Chapter 4Delivering appropriate and adapted care
For reproductive health care to be truly universal it must be able to provide care for everyone and everybody in our communities both confidently and competently. When it comes to reproductive health care, we all have different needs, different histories, different body parts, different partners and different futures. Universal reproductive health care needs to recognise and celebrate differences and approach each patient with a view to understanding their individual healthcare needs, because assumptions, judgement and discrimination have lifelong impacts.
4.1There is no one-size-fits all approach to reproductive and sexual healthcare. Service provision and care must be appropriate and adapted in order to provide positive reproductive health outcomes for all subsections of Australia's community.
4.2This chapter explores the barriers to reproductive healthcare for various groups within the community and recommended solutions to improve outcomes. Itbegins with an examination of transgender, non-binary and people with innate variations of sex characteristics and their experiences within the reproductive health system. It then moves to an analysis of accessibility barriers for people with a disability to reproductive healthcare.
4.3The chapter then discusses the importance of trauma-informed and culturally appropriate service delivery for culturally and linguistically diverse migrants and refugees and First Nations people. The chapter moves onto examine vulnerable women and their experiences of reproductive violence and concludes by exploring assisted reproductive technologies and barriers to accessing these services. Thecommittee's view and associated recommendations are made at the end of the chapter.
Transgender people, non-binary people, and people with variations of sex characteristics
4.4The committee heard that accessing reproductive healthcare can be a harmful experience for transgender people, non-binary people, and people with variations of sex characteristics. Furthermore, that reproductive healthcare services are often not affirming or trauma-informed.
People with variations of sex characteristics
4.5Intersex Human Rights Australia outlined that Australia has conducted two major national inquiries into the health and human rights of people with innate variations of sex characteristics (also known as intersex). This includes a 2013 report by the Community Affairs References Committee (committee) on the involuntary or coerced sterilisation of intersex people in Australia, and the more recent 2021 Australian Human Rights Commission's (Commission) report, Ensuring Health and Bodily Integrity.
4.6The Government is undertaking a national consultation with LGBTIQA+ people in relation to their experiences when accessing health services, and committed to the development of a 10 Year National Action Plan for the health and wellbeing of LGBTIQA+ people. Within this consultation, the Government will examine the Commission's report, which made recommendations on a human rights approach for people with innate variations of sex characteristics.
4.7LGBTIQ+ Health Australia submitted that people with innate variations of sex characteristics are often the subject of medical interventions at very young ages, usually before they can express their preferences and agency. Dr Ahmad Syahir Mohd Soffi elaborated that although some interventions are necessary for health reasons, others are conducted to 'normalise' genital appearance based on binary definitions of sex characteristics.
4.8According to the Commission report, stigmatisation can also arise in clinical guidelines, where justifications for gender assignments and medical interventions are grounded in normalisation. For instance, the Commission highlighted the 2006 Consensus Statement on Management of Intersex Disorders (the Consensus Statement), which states that gender assignment can be influenced by genital appearance and views of the family.
4.9Intersex Human Rights Australia reported on many negative sexual and reproductive health implications caused by unnecessary medical interventions. They submitted that many people have been subject to feminising or masculinising surgeries that do not align with their own preferences.
4.10Intersex Human Rights Australia also reported that some intersex people are unable to orgasm or suffer from pain because their feminising surgeries valued appearance over functionality. Additionally, experiences for those subjected to masculinising surgery also include a reliance on devices inserted into the urethra to urinate.
4.11Intersex Human Rights Australia submitted that these interventions create flow‑on effects for intersex people for the rest of their lives. They explained that the medical trauma of forced intervention, spurred by stigma, can have a deterrent effect on intersex people from engaging in the healthcare system, including accessing sexual and reproductive health services.
Clinician confidence and guidance
4.12Intersex Human Rights Australia observed that medical trauma fuels a perception that mainstream health services and health practitioners are not familiar with the needs of intersex people. LGBTIQ+ Health Australia echoed similar concerns, submitting that most healthcare providers do not have expertise on intersex variations. Healthcare providers have themselves expressed uncertainty on the needs of intersex people, with only 19 per cent of NSW Health staff expressing confidence. Intersex Human Rights Australia suggested that alack of understanding of intersex people and their needs can be partly attributed to the use of frames that are applied homogenously to this heterogenous group of people, where they are commonly, and incorrectly, understood to be an identity group or third gender.
Transgender people and non-binary people
4.13The committee heard that transgender and non-binary people are more likely to experience adverse health outcomes when compared to their cisgendered peers. Factors contributing to these outcomes are explored below.
Gendered language and services
4.14In their submission, LGBTIQ+ Health Australia stated that LGBTIQA+ people underutilise health services due to actual or anticipated experiences of stigma. They explained that this is fuelled by experiences where healthcare providers commonly misgender transgender people, or call them by their birthname which they no longer use, a behaviour known as 'dead-naming'. ACON, an HIV and LGBTIQA+ community health organisation, added that gendered language is also commonly used by health practitioners when referring to anatomy, and incorrect assumptions are routinely made about individuals' bodies. This can be particularly harmful for transgender people. Ms Karen Price, Deputy Chief Executive Officer of ACON, explained:
Reproductive health affects parts of the body that, while for some people might be a little bit uncomfortable or embarrassing, for trans and gender diverse people can be the site of self-hate, trauma and other complex emotions.
4.15ACON further demonstrated that gendered language is also used on a wider scale, which is illustrated by the divide between men's health and women's health services. This can act as a deterrent for transgender and non-binary people to engage with these services.
4.16To address these issues, ACON developed a variety of resources and models to assist health practitioners in becoming more inclusive and affirmative in their treatment of patients. For example, ACON's clear language guide for health practitioners is a comprehensive resource that could be used as a complementary tool for further health practitioner training.
Lack of access to appropriate care
4.17In addition to the evidence raised around gendered language, the committee heard that transgender and non-binary people also struggle to access appropriate care on a broader scale.
4.18ACON raised concerns that LGBTIQA+ people report much lower rates of screening, for both sexually transmitted infections and cancer of the sexual organs, than their cisgendered peers. ACON further added that this is particularly pertinent for lesbian cisgendered women and transgender people with a cervix. They outlined that low screening rates are driven by a lack of appropriate information and understanding of the sexual and reproductive health needs of lesbian, transgender and non-binary people.
4.19A lack of information regarding the health needs of the LGBTIQA+ community was reiterated by Rainbow Families, in which a community member told the organisation that they were:
… refused an STI and pap smear by a doctor because “lesbian [sic] only kiss each other's bits” and can't catch anything.”
4.20The committee notes that the commitment from the Government to develop with the sector a 10 Year National Action Plan for the Health and Wellbeing of LGBTIQA+ people that will guide how Australia addresses health disparities and makes improvements across the system, including in rural and regional contexts and consider the feasibility of peer support models of care.
People with disability
4.21Under Australia's Disability Strategy 2021–2031, federal, state, and territory governments have committed to improving health services to create better health outcomes for people with disability.Notwithstanding this, it was brought to the committee's attention that people with disability continue to face a range of barriers when accessing reproductive healthcare.
4.22When giving evidence to the committee, Ms Carolyn Frohmader, Executive Director of Women With Disabilities Australia, explained that women and girls with disability:
… are subject to widespread discrimination, systemic prejudice, paternalistic and ableist attitudes that denigrate, devalue, oppress and deny us our rights.
Inadequate access to sexual and reproductive healthcare services
4.23People with disability may struggle to engage with sexual and reproductive healthcare providers due to inaccessibility across a range of services, including general practices, hospitals, local surgeries and clinics. Common barriers to accessing these services manifest in a variety of different ways. For instance, Women With Disabilities Australia raised concerns that physical accessibility is limited in service provider settings. They explained that physical inaccessibility can range from a lack of accessible transport to and from the healthcare provider, to a lack of accessibility in and around the building, or inaccessible equipment relating to things like examination tables and diagnostic equipment.
4.24Women With Disabilities Australia also noted that barriers to accessing sexual and reproductive healthcare information for people with disability persist. It elaborated that there continues to be a lack of information that is produced by healthcare providers in formats such as ‘Easy English’ or screen-reader friendly websites. Women With Disabilities Australia explained that these barriers limit the capacity of people with disability to make informed decisions about their health.
Healthcare workforce: training and practices
4.25Down Syndrome Australia submitted that barriers to accessibility are compounded by inadequate workforce training. Forinstance, Chief Executive Officer, Mr Darryl Steff told the committee that:
Even if [health practitioners] understand all the content and the information they're seeking to deliver, they've had 2.5 hours in their whole degree to understand how they might need to tailor that for someone with an intellectual disability.
4.26Further, Down Syndrome Australia found that most nursing degrees do not have any content specific to intellectual disability. The Public Health Association Australia submitted similar findings, and highlighted that most service providers do not offer training to health practitioners on disability identification, documentation or referral pathways. The committee notes the Government’s commitment to establish the National Centre of Excellence in Intellectual Disability Health, that will bring together experts, resources and research on intellectual disability healthcare. Establishment of this centre is a priority under the National Roadmap for Improving the Health of People with Intellectual Disability.
4.27The Royal Women's Hospital echoed concerns that many hospitals and healthcare providers lack a basic understanding of the reproductive and sexual health rights and needs of people with disability, which results in ineffective communication when treating and engaging with people with disability. TheRoyal Commission into Violence,Abuse, Neglect and Exploitation of People with Disability highlighted that health practitioners are typically ill‑equipped to engage effectively with people with cognitive and intellectual disability, as they do not communicate healthcare information in accessible ways. This further limits the ability of people with disability to understand their sexual and reproductive health and to consequently make decisions about it.
4.28In addition to communication barriers and a lack of workforce training, expectant and new mothers with disability face unique barriers of their own in the healthcare system. Tailored pre and postnatal care, as well as parenting support for women with disability, typically does not occur. Evidence provided to the committee by the Royal Women's Hospital explained this is partly caused by a lack of consistent disability identification procedures in healthcare settings:
There is currently no national standardised way of asking about disability status. National standardised identification and recording of disability status is fundamental to providing appropriate funding, services and support for this at-risk group of women.
4.29The Royal Women's Hospital stated that there is a need for the development of disability identification, data collection and support services to ensure that all women with disability have access to quality maternal care nationwide. The Royal Women's Hospital has addressed this gap in the healthcare system by establishing the 'Women with Individual Needs Clinic', which supports women with physical, learning and intellectual disabilities by offering specialist midwifery antenatal and postnatal care. However, The Royal Women's Hospital stated that this clinic is the only one of its kind in Australia.
Lack of reproductive and sexual healthcare education for people with disability
4.30The Public Advocate (Queensland) highlighted that insufficient sexual and reproductive healthcare education is a particularly important factor that prevents people with disability from fully exercising their sexual and reproductive rights.
4.31Women With Disabilities Australia echoed similar views, noting that young people with disability are likely to be just as sexually active as their peers without disability but are less likely to receive the same standard of sexual education. They attributed poor education outcomes to a lack of schools teaching content on relationships and sexuality.
4.32Referring more broadly to the Australian curriculum, Dr Jacqui Hendriks, Founder of Bloom-ED, an alliance of teachers, researchers, students, parents and organisations that advocates for improved sexual and reproductive health literacy noted that it is difficult to find terms such as 'sex, sexuality, puberty, menstruation, pregnancy, abortion, contraception, sexually transmissible infection or pornography' in the newly revised Australian curriculum.
4.33Dr Hendriks commented on the limitations of teacher training programs:
We've got some really fabulous, engaging, high-quality programs, but our teacher training programs do not cover this area when someone is training to be a teacher, and the access to professional learning once you're out in classrooms is very limited. So people should feel really confident to deliver this stuff, because, if we don't do it well, we actually do more harm.
4.34Dr Hendriks explained how curriculum content is delivered in schools:
Just for some clarity on the curriculum: there's a section called the content descriptor, which is mandatory. For every content descriptor, there will be four or five elaborations. These are examples of how you might achieve that content descriptor … If the outcome is personal safety, we could teach about safer sex practices and contraception, or we could teach about road safety. So there's that diversity there. It's basically: 'Choose what you're comfortable with.'
4.35Noting that this education is not mandatory, Women With Disabilities Australia attributed the reluctance to teach such topics due to teachers being anxious, untrained and unwilling to discuss relationships and sexuality with people with disability.
4.36Additionally, Women With Disabilities Australia commented that when sexual and reproductive healthcare education is provided, it is typically through a narrow lens that is:
… cis-heteronormative, Eurocentric, body negative, sex negative and concerned with disease and pregnancy prevention.
Self-determination for people with disability
4.37The committee was informed that people with disability also regularly encounter issues regarding self-determination. The National Plan to End Violence against Women and Children highlighted the fact that women and girls with disability are at particular risk of forced or coerced medical interventions, such as sterilisation, contraception, and abortion.
4.38The Department of Health and Aged Care (the Department) explained that guardianship tribunals make decisions on behalf of individuals with an impaired capacity to make independent decisions, with interventions occurring when it is deemed to be in the individual's best interest.
4.39However, the Australian Lawyers for Human Rights contended that this can perpetuate harmful stereotypes that women and girls with disability lack the capacity to care for children, manage their own menstruation or control their own sexuality and fertility.
4.40Women With Disabilities Australia commented that forced intervention can be used to reduce the care burden of an individual with a disability. They explained that women and girls with disability will be presented with fewer contraceptive options than their peers without a disability, in order to favour the convenience of the caregiver at the expense of the individual's autonomy. Additionally, they put forward that the forced use of contraception can also be used to hide sexual abuse of a woman or girl with disability by preventing pregnancy.
4.41Raising similar concerns, Dr Emily Castell, Clinical Director of the Sexuality Education Counselling Consultancy Agency, told the committee that:
The absolute concern for us is the restrictive and coercive component. Actions like having long-acting reversible contraceptives or sterilisations may be legal and approved; however, they're coercive. So it's what we don't hear about that's particularly concerning. There often is a way to frame it or spin it so that it makes sense, but in fact it is violating someone's rights. Because people with disabilities are unfortunately socialised in some settings and communities to be compliant and to not ask those questions or to not have the opportunity for supported decision-making, we don't equip people with the skills or the knowledge to understand their rights and explore that further.
4.42The aforementioned lack of accessible reproductive and sexual health information and education for people with disability also promotes a lack of autonomy. If women and girls with disability are unaware of their sexual and reproductive health options, they then lack the ability to exercise their own decision-making, thus restricting their self-determination.
Trauma-informed and culturally appropriate service delivery
Culturally and linguistically diverse migrants and refugees
4.43The committee was told that culturally and linguistically diverse (CALD) women experience poorer sexual and reproductive healthcare outcomes than non-Indigenous Australian women.
4.44In response to these gaps, the Department advised that the Government has provided funding to increase access to services, boost community awareness, and provide sexual and reproductive healthcare information under the previous National Plan to Reduce Violence against Women and their Children 2010–2022.
4.45However, the committee heard that gaps in sexual and reproductive health outcomes for CALD migrants and refugees persist. For example, Women's Health East highlighted that CALD migrant and refugee women have lower participation rates in breast and cervical screening and lower sexual and reproductive health literacy compared to non-Indigenous Australian women. The Multicultural Centre for Women's Health submitted similar findings, as those born in non-English speaking countries have the lowest rates of contraception use in Australia, relying instead on techniques such as the withdrawal method.
4.46The Department explained that there are a variety of factors that drive poor sexual and reproductive health outcomes for CALD migrants and refugees, including low health literacy, a lack of understanding of Australia's healthcare system, prior experiences resulting in a lack of trust in the healthcare system, cultural and social norms potentially preventing open and frank discussions about sexual and reproductive health, and language barriers causing miscommunication between the patient and health practitioner, as well as misdiagnosis and inadequate follow-up care.
4.47Submitters also noted factors that contribute to poor sexual and reproductive health outcome for CALD migrants and refugees. The Multicultural Centre for Women's Health explained that temporary migrants, international students and temporary workers are all ineligible for Medicare, and therefore cannot claim rebates for medicines listed on the Pharmaceutical Benefits Scheme.
4.48The Multicultural Centre for Women's Health elaborated that temporary migrants face greater out-of-pocket costs if they wish to use contraception, compared to those who are eligible for rebates. They outlined that international students also face structural barriers related to pregnancy care asthey are not eligible for Medicare. Additionally, international students must have OverseasStudent Health Cover while studying in Australia which has a 12-month waiting period upon arrival for '[h]ospital treatment or hospital-substitute treatment that is for a pregnancy related condition, except for Emergency Treatment.'
4.49According to the Multicultural Centre for Women's Health, 70 per cent of pregnancy-related claims for international students occur within the first 12months of cover, thereby negatively impacting international students on a vast scale. As a result, international students potentially face limited options if they unintentionally become pregnant during this 12-month waiting period on overseas student health cover.
4.50Trauma-informed care is also paramount when considering how CALD refugees and migrants engage with Australia's reproductive healthcare system. Members of the Australian College of Nursing (ACN) raised concerns that there is a clear lack of trauma-informed training throughout tertiary education. They advised that numerous healthcare providers are not providing sufficient reproductive healthcare to refugee and migrant women.
4.51The Multicultural Centre for Women's Health mirrored this evidence and emphasised:
…[the] need to ensure that migrant and refugee communities can navigate the health system and feel informed and empowered to make decisions for their sexual and reproductive health without judgement and stigma.
4.52Consequently, the ACN argued for improved cultural competency training whilst studying, as well as ensuring that this training continues once qualified as a health practitioner.
4.53The committee heard about the Health in My Language Program from the Multicultural Centre for Women’s Health. The program was developed during COVID-19 to address health information inequities, in which Dr Adele Murdolo, Executive Director of the Multicultural Centre for Women's Health, explained that the program delivers:
… in-language education on COVID vaccination and information from COVID itself to people in an outreach capacity. [The Multicultural Centre for Women's Health] has supported all of these partner organisations around the country to recruit, train and provide ongoing support and resources to these bilingual, bicultural workers, and then they go out into the community and provide information about COVID.
First Nations people
4.54The Department provided evidence that First Nations women and girls continue to have poorer health outcomes compared to non-Indigenous women in Australia. The Department also identified that First Nations women and girls have a higher prevalence of sexually transmitted infections, higher rates of teenage pregnancy and birth, as well as significantly poorer maternal health outcomes, with higher rates of maternal mortality and infant deaths.
4.55The Department outlined that First Nations women and girls must navigate a health system that is characterised by a lack of culturally safe services and a lack of trained staff who operate in regional and remote areas. This makes it difficult to seek services for pregnancy terminations, tubal ligation and insertion of intrauterine devices.
4.56Further, First Nation's Women Legal Services Queensland, Inc reported that although First Nations women and girls are proactive in accessing contraception, they face judgement and bias from health practitioners when trying to do so.This was identified as contributing to distrust of doctors, which can manifest in general health service avoidance for First Nations women and girls.
4.57In recognition of these poor health outcomes, the Department advised that the Government has a range of strategies aimed at addressing these inequities, including the National Women's Health Strategy 2020–2030, Closing the Gap, and National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework and Implementation Plan 2021–2031. The Government has also provided funding to First Nations health professional organisations.
4.58First Nations people have reported to the First Nations Women Legal Services Queensland, Inc. (FNWLSQ) that some health practitioners in mainstream services still hold biases and misconceptions about First Nations patients. This is compounded by a lack of trust in government services driven by intergenerational trauma for First Nations people, as the FNWLSQ flagged. Further, they highlighted a broader problem where some health practitioners may lack the cultural competency to engage appropriately with First Nations patients. For instance, FNWLSQ submitted that lack of awareness of cultural taboos and men's and women's business was a common issue amongst these health practitioners.
4.59Consequently, the National Aboriginal Community Controlled Health Organisation has highlighted that First Nations people prefer to bypass mainstream services altogether, preferencing Aboriginal Community Controlled Health Organisations (ACCHOs) as their cultural safety can be guaranteed.
4.60However, as the Institute for Urban Indigenous Health told the committee, ACCHOs have suffered due to a lack of sufficient workers that can provide sexual and reproductive healthcare services. For instance, the Aboriginal Health & Medical Research Council (AHMRC) of New South Wales stated that ACCHOs are experiencing limited access to GPs, gynaecologists, nurses and midwives who are trained on IUD insertion. Consequently, they explain that patients are referred to non-community-controlled services, but as these services are viewed as being culturally unsafe, many First Nations women and girls are deterred from engaging with their services.
4.61The AHMRC of NSW also reported that limited access to trained GPs and gynaecologists impacts First Nations women and girls who are seeking surgical abortions. They flagged that there are no known ACCHOs in the state that provide surgical abortions, thus forcing First Nations women and girls into non-community-controlled and potentially culturally unsafe abortion clinics.
4.62To address these issues, submitters contended that continued investment in the First Nations health workforce is fundamental to ensuring that First Nations women and girls have access to maternal, sexual and reproductive care in culturally safe and trauma-informed spaces. Moreover, that to close the gap in health outcomes between First Nations and non-Indigenous Australians, it is imperative that ACCHOs are properly funded and well supported.
Vulnerable women and reproductive coercion and abuse
4.63Reproductive coercion and abuse are a form of gendered violence, in which a woman's reproductive autonomy is restricted or controlled. The Department explained how this can manifest in various ways, including the sabotage of contraception, pressuring a woman to become pregnant or to continue with a pregnancy, or pressuring a woman to have a termination or undergo a sterilisation procedure.
4.64SPHERE informed the committee that reproductive coercion is a public health concern and is associated with:
Higher rates of unintended pregnancies, abortion, and negative reproductive, maternal, parental, and child health outcomes.
4.65Consequently, the National Women's Health Strategy identified a reduction in the rate of reproductive coercion as a key measure of success in addressing the health impacts of violence against women and girls.
4.66Children by Choice commented that research on reproductive coercion and abuse in Australia is lacking but that this form of gendered violence clearly occurs at a much higher rate across intersectional groups of the community. Children by Choice pointed to current data which suggests that women and girls with disability experience this form of gendered violence at a higher rate than the general population.
4.67ACON advised that the LGBTIQA+ population can experience reproductive coercion and abuse at a rate that is four times higher than heterosexual and cisgendered members of the community. Additionally, Children by Choice flagged that reproductive coercion and abuse is more prevalent in women who are already experiencing other forms of family and domestic violence, compared with women who are not.
4.68The Department recognised that primary care providers are usually the first point of contact for victims of reproductive coercion. They noted that the provider's response influences whether that individual continues to seek help. Therefore, the Department argued that it is paramount that primary care providers are well trained to identify and respond to reproductive coercion and abuse.
Barriers to addressing reproductive coercion and abuse
4.69SPHERE noted that some women are more likely to confide in primary healthcare providers regarding domestic, family and sexual violence than presenting to dedicated support services. They also raised concerns from primary healthcare providers that there is a lack of adequate training and referral services, particularly in regional and remote Australia, to appropriately and effectively respond to reproductive coercion and abuse.
4.70Children by Choice echoed SPHERE's concerns and stated that reproductive coercion and control continues to be a hidden problem. They argued that a lack of research and information on this form of gendered violence precludes the development of practice guidelines that would assist primary care providers in responding effectively.
4.71The Department submitted to the committee that approximately one in six couples of reproductive age experience fertility problems and may utilise assisted reproductive technologies (ART). These technologies have, historically, been provided in a private setting and subsidised through the Medicare Benefits Schedule and PharmaceuticalBenefits Scheme. They further explained that access to free services under state and territory government programs has generally been limited.
4.72The MBS supports access to a range of relevant services involved in the clinical specialities of gynaecology (including ART and services involved in treating female and male infertility), obstetrics, participating midwifery, pathology, and diagnostic imaging.
4.73From 1 July 2023, the Government will introduce a new payment to subsidise costs associated with the storage of eggs, sperm, and embryos for patients with cancer, and people at risk of passing on genetic diseases or conditions who have undergone MBS-funded preimplantation genetic testing.
4.74The Government has also invested in a website, 'Your IVF Success', aimed at providing Australian couples with independent advice and information on fertility support services and IVF. Further, over the period between 2000 and 2021, the National Health and Medical Research Council has invested over $219million towards research regarding fertility and infertility.
Access to funded services
4.75Although Medicare items related to ART services exist, MrStephen Page submitted that current practices have created unequal access to these Medicare rebates.
4.76Section 4 of the Health Insurance Act 1973 (Health Insurance Act) stipulates that Medicare rebates can be claimed when 'a person renders a professional service'. Section 3 of theHealthInsurance Actexplains that a professional service must be a clinically relevant service, which means:
… a service rendered by a medical or dental practitioner or an optometrist that is generally accepted in the medical, dental or optometrical profession (as the case may be) as being necessary for the appropriate treatment of the patient to whom it is rendered.
4.77Mr Page explained that the person receiving treatment must be considered infertile for the ART services to be deemed a clinically relevant service under the Health Insurance Act.
4.78Mr Page outlined how the definition of infertility limited the cohorts of people who can access Medicare rebates for ARTs. Mr Page and Just Equal stated that infertility is traditionally defined as a disease of the male or female reproductive system, characterised by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse. This definition excludes a range of intended parents from claiming Medicare rebates when accessing ART, including, gay couples, single women, and lesbian couples. Mr Page explained that this is because these groups are biologically unable to conceive on their own or with their partner, as opposed to suffering from a physiological condition that renders them infertile.
4.79Alex and Tom told the committee that the international consensus shifted in 2017 when the International Committee Monitoring Assisted Reproductive Technologies published a revised definition of infertility. They stated that this revised definition, as below, accounts for what is commonly referred to as 'social infertility':
A disease characterized by the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or due to an impairment of a person's capacity to reproduce either as an individual or his/her partner.
4.80Mr Page submitted that the dichotomy of medical infertility and social infertility means that clinics vary in their interpretation of infertility and how it relates to Medicare rebates. He stated that some doctors still use the traditional definition of infertility, whereas others use the social infertility definition. Consequently, same-sex couples face uncertain out‑of-pocket costs associated with ART. As MrPage told the committee:
You then have a lottery when you turn up at a doctor's office: are you going to claim the Medicare rebate or not? […] you don't know, when you turn up at that particular clinic and that particular doctor, whether you'll get the rebate or not. It's $5,000 a pop.
Same sex couples and surrogacy arrangements
4.81Altruistic (non-commercial) surrogacy is legal in Australia, however, submitters flagged that the laws surrounding its process creates additional barriers for intended parents. Section 12 of the Prohibition of Human Cloning for Reproduction Act 2002 (the Human Cloning Act) stipulates that it is an offence to intentionally create a human embryo outside of the body of a woman, unless the person's intention in creating the embryo is to attempt to achieve pregnancy in a particular woman. This section is designed to address ethical concerns regarding the potential use of human embryos. Breaches of the section carry a penalty of up to 15 years imprisonment.
4.82Mr Page submitted that this becomes difficult for intended parents, whose sole intention in creating an embryo is to conceive a child, when they have not yet formed a surrogacy arrangement. He gave evidence that some doctors accept and acknowledge the intended parents intentions' and will interpret the legislation to mean that eventually the embryo will be implanted in a particular woman in the future.
4.83Alex and Tom told the committee that they had encountered this barrier when a clinic told them that they had to identify a particular woman at the time of embryo creation, as to do otherwise would be unlawful. They explained that:
The delivery of this news … was a complete shock, as all we were trying to do was create a family. It was cruel, offensive, and traumatising to be delivered this news. For the rest of the day, Alex was hysterical. He could barely speak. We do not wish this fate upon anyone. We were being categorised as criminals and being likened to the sorts of people that create embryos for embryo farming purposes.
4.84Submitters believe this hurdle is an additional layer of unequal access to reproductive healthcare for those whose only option is to conceive via surrogacy.
4.85The committee heard from Dr Sarah Jefford that the inconsistency of state and territory laws relating to surrogacy further compound access issues, including for same sex couples.
Surrogacy and Medicare rebates
4.86The committee also heard that once a surrogacy arrangement is in place, further barriers exist for intended parents. Surrogacy can cause immense financial strain as no Medicare rebates exist for ART processes associated with surrogacy, including the extraction of eggs, creation of embryos, or implantation of those embryos.
4.87Mr Page told the committee that the Government has banned Medicare subsidies for surrogacy since 1990, which he considers to be a historical anomaly. He submitted that the exclusion of surrogacy from Medicare leaves intended parents to suffer greater out-of-pocket costs, where a non‑subsidised round of in vitro fertilisation (IVF) costs approximately $8000. However, he gave evidence that IVF that is not for the purposes of surrogacy would allow patients to claim a rebate of approximately $4620.
4.88Just Equal cited an estimate that to remove the exclusion would cost less than $1 million per year. The 2020 Medicare Benefits Schedule Review Taskforce Report on Gynaecology MBS Items recommended that individuals undergoing an ART stimulated cycle as part of an altruistic egg donation or surrogacy arrangement should be provided MBS funding support.
Committee view
4.89The committee acknowledges that large cohorts within Australia have been overlooked, underrepresented, or underfunded in sexual and reproductive health policy, service-delivery, and education.
4.90The committee was concerned to hear that some sectors within the Australian community, as discussed in this chapter, encounter additional barriers to accessing appropriate, accessible, responsive and equitable reproductive health services and education.
4.91The committee notes the following actions that could address this:
Working with health practitioners to deliver further training and developing inclusive frameworks that ensure appropriate and adapted care.
Increasing funding and resourcing for peer support networks and specialist organisations, as well as enhancing education.
Improving access for a range of individuals who are currently excluded from receiving Medicare subsidised reproductive healthcare benefits.
Working with health practitioners
Providing appropriate training
4.92Appropriate reproductive healthcare services can only be provided to all sectors of the community if health practitioners delivering the service are adequately trained on the unique needs of the community. The committee acknowledges that this can be complex with different cohorts experiencing different barriers to accessing safe and appropriate reproductive healthcare services. However, the committee is of the view that these barriers can only be overcome by an adequately trained health workforce.
4.93The committee agrees with submitters that further training is required at the undergraduate and postgraduate level on: treating people with disability; the importance of CALD migrants and refugees accessing culturally appropriate and trauma‑informed care, through programs such as Health in My Language; and the need for culturally safe workforce development in the healthcare sector for First Nations people.
4.94The committee is also mindful that the current sexual and reproductive healthcare workforce is not sufficient to meet the needs of ACCHOs who are often the preferred healthcare providers for First Nations people. As such, the committee is supportive of exploring mechanisms for increasing access to trained reproductive health practitioners, including GPs and gynaecologists, as well as upskilling of nurses and midwives in these practice settings.
4.95The committee recommends that the Australian Government work with the relevant medical and professional colleges to support the development and delivery of training to health practitioners providing sexual, reproductive and maternal healthcare on:
engaging and communicating with people with disability;
providing culturally aware and trauma-informed services to culturally and linguistically diverse migrants and refugees; and
ensuring culturally safe healthcare for First Nations people in mainstream non‑community-controlled organisations, by ensuring practitioners are aware of intergenerational trauma, cultural norms and taboos.
4.96The committee recommends that the Australian Government consider options and incentives to expand the culturally and linguistically diverse (CALD) sexual and reproductive health workforce including leveraging the success of the 'Health in My Language' program.
Frameworks
4.97The committee recognises that current practices and standards in the healthcare industry can be unaffirming and exclusionary for LGBTIQA+ people. Gendered language can deter LGBTIQA+ people from engaging healthcare providers, and assumptions regarding a patient's anatomy and partner(s) can result in care that is neither appropriate nor adapted.
4.98The committee acknowledges that the Australian Government has committed to developing and implementing a 10-year National Action Plan for the Health and Wellbeing of LGBTIQA+ people, in consultation with the LGBTIQA+ community.The Plan is expected to ‘guide how Australia addresses health disparities and make improvements across the health system.’
4.99Therefore, the committee recognises the importance of practitioners utilising frameworks that support appropriate treatment of, and communication with, transgender and non-binary people.
4.100The committee is also cognisant that the use of gendered language in reproductive healthcare settings can be exclusionary and therefore create barriers for LGBTIQA+ people to access this healthcare.
4.101The committee recommends that the Department of Health and Aged Care consider sexual and reproductive healthcare for LGBTIQA+ people in the context of the 10-year National Action Plan for the Health and Wellbeing of LGBTIQA+ people.
Best practice guidelines
4.102The committee acknowledges that current guidance on obtaining consent from individuals for medical or surgical procedures is general in nature and currently no specific guidance exists on obtaining informed consent from intersex people prior to medical interventions.
4.103The committee also recognises that there is a lack of research on reproductive coercion and abuse. Further, the committee acknowledges that the limited research and understanding of reproductive coercion and abuse contributes to inadequate informational support for health practitioners in responding to this form of violence.
4.104The committee recommends that the Australian Government consult with people with innate variations of sex characteristics regarding surgical interventions in the context of the 10-year National Action Plan on the Health and Wellbeing of LGBTIQA+.
4.105The committee recommends that the Australian Government commissions research into reproductive coercion and abuse with a view to developing clinical guidelines, resources and training for primary care providers.
Education
4.106The committee acknowledges that the sexual and reproductive health educational gaps for people with disability and their families and carers must be addressed. To do so, the committee considers it necessary to increase reproductive health education programs and resources that are both accessible and disability inclusive. The committee also supports the development of resources that focus specifically on the reproductive health of young people with disability, thus empowering them to exercise their autonomy.
4.107The committee recommends that the Australian Government works with the sector to develop sexual and reproductive health education programs and resources for people with disability and their families and carers that are accessible, disability inclusive and empowering for young people with disability.
Expanding Medicare accessibility
Accessing pregnancy-related care for non-residents
4.108The committee notes the concerns of the Multicultural Centre for Women's Health regarding temporary migrants and temporary workers being unable to access Medicare, and international students not being covered for pregnancy care within their first 12 months in Australia and its impact on access to reproductive healthcare.
4.109The committee heard from the Multicultural Centre for Women's Health, Women's Health East, MSI Australia, and Birth for Humankind, that Medicare eligibility should be extended to all people living in Australia, irrespective of visa status. Those submitters considered that extending Medicare eligibility for reproductive health and pregnancy care will further Australia's provision of true universal access to reproductive healthcare.
4.110Further, the committee recognises the barriers that international students encounter when engaging pregnancy care in Australia. The committee is aware that international students are required to take Overseas Student Health Cover, but that Schedule 4d of the Overseas Student Health Cover Deed imposes a 12‑month wait period for students to access pregnancy-related care. This is particularly concerning given that 70 per cent of pregnancy-related claims for international students occur within the first 12-months of cover.
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4.111The committee recommends that the Australian Government, in consultation with state and territory governments, consider options for ensuring the provision of reproductive health and pregnancy care services to all people living in Australia, irrespective of their visa status.
4.112The committee recommends that the Australian Government work with relevant overseas health insurance providers to amend Schedule 4d of the Overseas Student Health Cover Deed to abolish pregnancy care related wait periods.
In vitro fertilisation services
4.113The committee recognises that the current medical definition of infertility is limited to a physiological condition. This definition effectively excludes LGBTIQA+ people from claiming Medicare rebates for IVF. As a result, LGBTIQA+ people can receive inconsistent advice from practitioners and incur greater out-of-pocket costs when engaging IVF services.
4.114The committee recommends that the Australian Government explores the feasibility of Medicare rebates for in vitro fertilisation (IVF) services for cohorts not currently eligible for subsidised services.
Surrogacy-related services
4.115The committee heard that surrogacy arrangements in Australia create further barriers for same-sex couples to start a family. The committee is aware that since ART services were subsidised through Medicare rebates in 1990, that surrogacy was explicitly excluded from Medicare claims.
4.116The committee recommends that the Australian Government implement the recommendations of the Medicare Benefits Schedule Review regarding removal of the exclusion of in vitro fertilisation (IVF) services for altruistic surrogacy purposes.