Comprehensive family planning for SGM people is important to address, so that all pregnancies are intended if at all possible. Since one’s sexual orientation and gender identity do not determine sexual partners, all individuals should be asked about family building intentions as well as contraception if pregnancy is undesired.
The majority of lesbians have been sexually active with men at some point in their lives (85–90%), and 30% of self-identified adult lesbians are currently sexually active with men as well as with women. Fewer lesbian youth use hormonal contraception than heterosexual female youth. On multiple surveys, one of the reasons that lesbians do not present for gynecologic care is the assumption by clinicians that they are heterosexual, and the (insensitive) advocacy of birth control in that assumptive atmosphere about their sexuality (ie, heteronormative). On the other hand, multiple studies show that the unintended pregnancy rate of self-identified lesbian youth is higher than that of the comparison heterosexual female youth. Unintended pregnancy risk continues into adulthood with one sample from the Chicago Health and Life Experiences of Women survey reporting 24% of sexual minority women having had unintended pregnancies. The reasons for disproportionate unintended pregnancy rates have not been fully elucidated but may involve discrimination and family rejection leading to higher-risk behaviors, increased alcohol and other substance use, less effective birth control usage, and multiple sexual partners. Another reason may be attempts to prove one’s “straightness” by engaging in penis-in-vagina sexual activity. If it has been determined that the patient self-identifies as a lesbian and is having (penis-in-vagina) sex with men, one suggested question might be, “Are you planning to get pregnant this year?” If the answer is no, this is an opportunity to explain that studies show a higher unintended rate of pregnancy in lesbian youth and to review effective contraception options. It is also a good time to talk about protection from STIs when having sex with men (ie, discuss condoms). As with any person engaging in penis-in-vagina sex, experts recommend additional contraceptives to condoms. Condoms are only 80% reliable in preventing pregnancy with typical use. Long-acting reversible contraceptives, which are not patient or sexual act dependent and function effectively despite alcohol or other substance use, are especially important to consider. Long-acting reversible contraceptives such as an etonorgestrel subdermal implant in the arm (0.05% annual failure) or either the copper (0.3% annual failure) or levonorgestrel (0.2% annual failure) intrauterine devices are highly effective and typical use is generally equivalent to ideal use.
Anyone with a vagina, uterus, ovaries, and fallopian tubes can potentially become pregnant if they engage in penis-in-vagina sex. Transgender women (women who were assigned male sex at birth) and non-binary individuals who have a penis and testes may still produce sperm capable of fertilizing an oocyte even if using gender affirming hormones. For transgender men and non-binary individuals who were assigned female sex at birth, contraception is important even if there is testosterone-induced amenorrhea; testosterone is not a reliable form of contraceptive. To underscore the point, transgender men taking testosterone (even if amenorrheic) who have a uterus and ovaries and are sexually active with sperm involved should use any of the contraceptive methods available for cisgender women if they want to avoid a pregnancy. There are multiple case reports in the literature of transgender men who have unintended pregnancies while taking testosterone. Since testosterone is a teratogen and no studies have been done to assess children born to gestational parents using testosterone, those who become pregnant while taking testosterone should receive counseling early in the pregnancy about their options. Little is known about contraceptive preferences and use profiles among transgender men and non-binary people who were female sex assigned at birth.
et al. Contraceptive use effectiveness and pregnancy prevention information preferences among heterosexual and sexual minority college women. Womens Health Issues. 2018 Jul–Aug;28(4):342–9.
et al. Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco. Contraception. 2017 Feb;95(2):186–9.
et al. Unintended pregnancy, depression, and hazardous drinking in a community-based sample of sexual minority women. J Womens Health (Larchmt). 2016 Sep;25(9):904–11.
et al. Sexual orientation and exposure to violence among U.S. patients undergoing abortion. Obstet Gynecol. 2018 Sep;132(3):605–11.
et al. Family planning and contraception use in transgender men. Contraception. 2018 Oct;98(4):266–9.
Family building should be discussed with all patients, regardless of sexual orientation or gender identity. Options include foster-parenting or adoption (in some countries these options are not open to SGM persons), co-parenting partners’ child/children, becoming pregnant, contracting with a surrogate, or step-parenting. Some fertility practices refuse to assist SGM people with conception even if it is legal. The American College of Obstetricians and Gynecologists published Committee Opinion No. 749 in 2018, reaffirming their stance 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. “Obstetricians-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 parties, such that equitable and comprehensive, reproductive health care can meet the needs of these communities.”
It is estimated that approximately 30% of SGM people are parents. The paths to parentage may differ broadly and include dependence on personal desires, organs, and gametes of the person and those of a partner(s) if any; any biologic/medical constraints; and legal/political options for adoption. Many options exist for conception; patients may ask the clinician for an opinion and to guide them to resources. Many patients may decide to have inseminations with an unknown donor (some unknown donors sign a release so that the child may contact the donor when the child reaches 18 years old), and some may decide to involve a known sperm donor. Most sperm banks are regulated in regard to the administration of medical history forms, the testing of sperm for STIs, and the performance of genetic screening. Known donors may have risk factors but are not routinely screened. It is important for future parents to be as informed as they can be about the legal implications of each option. In some states and countries, unless the insemination with known donor sperm takes place in the office of a physician, the known donor has full legal rights as well as financial responsibilities for the offspring. In one study of 129 lesbian mothers with 77 index offspring, 77.5% of the mothers were satisfied with the type of donor chosen (36% had chosen known sperm donors, 25% open-identity donors, and 39% unknown donors). Donor access and custody concerns were the primary themes mentioned by lesbian mothers regarding their (dis)satisfaction with the type of sperm donor they had selected.
Some lesbian women and couples in whom both partners have a uterus and ovaries decide to do “co–in vitro fertilization (IVF),” which is also known as “reciprocal IVF” or in some cases “co-maternity” in which one partner provides an egg, it is fertilized in the laboratory with sperm of a known or unknown donor, and then the other partner carries the pregnancy. Lactation for the nongestating parent can sometimes be induced by using a protocol that stemmed originally from the experiences of adoptive mothers who were motivated to breastfeed. Lactation has been achieved for transgender men and transgender women as well. Many SGM people delay childbearing until later in life, which has been demonstrated in lesbian women, and then the issues of fertility, pregnancy loss, and birth defects increase. Pregnancy outcomes of bisexual and lesbian women compared to heterosexually identified women include increased risk of miscarriage (odds ratio [OR] 1.77) and stillbirth (OR 2.85), as well as very preterm birth (OR 1.84).
There have been many studies on the overall outcomes of children of lesbian women, all of which have been positive when comparing their children to children raised by heterosexual parents, despite the stigma the children experience of having same-sex parents. Using the 2011–2012 National Survey of Children’s Health data set from the United States, children with female same-sex parents and different-sex parents demonstrated no differences in outcomes (spouse-partner relationships, emotional difficulties, coping behaviors, and learning behavior).
Biologic options for pregnancy for cisgender gay men or transgender women include conceiving with someone who may or may not be interested in co-parenting with them, or contracting with a friend, relative, or surrogate to carry the pregnancy after the sperm and a donor egg are fertilized and placed in the uterus of the surrogate. For transgender people, there are other options based on the organs they currently have. Prior to initiation of any gender affirming hormones or gender affirming surgical procedures, a consultation with either an obstetrician/gynecologist or a reproductive endocrinologist to discuss fertility preservation and future genetic offspring is encouraged. Reproductive planning is often not a priority for a transitioning youth but may become a desire in the future and may also be a priority for potential grandparents. Options are limited for transgender youth who have not undergone endogenous puberty before either starting gender affirming hormones (with estrogen or testosterone) or puberty blockers and then going directly to estrogen or testosterone. The only future fertility option is either testicular or ovarian tissue cryopreservation, which is considered experimental. For transgender women and gender non-binary individuals who were male sex assigned at birth and who have reached adulthood after endogenous puberty, sperm can be stored ideally prior to the initiation of estrogen. Of note, though some transgender women still produce sperm even after long-term estrogen exposure, it is recommended that sperm cryopreservation occur prior to hormone start because the effect on fertility is hard to quantify and coming off hormones can often be dysphoric. For transgender men and non-binary individuals who were female sex assigned at birth and have gone through endogenous puberty, next steps in genetic parentage will be based on the desire to carry a pregnancy and whether or not they have started gender affirming hormones. Options include penis-in-vagina sex, intravaginal insemination, intrauterine insemination, and egg cryopreservation for the individual, a partner, or surrogate to carry. If a hysterectomy is planned as part of gender affirmation, discussion of whether ovaries are left in place should occur in light of consideration of future genetic parentage as well as future hormone regulation. In one study in Australia, however, only 7% of transgender and non-binary adults had undertaken fertility preservation yet 95% said that fertility preservation should be offered to all transgender and non-binary people. Participants who viewed genetic relatedness as important were more likely to have undertaken fertility preservation. Perinatal care providers should also ensure that all components of perinatal care are welcoming to SGM people. A 2019 case study describes the system-wide modifications that were adopted to create gender-affirming and inclusive care for a transgender man who carried and successfully delivered a planned pregnancy.
All SGM persons planning a pregnancy should be encouraged to consult with a family attorney prior to conception, and if partnered, the partner needs to be aware of their rights and responsibilities. The law has not kept up with the variety of family constellations that are seen in SGM families. Examples of these constellations can include two gay cisgender dads parenting together each using the same egg donor so that their children are half-siblings biologically, a lesbian couple composed of a transgender woman and cisgender woman where one partner provides the sperm and another provides the egg and carries the pregnancy, a straight cisgender dad parenting with a lesbian cisgender mom, a lesbian cisgender couple with the sperm donor being the brother of the parent who did not provide the egg so one mother is genetically related via the egg and the other mother is genetically related to the sperm (her brother’s) thus being a biologic aunt, two cisgender lesbians each carrying a pregnancy conceived with their own eggs and using the same sperm donor so that their children are half-siblings, two gay men where one is a cisgender man and provides the sperm and one is a transgender man and provides the egg and a surrogate carries the pregnancy, and so on.
et al. Same-sex and different-sex parent families in Italy: is parents’ sexual orientation associated with child health outcomes and parental dimensions? J Dev Behav Pediatr. 2018 Sep;39(7):555–63.
et al. Same-sex and different-sex parent households and child health outcomes: findings from the national survey of children’s health. J Dev Behav Pediatr. 2016 Apr;37(3):179–87.
et al. Italian gay father families formed by surrogacy: parenting, stigmatization, and children’s psychological adjustment. Dev Psychol. 2018 Oct;54(10):1904–16.
et al. Sexual orientation disparities in pregnancy and infant outcomes. Matern Child Health J. 2019 Jan;23(1):72–81.
et al. Providing patient-centered perinatal care for transgender men and gender-diverse individuals: a collaborative multidisciplinary team approach. Obstet Gynecol. 2019 Nov;134(5):959–63.
et al. Case report: induced lactation in a transgender woman. Transgend Health. 2018 Jan 1;3(1):24–6.
et al. Fertility preservation decision making amongst Australian transgender and non-binary adults. Reprod Health. 2018 Oct 25;15(1):181.