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Susan (businesswoman, age 40) and Evan (lawyer, age 31) are a married couple in a major metropolitan city in California. Susan is female and Evan is a female-to-male transgender individual. They married in 2008 when same-sex marriages were first allowed, so they had legal marital status in the state. They had their first child (a daughter) in 2011, followed by a son in 2013.
To obtain sperm, they initially pursued known-donor options and asked a few men they thought might be a good fit. When one said no, they were crushed. Another agreed to do it, but by then they had moved toward the idea of using an anonymous donor. While they would have preferred a close friend who would leave the parenting to them but who the children could know, they were also highly aware of “horror stories” that could be involved in such a scenario. In the end, they chose to use an anonymous donor from a sperm bank, selecting a “willing-to-be-known” donor. They selected a donor with features similar to those of Evan’s “so that our first child would look like a mix of us.”
They decided Susan would carry both children. Evan noted, “It just made sense in our family for my partner to carry our child because she liked being pregnant and as a gender non-conforming person, I had decided that being pregnant, and all the femininity that is inextricably attached to that experience, would not work for me.” For their first child, they used Susan’s eggs because she was the one who wanted to have a baby more, and due to her age, it felt like it was “now or never.” For their second child, they used Evan’s eggs as they felt the younger eggs offered a better chance to successfully conceive. This brought up very mixed feelings for Evan. He noted, “As a genderqueer/trans person…it was a somewhat challenging and awkward experience to be at a fertility clinic and doing estrogen shots to retrieve the eggs. I also…gained a whole new level of gratitude around what my body was able to create, even though sometimes I wished that my body couldn’t create them.”
They described the process of becoming parents as “a bit stressful and incredibly expensive.” Susan was 36 at the time they started treatment. Like many women at that age, she was not sure whether she could successfully become pregnant, so each attempt was emotionally trying. Susan’s insurance did cover infertility, but according to the policy, they had to go through three rounds of insemination attempts before they could get any aspect of treatment covered. For their first child, they used IUI and were successful on the seventh cycle. Evan had to go through the second-parent adoption process to ensure he would have legal rights to their daughter. For their second child, they had to go through in vitro fertilization (IVF) due to their decision to use Evan’s eggs. They used the same sperm donor for both, stating, “We thought it would be cool to have two kids that shared genetics with the same sperm donor but be genetically linked to each of their parents that they were raised by.” They were successful on the first IVF cycle.
Evan observed that one of the largest challenges of the whole process was dealing with the insurance. He noted, “They don’t view you the same, and I believe it costs us more as LGBT people. With IVF, it was really challenging around how to label me as the egg donor? And my partner as the surrogate? This was confusing for insurance, for the doctors, the hospital and for us. It was confusing to do the birth certificate as we didn’t know which name should go where.” Though they noted feeling lucky to have doctors and hospital staff who were supportive, knowledgeable and accustomed to working with diverse types of families, they still felt that the paperwork was insensitive and did not reflect all the types of family configurations that can be involved in the LGBT childbearing process.
Now, having successfully conceived two children, Susan and Evan have found that they have become repositories of information for queer couples looking to start families of their own. While in some ways they enjoy being able to help others figure out this process, they observed they had not known anyone they could turn to with questions when they were going through it and had felt very much on their own. Evan noted, “I think this could be helpful for fertility counselors to know just how little is out there comparatively to the experience of non-LGBT people/families. There is a lot of education around how cognizant we need to be around language and experience for folks that don’t fit into the heterosexual binary model.”
Introduction
This chapter provides the background needed for counseling lesbian, gay, bisexual and transgender (LGBT) women and men as they undergo fertility treatment. The story of Susan and Evan illustrates many of the challenges that LGBT couples may face, including making complex childbearing decisions, navigating a treatment system designed for infertile heterosexual couples and confronting barriers such as insurance issues and uncertain legal rights. The goal of this chapter is to highlight the primary issues that many LGBT couples confront during treatment, and to provide guidance for fertility counselors on specific considerations to factor in when working with this group of prospective parents. Many aspects of treatment are no different for LGBT couples as for heterosexual couples and therefore are covered elsewhere in this book. As such, this chapter focuses on aspects of treatment particular to sexual minority patients. Further, while many of these issues pertain to LGBT individuals who seek treatment, this chapter will focus on couples since the experience of single parents by choice is covered in Chapter 12.
The experiences of LGBT families are highly diverse, so case examples (in the form of vignettes provided directly by real patients) are included to illustrate the range of issues that can arise. Lesbian couples comprise a dyad with two women, and gay couples are a dyad with two men. Given this chapter’s focus on couples, the experiences of bisexual patients (i.e., those who identify as sexually attracted to both men and women) will depend highly on the context of their current relationship. For example, if a bisexual woman is pursuing pregnancy with a male partner, the experience will be similar to that of heterosexual couples. If the bisexual woman is pursing pregnancy with a female partner, the experience will be similar to that of lesbian couples. Since lesbians represent the greatest proportion of LGBT fertility treatment patients, and because most research in this area is on the experience of lesbians, we note that much of the literature and vignettes presented come from lesbian couples. Specific information associated with gay and bisexual patients and their partners is highlighted when available.
For transgender individuals, their experience with fertility treatment will depend highly on the biological sex of the two partners. In the case of Susan and Evan, they were both biologically female. For the purposes of fertility treatment, their experience was that of a lesbian couple, with certain considerations linked to Evan’s transgender identification. Thus, couples with a transgender partner may have fertility treatment options more similar to that of heterosexual couples (i.e., a male-to-female transgender individual partnered with a female, or a female-to-male transgender individual partnered with a male), a lesbian couple (i.e., a female-to-male transgender individual partnered with a female), or a gay couple (i.e., a male-to-female transgender individual partnered with a male). What is different is that transgender patients may have to contend with extra levels of bias or discrimination during treatment, as well as consider the effects that steps required for gender transitioning (e.g., hormone therapy, surgery) may have had on their reproductive functioning.
Of note, guidelines for appropriate LGBT-related terminology are ever evolving, so part of the fertility counselor’s task is to be aware of contemporary conventions. For example, in current practice in the USA, the words “lesbian,” “gay,” “bisexual,” and “transgender” are used as adjectives, not nouns (e.g., “Sam is a gay individual,” rather than “Sam is a gay.”) The term “homosexual” has largely fallen out of favor and should generally be avoided. Conversely, the term “queer” is coming back into use as a self-affirming umbrella term encompassing all non-heterosexual identities; fertility counselors, however, should only use this term if there is a compelling reason for doing so (e.g., quoting someone who self-identifies as queer). The term “transgender” is now commonly used as the term for individuals whose gender identity does not match his or her physical sexual characteristics. More specifically, “transgender man” refers to a person who was considered female at birth but identifies as male (this is also represented by the term “female-to-male transgender person,” the acronym “FTM,” or the colloquial term “trans man”); vice versa for the term “transgender woman.” The term “transsexual” is considered antiquated and should generally be avoided. Some transgender individuals will use the term “genderqueer” to characterize all gender identities other than the binary categories of “male” and “female.” The process by which transgender individuals change their characteristics is termed “gender transition” (not “sex change”) and may include a change of name and/or pronouns, clothing, legal documentation and medical treatments. In general, the best rule of thumb is to determine what terms and gender pronouns the patient prefers, and to honor those preferences. For example, Evan identified as a “genderqueer/trans person” and used male pronouns. Other transgender people may prefer using gender neutral pronouns (e.g., ze, zir, sie, hir). A full review of all current conventions in LGBT terminology is beyond the scope of this chapter, but helpful resources can be found online (suggested links are provided in Addendum 13.1).
Background
It is important to have a sense of the various social and political forces that may influence LGBT patients’ feelings about pursing fertility treatment, their access to services, or the attitude of treatment providers. Historically, homosexuality and the family were viewed as incompatible categories [1]. LGBT parents typically had children within a heterosexual relationship and then came out after the relationship dissolved [2]. But in recent years, a growing number of couples are choosing to become parents in the context of a same-sex relationship. US Census data indicates that, in 1990, 1 in 20 male couples and 1 in 5 female couples were raising children; these number rose to 1 in 5 males couples and 1 in 3 female couples by 2000 [3]. The trend will likely continue as same-sex couples gain marriage rights and as social attitudes shift toward greater acceptance [4,5].
Fertility treatments, however, have not always been accessible to LGBT couples. In the past, discrimination against LGBT patients was overt, with providers citing legal, ethical, or moral arguments against same-sex parenting [6,7]. In certain countries, this still remains the case. For example, there is no access to fertility treatment for lesbian women in Austria, Czech Republic, France, Italy, Portugal and Slovenia [8]. These laws are not always relics of the past. In 2013, in Denmark, the law was amended to allow non-anonymous sperm donation for only heterosexual couples; in Croatia and Malta, new laws expressly ban women in same-sex relationships from access to fertility treatment [9]. But, fortunately, the situation in many places has improved. In the United States, in 2006, the Ethics Committee of the American Society for Reproductive Medicine (ASRM) published a statement declaring, “The ethical arguments supporting denial of access to fertility services on the basis of marital status or sexual orientation cannot be justified” [10, p. 1333]. ASRM went on to conclude that there is no basis for denying LGBT patients access to treatment, highlighting the absence of scientific evidence that parenting effectiveness is affected by parental sexual orientation [11,12]. In the USA, the ethical directive garnered some legal enforcement in 2008 when the California Supreme Court ruled that refusal to treat a lesbian based on the physician’s religious views violated state law [13]. Other countries have even stronger protections in place.1 For example, in the United Kingdom, the 2008 Human Fertilisation and Embryology Act protects patients from discrimination on the basis of sexual orientation, and both partners in a same-sex couple (provided they are in a civil partnership or conceived in a licensed clinic) have legal parenting rights to their child from birth [14,15]. In Canada, the law unequivocally states that those seeking reproductive services cannot be discriminated against on the basis of sexual orientation [16].
Even in countries that provide ethical and legal protections, however, potential barriers are still present. Fertility treatment services are still largely designed around a partnered, heteronormative paradigm [6,17]. As examples, clinic forms may not be designed appropriately for non-heterosexual clients, written materials may presume infertility and insurance coverage may be difficult to access or blocked altogether [17–19]. LGBT couples may also encounter overt homophobia or heterosexist practices. For example, while the ASRM issued a clear ethical directive, the guidelines are not legally binding, and different US clinics may have widely discrepant access policies [16]. In general, it is important to recognize that the policies and laws governing LGBT access to reproductive services vary dramatically from state to state and country to country, and all are subject to change. As a result, prospective LGBT parents may be still be subject to biased attitudes or denied service, and they cannot necessarily rely on policies to remain stable as they pursue parenthood. Taken together, these social, political and legal factors may significantly impact the experience of fertility treatment for LGBT couples.
Clinical issues: decisions, decisions, decisions
For same-sex partners on the path to parenthood, there are no “oops babies” or opportunities to just try “naturally” for a period of time. Rather, the process is an inherently intentional one that requires considerable planning and coordination. The start of this “child project” first involves making a choice: to become parents [20]. By the time LGBT couples sit down with a fertility counselor, they typically have made this first decision [2]. From that point, a series of choices must be evaluated and decisions made: What reproductive options to pursue? Whose egg will be used? Whose sperm will be used? Who will carry the child? Where can LGBT-friendly services be found? What are each partner’s legal rights? Will any of this be covered by insurance? A primary function of the fertility counselor is to help couples understand their options and the implications of their choices, as well as to support them through the evolving process of treatment. The counselor must additionally take into account complex interrelationships between social, legal, political and economic factors that may uniquely impact treatment options for LGBT patients [7].
Routes to parenthood
One of the first major decisions is what route to take to parenthood. For lesbian couples, there may be many possible options, while for gay couples, options are typically limited to surrogacy with egg donation or adoption. As noted above, for couples in which one member is bisexual or transgender, options will stem from the biological composition of the couple and their fertility potential. Specific considerations for LGBT couples are highlighted below.
Home insemination
Lesbian couples may use home insemination. This route involves vaginal insemination performed at home, either with the help of a known donor or with sperm from a sperm bank. Couples can use what has been called “turkey-baster technology” (e.g., a needleless syringe, eye dropper, cervical cap). Home insemination does not involve any medical staff, and couples may therefore feel a greater sense of autonomy and intimacy [20]. Further, it often represents the least expensive route.
“We did a home insemination using ‘fresh’ sperm from a known donor (my partner’s brother)…the alternative insemination program route was going to take quite a long time – there was a lengthy application and interview process for our donor, he was going to have to travel to our city to make the ‘donations,’ and then there would be the six-month quarantine on the sperm. The cost of collection, processing and storage was also going to be very high. We decided to try the ‘low tech’ method in the interim as we got the application process underway.”
There are important considerations to keep in mind with home insemination. Some couples carrying out self-insemination may not feel supported or safe, or have easy access to professional support or medical assistance should they need it [14]. If using fresh sperm from a known donor, the donor may not have been screened for sexually transmitted diseases (STDs), so there may be a higher level of health risk. Finally, and perhaps most crucially, in some jurisdictions, known-donor sperm must pass through the hands of a licensed medical professional, otherwise the donor can be granted legal rights and responsibilities for the resulting child.
Clinic-based treatments
Clinic-based treatments may involve an initial meeting with a gynecologist or reproductive endocrinologist, a fertility evaluation and genetic testing. Some clinics require a meeting with a fertility counselor. The most common treatment option used is intrauterine insemination (IUI), but couples can make use of the full range of fertility services depending on their needs, including IVF, egg donation, or embryo donation. Often multiple medical interventions (e.g., blood work, ultrasounds, medications) are also part of the treatment. Some LGBT couples may be uncomfortable with the degree of medicalization, while others will welcome the interventions as helpful tools for conception [7,21].
“We did our procedures at a clinic, mainly because we wanted to do whatever we could to increase our odds for success. We figured if something like an IUI can ensure the sperm gets right where it needs to go, then let’s do it. It took us seven cycles. The doctor always offered to let me squeeze the syringe. I can see why some people would like that – like they were a part of the conception. I always declined. For me, the syringe (and what was in it) was not a part of me, just a means to an end.”
Clinic-based treatments offer LGBT couples benefits that home insemination do not. If working with a known donor, the donor will have infectious disease testing. Working with a clinic offers greater protections of parental rights as the treatment process requires legal documentation defining parental status [7]. If pregnancy doesn’t occur, fertility interventions can be added to the treatment protocol as needed. However, some clinic policies may seem involved and cumbersome. Further, as reflected in one of the vignettes above, these procedures add a great deal of time and cost to the process.
Surrogacy
For gay couples, the options include surrogacy with egg donation and adoption. Surrogacy allows one of the partners to have a genetic link to the offspring, which is often valued by couples. Building a family with surrogacy means involving several outsiders in the process, including an egg donor and a gestational carrier, as well as a fertility doctor, legal counsel and an agency to help find the donor and carrier.
Surrogacy is expensive (typically between $75 000 to $120 000) and the legal issues can be complicated. In some states and countries (e.g., New York and Japan), surrogacy is prohibited (regardless of sexual orientation). In other states and countries, surrogacy may be permitted, but policies may prevent same-sex couples from accessing these services. For example, in Florida, Nevada and Texas, gestational services are restricted to married couples. Because same-sex couples can’t marry in these areas, they are by extension unable to use surrogacy [22]. In general, LGBT couples need to be very clear about the laws in their home state/country, the laws of the gestational carrier’s home state/country and the laws of the state/country in which the carrier delivers. Gay men are advised to use a gestational carrier who will deliver in a jurisdiction where the men can obtain a pre-birth order recognizing one or both of them as legal parents – otherwise the carrier will be a legal parent until her rights can be terminated. In some states/countries, if the gestational carrier is married, they will additionally need an order of non-parentage so that her husband’s name is not placed on the birth certificate [23]. Regardless of location, gay couples must also be certain to have legal contracts in place to define the rights and responsibilities of all parties involved [23].
Adoption or foster care
While adoption or foster care is an option for prospective LGBT parents, they again may face certain barriers. LGBT couples must first determine the policies of the state or the country from which they are attempting to adopt or foster. For example, as of 2014, 21 states in the USA (and Washington, DC) allowed same-sex couples to petition for a joint adoption; seven states had explicit obstacles to equal treatment (e.g., in Mississippi, same-sex couples are expressly prohibited from adopting); and in the remainder of states the regulations were unclear and decisions made on a case-by-case basis [24]. Policies for international adoptions can also vary dramatically. Due to the extreme variability of the laws, prospective parents should find out about laws in their jurisdiction and seek consultation at the outset of the adoption or foster process from either a family lawyer, state equality organization, or a national organization like the Human Rights Coalition (HRC) or the International Lesbian and Gay Association (ILGA) if needed [25].
Adoption agencies themselves can either function as supports or barriers. While many agencies work with LGBT prospective parents and are very helpful, others may not accept LGBT clients, may be less likely to place a child with LGBT families, or may demonstrate negative views toward same-sex families. Some agencies may operate on a “don’t ask, don’t tell” policy, which can be upsetting and confusing for clients [2,26]. Prospective parents should ask the agency about its track record in placing children with LGBT families, as well as the number of LGBT families it has worked with [25].
Complex arrangements
Until recently, LGBT families were frozen out of the institution of marriage and more “traditional” family structures. As a result, some couples have chosen to fully redefine what the notion of family entails. For example, a lesbian couple and a gay couple may decide to conceive children together and rear them together [27]. Other researchers have found that some lesbians may seek out gay donors, in part to give the donor an opportunity to take part in a parenting role that they might not otherwise have had [2]. Given the diverse paths lesbian and gay parents may take to family formation [27], fertility counselors need to be open-minded in supporting patients who may be creating relatively unique family structures. In these cases, the primary role of the counselor may be to help all parties involved consider the roles, rights and responsibilities of all of the individuals involved in the family system.
Gamete selection
Another major decision stems from whose gametes (i.e., sperm or egg) will be used. For cross-sex couples (i.e., in some dyads with a bisexual or transgender partner), the options are straightforward. For same-sex couples, presuming intact fertility in both partners, decisions will be based on a number of factors such as age, health and genetic history, family relationships and intensity of the desire to be a genetic parent. Some couples know in advance that they want to try to have more than one child, so then it becomes a question of whose gametes to use first. In some cases, infertility actually is an issue. For same-sex couples, this might mean that the other partner then becomes the gamete provider. Many times, some combination of any or all of these factors will be weighed in deciding which partner will provide half of the needed genetic material.
Same-sex couples are typically accepting of the fact that the child will only have a genetic link to one of the partners [2], though one job of the fertility counselor will be to make sure that any perceived loss around this issue has been processed. In surrogacy arrangements, some gay men ask that two embryos, one fertilized by each partner, be transferred to give the opportunity for both partners to have a genetic offspring. This scenario must be considered very carefully, however, because of the high risk of twins, the associated medical complexities for the carrier and the fetuses, and because (in cases when only one child is born) one partner may be disappointed in the end when he learns he was not the genetic provider. Sometimes men report that they do not want to know who the genetic provider actually was, but experience suggests that this is not advisable because of the uncertainty and confusion that can result (e.g., with the child’s pediatrician, and later for the child him or herself).
Sometimes one partner in a same-sex couple has a sibling (i.e., a brother or sister of the partner who will be the non-biological parent) who is willing to be the donor and provide the missing gamete. This arrangement can bring up complicated emotional and relational dynamics, so couples will often forgo this route [28]. For those who do use a sibling donor, the fertility counselor will play an important role in helping the individuals involved carefully think through their roles and consider the long-term implications of this decision.
Carrier selection
For same-sex female couples, the choice to use one partner’s eggs and which partner will carry often go hand in hand, though that is not always the case, as with Susan and Evan. A study by Goldberg [29] highlighted what is probably the most significant determining factor for lesbian couples: who has the greatest desire to experience pregnancy and childbirth.
“The first decision was that we would plan for two kids – one to be carried by me, the other by my wife…The hardest decision was which of us would go first. We both wanted to. In the end, I went first because I was ready first. She just wasn’t quite there yet, in terms of thinking of physically carrying a child, and I was.”
Other factors that can impact the decision of who carries the child include: age of each partner, medical history, insurance benefits, attitudes of extended family and the presence of existing children [30]. Some considerations stem from practical implications, such as who has the most job flexibility or can most easily take time off.
Donor selection
For same-sex couples, a third party donor will inevitably be a part of the picture, but the decisions around the donor can vary greatly. For some couples, having a known donor is a major part of the process of family formation [7]. Prospective parents may want the child to know the donor and have some contact with them. This does not mean the couple necessarily wants the donor to take a parenting role, but they may want to give the child the chance to know more about his or her biological origins [2].
“Anonymous donor sperm was never an option for us. This was especially true for my partner. She said, ‘I would just look at the kid and think Who Are You?’ Likewise, we did not consider adoption – it’s just not for us. Finding the perfect donor took time, painful experience and dumb luck. We were really looking for intangible things – character, ability to love and be loved, resilience – not just because we wanted to see those traits in the child, but because we wanted the donor to be a positive, loving presence in our child’s life.”
Other people prefer a known donor because they feel it gives them more control over the insemination process, or because they want more direct access to the donor’s health and genetic history. Regardless of the motivation, an important consideration for LGBT couples using known donors is to openly discuss, in advance, what role that individual will play in the family unit, as well as to have a legal agreement in place wherein the known donor relinquishes all legal rights and responsibilities to the child
Some couples have a strong preference for an unknown donor. Two major motivations stem from legal reasons (i.e., nobody else can lay claim to the child) and from the desire to raise the child without outside interference from a third party [2]. Non-biological parents may prefer unknown donors as it would pose less of a threat to his or her status as an equal co-parent [31]. Many sperm banks have increasingly popular “identity release” (or “willing-to-be-known”) options, wherein the donors allow the sperm bank to pass along requests for contact information from the offspring after they turn 18 [30]. This may be an appealing option for many LGBT couples as it enables them to engage in family formation without the involvement of an outside party, but still provides the offspring the later possibility of obtaining information about their biological origins.
“We used anonymous donor sperm from a bank. We chose ID release so our child would have the option to contact him if desired…We started our search limiting it to ID release donors and using characteristics of my wife – eye color, hair color, skin tone. We don’t expect our offspring to look like my wife but we wanted our child to look like she was born into this family, as she was. We then read profiles and likes and interest. My wife and I met working at summer camp and the donor we ended up choosing also indicated his love of working with kids at camp. We call him ‘camp guy’.”
Specific challenges for LGBT patients and their partners
This chapter will now examine some of the specific challenges that LGBT couples face when receiving fertility treatment. While each area is addressed individually, it should be recognized that these social, legal, political and economic forces are often inextricably interwoven in ways that may significantly affect treatment for LGBT couples.
Navigating a heteronormative system
The majority of fertility treatment services are targeted toward heterosexual women, and partners are presumed to be husbands. This heteronormative approach is reflected in the very term “infertility counseling” or “infertility treatment” that is used by providers. That is, these services were designed for people who met the criteria for infertility (defined as 12 months of regular, unprotected heterosexual intercourse without a successful conception). This construct does not create space for the experiences of LGBT couples. Take the example of a perfectly healthy lesbian in the USA with no known risk factors for infertility using anonymous donor sperm, who goes to a fertility clinic for IUI treatment. Based on clinic policy (and in accordance with ASRM guidelines), this patient would receive a fertility work-up and psychological counseling. All of this adds time and money to the process, and it can medicalize or pathologize a relatively straightforward situation.
“If you are going into a fertility clinic for help getting pregnant, it is difficult for them to get out of problem-solving mode. Everyone they deal with suffers from infertility issues. They default to interventions. As we told our doctor, the only problem we are solving for is that neither one of us makes sperm.”
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