LGBTQ+ service members report barriers to family planning, reproductive services

Key takeaways:

• LGBTQ+ service members who responded to a survey reported lack of knowledge and access to fertility services while in the military.
• Most respondents reported wanting to build a family during their military commitment.

DENVER — LGBTQ+ service members reported various barriers in both knowledge of and access to reproductive services while in the military, according to survey results presented at the ASRM Scientific Congress & Expo.

According to David Boedeker, DO, MHA, resident physician at Walter Reed National Military Medical Center, the military insurer, TRICARE, covers the cost of initial infertility consultation but not the cost of assisted reproductive technologies, and changes to this insurer require congressional acts. In February 2023, Boedeker said a new policy was enacted to allow service members to request leave of absence, a total of 21 days, for noncovered reproductive health care, including artificial reproductive technology, without losing pay or being charged leave.

“Although the military has made efforts to improve their infertility service coverage, historically, many of these policies have primarily benefited heterosexual married couples; for example, previously, assisted reproductive technology was only covered for individuals who have experienced infertility as a result of a service-related injury or illness. However, that benefit was extended to nonhigh-risk individuals this past spring,” Boedeker said. “Although the military has recently expanded reproductive health benefits and policies, we hypothesized that lesbian and gay military service members face continued obstacles when seeking fertility care.”

For the first survey, Boedeker and colleagues assessed family planning desires and barriers among LGBTQ+ service members. The survey was distributed at the obstetrics and gynecology clinic at Walter Reed National Military Medical Center and shared on various social media pages for LGBTQ+ service members.

From August to September 2023, 28 gay men (mean age, 32.9 years) and 40 lesbian women (mean age, 33.2 years) responded to the survey.

Compared with gay men, lesbian women were more likely to be married (50% vs. 78%) and in a relationship for longer than 3 years (64% vs. 68%), according to the survey responses. Lesbian women were more likely to plan to start a family while in the military (95.5% vs. 67.9%) and to cite the importance of a biological link to offspring (67.5% vs. 46.3%) compared with gay men, according to the survey responses. Lesbian women (57.5%) and gay men (50%) reported similar feelings of support in family planning while in the military.

Gay men reported lower rates of previously meeting with a fertility specialist (7.1% vs. 62.5%), less knowledge on who to approach for reproductive services (25% vs. 65%) and less knowledge of resources to pursue surrogacy or donor oocytes/sperm (21% vs. 50%) compared with lesbian women. Knowledge of financial resources for family planning was similarly low, according to the survey responses.

Boedeker said these disparities in survey responses suggest that men may benefit from more targeted educational resources regarding family planning options.

“As the military plans to retain a diverse workforce, they may consider continuing to gather infertility coverage to support LGBTQ+ individuals in building their families during the military service,” Boedeker said.

Kiley Hunkler, MD, MSt, MSc, resident physician at Walter Reed National Military Medical Center, and colleagues expanded the previous survey to also include transgender and gender-diverse (TGD) service members.

“Individuals were first granted the right to openly serve as transgender service members in June 2016. This was reversed in 2017 and then, in 2021, transgender service members were again granted the ability to serve openly,” Hunkler said. “We therefore hypothesized that transgender patients would report more barriers to initiating fertility treatment compared to their lesbian, gay and bisexual counterparts, despite having similar parenting desires.”

The survey was distributed, using the same methods as above, from August 2023 to March 2024. Overall, 93 individuals responded, of whom 25 self-identified as TGD and 68 as lesbian, gay or bisexual (LGB).

LGB service members reported a stronger desire to have children (97% vs. 76%; P < .01) and to start a family while in the military (82.4% vs. 57.9%; P < .05) compared with TGD service members, according to the survey responses. Both reported similar support for family planning (TGD, 40%; LGB, 52.9%) and similar feelings about the importance of a genetic link to offspring (TGD, 44%; LGB, 58.8%).

More LGB members reported previous pursuit of fertility services (32.4% vs. 28%) and previous requests to meet a fertility specialist (39.7% vs. 28%) compared with TGD members, according to the survey responses. Conversely, more TGD service members reported knowledge of reproductive services (48% vs. 37.1%) and awareness of financial resources (29.2% vs. 16.2%) in the military compared with LGB members.

“There are additional barriers that need to be explored that may rise from both institutional limitations and implicit biases in the system,” Hunkler said. “For example, although transgender, lesbian, gay and bisexual patients can now openly serve, these rights have historically been limited. Although these policies have been rewritten, we need to recognize they still may have created an environment in which transgender patients may feel unsupported in their efforts.”