When evaluating reproductive care for lesbian, gay, bisexual, transgender, and queer+ patients, there are multiple factors that must be addressed from a clinician, clinic, and social standpoint. Clinicians should be trained in culturally humble and trauma-informed care; clinics should have intake forms that identify sexual orientation, gender identity, and pronouns. The clinic environment should be inclusive, with all gender or single-stall bathrooms, and patient-facing educational materials that are representative of individuals with diverse partnerships, races, and ethnicities. In order to provide genuine culturally humble care, clinicians must be adequately trained and clinics must be appropriately prepared.
Key points
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When evaluating reproductive care for lesbian, gay, bisexual, transgender, and queer+ patients, there are multiple factors that must be addressed from a clinician, clinic, and psychosocial standpoint.
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The clinic environment should be inclusive, with all gender or single-stall bathrooms, and patient-facing educational materials that are representative of individuals with diverse partnerships, races, and ethnicities.
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As increasing numbers of transgender individuals are seeking care for fertility and clinicians must be educated on providing gender-affirming reproductive care, given that some transgender and gender-diverse patients will have started or will be planning a gender affirmation process, which may include hormones or surgical interventions.
Background
Given advances and innovations in medical science, lesbian, gay, bisexual, transgender, and queer+ (LGBTQ+) communities have the potential for improved access to assisted reproductive technology (ART). Yet, social and structural stigma and inequities perpetuate barriers to ART and other types of health care. Embedded reproductive stigma, racism, and cisheteronormativity continually impact LGBTQ+ individuals’ lives, including having the resources and ability to access family planning and building opportunities. Many clinicians lack training in cultural humility, and clinic environments may not be inclusive or welcoming (eg, not having all-gender bathrooms; lack of LGBTQ+ content on Web sites or education materials, including having opportunities to list pronouns, names, and relationship structure on intake forms).
Historically, it has been assumed that LGBTQ+ individuals did not want or waived parenthood for themselves or that they did not desire the option of keeping reproductive potential. , These assumptions are now largely considered myths, although efforts to restrict or limit access to ART or other family building options are ongoing. Such assumptions and restrictive efforts unveil historic and contemporary societal biases and stigma and illuminate additional harmful rhetoric that providing LGBTQ+ populations with ART is unethical due to fears that the children would be unwell due to mental health burdens. , Studies indicate that no evidence supports such claims, and major associations (eg, American Psychological Association; Ethics Committee of American Society for Reproductive Medicine [ASRM]) oppose discriminating about family building and ART on the basis of gender identity and/or sexual orientation. , Further, official statements and recommendations also suggest that transgender and gender-diverse individuals should have the same access to fertility options as cisgender individuals, and fertility and reproductive desires should be discussed with conversations related to gender transition. , ,
Many marginalized communities, including black, Indigenous, and people of color (BIPOC) and LGBTQ+ individuals, have historically had to undergo nonelective and coerced sterilization, despite what they might have actually wanted or what they wanted to discuss about their bodies and reproductive desires. Discussions of reproductive rights and the ability to raise children are hot-button topics for some, particularly given threats and legislative attacks contributing further to gatekeeping and invisiblization of sexual and gender-diverse families, particularly those who are BIPOC. Even though reports that LGBTQ+ people are the fastest growing population accessing fertility clinics in urban areas, studies also show that reproductive access focuses primarily on white, cisgender lesbian, and bisexual women with high education and income, highlighting inequities.
Cisheteronormativity and white supremacy impact all LGBTQ+ people, who have distinct health needs from their cisgender heterosexual peers, particularly in the context of ART. One example is that LGBTQ+ people accessing ART are often seeking reproductive assistance that is not necessarily based on a medical fertility problem but rather may represent social infertility. Transgender and gender-diverse individuals may be accessing services in an effort to plan for future family building. However, the existing definitions of fertility are rooted in a disease model, the gender binary, and heterosexuality as the norm, which further marginalizes LGBTQ+ individuals and creates barriers to insurance coverage (eg, requirements for having a “married spouse” to have insurance coverage). ART is a method of reproductive justice and is important for LGBTQ-affirming (including specifically gender-affirming) care. The medical advances and technological innovations are celebratory; however, the historic and ongoing systems of white supremacy and cisheteronormativity that impose “rules” and regulations regarding bodies, reproduction, and health care access, including within ART, must be acknowledged and addressed in order to further health equity.
Given the LGBTQ-specific considerations in the context of ART, it is important that health care clinicians are trained in cultural humility that aligns with the tenets of intersectionality. Lack of clinician training, education, and acceptance has led to delays and denial of services, which are at times upheld through policies protecting “religious liberty” or conscientious objections. Past studies indicate that ART programs and clinicians may refuse or discourage care services to single individuals and/or those who are LGBTQ+. Prior literature also suggest that transgender and gender-diverse individuals report discriminatory treatment in health encounters, and increased minority stress due to insurance denials related to the binary nature of health care systems or disclosure of their gender without permission to employers or others. However, a recent study also identified that the majority of fertility clinics (primarily on the West Coast) offered appointments to callers who reported they were transgender men, suggesting that getting an appointment may not be a barrier in certain states.
Ethical considerations
There is limited research on ethical issues in LGBTQ+ use of ART, as sexual orientation and gender identity data collection is relatively new to medical records and the ability (and safety) to disclose sexual and gender minoritized identities and in some cases nonmonogamous and other relationship structures, is only a recent phenomenon. Many of the ethical conundrums that present in ART are as equally applicable to cisgender and heterosexual people. These include ownership of embryos in the event the relationships ends, confidentiality and privacy concerns, being turned away from ART due to medical, psychological, financial concerns, and the potential for discord that may arise when disclosing (or not) the origins of the birth to children conceived through ART or disclosing this information to others in their lives. Additional concerns may arise when diagnosis and treatment of medical conditions require information about parents and/or other family members. There are also unique ethical issues that arise in the use of ART among gay men, lesbian women, transgender, and gender-diverse people of any sexual orientation; single people of any sexual orientation, and polyamorous unions that can include people of multiple or the same gender and sexual identities. In general, research suggests that LGBTQ+ experience stigma and discrimination receiving reproductive health services in general, from cancer screening to perinatal care due to system-level inequities and exclusionary practices within the health care system. This section reviews some ethical issues within and across these groups.
Gay, Bisexual, Queer Cisgender Men
Cisgender men in a relationship with other men, who wish to have a biologic child, will require a donated egg and uterus. It is highly recommended that the egg and uterus be from 2 different female individuals. This is due to legal and ethical concerns. ASRM recommends that gestational carriers have no genetic connection to the pregnancy to prevent legal issues related to parenthood.
The cost for these services averages $200,000 in the United States. While there are organizations that broker both egg donors and surrogates/gestational carriers, some couples have chosen to go a noncommercial route with family members. In either case, it is strongly recommended, and often required, to have legal documents in place so that expectations and responsibilities are clearly outlined; thus, helping to ensure clarity for all parties involved in the process. Another decision for the 2 men will be the question of whose sperm will be used. Some will make the choice based on medical or hereditary conditions that may warrant the use of one person’s sperm over the other. Others may leave the choice up to fate by mixing the sperm from both men. Another option considered at times is to plan for fraternal twinning, with embryos created by the sperm of each partner.
However, the American Society for Reproductive Medicine cautions against the transfer of more than one embryo due to the potential for twins, which confers increased risk to the pregnant person as well as the fetuses. Given the desire of some cisgender gay men to each have a genetically related child and or the costs associated with donor eggs, in vitro fertilization (IVF), and carriers, some families and singles may search for clinics and carriers that will allow multiple embryo transfers. This raises some ethical dilemmas as the risks to the carrier’s health include preeclampsia and gestational diabetes and are not insubstantial. Twin pregnancies often result in preterm birth and may be associated with higher risks of birth defects, fetal growth restriction, and twin–twin transfusion syndrome. All these outcomes may increase the mental health burdens, including stress and anxiety, for the intended parents. The desire to achieve a 2 child family and potential reduced costs must be balanced with the health risks for carrier and fetus (see following section for information on birth certificate listing).
There are no empirical studies comparing the mental health of LGBTQ+ people to cisgender heterosexual people. The ART process can be stressful for everyone. Multiple studies have concluded that the experience of infertility, financial stress associated with the use of ART, and the uncertainty of the outcomes in the hope of a healthy child can create significant anxiety and depression, as well as even more severe psychiatric disorders such as psychosis. It is possible that minority stress associated with LGBTQ+ status may exacerbate mental health issues while seeing ART care to build a family. Several studies have highlighted that the reproductive care landscape is often heteronormative, with Web sites that feature white, straight couples, and patient education that was not tailored to the LGBTQ+ community. The lack of a welcoming environment for LGBTQ+ people can certainly contribute to decreased mental health.
Lesbian, Bisexual, Queer Cisgender Women
Relationship structures involving 2 (or more) cisgender women have a few more options and potential for reduced expenses compared to cisgender men. The option for couples to make the best choices for themselves, based on their own wishes, will greatly reduce the mental health burdens and stresses that are already inherent in these difficult circumstances. Some may decide to use reciprocal egg donation, where one partner provides the oocytes and another partner carries the pregnancy with an embryo created through donor or sperm from a relative of the carrier or friend of any partner. Some choose to be pregnant with another partner at the same time with their own oocytes and the same sperm donor; still others may space pregnancies apart. In the case of 2 parents, states vary as to whether both cisgender women can be listed on the birth certificate and labeled the sole parents. Some states allow for parent 1 and 2; other states have birth certificates with the nomenclature mother/father. In some states, a legal marriage is not required to have both parents on the birth certificate. While many same-sex parents face societal stress due to prejudice and discrimination, multiple studies document that children with same-sex parents have no significant disadvantages over children with different-sex parents. However, the best outcomes for these families can be achieved by incorporating appropriate mental health services and support for the couples throughout their journey. Particularly mental health services that are tailored to LGBTQ+ people as culturally competent clinicians are often the key to improved mental health outcomes.
Transgender People
For transgender people, ART can be used for fertility preservation. For transgender women, hormone therapy promotes their gender embodiment goals while also inhibiting spermatogenesis. There is a common untested assumption that this inhibition is permanent, resulting in infertility ; however, this has been disproved, and spermatogenesis has been reversed in certain settings. There is a paucity of information regarding the effect of hormones on the ability to preserve gametes. For example, the effect of testosterone seems dose and duration related, yet guidelines have not been established. Options for preserving fertility for transgender women include sperm cryopreservation, preservation of testicular tissue, and possibly uterus transplantation, though the latter 2 are currently experimental and not offered across all centers. For transgender men, options include ovarian cryopreservation or ovarian tissue cryopreservation. While there are many promising techniques for future study, further research is needed in this area to investigate the feasibility and usability of these experimental options.
Some current literature suggests that the process of fertility preservation prior to gender-affirming care and subsequent pregnancy among transgender men may increase dysphoria and depression. One study showed that transgender men experiencing pregnancy felt “invisible, isolated and lonely due to highly gendered perinatal care environments.” (p121) The ASRM has issued guidance that fertility preservation should be offered to transgender and nonbinary people prior to gender-affirming care and that requests for ART should not consider gender identity. ASRM further recommends that programs collaborate on outcomes data related to the social and emotional well-being of transgender and nonbinary people’s experiences as there are scant data from these populations.
Polyamorous Unions and Throuples
Polyamorous unions have been defined as “the practice of, belief in, or willingness to engage in multiple romantic and/or sexual relationships with the consent of everyone involved,” though many definitions have been proposed. , People also use various terms (eg, consensual nonmonogamous), and some definitions emphasize that there can be any relationship type involved for individuals who are not monogamous. Additionally, throuples, defined as an intimate consensual relationship that involves 3 people, can also seek ART care. Given the legal complexities faced by same-sex parents, and the variation among states, this is a new area of LGBTQ+ care that must be clearly defined to ensure equal access to care for all patients involved and thus avoid further marginalization and the resultant mental health burdens in these circumstances.
Use of assisted reproductive technology and mental health: implications for clinicians and clinical care
Finding the Right Place
The first step in developing a relationship with a center for reproductive care happens before a patient steps through the door. As the number of LGBTQ+ families increases in the United States, so will the utilization of fertility services by these families who desire to have biologic children. Since the legalization of gay marriage in the United States, the number of married same-sex couples has more than doubled. Currently, it is estimated that LGBTQ+ people comprise 4.5% of the general population, and the majority of this population are within the reproductive age range. Additionally, among the adult population in the United States, it is estimated that 1 to 1.4 million people (0.4%–0.6%) self-report being transgender, although this number is almost certainly an underestimate. These populations are considered by the American College of Obstetricians and Gynecologists (ACOG) as being underserved and are subjected to societal discriminations, often resulting in inability to access obstetrician/gynecologist (OB/GYN) and mental health resources. Use of ART may be the only way that many of these families can achieve biologic children, and finding a center that is knowledgeable about the unique needs and is welcoming to this population is imperative.
One of the ways reproductive care centers that can improve their outreach to LGBTQ+ communities is through online marketing materials, and focusing on a Web site that feels welcoming and inclusive while also providing the necessary information for this population. A 2023 study examined fertility Web sites throughout the country and found that approximately half of Web sites had LGBTQ+ content. They found that private fertility clinics and fertility clinics with higher volumes show a positive relationship to the presence and type of LGBTQ+ content. Additionally, LGBTQ+ Web site content was similar across 4 geographic regions. Online materials are the main way patients seek information about various fertility clinics, particularly in this information age. With this, clinic Web sites are a main starting point for understanding a fertility clinic’s policies and culture regarding provision of care to LGBTQ+ patients. Although a Web site may not be a true representation of a clinic’s philosophy regarding fertility treatment of LGBTQ+ patients, it can provide a glimpse into patient care attitudes. This approach may be especially useful for these patients because they may already feel disenfranchised and may be unwilling to search out options in person.
Physical Space: Front Desk Personnel/Waiting Area/Environment
A welcoming LGBTQ+ environment must be present in every step of patients’ fertility clinic experiences in order for a center to practice intentional cultural competence and humility. This starts with the way that LGBTQ+ patients are greeted when they walk in the door. It has been shown that including members of the LGBTQ+ community as part of a staff, and training staff to refer to patients by their chosen names and pronouns, is an important step in creating a welcoming environment. Educational materials that are provided for patients in designated waiting areas should be inclusive as well and should address the varied populations of patients that the clinic intends to treat. Examples of ways to create inclusive and welcoming environments include but are not limited to ensuring patient education materials show photos of same-sex relationships, transgender and gender-diverse people, and people of a variety of racial/ethnic identities, having all-gender bathrooms that are conveniently located, and having intake forms that include pronouns, and use terminology such as partner as opposed to spouse. Additionally, administration should take note of artwork or posters on the wall, as these are the first things patients will see when waiting for care.
In regard to the impact of the physical space on mental health, there is a paucity of literature on empirical studies to show that this actually has improved mental health. However even if interventions to improve mental health among LGBTQ+ patients during ART were studied, there is a dearth of instruments normed for this population and we cannot expect to measure it with heteronormative instruments.
Clinician Training
ASRM has specific guidelines that encourage inclusivity, yet many fertility providers are unaware of the systemic inequities faced by LGBTQ+ communities. Studies show that clinicians acknowledge that their lack of training for working with socially marginalized populations can act as a barrier to patient care. There are many types of trainings that clinicians can undergo in order to develop more specialized expertise in these patient groups to shape attitudes toward LGBTQ+ individuals, and behaviors toward LGBTQ+-affirming practices. , These practices range from being aware of patients mental health, physical health, specific health concerns that may arise, and clinicians evaluating their own values and beliefs in the systems in which they work that may impact care.
The quest for culturally competent fertility clinicians remains paramount in a patient experience. While there are many comprehensive reviews that identify barriers for patients when providers are not adequately trained in cultural competence, there is a paucity of literature about ways this improves outcomes in these marginalized populations. Many of these reviews and guidelines call for the clinician training to start as early as possible in medical training and continue throughout a clinician’s career.
Intake Forms
Mental health awareness can start with a medical intake form, which is often sent to a patient prior to a first appointment, in anticipation of an office visit, with the goal of making the office visit more streamlined. Centers must tailor their intake forms to be inclusive of all persons. This means paying special attention to the language used on the forms and what is represented. It is well known that adding a diverse range of sexual and gender identities into these intake forms will symbolize that a clinic and its clinicians are both knowledgeable and open to discussing LGBTQ+ patients’ concerns. Using culturally relevant terminology and descriptors may ease patients’ fears that their physician will not understand them. Health care outcomes are more successful when patients are able to develop open, honest relationships with their clinicians.
One of the places this can be reflected most obviously is when the intake form asks patients about their gender with only binary male or female response options or asks about whether someone is in a relationship with a check box. Someone who is transgender or gender diverse is not able to provide this information, and there is no relevant information about relationship structure to learn if a patient is in a polyamorous relationship. The burden falls on the patient to provide the information to minimize assumptions based on this form—which can be an exhausting experience for patients. When designing these intake forms, it should be designed with these populations in mind—ideally in collaboration with LGBTQ+ individuals—have multiple response options for demographic information such as gender and relationship structure, and have a fill-in option where patients can provide additional information, if the patient wants to. This will provide a more positive experience for the patients and thus will result in a less stressful experience as they navigate this important life event.
Trauma-informed Care
In terms of patients’ physical health, it is important for clinicians to use trauma-informed care (TIC). In 2021, ACOG released a recommendation advocating the implementation of a trauma-informed approach in all health care encounters. Although there is no single definition of trauma, substance abuse and mental health services administration (SAMHSA) offers the following helpful conceptualization of trauma for health agencies and service systems: “individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” Unfortunately, the prevalence of trauma is staggering in the general population, and even higher among the LGBTQ+ community. An early study examining the prevalence of trauma in the general population showed that 63.9% of their sample of primarily white, non-Hispanic individuals with some college education had experienced at least one adverse childhood experience, and 12.5% had experienced 4 or more adverse childhood experiences. In terms of trauma in relation to LGBTQ+ communities, about 3 quarters of LGBTQ+ students report having been harassed at school, 35% have experienced physical assault, and 12% have been the victim of sexual violence at school.
This makes the argument for any clinician in the reproductive medicine space to use TIC for every visit. These visits should center on making a plan with the patient for a safe and thorough examination, including inquiring about patients fears regarding the examination. Additionally, clinicians should elicit fears and beliefs around disease/pathology in order to best address treatment options and compliance.
Within ART, one of the key parts of a patient’s visit typically involves a pelvic ultrasound. The use of transvaginal ultrasound versus transabdominal ultrasound must be addressed with the patient. Typically, a transabdominal ultrasound is sufficient for diagnosing pelvic pathology and with monitoring during ovarian stimulation. Contraindications and relative contraindications to a transvaginal ultrasound include patients with imperforate hymens, those with vaginal obstructions, pediatric populations, transgender populations, and patients with a history of trauma. Evidence suggests that there is no difference in ART outcomes between transabdominal and transvaginal monitoring.
The recommendation of universal TIC, which has been endorsed by ACOG, elicits how important this type of approach is for the mental health of patients with histories of abuse. This approach limits retraumatization for this population and allows for patients to have a positive association with their care. TIC helps to limit potential triggers given how invasive the fertility examination can be both physically and mentally, as to not reexpose patients to trauma in the medical setting. One of the pillars of TIC relies on shared decision-making, which allows patients with a history of trauma to have the power differential minimalized between doctor and patient. This approach has been shown to increase adherence to care and create trusting relationships.
Fertility Preservation and Gender-affirming Care
As increasing numbers of transgender individuals are seeking fertility preservation, clinicians must be educated on providing gender-affirming reproductive care, given that some transgender and gender-diverse patients will have started or will be planning a gender affirmation process, which may include hormones or surgical interventions. It is reported that at least 36% of transgender patients desire biologic children in the future. While few transgender patients seek care prior to starting hormone therapy, this number is beginning to increase as pediatricians and endocrinologists have increased awareness of fertility preservation in this population.
One of the barriers to fertility preservation in the transgender population already on hormones such as testosterone is that patients are typically advised to stop gender-affirming treatment prior to preservation. Most centers recommend stopping treatment 1 to 3 months prior to ovarian stimulation, which can cause significant and even life-threatening gender dysphoria for some patients. There are limited data on patients pursuing fertility preservation while on gender-affirming hormones, though case reports with successful stimulation and subsequent live births do exists, which is promising for patients where pausing gender-affirming treatment is not an option. Ovarian tissue cryopreservation is also an option for patients who cannot pause gender-affirming hormones due to gender dysphoria, though future autotransplantation of the tissue may re-trigger gender dysphoria.
The ideal time for fertility preservation within a transgender adolescents’ development has not yet been determined. However despite clinician awareness, transgender adolescents may prioritize medically transitioning to alleviate gender dysphoria over preserving their future fertility. Counseling regarding fertility preservation must be done with a multidisciplinary approach, including often in conjunction with the patients’ parents. Robust psychological support should be provided not only for the patients but also for their parents during this stressful journey. Pediatric and adolescent gynecologists and endocrinologists are the key players in adequately offering fertility preservation prior to gender-affirming care (if desired) and addressing the family unit in a comprehensive way. Some patients can be offered hormonal therapy prior to puberty to allow for additional time to make decisions regarding fertility preservation.
Summary
When evaluating When “providing” reproductive care for LGBTQ+ patients, there are multiple factors that must be addressed from a clinician, clinic, and psychosocial social standpoint. Clinicians should be trained in culturally humble and TIC; clinics should have intake forms that allow patients to self-identify identify sexual orientation, gender identity, and pronouns. The clinic environment should be inclusive, with all gender or single-stall bathrooms, and patient-facing educational materials that are representative of individuals with diverse partnerships, races, and ethnicities. In order to provide genuine culturally humble care, clinicians must be adequately trained and clinics must be appropriately prepared. There is a great deal of improvement to be made to provide high-quality and equitable care for LGBTQ+ patients. To aid these unique populations to attain parenthood, the clinical community must continue to pave the way and fight for equal rights for family building for all.
Clinics care points
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Finding the Right Place: Clinics should have various touchpoints of inclusivity for LGBTQ+ communities including welcoming and appropriate online resources that reflect the clinic environment.
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Physical Space: Front Desk Personnel/Waiting Area/Environment: There is a dearth of literature with validated analysis tools on this patient population. The physical space of the clinic should include inclusive patient education materials in waiting rooms and clinic staff should also reflect diversity.
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Clinician Training: Clinicians must have ongoing training in order to approach their care with cultural responsiveness and cultural humility when working Clinicians should have training in cultural relevance/humility for working with LGBTQ+ patients. Ideally training would begin early in one’s professional development and continue throughout their careers. For clinicians who did not receive prior training in cultural relevance/humility, it is never too late to receive this training.
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Intake Forms: Medical intake forms should allow patient to self-identify their sexual orientation, gender identity, pronouns, and partner(s) status.
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Trauma Informed Care (TIC): Clinicians should be thoroughly trained and approach all patients with TIC given a large majority of patients from LGBTQ+ backgrounds have encountered trauma in medical settings.
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Fertility Preservation and Gender-affirming Care: There is an integral time for intervention for fertility preservation in patients who are undergoing gender-affirming care. The ideal time for adolescents undergoing fertility preservation has not yet been determined, but all patients undergoing gender-affirming care should be counselled regarding risks of gender-affirming medication and surgeries on future fertility.
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