, and then transfer of one or more embryos to the womb. In the traditional case there is only one woman involved medically, as the eggs are retrieved from the same woman who will carry the pregnancy and intends to parent; in IVF with egg donation, the process involves two women. R-IVF, then, is a specific manifestation of IVF with egg donation, in which the gestating mother and the genetic mother are partnered and intend to parent the resulting child(ren) together.
The general approach taken up in recent bioethical discussions of R-IVF is to presume the moral permissibility of different-sex couple’s use of IVF with or without egg donation and to compare R-IVF to those practices. Thus the main question at stake is taken to be whether R-IVF is morally permissible—whether it ought to be legal and made available at the level of clinic/practitioner policy. The answer to these questions is taken to hang on the degree of similarity between R-IVF and more traditional (heterosexual) uses of IVF. [End Page 445]
One way in which R-IVF would obviously be relevantly morally different than heterosexual uses of IVF is if lgbq reproduction or parenting is morally objectionable in itself. Indeed, a number of bioethicists arguing for the permissibility of R-IVF take up this possibility and aim to refute the suggestion and defend the legitimacy of lgbq families in just the form of relitigation about lgbq reproduction/families decried by Murphy (Marina et al. 2010, 940; Woodward and Norton 2006, 219–220). Apart from these discussions, however, most of the moral evaluation of R-IVF does not focus explicitly on sexuality at all, but rather on the questions of (a) whether R-IVF “treats” a medical problem and (b) whether the benefits of the practice outweigh the risks.
(a) points to another possible difference between R-IVF and heterosexual uses of IVF—that the latter often is taken up as a treatment for a diagnosable form of medical infertility, for instance, blocked fallopian tubes that prevent conception. Alternative reproductive practices aimed at same-sex couples, however, do not obviously treat a medical problem generally speaking; in the typical same-sex case an “alternative” route to reproduction is needed only because both members of the couple have the genitalia, reproductive organs, and gamete production associated with only one sex—not because one or both partners is medically infertile.7
A number of responses are apt here. First, it is worth questioning to what extent alternative reproductive practices are ever truly “treatment” at all. After all, the fallopian tubes function no more “normally” after IVF than before; rather IVF simply allows the couple in question to employ a route to conception that avoids the need for fallopian tubes to function.
Yet, even if IVF does not actually treat medical infertility, perhaps there still remains a worthwhile distinction between uses of IVF in which pregnancy could not otherwise occur and those in which pregnancy is possible through other means.8 This distinction, however, will not neatly divide heterosexual uses of IVF from those of R-IVF—for in some cases IVF will be necessary to allow a member of a same-sex couple to conceive. For example, consider a case in which one partner experiences severe ovarian deficiency, leaving her with no viable eggs, and the other experiences a uterine dysfunction that prevents gestation; neither woman here will be capable of carrying a pregnancy without an IVF procedure (Zeiler and Malmquist 2014, 349; Marina et al. 2010, 940). Surely R-IVF in particular is not necessary for conception, but IVF with egg donation is required; and often it will be easiest, least expensive, and otherwise preferable for the eggs to be provided by the other partner. Thus at least where one or [End Page 446] both partners in a same-sex couple experience a dysfunction that interferes with conception or pregnancy, no moral distinction between heterosexual IVF and R-IVF can be drawn.
But what we might we say of the “elective” use of R-IVF, in which conception and pregnancy would be possible without an IVF procedure?9 Here we come to point (b). If pregnancy is achievable through the less risky (and much less expensive) donor insemination (DI), then perhaps the use of IVF is not justified—for what benefits does it offer beyond DI (Dondorp et al. 2010, 2–3)? Lurking here is a generalized worry about the “overuse” of IVF. Kamphuis et al. (2014), for instance, suggest that in many applications of IVF the couple (or individual) has a reasonable chance of conceiving naturally or with a lower degree of intervention. Since IVF does bring risk in the process of egg retrieval as well as to the pregnant woman and fetus(es) post-transfer, we should takes Kamphuis’s overuse worry seriously.10 Elective R-IVF, no doubt, would strike many as a clear case of overuse—for obviously in the vast majority of cases DI is perfectly able to produce a successful pregnancy in lgbq women, but without the expense, invasiveness, or medical risk associated with IVF.
Yet here we must pause to question what exactly the end goal for those pursuing R-IVF is likely to be. Consider that Dondorp et al. (2010), Zeiler and Malmquist (2014, 350), and Chan et al. (1993, 216) all point to a parallel between R-IVF and IVF with intracytoplasmic sperm injection (ICSI). The latter is performed in cases of different-sex couples in which natural conception is impossible due to a low sperm count. In such situations DI might be just as likely to produce a pregnancy as in the case of female–female couples, and again DI is generally easier, less risky, and less expensive than IVF. Further, similar to the case of elective R-IVF, the gestating woman in such a case does not experience a medical problem that IVF aims to treat. Yet few practitioners or bioethicists question the ethics of offering ICSI to those couples who could instead experience a healthy pregnancy produced through DI (Zeiler and Malmquist 2014, 350; Dondorp et al. 2010; Chan et al. 1993, 213). And notably, in their discussion of the potential overuse of IVF, Kamphuis et al. (2014) do not identify IVF with ICSI as a likely overuse. Rather, they take the expansion of IVF to cases of “mild male subfertility, the effect of ageing on ovarian function, and unexplained subfertility where no absolute barrier to conception can be proved” as their main targets (2014, 1).
Presumably IVF with ICSI is not taken to be an overuse or seen as particularly controversial given that it is commonly assumed that [End Page 447] heterosexual couples will prefer it over DI. Dondorp et al. (2010, 814) explain the appropriateness of IVF with ICSI by appeal to “the meaning, for human couples, of having a child from both partners . . . and the psychosocial dimension of the parent role . . . [which] includes elements such as the contribution of both partners in the creation of the child, the confirmation this entails for their relationship, and the foundation of a shared responsibility for the well-being of the child.”
If IVF with ICSI is taken to be a reasonable nonoveruse of IVF, why not R-IVF as well? Dondorp et al. (2010, 814) appear uncommitted on the question of whether the benefits of both members of a couple being biologically related to their child will apply to same-sex couples as well as different-sex couples and call for more research on the topic. They admit, however, the likelihood of such benefits and suggest that the main question to be answered is whether such advantages outweigh the drawbacks of that route to parenthood.
The most obvious benefit regardless of sexuality is satisfying the desire of both partners to be biologically related to their child. Such a preference might result from a variety of factors. Some couples might simply value biological connections in themselves. In other cases one partner might wish to have a genetic child but be unable or uninterested in gestation, while her partner strongly wishes to gestate but has little or no concern about a genetic relation to the child. For others the pursuit of R-IVF likely results from a complex interrelation of preferences, values, and negotiation with social norms that both privilege biological connections and are skeptical of same-sex families (Mamo 2007b). Thus R-IVF appears to offer possibilities for the strategic use of biology in response to social disapproval and lack of legal recognition. In addition, there is evidence in the small empirical literature on the subject of social or emotional benefits for same-sex couples; Pelka (2009b), for instance, finds lower reported levels of maternal jealousy amongst lesbian users of R-IVF (and adoption) as compared to DI.
Neither concerns about (a) the “treatment” as a medical problem or (b) the balance of risks and benefits, then, can morally distinguish between R-IVF and IVF with ICSI. And since there does not seem to be much controversy amongst bioethicists and practitioners regarding IVF with ICSI, we must conclude that R-IVF should be equally legally permitted and available.11 [End Page 448]
2. R-IVF AS LESS MORALLY CONCERNING THAN SIMILAR FORMS OF ART
The literature discussed in Section 1 largely focuses on showing that R-IVF is no more morally objectionable than traditional heterosexual uses of reproductive technology such as IVF and egg donation (which are assumed not to be morally concerning). But might R-IVF in fact be less concerning than those practices?
Consider first that R-IVF fundamentally alters the kind of egg “donation” occurring—moving from what is often a commercial exchange to a completely noncommercial exchange. Many objections to egg donation—i.e. worries about exploitation, commodification of human gametes, and (to some extent) the “designing” attitude of parents-to-be—rest on the commercial aspects of the practice in particular (Steinbock 2004). But R-IVF is obviously not subject to these kinds of concerns (Zeiler & Malmquist 2014, 352).
More rarely, some scholars raise moral concerns about even gift donations regarding bodily products, since relations of love, friendship, and family can still involve exploitation or coercion.12 But R-IVF largely avoids these worries as well. The “egg donation” here is not a gift, since of course the genetic mother who provides the egg will be a parent of the resulting child, which significantly alters—though does not completely eliminate—the potential for exploitation or coercion.
Other objections to (anonymous) gamete donation focus on the supposed disadvantage donor-conceived offspring face with regard to identity formation given the lack of knowledge of one’s heredity and lack of relations with their genetic progenitor (Velleman 2005; 2008; Somerville 2011).13 In this case all lgbq reproduction is objectionable. But even by the lights of such an anti-lgbq reproduction perspective, R-IVF might still turn out to be an improvement over more common alternative forms of lgbq reproduction.
For example, take a case of medical infertility in a female–female couple. A cannot carry a pregnancy, but has viable eggs, and her partner B is capable of sustaining a healthy pregnancy, but only through the use of an egg donor. Somerville and Velleman will oppose reproduction in this situation given that the use of donor sperm will be necessary. But suppose the couple in question is going to reproduce. Their choices seem to involve either R-IVF involving a sperm donor or the use of an egg donor as well as a sperm donor. If being in a parental relationship with all of one’s progenitors is important for children’s identity formation, then ceteris [End Page 449] paribus wouldn’t the former choice be obviously preferable on Velleman and Sommerville’s views?14
More controversially, perhaps R-IVF also has a moral advantage—again, from the point of view of opponents to donor conception—over DI as well. Suppose a female–female couple plans to procreate using anonymous sperm donation, but has not decided whether to pursue DI or elective R-IVF. What would be best for the future child in this sort of case? No matter which option the couple chooses the child in question will not have significant knowledge of or a relationship with one of her biological progenitors. But note that there is a question of whether she will be biologically related to only one or to both of her social parents. Could there be a benefit to a child of splitting up the possible biological relations here to allow them to have such a relationship to both social parents?
Consider the details of Velleman’s account of how knowledge of and a relationship with one’s biological progenitors is important for one’s identity formation. Velleman stresses the ability to see resemblance in one’s biological relatives and to tell a story—even, it seems, a false story—as to how one is like or not like them (Velleman 2005). If this is an accurate account of identity formation, then it is plausible that an offspring might also benefit in being able to look to both of one’s social parents as having contributed to who one is biologically. That is, dividing gestational and genetic motherhood increases the “resemblance” narratives available to donor-conceived offspring.15 If so, then it seems that R-IVF might be a better option—on this count at least—than DI.
A final way in which R-IVF might be less concerning than more familiar reproductive technologies has to do with feminist objections to IVF on the basis that the practice increases male control of women’s bodies and will be used in ways that primarily benefit men and disadvantage women. For example, in IVF with ICSI due to male-factor infertility, the female partner takes on all of the risk and discomfort associated with IVF for the purpose of allowing her male partner to be genetically related to the child she bears. One might conclude that this type of IVF privileges men’s preference to raise only children to whom they are biologically related over women’s health and bodies (Corea 1985). But again, this worry does not apply to R-IVF. For not only does the gendered-aspect of control of women’s bodies largely drop out of the R-IVF context, but also the partner who wishes to have a genetic connection to the child takes on the primary risks and discomforts associated with ovarian stimulation and egg retrieval (Zeiler and Malmquist 2014, 352). Thus R-IVF allows both parents to [End Page 450] be biologically related to their child(ren) without producing inequalities along gendered-lines.16
To reiterate what I have argued for thus far, there is little reason to think that R-IVF is any more morally problematic than IVF with ICSI, and in fact R-IVF may be less ethically concerning than some other alternative reproductive technology practices. It is easy to understand why those who have taken up the morality of R-IVF have concluded that it is a permissible practice; after all, were R-IVF to be singled out for prohibition, this would “reflec[t] a heteronormative bias in the legislation [or policies] on assisted reproduction, in the sense that the law [or policies] takes the heterosexual couple’s situation as its point of departure” (Zeiler and Malmquist 2014, 354).
I certainly agree with Zeiler and Malmquist. Inasmuch as sufficiently analogous reproductive technologies are permitted and routinely made available for different-sex couples, R-IVF must be permitted and made available as well. But notice that this is a rather weak conclusion. For it does not offer any reason to think that those parallel technologies ought to be permitted and available in the first place, nor (relatedly) does it press questions beyond mere permissibility and consistency to get at the ethics of these practices, and to consider that they might differently represent promise or danger for people of different social contexts and identities.
3. QUEER FAMILY VALUES
My approach to evaluating R-IVF asks what the practice means for the queer community in particular. What are the family values that underlie (many) queer people’s conceptions of family and reproductive choices? Does R-IVF cohere with these values?
Perhaps this approach will be met with skepticism. Why think that there are any “queer family values,” as opposed to family values generally? Do we have reason to believe that lgbq people actually approach family-making any differently than do straight people? Much of the rhetoric in favor of lgbq family rights, after all, stresses the sameness of both different-sex and same-sex couples: “love is love.”
Yet, there is good reason to expect differences between lgbq and heterosexual approaches to family-making, reproduction, and parenting. Consider the following ways in which lgbq and heterosexual people are significantly differently situated in this domain. (1) Same-sex couples obviously do not have the ability to reproduce in the usual way through intercourse with one’s partner. It follows, then, that (2) queer reproduction [End Page 451] is situated in a society like ours always as “alternative”—not “natural” and perhaps abnormal. As a result, (3) lgbq reproduction requires a kind of planning and intentionality not typical for different-sex couples; relatedly, (4) it is inherent in the situation of a same-sex couple that parents will have asymmetrical biological relations to their child, requiring them to face choices about each partner’s role in reproduction that most different-sex couples do not face. Finally, (5) there are massive differences in social expectations and stigma related to reproduction depending on sexual orientation and the gender make-up of (potential) parents. Given these differences in situatedness, it would actually be quite surprising if there were not differences in procreative/family-making perspectives and values along the lines of sexual identity.
Further evidence in favor of specifically queer family values comes from the literature on lgbq parenting and child outcomes. Biblarz and Stacey (2010) detail a variety of differences found in previous studies comparing same- and different-sex families. These include equality in the division of labor between the partners, relationship satisfaction, intensity of desire for child and time spent reflecting on reasons for wanting child, child/parent attachment or warmth, the perception of parents as dependable or available, the child’s interest and effort in school, and the exhibiting of a nontraditional gender or sexual identities or behaviors (all of which are higher in female–female couples than male–female couples). In addition, emphasis on gender, social conformity, and disciplinary control; the use of corporal punishment; and the frequency of parent/child disputes all appear less likely in female–female couples (Biblarz and Stacey 2010).
Such differences in outcome don’t necessarily indicate value differences based in the sexual identity of the parents, of course. But it is reasonable to surmise that at least some of the outcomes do stem from value differences, given other knowledge about same-sex and different-sex couples/parenting. For instance, it should not be surprising that children of same-sex couples are more likely to defy dominant norms regarding sexuality or gender socialization—for same-sex parents themselves challenge these norms and so inherently model alternatives for their children. In addition, differences in valuing biological relations are also to be expected—after all, same-sex families cannot be biologically intact, and academic work on queer families going back to Kath Weston’s 1991 Families We Choose has pointed to queer emphasis on choice over blood relations as the basis of kinship ties. Finally, it is also well-documented that same-sex couples tend toward more egalitarian relationships (even if they do not always [End Page 452] succeed at this), and no doubt nontraditional gender-related values play a strong role here (Patterson et al. 2004; Goldberg 2010; Perlesz et al. 2010; Malmquist 2015).
With that as background, we can ask: what are some queer values that are particularly relevant to the ethical evaluation of R-IVF? I refer here to three aspects of queer attitudes and approaches to parenting and family that largely contrast with dominant heterosexual values: DIY, anti-bionormativity, and parental egalitarianism. In doing so, I do not claim to offer a full conception of queer family values, nor do I mean to imply that all and only queer people hold these values. Rather I mean to point to values which are strongly associated with lgbq communities—much more so than amongst straight communities—and which are particularly relevant to the evaluation of R-IVF.17
One might wonder here, what is special about these values? How do we know that these are indeed queer values and why should we appeal to these values and not others in evaluating R-IVF?18 I answer the first question by drawing on various qualitative and quantitative social science literature (as was discussed above and will be discussed in the next three subsections) as well as my own experience as a member of queer communities in justifying the claim that these are indeed queer values. More threatening to my argument is the worry that the queer values in question have been chosen arbitrarily or that there are other relevant queer values that are not discussed which would significantly alter the analysis I offer. Indeed, in some sense the danger that there are other relevant queer values that I have failed to notice and take up is unavoidable. But it is not clear that is a worry unique to my particular project. For any attempt to evaluate a practice from a specific moral or political perspective runs the risk of inaccurately or incompletely representing the perspective in question. Readers will have to evaluate for themselves, then, whether any other relevant queer values have been neglected.
A first queer family value is the do-it-yourself (DIY) approach to reproduction, which eschews medicalization of nontraditional reproduction and instead promotes keeping control of the process of conception in the hands of the parents-to-be. DIY has some obvious practical benefits for individuals/couples of any sexuality—most obviously minimizing the substantial financial burdens involved in achieving pregnancy through the fertility industry.19 But other aspects of the attractiveness of DIY connect [End Page 453] directly to queer—and feminist—values and the situation of queer women in particular.
For instance, scholars characterize early lgbq women’s use of DI as stemming from the more general feminist health movement as well as the lesbian separatist movement, and thus as embodying the values of resisting patriarchy and the male-dominated medical establishment (Agigian 2004, 105–112). Further, given anti-lgbq discrimination among fertility specialists, knowledge of how to inseminate and to procure donors at this time was typically garnered completely outside of the medical establishment. Thus, Mamo (2007b, 46) points out an early version of Our Bodies, Our Selves and mimeographed instructions passed around in lesbian circles describing the methods of self-insemination. In this way, the shape of the practice of early queer DI was tied up in specifically lesbian values particular to that time period.
Today, of course, queer women’s reproduction looks quite different; queer reproduction, like reproduction generally, has become more medicalized as more types of Assisted Reproductive Technologies (ART) have been developed and become more widely available (Mamo 2007a; 2015).20 Yet the practice of DIY today—though no longer completely dominating the field of women’s same-sex reproduction—offers the same value-based appeal for some and thus remains a popular approach for many lgbq women. Mamo (2007a; 2007b), for instance, finds in her interviews with female–female couples a hybridization of DIY values and more technological practices. Most couples described the traditional DIY type of reproduction—employing household items and tropes of romance and intimacy—as the “ideal” (Mamo 2007a, 380), and moved to more medicalized options only when the DIY approach failed. Mamo (2015, 118–19) points to The Ultimate Guide to Pregnancy for Lesbians, which offers advice along these lines: “Make the first time special [at home, DIY], then move on” (Pepper 1999, 66). The “specialness” here appears to reference the private, intimate manner of achieving pregnancy in the comfort of one’s own home—where the nongestating partner can be fully a part of the process—in contrast to the potentially sterile-seeming environment of a clinical setting. Further, a recent New Republic article details contemporary “self-help” versions of home insemination, which are common amongst lgbq women, while likely unknown and out of the ordinary for the average straight person (Yarrow 2014).
The explicit feminist emphasis on autonomy and resistance to the medical establishment present in the early lesbian DI movement also [End Page 454] continues to motivate some queer women. Boyd et al., for example, report that a number of interviewees in their sample of straight and queer Canadian single mothers who conceived through DI at a fertility clinic felt that “their reproductive autonomy was hindered” in a variety of ways, including “the expectation among fertility doctors that . . . women would largely surrender their decision-making capacity and bodies to the doctors” (2015, 193). This presumption of alternative reproductive processes as properly controlled by clinicians is also noted by Haimes and Wenier 2000 (494), who point to discussions in the bioethics literature that cast home insemination as dangerous and inappropriate, while the clinic is portrayed as the only proper place for lesbian reproduction. This attitude toward queer women’s reproduction is particularly objectionable given that vaginal or intracervical insemination of sperm through a syringe is no more difficult or risky than the more “natural” depositing of sperm in the vagina through ejaculation during intercourse, and is likely to be less risky than many common forms of medical intervention in conception.
The assumption of medicalized control of the reproductive process can easily lead to pressure toward taking on escalating medical interventions, which of course come along with increased risks. Women of all sexual orientations undergoing fertility treatment face such risks, but queer women perhaps are especially vulnerable to overmedicalization and hence bearing these risks unnecessarily.21 For example, in Ross et al.’s (2006) article offering queer women’s recommendations for improving assisted reproductive services, the authors note that queer women with no known fertility difficulties report being offered and perhaps feeling pressured to pursue intensive fertility interventions in clinical settings.22 This indicates a failure to properly distinguish queer women’s very different situation from that of the main patient population. Whereas heterosexual couples present with strong evidence of medical infertility—typically a year or more of unprotected sex without producing a pregnancy—most queer women have no fertility difficulty, but merely a lack of sperm production amongst both partners.23 Treating the latter group similarly to the former, then, will lead to overly aggressive treatment of many perfectly fertile women. Thus queer women have reason to be suspicious of the medicalization of reproduction over and above such worries for straight women generally.
Some of Boyd et al.’s respondents framed these concerns very explicitly in terms of a value conflict. One woman, referencing her own employment in the medical field indicated, “I was very aware of how watered down feminism becomes in the institutional contexts. And the local fertility clinics [End Page 455] were not even pretending to be woman centered. . . . So it was . . . just not wanting to even subject my body [to that]. So part of the decision to use a known donor was a decision not to be part of a clinical establishment” (Boyd et al. 2015, 196). Another woman states that “the sperm bank route . . . really didn’t fit with our values” (ibid).
DIY as a value then seems not only to fail to support elective R-IVF, but perhaps even actively opposes it. If DIY is truly a queer value in the sense I’ve suggested, what then should we make of the practice of R-IVF? Is this practice likely to benefit the queer community overall? Notice that this is a distinct question from that of whether individual queer people/couples will benefit from additional medicalized options for family-making (as no doubt some—possibly many—will, particularly those who face fertility difficulties that would make DIY reproduction impossible as well as male–male couples who have many fewer options for becoming parents). Yet I wish to focus not on the decision-making of any particular individual/couple, but on the situation of the queer community generally. What would it mean for us were R-IVF to become a standard option for female–female couples to choose electively?
One worry has to do with entrenching the power of the medical establishment regarding queer lives and the social and legal acceptance of lgbq families. It is already the case that that the “correct” setting for queer reproduction in the mind of much of the public as well as many fertility specialists is the clinic; that inane legal technicalities sometimes push same-sex couples into clinical settings;24 and that once in those settings, a sense of loss of control over one’s own body and pressure to pursue increasing escalations are not uncommon. Should the medicalization of queer reproduction further increase—say, in the mainstreaming of R-IVF—these already existing problems might very well intensify.
Further, elective R-IVF and similar technological options for queer reproduction perhaps represent a threat of sorts to a particular aspect of lgbq women’s culture—specifically the traditional channels of knowledge and social support regarding reproduction. The old lesbian and the turkey baster joke might be hyperbole—a small syringe, not a turkey baster, is the tool of choice for home insemination, unless one is dealing with buckets of semen!—but the gist is accurate. The early “lesbian baby boom” was largely born, after all, of women impregnating themselves and their partners in just these ways—successfully, safely, and cheaply, and with support and knowledge generated from outside the established medical profession. There is something sad, perhaps, in the prospect of the community losing that tradition. [End Page 456]
Finally, there is the impact on queer women’s bodies and health. Whatever the benefits of R-IVF and other reproductive technologies that might be aimed at queer people specifically, we ought not lose sight of the fact that such practices come with additional risks and burdens compared to DIY options, and that these burdens can be greater for queer women than for women generally.
Presumably the primary benefit of R-IVF is the creation of a child to whom both parents are biologically related. And no doubt, as in the case of IVF with ICSI, many potential parents are willing to take on significant financial burden, medicalization, and risk in order to achieve that goal. Yet here in the very goal of R-IVF we see another way in which the practice appears to be at odds with another queer family value: resistance to bionormativity.
Bionormativity refers to the common presumption that the “natural nuclear family”—one in which two parents combine their genetic material to create children—is the paradigm of family, given the presumed fundamental importance of the biological connection between parent and child (Haslanger 2012). The biologically intact family, thus, is taken to be the norm in both the sense of being natural and being morally/socially superior. Those families that fail to meet that standard are taken to be inferior and are subject to various sorts of stigma and discrimination, including social and legal denial of their familial status (Halsanger 2012; Witt 2014; Leighton 2012).
Take the popular assumption that children do best when raised by their biological parents and that any other sort of family structure will have significant negative effects on children. In political and legal debate as well as philosophical work on same-sex marriage such views are sometimes put forth as obvious—common-sense even—yet they are in fact empirically unsupported, if not wholly undermined (Roth 2016; Murphy 2011; oral arguments in Obergefell v. Hodges). U.S. family law also continues to prioritize biological relations in determining parenthood in ways that do not acknowledge queer family ties.25
In insisting on the dignity and equality of their families, queer communities have long resisted bionormativity of this sort, instead insisting that “love makes a family,” and stressing choice rather than mere biology as a fundamental way of creating familial ties (Weston 1991; Roth 2016). Consider the striking contrast between two major ongoing issues in family-law/policy: [End Page 457] the “dead-beat dad” phenomenon in straight communities and the nonbiological mothers of the lgbq community. In the former case, the public policy problem is how to deal with large numbers of biological fathers who upon ending romantic relationships with women they have impregnated, fail to pay ordered child support, and refuse to engage in an emotional or parental relationship with the child. In direct contrast to the “dead-beat dad” phenomenon, lgbq nonbiological mothers implore the state to take them up on their willingness to provide emotionally, socially, and financially for a child who bears no biological relation to them at all.26
Doesn’t R-IVF becoming a standard option for queer reproduction, however, reintroduce the idea that biology is of primary importance in family-making?27 There are three primary ways in which R-IVF might be thought to lend support to bionormativity. First, a significant uptake in the use of technologies that allow both parents in a same-sex relationship to be biologically related to their child(ren) might lead to the (re)entrenching of bionormativity as both a social norm and a basis for public policy. Many couples might (rightly) believe that the parental rights of the nongestating woman will be more strongly legally secured and that her role as a mother will not be questioned or denied socially if she is genetically related to the child. Thus, queer potential parents may choose R-IVF not because they believe that biological ties are of paramount importance, but rather as a strategy; in using R-IVF one can easily respond to questions about who is the “real” mother: “You’re both 100% the mom” (Pelka 2009b, 211).
Yet, while the strategic use of biological ties in this manner might benefit the particular couples/families who pursue them, such strategic uses can easily further entrench bionormativity.28 The quote above—“You’re both 100% the mom”—may not be meant to advocate the idea that biology is what makes one a full mother, yet the wider society is likely to read this answer to the “realness” question as an endorsement of bionormativity. After all, another alternative for responding to the “realness” question is to explicitly rebut the presumption that biology determines “real” parenthood. Thus at heart, this first worry is that R-IVF becoming a standard kind of queer reproduction will entrench the stigma and disadvantage experienced by all families that defy the bionormative model.29
Second, there is a worry about what the choice to pursue R-IVF expresses: what does it say about biology and family if some queer people themselves prefer biological relations to their children strongly enough to electively pursue a costly, riskier, and more invasive mode of reproduction? There is a parallel here to the expressivist argument against prenatal [End Page 458] testing from a disability rights perspective—that “prenatal tests to select against disabling traits express a hurtful attitude about and send a hurtful message to people who live with those traits” (Parens and Asch 1999, 13). If reproductive choices can properly be taken to express attitudes and values in the manner suggested, then we might understand the choice to pursue elective R-IVF as implying that families in which parents lack biological relatedness to their children are in some way lesser or at least less preferable than biologically-intact families.
Finally, the pursuit of R-IVF might be thought to demonstrate the intertwining of bio- and heteronormativity. One Brazillian recipient of R-IVF explains her choice this way: “if you marry a man, you want to have his child, not his neighbor’s. You want a baby from the man you love. So, nothing can be more natural than carrying a baby from the person you love. . . . It is different to know that child will be born with the features of the person you love and it is you carrying it. It is like trying to imitate heteronormativity, isn’t it? Because it’s one thing that heterosexual couples can have, and we should be able to have too. To have a child from the person we love” (Machin 2014, 51, my emphasis). But surely if R-IVF is at heart about imitating heternormativity, it is a practice worthy of significant queer scrutiny.
Indeed, some of the rhetoric of bioethical defenders of R-IVF supports the above worries. Consider two examples. First, the very titles of most of the bioethical papers on R-IVF reveal objectionable attitudes about what biological relations mean in queer family-making: Dondorp et al. (2010), Marina et al. (2010), Machin (2014), and Zeiler & Malmquist (2014) all use the trope of “sharing” motherhood to describe R-IVF.30 But what does this terminology imply about those queer families formed through other means? If women who break up gestational and genetic relations to their children are “sharing” motherhood, then what are most women in same-sex couples raising children together doing exactly? Not sharing motherhood apparently, in which case it must be that one woman (the biological mother, no doubt) is considered to be more a mother than the other.
Similarly, consider Marina et al.’s (2010, 940) understanding of the motivation to pursue R-IVF: “[b]oth of the women . . . wish to share in the maternity experience, instead of having one partner be a mere spectator, as happens with [DI]” (my emphasis); they state further, regarding the possibility of each woman giving birth to a child conceived from the eggs of her partner, that “this would be the highest level of participation [End Page 459] in reproduction as a couple” (my emphasis). Notice the ways in which these appeals to joint contribution/participation fall back into the bioand heteronormative conceptions of family. Participation “as a couple,” here, seems to be a method more similar to heterosexual procreation than DI, which results in a family that is closer to genetically intact than a DI-created queer family. Further, the notion that DI leaves one partner a “mere spectator” is false, as nongestating partners can be very involved in DI when it comes to choosing a donor, calculating the timing of insemination, handling sperm, and even performing the insemination. Moreover, conception through intercourse by different-sex couples can often involve little participation by the male-partner beyond ejaculation, yet men as a group are not generally considered to be “mere spectator[s]” in reproduction.
Considered in light of the relation to bionormativity, (elective) R-IVF begins to appear potentially retrograde and undermining of the progress of queer communities in gaining acceptance for their non-biologically based families.
To add another layer of complexity to the issue, however, we must note that plenty of common reproductive choices made by queer people also raise the worries discussed above, yet most receive very little critical opposition within the queer community. Pelka (2009a), for instance, points to the choice to procreate rather than adopt, to pursue a known donor rather than an anonymous donor, to use the same donor for all the children in the family, and to establish contact with donor-siblings; presumably lgbq parents engage in these practices because biological ties do matter for some queer people, and thus there are many ways in which lgbq people are complicit with bionormativity in everyday reproductive and parenting decisions.
I am more hesitant than Pelka, however, to assume that such choices are typically motivated by attitudes that take parent–child genetic relations to matter in themselves or by a desire to create a family that is modeled on the heteronormative model. Rather, motivations behind such choices are no doubt complicated as are their meanings, making it difficult to determine that any given reproductive choice expresses or means anything in particular.31 For instance, the choice to procreate vs. adopt is loaded with considerations having nothing to do with biology—such as financial and institutional barriers (including discrimination on the basis of sexual orientation in some cases), risks of a placement falling through, desire to raise a child from birth, and so on. [End Page 460]
This point, however—that the motivations of potential parents cannot easily be read off of their reproductive decisions—no doubt also applies to the pursuit of R-IVF. And indeed, as I suggested earlier in this subsection, a major motivation for pursuing R-IVF might not be actual acceptance of bionormative ideas, but rather the use of biological relations as a kind of strategy to gain social and legal acceptance. In any case, focusing on the motivations of queer potential parents perhaps misses the point. Whatever one’s motivation for engaging in a particular practice, that practice can very well still contribute to bionormativity, whether we have in mind R-IVF or more common reproductive choices in the lgbq community.32 Perhaps the upshot here then is that the queer community ought to be more self-critical of the established queer modes of becoming a parent than we tend to be.
A third queer family value to consider is parental egalitarianism, an aspiration to create parental relationships in which partners equally share the physical, mental, and emotional aspects of parenthood. The notion that same-sex couples—particularly female–female couples—tend toward more equality in their partnerships is supported by a significant body of social science research (Patterson et al. 2004; Goldberg 2010; Perlesz et al. 2010; Malmquist 2015), and has begun to gain exposure in the mainstream media and popular culture as well, for instance, with the argument that same-sex marriages might provide a model for equal partnerships for straight couples (Hirschman 2011; Mundy 2013). How does R-IVF square with lgbq women’s commitment to equality?
In contrast to anti-bionormativity and the embracing of DIY, which seem on their face incompatible with elective R-IVF, a commitment to parental egalitarianism looks supportive of the use of R-IVF. The practice, after all, appears to apply the commitment to equality to reproduction itself in addition to other aspects of the relationship, such as paid work, domestic labor, and childrearing. One respondent of Pelka’s describes R-IVF this way: “It was a much more equal process with, you know, our both having gone through the [hormone] shots and I was going through the [egg] retrieval and Marci went through the [embryo] transfer and all that, so it was more of an equal—just like our relationship—type of event” (Pelka 2009b, 210). There is a real sense, then, in which R-IVF is more egalitarian than either traditional heterosexual reproduction or queer DI, since in those cases the gestating woman takes on all of the physical [End Page 461] burden and risk. This, to my mind, is a way in which elective R-IVF is very much in keeping with at least one major queer value.
Relatedly, previous bioethical work on R-IVF has suggested that an additional benefit of R-IVF in keeping with the goal of parental egalitarianism is overcoming jealousy and emotional difficulties over conflicting mother roles. A common complaint amongst nonbiological mothers in same-sex relationships is a sense of not feeling like a full or “real” mother in comparison to the gestating, birthing, and (often) lactating mother. Such doubts as to one’s standing as a mother likely stem from a variety of sources, including material differences in the parent–child relation. Research indicates that particularly in the infant and toddler years, birth mothers in female–female couples do more childcare work and tend to be favored by the child regarding the fulfillment of basic needs; such inequalities in parental labor and the child’s apparent emotional attachments often lead to “hurt feelings and jealousy” on the part of the non-bio mother (Pelka 2009b).33
Pelka (2009b) suggests that these difficulties might be assuaged by the personal or public knowledge that the nongestating/nonbreastfeeding mother is also biologically related to the child. Indeed, she (2009b, 213, 211) finds that couples using R-IVF report lower levels of parental jealousy in comparison to those using DI and that both parents having biological ties to the child allows both women to feel “secure in their early maternity” even in the face of infant preference for the birth mother. Thus, beyond providing more equal sharing of the physical burdens of reproduction, R-IVF also mitigates negative consequences of less avoidable inequality, such as infant preference for the birth mother.
But should we uncritically accept that considerations of maintaining equal relationships endorse R-IVF? Regarding the potential to mitigate maternal jealousy, we might question to what extent such feelings result from heterosexist, bionormative, and monomaternalistic social and cultural understandings of motherhood—which imply that a person can have only one “real” mother and that this realness is a matter of biology (Park 2013, 3–9). R-IVF does offer a potentially radical response to this paradigm, in breaking apart the genetic and gestational aspects of biology, and so undermining the monomaternalistic paradigm. Yet as I argued above, R-IVF simultaneously buttresses bionormativity inasmuch as it supports the more general notion that “realness” is a matter of biology.
Similarly, emotional difficulties related to actual differences in parental relationships or caregiving—such as the birthing mother being [End Page 462] the breastfeeder or infants and young toddlers preferring the birthing mother for nurturance and comfort—might also be influenced by these problematic cultural norms of bionormativity, heteronormativity, and monomaternalism. For instance, Pelka (2009b, 198) comments that, “[W]hile heterosexual parenting couples expect that infants will be more closely bonded to their mothers than to their fathers, different parenting dynamics are not often anticipated by lesbian co-mothers, particularly among couples in which both women aspire to occupy equally primary ‘maternal’ roles.” We can ask: how are these maternal roles envisioned and why are they so different from typical paternal roles? If the root cause of the difficulties in question is actually objectionable social norms and expectations about what a mother—compared to a father—is or ought to be, pursuit of an expensive and burdensome reproductive technology seems an odd kind of solution.
It is contentious then whether R-IVF’s potential to mitigate maternal jealousies in same-sex relationships speaks in favor of it. Much clearer is that the practice certainly does produce more equality in the material sense of sharing physical burdens involved in reproduction. How should we make sense, though, of this one aspect in which a queer value supports R-IVF, when the other values I’ve considered tell more obviously against R-IVF?
One way to frame the question is in terms of how much this particular kind of equality is worth. Notice, for example, that while physical burdens and risks are shared more equally amongst the partners in an R-IVF case, there is in fact more risk and burden overall in the use of R-IVF than in DI, and these risks are borne not only by the women involved, but by the fetus as well. Leveling down—achieving equality by making those who are better off worse off—has been highly controversial in the realm of political egalitarianism, and it seems similarly if not more objectionable in the case of “leveling down” through R-IVF to achieve parental egalitarianism. Further, recall that I have argued that the other two queer values—DIY and antibionormativity—speak against R-IVF. All of this taken together, then, seems enough to conclude that even though R-IVF might rightly be endorsed from the point of view of equality, as soon as we broaden our view to consider other equally relevant values (queer or not), the appeal of R-IVF fades. [End Page 463]
In short then, queer values and politics represent a significant challenge to elective R-IVF. In many ways, this challenge is similar to other major debates within the lgbq community, for instance regarding marriage and closeting. Similar to many positions that are skeptical of marriage as an institution but strongly favor the legalization of same-sex marriage, the case in favor of R-IVF is of a largely conditional sort: If analogous heterosexual ART is permissible and widely available, then R-IVF must be as well. Indeed, I accept that conclusion, but hold that the focus on legality, accessibility, and permissibility obscures consideration of further ethical issues: whether this is a choice-worthy option from the point of view of the queer community. I think there is good reason to question its choice-worthiness, as I have done above, though I hope it is possible to raise these concerns without condemning any individual choice to use R-IVF.
The politics of closeting provides a different sort of parallel. On one hand, events like National Coming Out Day encourage lgbtq people to be open about their identities, and rightly so—for it is clear that on a systemic level remaining closeted undermines the community as a whole. Yet on the other hand, we might also insist on the need to refrain from judging individuals who remain in the closet given that many such individuals make their decisions under significantly constrained circumstances. Similarly, the critique I have put forth here aims primarily to take a systemic perspective, asking what is good for us as a community; the answer to that question—that elective R-IVF is an ethically problematic practice for the queer community—may very well be quite different than the answer of what is good for any particular member of the community.
This brings me back, then, to the question that subtitles the paper: what difference does sexual identity make? Murphy’s discussions of sexual identity as well as the approaches offered by Woodward and Norton (2006), and Marina et al. (2010) imply that sexual identity is likely to matter in bioethics and regarding new reproductive technologies only in a defensive type manner. That is, since bioethics as a field does not yet view lgbq potential parents as the presumptive equals of heterosexual potential parents, sexual identity is taken to be relevant in a manner that undermines the claim of lgbq people to equal access to reproductive technology and parenthood generally (Murphy 2014b). Those opposing heterosexism and anti-lgbq stigma within bioethics, then, engage with such ideas by defending the legitimacy of lgbq parenthood; hence a number of the papers on R-IVF directly refute common objections to lgbq parenthood with [End Page 464] empirical data and/or moral argument (Marina 2010, 940; Woodward and Norton 219–20).
But what if sexual identity were taken to make a positive difference rather than a negative one? This is what I have been aiming for in evaluating R-IVF through the lens of queer values. Doing so highlights the complexity of the meanings and possible consequences of this and other technologies for the queer community and thus can encourage a kind of reflection amongst lgbq people both looking forward as they are faced with new reproductive options, and also regarding current trends in queer reproductive choices. My suggestion is that these technologies are likely to be double-edged swords, promising real legal, social, and emotional benefits to same-sex couples, yet simultaneously buttressing traditional hetero- and bionormative conceptions of family in ways that inevitably harm queer (and other nonnormative) families.
It is not enough then, in my view, to argue for equal treatment of same-sex and different-sex couples, as much of the work on R-IVF does. For sexual identity makes a difference when it comes to the (bio)ethics of practices like R-IVF that goes beyond questions of permissibility and accessibility. The queer community as a whole simply has much at stake in these debates that is not at stake for the straight community. While it is true enough of course that lgbq people deserve every option and benefit provided to straight people when it comes to reproduction, we ought not lose sight of the possibility that some of those options bring dangers to the queer community that are not shared by the straight community in the same way.
Lgbq people have for decades offered a radical critique of dominant societal conceptions of reproduction and family, offering alternative and often better family values than the bio- and heteronormativity of straight family values. Whatever the future of queer reproduction and the place of new reproductive technologies in it, I hope we continue to do so. And this is why, even if existing inequalities and lack of accessibility based on sexual orientation were rectified, I would still not want sexual identity to fade from bioethics. Because in so many ways beyond these, sexual identity makes a difference.
Amanda Roth is an assistant professor of philosophy and women’s & gender studies at SUNY Geneseo. She earned her PhD in philosophy from the University of Michigan. Her ongoing research interests include reproductive ethics and lgbq family-making; abortion, pregnancy loss, and fetal status; and pragmatist approaches to ethical inquiry.
1. Throughout the paper I use “queer” in a few different senses, consistent with its use in the academic literature and the broader lgbtq community. When it appears in lgbq, “queer” should be understood as a specific identity marker [End Page 465] as employed by some particular individuals within the community. On the other hand, when I refer to queer families, the meanings at issue are both the umbrella use of queer—a reference to membership in the lgbtq community, whatever one’s specific sexual identity—but also a more politicized meaning—referring to resistance to heteronormativity.
2. Murphy (2014b, 762–63) points to recent work on the possibility of synthetic gametes as an example in which a number of bioethicists raise the use of such technology by same-sex couples as an ethical concern distinct from its use amongst different-sex couples.
3. Importantly, Murphy’s (2014b) view does not imply that sexuality makes no difference at all. In fact, in another piece on lgbq issues and bioethics Murphy (2014a, S10) identifies a number of research areas imperative for bioethicists to continue pursuing, particularly regarding ongoing disadvantages faced by queer people (S9). And in his article on synthetic gametes, Murphy (2014b, 765) does note that there will still be ethical questions that arise regarding the use of synthetic gametes and other sorts of reproductive technology by same-sex couples, but these legitimate questions will focus on ensuring “access and equity” analogous to that provided to different-sexed couples. In both cases, Murphy suggests that sexuality ought rightfully to make a difference in bioethics inasmuch as there continues to be significant disadvantage or inequality on account of sexuality, but in the (much) longer term he “would be happy to see the topic of homosexuality as a special concern retired from bioethics” (2014a, S10).
5. I use “cisgender” here with its common colloquial meaning—not transgender—and my references to same-sex couples throughout the paper generally denote couples involving cisgender women, as this is the group most obviously targeted by R-IVF as a practice. However, some users of R-IVF might have other gender identities as well; all that is required to be a candidate for the practice is one partner who produces useable ova, and another partner who is able to gestate.
6. R-IVF is also referred to as “IVF with ROPA” (reception of oocytes from partner) or “intra-partner oocyte donation” in the literature and is often characterized as a specifically lesbian practice. The latter is worrisome as “lesbian”—a description of a sexual identity—erases the non-lesbian sexual identities of many women in such couples. To avoid this problem I refer to couples involved in use of the various IVF technologies in terms of “same-” and “different-sex” and the families created by same-sex couples as “queer” or “lgbq.” [End Page 466]
7. Debates about same-sex couples using assisted reproductive technology (ART) have sometimes focused on the question of whether same-sex couples might be productively thought of as “socially infertile.” See: Murphy 1999.
8. The move here from “medical problem” to IVF being necessary to produce a pregnancy makes room for some heterosexual uses of IVF in which there is no medical problem—e.g. female infertility due to aging (Zeiler and Malmquist 2014, 351).
9. In contrast to my focus for the rest of the paper on elective uses of R-IVF, much of the existing literature on R-IVF is more concerned with nonelective uses—e.g. in cases in which the preferred gestating partner cannot conceive without the medical intervention of IVF (though see Zeiler and Malmquist 2014 and Machin 2014 for exceptions).
10. Kamphius et al. 2014 identify the following risks: increased chance of maternal and perinatal complications in multiple pregnancies (which are more common in IVF compared with natural conception), as well as the potential for increased risks to children born through IVF even in singleton pregnancies. In addition, ovarian stimulation and egg retrieval involve the risk of ovarian hyperstimulation, which can be life-threatening; the general risks associated with laparoscopy and anesthesia; and at least the possibility of long-term higher risk for ovarian cancer (ASRM 2015). Of course, we must also consider how the risks of IVF balance against the costs of pursuing other options. For instance, as Sills and Collins (2014) point out in response to Kamphius, lower level interventions like the use of ovarian stimulating drugs can also have significant risks, particularly in the form of multiple pregnancies.
11. Of course, there has been plenty of feminist criticism of IVF generally, particularly of the use of IVF for the purpose of allowing men to be biologically related to their children. Yet these criticisms do not seem to have influenced the availability or use of IVF.
13. Here I do not mean to endorse the concerns raised; in fact, I will actively contest them in Section 3.
15. Complicating things here is the different role genetics and gestation play in making an individual who they are. Velleman appears to take “resemblance” to be a matter of genetics alone. But understood more broadly, in terms of looking to (vaguely) scientifically informed (but not necessarily true) explanations of who one is, which are garnered through observation or relationship [End Page 467] with those with whom one has a biological connection, it seems remiss to ignore gestation. After all, the environment of the womb has far-reaching effects on a fetus, through epigenetics and otherwise. (One wonders if there might be an androcentric bias lurking in the over-emphasis of genetics and comparative neglecting of gestation when it comes to ideas about what biologically makes us who we are and is thus relevant to identity formation.)
16. In fact, R-IVF creates a more equitable division of burdens between the partners in comparison to DI—a point I develop in Section 3.
17. In discussing these three values, I do not mean to imply that individual same-sex couples are necessarily motivated by these values in their specific reproductive choices. Motivations are likely to vary greatly among couples and in some cases potential parents themselves may be unclear as to what exactly is the primary impetus for their own choices. I do not mean for the analysis I offer to hinge on what is in fact motivating individual choices to pursue elective R-IVF since I aim to evaluate what the practice means for the queer community as a whole. I take it that if elective R-IVF fits well with queer values, this will exonerate the practice regardless of the motivations of particular same-sex couples, and similarly, if queer values tell against elective R-IVF, the practice will be ethically concerning whatever the specific motivations of those who pursue it.
18. I thank an anonymous reviewer for raising these questions.
19. Though all who pursue alternative reproductive technologies are likely to face such costs, this burden can be particularly onerous for same-sex couples as they are often ineligible for fertility-related insurance coverage in the U.S. (in comparison to different-sex couples). See Blake 2011 as well as footnote 7 on the issue of whether same-sex couples should be understood to be infertile.
20. The choice to pursue medicalized reproduction vs. DIY can often be quite complex. As Mamo describes, finances, health or fertility concerns, a desire or need to become pregnant quickly, and legal vulnerabilities often lead couples in her study to opt for a medicalized route for pragmatic reasons, even if DIY is otherwise preferable (Mamo 2007a, 54). In addition, it is worth nothing also that some same-sex couples will have no option for reproduction but a medicalized route—e.g. male–male couples with neither eggs nor uteruses.
21. There is an abundant feminist literature critiquing ART on the basis of (over) medicalization of women’s bodies, though without a specific focus on lgbq women. See e.g.: Corea 1985, Raymond 1995, Lorber 1989.
22. Anecdotally, Ross et al.’s findings cohere with my own experience and that of a number of my lgbq acquaintances—e.g. being advised and sometimes pressured by clinicians to pursue ovarian stimulating drugs or IVF before ever [End Page 468] trying to conceive and often with little or no evidence of a fertility problem. See: Roth and Murphy 2017.
23. Of course, some queer women will have fertility difficulties that go beyond a lack of sperm and it is equally important that medical professionals do not ignore that reality either.
24. Here I refer to varying state laws governing alternative reproduction and parental rights, many of which provide more certainty and security for the parental standing of a nongestating partner when insemination is undertaken as a medical procedure by a physician as compared to DIY cases.
25. For example, unmarried same-sex couples have often had no way to secure parental rights (or obligations) for the nongestational or nonadopting parent; and where avenues have been available, they have generally taken the form of “second-parent adoption,” in which a nongestational mother must adopt her own child (Polikoff 2009).
27. Others raise this worry in discussion of technologies like R-IVF, though not as a specifically queer concern. Invariably, however, since these authors focus on moral permissibility, they quickly conclude that even if R-IVF were problematic for this reason, this could not justify restricting the use of it for queer couples when analogous technologies aimed at heterosexuals are widely available (Zeiler and Malmquist 2014; Murphy 2014b).
28. Whether the biological gambit described here will pay off even for those couples who successfully pursue R-IVF is unclear. After all, a female–female couple will still need to use donated sperm in order to procreate, and the result will be a non–biologically-intact family—hence an inferior family according to the bionormative standard.
31. Indeed, in continuing the analogy to the disability rights critique, it is worth noting that the same concern arises in that context as well: it simply is not clear that one can read off of the choice to selectively abort, given a fetal diagnosis of disability, any sort of attitude at all about disability or disabled individuals (Parens and Asch 1999, 15).
32. Still, I think the motivations and understandings of the (potential) parents are at least somewhat relevant here inasmuch as how parents display their [End Page 469] motivations and understandings to others can possibly affect whether—or to what degree—their engagement in the practice contributes to bionormativity. Consider again Pelka’s respondent who explains that in having used R-IVF, she and her partner are now both “100% the mom” (2009b, 211). This sort of use of R-IVF, and particularly expressing the notion that biological connectedness determines or shores up parental status, surely encourages bionormativity in ways that other expressions of the meaning of one’s choice to use R-IVF might not.
33. My wife (the non-bio mom in our case) has expressed this point in terms of the pressure of living up to societal notions of what a mother ought to be, combined with the continual ability to compare oneself as a mother in relation to one’s partner, and thus to have a constant reminder of one’s perceived maternal inadequacies.