The Ultimate Goal is Equity in Family Building: What Do We Know and Where Are We Going?
by: Ava Cecilia Snow
Family building has been understudied in the LGBTQ+ community compared to cisgender and straight populations. This is particularly true for LGBTQ+ people who are assigned male at birth (including transgender women, some gender expansive people, and cisgender gay and bisexual men).
Why is it important to study family building in LGBTQ+ populations?
There are many pathways to parenthood in all communities but LGBTQ+ people can face a different set of circumstances than cisgender straight people do when it comes to starting a family. Oftentimes, it is not biologically possible for LGBTQ+ couples to conceive a child independently without medical intervention, the way that many straight and cisgender couples without fertility issues can. Medical interventions such as assisted reproductive technology are important for those LGBTQ+ people who want to have children and need additional support. This brings the larger issue of disparities in medical care into play.. Research has shown that cisgender women who are sexual minorities and/or people of color are less likely to receive medical assistance to get pregnant than heterosexual white women. The topic of family building is also influenced by a multitude of factors. There are biological factors that need to be studied (such as how gender-affirming hormones for transgender people can impact their ability to have biological children) but there are also social and environmental elements. For example, if LGBTQ+ people live in an area where they experience high rates of discrimination and harassment, how does that influence their choice to have children? We do not yet have answers to many of these questions, but they are important to better understand and support LGBTQ+ people throughout the family building process.
What is the current state of research about family building for LGBTQ+ people?
The majority of (still very limited!) family building research thus far has focused on people who are assigned female at birth (such as cisgender lesbian and bisexual women and increasingly on transgender men). In terms of research about family building desires, studies have shown that cisgender sexual minority people are less likely to report parenting desires than cisgender heterosexual people. Among cisgender sexual minority folks, differences exist as well. Bisexual women report parenting desires more frequently than lesbian women who report higher parenting desires than gay men. However, cisgender bisexual men report parenting desires similar to those of cisgender gay men. For transgender individuals, transgender women overall express the desire for children at twice the rate of transgender men. Many people express the desire to have a child they are related to, as well as consideration of barriers such as physical limitations due to medical transition, the possibility of legal discrimination (such as losing custody to a sperm donor because of a lack of legal protections), and financial issues like the high cost of surrogacy.
Health insurance is also a prominent issue because assisted reproductive services and related expenses such as the cost of surrogacy are not often covered by insurance and therefore usually far too expensive for many individuals and families. In addition, LGBTQ+ people (especially transgender people) can face particular financial constraints due to discrimination. For example, studies have shown that it can be more challenging for transgender people to find jobs and secure housing compared to cisgender people.
Even where insurance support may be possible, studies have shown that LGBTQ+ adults are more likely to be uninsured than cisgender heterosexual adults (although this has improved somewhat in recent years due to the Affordable Care Act and the expansion of marriage equality). Even if an LGBTQ+ person does have insurance, many insurance companies require couples to meet an exclusionary definition of infertility before they will cover the cost of fertility treatments: the couple must unsuccessfully try to become pregnant for a year. Additionally, transgender people whose medical transitions have made it challenging or impossible for them to have children biologically may still not meet the definition of infertility required for coverage by insurers. All of these factors combine to make the financial demands of family building an enormous problem for many LGBTQ+ people.
When considering all of the legal, social, and financial barriers that they face, it is not surprising that LGBTQ+ people report a greater gap between parenting desire and intention than cisgender heterosexual people do–this means that LGBTQ+ people are more likely to want children but not plan to have them. This aspect of the existing research in particular supports the need to further explore family building in LGBTQ+ populations, because it suggests that there may be unmet needs for LGBTQ+ people who desire families that lead to dissatisfying outcomes.
There has also been some minimal research done about fertility in transgender people. Studies show that many transgender people report interest in fertility preservation, but it is rarely actually used. This is possibly because of poor communication with clinicians, and/or financial constraints. Despite low use rates, fertility preservation may be an important strategy to support transgender people with the desire for biological parenthood since various aspects of medically transitioning (such as surgeries and gender-affirming hormone treatments) can negatively impact fertility. For example, estrogen has been shown to negatively impact sperm quality, but it is unclear to what extent or what the implications are for transgender women and transfeminine people undergoing gender-affirming hormone treatment who may want to have biological children.
Research that focuses on the viability of biological parenthood for transgender women has found that they can benefit from sperm freezing — it was most successful with those who had not begun gender-affirming hormonal treatment (96%), 80% successful with those who temporarily stopped gender-affirming hormonal treatment, and 50% successful with those who were undergoing gender-affirming hormone therapy at the time of sperm freezing. For transgender men, there is the option to freeze oocytes (eggs), which is most likely to be effective if done before starting gender-affirming hormone therapy. However, there is research showing that they can and do achieve pregnancy even after having used gender- affirming hormones.
The largest report on pregnancy in transgender and gender expansive people who were assigned female or intersex at birth was done by researchers with The PRIDE Study and included 1,694 participants. 12% of the respondents had ever been pregnant — 15 of the pregnancies occurred after starting testosterone, and 4 of them happened while taking it. Out of all the pregnancies, 39% resulted in a live birth, 33% in miscarriage, and 21% in abortion. Additionally, 11% of the survey respondents reported a desire to get pregnant, while the same percentage felt they were at risk of unwanted pregnancy. Other studies have shown that transgender people generally face many obstacles in relation to pregnancy, including a lack of resources and provider knowledge. Overall, the existing research reveals that family building is an extremely relevant issue for the LGBTQ+ community, and that there is a great need for more knowledge and support from health care providers.
What are the next steps for research about family building in LGBTQ+ people?
Although family building research is limited for LGBTQ+ people in general, there is a particularly acute lack of research on people who are assigned male at birth, gender expansive people, and the Bi+ community. There is also a great need for more research about how experiences of family building intersect with race, ethnicity, and socioeconomic status for LGBTQ+ people. The PRIDE Study has already done some research about topics related to family building, and it remains a priority for future research. Most recently, The PRIDE Study received a grant funded by the Stanford Maternal & Child Health Research Institute. Principal investigator Juno Obedin-Maliver and co-investigator Stephanie Leonard will explore Sexual and/or Gender Minority Family Building: Understanding Barriers, Facilitators, Patterns, and Health Outcomes through a National, Community-Engaged Study, with PRIDEnet as a community engagement partner. If you would like to contribute to these efforts, we invite you to join The PRIDE Study as a participant and share your own experiences related to family planning.
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