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 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.

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 5 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 13 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.