“The right to motherhood was a luxury, a privilege, one that I was often made to feel as if I was stealing. Because the big message is that you shouldn’t even exist, let alone become a mother.” Demetra speaks in a low voice, trying not to be noticed by the customers of the shop where the interview is taking place. Demetra, an intersex person, asked to speak to MIIR under a pseudonym. Her physical difference can be a cause for harassment.

The initial findings of a recent survey by the NGO Intersex Greece  on hate speech against intersex people (i.e. individuals whose anatomical gender is ambiguous) confirm that little is known about this unusual condition. The subject is not openly discussed, and when it is, is often presented as a problem rather than just a peculiarity of human biology. The prevalence of the unscientific term “hermaphrodite”, with its negative connotations, is indicative of the way intersex people have been presented in Greece.

“Doctors told me not to talk to other doctors [about the difference], because they all wanted to use me for their own scientific publications,” says Demetra. From the testimonies of intersex people, hospitals are the places where prejudices about intersex anatomy most often manifest themselves. “Any doctor I approached would put me in for tests. Tests and more tests, as if they had found some treasure. All without dealing with me personally, without asking me how I felt, without explaining what was wrong with me, what I could do, what the prospects were.”

Demetra found out she had no ovaries after an appendectomy when she was 12. Her intersex variation, very rare, is a completely female body but with male chromosomes (XY). “Many transsexual variations, but not all, result in infertility,” according to Intersex Greece. But some intersex people can procreate, and the use of reproductive technologies is straightforward enough. However, their access to these solutions is not without financial or psychological obstacles.

Demetra recounts: “A doctor told me: ‘Don’t say anything, ever, to your future husband. When he realises you can’t have children, if he has loved you then he’ll keep you’.” Doctor’s orders are often to conceal one’s biological status. “And always the question of a child was, for me, a fantasy. To a person who has been told from the age of 12 that you’re never going to be a parent you understand that the idea takes on another dimension.”

But at 25, Demetra was told for the first time that she could undergo in vitro fertilization (IVF) with donor eggs, with a success rate of 10-13%. “From the 0% up till then, it seemed like a huge opportunity,” she says.

Mother of triplets, father of one

IVF through egg donation has been practised in Greece since 1987. However, the service has only been systematised since the 2010s, since it has depended on both the availability of genetic material and the development of cryopreservation techniques (vitrification).

Since around 2015, Greece can claim to be one of the most popular destinations for services in assisted reproduction technology (ART) in Europe. According to companies promoting fertility-tourism packages, the country is currently second only to Spain, which holds the lead in the sector.

The graph below shows the spread of various assisted reproduction methods. According to data from Greece’s National Assisted Reproduction Authority, the proportion of births resulting from the use of any assisted reproduction method was 6.4% of the total in 2019. Specifically, according to the available data, the method that yielded the highest number of births was IVF using donor eggs, followed by IVF using fresh eggs from the expectant mother. In 2019, 219 inseminations using donor sperm were also performed. This category is the most likely to include lesbian women.

Despite the permissive legal framework and state-of-the-art technology, Demetra discovered a field riddled with taboos. With donor eggs fertilised with her partner’s genetic material, she conceived on the first try. “The doctor who did my IVF told me, ‘You’ll never say anything to the child or you’ll destroy it’,” she says, recalling the secrecy with which she was advised to handle the whole issue.

More than a decade after Demetra’s successful IVF, Vasilis (not his real name) has become the father of a boy, again through assisted reproduction. Vasilis is gay and under the current legislation there is no way for him to officially become a parent. “I grew up in a country and in a generation where synonyms for the word ‘gay’ were ‘single’ and ‘outcast’.” Vasilis agreed with his friend Helen, also gay, to present themselves as a couple, and to make use of reproductive technologies from which he, in particular, is usually excluded.

Not all gay people are equal

Gay women who want to procreate are referred to ART departments with the status of “single” even if they are in a relationship with another woman. Greek law allows unpartnered women to have IVF (using donor sperm), but prohibits it for unpartnered men, regardless of their sexual orientation. The practical result is to exclude homosexual couples of any gender.

In a study  , EDJNet’s member Civio compiled data on gay women’s access to assisted reproduction across Europe. The majority of 43 European countries prohibit access to openly lesbian women (and therefore to lesbian couples), while a third of countries do the same for unpartnered women. According to the survey, the worst off are intersex and transgender individuals. In several European countries, these people are still subject to compulsory sterilisation when they undergo a sex-change procedure.

“In Greece, assisted reproduction for homosexuals will be linked to the recognition of gay marriage, whenever that happens,” legal experts told MIIR. “The cases that we know about of homosexuals who became parents were either people living abroad or a few exceptions of Greeks who might have had the money to move mountains and get around the law,” says Vasilis.

As not all gay men have a close friend ready to share parenthood, IVF clinics sometimes offer under-the-table ways to circumvent the law. “Doctors smell desperation, so clinics spread the word – ‘gay people, come have kids’ – and exploit those who are desperate.” During his period of research into the potential ways of having a child, Vasilis was put in touch with a large ART unit with the promise of success through a surrogate mother. With the help of a friend of his who would pretend to be his partner, “we found a doctor who was willing to bear false witness – a legal document was required – that my friend had done many IVFs, had endured psychological suffering, and that we could only procreate through a surrogate,” he says.

Despite the pressure from the clinic to quickly close a deal with a Moldovan surrogate – or rather precisely because of it – Vasilis concluded it was a scam. There was no shortage of experiences among his gay friends whose attempts to become parents in this way had not come to fruition. The clinic’s justifications, of “incompatibility of genetic material” or “weak sperm”, did not convince the would-be parents.

Missing letters

It is not just the law that sets limits on access to assisted reproduction. Even when it is guaranteed, the cost can be a deterrent.

For procreation through a surrogate mother, the large and well-known clinic that Vasilis approached asked him for €25,000 to cover the fee of the woman who would carry the child, €5,000 for the IVF, “5 or 8 thousand for the doctor’s commission – that’s exactly what the doctor said” and €3,000 for “egg selection”. As the use of a surrogate requires an official document, the price goes up. In the end, the IVF procedure cost €8,000, including the tests and 8 failed inseminations. He and his female friend are currently raising their baby together.

A ticket to a seat in the waiting room of parenthood cost Demetra €3,000. In her case, the drugs for ovarian stimulation are acquired by the donor and the cost was borne by the recipient. The Greek public health service does not cover the cost of the drugs when IVF is done with a donor. However, according to MIIR’s information, many couples using borrowed eggs manage by some irregularity to secure the expensive drugs for free, at least for the first attempt. “The loophole to get them illegally requires you to have a uterus and ovaries and a rudimentary chance of producing eggs,” says a former employee of a large ART unit in Athens, who wishes to remain anonymous.

Demetra is left wondering: “It’s not that I took too long to decide to have children, it was for biological reasons. Shouldn’t I be entitled to a discount?” After an easy pregnancy where everything went well, Demetra became, as she says, one of the few people with this physical condition who managed to become a parent. “If I am not the first in Greece, then I am certainly one of the first. Both here and worldwide.”

Of the letters in the acronym LGBTI, none of the people concerned has unfettered access to assisted reproduction. Gay men are completely shut out, and intersex people are likely to experience the same obstacles that accompany them through the rest of their social lives.

“If you ask me what the ideal is, I can’t tell you. Because I don’t have that much imagination. I’m very realistic. I don’t even daydream when I know it won’t work out. In an ideal world, I might want a child with my partner,” says Vasilis. As his friends remind him, he can overcome “written and unwritten laws” if he formally conceals his sexual orientation. “And if the kid asks me ‘Why, daddy?’, then I’ll tell him that we wanted him so much, we turned the world upside down.”

Of the 43 countries analysed for this investigation, 12 do not allow single women to access in vitro fertilisation. Even more countries, 16, also prevent single women from getting assisted insemination. The list of countries that prevent single women from getting a donated egg is even longer.

The situation is worse for female couples: 24 countries ban their access to ART outright. For the LGTBIQ+ community, having children via ART is not an easy path in Europe. “The places where it’s most difficult for LGTBIQ+ people to get a job or to be out or to get married or to undergo legal gender recognition are also the places where it’s most difficult to have access to assisted reproductive technologies,” says Cianan Russell, from ILGA Europe, a federation of European lesbian, gay, bisexual, trans and intersex rights groups. They say Hungary and Poland are the countries where the situation is the worst, but the problem is widespread in Europe. Even where people can obtain reproductive assistance legally on paper, reality sometimes brings “discrimination, harassment or even violence” to the process, Russell says. Those who are suffering the most problems are trans and intersex people, they add.

People facing these forms of discrimination grapple with difficult alternatives. In the case of the LGTBIQ+ collective, says Russell, there are three. The first is misrepresenting one’s identity, such as female couples who lie by saying that just one of them is seeking treatment as a single woman, if that is allowed, or non-binary people or trans men who say they are women. The second alternative is crossing borders to seek access in another country. The third is conceiving with friends or trusted people even if they are not attracted to them.

Although this is not common, it is a path that many people who want to have children may take if the barriers seem otherwise insurmountable. In the case of single women, Izaskun Gamen, spokesperson for the association Single Mothers By Choice (MSPE), says that, during her years-long process to try to have children, some people suggested that she get pregnant by a stranger after a one-night stand and not tell the father. That seems unthinkable to her, she says: “How do you explain that to your child later? How do you explain that he or she was born of a deception?”

Older and older mothers

The only legal barrier for heterosexual couples, in most cases, is age. The women seeking ART are getting older. In the last decade, the average age of mothers at the birth of their first child , whether natural or assisted, has increased in most of Europe. In Spain and Ireland the average age was over 32 years old in 2019.

That’s average, which means that many women access ART later, when, because of their age, conceiving naturally becomes more difficult. Most countries put the legal ceiling for assisted reproduction around 50 years. This is the maximum age in Greece, for example, but in response to COVID-19 pandemic-related treatment delays the government extended the age to 52 years until June 30, 2023.

Juana Crespo, director of an eponymous fertility clinic in Spain specialised in difficult cases, says the main problem for her patients is old age: “We get old and, when our reproductive system becomes old, the whole orchestra is old.” She calls this a “new disease”: “The history of delayed motherhood is unwritten.”

Although women’s ages are a common source of reproductive difficulties, Carlos Calhaz-Jorge, a fertility doctor and researcher at the Universidade de Lisboa in Portugal and president of the European Society of Human Reproduction and Embryology (ESHRE), says that half of the problems of couples who seek ART are from the male partner.

Yet age is not a factor of legal exclusion for men and, in general, there are no limits in European countries. Only three of the 43 countries have maximums: France, 59 years; Finland, 60 years; and Switzerland, 56 years, although in these last two cases they are recommendations, not legal prohibitions. In fact, in Switzerland the recommendation is that the father can be alive until the child turns 18, a more sociological than medical recommendation.

The most common obstacle: lack of financial resources

Once the legal obstacles are overcome, the economic ones rear their heads. According to Calhaz-Jorge, “the problem for most of the population is the lack of public funding. Even in countries where heterosexual couples are allowed to have ART it depends a lot on the public financial support.” Another discrimination, to add to the previous ones, is the economic one: not all countries cover these techniques (six do not cover it at all), and those who do sometimes only pay part of it, or the waiting lists are years-long, in a matter in which every delay works against you.

For example, in Switzerland and Poland, only insemination is funded, not in vitro fertilisation, which is much more expensive. In Greece, the public healthcare system only covers very specific cases, such as people living in faraway islands.

In fact, there are gaping differences between European countries. There are even differences between regions of the same country, such as in the United Kingdom, Italy and Spain. In Spain, for example, single women can access artificial insemination in Navarra, but not in vitro fertilisation, even if they have medical problems that prevent them from becoming pregnant through insemination. Spain’s other regions do permit that. Germany, meanwhile, does not cover in vitro fertilisation for lesbians and single women.

Age limits, already an important legal barrier for those seeking private ART access, are lower for people seeking ART through national health services. Once again, in the case of heterosexual couples, very few countries put a ceiling on the age of men. Portugal sets it at 60 years and Austria, 49. For women there are limits: from 38 in Latvia to 46 in Italy or 48 in Malta, to the most common figure in Europe, 40.

In other countries, publicly funded assisted reproduction has additional barriers, such as not exceeding a certain weight (in Serbia, Romania and some Spanish regions) or not having previous children, as in Denmark, Malta, Portugal, Romania, Spain, Sweden and Turkey.

Another of the most common limits is to cover only a maximum number of attempts. Few countries are clear on insemination, or do not establish limits, although if they do, it is usually six or three cycles. Countries are clearer about in vitro fertilisation: almost all limit the number of funded attempts. Belgium, Slovenia and Italy fund six attempts. 15 other countries fund three attempts. Romania, Moldova, and Kazakhstan fund only one. There, either you get pregnant the first time, or if you want to keep trying you have to pay for it out of pocket.

Irene Cuevas, director of the embryology laboratory of the public General Hospital of Valencia (Spain), says that after a certain number of attempts the probability of success drops a lot. “We have very limited resources and we have to try to optimise them in some way. It is a very logical number,” she argues.

Then there are the copays, which mean that access is not free in practice. The most common are those for medicines, and they are significant. Each round of hormonal treatment for in vitro fertilisation in Spain, for example, can cost more than a thousand euros.

There are also the long waiting lists. Cuevas calls them, “the fundamental problem.” Long waits are also common, for example, in Hungary. At one point Hungary did not permit sperm donors that were not Hungarian. Even after they removed that obstacle, things did not improve, Sandor says. Last summer, Hungary nationalised all fertility clinics. “Everyone knows that this means that they’re going to be five- to 10-years-long waiting lists for those who don’t have any money,” Sándor says.

Calhaz-Jorge says this is not only a problem of rights: “I’d like to have more support in my country, Portugal, because there are too-long waiting lists and as in the rest of Europe. Our fertility is declining. More support could help slow the decline. We have an intention of providing reproductive assistance to up to 5% of all babies born in Portugal. This is realistic but for that we need more money.”

Spain is the country in Europe, together with Greece, in which more children are born thanks to assisted reproduction procedures, reaching 7.9% of the total number of children born in 2017 (last year with comparable data, but in 2019 this number grown to 9,5%). In Italy, the UK, and Portugal, the rate is around 3%.

Faced with all these difficulties, is a common European regulation possible that guarantees equal access for all? Russell, the LGBTIQ+ spokesperson, says that would be difficult. European countries, not the EU, have jurisdiction over this matter, so the only alternative when it comes to defending LGTBIQ+ rights are the courts.

Calhaz-Jorge, chairman of the ESHRE, says: “I’m convinced that it is not possible to have similar rules. If in one country it is not legal to treat single women, which kind of regulation will they have if going abroad? The political views and the cultural sensitivities are very different.” Indeed.