Understanding and supporting LGBTQ+ parents within paediatric care
Dr Ilana Levene & Dr Rhiannon Furr
Safiyah has come to paediatric outpatients with her mothers. She has a heart murmur and the paediatric registrar wants to take a family history. The registrar says “which of you is her real mother, and who is Safiyah’s father?” The family look taken aback and upset at this question.
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4 month old Ava is brought to paediatric ED by her parent, Vic, because of breathing difficulties. Vic is wearing a pin lapel saying “he/they”. They ask if they can use a private space to feed Ava. The paediatric nurse talks to the nurse in charge and says “I don’t understand, why does her dad need a private space to give his baby a bottle?”
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Sam has been admitted to the neonatal unit immediately after birth because he was born very premature. One of his fathers comes to the unit with Sam, while the other has stayed with their gestational surrogate in the delivery suite. The ANNP wants to get consent for the use of donor breastmilk. He asks a colleague “I wonder who has parental responsibility for Sam? And do you think we can ask the mum to express colostrum?”
These case studies show examples where paediatric professionals are giving suboptimal care for LGBTQ+ parents and their children, because of a lack of understanding of and sensitivity to their particular needs. They may have made you question whether you would have made the same assumptions, used the same inappropriate language or had the same knowledge gaps.
The majority of people in the UK, and of paediatric health professionals, are cisgender and heterosexual (defined below). UK society is deeply cisheteronormative, which means that it is structured on an assumption (often unconscious) that members of society are cisgender and heterosexual. However the 2021 Census, which for the first time asked everyone over 16 years about their sexual orientation and gender identity, showed that at least 3.2% of the UK population are lesbian, gay, bisexual or have another sexual orientation other than heterosexual (LGB+); and at least 0.5% of the UK population are transgender, non-binary (TNB) or have another gender identity other than cisgender.
LGBTQ+ identity is more common in younger than older people; 1% of people aged 16-24 years identify as transgender and 7% identify as LGB+. This impacts on the population of people becoming new parents. The CQC maternity survey 2022 notes that 4% of people who had recently given birth were LGB+ (rising from 2% in 2013), and 1% said that their gender was not the same as the sex registered at birth. This may surprise you if you feel that you haven’t encountered any TNB parents in paediatric practice. With these figures, a paediatric SHO doing 5 baby checks every weekday would expect to encounter a TNB parent every two weeks. A paediatric consultant seeing 10 children in outpatient clinics each week would expect to encounter an LGB+ parent every three weeks. The 2022 announcement that artificial insemination and IVF will be made more easily available to lesbian couples on the NHS will likely have an impact on this in the future as well.
One reason that paediatric professionals may not feel that they see LGBTQ+ families at the expected rate seen in these statistics is because LGBTQ+ parents may be particularly cautious of revealing their identities to health professionals. For example in a very large UK survey in 2017, 70% of LGBT respondents say they avoid being open about their sexual orientation in public because of fear of negative reactions. 18% of trans respondents said they avoid contact with healthcare professionals because of fear of discrimination or intolerance.
As paediatric professionals, regardless of our own identities and experiences, we must educate ourselves on the needs and experiences of all LGBTQ+ parents in order to make sure we are open, sensitive and proactive in delivering family centred care. Demonstrating an open, educated and accepting attitude will help LGBTQ+ parents to feel comfortable sharing this part of their identity with you. This self-education will also make us more effective practitioners to support LGBTQ+ children and young people within paediatric care, which is another important area – for a starter on that topic, see this article.
Before we discuss LGBTQ+ family structure, we need to establish some basics:
What does LGBTQ+ mean? This stands for lesbian, gay, bisexual, transgender, queer and other related identities discussed above. Sometimes other letters are included like I for intersex and A for asexual.
What is sexuality? Sexuality is who you are physically and/or romantically attracted to. People who are heterosexual or ‘straight’ are attracted to people of the opposite gender. People who are homosexual (or specifically gay or lesbian) are attracted to people of the same gender. Other terms include bisexual (attracted to both genders), pansexual (attracted to all genders, or attraction has no relationship to gender), queer (a reclaimed term which is defined by the individual. Note that some LGBTQ+ people like this term and some find it offensive) and asexual (no sexual attraction). Sexual orientation is a protected characteristic within the Equality Act 2010 and it is illegal to discriminate against someone because of their sexual orientation (directly or indirectly).
What is sex? Biological sex is surprisingly difficult to define. Sex assigned at birth relates to a baby’s external genitalia. A small minority of babies have ambiguous genitalia requiring further investigation of whether their internal anatomy or chromosomes match this assignment. The majority of people assigned at male at birth have XY chromosomes, but some do not – including for example those with XX chromosomes and virilisation or XXY chromosomes. The majority of people assigned female at birth have XX chromosomes, but some do not – for example those with XO chromosomes or XY chromosomes and androgen insensitivity. People with XX and XY chromosomes may or may not have functioning reproductive anatomy to produce viable eggs and sperm.
What is gender identity? Gender identity is each person’s own sense of what their gender is, which may or may not correlate to the sex that they were assigned at birth. People who are cisgender have a gender identity aligned with the sex assigned at birth, whereas people who are transgender do not. Transgender can be used as an umbrella term for anyone who is not cisgender, or can mean someone with a binary gender identity (male/female) that is opposite the sex assigned at birth. A trans person with a male gender identity is a transgender man, and a trans person with a female gender identity is a transgender woman – when new to this area, some people find this difficult to remember.
Some people don’t have a single binary gender identity – for example, they may feel female some of the time and male some of the time; both genders all the time; neither gender etc. They may use terms like non-binary, genderqueer, bigender or agender to describe themselves, and may or may not identify with the word ‘trans’.
“Gender reassignment” is a protected characteristic within the Equality Act 2010. No specific medical or surgical treatment, or legal status, is needed to protect TNB people from discrimination within this definition (as noted in this Equality and Human Rights Commission guidance).
What is gender expression? Gender expression is how a person chooses to present themselves to the world. For example it may involve how someone dresses, their hair length and style. Someone who is transgender will not necessarily have a gender expression typical of the gender they identify with, and this should not be seen as invalidating of their identity. Avoid making assumptions about someone’s gender identity or sex assigned at birth from their external gender expression.
What is a gender recognition certificate? Under the Gender Recognition Act 2004, people who are aged 18 years or older can apply for a gender recognition certificate (GRC), which legally changes their gender. With a GRC, transgender people can get a new birth and marriage/civil partnership certificates with their affirmed gender (if already married), and can be recorded as their affirmed gender on future marriage/civil partnership and death certificates.
Currently the process involves a medical report of a gender dysphoria diagnosis, evidence of having lived in the affirmed gender for at least two years, and a declaration of intention to live in the affirmed gender permanently. It does not change a legal status of mother or father to an existing child. Scotland has plans to simplify this process. It should be noted that without a GRC, trans people can already change their driving license, passport, medical records and some financial records to their affirmed gender with a supportive letter from a doctor. There is no current UK route to record gender as anything other than male or female, but some other countries do have this option, for example recording X on a passport instead of M or F.
Language
Inclusive language is a controversial area, as there are concerns that totally gender-neutral language (such as using only the terms ‘birth parent’ or ‘menstruating person’) could have negative consequences for cisgender women. For example, women with learning difficulties, a lower level of education or whose first language is not English might find the terms difficult to understand. Some women feel that language that focuses only on their biology negatively affects their relationship with health care professionals. However, these concerns don’t mean that we should ignore the poor care and discrimination being imposed on TNB pregnant people when language is entirely female coded. A pragmatic approach may be to use additive language such as “mothers and birth parents”, “breastfeeding and lactation” in information targeted generically.
What is never in doubt is that in an individual setting, professionals should use the language desired by their patients and families – this includes their pronouns and the language they would like to use to refer to their body and perinatal processes. As we’ve talked about, if you do not actively find out what language they prefer, TNB parents may be cautious to bring this up themselves. Ensuring that all ‘intake’ forms – such as pregnancy booking forms, parent information forms at baby/child hospital admission etc – have questions about pronouns and preferred language is a good way of ensuring that everyone has the chance to share this information.
Sometimes people are nervous about how to use “they/them” pronouns and are not sure what pronoun sets like “he/they” and “she/they” mean. Usually “he/they” or “she/they” means that the person likes to use both sets of pronouns and is happy with either, but you can always ask them what it means for them. If you make a mistake with pronouns, apologise briefly, correct yourself and move on. Here is an example of using “they/them” pronouns:
“Jenny was diagnosed with type I diabetes when they were 12 years old. They currently use an insulin pump and a continuous glucose monitor. Their parents are worried about whether they can go to a scout camp this summer”
Family structures and lactation within LGBTQ+ families
There is an infinite variety in potential family structures for all families, regardless of sexual orientation and gender identity. However it is worth describing common ways in which LGBTQ+ families may decide to have babies, as this affects our understanding of their healthcare needs. Unfortunately, LGBTQ+ people experience worse perinatal outcomes – for example higher rates of miscarriage, stillbirth, very preterm birth and postnatal mental health problems. In addition to the outline below, of course some families decide not to have children or to pursue fostering and adoption.
Assisted reproduction and sperm donors
Cisgender lesbian couples may source sperm informally, or formally through sperm banks or assisted reproduction facilities. They may therefore know the sperm donor well and the donor may be involved in their child’s life (for example, a family friend), or the donor may have no relationship with the child. The parents may have been provided with some specific facts about the genetic background of the sperm donor where this was sourced through regulated routes.
If a full IVF process has been used, the pregnant partner may be using their own or their partner’s egg (or a donor egg if needed). This means the partner who isn’t pregnant may be the genetic parent, meaning that the term ‘biological parent’ is not specific; both are biological parents in different ways.
Both parents may want to breastfeed. The non-birth parent may try to induce lactation using medications such as the contraceptive pill and domperidone, and by regular attempts to express milk. Some people can induce a full milk supply with these methods whilst others struggle to get any milk at all. This route may also apply to other couples where neither partner can provide sperm, for example one partner is a trans man and the other is a cis woman.
Surrogacy
Cisgender male gay couples may pursue gestational surrogacy. In the UK, surrogates cannot be paid apart from reasonable expenses and it is illegal to advertise that you are looking for a surrogate or are willing to be a surrogate. This means that surrogacy is relatively rare, estimated at around 450 cases per year, less than half of which relate to same sex couples. Sperm will likely be provided by one partner, or a donor if needed. The egg may be provided by a donor or the surrogate.
The government encourages people to involve an established surrogacy organisation and to write a comprehensive (non-legally binding) surrogacy agreement considering potential difficulties such as pregnancy complications.
Government advice for health professionals is that intended parents should be supported in the same way as other new parents and recognised as the main carers for the child. They recommend involving all parties (parents and surrogate) in information-giving and decision-making. If the child is sick, they recommend that if the surrogate is happy to do so, they provide written consent delegating treatment-related decision making to the parents. This route may also apply to other couples where neither partner can carry a baby, for example one partner is a trans woman and the other is a cis man.
Transgender men and non-binary people assigned female at birth
Transgender men and non-binary people assigned female at birth may want to get pregnant using a partner’s sperm or donor sperm. Testosterone does not cause infertility directly and pregnancy can occur accidentally while taking testosterone. If pregnancy is planned, it is advised that testosterone be stopped because of possible teratogenic effects on the fetus. If they have had chest surgery before pregnancy, full lactation may not be possible due to reduced mammary tissue and potential interruption to milk ducts – however, there is still a risk of mastitis even if lactation is not attempted or desired. Some TNB people prefer not to use the term breastfeeding – some common alternatives are chestfeeding, nursing and body feeding.
The visible effects of testosterone are not reversible, therefore a TNB person who gets pregnant may have a typically male appearance throughout pregnancy and lactation, for example with facial hair and deep voice.
Transgender women and non-binary people assigned male at birth
Transgender women and non-binary people assigned male at birth may want to provide sperm for a partner or surrogate to become pregnant. Sperm count and motility is reduced by the use of oestrogen (although this may be reversible).
Some TNB people may have frozen sperm or eggs before medical or surgical transition for future use by a partner or surrogate.
Parental responsibility within LGBTQ+ families
The UK legal structures around parental responsibility are complex, as they have been created piecemeal to keep pace with increases in LGBTQ+ rights within a historically cisheteronormative system. The following is accurate as of October 2023. There are some differences to this process in Scotland.
The most central piece of law affecting LGBTQ+ families is that the person giving birth is considered to be the mother and has parental responsibility (currently they must be labelled as mother on the birth certificate, even if they have a gender recognition certificate and are legally male in every other context). The second parent entitled to be named on the birth certificate – and therefore with automatic parental responsibility – is the person married to or in a civil partnership with the birth parent at the time of birth or conception. An unmarried male partner can be named on the birth certificate and therefore acquire parental responsibility if both are present at birth registration.
How does this affect same-sex couples? Lesbian couples both have parental responsibility if they were married or civil partners at the time of assisted reproduction. If not, the non-birth parent can also be named on the birth certificate if they made a legal ‘parenthood agreement’ as part of assisted reproduction in a UK licensed clinic. However male same-sex couples must get a parental order from the court (with the permission of the surrogate) before they acquire parental responsibility. This can only be started from six weeks of age and takes months to complete so until this time parental responsibility remains with the gestational surrogate (and their spouse/partner!), even though the child is not living with them. Same-sex couples can only apply for a parental order if one is genetically related to the child and the child lives with them. If neither parent is genetically related to the child they must adopt to acquire parental responsibility.
Trans and non-binary parents giving birth
As mentioned above, about 1% of people in the UK who had given birth in February 2022 were TNB in a recent CQC survey. Because ‘maternity’ services are a deeply gendered area of the NHS – in language, visual representation and the expectations of staff – pregnancy care can be challenging for TNB people. The best understanding you can get is to hear directly from those with lived experience, for example here in a report by the LGBT Foundation in 2022. Key themes from the report are:
- TNB people often have poor experiences of perinatal care
- Some TNB pregnant people do not engage with perinatal care, and particularly postnatal care, because of experiences and fear of discrimination
- Transphobia and racism intersect so that TNB parents of colour have particularly poor experiences
You can also hear more from TNB parents by watching this documentary or listening to this podcast on pregnancy and this podcast on lactation.
Summary
- We must all be aware of the variety of ways that families can be structured so that we can give educated and sensitive care to the families we work with and avoid accidentally causing distress and poor care through cisheteronormative assumptions. Hopefully this article has helped you to understand the pragmatic and legal structures that LGBTQ+ parents may encounter in forming their families.
- Challenge yourself to be more open and additive in the language you use, ask more questions and give opportunities for parents to share their identities rather than making assumptions. This doesn’t need to be a big deal, how about (to parents) “what do I need to know about your family to give you the best care?” or (to children) “who have you brought with you today? Who is in your family?”
- Sometimes we need to know biological facts to provide healthcare – if this is the case then remember to explain to LGBTQ+ families why you are asking sensitive and potentially intrusive questions. If you don’t need to know then don’t ask – TNB people in particular are often subject to dehumanising questions about their anatomy that are unnecessary for their care (18% say they have been subject to inappropriate curiosity within the healthcare setting)
How do we put all of this together? Let’s revisit the case studies:
- The registrar says “I need to ask some questions about diseases that might run in the family that might cause heart problems. Could you tell me who provided the egg and sperm when Safiyah was conceived? Do you know anything about illnesses that might run in the family for your sperm donor?”
- . During triage the nurse asks Vic if he would mind telling them a bit more about his pronouns. Vic explains that he has a non-binary identity and uses both he/him and they/them pronouns – he is happy with either. They gave birth to Ava and would like to be referred to as a parent rather than a mother or father. The nurse asks if there is anything else they need to know to give the best care to Ava and Vic. Vic asks if they can use a private space to feed Ava as they are chest feeding and Vic is uncomfortable with strangers watching him feed. The nurse arranges a private space and lets the doctor know that Vic is Ava’s birth parent and is chest feeding her, and about the language Vic likes to use so that the doctor can take a sensitive and appropriate history.
- The ANNP wants to get consent for the use of donor breastmilk. He knows that parental responsibility lies with the gestational surrogate. He is also aware that he wouldn’t usually ask a heterosexual father about his marital status to ensure he has parental responsibility before getting consent for donor milk – he decides to raise this issue with the senior team later to see whether it is necessary for someone with parental responsibility to consent, or whether simple assent from a presumed parent is sufficient. The ANNP asks Sam’s dad about their feeding intentions and whether the surrogate had previously considered if she wanted to express milk – he says the surrogate had been clear she did not want to express in any circumstances. The ANNP asks if he can have a conversation with Sam’s fathers and the surrogate together to check they are all happy with a decision on donor breastmilk. He also recommends that if they are happy to do so, the surrogate give written consent to delegate treatment-related decision making to the parents given the likely prolonged stay in NICU.
Authors: Dr Ilana Levene, Paediatric Registrar, Thames Valley. (twitter/x: @ilana_abc) and Dr Rhiannon Furr, Paediatric Consultant, Oxford Children’s Hospital