Expert Commentary

Why we must make a stronger commitment to lesbian family health

OBG Manag. 2009 November;21(11):40-50

“Equitable treatment” recommended by ACOG does not eliminate health-care disparities between families headed by heterosexual parents and those headed by same-sex parents

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IN THIS ARTICLE

First-trimester androgen exposure and sexual orientation
Case studies in discrimination
We should take a principled stand for the sake of women’s health

References

1. Stern JE, Cramer CP, Garrod A, Green RM. Access to services at assisted reproductive technology clinics: a survey of policies and practices. Am J Obstet Gynecol. 2001;184:591-597.

2. Kingsberg SA, Applegarth LD, Janata JW. Embryo donation programs and policies in North America: survey results and implications for health and mental health professionals. Fertil Steril. 2000;73:215-220.

3. American College of Obstetricians and Gynecologists. ACOG Committee Opinion. No. 385. November 2007. The limits of conscientious refusal in reproductive medicine. Obstet Gynecol. 2007;110:1203-1208.

4. American College of Obstetricians and Gynecologists ACOG Committee Opinion. No. 428. February 2009. Legal status: health impact for lesbian couples. Obstet Gynecol. 2009;113(2 Pt 1):469-472.

5. Ethics Committee of the American Society for Reproductive Medicine. Access to fertility treatment by gays, lesbians, and unmarried persons. Fertil Steril. 2009;92:1190-1193.

6. Rahman Q. The neurodevelopment of human sexual orientation. Neurosci Biobehav Rev. 2005;29:1057-1066.

7. Pasterski V, Hindmarsh P, Geffner M, Brook C, Brain C, Hines M. Increased aggression and activity level in 3- to 11-year-old girls with congenital adrenal hyperplasia (CAH). Horm Behav. 2007;52:368-374.

8. Savic I, Lindstrom P. PET and MRI show differences in cerebral asymmetry and functional connectivity between homo- and heterosexual subjects. PNAS. 2008;105:9403-9408.

9. Rahman Q, Koerting J. Sexual orientation-related differences in allocentric spatial memory tasks. Hippocampus. 2008;18:55-63.

10. Meyer-Bahlburg HF, Dolezal C, Baker SW, New MI. Sexual orientation in women with classical or non-classical congenital adrenal hyperplasia as a function of degree of prenatal androgen excess. Arch Sex Behav. 2008;37:85-99.

11. Meyer-Bahlburg HF, Dolezal C, Baker SW, Ehrhardt AA, New MI. Gender development in women with congenital adrenal hyperplasia as a function of disorder severity. Arch Sex Behav. 2006;35:667-684.

12. Ehrhardt AA, Meyer-Bahlburg HF, Rosen LR, et al. Sexual orientation after prenatal exposure to exogenous estrogen. Arch Sex Behav. 1985;14:57-77.

13. Agrawal R, Sharma S, Bekir J, et al. Prevalence of polycystic ovaries and polycystic ovary syndrome in lesbian women compared with heterosexual women. Fertil Steril. 2004;82:1352-1357.

14. Bailey JM, Pillard RC, Neale MC, Agyei Y. Heritable factors influence sexual orientation in women. Arch Gen Psychiatry. 1993;50:217-223.

15. Baba T, Endo T, Honnma H, et al. Association between polycystic ovary syndrome and female-to-male transsexuality. Hum Reprod. 2007;22:1011-1016.

16. Bosinski HA, Peter M, Bonatz G, et al. A higher rate of hyperandrogenic disorders in female-to-male transsexuals. Psychoneuroendocrinology. 1997;22:361-380.

17. Ryan C, Huebner D, Diaz RM, Sanchez J. Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics. 2009;123:346-352.

18. Henry J. Kaiser Family Foundation. A Report on the Experiences of Lesbians, Gays and Bisexuals in America and the Public’s Views on Issues and Policies Related to Sexual Orientation. Menlo Park, Calif: Henry J. Kaiser Family Foundation; 2001.

19. Mays VM, Cochran SD. Mental health correlates of perceived discrimination among lesbian, gay, and bisexual adults in the United States. Am J Public Health. 2001;91:1869-1876.

20. Mays VM, Cochran SD, Barnes NW. Race, race-based discrimination, and health outcomes among African Americans. Annu Rev Psychol. 2007;58:201-225.

21. Valanis BG, Bowen DJ, Bassford T, Whitlock E, Charney P, Carter RA. Sexual orientation and health: comparisons in the Women’s Health Initiative sample. Arch Fam Med. 2000;9:843-853.

22. Case P, Austin SB, Hunter DJ, et al. Sexual orientation, health risk factors, and physical functioning in the Nurses’ Health Study II. J Womens Health. 2004;13:1033-1047.

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24. Eaker ED, Sullivan LM, Kelly-Hayes M, D’Agostino RB, Sr, Benjamin EJ. Marital status, marital strain, and risk of coronary heart disease or total mortality: the Framingham Offspring Study. Psychosom Med. 2007;69:509-513.

25. Shenson D, Adams M, Bolen J. Delivery of preventive services to adults aged 50–64: monitoring performance using a composite measure, 1997-2004. J Gen Intern Med. 2008;23:733-740.

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27. Aronson SR, Huston AC. The mother-infant relationship in single, cohabiting, and married families: a case for marriage? J Fam Psychol. 2004;18:5-18.

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Fast Track

Sexual orientation and gender identity are not specifically mentioned in the nondiscrimination clause of ACOG’s Code of Professional Ethics

13 published studies have revealed that 20% to 50% of females who have congenital adrenal hyperplasia will identify as lesbian or bisexual in adulthood

All of the states with laws that permit civil marriage for same-sex couples have explicitly endorsed a religious right for clergy to refuse to certify the licenses of same-sex couples

The American Psychiatric Association endorsed civil marriage in 2004

The author reports no financial relationships relevant to this article.

CASE 1: Refusal to treat—is it legal?

Two lesbians in South Carolina, together for 7 years, seek insemination services from their HMO gynecology service. The doctors at that service decline to inseminate them—saying that they do not offer this service to lesbians because they believe that only heterosexual, married women should have children—and refer them to another physician outside the HMO. The couple pays $8,000 out of pocket to conceive their son. Because it is legal to discriminate against homosexuals in South Carolina, the doctors cannot be sued, and ACOG cannot discipline the doctors.

Currently, 25% to 45% of clinics in the United States report that they refuse to inseminate lesbians.^1,2 What can we do to end such discrimination?

“Physicians and other health care professionals have the duty to refer patients in a timely manner to other providers if they do not feel that they can in conscience provide the standard reproductive services that their patients request.” So says Committee Opinion #385 of the American College of Obstetricians and Gynecologists (ACOG).³ This formal opinion implies that a physician who objects to same-sex couples may refer a lesbian patient to another physician for insemination, thereby communicating his or her discrimination to the patient.

In addition, ACOG’s Committee on Underserved Women released Committee Opinion #428, endorsing “equitable treatment for lesbians and their families, not only for direct health care needs but also for indirect health care issues; this should include the same legal protections afforded married couples.”⁴ The opinion does not endorse access to civil marriage, per se.

And although ACOG includes a nondiscrimination clause in its Code of Professional Ethics stating that the “principle of justice requires strict avoidance of discrimination on the basis of race, color, religion, national origin, or any other basis that would constitute illegal discrimination,” sexual orientation and gender identity are not specified.

To remain consistent with its mission of “advancing women’s health,” ACOG must include sexual orientation and gender identity in its nondiscrimination statement and endorse access for same-sex couples to civil marriage—not just “equitable treatment.”

In 44 states, laws mandating so-called equitable treatment deny the families of lesbian couples the legal and financial protections of civil marriage that are deemed essential to the health of families headed by heterosexual couples.

In 30 states, ACOG’s nondiscrimination policy, as written, could be interpreted to permit gynecologists to discriminate on the basis of sexual orientation in their practices.

The American Society for Reproductive Medicine issued a statement affirming that there is no justification for denying same-sex couples assisted reproductive technologies.⁵

Both the American Academy of Pediatrics (AAP) and the American Psychiatric Association (APA) prohibit discrimination on the basis of sexual orientation and endorse civil marriage for same-sex couples in richly evidence-based policy statements. Both organizations affirm that:

homosexuality is natural, immutable, and noncontagious
the children of homosexual parents develop with outcomes equal to those of heterosexual parents
the families of same-sex couples need the same protections that their heterosexual counterparts enjoy.

The American Medical Association (AMA) issued policy statements prohibiting discrimination based on sexual orientation and gender identity because of documented health disparities that arise from discrimination.

In this article, I present evidence to support these positions; provide examples of how the current ACOG statement contributes to disparities; and challenge ACOG to clarify the wording of its opinions.

There is no scientific rationale for any discrimination against same-sex families. There is abundant scientific evidence that these families are harmed by discriminatory laws and treatment.

Civil unions, domestic partnerships do not equal civil marriage

ACOG Committee Opinion #428 makes it clear that “equitable treatment” does not affect religious rules about marriage ceremonies: Marriage licenses must be solemnized either in a religious ceremony performed by a clergy member, or in a civil ceremony performed by a judge, justice of the peace, or elected official.⁴ The Committee Opinion recognizes that domestic partnerships and civil unions do not provide the same rights as a state civil marriage license, and notes that neither is portable to all other states or recognized by the United States government.⁴