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Keywords:

  • Artificial insemination;
  • Childbirth;
  • Health care providers;
  • Lesbian;
  • Parental rights;
  • Parenting;
  • Pregnancy

Abstract

  1. Top of page
  2. Abstract
  3. Sources of information
  4. Review of the literature
  5. Disclosure of sexual orientation to HCPs
  6. Options for conception
  7. Partner involvement
  8. Legal considerations
  9. Limitations of the literature
  10. Implications for HCPs
  11. Disclosure of sexual orientation
  12. Options for conception
  13. Partner involvement
  14. Legal implications of lesbian motherhood
  15. Conclusion
  16. References

Objective:  To provide an overview of the literature regarding lesbian experiences of childbirth and to offer health care providers guidance in supporting the childbearing lesbian couple.

Data sources:  A search of the literature from 1980 through 2004 was conducted using PsycINFO, Ovid, PubMed, Ebscohost, and Cinahl, and the key words, lesbian, childbirth, parenting health care providers, pregnancy, artificial insemination, parental rights.

Data extraction:  A critical review of all articles from relevant journals was included with attention to the needs of lesbian women concerning childbirth and implications for health care provider care.

Data synthesis:  The four areas of concern identified for lesbians considering parenting were (a) the pros and cons of disclosing sexual orientation to caregivers and finding lesbian-sensitive caregivers, (b) the options available when deciding how to conceive, (c) assurance of the desired level of partner involvement, and (d) the legal considerations for the conception process and for the protection of both parents as well as the child. Methods and strategies to assist health care providers to meet the needs of lesbian clients were gleaned from the literature.

Conclusion:  A growing numbers of lesbian women are becoming consumers of childbirth health care. Health care outcomes of lesbian women and their infants are affected by experiences during pregnancy and childbirth and by the attitudes and actions of health care providers. Evidence exists that health care outcomes for lesbians are improved when health care providers are knowledgeable about and sensitive to the unique needs of lesbian clients. JOGNN, 35, 13-23; 2006. DOI: 10.1111/J.1552-6909.2006.00008.x

Since the Stonewall1 event, the visibility of the homosexual lifestyle in the United States has continued to increase, as gays and lesbians become more visible in all aspects of life. Homosexuality, though still not considered mainstream, has become a common occurrence in the eye of the American public, thereby increasing the public's awareness of gays, lesbians, and their families. A recent Gallup poll demonstrated that the percentage of American adults who believed that homosexuality was an acceptable lifestyle increased from 14% in 1981 to 46% in 2003 (Herek, 2004). Increasing visibility and acceptance of the homosexual lifestyle has encouraged more gay and lesbian couples to consider parenthood. This “new generation of gay parents” was identified by Salholz (1990) as being “the first ever gayby boom” and has been responsible for one third of all lesbian couples choosing to raise children (Chosnoff & Cohen, 2002). Contrary to Wong, Perry, and Hockenberry (2002), who commented that “most children in gay/lesbian households are the biologic offspring from a former legal marriage” (p. 10), a 1999 study of lesbian mothers reported that 76% of lesbian offspring resulted from donor insemination (DI) within the lesbian relationship (Dunne, 1999). Despite the rising incidence of lesbian motherhood, a review of several current undergraduate maternal-newborn nursing textbooks (Littleton & Engebretson, 2002; Lowdermilk & Perry, 2004; Wong et al., 2002) revealed little or no information addressing issues specific to caring for the gay or lesbian childbearing family. All three sources acknowledged that the gay or lesbian family had unique needs, although only the most recent text by Lowdermilk and Perry identified what even one of these needs might be and subsequently provided one paragraph that addressed the issue of postpartum family adjustment for a lesbian couple.

The decision to have a child is possibly one of the most challenging decisions that any couple will ever make. Nonetheless, this decision has been made countless times by lesbian couples, resulting in an estimated 10,000 babies having been conceived through DI by 1998 (Haimes & Weiner, 2000). For the lesbian couple considering parenthood, the decision to have a child involves processes and choices not encountered by most heterosexual couples living in a heteronormative world. The decision to parent, for lesbian women, often involves the threat of homophobic reactions from health care providers (HCPs). At times the dehumanizing manner and potentially prohibitive cost of technologically guided conception, the chance of rejection and lack of support by non-childbearing friends and social groups, the alienation by disapproving family, and the reality of facing the stigma of raising a child in a same-sex household add increased stressors.

An examination of the social impact of the growth of the lesbian baby boom may serve to illuminate methods to ease this decision making process, but such a social commentary is beyond the scope of this article. What is of prime concern in this review is how HCPs can learn from the experiences of lesbian couples who have gone through the pregnancy and childbirth process. It is the aim of this article to conduct a review of current nursing literature concerning lesbian experiences of childbirth in order to determine how HCPs can best aid lesbian couples in coping with the many unique questions and decisions they face when making the choice to become parents.

Sources of information

  1. Top of page
  2. Abstract
  3. Sources of information
  4. Review of the literature
  5. Disclosure of sexual orientation to HCPs
  6. Options for conception
  7. Partner involvement
  8. Legal considerations
  9. Limitations of the literature
  10. Implications for HCPs
  11. Disclosure of sexual orientation
  12. Options for conception
  13. Partner involvement
  14. Legal implications of lesbian motherhood
  15. Conclusion
  16. References

An inclusive search of the electronic literature databases PsycINFO, Ovid, PubMed, Ebscohost, and Cinahl from 1980 to 2004 was conducted using a combination of the following key words: lesbian, childbirth, parenting, health care providers, pregnancy, artificial insemination, and parental rights. To be included in the literature review, articles need to directly address factual accounts of lesbian experiences during childbirth or provide guidance for HCPs caring for this patient population. This search quickly revealed the insufficiency of information and research done on lesbian women's experiences during pregnancy and childbirth. Harvey, Carr, and Bernheime (1989) experienced the same challenge and commented, “Although increasing numbers of lesbians are choosing to become pregnant, few studies have addressed the unique needs of this population and the effects of societal attitudes on the provision of care to these women” (p. 115). The literature review included 15 articles that spanned the years 1980 to 2000. The fact that the earliest article was written less than 25 years ago supported the authors’ observations that lesbian motherhood has become a topic of interest in the health care field only recently. So, while the incidence of lesbian motherhood and lesbian-headed families has become more common in recent years, only 0.1% of all health care research dollars are being directed toward gay/lesbian issues (Boehmer, 2002).

Review of the literature

  1. Top of page
  2. Abstract
  3. Sources of information
  4. Review of the literature
  5. Disclosure of sexual orientation to HCPs
  6. Options for conception
  7. Partner involvement
  8. Legal considerations
  9. Limitations of the literature
  10. Implications for HCPs
  11. Disclosure of sexual orientation
  12. Options for conception
  13. Partner involvement
  14. Legal implications of lesbian motherhood
  15. Conclusion
  16. References

Lesbian women considering parenting face unique challenges: finding a caregiver, options for conception, involvement of their partner, and legal implications of same-sex parenthood.

An overview of the literature identified four primary areas of concern for lesbians considering parenting, the 1st of which was the pros and cons of disclosing sexual orientation to HCPs coupled with the difficulty of finding lesbian-sensitive HCPs. The 2nd concern revolved around the options when deciding how to conceive. The couples also wanted to be assured that the desired level of partner involvement could be achieved. The last concern centered on the legal considerations necessary throughout the conception process and beyond to provide for legal protection of both parents as well as the child.

Disclosure of sexual orientation to HCPs

  1. Top of page
  2. Abstract
  3. Sources of information
  4. Review of the literature
  5. Disclosure of sexual orientation to HCPs
  6. Options for conception
  7. Partner involvement
  8. Legal considerations
  9. Limitations of the literature
  10. Implications for HCPs
  11. Disclosure of sexual orientation
  12. Options for conception
  13. Partner involvement
  14. Legal implications of lesbian motherhood
  15. Conclusion
  16. References

One of the 1st questions that arose for any lesbian couple was whether to disclose their sexual orientation, more commonly known as “coming out” to HCPs. The review of the literature revealed that many lesbians feared that their degree of honesty, with respect to sexual orientation, might affect their experience throughout the pregnancy, birth, and through their child's formative years (Harvey et al. 1989; Tash & Kenney, 1993). Dardick and Grady (1980) found that lesbian (and gay male) satisfaction with HCPs was greater after coming out, yet studies demonstrated that 41% to 72% of lesbians surveyed did not reveal their sexual orientation to their HCP (Lehmann, Lehmann, & Kelly, 1998; Marrazzo & Stine, 2004; Smith, Johnson, & Guenther, 1985) and more than one third (37.5%) believed that to do so would negatively impact their care. Another study (Harvey et al.) reported that over 90% of 35 lesbian mothers surveyed disclosed sexual orientation to their HCP, and the 1995 study replication, by Roberts and Sorensen (1995) found that 80% of lesbians were likely to be out to their HCP versus 63% in the 1987 results. Buchholz (2000) discovered that many lesbians believed that “homophobia and differences in the quality of care” might arise subsequent to their coming out (p. 307). This fear was supported by Smith et al. (1985) who described HCP responses ranging from embarrassment to outright rejection and referral to a mental health professional. Tash and Kenney (1993) also reported lesbian couples being refused prenatal care and this was supported by the anecdotal evidence of Wilton and Kaufmann (2000):

The midwife said that she had never heard of people like us.

She refused to book us in; espoused her Christian beliefs.

My GP stated that he did not agree with two women bringing up children.

When I first disclosed my relationship status with my GP she was very disappointing. She stated outright that a woman should not consider childbearing unless married to a man; she was in fact very rude. (p. 205)

Homophobia, defined as “fear of same-gendered sexuality … and hatred toward homosexuals” (Gruskin, 1998, p. 29), has far reaching implications for the same-sex couple. Overt or even suspected homophobia may inhibit the lesbian couple's interaction with and trust in the HCP, leading to impairment in both the quality and quantity of health care that the couple and their child receive. There may also be reluctance on the part of the couple to ask for help or assistance when needed. Stewart (1999) described the reluctance of one lesbian mother to request aid from her HCP for postpartum depression because she feared it would reinforce the belief of the HCP that lesbian mothers exert negative social consequences on the children they raise. In this case, the HCP had made it clear to the couple that she did not support their decision, or the decision of any lesbian couple, to have a child. Stewart concluded that this type of attitude leads to alienation of the HCP from the parents and negatively influenced the care that they and their child received.

Several sources suggested that lesbian women preferred to seek care from lesbian providers and utilize nontraditional sources of health care to minimize the negative consequences of revealing their sexual orientation. Smith et al. (1985) reported that almost 25% of respondents sought care from sources such as alternative health clinics or nurse practitioners. Tash and Kenney (1993) found that lesbian women preferred to receive their care from lesbian gynecologists or midwives. Harvey et al. (1989) analyzed a survey of 35 lesbian women who had delivered a child within the past 5 years. Their findings revealed that almost half the women (48.6%) utilized a midwife for their care, and those accessing midwifery care expressed greater levels of satisfaction (83.3%) compared to those who utilized physicians (57.1%). The above results were not surprising when one looks at the contents of major textbooks used for women's health professions. Both Varney, Kriebs, and Gegor's (2004) text for midwives and Youngkin and Davis's (2004) text for nurse practitioners devote an entire chapter to the needs of lesbians. William's Obstetrics (Cunningham et al., 2001), commonly used by obstetrical residents, is markedly void of any cultural competence material. Lesbian mothers appeared to favor receiving care from lesbian gynecologists and midwives (Kenney and Tash, 1992; Smith et al.), but they ultimately desired an HCP who was sensitive, open, and nonjudgmental, willing to listen to the concerns of the prospective parents, and avoided the assumption that all childbearing women were heterosexual (Kenney and Tash, 1992).

Lesbian women desire a caregiver who is sensitive, accepting, and nonjudgmental.

Previous studies suggested that HCPs often overlooked the health needs of lesbians because they were unaware of the presence of lesbians within their patient populations (Harvey et al., 1989; Percy, 1997; Kenney and Tash, 1992). This led to a lack of access to appropriate or adequate (or both) health care for the lesbian population. Like Harvey et al., Wilton and Kaufman (2000) discovered that while the majority of lesbian women surveyed were satisfied with the maternity care they received, they still encountered specific problems when accessing maternity services. Responses of the women interviewed by Wilton and Kaufmann included reports of “ignorance of their needs, assumptions that made them feel excluded or marginalized, moral disapproval or even, albeit rarely, outright hostility and negligence” (p. 210).

Options for conception

  1. Top of page
  2. Abstract
  3. Sources of information
  4. Review of the literature
  5. Disclosure of sexual orientation to HCPs
  6. Options for conception
  7. Partner involvement
  8. Legal considerations
  9. Limitations of the literature
  10. Implications for HCPs
  11. Disclosure of sexual orientation
  12. Options for conception
  13. Partner involvement
  14. Legal implications of lesbian motherhood
  15. Conclusion
  16. References

The question of how to conceive a child was not an issue usually faced by heterosexual couples,2 although it was of prime concern to the lesbian couple. The 1st choice must be whether to conceive through sexual relationship or through DI techniques. Historically, lesbians may have had trouble accessing clinic-based DI due to both legal and ethical/moral arguments against lesbian insemination, and in one older study, researchers reported four women being refused insemination due to their sexual orientation (Harvey et al., 1989). However, lesbian mothers are becoming more visible, and while a large number of women have concerns over the medicalization of conception and the increasing use of high-tech options for obstetric care (Wajcman, 1991), research revealed that DI was becoming recognized as the method of choice for most couples when choosing an option to facilitate conception of a child (Kenney & Tash, 1992; Lewin, 1993). Olesker and Walsh (1984) reported that eight out of the nine women interviewed chose conception by coitus, with most of the men involved not being informed about the desire for conception. Harvey et al. and Buchholz (2000) revealed much higher numbers of lesbian women (87% and 100%, respectively) choosing to conceive by artificial insemination.

The decision to utilize DI as the method of conception, however, is not one that can be taken lightly. Haimes and Weiner (2000) identified the challenges of finding a donor, deciding on the desired level of interaction with the donor, and deciding how much and when to tell the child about his or her origins as key themes that must be discussed prior to insemination. Prior to selecting a donor, the couple must be either self-educated or educated by others as to realistic sources of potential donors. They may experience rejection by certain clinics due to their self-identification as lesbian. The financial cost of donor selection can be prohibitive and may involve travel costs if the couple is required to leave their immediate geographic area. They may or may not have potential donors within their social network who they are comfortable approaching. The presence or absence of social support networks or insemination groups, or both, may also influence their success in the search for a donor.

The search for a donor is influenced by the outcome of the couple's decision whether or not to utilize a donor who is known to them or one who is anonymous and what, if any, role the donor will play in the child's life. Kenney and Tash (1992) identified the pros of anonymous DI as being confidentiality, screening of donor sperm for health risks (HIV, etc.), and a decreased fear of potential coparenting complications. They were critical of anonymity because the resultant children grow up not knowing their biological origins and may or may not have accurate information regarding genetic risk factors and history. Conversely, they viewed known DI as more complete with regard to genetic information but recognized that if the couple chose to use a donor known to them, they may encounter difficulty or discomfort requesting recommended preconception screening tests and obtaining accurate medical history. However, there is a very real risk that the donor may request (now or in the future) more involvement with the child than the lesbian parents are comfortable with. Known DI also may include custody complications that do not exist with anonymous donation. Haimes and Weiner (2000) found that some women believed gay donors pose less risk should the question of custody arise in the future, as they believed that a gay man would be less likely than a straight man to be awarded custody over a lesbian.

Coupled with the decision regarding donor identity and source are the questions of whether the parents will inform the child of her or his biological origins, and if so at what age. If they decide not to tell the child, how will they explain the child's conception? In addition, there is the question of who will carry the child. This decision is assumed in some relationships but cannot be taken for granted. Often one partner will be the natural choice of both women and will carry any children that the couple chooses to have. However, there must be negotiation and discussion around this issue. Some couples will decide to have more than one child in order for both women to have the opportunity to experience pregnancy and childbirth. The lesbian couple will also need to decide whether they want to perform the insemination themselves or enlist the assistance of the medical system. Self-insemination can be performed with known or anonymous donor sperm and is an option for couples who wish to minimize the intrusion of HCPs into the conception process. Regardless of the outcomes of these decisions, it is recognized that the lesbian couple considering parenting will shape their choices based on practical considerations as well as their unique values and priorities (Haimes & Weiner, 2000).

Partner involvement

  1. Top of page
  2. Abstract
  3. Sources of information
  4. Review of the literature
  5. Disclosure of sexual orientation to HCPs
  6. Options for conception
  7. Partner involvement
  8. Legal considerations
  9. Limitations of the literature
  10. Implications for HCPs
  11. Disclosure of sexual orientation
  12. Options for conception
  13. Partner involvement
  14. Legal implications of lesbian motherhood
  15. Conclusion
  16. References

While caregivers, friends, or society do not usually question the role of the father in a heterosexual family, the role of the lesbian coparent is frequently not only questioned but also misunderstood and ignored (Kenney & Tash, 1992). Wilton and Kaufmann (2000) found that over 30% of the women surveyed reported their partner had been excluded from the process at some point. This problem becomes particularly acute when couples choose not to let their sexual preference be known to HCPs, as efforts to conceal the relationship may render the nonpregnant partner invisible and unimportant in the process. However, even in the case of couples who disclose their sexual orientation, confusion or a lack of understanding over the role of the partner frequently occurs. In studies where participants were lesbian couples who had delivered a child within the relationship, lack of partner participation was noted. Only one study specifically identified the necessity to include the experiences of both parents in the findings (Stewart, 2002). Reactions of HCPs to the lesbian partners of pregnant women range from total acceptance and inclusion (Buchholz, 2000) to exclusion and rejection. This was evidenced by the comments of several lesbian women interviewed by Wilton and Kaufmann:

My partner had to fight to be acknowledged as the baby's mother and to be included in her care.

She was not listened to by the doctor.

Although the midwives were great, the doctors and consultants in the hospital were not. Actually ignored my partner completely.

She didn’t talk to or even look at my partner. (p. 208)

Confusion may stem from the variety of terms that can be used to refer to the mother who is not carrying the pregnancy. Terms such as “non-biological mother, co-parent, co-mother, social mother, other mother, and second female parent” (Varney et al., 2004, p. 306) are frequently used and often mean different things to different couples. These terms may also reflect differing biological and social relationships between the parents involved in the pregnancy. It is important for HCPs to recognize that there are a number of arrangements that may present themselves in the lesbian family. One woman may have become pregnant (through a variety of methods) and be preparing to deliver a child that is genetically related to her. On the other hand she may have had the fertilized egg of the other female parent implanted into her uterus and be preparing to deliver a child that is genetically related to the nonpregnant partner. Alternatively, she may be carrying a child that is the result of fertilization of an egg from a donor; in which case, the child will not be genetically related to either mother. In any case, the child that is being delivered will be the child of both mothers. Lesbian couples will undoubtedly have a preference about how they wish to be identified, regardless of the structure of their family. Health care providers can help validate the role of the partner through recognition of and respect for the family regarding their choice of terminology and the roles of each partner in the pregnancy and childbirth process.

The ability of the nonpregnant partner to share fully in the pregnancy experience can be impacted by feelings of jealousy, ambivalence, and doubt that are similar to those experienced by heterosexual partners (Tash and Kenney, 1993; Pies, 1985) or by intentional or accidental exclusion from the process by HCPs. It has been recognized that lesbian couples may not be able to express the same level of intimacy with regard to their language and behaviors, such as caressing or kissing, as heterosexual couples (Kenney & Tash, 1992; Stewart, 1999; Wismont & Reame, 1989). This may occur repeatedly throughout the pregnancy and birth or only in the presence of certain HCPs. The acceptance by HCPs of outward expressions of the lesbian couple's intimacy demonstrates the presence of supportive care for the lesbian family which has been shown to “improve women's experiences of pregnancy and birth” as well as having “the potential of benefiting the long term health of women and children” (Stewart, 2002).

The non-childbearing partner in a lesbian relationship may also face the additional stressors of invisibility and a lack of support, particularly from their work community (Tash & Kenney, 1993) or a social community that has been unsupportive of the couple's decision to have a child. The nonpregnant partner may or may not be “out” to her coworkers and friends. The new lesbian mother who has not revealed her sexual orientation will not be able to participate in the social celebration and recognition that usually accompanies the arrival of a new child. In addition, the social support system that can aid new parents in the transition to their new role will not extend to the new mother who does not feel able to announce her news. This new parent will not be able to participate in discussions of parenting issues and will not garner much needed support from other parents. Even for new parents who are open with friends and coworkers, the nonpregnant partner is frequently socially invisible and unacknowledged. Employers who do not recognize domestic partnerships usually do not have provisions for parental leave for the nonpregnant partner. Employer-sponsored health insurance is usually not available to nonrelated individuals, resulting in an inability of this new mother to ensure provision of health care for her new child.

Nonpregnant female partners, however, possess an option not available to their male counterparts in that they may choose to breastfeed their infant through induced lactation. This experience serves to increase emotional bonding and nurturing between the non-childbearing parent and their infant. A commitment to this process is applauded by advocates of breastfeeding such as the La Leche League (Luttkus, 2001); however, it is also recognized as a time-consuming and demanding venture. The nonpregnant partner who wishes to breastfeed her infant may need to take medications such as high levels of estrogen followed by a prolactin-enhancing drug such as metoclopramide (Reglan) to mimic hormonal changes during pregnancy and birth. She will have to pump her breasts or feed the infant on a frequent schedule and must recognize and agree to the potential need for nutritional supplementation for the infant (Wilson-Clay, 1996).

The logistics of making breastfeeding a successful venture, as well as the realities of fulfilling the role of the non-childbearing partner, can be difficult. This is made more difficult when, for financial reasons, one partner (usually the non-childbearing woman) is required to work, is not offered or does not have access to parental supports, or is rendered invisible due to the heterosexist assumptions of society and the health care industry.

Legal considerations

  1. Top of page
  2. Abstract
  3. Sources of information
  4. Review of the literature
  5. Disclosure of sexual orientation to HCPs
  6. Options for conception
  7. Partner involvement
  8. Legal considerations
  9. Limitations of the literature
  10. Implications for HCPs
  11. Disclosure of sexual orientation
  12. Options for conception
  13. Partner involvement
  14. Legal implications of lesbian motherhood
  15. Conclusion
  16. References

The legal issues of parenthood can be daunting for the lesbian couple. Lesbians identify the “lack of social and legal recognition of their family structure and of the non-biological mother as a parent” (McNair, 2003, p. 644) as a major challenge throughout the process of pregnancy and childbirth. Three primary legal issues that should be addressed with the lesbian couple include the legal relationship between the women, the legal relationship between the child and the non-childbearing mother, and the legal rights and obligations of the donor.

While the argument for or against gay marriage is not a focus of this article, it is important that those caring for the gay/lesbian patient be aware of the legal difficulties that may be faced by these couples during a hospitalization. Currently, Belgium, the Netherlands, several provinces in Canada3, and the state of Massachusetts in the United States are the only places where gay and lesbian couples are able to legally marry and obtain the same benefits and obligations as heterosexual married couples. California and New Jersey are the only states that presently have Domestic Partner (DP) agreements in which many of the rights of married couples are extended to same-sex couples. However, at this time, these rights are recognized only at a state level and do not include any of the federal rights to which heterosexual couples are entitled. In addition, DP agreements filed in one state are not recognized by other states, so if the couple moves, they are subject to the laws of their new location (Gruskin, 1998). This lack of legal recognition contributes to concern over the rights of same-sex partners to protect each other, such as through an inability to make medical decisions, to secure visitation, and to obtain information regarding a hospitalized same-sex partner (Caulfield & Platzer 1998; Epstein, 2003).

While many facilities are beginning to recognize the relationship between same-sex partners, many remain bound by state laws or facility policies (or both) that require a legal or blood relative to be designated as next of kin. The law is often unclear and confusing regarding who can be recognized as the legal next of kin, and even with appropriate documentation the lesbian couple may face difficulties. Buchholz (2000) described the experience of one couple: “even with the power of attorney papers, a nurse had difficulty understanding” (p. 309). Should the hospitalized lesbian become incapacitated, it is not implausible that her female partner will be denied the right to make medical decisions for her. Caulfield and Platzer (1998) argue that, “There is no legal definition that shows that blood relatives or some other group qualifying as next of kin assumes precedence in health decisions over someone who has no blood relation with a patient” (p. 48). They also recognizes that, “Nursing and administration staff involved in the admission process often disregard the request of a patient who names their same sex partner as ‘next of kin’ and insist that the patient name a blood relative” (p. 48). Epstein (2003) advises seeking legal counsel to enact a Durable Power of Attorney for Health Care which should provide, at a minimum, a provision to ensure that same-sex partners have 1st priority for visitation, are entitled to receive information about their partner's condition, and are empowered to authorize medical treatment or the release of remains if indicated. This source of stress and frustration is one that can forever influence the couple's memories of their child's birth.

In addition to not being legally related to her female partner, the non-childbearing lesbian is not legally related to her child. Gruskin (1998) noted: “If the legal mother dies, then her biological family has stronger legal ties to the child than does the non-legal parent, even if she has raised the child as a mother for the child's entire life” (p. 116). The details and implications of any custody arrangement will differ depending on where the couple lives, their access and ability to pay for legal counsel, and the presence of any legal documentation in place before conception or birth (or both). Arrangements may include 2nd-parent adoptions, coparenting/guardianship contracts, uniform parentage acts, wills, trusts, or termination of the sperm donor's parental rights (Toevs & Brill, 2002) or all. Not all contracts and agreements available to the lesbian couple are legally binding, although they may be helpful in determining the original intent of the couple or donor, or both, should the issue of custody ever be questioned by the legal system (Tash & Kenney, 1993; Toevs & Brill).

Additionally, the rights of the sperm donor must be considered. As with guardianship, legal rights and obligations of sperm donors vary from state to state and differ when a donor is known or anonymous. Unlike the early days of lesbian childbearing when most lesbians conceived through intercourse with men (Kenney & Tash, 1992), couples today typically access sperm banks that provide legal protections for both the lesbian couple and the donor. For example, California Family Code states: “The donor of semen provided to a licensed physician and surgeon for use in artificial insemination of a woman other than the donor's wife is treated in law as if he were not the natural father of a child thereby conceived” (California Family Code, Section 7613(b)). This has been interpreted to mean that the donor has no legal right to sue for guardianship, visitation, or custody and is not to be held legally, financially, or morally responsible for the child at any time.

In cases where the lesbian couple chooses to use a known donor, the donor is determined to have parental rights until he legally severs those rights. Despite the presence of donor contracts, the parents of a known donor may sue for custody as the child's grandparents validating the fear of many lesbians that they may lose custody of their child to the sperm donor or his family (Haimes & Weiner, 2000; Pollack, 1987; Toevs & Brill, 2002). The lesbian couple considering childbearing must be aware of the inequities of the legal system with regard to same-sex parents and recognize the risks to their parental authority that accompany known DI.

Limitations of the literature

  1. Top of page
  2. Abstract
  3. Sources of information
  4. Review of the literature
  5. Disclosure of sexual orientation to HCPs
  6. Options for conception
  7. Partner involvement
  8. Legal considerations
  9. Limitations of the literature
  10. Implications for HCPs
  11. Disclosure of sexual orientation
  12. Options for conception
  13. Partner involvement
  14. Legal implications of lesbian motherhood
  15. Conclusion
  16. References

In the limited literature on childbearing lesbians available for review at this time, it is discouraging to note that the same concerns identified by Harvey et al. (1989) are still being addressed by Wilton and Kaufmann (2000) and by Buchholz (2000). In the research reviewed, several significant social limitations are noted. All authors cite obtaining an adequate sample size as a problem. Wilton and Kaufmann (2000) obtained the largest sample, but with 50 participants, their study cannot be considered large enough to prescribe generalizability to the results. Out of a total of 90 women interviewed in the three major studies discussed, 83 (92%) were White, the majority were college educated and worked full or part time during their pregnancy, had access to health care insurance, lived in urban areas, and were over the age of 30 at the time that they became pregnant (Buchholz; Harvey et al.; Wilton & Kaufmann). These demographics shed light on one of the most crucial limitations of these studies as a collective representation of the lesbian experience: the lack of cultural diversity among the participants. The authors recognize this fact and cite this as a significant limitation.

Further limitations stem from the fact that all of the studies utilized convenience and self-selected sampling thereby rendering randomization difficult if not impossible. The risk of using these sampling methods within this population is the “inclusion of a majority of women who were more vocal and who openly disclosed and accepted their lesbian identity” (Buchholz, 2000, p. 308). Obtaining information from marginalized populations presents a challenge, particularly in the lesbian community where there is risk of stigmatization and retaliation. Women living in more isolated areas, those not comfortable revealing their sexual orientation, and those not actively participating within a lesbian social network are noticeably excluded. Solarz (1999) identifies one of the most important challenges for those performing research within the lesbian community as the development of instruments that encourage women to reveal sensitive information in an environment of trust, openness, and acceptance. We suggest that this goal be more encompassing and challenge HCPs to ensure that all care provided to lesbian women, not just that associated with research, be competent, inclusive, informed, and nonjudgmental.

Implications for HCPs

  1. Top of page
  2. Abstract
  3. Sources of information
  4. Review of the literature
  5. Disclosure of sexual orientation to HCPs
  6. Options for conception
  7. Partner involvement
  8. Legal considerations
  9. Limitations of the literature
  10. Implications for HCPs
  11. Disclosure of sexual orientation
  12. Options for conception
  13. Partner involvement
  14. Legal implications of lesbian motherhood
  15. Conclusion
  16. References

It is vital that both lesbian couples and their HCPs are aware of the issues relating to lesbian childbirth and how to communicate about them. As outlined, the considerations for lesbians contemplating parenthood are immense and often overwhelming. Many couples seek support from friends or relatives, or both, others from parenting groups and lesbian/gay organizations, and some others will turn to their HCPs as being the experts in this field. The information and education provided to the couple during this time has the potential to shape their birth experience and can have an untold impact on both the couple and their child.

Health care providers should begin by examining their own attitudes and assumptions regarding homosexuality and recognize that these may influence the care they provide to the gay/lesbian client. Health care providers need to advocate for culturally sensitive training as a method of educating staff regarding inaccurate assumptions regarding lesbian couples. Current knowledge of lesbian health needs and methods for the provision of inclusive care should be part of the competent sensitivity training.

All lesbians considering parenthood and their HCPs should be aware of the challenges they will face and be informed of options available to them. The partners need to advocate for their right to satisfying, individualized health care. In order to competently care for the childbearing lesbian couple, HCPs must be understanding and knowledgeable of lesbian health concerns and sexuality. They should be open to the desires of the lesbian couple regarding their birth options, for example, where and how to give birth, whom to have present for support and they should be proactive in providing both information and resources to the lesbian women within their practice. Health care providers do not need to know the answers to all of the questions that the couple may have, but they are obligated to be aware of resources available to answer any questions that may be beyond their expertise. The following sections provide HCPs with some suggestions on how to best meet the needs of their lesbian clients. Practitioners are encouraged to access the resource list 1Table 1 for guidance and further suggestions on providing care to the lesbian childbearing client.

Table 1.  Resources for Lesbian Parents
Lesbian Mothers National Defense Fund—P.O. Box 21567, Seattle WA 98111. Phone 206-325-2643
Lambda Legal National Headquarters—120 Wall Street, Suite 1500, New York, NY 10005. Phone 212-809-8585. Or, search online at www.lambdalegal.org for the regional office nearest you
Proud parenting–7336 Santa Monica Boulevard, Los Angeles, CA 90046. Phone 323-512-2922. Or, online at www.proudparenting.com
Family Pride Coalition—P.O. Box 65327, Washington, DC 20035. Phone 202-331-5015. Or, online at www.familypride.org
American Civil Liberties Union–125 Broad Street, 18th floor, New York, NY 10004. Or, online at www.aclu.org
GLBT Local Family Resources—www.dv-8.com/resources/us/local/family.html Web site provides contact information for GLBT family resources in the 50 states. www.babycenter.com—you need to search a little, but there are some great articles on this Web site and a lesbian bulletin board discussion that is both informational and supportive www.lesbian.org/mom/drs_sb.htm-search for lesbian friendly health care providers and sperm banks in your local area
The Essential Guide to Lesbian Conception, Pregnancy and Birth by Kim Toevs and Stephanie Brill. Published by Alyson Publications, 2002
The Lesbian Parenting Book: A Guide to Creating Families and Raising Children by Merilee Clunis and Dorsey Green. Published by Seal Press Feminist Publishers, 1995
Resources for HCPs Caring for Lesbian Patients
Gay and Lesbian Medical Association—459 Fulton Street, Suite 107, San Francisco, CA 94102. Or, online at www.glma.org
Royal College of Nursing, London—20 Cavendish Square, London UK. W1G0RN, although a foreign resource, provides great resource information for caring for gay/lesbian clients. Or, online at www.rcn.org.uk/london/resources/out.php. Download a copy of the “Best practice guidance on health care for lesbian, gay and bisexual service users and their families”
Kaiser Permanente National Video Communications and Media Services—Colorado Boulevard, Suite 301, Los Angeles, CA 95041—purchase a copy of the award winning video “Cultural Issues in the Clinical Setting
www.healthservices.gov.bc.ca/whb/publications/caring.pdf—Obtain a copy of “Caring for Lesbian Health—A resource for health care providers, policy makers and planners”

Disclosure of sexual orientation

  1. Top of page
  2. Abstract
  3. Sources of information
  4. Review of the literature
  5. Disclosure of sexual orientation to HCPs
  6. Options for conception
  7. Partner involvement
  8. Legal considerations
  9. Limitations of the literature
  10. Implications for HCPs
  11. Disclosure of sexual orientation
  12. Options for conception
  13. Partner involvement
  14. Legal implications of lesbian motherhood
  15. Conclusion
  16. References

The ability of the patient to be candid about sexual orientation leads to increased satisfaction and improved outcomes for the childbearing lesbian (Dardick & Grady, 1980). It has been recognized that lesbians are more likely to disclose their sexual orientation to an HCP who is perceived to be sensitive to the needs of lesbian women (Tash and Kenney, 1993; Zeidenstein, 1990). Clues that an HCP is lesbian sensitive may be demonstrated by the use of gender-inclusive wording and images in literature, posters, or artwork that are displayed in the health care environment and the use of gender-inclusive wording in conversations with hospital/office staff and in the forms that need to be completed.

Lesbian women stress that HCPs must not assume that all women presenting to their practice are heterosexual and suggest that providers receive education regarding the diversity of the childbearing population (Wilton & Kaufmann, 2000). It is crucial that HCPs recognize that they are caring for lesbian women, whether they know it or not, and that they conduct their practice in a manner that conveys acceptance, nonjudgment, and competence in caring for the lesbian population. Kaiser Permanente has addressed this issue by using the video “Cultural Issues in the Clinical Setting” to provide education regarding cultural diversity to their HCPs (Kaiser Permanente National Video Communications and Media Services [n.d.]). This video presents a series of vignettes, including one of a physician who must address the needs of a childbearing lesbian couple.

The wording of both written and verbal communication between HCPs and patients is key in demonstrating acceptance of the lesbian couple (Adkins & Bates, 2002). To prevent an appearance of heterosexist assumption, Adkins and Bates recommended avoiding gendered terms and suggested using neutral terms such as “partner” or “significant other.” Health care providers should be aware that relationship status and sexual identity will vary among patients and must be careful not to assume that because a woman presents with a female partner that she identifies as lesbian. The key is to be open and accepting toward the woman however she identifies herself and in partnership with whomever she chooses to parent her child. The HCP must recognize that every couple is unique and should take the time to learn how best to care for them in order to make their experience satisfactory and rewarding.

Options for conception

  1. Top of page
  2. Abstract
  3. Sources of information
  4. Review of the literature
  5. Disclosure of sexual orientation to HCPs
  6. Options for conception
  7. Partner involvement
  8. Legal considerations
  9. Limitations of the literature
  10. Implications for HCPs
  11. Disclosure of sexual orientation
  12. Options for conception
  13. Partner involvement
  14. Legal implications of lesbian motherhood
  15. Conclusion
  16. References

Health care providers involved in gynecological care, preconception counseling, and prenatal care require a knowledge of insemination options. Health care providers need to know that success rates for home inseminations are slightly less than for those done in medical offices (Smith, 2004). They need to have an understanding of the differences in success rates with and without fertility medications or with the use of fresh sperm as compared to frozen. This knowledge enables the caregiver to appropriately counsel the couple as to the choice that will best meet their needs.

Parents must consider the potential emotional or legal relationship (or both) between themselves, the child, and the donor. For example, does a known donor want to be involved in the child's life? Do the parents want the donor involved? Conversely, for the unknown donor, what do the parents want to do if the child wishes to find the donor later? How they can be sure of the health status of the donor and of any health conditions that may not be readily apparent but may be of concern in the future? With their knowledge of health conditions and genetic conditions, HCPs are an invaluable resource to aid the couple in procuring answers to health-related questions. Health care providers are in a position to raise and ask questions that the couple may have not considered or may be having trouble answering. Discussion of health conditions and safe sex practices are acknowledged as two of the most difficult topics for the lesbian couple to broach with a known prospective donor (Haimes & Wiener, 2000; Toevs & Brill, 2002). A knowledgeable HCP should be able to guide and facilitate this vital discussion to minimize discomfort with the process.

There are no easy answers to many of the questions that prospective lesbian parents may ask, yet it is important that they be negotiated and discussed by the couple prior to embarking on their journey into parenthood. It is advisable that all HCPs be aware of the issues related to artificial insemination and be prepared to either discuss the options with the couple or refer them to the appropriate resources.

Partner involvement

  1. Top of page
  2. Abstract
  3. Sources of information
  4. Review of the literature
  5. Disclosure of sexual orientation to HCPs
  6. Options for conception
  7. Partner involvement
  8. Legal considerations
  9. Limitations of the literature
  10. Implications for HCPs
  11. Disclosure of sexual orientation
  12. Options for conception
  13. Partner involvement
  14. Legal implications of lesbian motherhood
  15. Conclusion
  16. References

Health care providers must ensure that the needs and desires of the couple are recognized and met by the entire health care team. This can be accomplished through incorporating all previous suggestions as well as by utilizing a process of anticipatory preparation for all HCPs who will be present during the labor and birth (Buchholz, 2000, p. 308). Health care providers should be aware that their attitudes, both conscious and unconscious, can be reflected in both verbal and nonverbal behavior and will affect the childbearing experience of the lesbian couple. Subtleties in caregiver behavior and language will be noticed by a couple sensitive to the inherent homophobia of society. Small gestures of acceptance and support, such as making eye contact and utilizing language with which the couple is comfortable, have been found to greatly improve the childbirth experience of both members of a lesbian couple (Wilton & Kaufmann, 2000).

Acknowledgement of their partner has been reported as being “clearly important” (Wilton & Kaufmann, 2000, p. 207) to lesbian women. It is essential that caregivers afford friends and partners of lesbian women the same respect, caring, and attention offered to the partners and support persons of heterosexual mothers. Simkin (1998) advocated for the involvement of “your patient's significant others in decision-making and planning” (p. 374). Wismont and Reame (1989) advised providing the couple with an environment conducive to a level of intimacy the same as would be afforded a heterosexual couple. Spinks, Andrews, and Boyle (2000) suggested actively soliciting the input and involvement of the female partner throughout the process. Opportunities such as cutting the cord, announcing the sex of the baby, and “catching” the baby that would normally be extended to the male partners of heterosexual patients should also be offered to the female partners of laboring lesbians. If a birth does not go as planned, and an infant is admitted to the neonatal intensive-care unit, it is vital that the HCP advocate for the lesbian partner and secure the same access that would be granted to the father of an infant of a heterosexual couple.

Attending the birth of one's child is a wondrous and unique opportunity. For the non-childbearing partner, being left out, ignored, and disregarded can forever taint the precious memories of their child's birth. Similarly, including and integrating the non-childbearing partner into the process can be the greatest gift that a caring and sensitive HCP can give the couple. Health care providers who advocate for an inclusive, accepting environment will ensure that their patients feel respected and will ultimately achieve favorable health care outcomes for the parents and their child.

Legal implications of lesbian motherhood

  1. Top of page
  2. Abstract
  3. Sources of information
  4. Review of the literature
  5. Disclosure of sexual orientation to HCPs
  6. Options for conception
  7. Partner involvement
  8. Legal considerations
  9. Limitations of the literature
  10. Implications for HCPs
  11. Disclosure of sexual orientation
  12. Options for conception
  13. Partner involvement
  14. Legal implications of lesbian motherhood
  15. Conclusion
  16. References

The legal issues associated with lesbian childbirth are of concern, not only to lesbian couples but also to HCPs. Ideally, HCPs should educate themselves with a basic knowledge of how local laws affect the same-sex couple. For the legal protection of the child as well as both mothers, details such as power of attorney, 2nd-parent adoption, and legal guardianship should be addressed with the couple before the birth of their child (Kaufman & Dundas, 1995). It can be helpful for HCPs to ensure that the couple is aware, before the birth, of whose name can legally be recorded on the birth certificate. It is the responsibility of all HCPs to be aware of laws surrounding disclosure of information and patient confidentiality. This may be of particular concern to the lesbian patient due to the legal, civil liberty and custodial implications for guardianship that can be affected by disclosure of one's sexual orientation. Harvey et al. (1989) caution HCPs not to document the sexual orientation of the pregnant partner on the medical record or share that information with other HCPs unless informed consent is 1st obtained from the couple. Health care providers can aid the couple in identifying the questions that need to be asked concerning the legalities of parenthood, but should refer the couple to an appropriate legal resource for guidance in completion of any legal documents or proceedings that may be indicated (see Table 1).

Conclusion

  1. Top of page
  2. Abstract
  3. Sources of information
  4. Review of the literature
  5. Disclosure of sexual orientation to HCPs
  6. Options for conception
  7. Partner involvement
  8. Legal considerations
  9. Limitations of the literature
  10. Implications for HCPs
  11. Disclosure of sexual orientation
  12. Options for conception
  13. Partner involvement
  14. Legal implications of lesbian motherhood
  15. Conclusion
  16. References

This article provides an overview of the literature on the subject of lesbian experiences with the health care system during the processes of conception, pregnancy, and childbirth. Four primary issues facing these women are identified and suggestions provided to enable HCPs to become more culturally competent in the care of the childbearing lesbian woman and her partner. A discussion of the limitations of the literature describes the invisibility with which many lesbians are forced to live their lives but serves also to illustrate the wealth of opportunity for those interested in discovering more about the burgeoning field of lesbian motherhood and the experiences of lesbian childbearing women.

The potential for further research in this area is immeasurable. In 1997, the Institute of Medicine's Committee on Lesbian Health Research Priorities recommended that “Federal agencies, including the National Institutes for Health and the Centers for Disease Control and Prevention, foundations, health professional associations, and academic institutions should develop and support mechanisms for broadly disseminating information and knowledge about lesbian health to health care providers, researchers and the public” (Solarz, 1999, p. 14). While this article serves as an initial step, much more is needed. It is up to HCPs entering this field to continue the work of the researchers and scholars discussed here to broaden the focus of academia and include perspectives from women of color, women who are financially disadvantaged, and those living in small towns and homophobic environments in this and other countries.

Lesbian health care is not a lesbian issue; it is a health care issue, and therefore a concern for all health care providers.

Health care providers have a unique opportunity to improve the health outcomes of a population of women, many of who have historically been marginalized and ostracized. As the numbers of lesbian women choosing to have children continues to increase, so too should the education of HCPs to the issues of this diverse and specific group of women. With education, guidance, and support from HCPs, couples can decide what they want, advocate for their choices, and give birth to the child that they both desire. It is up to HCPs to become armed with the knowledge and resources that are needed to provide care to lesbian women. Appropriate care for lesbians is not a lesbian issue; it is a health care issue. It is up to all HCPs to provide exceptional care to lesbian clients and to realize that excellent lesbian care equates to excellent health care, a sound and admirable goal for all clients.

Footnotes
  • 1

    The term Stonewall signifies possibly the most important event in the history of the struggle for gay, lesbian, and bisexual rights. In June 1969, police in New York City raided a well-known gay bar, the Stonewall Inn. They threw the patrons out and began to ransack the place. This was not an unusual occurrence, but this night the gay men and lesbians who were present began to fight back. A rebellion ensued that lasted for 3 days and attracted gay supporters from miles around. That night, commonly known as “Stonewall,” began a fight for homosexual rights that continues to this day (Batie, n.d.).

  • 2

    This comparison is not meant to discount the large numbers of heterosexual couples who are unable to conceive via “natural” means but is used simply to illustrate the fact that it is a consideration for all lesbian women considering childbirth, not just a small percentage.

  • 3

    On 1 July 2005 (after this paper was accepted for publication) gay marriage was legalized throughout Canada.

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  2. Abstract
  3. Sources of information
  4. Review of the literature
  5. Disclosure of sexual orientation to HCPs
  6. Options for conception
  7. Partner involvement
  8. Legal considerations
  9. Limitations of the literature
  10. Implications for HCPs
  11. Disclosure of sexual orientation
  12. Options for conception
  13. Partner involvement
  14. Legal implications of lesbian motherhood
  15. Conclusion
  16. References
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