The Overlapping Histories of Assisted Reproduction, HIV/AIDS and LGBT
Coinciding with the LGBT History Month, celebrated in the UK in February, I recently had an exciting opportunity to visit the Mortimer Market Centre, a sexual health clinic in London. I was there to give a talk to healthcare practitioners and researchers about the concurrent histories of HIV (the focus of their work) and sperm donation (a research area of mine). In different ways and under contrasting circumstances, both HIV/AIDS and assisted reproduction have played a substantial role in the lives of lesbian, gay, bisexual and transgender people, mobilising civil rights movements and uniting communities. The two histories, however, have been rarely told collectively – which is perhaps unsurprising, considering that AIDS activism and the politics concentrated around assisted conception, with their corresponding areas of medicine, seem to concern quite disparate issues. After all, one is about preventing death and the other about creating life. Yet, there are many interesting connections between them.
My visit to the Mortimer Market Centre was well-timed, not only because of the LGBT History Month but also thanks to another 'historical coincidence'. This year marks the thirtieth anniversary of two important events that make the year 1984 significant, both to those who work on HIV/AIDS and to those whose work relates to assisted reproduction. For the former, 1984 is the year when the American scientist Robert Gallo announced that he had discovered the cause of AIDS, which two years later was named the human immunodeficiency virus. For the latter, particularly those based in the UK, 1984 is meaningful because it was then that the so-called Warnock Committee, chaired by the philosopher Mary Warnock, published its report – the culmination of a two-year inquiry into human fertilisation and embryology.
It is noteworthy that news about initial HIV infections and AIDS-related deaths hit international headlines around the same time as stories about 'miracle babies' born through in vitro fertilisation and those conceived with donated sperm or eggs. Both the identification of HIV and the more expansive clinical application of IVF and gamete donation (the latter introduced more gradually over time) prompted rapid developments of largely new medical and pharmaceutical industries, as well as massive research infrastructures concentrated around them. Over the past three decades, treatment of HIV and treatment of infertility have both improved markedly. Medical advancements have enhanced health prospects, alleviated suffering and given hope. But they have also created new categories of patients and led to challenges and dilemmas previously unheard of.
Readers of this blog, most probably interested in reproduction, may be aware of the impact HIV has had on infertility treatment. One of the most significant consequences of the AIDS epidemic, especially in the United States, has been evident in the practice of donor insemination. As documented by researchers such as Cynthia Daniels and Rene Almeling, up until the 1980s, it was commonplace for physicians to use fresh semen when helping women conceive with donor sperm. Although cryopreservation, the process of freezing and thawing sperm, had already been in use with humans, there was a strong scepticism about its effectiveness. Further concerns pertained to the inevitable consequence of relinquishing part of the control over the reproductive process to commercial sperm banks (these, unlike physician-led services, were able to store and manage large amounts of frozen specimens). The resistance towards the use of cryopreserved sperm would have most likely lasted longer if it hadn't been for the advent of AIDS.
Between 1986 and 1989, six women in the United States were infected with HIV as a result of artificial insemination. Although the use of fresh semen was not banned, professional guidelines and fears of further infections led to a more widespread use of cryopreservation. Freezing eliminated the risk of infection as donated semen was quarantined for six months, after which the donor could be retested for HIV (later, the tests improved, allowing a quicker detection of the virus). The growing popularity of sperm freezing led to an increasing corporate concentration of the service provision. As founders of some of the first commercial sperm banks pointed out in the study by Almeling, AIDS was a key moment of 'market expansion'.
In the United States and elsewhere, the sperm banking industry grew quickly, diminishing the role of small providers. Initially, most sperm banks didn't accept lesbians and single women as clients. However, this restriction gradually changed as treatment for male-factor infertility improved. Most importantly, the introduction in the early 1990s of intracytoplasmic sperm injection (ICSI) offered the possibility of genetic fatherhood to a substantial proportion of men (for example, those with a low sperm count) who would have otherwise had to rely on donor sperm. Already-established sperm banks began to lose their clients, which meant that they had to revisit the inclusion criteria of those they were willing to serve. This, coupled with a growing interest in donor insemination among non-heterosexual women, eventually led to the current scenario where lesbians constitute about a third of sperm bank users.
What drew more lesbians to sperm banks was partly the fact that they became wary of undertaking insemination with semen from a male gay friend without clinical supervision – a practice that in areas with large sexual minority communities had become very popular by the 1980s. For a long time, gay men were, and to an extent still are, rejected by sperm banks as potential donors – mainly because of being a high-risk group for HIV infection, but also because homosexual orientation is perceived to come with a specific kind of masculinity that isn't necessarily in demand (just like there is little demand for donors who are short, overweight or ginger). This commodification of reproductive substance is less noticeable and prevalent in the UK, where sperm donors cannot donate anonymously and they are unlikely to do it for money (payments for donations mustn't exceed £35 per sample); thus, the supply of sperm is limited. Here, gay men can donate – as long as their HIV-negative status is confirmed.
Although necessary and justified, the strict clinical criteria safeguarding assisted reproduction from HIV may give a wrong impression that gametes from HIV-positive people unavoidably result in births of HIV-positive babies. However, this is not the case. By carefully managing the use of antiretroviral drugs, men and women living with HIV can now conceive with minimal risk of transmitting the virus to their baby or their HIV-negative partner. In pregnancies of HIV-positive women, mother-to-child transmission rates are now below 1%, while timed unprotected intercourse and sperm washing almost eliminate the likelihood of infection where the man is HIV-positive.
In the UK, clinicians working in HIV medicine are increasingly expected to provide a more integrated sexual and reproductive health service. With life expectancy similar to that of the rest of the population, and 75% of those currently infected in their childbearing years, it is not surprising that many people living with HIV consider and pursue parenthood. In this context, access to reproductive healthcare (including adequate, evidence-based advice) is important not only because there is nothing inherently unacceptable about an HIV-positive person becoming a parent, but also because lack of relevant support is likely to lead to conceptions that involve more risk – and, as a result, to more people facing stigma and requiring (expensive) HIV treatment.
The topic of reproduction in HIV clinics and HIV-related medical journals has thus far seemed to be limited to heterosexual family planning. However, with the prevalence of HIV among gay and bisexual men at an all-time high and the use of donor insemination among non-heterosexual women still growing, this is also likely to change – especially if sperm providers experience 'the real banking crisis', as adverts on the London Underground announced fairly recently. One can argue that the circulation of sperm has acquired new public and private meanings. It has a lot to do with the fact that, over the past three decades, both HIV and assisted reproduction have become, to a certain extent and in their own ways, normalised. With the pace of change in this 'repro-sexual landscape', it is difficult to catch up with the fast-evolving reality. It is also intriguing to think about what the next thirty years of the simultaneous developments in medicine and kinship will bring. And what other shifts we will witness in the LGBT history.
photograph via Flickr Stéphane Moussie