BarriersEllen C. Perrin, MD,a,​ b​ Sean M.and Hurley, PhD, Stigmac​ Kathryn Mattern, BA, Experienced​a Lila Flavin, BA,d​ Ellen E. Pinderhughes, PhDb

BACKGROUND: by Fathers and Their Childrenabstract

Gay men have become fathers in the context of a heterosexual relationship, by , by donating sperm to 1 or 2 women and subsequently sharing responsibilities, and/or by engaging the services of a surrogate pregnancy carrier. Despite legal, medical, and social advances, gay fathers and their children continue to experience stigma and avoid situations because of fear of stigma. Increasing evidence reveals that stigma is associated with reduced well-being of children and adults, including psychiatric METHODS: symptoms and suicidality. “ ” Men throughout the United States who identified as gay and fathers completed an online survey. Dissemination of the survey was enhanced via a snowball method, yielding 732 complete responses from 47 states. The survey asked how the respondent had become a father, whether he had encountered barriers, and whether he and his child(ren) had RESULTS: experienced stigma in various social contexts. are increasingly becoming fathers via adoption and with assistance of an unrelated pregnancy carrier. Their pathways to fatherhood vary with socioeconomic class and the extent of legal protections in their state. Respondents reported barriers to becoming a father and stigma associated with fatherhood in multiple social contexts, most often in religious institutions. Fewer barriers and less stigma were experienced by fathers CONCLUSIONS: living in states with more legal protections. ’ Despite growing acceptance of parenting by same-gender adults, barriers and stigma persist. States legal and social protections for lesbian and gay individuals and families appear to be effective in reducing experiences of stigma for gay fathers.

WHAT’S KNOWN ON THIS SUBJECT: Gay men are increasingly becoming fathers in various ways. aDivision of Developmental-Behavioral , Floating Hospital for Children, Tufts Medical Center, Boston, Massachusetts; bDepartment of Child Study and Human Development and dSchool of Medicine, Tufts University, Barriers and stigma have been described in their Boston, Massachusetts; and cDepartment of Leadership and Developmental Sciences, University of Vermont, experiences as fathers in their families, in jobs and Burlington, Vermont children’s schools, and in health care settings. Drs Perrin and Pinderhughes conceptualized and designed the study, created the survey WHAT THIS STUDY ADDS: The frequency and instrument, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Hurley pathways by which gay men are becoming fathers designed the analytic approach, conducted the analyses, and created the figures; Ms Mattern is changing, but barriers and stigma remain. assisted in creating the survey instrument, supervised the data collection, and managed the Structural stigma reflected in state laws and the data; Ms Flavin assisted in editing and preparing the manuscript for submission; and all authors beliefs of religious communities affect gay fathers’ approved the final manuscript as submitted and agree to be accountable for all aspects of the experiences in multiple social contexts. work. DOI: https://​doi.​org/​10.​1542/​peds.​2018-​0683 Accepted for publication Oct 25, 2018 Address correspondence to Ellen C. Perrin, MD, Division of Developmental-Behavioral Pediatrics, Floating Hospital for Children, Tufts Medical Center, 800 Washington St, Boston, MA 02111. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). To cite: Perrin EC, Hurley SM, Mattern K, et al. Barriers Copyright © 2019 by the American Academy of Pediatrics and Stigma Experienced by Gay Fathers and Their Children. Pediatrics. 2019;143(2):e20180683

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 143, number 2, February 2019:e20180683 ARTICLE 8 Social attitudes about gay and lesbian . Same-gender couples children with gay fathers must learn parenting have changed dramatically. have been increasingly invited and to cope with the pressure of being Heterosexual identity is no longer even encouraged to become foster different from their peers in both considered a prerequisite for the and/or– to adopt children their biologic origins and family formation of intimate partnerships, through domestic9 11 and international structure. , or even parenthood. agencies. ‍ ‍ More recently, new Our objective in this study was to reproductive technologies have Many court cases over the past discover whether gay men continue ’ allowed gay men to provide sperm decade have been resolved in favor to encounter barriers in becoming to a woman who would carry a of same-gender parents rights fathers and stigma in various ’ pregnancy for them, a surrogate to legal parenthood. The 2013 US 12 contexts and to examine associations carrier. Supreme Court s legalization of full between these experiences and legal rights to marriage for same-gender Thus, gay fathers have risen in and social structures that surround partners provided full to numbers and visibility over the last these families. families created by lesbian and gay decade, challenging assumptions We report on a survey of gay couples and recognized that their that embracing a gay identity men from 47 states who became children would be beneficiaries of meant forgoing the possibility of parents through diverse pathways. the sanctioned legal status of their parenthood. Most national surveys Respondents provided information parents. research do not include questions about about the pathways they used to has documented the well-being of parental , limiting become fathers, barriers they faced children raised by same-gender large-scale research regarding these in becoming parents, and their 1,2​ ’ parents,​ ‍ and many professional families. The 2010 census reported experiences of stigmatization. We “ ” associations that address parenting 377903 male-couple households in consider individuals experiences have endorsed confidence and the United States, of which 11% are of active stigma and avoidance “ ” optimism about gay or lesbian raising a biological, step, or adopted of desirable activities on the basis 13 “ 18 ” parents raising children, including child <18 years old. An unknown of anticipated stigma. ‍ We the American Academy of Pediatrics, number of gay men who are raising also consider structural stigma : Academic Pediatric Association, children without a cohabiting partner beliefs, policies, and laws that either American Medical Association, and are not counted in the census. intentionally or unintentionally ’ American Academy of Child and Nevertheless, gay men report limit the well-being19 of particular Adolescent Psychiatry. The American “… ’ suspicion and criticism for their individuals. We use each state s Academy of Pediatrics noted that decision to be parents from gay laws and policies and the stated children s well-being is affected ’ friends who have not chosen beliefs of religious institutions to much more by their relationships parenthood, barriers in the reflect elements of structural stigma. with their parents, their parents adoption process, and isolation in METHODS sense of competence and security, 14,15​ their parental role. ‍ Gay men and the presence of social and Survey Instrument who became parents while in a economic support for the family ” heterosexual relationship may face than by the gender or the sexual3 difficulties maintaining custody We created an anonymous online orientation of their parents. ‍ ∼ or obtaining legal14 parenting rights survey instrument that required As a result of these developments, for a new spouse. Adoption and 30 minutes to complete and was over half of gay teenagers4,5​ expect to options16 are also limited by approved by the Tufts University become fathers,​ ‍ and their possible their high cost. Gay fathers have to Institutional Review Board. pathways to parenthood6 have contend with the still-prevalent belief Participants gained access to the expanded enormously. Previously, that children need a to thrive survey after self-identifying as a gay most gay men became fathers and stereotypes associated with gay father, >18 years old, living in the in the context of a heterosexual men as frivolous,15 unstable, and unfit United States, and giving consent. marriage; some knew that they parents. A recent study revealed Participants were asked to send the were gay and saw marriage as the that although gay fathers did not survey link to other gay fathers and only route to parenthood; others differ from heterosexual fathers encourage them to participate. recognized and acknowledged7 their in the strength and quality of their later. Occasionally, relationships, feelings of rejection Sections of the questionnaire ’ gay men partnered with single or and having to justify themselves as included the following: lesbian women, donating sperm and parents affected fathers17 feelings of 1. demographic information about working out unique arrangements for competence as parents. Moreover, the respondent and his children; Downloaded from www.aappublications.org/news by guest on September 29, 2021 2 PERRIN et al Social Climate ’ 2. the method(s) by which the analyses, as well as those in which child(ren) joined the family; the link between the religion s To understand the influence of the tolerance scores and stigma social environment on gay fathers 3. whether the respondent had faced “ ” experienced in religious contexts was and their children, we used the barriers in accessing pathways to examined, were conducted as mixed- equality ratings created by the parenthood; and effects regressions with state-specific Movement Advancement Project random intercepts (to account for “ (http://​www.​lgbtmap.​org/​state-​ 4. whether respondents had been ’ clustering within the state) and the policy-​tally-​faq) based on each made to feel uncomfortable, distribution defined as log-normal ” state s laws for protection of LGBT excluded, shamed, hurt, or to account for the positively skewed families (eg, laws regarding adoption unwelcome in specific social distribution of the dependent and by and gay contexts because of being/having variables. “ men, the availability of legal domestic a gay father (active stigma), or ’ partnerships, civil unions, and civil Analyses examining the associations had avoided various situations ” marriage, regulations about bullying between state equality score and because of worry about people s ’ in schools, etc). Each state is rated barriers to parenthood by various judgments (anticipated stigma). between 0 and 3; higher numbers pathways, and fathers experiences Fathers of children between 5 ’ reflect more legal protections offered of stigma, were conducted similarly, and 18 years old were asked by the state. We used rankings of but with an additional -specific similarly about their children s specific religious groups reported by intercept to account for the fact that experiences of stigma. Table 2 lists 20 Hatzenbuehler et al,​ which were some fathers reported on more than the social contexts specified (eg, based on the explicit beliefs of each 1 child. All inferential statistics were family, friends, school, religious religion regarding homosexuality and calculated by using the GLIMMIX gatherings, etc). Each respondent marriage equality; each religion was procedure in SAS software, version thus received 4 scores: the sum ranked from 0 to 4. Higher numbers 9.4 of the SAS System (SAS Institute, of social contexts in which he Analysesreflect greater tolerance. Inc, Cary, NC) for Windows. reported active stigma, the sum of contexts that he reported RESULTS avoiding, and parallel categories for his child(ren). Descriptive statistics were calculated Procedures to describe the demographics, ‍Table 1 describes the sample. In pathways and barriers to total, 732 fathers reported on 1316 Recruitment of Sample parenthood, and stigma experiences children, with an average age of 13.4 in a variety of social contexts, years (916 were <18 years). With an both globally and by state equality anonymous survey, we cannot know ratings. Reported experiences and We distributed a link to the whether respondents were partners avoidance of stigma in each context or reporting on the same children. Gaysurvey Parent through Magazine targeted Facebook were dichotomized (experienced, The majority (81.3%) of respondents advertising, an advertisement in ’ avoided, or not in past year). Overall , Twitter, were white and non-Hispanic; 64.2% stigma was calculated as the sum of Meetup groups, and direct contacts – had earned a bachelor s degree or these dichotomized values across with lesbian, gay, bisexual, and – higher. Household income ranged all contexts (range = 0 9 for fathers, (LGBT) parenting from <$25k to >$200k. Over 80% and 0 7 for children), although we groups, advocacy organizations, had a male partner, and 2.5% had a recognize that stigma in various LGBT community and cultural Pathwaysfemale partner. to Parenthood social contexts may vary in their centers, surrogacy and adoption relative impact on individuals (for agencies, and church groups example stigma from family members throughout the United States. Groups Children had entered their families in may be experienced differently from were asked to share the survey link various ways: 35.4% came through stigma in the workplace, etc). with their membership through their foster care and/or adoption, 13.5% listservs or newsletters and/or by Statistical tests of the relations with the assistance of a pregnancy physically posting an advertisement. between stigma experiences and carrier or surrogate, and 39.1% We contacted >100 organizations state equality ratings, household through a heterosexual relationship. throughout 50 states and staffed income, and family racial Pathways to fatherhood varied ’ ’ a table at the Family Equality composition were conducted by dramatically on the basis of the Council s Gay Parents Weekend in using the sum of these dichotomized birth date of the eldest child (Fig 1), Provincetown, Massachusetts. scores across contexts. These reflecting greater social acceptance of Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 143, number 2, February 2019 3 TABLE 1 Demographic Information on the Sample Fathers, n Fathers, % Children, n Children, % Sample Fathers: 732 Age, y, mean (SD): 47.1 (10.2) Children, all: 1316 Age, y, mean (SD): 13.4 (11.0) Children <18: 916 Age, y, mean (SD): 7.3 (5.0) States: 47

Characteristics Race and ethnicity White, non-Hispanic 595 81.3 842 64 African American, non-Hispanic 10 1.4 82 6.2 Hispanic 83 11.4 193 14.6 Multiracial 19 2.6 150 11.4 Asian American 14 1.9 23 1.7 Current relationship Single 115 15.7 — — Partnered (male sex) 599 81.8 — — Partnered ( sex) 18 2.5 — — Income, $ <50 000 240 32.8 — — 51–100 000 230 31.4 — — 100 000–200 000 163 22.3 — — 200 000+ 75 10.2 — — Religion Protestant 137 18.7 — — Catholic 109 14.9 — — Jewish 61 8.3 — — Atheist or agnostic 172 23.5 — — Unaffiliated 303 17.8 — — Other 123 16.8 — — Pathways Heterosexual relationship 514 39.1 — — Surrogacy 178 13.5 — — Foster to adopt 166 12.6 — — Adoption 240 18.2 — — Foster 61 4.6 — — 23 1.8 — — Already partner’s child 63 4.8 — — —, not applicable.

– gay men becoming parents in recent associated with their income. Among 1.11 1.81). Families living in states years. Over 70% of respondents who fathers with household income with higher equality scores were became fathers before 1996 had done <$100000, 78.7% of the children more likely to have been formed – so in the context of a heterosexual were conceived in a heterosexual by surrogacy (OR, 1.41; 95% CI, relationship, whereas <6% of relationship, and 18.8% had been 1.08 1.84). respondents who became fathers foster children. Children of fathers after 2010 reported this pathway. with household incomes >$100000 Because a growing number of were more likely to have been born respondents became fathers with the Fathers had adopted through through the assistance of a surrogate assistance of a surrogate carrier, we a private US agency (36.5%), carrier (26.2%) or adopted through a explored this pathway further. Most independently (12.8%), via foster private agency (12.5%). arrangements were made through care (39.3%), or internationally an agency (70.6%), whereas 12% ’ (8.8%). Because the cost of adoption Families in states with fewer legal were arranged through a relative or varies considerably and enlisting the protections were more likely to have friend. Usually 1 man s sperm was cooperation of a surrogate carrier is been formed through heterosexual used for conception, but 17.5% used often expensive, the pathways used relationships (odds ratio [OR], a mixed sample from both partners. by each respondent were closely 1.42; 95% confidence interval [CI], In 86% of these pregnancies, the egg Downloaded from www.aappublications.org/news by guest on September 29, 2021 4 PERRIN et al ’

children s school and health care environments were unlikely contexts for stigma. ’ The likelihood of experiencing stigma differed on the basis of the state s equality rating. In lower-equality − F P states, fathers reported moreF active 1,682​ − (b = P0.059, = 5.10, = .024) and avoidant (b = 0.054, 1,680​ = 6.30, = .012) stigma experiences across social contexts, especially in – religious settings (OR, 0.86; 95% CI, – 0.78 0.95), among family members – (OR, 0.95; 95% CI, 0.90 1.00), and neighbors (OR, 0.92; 95% CI, 0.87 0.97; Fig 3). Among fathers who identified with a particular religion, the likelihood of having experienced stigma in a religious context was directly associated with the tolerance ranking of the religious group with which they affiliated; greater tolerance was associated with a lower probability – of having experienced active stigma (OR, 0.575; 95% CI, 0.462 0.714). Almost one-third of respondents FIGURE 1 Pathways to fatherhood by birth year of oldest child. affiliated with a religious community had avoided such contexts in anticipation of stigma. Additionally, we looked at whether was donated by a separate donor differences in the number of fathers experiences of stigma differed on who was permanently anonymous who described barriers to becoming ’ the basis of the partnership status (45%) or could be identified when and/or being a parent in relation to of the father (partnered versus the child was an adult (23.7%). In the state s equality score. nonpartnered), as well as on the basis 15.3% of cases, the egg donor was a Experiences of Stigma of the racial composition of the family friend or relative of 1 of the partners. (at least 1 member is a person of In general (>90%), neither the egg color versus all members are white). donor nor the surrogate carrier was We found no significant differences reported to have legal parenting Almost two-thirds of respondents ’ attributable to either characteristic. (63.5%) reported that they had status or to function as a parent With 1 exception, there was also experienced stigma based on being figure in the child s life, but 51% of no association between reports of surrogate carriers continued some a gay father, and half (51.2%) had ’ stigma among fathers or children avoided situations for fear of stigma, involvement with the family after the and household income. Fathers in the past year. Most stigma had child s birth. with household income >$100000 occurred in religious environments reported slightly fewer instances of Many fathers reported having (reported by 34.8% of fathers). b − F P avoiding certain social contexts experienced barriers to becoming Approximately one-fourth of ( = 0.124, 1,657​ = 5.62, = .018). or being a parent: 40.6% of those respondents reported experiencing who attempted to adopt a child faced stigma in the past year from family Fathers reported few stigma barriers, and 33% had difficulties members, neighbors, gay friends, experiences related to having gay in arranging for custody of their and/or service providers such as parents directed at children from child(ren) born in a heterosexual waiters, service providers, and family members, neighbors, or in relationship. Figure 2 reveals salespeople (see Table 2). Notably, religious, school, or health care Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 143, number 2, February 2019 5 TABLE 2 Number and Percent of Fathers and Children Who Experienced and Avoided Stigma by Social Context Father Stigma Child Stigma Active Avoid Active Avoid n % n % n % n % Family 169 23.9 147 20.7 35 10.6 32 9.5 Neighbors 195 27.7 146 20.7 46 14.7 32 10.2 Religious 151 34.8 141 31.9 37 17.0 28 13.0 Health care 78 11.2 49 7.02 12 3.7 9 2.7 Child’s school 91 18.3 5 10.1 50 16.4 25 8.2 Dad’s gay friends 167 23.7 107 15.2 NA NA NA NA Dad’s straight friends 141 19.7 101 14.1 NA NA NA NA Workplace 111 16.3 94 13.7 NA NA NA NA Restaurant, salespeople 180 25.5 89 12.7 NA NA NA NA Child’s friends NA NA NA NA 96 32.8 54 18.6 Child’s extracurriculars NA NA NA NA 42 14.3 27 8.9

Only 1 context 159 21.8 159 21.9 59 16.8 50 14.2 2–3 contexts 165 22.6 125 17.2 54 15.3 30 8.6 4 or more contexts 139 19.1 88 12.1 27 7.7 18 5.1

Fathers were asked about stigma directed at children if at least 1 child was age 5–18. Because of responses of “don’t know” or “not applicable,”​ denominators for percentages vary by context, particularly for child reports, for which denominators range from 216 to 418. NA, not applicable.

DISCUSSION contexts. However, 32.8% of fathers and almost 19% reported that their reported that their child(ren) had child(ren) had avoided friendship This national sample of gay fathers experienced active stigma in the activities for fear of experiencing reflects historical changes in past year from their own friends, stigma. pathways through which gay men

have become21 parents, as previously reported. Adoption and surrogacy, 2 routes dependent on systems supporting the formation of families, have been increasingly common in recent years and in states with more legal protections, whereas heterosexual relationships were more common in earlier years and in states with fewer protections. Respondents reported experiencing difficulties in the process of becoming fathers by all methods, more often in states with fewer legal protections. Despite encouraging legal and social changes, gay men and their children still face stigma and . It is noteworthy that >60% of gay fathers experienced stigma in at least 1 context within the past year. Because perceived stigma– has

been shown to interfere with22 both24 mental and physical health,​ ‍ ‍ we attempted to understand the extent and contexts of these experiences. The reported stigma experiences FIGURE 2 occurred most often in the context Barriers to parenthood by state equality score. Custody refers to obtaining legal custody of the child(ren) after . of religious institutions, but some fathers also reported experiencing exclusion and discrimination at the Downloaded from www.aappublications.org/news by guest on September 29, 2021 6 PERRIN et al reported on multiple children or fathers were partners. We believe that anonymity increased the number of respondents, especially in low-equality states. We did not use a standardized stigma scale; unfortunately, appropriate scales are still in their infancy. Despite a renewed interest in studying and discrimination and assessing their impact on health outcomes, individuals tend to underreport these experiences and

psychometrically valid31 measures are still not available. In addition, it is difficult to correctly categorize variations in social environments, especially in the context of rapid ’ political change. We relied on the Movement Advancement Project s assessment of the legal protections ’ in place in 2012 in each state, and on FIGURE 3 20 Stigma by state equality score for selected contexts. Hatzenbuehler et al s calculations to estimate religious climate. CONCLUSIONS 29,30​ hands of their families, neighbors, disorders. ‍ Particularly relevant and friends. Although these is the recent work demonstrating We provide information about gay experiences were not commonly the associations between structural ’ fathers and their children that will be reported, the fact that they happened stigma (eg, state equality scores, helpful for clinical care and advocacy. in settings that are traditionally religions tolerance ratings) and Discussions of decisions about and expected to be sources of support indicators of individual mental ’ pathways to parenthood can facilitate and nurturing is particularly health. Given their important role as understanding of families and children. troubling. It is important for leaders in the community s support Ongoing health supervision should pediatricians caring for these families for all families, pediatricians caring include discussions about stigma to help families understand and for children and their gay fathers ’ and help families learn strategies to cope successfully with potentially should recognize the likelihood that counteract its corrosive effects. stigmatizing experiences. stigma may be a part of the family s experience and help both families ACKNOWLEDGMENTS The legal protections afforded in and communities to counteract ’ each state to its LGBT citizens are it. Pediatricians also have the disparate and have a meaningful opportunity to be leaders in opposing We appreciate many people s link to the experience of gay fathers discrimination in religious and other contributions to this study. We and their children. Both active and community institutions. thank all the men who took the avoidant stigma were reported more time in the midst of their busy frequently by fathers who lived in This study has limitations that must lives as parents to respond to our states with fewer legal protections. be considered. The recruitment survey and to pass it along to their The amount of community support of the sample through informal friends. Many people contributed provided to members of sexual distribution networks, and its limited financially to allow us to create and minorities has been shown to be ethnic and/or racial diversity limit its distribute the survey and to do the related to the well-being of lesbian generalizability; however, the sample analyses: James D. Marks, Mark Scott, 25,26​ 24,27​ ’ and gay adolescents,​ ‍ adults,​ ‍ size of >700 fathers from 47 states Mark Hostetter, Alexander Habib, and children28 with lesbian or is a strength. Fathers responses William Donnell, Robert Mancuso, gay parents,​ including rates were anonymous, constraining our and Richard Meelia. In addition, we of suicidality and psychiatric ability to determine whether fathers appreciate supplementary funding Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 143, number 2, February 2019 7 ABBREVIATIONS provided by the Boston Gay Rights about the construction of the survey Fund, the Gill Foundation, and the instrument and about its distribution, Arcus Foundation. We profited from including William Lewis Walker, CI: confidence interval the advice of Josh Rosenberger and Ricardo Antonio Tan, Liming Zhou, LGBT: lesbian, gay, bisexual, and Kelly Woyewodzic in the design of Kevin Johnson, Christopher Harris, transgender the survey instrument. Our advisory Ru Stevens-Ortiz, Miguel Stevens- OR: odds ratio group provided wise feedback Ortiz, and Edward Coleman.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Funded by the Gil Foundation, Arcus Foundation, and private donations. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

REFERENCES 1. Cornell University. What does the 8. Bos H. Lesbian-mother families formed social interactions. Fam Relat. scholarly research say about the through donor . In: 2015;64(2):263–277 well-being of children with gay or Goldberg AE, Allen KR, eds. LGBT-Parent 16. Riggs DW, Due C. Gay fathers lesbian parents? Available at: http://​ Families: Innovations in Research and ’ reproductive journeys and parenting whatweknow.​law.​columbia.​edu/​topics/​ Implications for Practice. New York, experiences: a review of research. -​equality/​what-​does-​the-​scholarly-​ NY: Springer New York; 2013:21 37 – J Fam Plann Reprod Health Care. research-​say-​about-​the-​wellbeing-​of-​ 9. Goldberg AE. Gay Dads: Transition to 2014;40(4):289 293 children-​with-​gay-​or-​lesbian-​parents/​. – Adoptive Fatherhood. New York, NY: Accessed December 8, 2018 Press; 2012 17. Furlong M. Planned gay father families 2. Tasker F. Lesbian , gay fathers, in kinship arrangements. Aust N Z 10. Farr RH, Patterson CJ. Lesbian and gay and their children: a review. J Dev J Fam Ther. 2010;31(4):372–373 adoptive parents and their children. In: Behav Pediatr. 2005;26(3):224 240 – Goldberg AE, Allen KR, eds. LGBT-Parent 18. Link BG, Phelan JC. Conceptualizing 3. Perrin EC, Siegel BS; Committee on Families: Innovations in Research and stigma. Annu Rev Sociol. Psychosocial Aspects of Child and Implications for Practice. New York, 2001;27:363–385 Family Health of the American Academy NY: Springer New York; 2013:39–55 19. Hatzenbuehler ML. Structural stigma: of Pediatrics. Promoting the well-being 11. Gianino M. Adaptation and research evidence and implications of children whose parents are gay for psychological science. Am Psychol. or lesbian. Pediatrics. 2013;131(4). transformation: the transition 2016;71(8):742–751 Available at: www.​pediatrics.​org/​cgi/​ to adoptive parenthood for gay content/​full/​131/​4/​e1374 male couples. J GLBT Fam Stud. 20. Hatzenbuehler ML, Pachankis JE, Wolff 2008;4(2):205–243 J. Religious climate and health risk 4. Patterson CJ, Riskind RG. To be a behaviors in sexual minority youths: parent: issues in family formation 12. Berkowitz D. Gay men and surrogacy. a population-based study. Am J Public among gay and lesbian adults. J GLBT In: Goldberg AE, Allen KR, eds. LGBT-Parent Families: Innovations Health. 2012;102(4):657–663 Fam Stud. 2010;6(3):326–340 in Research and Implications for 21. Tornello SL, Patterson CJ. Timing of 5. D’Augelli AR, Rendina HJ, Sinclair Practice. New York, NY: Springer New KO, Grossman AH. Lesbian and gay parenthood and experiences of gay York; 2013:71–85 youths aspirations for marriage and fathers: a life course perspective. raising children. J LGBT Issues Couns. 13. Gates GJ. LGBT parenting in the United J GLBT Fam Stud. 2015;11(1):35–56 States. Los Angeles, CA: Williams 2007;1(4):77–98 22. Hatzenbuehler ML, McLaughlin KA, Institute; 2013. Available at: http://​ 6. Golombok S, Tasker F. Gay fathers. Keyes KM, Hasin DS. The impact williamsinstitute​.​law.​ucla.​edu/​wp-​ In: Lamb ME, ed. The Role of Father of institutional discrimination on content/​uploads/​LGBT-​parenting.​pdf. in . New York, NY: psychiatric disorders in lesbian, Accessed December 8, 2018 Wiley; 2010:319–333 gay, and bisexual populations: a 14. Perrin EC, Pinderhughes EE, Mattern K, prospective study. Am J Public Health. 7. Tasker F. Lesbian and gay parenting Hurley SM, Newman RA. Experiences of 2010;100(3):452 459 post-heterosexual divorce and – children with gay fathers. Clin Pediatr separation. In: Goldberg AE, Allen KR, 23. Hatzenbuehler ML, Nolen-Hoeksema (Phila). 2016;55(14):1305–1317 eds. LGBT-Parent Families: Innovations S, Dovidio J. How does stigma “get in Research and Implications for 15. Vinjamuri M. Reminders of under the skin”?: the mediating role Practice. New York, NY: Springer; : gay adoptive of emotion regulation. Psychol Sci. 2013:3–20 fathers navigating uninvited 2009;20(10):1282–1289

Downloaded from www.aappublications.org/news by guest on September 29, 2021 8 PERRIN et al 24. Pachankis JE, Hatzenbuehler ML, gay, bisexual, and transgender 29. Hatzenbuehler ML. The social Starks TJ. The influence of structural youth: research evidence and clinical environment and suicide attempts stigma and rejection sensitivity on implications. Pediatr Clin North Am. in lesbian, gay, and bisexual youth. young sexual minority men’s daily 2016;63(6):985–997 Pediatrics. 2011;127(5):896–903 tobacco and alcohol use. Soc Sci Med. 27. Hatzenbuehler ML, Keyes KM, Hasin 30. Raifman J, Moscoe E, Austin SB, 2014;103:67–75 DS. State-level policies and psychiatric McConnell M. Difference-in-differences 25. Hatzenbuehler ML, Jun HJ, Corliss morbidity in lesbian, gay, and bisexual analysis of the association between HL, Austin SB. Structural stigma and populations. Am J Public Health. state same-sex marriage policies and cigarette smoking in a prospective 2009;99(12):2275 2281 – adolescent suicide attempts. JAMA cohort study of sexual minority and 28. Lick D, Tornello S, Riskind R, Schmidt K, Pediatr. 2017;171(4):350–356 heterosexual youth. Ann Behav Med. Patterson C. Social climate for sexual 2014;47(1):48–56 minorities predicts well-being among 31. Meyer IH. Prejudice as stress: 26. Hatzenbuehler ML, Pachankis JE. heterosexual offspring of lesbian conceptual and measurement Stigma and minority stress as social and gay parents. Sex Res Soc Policy. problems. Am J Public Health. determinants of health among lesbian, 2012;9(2):99–112 2003;93(2):262–265

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 143, number 2, February 2019 9 Barriers and Stigma Experienced by Gay Fathers and Their Children Ellen C. Perrin, Sean M. Hurley, Kathryn Mattern, Lila Flavin and Ellen E. Pinderhughes Pediatrics originally published online January 14, 2019;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2019/01/10/peds.2 018-0683 References This article cites 23 articles, 3 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2019/01/10/peds.2 018-0683#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Community Pediatrics http://www.aappublications.org/cgi/collection/community_pediatrics _sub Developmental/Behavioral Pediatrics http://www.aappublications.org/cgi/collection/development:behavior al_issues_sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 29, 2021 Barriers and Stigma Experienced by Gay Fathers and Their Children Ellen C. Perrin, Sean M. Hurley, Kathryn Mattern, Lila Flavin and Ellen E. Pinderhughes Pediatrics originally published online January 14, 2019;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2019/01/10/peds.2018-0683

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2019 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news by guest on September 29, 2021