Service Use and Gaps in Services for Lesbian and Bisexual Women During Donor Insemination, Pregnancy, and the Postpartum Period

Lesbian couples’ childbearing experiences using assisted reproductive technology: A netnography study

OBJECTIVE

This study aimed to explore how Chinese lesbian couples perceived having children through assisted reproductive technology (ART) and its impact on their experiences of family formation.

DESIGN

This study adopted netnography to investigate online forum data created by self-identified lesbian couples in relation to assisted reproduction. Summative content analysis was used to analyse data.

FINDINGS

Based on data analysis, A luan B huai, in which a lesbian conceives a child using her partner's egg, was seen as the best way to establish a family because it created a sense of symbolic connectedness with the child for both of them. Moreover, lesbian couples also indicated the crucial role that having children plays in maintaining family harmony, despite their opposition to heterosexual family traditions. With the stratification of reproductive tourism, certain groups of lesbians for instance, those with limited social and cultural capital- might be at a disadvantage in the global setting of reproductive tourism.

CONCLUSIONS AND IMPLICATIONS

Lesbian couples valued the benefits of ART in assisting them to achieve their childbearing goals and build a family. Healthcare providers should take the initiative to enhance fertility care by addressing the concerns and unique challenges faced by lesbian populations.

"Who's the Mom?": Heterosexism in Patient-Provider Interactions of Queer Pregnant Couples

Previous scholarship has discussed how queer individuals experience discrimination in healthcare settings. This study furthers this area of research by exploring how queer pregnant couples encountered heterosexism within patient-provider interactions. Heterosexism is being used as a framework for the study by looking at how healthcare acts as a power system to promote heterosexual identity. Through using a multiadic analysis, I interviewed 16 couples both together and separately, resulting in 46 total interviews. The analysis demonstrated that the couples experienced heterosexism by providers not understanding who the "mom" is, having to explain sexual identity to providers and providers reinforcing heterosexist expectations. The couples also provided advice for healthcare providers to improve their interactions with future queer pregnant couples.

Building Families Through Healthcare: Experiences of Lesbians Using Reproductive Services

The use of assisted human reproduction (AHR) represents a meaningful and important life event for lesbians wishing to create biologically related families. Despite increasing numbers of lesbians utilizing AHR services, barriers to access persist. This qualitative study investigated the experiences of lesbians and their interactions with reproductive services in Ontario, Canada, where limited public funding is available for all AHR patients and where the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community makes up to 30% of clientele. Eleven semi-structured interviews were conducted, and findings revealed a wide range of experiences. Lesbian patients expressed a desire for more support from their care providers in navigating a complex and costly medical journey through a system largely designed for the needs of heterosexual patients. Additionally, private fertility clinics, as the environment for accessing publicly funded services, were felt to contribute pressure to pay out-of-pocket for add-on medical procedures. To improve the quality of care, participants recommended providing more high-level information on the medical journey and taking an individual approach with lesbian patients, in particular, assuming a patient has sufficient fertility until proven otherwise.

LGBTQ2S+ childbearing individuals and perinatal mental health: A systematic review

BACKGROUND

The perinatal period may uniquely impact the mental health and wellbeing of lesbian, gay, bisexual, transgender, queer, and Two-Spirit (LGBTQ2S+) childbearing individuals.

OBJECTIVES

To characterise and synthesise the experiences of LGBTQ2S+ childbearing individuals regarding perinatal mental health, including symptomatology, access to care and care-seeking.

SEARCH STRATEGY

We conducted and reported a systematic review following PRISMA guidelines of eight databases (EMBASE, MEDLINE-OVID, CINAHL, Scopus, Web of Science: Core Collection, Sociological Abstracts, Social Work Abstract, and PsycINFO) from inception to 1 March 2021.

SELECTION CRITERIA

Original, peer-reviewed research related to LGBTQ2S+ mental health was eligible for inclusion if the study was specific to the perinatal period (defined as pregnancy planning, conception, pregnancy, childbirth, and first year postpartum; includes miscarriages, fertility treatments and surrogacy).

DATA COLLECTION AND ANALYSIS

Findings were synthesised qualitatively via meta-aggregation using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI), and the ConQual approach.

MAIN RESULTS

Our systematic search included 26 eligible studies encompassing 1199 LGBTQ2S+ childbearing participants. Using the JBI SUMARI approach, we reported 65 results, which we synthesised as six key findings. The studies described unique considerations for LGBTQ2S+ individuals' perinatal mental health, including heteronormativity, cisnormativity, isolation, exclusion from traditional pregnancy care, stigma, and distressing situations from the gendered nature of pregnancy. Many participants described a lack of knowledge from healthcare providers related to care for LGBTQ2S+ individuals. In addition, LGBTQ2S+ individuals described barriers to accessing mental healthcare and gaps in health systems. Strategies to improve care include provider education, avoidance of gendered language, documentation of correct pronouns, trauma-informed practices, cultural humility training and tailored care for LGBTQ2S+ people.

CONCLUSIONS

Pregnancy, postpartum, and the perinatal period uniquely impacts the mental health and wellbeing of LGBTQ2S+individuals, largely due to systems-level inequities and exclusion from perinatal care. Healthcare providers should implement the identified strategies to improve perinatal care and address inequities.

Double intrauterine insemination (IUI) of no benefit over single IUI among lesbian and single women seeking to conceive

PURPOSE

To explore clinical benefit of performing two intrauterine inseminations (IUI) 24 h apart-a double IUI vs. a single IUI among lesbian and single women.

METHODS

Retrospective cohort study using electronic medical record review during a 17-year period (11/1999-3/2017). A total of 11,396 patients at a single academic-affiliated private practice were included in this study. All cycles with a single or double IUI were included. A sub-analysis of first cycles only (n = 10,413) was also performed. Canceled IVF cycles converted to IUI were excluded. T tests and Wilcoxon rank-sum tests were used for continuous data, and chi-square for categorical data. Multivariable logistic regression controlled for patient age, day 3 follicle-stimulating hormone (D3 FSH), body mass index (BMI), peak estradiol (E2), and post-wash total motile sperm counts to model the association between IUI number and ongoing pregnancy rate (OPR) according to sperm source (autologous vs. donor). Generalized estimating equations and mixed effect models accounted for multiple cycles from the same woman. Adjusted odds ratio (AOR) with 95% CI was determined. Sub-analyses of sexual orientation and partner status were performed to compare heterosexual couples with proven infertility to women with lesbian and single women.

RESULTS

During the study period, 22,452 cycles met inclusion criteria (single IUI 1283 vs. double IUI 21,169). Mean patient age and BMI were similar between groups. For couples using autologous sperm, OPR was significantly higher with double IUI (12.0% vs. 14.1%; p = 0.0380). A similar increase was observed for donor sperm OPR among heterosexual couples (14.4% vs. 16.2%), though this did not reach statistical significance (p = 0.395). A sub-analysis restricted to donor sperm demonstrates a clinical benefit of second IUI in heterosexual couples, 8.5% vs. 17.6% OPR (AOR 2.94; CI 1.00-10.99; p = 0.0496). When lesbian and single patients were evaluated, there was no difference (17.2% vs. 15.2%; AOR 0.99; CI 0.59-1.70; p = 0.0958).

CONCLUSIONS

Double IUI is associated with a significantly higher OPR for heterosexual couples using an autologous or donor sperm source. The benefit of a second IUI is less clear in patients with undocumented fertility status using donor sperm, such as single and lesbian women.

Health and Access to Care among Reproductive-Age Women by Sexual Orientation and Pregnancy Status

BACKGROUND

A large body of research has documented disparities in health and access to care among sexual minority populations, but very little population-based research has focused on the health care needs among pregnant sexual minority women.

METHODS

Data for this study came from 3,901 reproductive-age (18-44 years) women who identified as lesbian or bisexual and 63,827 reproductive-age women who identified as heterosexual in the 2014-2016 Behavioral Risk Factor Surveillance System. Logistic regression models were used to compare health care access, health outcomes, and health behaviors by sexual orientation and pregnancy status while controlling for demographic characteristics and socioeconomic status.

RESULTS

Approximately 3% of reproductive-age sexual minority women were pregnant. Pregnant sexual minority women were more likely to have unmet medical care needs owing to cost, frequent mental distress, depression, poor/fair health, activity limitations, chronic conditions, and risky health behaviors compared with pregnant heterosexual women. Nonpregnant sexual minority women were more likely to report barriers to care, activity limitations, chronic conditions, smoking, and binge drinking compared with nonpregnant heterosexual women. Health outcomes were similar between pregnant and nonpregnant sexual minority women, but pregnant sexual minority women were more likely to smoke cigarettes every day compared with other women.

CONCLUSIONS

This study adds new population-based research to the limited body of evidence on health and access to care for pregnant sexual minority women who may face stressors, discrimination, and stigma before and during pregnancy. More research and programs should focus on perinatal care that is inclusive of diverse families and sexual orientations.

Providing quality family planning services to LGBTQIA individuals: a systematic review

OBJECTIVE

Lesbian, gay, bisexual, transgender, queer/questioning, intersex and asexual (LGBTQIA) individuals have unique sexual and reproductive health needs; however, facilitators and barriers to optimal care are largely understudied. The objective of this study was to synthesize findings from a systematic review of the literature regarding the provision of quality family planning services to LGBTQIA clients to inform clinical and research strategies.

STUDY DESIGN

Sixteen electronic bibliographic databases (e.g., PubMed, PSYCinfo) were searched to identify articles published from January 1985 to April 2016 relevant to the analytic framework.

RESULTS

The search parameters identified 7193 abstracts; 19 descriptive studies met inclusion criteria. No studies assessed the impact of an intervention serving LGBTQIA clients on client experience, behavior or health outcomes. Two included studies focused on the perspectives of health care providers towards LGBTQIA clients. Of the 17 studies that documented client perspectives, 12 elucidated factors facilitating a client's ability to enter into care, and 13 examined client experience during care. Facilitators to care included access to a welcoming environment, clinicians knowledgeable about LGBTQIA needs and medical confidentiality.

CONCLUSIONS

This systematic review found a paucity of evidence on provision of quality family planning services to LGBTQIA clients. However, multiple contextual facilitators and barriers to family planning service provision were identified. Further research is needed to assess interventions designed to assist LGBTQIA clients in clinical settings, and to gain a better understanding of effective education for providers, needs of specific subgroups (e.g., asexual individuals) and the role of the client's partner during receipt of care.

Postpartum depression among visible and invisible sexual minority women: a pilot study

PURPOSE

Significant numbers of sexual minority women are choosing to parent. Despite this, there is limited research on postpartum depression (PPD) with sexual minority mothers and less research considering differences within sexual minority women in the experience of PPD. This research examines two questions to address this gap in research: (1) Do experiences of PPD symptoms vary between different subgroups of sexual minority women, and (2) Which recruitment strategies effectively address the challenge of recruiting sexual minority women who are pregnant?

METHODS

Two Canadian studies recruited participants via consecutive or convenience sampling from midwifery clinics and hospital sites. Participants completed prenatal and postnatal measures of PPD symptoms, social support, and perceived discrimination.

RESULTS

Considering our first question, we found an interaction effect between past sexual behavior and current partner gender. Women currently partnered with men reported higher scores on the Edinburgh Postpartum Depression Scale when their sexual history included partners of more than one gender, whereas this effect was not found among women who were currently partnered with women or not partnered. Regarding our second question, most sexual minority participants recruited through convenience sampling were partnered with women and identified as lesbian or queer, while most participants recruited through consecutive sampling were partnered with men and identified as bisexual.

CONCLUSIONS

Women whose sexual histories include more than one gender and are currently partnered with men may be at a higher risk for PPD symptoms. Recruitment method may influence the type of sample recruited for perinatal mental health research among sexual minority women.

Fertility-related research needs among women at the margins

Fertility-related research encompasses fertility intentions, preconception care, research amongst pregnant women, and post-partum outcomes of mothers and children. However, some women remain under-represented within this domain of study. Women frequently missing within fertility-related research include those who are already the most vulnerable to health disparities, including female sex workers, lesbian, gay, bisexual, and transgender women, women living with HIV, and women who use drugs. Yet characterization of the needs of these women is important, given their unique fertility-related concerns, including risks and barriers to care emanating from social stigmas and discrimination. This synthesis provides an overview of fertility-related evidence, highlighting where there are clear research gaps among marginalized women and the potential implications of these data shortfalls. Overall, research among marginalized women to date has addressed pregnancy prevention and in some cases fertility intentions, but the majority of studies have focused on post-conception pregnancy safety and the well-being of the child. However, among female sex workers specifically, data on pregnancy safety and the well-being of the child are largely unavailable. Within each marginalized group, preconception care and effectiveness of conception methods are consistently understudied. Ultimately, the absence of epidemiologic, clinical and programmatic evidence limits the availability and quality of reproductive health services for all women and prevents social action to address these gaps.

Using interactive theatre to help fertility providers better understand sexual and gender minority patients

OBJECTIVE

To determine the effectiveness of interactive theatre as a knowledge translation and exchange (KTE) method to educate assisted human reproduction (AHR) service providers about lesbian, gay, bisexual, trans and queer (LGBTQ) patients.

DESIGN

We transformed data from the 'Creating Our Families' study, a qualitative, community-based study of LGBTQ peoples' experiences accessing AHR services, into a script for an interactive theatre workshop for AHR service providers. Based on forum theatre principles, our workshop included five scenes illustrating LGBTQ people interacting with service providers, followed by audience interventions to these scenes. Before and after the workshop, service providers completed surveys to assess their knowledge and comfort concerning LGBTQ patients, as well as the modality of the interactive theatre workshop as a KTE strategy. Wilcoxon signed-rank tests were used to determine changes in preworkshop and postworkshop knowledge and comfort scores.

RESULTS

Thirty AHR service providers attended the workshop. Twenty-three service providers (76.7%) fully completed the preworkshop and postworkshop evaluation forms. Service providers' knowledge scores significantly improved after the workshop, while their comfort scores minimally decreased. Most agreed that the interactive workshop was an effective KTE method.

CONCLUSIONS

In comparison with traditional forms of KTE, interactive theatre may be particularly effective in engaging service providers and addressing their attitudes towards marginalised patient populations. Although the evaluation results of our interactive workshop were mostly positive, the long-term impact of the workshop is unknown. Long-term evaluations are needed to determine the effectiveness of arts-based KTE efforts. Other considerations for developing effective arts-based KTE strategies include adequate funding, institutional support, attention to power dynamics and thoughtful collaboration with forum theatre experts.

LGB-parent families: the current state of the research and directions for the future

Over the past several decades, lesbian, gay, and bisexual (LGB) parenting has grown more visible. Alongside this enhanced visibility, research on the experiences of LGB parents and their children has proliferated. The current chapter addresses this research, focusing on several main content areas: family building by LGB people, the transition to parenthood for LGB parents, and functioning and experiences of LGB parents and their children. In the context of discussing what we know about LGB-parent families, we highlight gaps in our knowledge and point to key areas that future research should aim to answer, including how race, ethnicity, social class, and geographic factors shape the experiences of LGB-parent families.

The other mother: a narrative analysis of the postpartum experiences of nonbirth lesbian mothers

The purpose of this study was to develop a metastory of nonbiological lesbian mothers' postpartum experiences utilizing Riessman's structural approach to thematic analysis. Ten nonbirth lesbian mothers were interviewed. Each shared a unique story of her first year of motherhood. Themes were individually analyzed within each story. The metastory of the postpartum experiences of nonbirth lesbian mothers revealed 6 themes including the following: At the mercy of health care providers, Nursing is the major difference between us, Defined by who I am not, Fighting for every piece of motherhood: The world can take them away, What's in a name?, and Epilogue: The new normal.

Lesbian women's experiences with healthcare providers in the birthing context: a meta-ethnography

OBJECTIVE

to explore research knowledge about lesbian women's experiences with health-care providers in the birthing context.

METHOD

a systematic search for relevant qualitative studies in selected databases identified 13 articles of sufficient quality. The findings were synthesized using a meta-ethnographic approach as described by Noblit and Hare. SYNTHESIS AND FINDINGS: issues related to covert or overt homophobia and prejudice were demonstrated and were sometimes mediated by subtle mechanisms that were difficult to understand and to manage. On the other hand, small gestures of support were described to make a huge difference. A lack of knowledge was demonstrated, contrasted by staff showing a positive and informed attitude. Disclosure was an important issue, but due to the risk involved the women demonstrated a need to be in control. Finally, being acknowledged, both as individuals and as family were considered vital. In this regard, it was essential to recognize and include co-mother as equal parent and to look upon lesbian sexuality as normal and natural.

KEY CONCLUSIONS

midwives' emotional involvement in the situation is significant for moral perception of the women's intimate citizenship, even when they are distressed by lesbian sexuality.

IMPLICATIONS FOR PRACTICE

our findings reveal the importance of including sexuality as an issue deserving reflection in maternity wards, whether or not this might cause unrest in midwives who do not feel comfortable with intimate citizenships beyond mainstream.

Miscarriage Experiences of Lesbian Couples

This was a descriptive phenomenological study of 10 self-identified lesbian couples who had experienced miscarriage in the context of a committed relationship. Analysis of individual and joint open-ended interviews revealed that the experience of miscarriage for lesbian couples must be viewed from the perspective of the difficulties surrounding conception as well as the actual pregnancy loss. The overarching theme, "We are not in control," captures the struggles lesbian couples faced in conceiving their pregnancies and the sense of loss that accompanied miscarrying. These experiences constituted two sub-themes: "We work so hard to get a baby" and "It hurts so bad: The sorrow of miscarriage." Our results indicate that the experience of miscarriage is compounded by the complexities of planning and achieving pregnancy. Practitioners need to be aware of the unique perspectives lesbian couples have on pregnancy and miscarriage and remain sensitive to their unique needs. Findings may serve as an intervention framework for nurse midwives and others caring for lesbian couples after miscarriage.

Perspective: A grand challenge to academic medicine: speak out on gay rights

Social responsibility, a dearly held value in the medical community, requires that medicine use its influence to end discrimination and to reduce barriers that affect access to care. Although the gay, lesbian, bisexual, and transgender (GLBT) population has been identified as suffering from health care disparities and oppression, the medical community and its affiliated organizations have done little to lobby in defense of the GLBT population. And with regard to the specific issue of gay marriage, medicine has yet to raise its voice in that debate, even if only to correct unscientific, capricious, and slanderous depictions of GLBT relationships. Closer to home, in medical schools and residencies, GLBT faculty and students are not provided with a safe and equal environment in which to work and learn. No credentialing provisions require residencies and their affiliate hospitals to include GLBT status in their nondiscrimination policies or to offer GLBT faculty and residents equal benefits. There is no assurance that those in power at peer-reviewed journals will use reviewers who are familiar with the research on sexual minorities to review manuscripts on GLBT topics, a situation that likely contributes to the community's status as an understudied population. Medicine cannot fulfill its obligation to GLBT patients, students, and faculty without a considerable and determined commitment to change. Some of the suggested remedies would require amending policy at the level of the Accreditation Council for Graduate Medical Education and the Association of American Medical Colleges.