Rudolph's Pediatrics, 22nd Ed.

CHAPTER 16. Gay and Lesbian Parents

Cindy M. Schorzman and Melanie A. Gold

BACKGROUND

Same-gender couples live in almost every county in the United States, and nearly 25% are raising children.1 Recent estimates are that there are between 1 million and 9 million gay and lesbian parents in the United States, and between 2 million and 14 million children in the United States have at least one gay or lesbian parent.2,3 More specific estimates have been limited because many gays and lesbians have historically not reported their sexual orientation, in part because of concern regarding potential discrimination against themselves and their children.4

Since same-sex partners cannot conceive together, gay and lesbian families comprised a variety of family structures. Until relatively recently, most gay- and lesbian-parented families started with a gay man or lesbian woman becoming a parent in the context of a heterosexual relationship before recognizing or acknowledging their own homosexuality. However, growing numbers of individuals are expanding their families to include children in the context of their lives as gay men or lesbian women, whether single or as part of a same-gender couple.

Research on gay and lesbian parenting has focused on assessing the development and well-being of children raised by gay or lesbian parents. Concerns include the psychological development and well-being of children, including whether the children of gay and lesbian parents are ostracized by their peers and whether children raised in single-gender parent households demonstrate nonnormative gender and sexual development, specifically including whether these children have a higher incidence of gay or lesbian sexual orientation when they reach adolescence or young adulthood.

Despite methodologic limitations, there is adequate data demonstrating no significant differences in children’s development based on the sexual orientation of their parents. This has led several major organizations to officially support gay and lesbian parenting. The American Academy of Pediatrics’ Committee on Psychosocial Aspects of Child and Family Health, issued a technical report in 2002 that supports coparent or second-parent adoption by same-gender parents based upon “a growing body of scientific literature demonstrating that children who grow up with one or two gay and/or lesbian parents fare as well in emotional, cognitive, social, and sexual functioning as do children whose parents are heterosexual” and that “children’s optimal developments seems to be influenced more by the nature of the relationships and interactions within the family unit than by the particular structural form it takes.”8 In its July 2004 “Resolution on Sexual Orientation, Parents, and Children,” the American Psychological Association reported that “there is no scientific basis for concluding that lesbian mothers or gay fathers are unfit parents on the basis of their sexual orientation. . . . Overall, results of research suggest that the development, adjustment, and well-being of children with gay and lesbian parents do not differ markedly from that of children with heterosexual parents.”9

PARENTING SKILLS AND FAMILY FUNCTION

Surveys of lesbian and gay communities in the United States indicate that approximately 1 out of 10 gay men identify themselves as fathers, and 1 out of 5 lesbian women identify themselves as mothers.10Overall, studies indicate that families headed by gay men or lesbian women function similarly to those headed by heterosexual individuals. A study in Belgium and the Netherlands compared 30 lesbian couples who conceived through donor insemination with 30 heterosexual couples who conceived naturally and 38 heterosexual couples who conceived through donor insemination. The children, ages 4 to 8, were found to be well adjusted, and no negative differences in parenting were noted; in fact, the nonbiological lesbian mothers were found to have better-quality interaction with the children and helped more with disciplining of the children than the heterosexual fathers.11

Despite the evidence showing lack of negative impact of lesbian couples raising children, there are some ongoing limitations in terms of fully understanding the extent to which specific types of role division impact family dynamics. Patterson conducted a study of 26 lesbian couples in the United States, each with at least 1 child between ages 4 and 9. This study examined parental roles and children’s adjustment and showed that although both the biological and nonbiological mother shared equally in decision making and household tasks, some traditionality in roles exists, such as biological mothers spending more time at home involved in childcare, while nonbiological mothers tend to work more outside the home.12 Whether this traditionality in parental roles translates into nonbiological mothers taking on more traditionally paternal roles, such as physical play style, and the impact of these roles on children, has not yet been established.13

Fewer studies involve gay male parents. The quality of relationships between homosexual cohabitating partners are of similar quality to those of heterosexual partners14 but like their lesbian counterparts, gay male parents are more likely than heterosexual couples to share child-rearing duties.15

CHILD DEVELOPMENT

Children raised by gay or lesbian parents do not differ from children with heterosexual parents in terms of physical or psychological health, cognitive or emotional functioning, or social relationships. These children are found to consistently meet developmental milestones similar to those of their peers raised in heterosexual households, and no significant differences have been found in terms of behavioral adjustment or cognitive functioning.17,18

Studies have also demonstrated no consistent differences in the psychological profiles of children raised by gay and lesbian parents.4,18,19

A seminal literature review in 1992 examined 12 studies of children whose parents were gay or lesbian and equivalent numbers of children with heterosexual parents, and concluded that children who have gay or lesbian parents did not differ from children who have heterosexual parents in terms of psychological health and social relationships.4 A more recent study that compared a group of 15 lesbian couples living with their 3-year-old to 9-year-old children (born through alternative insemination) to a matched sample of heterosexual parents and their children found no differences in cognitive or emotional functioning between those children raised by lesbian couples and those raised in matched, heterosexual parented families.18 Another study comparing lesbian couples and heterosexual couples whose children were conceived via donor insemination found that child behavior problems were unrelated to family structural variables such as maternal sexual orientation but rather were associated with higher levels of parental stress and interparental conflict.19 The few studies conducted with older children and adolescents raised in nonheterosexual family structures, who may be more likely to recognize that their own family structure is considered atypical in society, also showed no differences among groups.20 Children living in nonheterosexual households are subjected to the same potential stressors as those living in heterosexual households, and divorce and parental conflict have been shown to impact upon these children’s well-being.21

A large, community-based study, the Avon Longitudinal Study of Parents and Children, demonstrated a positive mother-child relationships and well-adjusted children of lesbian mothers. There were few significant differences between children from lesbian-parented families and children from heterosexual families, and the mother’s sexual orientation was not related to the children’s psychological adjustment.22

There is no evidence that children of gay and lesbian parents are at an increased likelihood to experience confusion about their gender identity. Current research indicates that the sexual orientation of parents does not impact the gender identity of their children.23 A longitudinal study that followed 25 young adults from lesbian families and 21 young adults raised by heterosexual single mothers found that the gender identity of children raised by lesbian mothers appeared to be consistent with their biologic sex, and no differences were found between the two groups in gender role.24 However, some studies have shown differences in gender role behavior such that girls raised by lesbians may be more “masculine” in their play and life goals, and boys raised by lesbians may be less aggressive.25,26 Despite that these children were no more likely than the children of heterosexual mothers to identify themselves as gay or lesbian, children raised by lesbian mothers are more accepting and had more open attitudes toward nonheterosexual sexual identities. In addition, children raised by lesbian mothers are more likely to explore same-gender sexual relationships, particularly if their childhood family environment was characterized by an openness and acceptance of lesbian and gay relationships.27

Although children growing up with gay fathers have been studied less extensively than those with lesbian mothers, the available data suggests that the lack of difference in sexual orientation of children growing up in lesbian households is true for children with gay fathers as well.28

STIGMATIZATION AND SOCIAL SUPPORT STRUCTURES

One concern surrounding nontraditional families, specifically those headed by nonheterosexual parents, is that the children will be stigmatized because of their family structures. Studies have indeed found that the psychological experience may differ for children raised in heterosexual versus homosexual parenting environments. While most studies have demonstrated no overall increase in stigmatization, children of nonheterosexual couples are more likely than those of heterosexual couples to be teased and to be concerned about being harassed. Adults from lesbian families are more likely to recall having been teased about being gay or lesbian themselves; however, they were no more likely to remember general teasing or bullying by their peers than were adults raised in heterosexual single-parent homes.27

Some adolescent children of lesbian divorced mothers have been reported to experience shame because of conflicts between loyalty to their parent and the perceived need to conceal their parents’ sexual orientation for self-preservation.29 In this study, children of nonheterosexual couples reported being more likely than those of heterosexual couples to be teased and to be concerned about being harassed.29Another study of older children found no differences in self-esteem, social acceptance, and friendship in children raised by nonheterosexual couples compared to those raised by heterosexual couples but a minority of respondents did report negative attitudes from peers when they disclosed information about their family structure.

Overall, the lesbian families that have been studied generally have good social support from close family, friends and relatives. A study of the broader community support for lesbian mothers found that 68% of the mothers reported acceptance by neighbors, and 54% were active in religious communities in which their family lifestyle and sexual orientation were accepted.31 A study of 37 lesbian-headed families found that the majority of children had at least monthly contact with grandparents and most had contacts with neighbors. The children’s feeling of well-being was significantly associated with contacts with unrelated adults and that there were fewer behavioral problems among those with closer contact with their grandparents.32

These issues of child development and the social structures in which they develop directly impact how clinicians care for children of gay and lesbian parents. These clinical care issues are addressed within this familial and societal context.

CLINICAL CARE ISSUES

Meeting the needs of children of gay and lesbian parents means addressing the needs of the children themselves as well as understanding those issues within the context of their family as a whole. Gay or lesbian parents may choose not to identify their sexual orientation to their child’s clinician, often worrying that bias among the staff will jeopardize their child’s level of medical care, even to the point of refusal to provide care. The challenge for the entire medical staff caring for these children often lies in creating an environment in which these individuals feel comfortable enough to disclose and discuss their sexual orientation and family constellation.

Health care professionals have traditionally received little or no training about homosexuality.33-35 In fact, several studies suggest that gay and lesbian adults often find the health care system to be apathetic and sometimes adversarial toward their medical needs and concerns.33,36,37 A large majority of gay and lesbian parents believe that their children receive pediatric care that is competent and that the staff are supportive and nonjudgmental.36However, many experience specific problems related to the parents’ sexual orientation, such as lack of understanding and acceptance of both parents’ roles in their child’s life (including exclusion of the nonbiological parent from the evaluation and treatment process), provision of disparate care including inappropriate diagnoses based on the family constellation, and heterosexist assumptions on office forms.36 In addition, those parents who had not disclosed their sexual orientation to their child’s clinician had concerns that such disclosure might compromise their child’s care, result in negative judgments about their parenting, and infringe on their confidentiality.36

OFFICE ENVIRONMENT

Health care providers should create a safe and inclusive environment for same-gender parents and their children. Establishing such an environment mandates that clinicians examine their own attitudes toward gay and lesbian parenting. Health care providers “who cannot reconcile their personal beliefs with their professional obligation to provide supportive, understanding, and respectful care to gay and lesbian families should recognize this limitation and refer these families to a clinician who can better meet their needs.”35 Once the clinician has addressed these issues personally, then health care staff attitudes should be similarly addressed with interventions such as diversity training and strict guidelines regarding confidentiality.

The physical office environment should also be assessed and modified to reflect a supportive, safe environment for children of diverse families. Hospital and office policies regarding the use of gender-neutral language and the inclusion of nonbiological parents during the child’s office visits should be discussed and enforced. Table 16-1 illustrates examples of questions to clarify family constellation. Through their work with gay and lesbian parents, Perrin and Kulkin identified several changes in the office or hospital environment that demonstrate support for a diversity of family structures. A nondiscrimination policy, prominently displayed in the waiting area, should be considered to assure diverse families that the office is a safe environment for disclosure of sensitive issues (see Table 16-2). Standard office forms should be modified to include gender-neutral terms, such as “parent” and “family member.” Other resources should be available in the office, such as books about gay and lesbian parenting and information regarding community and national resources (see eTable 16.1 ).

LEGAL ISSUES

The physical resources available in the office should also include standard medical forms, such as medical power of attorney designation, as well as information on community resources regarding other legal resources. Legislation constantly shifts the parameters of parental rights and responsibilities and is of concern for gay-parented and lesbian-parented families. While there is a growing overall trend toward securing legal parental rights for gay and lesbian parents, laws vary dramatically between states and countries.38 In the frequent circumstance that only 1 of the same-gender couple is legally recognized as a child’s parent, the clinician should clarify how responsibility for the medical decisions and consent for treatment for the child will be shared and document this information in the medical record. In the event of serious injury, illness, death, or voluntary separation of the legal parent, a prior written agreement giving the other parent power of attorney in making medical decisions for the child is necessary. In general, when gay or lesbian couples first contemplate raising a child together, they should agree in writing on issues concerning child custody, support, and consent for treatment. Curry, Clifford, and Hertz offer guidelines for writing agreements that specify parental rights and responsibilities (their book is listed eTable 16.1 ). Without a written agreement, a nonbiological/nonadoptive parent may have difficulty proving his or her status as the child’s parent.

ANTICIPATORY GUIDANCE AND CHILD DEVELOPMENT

Just as the physical office environment and resources provided should encourage and reflect patient and family diversity, so should the clinical assessment and guidance provided by the clinician. As the child raised in a gay or lesbian household grows and develops, in addition to standard anticipatory guidance issues, particular issues tend to surface regarding different developmental stages.

In the preschool period, common concerns include how to explain the construct of their own family and the methods of reproduction.37 Early childhood “is a good time to initiate explanations to the child about his or her own origin and to introduce concepts of the variety of loving relationships.”35 Parents should be encouraged to help their children come up with their own creative ways to describe their family in positive terms.36 A gay or lesbian couple might celebrate their essential roles as two loving, supportive parents while additionally recognizing the other important adults who help comprise that child’s extended family. For example, in the context of a gay male couple with children, one approach to Mother’s Day might be to redefine it as a celebration of that child’s female role models, such as writing cards to an aunt or close female family friend.

Table 16-1. Questions to Clarify the Family Constellation

Is there anything about your family that would be helpful for me to know?

Who are the adults who make up your family?

Who are the important people in your child’s life?

Who lives at home? What is your relationship with each child caretaker?

By what name does your child call each family member?

Who are the other important members of your family or support system who help care for your child?

With whom do you share parenting responsibilities?

Do(es) the biological parent(s), if not part of the current constellation, have any involvement in child care?

Which of your child’s caretakers can give legal consent for medical care?

What medical conditions do your child’s biological relatives have?

The transition to school years also poses particular challenges for children from a nontraditional family background. For parents and children alike, this involves whether to disclose their nontraditional family status to teachers and the families of the child’s friends.

Gay and lesbian parents frequently fear that school staff, as well as the families of classmates, will treat their children differently if they disclose their sexual orientation and family constellation. As a result, many parents help children to learn “differential disclosure”—to be open about their parents’ homosexuality to some people but not to others—so that harassment and social isolation can be minimized. Parents should understand that both secrecy and disclosure represent potential burdens for their children. Clinicians can help parents empower their children to deal with these issues by encouraging them to allow the child to help control the information they disclose to friends or teachers; parents should simultaneously help their children prepare for the possible negative consequences of disclosure.34

Table 16-2. Example of Nondiscrimination Policy for the Pediatric Office

Office Nondiscrimination Policy

This office appreciates diversity and does not discriminate based on race, ethnicity, national origin, age, religion, ability, sexual orientation, or perceived gender.

It is during these early school years that peer acceptance and teasing often become concerns. Children who have gay or lesbian parents may be assumed to be homosexual and experience stigmatization by peers when their parents’ sexual orientations become known. In the National Lesbian Families Study, 18% of children had experienced some form of discrimination by age 5, and 43% had experienced homophobia by age 10.32,39 It is important for all children, especially as they reach school age, to develop a wide range of relationships outside their nuclear family. The conflict raised when there is a discrepancy between the dominant cultural values reflected in the way the school community defines “family” from what the child experiences in his or her own home can be distressing to children and add to their social isolation and uncomfortable relationships with peers.40 Clinicians can help in coping with stigma and discrimination by empathic listening and by providing information to parents and their children about local support groups and, when appropriate, qualified therapists.41 In many larger cities, active networks of gay and lesbian parents work to create environments of peer support in which their children are more accepted and supported than they may be in other social contexts. Clinicians can act as intermediaries between the family and the school to help make the educational environment more supportive. They can educate child care providers and teachers and encourage schools to include information about diverse family structures in their libraries and curricula.

Older school-aged children raised in gay and lesbian households face their own challenges. Early adolescents may feel marginalized and stigmatized by being seen as part of a nontraditional family.35Teenagers may feel guilty, torn between their loyalty to their family and pride in their family structure and their intense desire to form and maintain both platonic and romantic relationships. Although individual situations vary, there is some evidence to support encouraging adolescents to disclose their nontraditional family status to their friends.41 Clinicians caring for these teenagers should have available a list of local and national support groups and community resources and should become familiar with school-based resources available to their patients, including gay-straight alliance or similar student groups.