Family Planning and the LGBTQ Community Adarsh E. Krishen, MD, MMM, FAAFP Chief Medical Officer Brian W. Lutz Community Health Educator Andrew E. Kohn, JD Copywriter, Marketing and Communications
Conflict of Interest Statement We have no real or perceived vested interests that relate to this presentation nor do we have any relationships with pharmaceutical companies, and/or other corporations whose products or services are related to pertinent therapeutic areas.
Objectives List special considerations regarding family building for the LGBT community. Examine the ways parenting impacts health outcomes for LGBT people. Describe "pearls of wisdom" from the lived experience of LGBT families.
What is Family? U.S. Census Bureau definition: "A family is a group of two people or more (one of whom is the householder) related by birth, marriage, or adoption and residing together." https://www.census.gov/programs-surveys/cps/technical-documentation/subject-definitions.html#family
Ohio Same-sex Households Same-sex couples per 1,000 households by census tract (adjusted) 2010 data https://williamsinstitute.law.ucla.edu/uncategorized/ohio/
Population Data 19,684 same-sex couples living in Ohio Nearly one in five same-sex couples in the state (19%) are raising children under age 18 in their homes http://news.gallup.com/poll/201731/lgbt-identification-rises.aspx?g_source=social%20issues&g_medium=newsfeed&g_campaign=tiles
Population Data Nearly three in ten individuals in same-sex couples who are members of racial or ethnic minorities (29%) are raising a child under age 18, compared to 18% of their white counterparts http://news.gallup.com/poll/201731/lgbt-identification-rises.aspx?g_source=social%20issues&g_medium=newsfeed&g_campaign=tiles
Population Data Millennials comprised 58 percent of the total number of self-identified LGBT Americans
Some General Thoughts The discussion around family building should start early, even earlier than the time when we re actually thinking about wanting to conceive
Some General Thoughts LGBTQ community is at higher risk for unplanned pregnancy particularly in the adolescent years Begin family-building conversation as early as possible with LGBTQ patients helps set realistic expectations
Some General Thoughts Starting the conversation early helps preserve patient s options For almost every scenario there will be some sort of logistic delay
Some General Thoughts Identity and preference do not necessarily translate to sexual behavior. Asking both how patients identify and also who they re having sex with will help us navigate their pregnancy desires
Some General Thoughts Stereotypes are only partially true (they can help & hurt) Every family is a culture unto itself One LGBTQ family is one LGBTQ family Intersectionality (AA, gay male, single parent family) Open ended questions: Tell me your story or journey
Physician Role Physicals and Affirmation of fitness to parent Assistive reproduction Sperm washing for HIV discordant couples OB/GYN Newborn and new parent care Pediatrics Family Medicine
Physician Role Transitioning Considerations Address & optimize current health Vaccinations up to date Alcohol and tobacco use Depression Obesity Medications Legal preparations
Major LGBTQ Health Risks Alcohol and substance use Tobacco use Depression Suicide Overweight and Obesity Sexual Risk Taking Violence https://www.cdc.gov/lgbthealth/
Parenting as Protective? Sexual risk taking behavior may be reduced More harmony among same-sex parents due to increased need to negotiate roles based on strengths, not gender roles The Contemporary Context of LGBT Family Building: What Providers Need to Know www.aamc.org/initiatives/diversity/475054/thecontemporarycontextofam.html
Parenting as Protective? Pregnancy/becoming a parent can be life-changing even where one sheds unhealthy behaviors More research is needed to determine differences between LGBTQ parents, heterosexual parents and childless LGBTQ individuals The Contemporary Context of LGBT Family Building: What Providers Need to Know www.aamc.org/initiatives/diversity/475054/thecontemporarycontextofam.html
The Important Stuff The important stuff (with or without a family) Powers of attorney Advanced directives Wills
Family Building Options No children Relationship with an opposite-sex partner Interfamily custody/adoption Adoption (public, private, local, national, international)
Family Building Options Artificial insemination or In vitro fertilization Surrogacy (traditional or gestational) Co-parenting agreement Step-parenting
No Children Having the conversation with your partners Having the conversation with family members Need for sterilization?
Adoption Know your local laws Obergefell v. Hodges supreme court ruling was for marriage but not adoption Laws will vary from state to state
Adoption Research Networking Physical examination Budget and finances Home study Create a profile Choose an agency/facilitator
Home Study Typically performed by licensed social worker Review extensive questionnaire about your parenting style, childhood, expectations, FBI and background checks, physical exam from your physician, letters of recommendation, financial statements including tax returns and inspect the home during 3-4 hour interview Post placement home study
After The Match Talk to the birth mother as soon as possible Meet in person prior to delivery Get to know her-just as important as letting her get to know you Create a birth plan Keep in touch
Adoption Tax Credit https://www.irs.gov/taxtopics/tc600/tc607 Used to offset reasonable and necessary adoption fees, court costs, attorney fees and travel May not be used to adopt spouse s child
Parental Leave Some employers may differentiate between maternal, paternal and adoption leave Check with HR Plan to stay in state where child is born for 7-10 business days to comply with Interstate Compact on the Placement of Children (ICPC) Federal Maternity & Medical Leave Act allows up to 12 weeks unpaid leave for adoptive families
Factors for Female Couples If planning biological child Whose egg? Donor options Anonymous: profiles form sperm banks Known/directed: legal process
Factors for Female Couples Make sure all parties have the same expectations and define those in a legal agreement before trying to conceive Work with a lawyer who is experienced in assisted reproductive technology (ART) law is helpful Maternal Age
Once Pregnant Plan for second parent/coparent adoption Consult with lawyer Obtain necessary documents (official copy of marriage certificate, birth certificate, letters of support) Make provisions for frozen genetic material in will
Assisted Reproductive Technologies Intrauterine insemination In Vitro Fertilization Surrogacy (i.e. gestational carrier) Gamete and Embryo donation
Intrauterine Insemination Indications wide range: targeted or empiric Efficacy Cost 10-20% $350 + monitoring, meds
IUI Alone or With Medications? Depends on Diagnosis Ovulation dysfunction vs unexplained Natural cycle/opk Clomiphene citrate Letrozole rfsh, hmg 5-25%+ twin rate, $$$
Donor Sperm Anonymous CLIA certified labs Numerous sperm banks Donors Eligibility determination FDA required by law 18-39 year old Voices, baby pictures, essays, physical Characteristics, contributed to pregnancy, etc. $200-1000 per ampule (1 IUI cycle per ampule)
Donor Sperm (Cont) Known Requires donor eligibility determination Legal consultation HIGHLY encouraged to minimize risk of parentage disputes
In Vitro Fertilization (IVF) Indications Wide ranging: targeted or empiric failed IUI co-maternity need for gestational carrier Efficacy 50-70%
In Vitro Fertilization (IVF) Cost Self Pay $12,000 + medications ($3-6000) package pricing, risk sharing options Insurance coverage IUI s required for coverage, medical necessity State mandates, employers
Surrogacy Not traditional (woman provides egg AND uterus) legal and emotional risk is very HIGH Gestational Carriers <45 years & have delivered at least one child before No medical contraindications to pregnancy < 5 NSVDs/< 3 C-sections Recommending FDA screening process as they are tissue recipients form a non sexually intimate partner Legal contract between IP and GC 6 month quarantine of tissue
Gestational Carriers Someone you know Costs: Agency IVF + meds = $16,000 Carrier fees and testing + $4,000 Costs are the same plus overhead and cost for carrier
Egg Donation Fresh Egg Donors Wait time can be 1-12 months 70% success rate Cost IVF + meds + donor fees and compensation = ~$24,000 Known or anonymous
Egg Donation (cont.) Frozen Egg Donors Readily available 6-8 eggs frozen available for purchase 40-65% success rate Cost ~$16,500
Embryo Donation Embryos donated by infertile couple that is done building family Success rate ~40-60% Adoption vs Donation Personhood Open vs anonymous Home visits and court order Cost $8-12,000
Special Considerations Transgender Individuals Fertility preservation HIV discordance IUI + prep IVF-ICSI The role of reproductive counselor in 3 rd party reproduction
Trans Considerations Medical Storage Endocrinology Impact Health Surgical Societal Legal Statutes Documentation Court Orders or Judges State Family Medical Professionals
Access to Care 60% of trans people lack employer based health insurance 50% have to educate their providers 19% have been denied health insurance The average medical student receives 5 hours of training in transgender issues in four years of Medical School
Our Stories Andrew Kohn Brian Lutz
References Family Planning Options For LGBT Couples. Dr. Richard T. Scott, Jr. http://www.huffingtonpost.com/dr-richard-t-scott-jr/family-planning-optionsf_b_10733982.html 20 Common Questions Asked About LGBT Family Planning. July 6, 2016. Jeff Levin. http://www.gayparentstobe.com/gay-parenting-blog/20-common-questions-askedabout-lgbt-family-planning/ The Contemporary Context of LGBT Family Building: What Providers Need to Know. https://www.aamc.org/initiatives/diversity/475054/thecontemporarycontextofam.html Association of American Medical Colleges and American Medical Association. "The Contemporary Context of LGBT Family Building: What Providers Need to Know" (January, 2017). AAMC Videos and Resources. Washington, DC: Association of American Medical Colleges. https://www.aamc.org/initiatives/diversity/475054/thecontemporarycontextofam.html
Contact Adarsh Krishen adarsh.krishen@ppoh.org Andrew Kohn andrew.kohn@ppoh.org Brian Lutz brian.lutz@ppoh.org