CommitteeOpinion2017
Number 749
(Replaces Committee Opinion Number 574, September 2013


Committee on Health Care for Underserved Women
This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women in collaboration with committee member Colleen McNicholas, DO, MSCI.

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Marriage and Family Building Equality for Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, and Gender Nonconforming Individuals

ABSTRACT: The American College of Obstetricians and Gynecologists reaffirms its support of unrestricted access to legal marriage for all adults. The American College of Obstetricians and Gynecologists believes that no matter how a child comes into a family, all children and parents deserve equitable protections and access to available resources to maximize the health of that family unit. Obstetrician–gynecologists should recognize the diversity in parenting desires that exists in the lesbian, gay, bisexual, transgender, queer, intersex, asexual, and gender nonconforming communities and should take steps to ensure that clinical spaces are affirming and open to all patients, such that equitable and comprehensive, reproductive health care can meet the needs of these communities. This Committee Opinion is updated to include and capture a broader diversity of the lesbian, gay, bisexual, transgender, queer, intersex, asexual, and gender nonconforming communities, and their desires surrounding family formation, including legal recognition and benefits, and additional support of the positive effect marriage equality has on physical, mental, and financial health.


Recommendations

The American College of Obstetricians and Gynecologists makes the following recommendations regarding lesbian, gay, bisexual, transgender, queer, intersex, asexual (LGBTQIA), and gender nonconforming individuals in their pursuit of equitable access to all health care resources. Obstetrician–gynecologists should do the following:

  • Work to understand, recognize, and address the challenges the LGBTQIA and gender nonconforming communities experience in accessing reproductive health care, including family building.
  • Work to eliminate overt and covert discriminatory procedures and practices in their clinical spaces through creation of affirming and welcoming environments.
  • Understand that members of the LGBTQIA and gender nonconforming communities may desire family building and achieve such through multiple modalities.
  • Recognize the preponderance of research that supports healthy outcomes for children of same-sex couples.
  • Continue to include LGBTQIA and gender nonconforming health and advocacy topics in medical education at the student and resident level.

Background

Despite significant and important strides to recognize disparities in care for the LGBTQIA and gender nonconforming communities (see Table 1), individuals still face tremendous difficulty in accessing equitable health care. Efforts to reduce disparities should be supported at all levels, including the federal government; a broad public health approach should be prioritized; and support needs to be provided for continued research of the unique health care needs of the population. Barriers to health care are not specific to an individual service, but encompass concerns about confidentiality and disclosure, stigma and discriminatory attitudes and treatments, limited access to care and insurance, and often a lack of understanding of the health care needs and risks of these communities.

Table 1

Data from Human Rights Campaign. Glossary of terms. Available at: http://www.hrc.org/resources/glossary-of-terms. Retrieved March 29, 2018; and U.S. National Library of Medicine. MedlinePlus: intersex. Bethesda (MD): NLM; 2018. Available at: https://medlineplus.gov/ency/article/001669.htm. Retrieved March 29, 2018.


It also has been demonstrated that lack of relationship recognition has adverse health effects and often translates into limited resources and lack of protections for desired family formation. Although the 2015 Supreme Court ruling, Obergefell v. Hodges, which held that marriage is a fundamental right for same-sex couples, has and will continue to positively affect the health and well-being of these communities, it should not be interpreted as affording automatic and complete equality (1). Therefore, obstetrician–gynecologists should work to understand, recognize, and address the challenges the LGBTQIA and gender nonconforming communities experience in accessing reproductive health care, including family building.

Marriage Equality

Realization of marriage equality has been met with struggle for some. In the wake of the historic Obergefell v. Hodges decision, legal challenges and legislative and judicial attempts to evade the ruling were initiated in several states (2, 3). Even in states that immediately changed policies and procedures to comply with the ruling, many same-sex couples still face routine discrimination, including barriers to legal marriage. For many, they still must balance fear and safety with the benefits of an intimate union and a legally recognized relationship. Because reduced access to marriage, whether through legal maneuvers or cultural messaging, adversely affects individual and family health, the American College of Obstetricians and Gynecologists reaffirms its support of unrestricted access to legal marriage for all people.

The positive effect marriage equality has on physical, mental, and financial health has been consistently demonstrated (4–6). For example, same-sex couples in legally recognized relationships experience fewer depressive symptoms and lower levels of stress when compared with those with similar long-term relationships that lack legal recognition (7). Additionally, significant increases in mood, anxiety, and substance use disorders were noted in self-identified lesbian, gay, and bisexual individuals living in states where same-sex marriage had been constitutionally banned (8). Conversely, lesbian, gay, and bisexual married individuals who live in states in which legal recognition preceded the Supreme Court decision demonstrated significantly less psychological stress when compared with those not in a legally binding relationship (9).

The Obergefell v. Hodges decision has had a variety of effects on health insurance coverage for these communities. With the legal possibility of marriage, many employers have discontinued domestic partner benefits, potentially leaving those who are not pursuing marriage uninsured (10). In addition to employer-based changes, lawsuits have been filed that argued that the Obergefell decision does not necessarily give same-sex couples the right to marriage-related benefits (11). A unanimous decision by the Texas Supreme Court in June 2017 determined that the Obergefell decision, although requiring Texas to license and recognize same-sex marriages, does not automatically compel cities in Texas to furnish tax-funded employment benefits to same-sex couples equal to the benefits received by opposite-sex couples. The city of Houston, challenging this assertion, requested and was denied review by the U.S. Supreme Court. Because the Texas Supreme Court sent the case back to the lower court, the case is now moving through the state courts. The importance of consistent and comprehensive insurance coverage in achieving and maintaining health cannot be overstated, and equitable access to such continues to pose a challenge in these communities.

In addition to physical and mental health, legal relationship recognition also affords communities improved opportunity for financial health. Taxation, Social Security benefits, veteran’s survival benefits, retirement and inheritance access, and rights to shared property are a few examples of the financial protections marriage affords couples (12–14). Financial security is instrumental to health for all individuals because it closely ties to health care access and reduction of disparities.

Family Building

Many LGBTQIA and gender nonconforming individuals have children or plan to raise children. Accurate estimates of family formation, specifically in the queer, intersexual, asexual, and gender nonconforming communities, are difficult because data have not been collected for these groups. In 2012, an estimated 3 million lesbian, gay, bisexual, and transgender Americans reported having had a child, and 35% of lesbian, gay, bisexual, and transgender self-identified individuals were raising a child younger than 18 years (15). Despite this reality, many face inequities in accessing the resources available to support the health and growth of their families. Research has consistently demonstrated that members of these communities can provide loving, safe, and healthy homes for children (16). Family building for these communities includes multiple modalities, but some may require assisted reproductive technologies or adoption (17, 18). Persistent stigmatization of the LGBTQIA and gender nonconforming communities may result in difficulty finding physicians to assist with achieving pregnancy or identifying surrogates. Insurance coverage for these services can be challenging for many populations, and additional barriers, such as documenting infertility using traditional definitions, further impede access. Although same-sex couples are four times more likely than their counterparts to raise an adopted child (15), pursuing adoption also can be difficult. Private agencies can refuse to work with LGBTQIA and gender nonconforming individuals. In addition, many international adoption agencies still operate under the laws of the child’s country of origin, some of which prohibit adoption to LGBTQIA parents.

As seen with health insurance in the wake of the Obergefell v. Hodges decision, there also has been a variety of challenges related to the ways in which states recognize same-sex parents. State policies to accurately acknowledge and identify same-sex parents on birth certificates are one example. In June 2017, the U.S. Supreme Court sided with two lesbian-identified couples who challenged Arkansas’s refusal to list nonbiologic parents on a newborn’s birth certificate (19). However, limitations on the number of parents listed on the birth certificate or other rules may require biologic parents to give up parental rights before listing a nonbiologic parent, which may not reflect the family’s intentions for family formation. The American College of Obstetricians and Gynecologists believes that no matter how a child comes into a family, all children and parents deserve equitable protections and access to available resources to maximize the health of that family unit. Obstetrician–gynecologists should recognize the diversity in parenting desires that exists in the LGBTQIA and gender nonconforming communities and should take steps to ensure that clinical spaces are affirming and open to all patients, such that equitable and comprehensive reproductive health care can meet the needs of these communities.

Conclusion

The legal landscape around the civil, human, and reproductive rights of the LGBTQIA and gender nonconforming communities is constantly changing. The American College of Obstetricians and Gynecologists supports efforts to affirm and uplift these communities. The American College of Obstetricians and Gynecologists recognizes that unrestricted access to marriage and family building resources is essential to the health and well-being of these communities and recognizes that legal protections do not preclude persistent discrimination, which negatively affects health. The American College of Obstetricians and Gynecologists will continue to advocate for competent and equitable care for the LGBTQIA and gender nonconforming communities.

References

  1. Obergefell v. Hodges, No. 14-556, slip op. at 23 (U.S. June 26, 2015). Available at: https://www.supremecourt.gov/opinions/14pdf/14-556_3204.pdf. Retrieved March 30, 2018.
  2. Tennessee General Assembly Fiscal Review Committee. Fiscal note HB1412 - SB 1437. Nashville (TN): Tennessee General Assembly; 2016. Available at: http://www.capitol.tn.gov/Bills/109/Fiscal/HB1412.pdf. Retrieved March 29, 2018.
  3. Moore RS. Administrative order of the chief justice of the Alabama Supreme Court. Montgomery (AL): Alabama Supreme Court; 2016. Available at: https://www.splcenter.org/sites/default/files/roymoore-adminorder_jan6-2016.pdf. Retrieved March 29, 2018.
  4. Herdt G, Kertzner R. I do, but I can't: the impact of marriage denial on the mental health and sexual citizenship of lesbians and gay men in the United States. Sex Res Social Policy 2006;3:33–49.
  5. Herek GM. Legal recognition of same-sex relationships in the United States: a social science perspective. Am Psychol 2006;61:607–21.
  6. Institute of Medicine. The health of lesbian, gay, bisexual, and transgender people. Washington, DC: National Academies Press; 2011.
  7. Riggle ED, Rostosky SS, Horne SG. Psychological distress, well-being, and legal recognition in same-sex couple relationships. J Fam Psychol 2010;24:82–6.
  8. Hatzenbuehler ML, McLaughlin KA, Keyes KM, Hasin DS. The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: a prospective study. Am J Public Health 2010;100:452–9.
  9. Wight RG, Leblanc AJ, Lee Badgett MV. Same-sex legal marriage and psychological well-being: findings from the California Health Interview Survey. Am J Public Health 2013;103:339–46.
  10. International Foundation of Employee Benefit Plans. Domestic partner benefits after the Supreme Court decision: 2015 survey results. Available at: http://www.ifebp.org/bookstore/domestic-partnership-survey/Pages/default.aspx. Retrieved March 30, 2018.
  11. Amicus curiae brief of L. J. and M. P., a married couple, and equality, Pidgeon et al. v Turner et al., (TX 2017) (No.15-0688). Available at: https://www.equalitytexas.org/wp-content/uploads/2017/02/Amicus-Curiae-Brief-of-LJ-and-MP.pdf. Retrieved March 29, 2018.
  12. Badgett MV. Unequal taxes on equal benefits. The taxation of domestic partner benefits. San Francisco (CA): The Williams Institute; Washington, DC: Center for American Progress; 2007. Available at: https://www.americanprogress.org/wp-content/uploads/issues/2007/12/pdf/domestic_partners.pdf. Retrieved March 29, 2018.
  13. U.S. Government Accountability Office. Defense of marriage act: update to prior report Washington, DC: GAO; 2004. Available at: https://www.gao.gov/assets/100/92441.pdf. Retrieved March 29, 2018.
  14. Monopoli PA. Inheritance law and the marital presumption after Obergefell. 8 estate planning and community property law journal 437 (2016). University of Maryland legal studies research paper no. 2016–31. 2016;8:437. Available at: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2830201. Retrieved March 29, 2018.
  15. Gates GJ. LGBT parenting in the United States. San Francisco (CA): The Williams Institute; 2013. Available at: http://williamsinstitute.law.ucla.edu/wp-content/uploads/LGBT-Parenting.pdf. Retrieved March 29, 2018.
  16. Perrin EC, Siegel BS. Promoting the well-being of children whose parents are gay or lesbian. Committee on Psychosocial Aspects of Child and Family Health of the American Academy of Pediatrics. Pediatrics 2013; e1374–83.
  17. Access to fertility treatment by gays, lesbians, and unmarried persons: a committee opinion. Ethics Committee of American Society for Reproductive Medicine. Fertil Steril 2013;100:1524–7.
  18. Access to fertility services by transgender persons: an ethics committee opinion. Ethics Committee of the American Society for Reproductive Medicine. Fertil Steril 2015;104:1111–5.
  19. Pavan v. Smith, 582 U. S. (2017). Available at: https://www.supremecourt.gov/opinions/16pdf/16-992_868c.pdf. Retrieved March 30, 2018.

Published online on July 25, 2018.

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Marriage and family building equality for lesbian, gay, bisexual, transgender, queer, intersex, asexual, and gender nonconforming individuals. ACOG Committee Opinion No. 749. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132:e82–6.

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