When it comes to starting a family, the options available to lesbian, gay, bisexual, transgender and queer (LGBTQ) people have expanded greatly in recent years. Physicians, especially ob-gyns, are expected to know about these options and the limitations of each. A recent webinar on LGBTQ family building includes guidance from an ob-gyn on how to support LGBTQ patients seeking to start families.
"The Contemporary Context of LGBT Family Building: What Providers Need to Know,” hosted recently by the Association of American Medical Colleges and the AMA, features a presentation by Colleen McNicholas, DO, assistant professor of obstetrics and gynecology and assistant director of the fellowship in family planning at Washington University School of Medicine in St. Louis. Dr. McNicholas’ guidance focuses on four key areas of communication and care.
Asking and affirming
“The discussion around family building should start early, even earlier than the time when we’re actually thinking about wanting to conceive,” said Dr. McNicholas, who is also the mother of a six-year-old son conceived through intrauterine insemination. “We know that [the LGBTQ] community is at higher risk for unplanned pregnancy, particularly in the adolescent years. So preventing a pregnancy, particularly at young ages, is just as important as helping to achieve a pregnancy or build your family when you’re ready for that.”
Beginning the family-building conversation as early as possible with LGBTQ patients also helps set realistic expectations, she said.
“For almost every scenario, except for potentially home intravaginal insemination with a known donor, there will be some sort of logistic delay,” she explained.
Starting the conversation earlier also helps preserve patients’ options. Lesbians, she noted, tend to seek pregnancy later in life than heterosexual women, and discussing age-related maternal and fetal risks can help manage those risks. In addition, engaging transitioning patients before transition procedures provides opportunities to preserve their fertility.
Dr. McNicholas also recommended keeping assumptions in check.
“Even amongst those of us who are supportive of the [LGBTQ] community, sometimes there is a tendency to forget that identity and preference [do] not necessarily translate to sexual behavior,” she said, noting, for example, that a patient who identifies as lesbian might also have sex with men. “Asking both how patients identify and also who they’re having sex with will help us navigate their pregnancy desires.”
“One of the biggest things that ob-gyns, and even family medicine physicians, seeing young reproductive-age women and men can do is to address and optimize their current health,” Dr. McNicholas said.
She recommended making sure patients are up to date on vaccines and routine screenings; addressing issues with alcohol or tobacco use, depression or obesity; making sure none of their medications are contraindicated during pregnancy; and helping them think through any necessary legal preparations.
Know all the available routes to family building, Dr. McNicholas said—from assisted reproductive technologies, such as in vitro fertilization and surrogacy, to the many forms of adoption—and the limitations of each.
As a case in point, she cited a 40-year-old lesbian patient who was already having irregular periods yet was seeking intravaginal insemination because of its relatively low cost.
“We had to have a real conversation about the time it would take for her to conceive potentially via this route,” she said. “My recommendation was that she needed to get to a reproductive endocrinologist sooner rather than later if [she and her wife] really wanted a good chance at a successful conception.”
Thinking beyond the pregnancy test
There are many models of prenatal care, and many physicians are moving to group practices where patients can see a variety of providers. Establishing trust is crucial, Dr. McNicholas said, so patients can embrace being cared for by a team.
“Understanding the complexities of the health care system as it pertains to this population is also really important,” Dr. McNicholas said. “Depending on the state you live in or the conservativeness of the hospital in which patients might be delivering, it’s important to consider what the policies of the hospital are.” Policies can encompass areas such as who can be in the delivery room and who can make decisions for the newborn or the pregnant woman if a complication arises.
She also noted the need to be aware of postpartum issues that may arise. Know who, if anyone in the relationship will be breastfeeding, provide screening for postpartum depression, and have LGBTQ-friendly pediatricians available for referral.
The 90-minute webinar features presentations by five other LGBTQ health experts, including two other LGBTQ physician parents, and a reproductive endocrinology and infertility specialist.
At the 2016 AMA Interim Meeting, the House of Delegates adopted policy saying that if health insurers cover fertility treatments, they should offer such benefits regardless of their beneficiaries’ marital status or sexual orientation. The Association will support local and state efforts to promote such an approach to reproductive health insurance coverage.
The AMA provides resources for creating an LGBTQ-friendly practice, including links to prominent LGBTQ practice and facility directories. The AMA Journal of Ethics offers a collection of articles on the ethics of caring for transgender patients in its November 2016 issue. Learn more about the AMA's Advisory Committee on LGBTQ Issues.