Sterile arguments

Lesbians and single mothers in the Basque Country, Andalusia and the Balearic Islands are able to get fertility treatment via the national health service. But those living in Madrid, Catalonia, Murcia and Castilla-La Mancha have to pay. The reason behind this difference is the individual interpretation of the law by regional health departments.

Legislation passed in 2006 on assisted reproduction clearly states that such treatment is available to women over the age of 18, "regardless of their civil status or sexual orientation." In other words, treatment is open to lesbians and single mothers. But the law adds that access is limited to cases where there is "a diagnosis of sterility or an established clinical indication, in line with the programs of each health service."

This somewhat ambiguous wording has allowed some regional health departments to close their doors to lesbians and single mothers, as well as to women who have undergone tubal ligation and now want to be mothers.

The debate on whether the public health system should make a distinction between heterosexual and same-sex couples, or include single mothers, is far from new in Spain. In 2011, a lesbian couple in the northern region of Asturias brought a case against their local government for refusing them access to reproductive treatment.

The law says that access is limited to cases when "sterility is diagnosed"

In the first years after the new legislation was introduced in 2006, state hospitals, with one or two exceptions, offered fertility treatment to single mothers and lesbians. Then, in the summer of 2011, the Catalan regional health authorities decided to limit treatment to heterosexual couples, and it was soon followed by others, among them Valencia.

The Valencian authorities have published a leaflet that has been distributed to fertility treatment centers and state hospital gynecology units entitled "Criteria for access to assisted reproductive treatment in state hospitals."

The leaflet states that treatment will be limited to women "affected by a documented clinical reproductive problem." It adds: "Women requesting treatment must prove they are in a long-term relationship or married." It also excludes couples where either partner has undergone "voluntary sterility."

It bases the new restrictive policy on the 2006 law, saying it is aimed at women "whose decision to undergo assisted reproductive therapy is based on personal reasons rather than in response to clinical problems." There is also a veiled reference to the ongoing cuts in health spending, saying that the new policy is based on "developments in society and in public health," which have prompted the need to "redefine" selection criteria. A recent case in Valencia has once again put the issue in the spotlight.

The new policy is based on "society and public health developments

Raquel and Elena are a lesbian couple living in Valencia aged 36 and 33, respectively. Raquel has been diagnosed by her gynecologist as unable to reproduce, although the exact cause, as stated in the medical report issued by a state-run sexual health clinic, is not known. They went to the clinic to explore the possibility of undergoing assisted reproductive therapy.

The couple's first visit took place in March this year. A specialist subjected Raquel to a range of tests to determine the condition of her womb and ovaries, and then sent her to an assisted reproduction clinic at the city's main hospital. Further tests confirmed that she was unable to have a baby. In July, the hospital turned down her request for fertility treatment. In the period between her first visit, the regional government had changed its rules, vetting access to treatment for lesbians and single mothers. Raquel and Elena lodged a complaint with the hospital's patient information desk. They were told that in accordance with the 2006 legislation on fertility treatment and the regional government's new criteria, from now on the hospital would only treat cases where there was "a diagnosis of sterility or clinical indication."

The couple pointed out that Raquel's gynecologist had diagnosed her as sterile. "This is nothing else but discrimination on the grounds of sexual orientation. If the gynecologist has given us a report with a diagnosis of sterility, how can they turn us down on the grounds of not being sterile?" asks Raquel. They are now preparing an appeal.

Luisa Notario, who, until March headed up the family unit of FELGTB, the national federation of lesbians, gays, transsexuals, and bisexuals, along with Francisco Pérez Milán, president of the Spanish Fertility Association (SEF), both agree that lesbians and single women are being discriminated against in some regions. They add that even in regions that still offer access to treatment to single women and lesbians, some take on the cost of the semen bought from sperm banks, which can cost up to 300 euros, while others pass that cost on to the patient.

How can they turn us down on the grounds of not being sterile?"

The Health Ministry says it wants to address the lack of clarity of the current law, and its interpretation by different regions regarding assisted reproductive treatment in state-run hospitals, as well as introducing nationwide criteria through patient screening.

But it is worth bearing in mind that it is also interested in seeing where it can make the biggest savings as part of the government's cuts to health spending.

The deficit in Spain's public healthcare system, coupled with the current Spanish public deficit crisis, has pushed the Health Ministry to adopt wide-reaching spending cuts - and further budget reductions are expected in the face of an increasingly bleak economic picture for the rest of this year and for 2013.

The government's spending cuts also include a new central purchasing system for prescription drugs, along the lines of the government's existing vaccine procurement facility, which it anticipates will save around one billion euros. A further 400 million euros will be derived from the removal from the national healthcare system of drugs deemed to be of little or no therapeutic value. An additional 500 million euros will be saved from the use of health technology assessments (HTAs) and 350 million euros from the wider use of generics. Spain passed a law last year requiring doctors to prescribe medicines by their generic name only. Doctors now write prescriptions specifying a drug's active ingredient only, plus the dosage and format, and pharmacists then dispense the cheapest version available.

Some fear that lesbians will be excluded by hospitals all over the country

The Health Ministry believes it can save up to 700 million euros by imposing more stringent screening on access to a wide range of services currently available free of charge in state-run hospitals.

Some in the assisted reproductive treatment sector, along with same-sex civil rights groups, have expressed concern that the government will use the need to set national criteria for access to fertility treatment - and to save money - as an excuse to reduce access to assisted reproduction and that lesbians and single-sex mothers will be excluded by hospitals throughout the country.

Federico Pérez Milán, the head of the assisted reproduction unit at Madrid's Gregorio Marañón hospital, and who attended a meeting of experts in the field on September 14 organized by the Health Ministry to discuss revising fertility treatment services, says that the ministry should be given an opportunity to present its arguments. He says that savings can be made "without eliminating certain services."

He and other health service professionals believe that the use of cheaper medicines and equipment related to ovary stimulation would help. He argues that looking at revising the range of services currently available under the state health system will help establish a better understanding of costs, and find where savings can be made..

A spokeswoman for the Health Ministry dismisses charges that there are ideological reasons for excluding single mothers and lesbians

Luisa Notario is less optimistic. "I think that by using the excuse of the current economic situation and the ongoing crisis, they are going to get the scissors out and we will be excluded." She and others in the gay rights movement are convinced that behind the financial arguments put forward by the regional government of Valencia are ideological reasons rooted in a belief that access to fertility treatment should be limited solely to traditional family models, and that single mothers and lesbians fall outside that realm.

Ana Monzó is the coordinator of the assisted reproduction unit at the La Fe hospital in Valencia. As a health sector professional, she argues that lesbians and single mothers should not be refused access to fertility treatment or assisted reproduction in state hospitals.

"I consider it very unfair," she says. "Sterility is a medical and an emotional problem," she adds. At the same time she warns that failing to provide such services to single mothers or lesbians will not save money. She points out that single mothers and lesbians make up a tiny proportion of women seeking assisted reproduction or fertility treatment compared to heterosexual couples. Furthermore, if these women are excluded, their place will simply be occupied by other women, the only consequence of which is that the service will in effect be offered solely to heterosexual women, a practice that clearly constitutes discrimination.

Luisa Notario agrees that the health service is unlikely to save any money by refusing treatment to single women and lesbians, and not just for the reasons outlined by Ana Monzó. The majority of women in same-sex relationships do not seek fertility treatment because they are infertile, and usually want artificial insemination, a process that costs around 1,000 euros, compared to the 6,000 euros for a cycle of in vitro fecundation. If state hospitals close their doors to lesbians, then private centers will take up the demand, including that of the small proportion of single mothers and lesbians still able to get treatment in some regions.

A spokeswoman for the Health Ministry dismisses charges that there are ideological reasons for excluding single mothers and lesbians from fertility treatment in state hospitals. "This is why we have brought together specialists from around the country to discuss the issue." Pérez Milán, who is the president of the Spanish Fertility Society, says that his organization is yet to adopt a position on the rights of single women and same-sex couples to have access to assisted reproductive therapy in state hospitals. "This is not a debate about the health service or reproductive health, but a social question," he says, adding: "It is up to health services to decide if they are prepared to finance this type of treatment. I do not think that it is about health, but rather about costs."

Lesbian calls for compensation

EMILIO DE BENITO, Madrid

A lesbian who was imprisoned in the final years of the Franco regime due to her sexual orientation has become the first woman to apply for damages under legislation passed in 2009 aimed at compensating those who suffered repression during the military dictatorship.

The Association of Former Social Prisoners (APS), a group that works on behalf of the gays, lesbians and transsexuals who were jailed during the Franco years, says that the woman, named only as MCD, presented her request to the courts on October 15. She was arrested in 1974 when she was aged 17. After a trial, she was sent to prison for four months.

Antoni Ruiz, the president of the APS, says the association has already presented damages claims on behalf of several gay men and transsexuals who were imprisoned or held in mental hospitals during the dictatorship.

Ruiz says that MCD does not want her identity to be made public because "homophobia is still a real problem, and this woman and her partner would find their lives in the community where they live made difficult."

MCD spoke briefly about her story at the offices of the APS after filing her claim. "I no longer remember much about the case: where I was arrested or when exactly. A group of plain-clothes police came up to me in the street and that was that. I have spent my life since then trying to forget what happened, and to overcome the ordeal." She says she never discovered the exact circumstances that led to her arrest. "I was held for months and interrogated. I didn't know what was going on."

She says that she knew people during the Franco years who were given electric shock therapy in hospitals. "Three of my friends committed suicide when they were outed by the police," she adds. "You have no idea what went on in those days. Some got married and tried to hide that way, but it was no use."

The court's report from the time of her arrest reads: "The daughter of an honorable family, MCD shows clear signs of homosexual orientation, and has had impure relations with another young woman whom she dominates, pursues and attracts. She is a rebel and disobeys her family and threatens them when they try to correct her and bring her up properly. She is a danger to her family and to society."

Based on legislation passed in 1970 covering "Social Dangers," MCD was sentenced to spend "between four months and three years in an establishment for the purposes of re-education." She was also forbidden for two years to attend any form of nightclub or disco "where alcohol is consumed." The lawyer assigned to her presented no arguments in her defense.

"We hope that this case will encourage other lesbians who were locked up at that time in prison or mental asylums to take action to get their dignity back," says Antoni Ruiz.

Gays, lesbians and transsexuals were persecuted during the Franco regime under a number of different laws. The "Social Danger" act remained in place until 1979, four years after the death of the dictator. Homosexuals who had been jailed were not included in the amnesties of 1975 and 1976. Antoni Ruiz spent three months in jail in 1976 after being arrested for being homosexual.

MCD says that she was sent to the Alzázar de San Juan prison in Ciudad Real province. "There was no attempt to re-educate me. We spent most of the time engaged in some kind of manual activities, like sewing. We were paid a pittance for the work - I guess somebody was making a fortune out of us," she says.

The Commission for Compensation of Former Social Prisoners, the body that reviews damages claims under the auspices of the Finance Ministry, will decide on MCD's case. She says that she is not expecting money, and simply wants recognition of the injustice she suffered.