What makes a family?
When LGBTQ+ people come out, they’re often told “but now you can’t have kids.” How can we change that legacy?
Nobody drank orange juice. Not until Anita Bryant, a former beauty pageant winner, became the face of the Florida Citrus Commission. With a wholesome smile, she took OJ from a niche product to a refrigerator staple.
In the 1960s her dulcet voice also wafted from the radios. Earworms like “Paper Roses” and “Till There Was You” became country hits. As Bryant’s star rose, she became a fixture of family gatherings around the television too: the Ed Sullivan Show; USO holiday missions for the troops; the Super Bowl halftime. She even sang at President Johnson’s funeral.
Bryant wasn’t just the face of orange juice; she was the face of traditional American values. She was also the most prominent anti-gay activist in the nation.
In 1977, Miami Gays United had been lobbying the Dade County commission for years. In a pioneering win they secured legal protections against housing and employment discrimination. But Bryant wasn’t having it. At a public hearing, she insisted that gay civil rights infringed on her own rights as a mother to keep her children safe.
“Homosexuals cannot reproduce, so they must recruit. And to freshen their ranks, they must recruit the youth of America,” she told the room.
Almost as soon as it had passed, the anti-discrimination ordinance was repealed. But her short-term victory also galvanized a growing and highly committed gay rights movement in Miami, and in New York, and in San Francisco. Over 3,000 miles away, Harvey Milk–the first openly gay man to be elected to public office in California–considered Bryant to be his chief nemesis.
Today the anti-gay crusade in the United States remains relentless. Still, few movements in past decades have celebrated as many victories as gay rights. And because gay rights, like all civil rights, are human rights, queer activism in the 20th and 21st centuries made life better for everyone. It advanced sexual freedom and privacy, secured greater discrimination and harassment protections, and helped reimagine what modern, inclusive, and loving families can look like.
Modern families
Soon after her 1977 testimony, Bryant descended into ignominy. At a televised speech that year, she became one of the first people to get “pied” in the face as a political act (FWIW: it was a fruit pie covered in whipped cream). From there, her luck got worse. The Florida Citrus Commission dropped her as their spokesperson. Other sponsors followed. She retreated from the public eye and declared bankruptcy.
Yet progress is seldom linear, just as hero-villain stories are seldom straightforward. Though Bryant the person faded, her ideas lingered, positioning gay rights and family building as incompatible causes.
Dr. Monseur (they/he) is a reproductive endocrinologist, devoted to eradicating this false premise. They are the founder of the Q+ Family Building Clinic at Stanford University which promises “compassionate, culturally sensitive care” to the LGBTQ+ community. When we spoke last week they told me about the experience many LGBTQ+ people have when they come out. “A very common response is oh, but you won't be able to have kids. There’s this idea that if you're gay, you can't have kids, or even that you must not want to have kids.”
According to Gallup, 7.6% of Americans identify as lesbian, gay, bisexual, transgender, or something other than straight/heterosexual. The U.S. Census Bureau only began collecting data on same-sex cohabitating couples in 2020. But a Human Rights Campaign analysis of these data suggests that nearly 20 million people in the United States could be LGBTQ+.
Despite facing significant financial and societal barriers in having children compared to heterosexual couples, about one third of LGBTQ+ adults are parents to children under the age of 18. And the number who want to be parents is far larger.
Half of LGBTQ+ Millennials are actively planning to grow their families, a number that only slightly trails the 55% of non-LGBTQ+ Millennials. Which begs the question: how can a fertility system that primarily centers cisgendered heterosexual couples catch up?
Queering fertility care
In my ob/gyn residency class of eleven there were two men. I was one. Dan Kaser was the other.
As an intern, one of our senior residents nicknamed him “Laser Kaser,” which befit Dan’s precision in all settings: in the operating room, during early morning rounds, or overnight while perched on the labor floor, he always seemed to know exactly what to say and do.
It was no surprise when he secured one of the highly competitive fellowship positions in reproductive endocrinology and infertility at Harvard, nor when he supplemented his research year at MIT. Our residency program was known for producing academic superstars and I was fully convinced that Dan was the future chair of our department.
One day towards the end of Dan’s fellowship I ran into him on the street. He told me he wouldn’t be in Boston much longer and when I asked what was coming next, Dan surprised me. Rather than assuming a professorship at one of the big academic centers, he was joining a private practice.
“A very common response is oh, but you won't be able to have kids. There’s this idea that if you're gay, you can't have kids, or even that you must not want to have kids.”
Dan had been named Director of Third Party Reproduction and LGBTQ+ for Reproductive Medical Associates, a national network of fertility clinics. It was a role I had neither heard of nor contemplated. At the time, there were very few fertility specialists with an explicit focus on the needs of LGBTQ+ people.
Dan, of course, sought to change this. And years before Dr. Monseur founded the Q+ Family Building Clinic at Stanford, they sought Dan out as a mentor. All of modern fertility care is built around female infertility. And so, though Dr. Monseur had long known they wanted to pursue a career in helping gay men and trans women build their families, the only medical path to pursue that was through training first as a women’s health specialist.
By the data
A fertility care system that is solely tuned to infertile women is poorly configured for everyone. As we explored in the last Preprint, inattention to male fertility impacts men and women alike. Within the LGBTQ+ community the gaps in care are as diverse as the community itself.
Many same-sex female couples, for example, may only need donor sperm to achieve pregnancy. In other words, no medication is required. Yet one study found that over a third of lesbian couples undergoing intrauterine insemination receive medicated cycles anyway. Why? Because this is how modern fertility care tends to approach heterosexual couples with unexplained infertility.
Unnecessary medication makes otherwise fertile people produce multiple eggs, putting them at risk for multiple gestations, complicated pregnancies and births. Indeed, compared to mother-father partnerships, pregnancies with mother-mother partnerships have a nearly 400% increase in adjusted risk for multiple gestation and a 40% increase in adjusted risk for severe morbidity in childbirth.
Despite facing significant financial and societal barriers in having children compared to heterosexual couples, about one third of LGBTQ+ adults are parents to children under the age of 18. And the number who want to be parents is far larger.
Cisgender gay men, who may have sperm but need a donor egg and gestational carrier, face a different version of the same plight. Assisted reproduction is expensive. For same-sex male couples it is very expensive. In some cases, gay men are referred to centers that will transfer multiple embryos in pursuit of twins so they can have multiple children from one surrogate (a two birds, one stone approach). For couples desperately wanting to avoid exorbitant costs, this may be well-intentioned, but it puts both the baby and the surrogate at much higher risk of complications.
Transgender people may be at greatest risk of receiving poor care–particularly when it comes to appropriate counseling about their fertility preservation options before they undergo transition.
Dr. Paula Amato, a Professor and Director of the Division of Reproductive Endocrinology and Infertility at Oregon Health and Science University, sees many trans people through their Transgender Health Program. She says that the majority of trans people, like the majority of all people, desire children, and there’s no reason medicine can’t help them.
“You might find a clinic that says, we have no expertise in transgender care. But if you have a trans man coming in for donor insemination, they do know how to do that. The technique, medically, is the same. There are nuances, but the actual technology is the same,” she told me.
Towards better
Years before Anita Bryant’s testimony, nine mothers assembled in a West Village apartment with psychotherapist Bernice Goodman to discuss their experience raising children as lesbians.
Some of the mothers had left unhappy marriages with men, and chosen to raise their children with new partners. Others had recruited friends, often gay men hoping to have biological children of their own, to serve as sperm donors. Some merged children from one marriage, with their partner’s children from another, to cobble together families with flimsy legal bindings.
Through the 1960s and into the 1980s, queer people faced enormous pressure to give up their children, flee the country with their children, or accept custody with mighty strings attached. At the same time, queer parents worked together to chip away at existing custody law, systematically challenging assumptions of what it means to be a good and worthy parent.
LGBTQ+ advocacy groups similarly chipped away at discriminatory practices by the fertility industry. In 1975 the Sperm Bank of Northern California was founded, one of the first major sperm banks to openly provide donor insemination services to single women and lesbians. By 2006, the American Society of Reproductive Medicine (ASRM) explicitly urged all fertility clinics to accept LGBTQ+ patients. Thereafter, many clinics began directly advertising services catered to LGBTQ+ families.
“You might find a clinic that says, we have no expertise in transgender care. But if you have a trans man coming in for donor insemination, they do know how to do that. The technique, medically, is the same. There are nuances, but the actual technology is the same.”
This year Dr. Amato, who also identifies as a member of the LGBTQ+ community, is serving as the President of the American Society for Reproductive Medicine (ASRM). Under her leadership, the society expanded their infertility guidelines to include anyone who needs “donor gametes or donor embryos in order to achieve a successful pregnancy, either as an individual or with a partner.”
Payers typically rely on the guidance of clinical societies to set criteria for covered services. Therefore, under ASRM’s updated infertility definition, access to fertility services for LGBTQ+ people may become more equitable. Still, better access doesn’t automatically translate to equitable treatment at the clinic.
Dr. Monseur has no shortage of ideas for routine changes to clinical practice. “We do a really good job in check-ups of asking all people if they use birth control, even when it’s not relevant to them,” they said. “But I’d like to see us do a better job of asking people about their family building goals. LGBTQ+ individuals particularly need to be asked that, because the process can take years.”
And Dr. Amato dreams of a world where no clinic has to “specialize” in LGBTQ+ fertility care; where LGBTQ+ people are affirmed everywhere. “Sometimes with providers, I think there’s just fear. It might not be intentional discrimination. It hasn’t clicked for them yet that technically speaking the treatment is the same. There is a lot more work to be done just teaching people that it’s not that hard,” she told me.
What my team is reading, thinking, and building against:
Famed gay activist Larry Kramer once said, “If we don’t keep reexamining history, we’ll never learn from it.” For generations, the medical establishment has failed to earn the trust of LGBTQ+ people by pathologizing homosexuality. Eugenics efforts long sought to eliminate gay people from existence altogether, and governments have leveraged hormones to chemically castrate gay men. During the HIV/AIDS crisis of the 1980s that disproportionately decimated the LGBTQ+ community, a slow and inadequate response cost countless lives.
Trust is hard earned and easily lost. That being said, one of my favorite stories of reparation and reconciliation also involves Larry Kramer and his long time nemesis: Anthony Fauci. If you observed their interactions in the 1980s you might have considered them enemies. And yet, last year Dr. Fauci penned one of the most beautiful remembrances and depictions of love I’ve ever read.
A close colleague shared this essay from Michael Hobbes with me, calling it one of her “very favorite long-form pieces.” I have to agree. It is as arresting as it is insightful. Even as gay rights have advanced, the mental health of gay men has lagged. And the reasons are not at all what most people would assume. One topline learning we’re holding close at Maven Clinic: to affirm gay men, we need to learn how to affirm the masculine sensitivities of all men.
An excellent piece for Bay Area public radio chronicles the efforts of the Lesbian Mothers Union starting in the 1970s, with a particular focus on legendary Black lesbian activist, Pat Norman. During the 1990s, a billboard campaign with Pat, her partner, and their baby swept the nation. Their tagline? “Another traditional family.”
It is often the most marginalized that have the most to teach us about justice. To that end, we have much to learn from trans patients, trans clinicians, and trans medicine. A missive in The Atlantic (by the wonderful Rachel E. Gross) makes the case that we should really be asking menopausal women the same kinds of questions we ask trans people when we deliver care. Extra points for a cameo from Preprint friend, Dr. Marci Bowers.