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Home , LGBT parenting, Surrogacy, Transgender pregnancy

PATHWAYS TO PARENTHOOD for LGBT PEOPLE

A GROWING NUMBER OF , , bisexual, and (LGBT) people are starting . The 2010 US Census reported that approximately 19% of same- couples are currently raising children, and a 2013 Pew Research national survey found that 51% of LGBT adults of any age have children or would like to have children in the future.1 With the 3 changes in laws across the country, LGBT individuals and couples who may have once been on the fence about parenthood may now feel even more encouraged to start families.2

As more LGBT individuals and couples seek to have children, many will turn to their health care providers for resources and guidance on what to do. It is therefore important for providers in health centers and other health care organizations to understand the various pathways to parenthood for LGBT people, as well as the unique issues they face as they consider their options. Below we offer an overview of several options

available to LGBT people interested in becoming and encourage for LGBT People to Parenthood Pathways health care providers to use this information as a baseline from which to have a tailored, patient-driven conversation. Pathways to Parenthood for LGBT People 4 &Foster The numberofsame-sex couples adopting children intheUnited States increased over 10%between the years 2000to 2009. According to U.S. Census data, LGB parents addition, approximately 2,600 same-sex couples are raising foster children; they are six are 4.5timesmore likely to beraising adopted children thanheterosexual parents. times more likely to beraising foster children thanheterosexual couples. 4 3 In Lionel, andwhatissuesdoheTrevor needtoconsider? fostering andadoption.Whatinformationcanbeshared with provider, Lionelmentionsthatheandhispartner, Trevor, desire to becomeparents. Neither feelsastrong desire tobebiologically and theadoptive (s) are known toeach In anopenadoption,thebiologicalparent(s) Open orClosedAdoption for adoptive parents. often includetheprovision ofsupportservices families. Private agenciescharge afee, which others specificallyfocusonhelpingLGBT disadvantage LGBTadoptive parents, while have stated orunstated preferences that owned andoperated agenciessometimes are oftennon-profit organizations. Privately- Private agenciesare regulated by thestate and patients’ circumstances. of your state inorder tobetterunderstand your familiarize yourself withthespecificpolicies uniformly appliedacross allstates. It isbest to sex couplestoadoptor foster have yet tobe the abilityforLGBTindividualsandsame- care andadoption.Laws andpoliciesregarding or fundedby governmental sources forfoster private agency. Publicagenciesare owned and/ need toconsiderwhetheruseapublicor If seekingtoadopt,LionelandTrevor will Public orPrivate Agencies CLINICAL CASE VIGNETTE connected toachild.Lionelwould like tolearnmore about

During hisannualvisitwithprimarycare

moves ortravels. parental rightsregardless ofwhere thefamily parental rights;italsoprotects thecouple’s a childwithoutthefirst parent losingany adoption allows asecondparent toadopt known adoption.Secondparent asco-parent child through second-parent adoption,also (e.g., Trevor) couldthenpetitiontoadoptthe individually adoptthechild.Theotherpartner one partnerinacouple(e.g., Lionel)could unmarried orsame-sex couplestojointlyadopt, for example inajurisdictionthatprohibits In caseswhere jointadoptionisnotanoption, Trevor, whodesire toadoptachildtogether. are forcouples, suchasLioneland petition toadoptachildsimultaneously. Joint In ajointadoption,bothpartnersjointly Joint Adoption orSecond-Parent Adoption adoptive parent(s) andfrom theadoptive child. the biologicalparent(s) iswithheldfrom the parent(s). Inaclosedadoption,theidentityof between theadoptive childandthebiological other andagree onthedegree ofcontact

Pathways to Parenthood for LGBT People 5 Other Issues to Consider agency, the process of adopting a child can also • Most countries prohibit adoptions by lesbian be very quick. and gay people, making international adoption • The steps for becoming a foster parent are very rarely an option for those who reveal their similar to those for adopting a child.6= , including married same-sex couples.5 Approximate Cost of Adoption7,8 • Adoptions may take 12-36 months for matching • Public domestic adoption: $2,000 between adoptive parents and child and an • Second-Parent adoption: $2,000 additional year for the termination of parental • Private domestic adoption: $20,000-35,000 rights of the parents and legal adoption • Private international adoption: $25,000-50,000 proceedings. However, once prospective parents have completed entry steps with an Assisted Reproduction: DonorInsemination&IVF Donor (sometimes referred to asalternative orartificialinsemination) implanted into theuterus. fertilization, orIVF, iswhenanegginseminated inalaboratory andthen is whensperminjected into thecervix oruterus inorder to fertilize anegg.Invitro

Pathways to Parenthood for LGBT People 7 Pathways to Parenthood for LGBT People 8 What are thepotentialissuestheyneedtoconsider? Maria’s OB-GYN counselthemabouthavingMaria’s biologicalchildren? OB-GYN at theirhealthcenterbecausetheydesire tohave biological appointment withtheobstetrics andgynecologydepartment even ifthecoupleismarried. second parent adoption (see Adoption section), biologically related tothe childshouldconsider donor insemination.Theparent whoisnot the cost ismuchhigherthanwithinvivo biological connectiontothechild;however, . Thisallows bothpartnerstohave a and thenimplantedintotheotherpartner’s one partner’s eggisinseminated through IVF insemination,inwhich “partner topartner” carrying apregnancy. Othersmay choose or more children, withbothpartners each . Somecouplesdecidetohave two decide whowillbeinseminatedandcarrythe with akitandinstructions. Couplesneedto setting by medicalpractitioners orathome Inseminations canbeperformedinaclinical Insemination andCarryingthePregnancy and follow strict medicalscreening processes. interests, education, andfamilymedicalhistory, anonymous spermdonors, suchasethnicity, banks provide background informationon generally avoids paternity claims. Most parents withanonymous spermdonors, whereby aspermbankconnectsprospective such agreements. Anunknown spermdonor, rights; however, somestates donotrecognize which typicallyhasthedonorwaive parental are advisedtohave aformallegalagreement desired). Whenusingaknown donor, parents can becomeinvolved inthechild’s life(if donor allows forthepossibilitythat donor or relative oftheprospective parents. Aknown A known spermdonorisafriend,acquaintance, Known orUnknown SpermDonor CLINICAL CASE VIGNETTE children butare unsure how to proceed. How canKendra and

Kendra andherwifeMaria make an or priortotreatment. as well asoptionstopreserve sperm,, affect fertilityand reproductive processes, include ways inwhichdifferent treatments therapy or to have surgery. Thisdiscussioncan who are preparing tostart cross-sex hormone parental desires withtransgender patients to discussfuture reproductive optionsand It istherefore very importantforproviders their abilitytoreproduce orcarryapregnancy. surgical procedures thatcanlimitorprevent Many transgender peopleundergo medicaland Considerations forTransgender Pregnancy manageable withaffirmative care andsupport. the Resources section. pregnancy optionsfortransgender people, see information onfertility, reproduction, and can raise somepsychosocial issues, women, usingnatalsex organs inpregnancy pregnant. For bothtransgender menand suspend testosterone therapy priortobecoming carry apregnancy, butshouldbeadvisedto retained femalereproductive organs may also donor through IVF. Transgender menwhohave who have preserved eggscanserve astheegg donor insemination;transgender men(FTM) transition canserve asthespermdonorin who have preserved spermbefore medical chemotherapy). Transgender women (MTF) procedure known toaffectfertility(suchas and alsoforpatientswhounderwent a This canbethecasefortransgender patients, embryos thattheywishtouseforinsemination. Some patientshave frozen eggs, sperm, or andInsemination

10 For more 9 whichare Approximate Cost of Donor Insemination • Costs associated with freezing eggs, sperm, and IVF11,12 and embryos vary greatly, and might not be • The costs associated with donor covered by insurance. While the technology insemination and IVF range from: $5,000- of freezing and thawing is getting $60,000. Donor insemination is much less better, frozen and thawed embryos have a expensive than IVF. better chance of successfully implanting in • Insurance typically only covers these the uterus. However, for some patients the costs for , and some policies only freezing and use of embryos may bring up cover those who are trying to get pregnant religious or ethical concerns. through heterosexual sex. Therefore • Legal costs associated with known donor most same-sex couples are excluded from insemination range from $750-$1500. insurance coverage and must pay out of pocket. 10 Pathways to Parenthood for LGBT People Assisted Reproduction: These arrangements are extremely expensive, highly regulated, and legallylimited. A surrogacy arrangement isthecarryingofapregnancy for otherintended parent(s). Both ofthesecanbeextensive processes. Making thesearrangements requires bothidentifying aneggdonorandasurrogate. CLINICAL CASE VIGNETTE During a routine visit, Rafael tells his primary care provider that he and his husband Andrew desire to have a child. A close friend has offered to act as a gestational surrogate. They have heard that surrogacy is challenging and expensive, but they feel strongly about having a biological child. What issues should Andrew and Rafael be aware of when considering surrogacy?

Traditional and Gestational Surrogates Approximate Cost of Surrogacy14,15 A traditional surrogacy arrangement is when • The costs typically associated with the same person donates the eggs and carries surrogacy arrangements average between the child. A gestational surrogate is implanted $80,000-140,000. Surrogates receive with a donated and fertilized egg and carries compensation depending on factors 11 the child to term. Both types of surrogacy including the type of pregnancy and the arrangements require extensive physical, number of previous (surrogate emotional, and psychological tests and matching experience) and for expenses such and interviewing procedures for both the as lost wages, medical co-pays, medical intended parents and the surrogate. Surrogacy insurance, travel, and medications. agreements between the surrogate and intended • There are also costs involved with the parents should be prepared by qualified legal purchase of eggs or sperm, egg harvesting, counsel; however, surrogacy is not legal or transfer, and medical procedures. recognized by courts in every state.13 • Legal costs can also be significant, and the intended parents often pay the surrogate’s Known and Unknown Egg Donors legal costs. As with sperm donors, couples can choose a known or unknown egg donor. Similarly, it is

recommended that parents have the egg donor for LGBT People to Parenthood Pathways sign a legal agreement waiving their parental rights. For an unknown egg donor, neither the egg donor nor the gestational surrogate may have a full legal claim to the child, which may be desirable for reducing legal risks. Couples must decide which partner’s sperm to use in the surrogacy.

Organizational Support for LGBT Parents On a system level, there are many ways that health centers and other health care organizations can incorporate LGBT-affirming planning services throughout their organization. For example, health centers can develop referral lists of local LGBT- inclusive adoption agencies, sperm banks, cryobanks, obstetric practices, and legal services. A health center may also consider adding insemination services in its practice, such as the Alternative Insemination Program at Fenway Health (see Resources). Holding workshops and support groups for LGBT parents and prospective parents is another way for a health center to proactively support LGBT families. Conclusion When LGBT patients express a desire to start a family, clinicians should be prepared to advise LGBT patients on their options as well as any unique medical issues that might be implicated, much as they would advise any other patients. If patients seek additional sources of information, we encourage clinicians to refer patients to the resources identified in this publication and to research local resources as well. It is also important to provide welcoming and inclusive environments for LGBT patients so they are comfortable opening up about their relationship and familial desires. At times, the road to parenthood for LGBT people and same-sex couples can be difficult. It is important for clinicians, and the entire health center, to ensure that all of their patients have full access to the supports and resources needed to enjoy an expanding family.

16 Pathways to Parenthood for LGBT People resources/surrogacy-what-to-expect what toexpect from surrogacy –hrc.org/ Human RightsCampaignhasaresource about Surrogacy agreement sperm donor–hrc.org/resources/donor- agreement resource forthoseusingaknown Human RightsCampaignhasadonor insemination – fenwayhealth.org/care/medical/alternative- resources, supportnetworks, andreferrals achieving conception,aswell aseducation, program provides medical alternatives for Fenway Health’s Alternative Insemination Donor Insemination informed/equality_maps/joint_adoption_laws parent adoptionlaws –familyequality.org/get_ by state forfostering, adoption,andsecond Family EqualityCouncilhasinformation starting-the-adoption-process – hrc.org/resources/8-questions-to-ask-before- as well asquestions toconsiderbefore adopting Overview –hrc.org/resources/topic/adoption – resources onadoptionintheirAdoption Human RightsCampaignhascompiledmany Adoption and Adoption Pathways toParenthood: Assisted Reproduction Health Care Families:LGBT Improving Access toBetter following webinars: lgbthealtheducation.org National LGBTHealth EducationCenter, There are many resources available from the Resources , includingthe System-Wide Approach forHealth Centers Taking Routine Histories ofSexual Health: A being LGBT DoTell:Do Ask, Talking to yourprovider about Environments People forLGBT Ten Things: Creating Inclusive Health Care including: website, lgbthealtheducation.org/publications National LGBTHealth EducationCenter’s There are many publicationsfrom the Welcoming Environment pubmed/24468761 2013;20:575-9. Available at:ncbi.nlm.nih.gov/ Curr OpinEndocrinolDiabetesObes. TransgenderismK. andreproduction. T’Sjoen G, Van CaenegemE,Wierckx pdf+html early/2015/10/21/1753495X15612658.full. Available at:obm.sagepub.com/content/ 2015 asdoi:10.1177/1753495X15612658. OnlineFirst, publishedonOctober28, The Medicine ofPregnancy. 2015. Men andPregnancy. Obstetric Medicine: Obedin-Maliver J, Makadon HJ. Transgender information: The following articlesprovide more Transgender Reproduction andPregnancy law-by-state/f49jq creativefamilyconnections.com/#!surrogacy- surrogacy informationby state – Creative Family Connectionshas problems_proliferate as_surrogacy_becomes_more_popular_legal_ yourself –abajournal.com/magazine/article/ article aboutusinganagencyordoingit American Bar AssociationJournal has an , 9. 8. 7. 6. 5. 4. 3. 2. 1. References collaboration withtheNational LGBTHealth EducationCenter, March 2016. We would like tothankFeldesman+Tucker+Leifer+Fidell, LLPforwritingthispublicationin Acknowledgments

& Women’s Health 2015;60:62-69. How We CouldHave aFamily. JMidwifery and GenderVariant Gestational Parents: It’s Pregnancy, andBirthExperiences of Male Ellis S, Wojnar D, Pettinato M.Conception, much-does-adoption-cost Adoption Cost? hrc.org/resources/how- Human RightsCampaign.How Much Does Children’s Bureau. Department ofHealth andHuman Services, of adopting. 2011.Washington, DC:U.S. Child Welfare Information Gateway. Costs org/for-families/how-to-foster Adopt Us Kids. How toFoster. adoptuskids. resources/adoption-options-overview Human RightsCampaign.hrc.org/ Levine S. Adoption OptionsOverview. Ibid. article/122349/new-nuclear-family New Republic. 2015newrepublic.com/ Khimm S. TheNew . The LGBT-Americans_06-2013.pdf pewsocialtrends.org/files/2013/06/SDT_ D.C.: Pew Research Center;2013. Values inChangingTimes. Washington, Americans: Attitudes, Experiences and Pew Research Center. ASurvey ofLGBT parenting-in-the-united-states census--demographics-studies/lgbt- williamsinstitute.law.ucla.edu/research/ States. TheWilliams Institute. 2013. Gates GJ. LGBTParenting intheUnited

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costs Tucker. 2014. tuckerlegal.com/surrogacy- Intended Parents. Law OfficeofCatherine Tucker, C. Surrogacy Costs: AGuideFor adoption-vs-surrogacy.aspx com/finance/smart-spending/costs- surrogacy. Bankrate.com. 2013. bankrate. Herron, J. Thecosts ofadoptionvs. com/#!surrogacy-law-by-state/f49jq States. 2015. creativefamilyconnections. Surrogacy Law Across theUnited Creative Family Connections. Gestational motherhood-and-biological-clock learnvest.com/2010/08/cost-to-delay- Your BiologicalClock?Learnvest. 2010. Kane, L.How Much DoesIt Cost To Delay infertility-treatment.html making-treatment-affordable/the-costs-of- resolve.org/family-building-options/ Association. TheCosts ofInfertility. RESOLVE: TheNational Infertility Practical Guideline. 2013;94(9):3132-3154. Persons: AnEndocrineSociety Montori VM.EndocrineTreatment of Meyer, IIIWJ, SpackNP, Tangpricha V, Delemarre-van deWaal Gooren LJ, HA, Hembree WC, Cohen-Kettenis P, 17 Pathways to Parenthood for LGBT People 18 Pathways to Parenthood for LGBT People policy of, norshouldany HHS, endorsements beinferred by HRSA, ortheU.S. Government. content andconclusionsareor thoseoftheauthorandshouldnot beconstrued astheofficial position $449,985.00 with0%ofthetotalNCA project financed withnon-federal sources. Thisinformationor U30CS22742, Training andTechnical Assistance National Cooperative Agreements (NCAs) for U.S. DepartmentofHealth andHuman Services(HHS) undercooperative agreement number This project was supportedby theHealth Resources andServicesAdministration (HRSA) ofthe services ofacompetentprofessional shouldbesought. legal, financial,orotherprofessional service. If legaladviceorother expert adviceis required, the matter covered. It ispublishedwiththeunderstanding thatthepublisherisnotengagedinrendering This publicationisdesignedtoprovide accurate andauthoritative information inregard tothesubject COM-2852 tel 617.927.6354 web lgbthealtheducation.org email [email protected]

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