
Evidence
What evidence is already out there?
As part of our Priority Setting Partnership, we looked to see what evidence has already been published on the 48 summary questions that LGBTQIA+ people, supporters and health professionals submitted (see more about the process here).
Short summaries of the evidence that we found are on this page, next to the question they are related to. Each summary gives a link to the published paper or report, most of which are free for anyone to read (“open access”).
Our evidence check took place in spring of 2025. We will not be keeping it up to date as more evidence is published. The evidence check was not a ‘systematic review’ – there were too many questions to do exhaustive searches for each one. We may have missed some evidence.
We have not ‘appraised’ the evidence – this means trying to decide the quality of the evidence or whether it might be biased and inaccurate. Some of the evidence on this page is likely to be of low quality and may be biased. LGBTQIA+ people should discuss evidence with their health professionals before making any medical decisions
Q1. How do healthcare responses to LGBTQIA+ people’s intersectional identities affect whether they can become parents and have good perinatal care? (For example, those who may be subjected to disable-ism, fatphobia, racism or faith-based discrimination). What are the barriers to improving this?
LGBT Foundation 2022: Trans and non-binary experiences of maternity services. This is a report compiled by a charity, found here: https://lgbt.foundation/wp-content/uploads/2024/01/ITEMS20final.pdf Open Access
Summary: This project carried out a large non-systematic survey and also interviewed 4 trans and non-binary people about their experiences of ‘maternity’ services, including two people of colour. These participants described the impacts of the intersections of racism and transphobia in their perinatal experience.
Q2. What does LGBTQIA+ inclusive care look like? What models of perinatal care (for example, specialist midwives, LGBTQIA+ ‘out’ healthcare professionals, continuity of carer) work for LGBTQIA+ people?
Murdock, 2024: Midwives defining what they feel constitutes inclusive care https://doi.org/10.1111/jmwh.13557 Open Access
Summary: When defining inclusive care, midwives described the following principles: using inclusive language, changing the clinical environment, amending documents and websites, and tailoring care for each client.
LGBT Foundation 2022: Trans and non-binary experiences of maternity services. This is a report compiled by a charity, found here: https://lgbt.foundation/wp-content/uploads/2024/01/ITEMS20final.pdf Open Access
Summary: This project gathered non-systematic survey data from 121 trans and non-binary people in the UK who had ever given birth or were pregnant and also interviewed 4 people. To increase inclusive care, the report recommends that the NHS should provide targeted information for trans and non-binary pregnant and birthing people; ask people about the most appropriate language to use and then record this for implementation during care; ensure IT systems can recognise gender appropriately and routinely record gender identity; increase the visibility of a commitment to inclusive care; co-create personalised support plans; recognise the importance of trauma informed care; and implement training for perinatal staff and managers.
Riggs et al 2021: Pregnant transmasculine and non-binary people’s experiences of midwifery care. This is a chapter of a midwifery textbook available here: https://ruthpearce.net/wp-content/uploads/2024/01/men-transmasculine-and-non-binary-people-and-midwifery-care.pdf Open Access
Summary: 51 trans and non-binary people with experience of conception were interviewed from UK, US, Australia, Canada and Germany. Positive experiences with midwives included asking for consent to touch people’s bodies, ensuring correct gender markers were recorded on paper and electronically, and advocating for inclusive care from colleagues. Some participants felt supported by midwives disclosing that they had trans and non-binary family members. Some participants felt well supported by male midwives. Recommendations for inclusive care included gathering information on pronouns, names and preferred terminology, collating it and ensuring all staff were aware of it; ongoing training due to the fast moving past of literature in this area; continuity of care; avoidance of simplistic comparisons; proactively seeking to minimise any gender related distress from the perinatatal process; advocating for systemic change such as in data collection, inclusive imagery and language; understanding the limits and challenges of chestfeeding; and advocating for further research.
Hoffkling et al, 2017: Recommendations arising from the experience of pregnant trans men https://doi.org/10.1186/s12884-017-1491-5 Open Access
Summary: 10 transgender men who had given birth were interviewed. Using the correct name and pronouns and providing increased levels of privacy were reported as being fundamental to feeling safe. Healthcare providers educating themselves rather than asking the patient to educate them, treating trans pregnancy as within the normal spectrum of care, and making joint assessments of risk in the absence of good evidence, were all perceived as good elements of care. Respecting and accepting trans people was reported to be more important than being expert in trans medical care.
Q3. What training do healthcare professionals and their educators need about how LGBTQIA+ people become parents (including family creation, perinatal care and infant feeding)?
Parker et al, 2025: An example of embedding LGBTQ+ training in midwifery training https://doi.org/10.1016/j.wombi.2024.101850 Open Access
Summary: This paper provides a context and a pedagogical approach to embedding LGBTQIA+ health equity in one school of midwifery in Aotearoa New Zealand. It describes the steps taken using a holistic whole-of-programme approach grounded in intersectionality, cultural safety and humility, and indigenous justice.
Murdock, 2024: Defining existing training and gaps https://doi.org/10.1111/jmwh.13557 Open Access
Summary: Eleven midwives were interviewed. When defining training needs for inclusive care, midwives described the following principles: using inclusive language, changing the clinical environment, amending documents and websites, and tailoring care for each client
Pezaro et al, 2022: Defining educational needs of professionals related to perinatal care for trans and nonbinary people
https://doi.org/10.1177/08912432221138086 Open Access
Summary: This paper explored the educational needs of 108 perinatal staff in the United Kingdom (97% midwives or student midwives) as related to the needs of trans and nonbinary service users. It used a self-administered internet survey. The educational needs identified included information about the practicalities of childbearing as a trans or nonbinary person, how to use inclusive language effectively, and creating policies and processes for supporting childbearing trans and nonbinary people. These caregivers’ preferences included hearing from trans and nonbinary people and sharing best practices among themselves, with open discussions about how to be inclusive
Arias et al, 2021: Midwives’ and midwifery lecturers’ views on current LGBTQ+ content in midwifery training https://doi.org/10.1016/j.midw.2021.103050 Paywall
Summary: There were 47 survey respondents and 16 focus group participants. Two themes were developed from the data analysis: Practising Open Mindedness and Cultivating Openness and four sub themes; Making Assumptions, Developing self- awareness, Challenge and Discomfort and Safe spaces. Participants proposed learning strategies that they thought would facilitate cultivating openness and open mindedness.
Hoffkling et al, 2017: Experiences of pregnant trans men https://doi.org/10.1186/s12884-017-1491-5 Open Access
Summary: 10 transgender men who had given birth were interviewed. Aspects relevant to training needs where how to use inclusive language and promote privacy; how to collaboratively come to care decisions with minimal evidence; and the need to educate oneself rather than relying on a trans patient to do so.
Q4. How do puberty blockers and gender affirming hormones (both regulated and unregulated) affect fertility, pregnancies, the foetus, birth and postnatal healing?
No evidence found
Q5. What does good perinatal mental health support look like for LGBTQIA+ people, and is this different for gestational and non-gestational parents, or for people with different genders or gender identities?
No evidence found
Q6. Are perinatal outcomes different for LGBTQIA+ people, and are they affected by how someone attempted pregnancy or became pregnant?
By perinatal outcomes we mean live birth rates, stillbirths and miscarriages; pregnancy, labour and birth complications; interventions to start labour or during labour; mode of birth; gestational parent/surrogate mortality rates; birth trauma; mental health; infant feeding, health, developmental and mortality outcomes
Although many papers are included here, the question is not considered answered because only a subset of outcomes and sections of the LGBTQIA+ community are covered
Mental and physical health:
Mamrath et al, 2024: Higher anxiety in sexual minority women postnatally during the pandemic lockdown https://doi.org/10.1371/journal.pone.0297454. Open Access
Summary: 381 postnatal women (including 20 sexual minority women) completed an online survey during the first UK lockdown, including completing a psychometric test. Sexual minority women were more likely to score highly on an anxiety scale than their heterosexual counterparts. Lesbian, gay, bisexual, and pansexual participants scored highly in the ‘psychosocial adjustment to motherhood’ category.
Shenkman et al, 2023: Better mental health of lesbian mothers compared to heterosexual mothers
https://doi.org/10.1007/s13178-023-00800-8 Paywall
Summary: Seventy-two lesbian mothers by donor insemination (from 36 families) were compared with 72 heterosexual parents by assisted reproduction (without donated gametes; from 36 families) on positivity, life satisfaction, and depressive symptoms. All parents were cisgender and had at least one child born through assisted reproduction, aged 3–10 years. Lesbian mothers reported greater positivity, greater life satisfaction and less depressive symptoms
Carone, Rothblum et al, 2021: Good mental and physical health outcomes for transgender parents compared to cisgender parents https://doi.org/10.1037/fam0000776 Paywall
Summary: The study compared the quality of life and several mental health (psychological distress, life satisfaction, happiness, social wellbeing) and health (physical health, alcohol and drug use) dimensions by gender identity and parenthood status in a sample of 1,436 transgender and cisgender respondents to the U.S. Transgender Population Health Survey (TransPop study). An estimated 18.8% of transgender respondents were parents, with the majority (52.5%) being transgender women. After controlling for age, education, and relationship status, there were no significant differences between trans- and cisgender parents and their nonparent counterparts on any mental health or health dimensions.
Van Rijn-van Geldern et al, 2018: No difference in mental health and wellbeing of gay fathers through surrogacy compared to lesbian mothers and heterosexual parents using IVF https://doi.org/10.1093/humrep/dex339 Open Access
Summary: This cross-sectional study is part of an international research project involving 38 gay-father families, 61 lesbian-mother families and 41 heterosexual-parent families with 4-month-olds in the UK, the Netherlands and France. There were no differences in levels of parental wellbeing (parental stress, psychological adjustment and partner relationship satisfaction) between gay-father families with infants born through surrogacy, lesbian-mother families with infants born through donor insemination, and heterosexual-parent families with infants born through IVF.
Goldberg, Gartrell & Gates, 2014: Transition to parenthood for LGB people was similar to heterosexual people (report) https://escholarship.org/uc/item/7gr4970w. Open Access
Summary: This report addresses the research on LGB parenting, including functioning and experiences of LGB parents and their children. Relevant summary points are that, similar to heterosexual parents, LGB parents’ mental health and relationship quality decline across the transition to parenthood, although support from friends, family, and the workplace buffered all parents from the challenges of new parenthood. Studies comparing LGB and heterosexual parents in regard to mental health, parenting stress, and parenting competence have found few differences based on family structure. Conditions linked to poorer wellbeing for LGB parents include living in less supportive legal contexts, perceiving less support from family or supervisors, having higher levels of internalized homophobia, and encountering more child behaviour problems. Compared to heterosexual parents, LGB parents have not been found to differ on average, in parental warmth, emotional involvement, and quality of relationships with their children.
Borneskog et al, 2014: Higher relationship satisfaction of lesbian couples compared to heterosexual couples https://doi.org/10.1186/s12905-014-0154-1 Open Access
Summary: Three-year follow up assessment of lesbian and heterosexual couples after assisted reproduction. Participants requesting assisted reproduction at all fertility clinics performing gamete donation in Sweden were recruited consecutively 2005–2008. A total of 114 lesbian couples (57 treated women and 57 partners) and 126 heterosexual couples (63 women and 63 men) participated. Lesbian couples reported higher relationship satisfaction than heterosexual couples, however the heterosexual couples’ satisfaction with relationship quality was not low. At a follow-up after assisted reproduction with donated sperm, lesbian couples reported stable relationships and a high satisfaction with their relationships, even when treatment was unsuccessful.
General pregnancy-related:
Leonard et al, 2022: Comparison of mother-father, mother-mother and father-father birth outcomes
https://www.sciencedirect.com/science/article/abs/pii/S0002937822001727. Paywall
Summary: A population-based cohort study of all live births in hospital 2016-2019 in California. Likely sexual and/or gender minority parents were identified by a birthing parent identifying as a father (n = 498), or both parents identifying as a mother (n = 2572). The comparison group were those where the birthing parent identified as a mother and the other parent identified as a father (n = 1,483,119). Compared with mother-father partnerships, birthing parents in mother-mother partnerships were significantly more likely to have a multiple pregnancy (adjusted risk ratio, 3.9; 95% confidence interval, 3.4–4.4), induction of labour (adjusted risk ratio, 1.2; 95% confidence interval, 1.1–1.3), excessive bleeding after birth (adjusted risk ratio, 1.4; 95% confidence interval, 1.3–1.6) and severe illness/morbidity (adjusted risk ratio, 1.4; 95% confidence interval, 1.2–1.8). There was no difference in gestational diabetes, pregnancy related hypertension, caesarean birth, premature birth or low birthweight. No outcomes significantly differed between father birthing parents and birthing parents in mother-father partnerships.
Hodson, Meads and Bewley, 2017: Systematic review of likelihood of pregnancy for lesbian and bisexual women https://doi.org/10.1111/1471-0528.14449 Open Access
Summary: 30 papers (28 studies) were included. In the general population, the odds of pregnancy were nine-fold lower among lesbian women and over two-fold lower among bisexual women compared to heterosexual women (the odds ratios were 0.12 [95% CI 0.12–0.13] and 0.50 [95% CI 0.45–0.55], respectively). The odds of adolescent pregnancy were higher for lesbian adolescents and particularly for bisexual adolescentscompared to heterosexual adolescents (odds ratios of 1.37 [95% CI 1.18–1.59] and 1.98 [95% CI 1.85, 2.13]). There were inconsistent results regarding abortion rates. The odds of pregnancy after assisted reproduction were higher for lesbian women compared with heterosexual women (the odds ratio was 1.56, 95% CI 1.24–1.96). This analysis included eight papers, most of which were designed to look at outcomes other than pregnancy/birth rate. The single paper designed to look at the question of birth rate after assisted reproduction with donor sperm showed no differences between lesbian and heterosexual couples (this specific study is https://doi.org/10.1093/humrep/det445, Open Access).
Own egg versus partner egg (reciprocal IVF):
Matorras et al, 2023: Comparing the outcomes of in-vitro fertilisation in lesbians using their partner’s egg IVF versus artificial insemination https://doi.org/10.1093/humrep/dead035 Open Access
Summary: Single pregnancies after shared motherhood IVF compared to own-egg artificial insemination had similar outcomes, except for a non-significant increase in the rate of preeclampsia/hypertension after shared motherhood IVF (age-adjusted odds ratio = 1.9, 95% CI = 0.7–5.2). Twin pregnancies after shared motherhood IVF had a much higher frequency of preeclampsia/hypertension (age-adjusted odds ratio = 21.7, 95% CI = 2.8–289.4; p = 0.01).
Wrande et al, 2022: Comparing the outcomes of own egg IVF versus artificial insemination
https://pmc.ncbi.nlm.nih.gov/articles/PMC8995219/ Open Access
Summary: This is a prospective cohort study of 251 women undergoing intrauterine insemination (IUI) or in vitro fertilization, all with donor sperm, between 2017 and 2019 at one department in Sweden. This was 112 lesbian women in a relationship and 139 single women. The single women were older and more often had IVF at first treatment. There was no statistically significant difference in live birth rate after IUI between the two groups, when adjusted for age. Live birth per insemination was 19% for lesbians in a relationship compared to 14% for single people. In those using IVF, there was a higher pregnancy rate for lesbian women in relationships compared to single women (even after adjustment for age). Pregnancy per embryo transfer was 67% compared to 40% (p = 0.005, after adjustment for age) and birth per embryo transfer was 45% compared to 24% (p = 0.08 after adjustment for age).
Diego et al, 2022: Similar outcomes of in-vitro fertilisation in lesbians using their partner’s egg versus their own egg https://pmc.ncbi.nlm.nih.gov/articles/PMC9464617/ Open Access
Summary: This is a retrospective review of patients who used donor sperm at an urban, southeastern USA centre 2014-2020. Among the 374 patients, 88 (24%) were single, 188 (50%) were in a same-sex female partnership, and 98 (26%) had a male partner with a diagnosis of male factor infertility. Most patients did not have infertility (73.2%). Live birth rates per cycle were 11% in intrauterine insemination (IUI), 42% in in-vitro fertilisation (IVF), and 61% in co-IVF (where one partner’s egg is used and the other partner carries the pregnancy). Same sex partners were no less likely than opposite sex partners to have a live birth (adjusted odds ratio was 1.48, 95% confidence interval 0.92 to 2.36). Same sex partners were no more likely than opposite sex partners to have pregnancy complications (adjusted odds ratio was 0.49, 95% confidence interval 0.19 to 1.25, p = 0.1) or miscarriage (adjusted odds ratio was 0.69, 95% confidence interval 0.32 to 1.49, p = 0.3).
Brandao et al, 2022: Similar outcomes of in-vitro fertilisation in lesbians using their partner’s egg versus their own egg https://pmc.ncbi.nlm.nih.gov/articles/PMC9474973/ Open Access
Summary: Retrospective multicentre cohort study 2011-2020 in 18 fertility clinics in Spain. A total of 99 partner-egg cycles (73 couples) and 2929 own-egg cycles (2334 couples or single patients) of women younger than 38 years old with no known fertility disorder were included. Couples using partner egg were younger than those using own egg. A greater number of eggs and embryos were obtained for couples using partner egg than own egg. No differences were found between groups in outcomes, with or without adjustment for age. The total clinical pregnancy rates per embryo transfer were 57% and 50% and the live-birth rates were 46% and 41%. There was no difference in premature birth (8% vs. 12%) or birthweight (2.8 kg vs. 3.1 kg).
Nunez et al, 2021: Better outcomes of in-vitro fertilisation in lesbians using their partner’s egg versus their own egg https://pubmed.ncbi.nlm.nih.gov/34061679/ Paywall
Summary: This was a retrospective matched cohort study of couples performing a first cycle of either partner-egg (n = 60) or own-egg in-vitro fertilisation or intra-cytoplasmic sperm injection (IVF/ICSI; n = 120) 2012-2018. Pregnancy and birth rates were better with partner-egg embryo transfers: biochemical pregnancy 70% versus 48% (p = 0.004), clinical pregnancy 60% versus 40% (p = 0.01), ongoing pregnancy 60% versus 37% (p = 0.003), and live birth 57% versus 30% (p = 0.001). After adjusting for age, body mass index, and number of mature oocytes, there was still a significant improvement across all outcomes in partner egg cycles (live birth rate odds ratio 3, 95% confidence interval 1.4-6.6). Cumulative live birth rates were higher with partner eggs (66% vs. 43% [p = 0.005]).
Surrogacy:
Fuchs et al, 2018: Perinatal outcomes for surrogacy if the surrogate uses their own egg versus a donated egg https://pmc.ncbi.nlm.nih.gov/articles/PMC5962328/ Open Access
Summary: 222 women living in the United States completed a brief online survey between November 2015 and February 2016. There were 204 gestational carriers (using donated egg) and 18 traditional surrogates (using own egg). Overall, obstetric outcomes were similar. Traditional surrogates were younger, more likely to be Hispanic, more likely to be a full-time student, more likely to be on Medicaid, less likely to be a first-time carrier and more likely to have a high Depression Scale score (38% vs. 4%)
Woo et al, 2017: Perinatal outcomes for own egg pregnancy vs a donated egg surrogacy
https://www.fertstert.org/article/S0015-0282(17)31941-6/fulltext. Open Access
Summary: We identified 124 gestational surrogates who achieved a total of 494 pregnancies (312 their own spontaneous pregnancies and 182 surrogate pregnancies with donated egg). Surrogate pregnancies more likely to result in twin pregnancies than own egg pregnancies (33% compared to 1%, p<0.01). Miscarriage and ectopic rates were similar. Surrogate births had higher rates of preterm birth (10.7% vs. 3.1%), and higher rates of low birth weight (7.8% vs. 2.4%, 105 g lower birthweight on average). Surrogate births had significantly higher obstetrical complications, including gestational diabetes, hypertension, use of amniocentesis, placenta previa, antibiotic requirement during labour, and caesarean section.
Pavlovic et al, 2010: Perinatal outcomes for own egg pregnancy vs a donated egg surrogacy
https://pmc.ncbi.nlm.nih.gov/articles/PMC7183021/ Open Access
Summary: 78 donated-egg surrogacy pregnancies (with single baby) were compared to 71 own-egg pregnancies that the surrogate had previously been through for their own family building. Surrogacy cycles had worse perinatal outcomes than own pregnancies (a combination of preterm delivery, postpartum haemorrhage, preeclampsia, gestational hypertension, gestational diabetes, in utero growth restriction, oligohydramnios, abnormal placentation, placental abruption, and NICU admission; 25.6% vs. 9.9%; p = 0.02). There were no significant differences in the incidence of vaginal or caesarean birth.
Söderström-Anttila et al., 2016: Systematic review of surrogacy health outcomes for surrogate, child and family https://doi.org/10.1093/humupd/dmv046 Open Access
Summary: Most studies reporting on surrogacy have serious methodological limitations. According to these studies, most surrogacy arrangements are successfully implemented and most surrogate mothers are well-motivated and have little difficulty separating from the children born as a result of the arrangement. The perinatal outcome of the children is comparable to standard in-vitro fertilisation and egg donation and there is no evidence of harm to the children born as a result of surrogacy. There were no studies on children born after cross-border surrogacy.
Q7. How much emotional labour are LGBTQIA+ people doing when accessing (or thinking about accessing) perinatal healthcare? How can this situation be improved?
By emotional labour we mean the mental work people do in order to access services or meet someone else’s needs. It might include giving explanations of how LGBTQ+ people conceive, answering homophobic comments, dealing with your own emotions when forms or systems don’t fit your family, or thinking about any of these issues before making or going to an appointment.
Hoffkling et al, 2017: Experiences of pregnant trans men https://doi.org/10.1186/s12884-017-1491-5 Open Access
Summary: 10 transgender men who had given birth were interviewed. Some participants avoided interacting with health professionals because of fear of transphobia and poor care. Some chose not to be ‘out’ to their providers because of fear of being denied fertility care. Most participants reported anxiety about how to identify supportive healthcare providers in advance.
Q8. How does using inclusive language throughout any treatment, pregnancy and birth, healthcare encounters, and within the first year of a baby’s life affect LGBTQIA+ families?
By emotional labour we mean the mental work people do in order to access services or meet someone else’s needs. It might include giving explanations of how LGBTQ+ people conceive, answering homophobic comments, dealing with your own emotions when forms or systems don’t fit your family, or thinking about any of these issues before making or going to an appointment.
Riggs et al 2021: Pregnant transmasculine and non-binary people’s experiences of midwifery care. This is a chapter of a midwifery textbook available here: https://ruthpearce.net/wp-content/uploads/2024/01/men-transmasculine-and-non-binary-people-and-midwifery-care.pdf Open Access
Summary: 51 trans and non-binary people with experience of conception were interviewed from UK, US, Australia, Canada and Germany. Negative experiences with midwives included dismissing the importance of preferred terminology for body parts and repeated misgendering despite correction.
Hoffkling et al, 2017: Experiences of pregnant trans men https://doi.org/10.1186/s12884-017-1491-5 Open Access
Summary: 10 transgender men who had given birth were interviewed. Some reported that it was critical to emotional safety and wellbeing to be seen and treated as males, with the correct name and pronouns, but others were minimally bothered by misgendering. Using the correct name and pronouns was reported as being fundamental to feeling safe.
Q9. How does perinatal and reproductive loss affect LGBTQIA+ people’s mental health and decisions about trying to conceive again? What are their experiences of support during perinatal loss, and how can this be improved?
By perinatal loss we mean being unable to try to conceive (can’t find a surrogate or donor, can’t afford fertility treatment); not getting pregnant; miscarriage; stillbirth; death of a baby
Rose and Oxlad, 2023: LGBTQ+ people’s experiences of employment leave and support following perinatal loss
https://doi.org/10.1080/13668803.2021.2020727 Paywall
Summary: 12 LGBTQ+ people were interviewed, aiming to explore their workplace leave and support experiences following pregnancy losses as gestational or non-gestational parents in the previous 6 months to 10 years. Reflexive thematic analysis generated three themes (1) Disclosure in the workplace: support, shame, and self-protection, (2) Navigating discriminatory workplace policies, leave, and entitlements and (3) Coping at work: Getting the balance right for each person. Heteronormative policies and entitlements can compound the distress of LGBTQ+ people experiencing pregnancy loss, including increasing difficulties in accessing leave, misgendering leave entitlements, failing to accommodate for high attachment to unborn babies in early gestation, and the impact of distance for parents who have engaged in surrogacy. The authors suggest that employers can assist by using inclusive language in leave policies and forms, providing people of all genders and sexualities access to parental and bereavement leave irrespective of family formation method and gestational age and allowing flexibility in hours, workload, and tasks after a pregnancy loss.
Lacombe-Duncan et al, 2022: Uses minority stress model to explain how LGBTQ+ perinatal loss might be different to cisheterosexual perinatal loss https://doi.org/10.1371/journal.pone.0271945 Open Access
Summary: Informed by minority stress theory, this qualitative study aimed to explore the experiences of multi-level stigma and resilience among LGBTQ+ people in the context of conception, pregnancy, and loss. Seventeen semi-structured interviews were conducted (2019) with a purposive sample of US LGBTQ+ people who had experienced pregnancy loss (n = 14) or in an intimate partnership in which a pregnancy was lost (n = 3) in the last two years. Participants described the profound sadness of pregnancy loss due to unique challenges of LGBTQ+ conception. Multiple types of stigma manifested at intrapersonal (e.g., anticipated sexual stigma upon disclosure), interpersonal (e.g., unsolicited advice about conception decisions), and structural levels (e.g., differential requirements to access conception compared to heterosexual/cisgender couples).
Resilience was also seen individually (e.g., purposeful disclosure of conception, pregnancy, and loss), relationally (e.g., connecting with other LGBTQ+ community members), and collectively (e.g., creating/engaging in LGBTQ+-specific conception, pregnancy, and loss online spaces).
Pyle et al, 2021: Disclosure and non-disclosure of pregnancy loss amongst LGBTQ+ people
https://doi.org/10.1145/3411764.3445331 Open Access
Summary: 17 US LGBTQ people who used social media and had recently experienced pregnancy loss were interviewed, recruited through personal contacts. Decision making about disclosure of pregnancy loss on social media is discussed. The authors argue that social media platforms can better facilitate disclosures about silenced topics by enabling selective disclosure, enabling proxy content moderation, providing education about silenced experiences, and prioritizing such disclosures in news feeds.
Riggs et al, 2020: Men, trans/masculine, and non-binary people’s experiences of pregnancy loss
https://doi.org/10.1186/s12884-020-03166-6 Open Access
Summary: Interviews were undertaken with a convenience sample of 16 trans masculine and non-binary people who had undertaken at least one pregnancy and experienced pregnancy loss, living in either Australia, the United States, Canada, or the European Union (including UK). There were 10 themes: (1) pregnancy losses count as children, (2) minimizing pregnancy loss, (3) accounting for causes of pregnancy loss, (4) pregnancy loss as devastating, (5) pregnancy loss as having positive meaning, (6) fears arising from a pregnancy loss, (7) experiences of hospitals enacting inclusion, (8) lack of formal support offered, (9) lack of understanding from family, and (10) importance of friends.
Cacciatore and Raffo, 2011: Lesbians’ experiences of support following a pregnancy or baby loss
https://doi.org/10.1093/sw/56.2.169 Paywall
Summary: This multiple-case study focused on child death in same-gendered-parent families. The study used in-depth interviews with six self-identified lesbian mothers who had experienced the death of a child at various ages and from various causes. Results suggest that lesbian bereaved mothers experience a type of double-disenfranchisement after their losses and that social support is often insufficient to meet their psychological needs.
Peel, 2010: Lesbian and bisexual women’s experiences of perinatal loss https://doi.org/10.1093/humrep/dep441 Open Access
Summary: This study analysed predominantly qualitative online survey data from 60 non-heterosexual, mostly lesbian, women from the UK, USA, Canada and Australia. All but one of the pregnancies was planned. Most respondents had physically experienced one early miscarriage during their first pregnancy, although a third had experienced multiple losses. The analysis highlights three themes: processes and practices for conception; amplification of loss; and health care and heterosexism. The experience of loss was amplified due to contextual factors and the investment respondents reported making in impending motherhood. Most felt that their loss(es) had made a ‘significant’/‘very significant’ impact on their lives. Many respondents experienced health care during their loss. A minority reported experiencing heterosexism from health professionals.
Q10. How does where LGBTQIA+ families are in the UK affect their access to reproductive options, and how are their decisions and experiences affected by this?
No evidence found
Q11. How does the way LGBTQIA+ people got pregnant (home insemination, IUI, IVF with own egg, IVF with someone else’s egg) affect healthcare recommendations (for example, obstetric-led care and induction of labour)? How do these recommendations affect parents and babies?
No evidence found
Q12. What are LGBTQIA+ people’s experiences of abortion and abortion support in the UK?
Bowler, Vallury and Sofija, 2023: Scoping review of the experiences and needs of LGBTIQA+ people when accessing abortion care https://doi.org/10.1136/bmjsrh-2022-201692 Paywall
Summary: Seven publications were included in the review that described experiences of LGBTIQA+ people accessing abortion-related care. The included studies were predominantly conducted in the USA using quantitative and qualitative research designs. Thematic analysis highlighted participants’ experiences of discrimination and exclusion in healthcare settings, healthcare avoidance, unsafe abortion, non-disclosure to providers, and poor health outcomes for LGBTIQA+ people. The authors suggest that gender-inclusive services and training for health providers is necessary to provide safe and accessible abortion care and overcome generations of mistrust held by the LGBTIQA+ community.
Q13. Where do LGBTQIA+ people and healthcare professionals look for information about reproductive choices (including success rates, health, legal, financial and employment implications)? Is the information they get accurate, and how can access to information be improved, including from NHS sources?
Greenfield, 2023: Charity commissioned report into the perinatal experiences of LGBTQ+ women
https://doi.org/10.5281/zenodo.8326480. Open Access
Summary: 16 LGBTQ+ women over 18 who had either conceived a baby whilst in a relationship with another woman or conceived a baby as a solo parent were interviewed. Seven had been gestational parents only, seven had been non-gestational parents only, and two were both gestational and non-gestational parents of their children. In addition, three healthcare professionals who had provided perinatal care to LGBTQ+ women, and were LGBTQ+, were interviewed. The findings from this research showed that currently, LGBTQ+ women who are on the journey to parenthood face gaps in the information available to them in some areas. LGBTQ+ women who wish to conceive may face difficulties in obtaining accurate and appropriate information about conception options. Some healthcare professionals may have inaccurate information about Parental Responsibility for non-gestational mothers.
LGBT Foundation 2022: Trans and non-binary experiences of maternity services. This is a report compiled by a charity, found here: https://lgbt.foundation/wp-content/uploads/2024/01/ITEMS20final.pdf Open Access
Summary: This report gathered survey data from 121 trans and non-binary people in the UK who had ever given birth or were pregnant, and also interviewed 4 people. In the survey, a third did not feel that midwives provided relevant information on infant feeding antenatally; or took into account their personal circumstances when giving feeding advice postnatally. In interviews, some participants reported not being ‘out’ during pregnancy due to fear of discrimination or simply because there was no opportunity to come out, which interfered with accessing appropriate information. The report recommends that the NHS should provide targeted information for trans and non-binary pregnant and birthing people; and co-create personalised support plans.
Q14. What are the most successful methods for inducing lactation in a non-gestational parent? What are the barriers to healthcare professionals providing lactation support to a non-gestational parent and how can these be overcome?
Bertollo et al, 2024: Scoping review on inducing lactation in trans women
https://doi.org/10.1590/1413-81232024294.18232023 Open Access
Summary: The article aimed to conduct a scoping review of lactation induction for transfeminine people in the health care context. Twenty-one articles were included, published between 2018 and 2023. Among them, six are case reports and the others are publications in various formats. Lactation induction was achieved in all the case reports, with varying quantities of milk produced. Constituents of induced milk are similar to those of non-induced human milk. One included study assessed knowledge among professionals working in trans health.
Cazorla-Ortiz et al, 2020: Scoping review on inducing lactation https://doi.org/10.1177/0890334420950321 Paywall
Summary: The aim of this scoping review was to assess the different methods used to induce lactation. Twenty four articles were included. Pharmacological methods were not always used to produce milk, although breast stimulation was essential. The age of the child, interference due to bottle feeding, breast stimulation, and the support received were important factors in the induction of lactation. There were several factors that may account for the differences between developing and higher income countries in methods of induced lactation and the amount of milk that study participants produced. There was no consensus over whether previous pregnancy and/or breastfeeding experience influenced induced lactation.
Q15. When planning a pregnancy, what are the right timings to pause and restart gender affirming hormones?
Pfeffer et al, 2023: Decision making around testosterone and transgender pregnancy https://doi.org/10.1016/j.ssmqr.2023.100297 Open Access
Summary: 70 trans/non-binary people who had conceived or were considering conception and 22 healthcare providers with a focus in trans health were interviewed. In the context of uncertainty, healthcare providers tended to recommend caution and centring potential risks to the foetus/child. They often viewed any desire to use testosterone during pregnancy as selfish. Trans people felt that they were juggling competing priorities to maintain their sense of self and wellbeing, ensure continuing access to healthcare and protect their foetus/child. Most healthcare professionals and trans people defaulted to pausing testosterone before conception attempts, throughout pregnancy and until lactation was complete. Some trans people reported impaired mood and increased dysphoria during this time. A small number of healthcare providers and trans people were willing to consider the use of testosterone during pregnancy/lactation, sometimes at low dosage, feeling that the level of concern to the foetus/child was no more than for many lifestyle habits and medications that are used or taken in pregnancy/lactation.
Hoffkling et al, 2017: Experiences of pregnant trans men https://doi.org/10.1186/s12884-017-1491-5 Open Access
Summary: 10 transgender men who had given birth were interviewed. Some participants had delayed taking testosterone to ensure fertility, others went ahead with testosterone despite uncertainty over the effect on fertility and some took testosterone while confident that it would not impair fertility (all had stopped testosterone in order to conceive). Some participants did not have any emotional impact of pausing testosterone for conception, others enjoyed the process and some had impaired mood, particularly after birth.
Q16. What increases good experiences of care and good perinatal outcomes for surrogates and LGBTQIA+ people becoming parents through surrogacy?
No evidence found
Q17. How do the parental titles on birth certificates affect LGBTQIA+ parents?
Hoffkling et al, 2017: recommendations arising from the experience of pregnant trans men https://doi.org/10.1186/s12884-017-1491-5 Open Access
Summary: 10 transgender men who had given birth were interviewed. Some participants described the impact of not being able to be listed as ‘father’ on the birth certificate as conveying a message that their identities did not matter.
Q18. How confident and competent are perinatal staff in using up to date LGBTQIA+ inclusive language, and how can this be improved?
Greenfield, 2023: Charity commissioned report into the perinatal experiences of LGBTQ+ women
https://doi.org/10.5281/zenodo.8326480. Open Access
Summary: 16 LGBTQ+ women over 18 who had either conceived a baby whilst in a relationship with another woman or conceived a baby as a solo parent were interviewed. Seven had been gestational parents only, seven had been non-gestational parents only, and two were both gestational and non-gestational parents of their children. In addition, three healthcare professionals who had provided perinatal care to LGBTQ+ women, and were LGBTQ+, were interviewed. The findings from this research include experiences of inclusive and non-inclusive language from perinatal service providers. The language currently used to describe LGBTQ+ parents is not static, and there is no agreed terminology, requiring a nuanced approach of everyone involved in providing perinatal services that centres individual parents' preferences.
Hoffkling et al, 2017: Experiences of pregnant trans men https://doi.org/10.1186/s12884-017-1491-5 Open Access
Summary: 10 transgender men who had given birth were interviewed. Participants reported that many staff did not read intake forms where pronouns had been requested, so these were ignored. They reported frequent misgendering and use of the wrong name. Some participants had affirming healthcare providers who used inclusive language well.
Q19. What are the similarities and differences for gestational and non-gestational LGBTQIA+ parents bonding with their baby, and how can bonding be maximised?Greenfield, 2023: Charity commissioned report into the perinatal experiences of LGBTQ+ women
Leter et al, 2024: Similar caregiving roles and parental affect between same-sex and different-sex parents https://doi.org/10.3389/fpsyg.2024.1332758. Open Access
Summary: 135 different-sex, same-sex male, and same-sex female couples (113 fathers and 157 mothers, comprising 147 primary and 123 secondary caregivers) who conceived through artificial reproductive techniques and lived in Netherlands, France or the UK were studied. The couples were videorecorded at home while in feeding, cleaning, and playing contexts to assess the levels of positive and negative parental affect. In addition, the couples completed questionnaires about their caregiving role, parenting stress, and the infants’ temperament. The levels of positive and negative parental affect toward the infant in all contexts were not related to parental gender, caregiving role or the interaction between parental gender and caregiving role.
Goldberg, Gartrell & Gates, 2014: Transition to parenthood for LGB people (report) https://escholarship.org/uc/item/7gr4970w. Open Access
Summary: This report addresses the research on LGB parenting, focusing on several main content areas: family building by LGB people; the transition to parenthood for LGB parents; and functioning and experiences of LGB parents and their children. They report that children’s relationships with their biological mothers appear similar in quality to their relationships with their nonbiological mothers, which researchers attribute in part to the fact that lesbian mothers tend to share coparenting.
Q20. What are LGBTQIA+ people’s experiences of taking leave from work when trying to conceive, during pregnancy or as new parents?
Rose and Oxlad, 2023: LGBTQ+ people’s experiences of employment leave and support following perinatal loss
https://doi.org/10.1080/13668803.2021.2020727. Paywall
Summary: 12 LGBTQ+ people were interviewed, aiming to explore their workplace leave and support experiences following pregnancy losses as gestational or non-gestational parents in the previous 6 months to 10 years. Reflexive thematic analysis generated three themes (1) Disclosure in the workplace: support, shame, and self-protection, (2) Navigating discriminatory workplace policies, leave, and entitlements and (3) Coping at work: Getting the balance right for each person. Heteronormative policies and entitlements can compound the distress of LGBTQ+ people experiencing pregnancy loss, including increasing difficulties in accessing leave, misgendering leave entitlements, failing to accommodate for high attachment to unborn babies in early gestation, and the impact of distance for parents who have engaged in surrogacy. The authors suggest that employers can assist by using inclusive language in leave policies and forms, providing people of all genders and sexualities access to parental and bereavement leave irrespective of family formation method and gestational age and allowing flexibility in hours, workload, and tasks after a pregnancy loss.
Greenfield, 2023: Charity commissioned report into the perinatal experiences of LGBTQ+ women
https://doi.org/10.5281/zenodo.8326480. Open Access
Summary: 16 LGBTQ+ women over 18 who had either conceived a baby whilst in a relationship with another woman or conceived a baby as a solo parent were interviewed. Seven had been gestational parents only, seven had been non-gestational parents only, and two were both gestational and non-gestational parents of their children. In addition, three healthcare professionals who had provided perinatal care to LGBTQ+ women, and were LGBTQ+, were interviewed. The findings from this research included that the uptake of Shared Parental Leave amongst LGBTQ+ women may be high.
Q21. How do transgender parents’ experiences of their gender in the perinatal period affect their relationship with their baby?
No evidence found
Q22. What are non-gestational parents’ experiences of inducing lactation, and/or sharing lactation? What are the effects on the parents, and on the baby who is drinking induced milk?
Greenfield, 2023: Charity commissioned report into the perinatal experiences of LGBTQ+ women
https://doi.org/10.5281/zenodo.8326480 Open Access
Summary: 16 LGBTQ+ women over 18 who had either conceived a baby whilst in a relationship with another woman or conceived a baby as a solo parent were interviewed. Seven had been gestational parents only, seven had been non-gestational parents only, and two were both gestational and non-gestational parents of their children. In addition, three healthcare professionals who had provided perinatal care to LGBTQ+ women, and were LGBTQ+, were interviewed. The findings from this research included that non-gestational parents who wish to breast or chestfeed their babies do not have adequate support, and that the lack of knowledge about co-feeding poses a risk for newborn babies.
Juntereal & Spatz, 2019: Same-sex breastfeeding mothers https://doi.org/10.1111/birt.12470. Paywall
Summary: This study used an online survey and qualitative interviews to provide an in-depth understanding of same-sex breastfeeding mothers' experiences. Sixty-eight participants completed the online survey. Thirty-seven mothers (59%) reported breastfeeding for more than one year. Fourteen (21%) respondents reported accessing induced lactation information for the non-gestational parent from their health care practitioner. Forty-three (63%) respondents reported receiving breastfeeding and induced lactation information from other sources. Only nine (13%) non-gestational parents underwent induced lactation. Eighteen gestational mothers participated in qualitative interviews. Five themes emerged from the qualitative data: (a) committed to a year, (b) deciding “how to do it,” (c) sources of information, (d) involvement of partner, and (e) need for inclusive and educated health care practitioners.
Q23. How often is written language (for example, letters, forms and policies) used by perinatal services inclusive or exclusive of LGBTQIA+ people? How can institutions keep up to date with inclusive language?
Greenfield, 2023: Charity commissioned report into the perinatal experiences of LGBTQ+ women
https://doi.org/10.5281/zenodo.8326480. Open Access
Summary: 16 LGBTQ+ women over 18 who had either conceived a baby whilst in a relationship with another woman or conceived a baby as a solo parent were interviewed. In addition, three healthcare professionals who had provided perinatal care to LGBTQ+ women, and were LGBTQ+, were interviewed. The findings from this research showed that some, but not all, families encountered exclusive written language, including “booking” forms.
LGBT Foundation 2022: Trans and non-binary experiences of maternity services. This is a report compiled by a charity, found here: https://lgbt.foundation/wp-content/uploads/2024/01/ITEMS20final.pdf Open Access
Summary: This report gathered survey data from 121 trans and non-binary people in the UK who had ever given birth or were pregnant, and also interviewed 4 people. The report recommends that the NHS should provide targeted information for trans and non-binary pregnant and birthing people; ask people about the most appropriate language to use and then record these for implementation; and ensure IT systems can recognise gender appropriately and routinely record gender identity.
Riggs et al 2021: Pregnant transmasculine and non-binary people’s experiences of midwifery care. This is a chapter of a midwifery textbook available here: https://ruthpearce.net/wp-content/uploads/2024/01/men-transmasculine-and-non-binary-people-and-midwifery-care.pdf Open Access
Summary: 51 trans and non-binary people with experience of conception were interviewed from UK, US, Australia, Canada and Germany. Positive experiences with midwives included ensuring correct gender markers were recorded on paper and electronically. Recommendations for inclusive care included gathering information on pronouns, names and preferred terminology, collating it and ensuring all staff are aware of it; ongoing training due to the fast-moving past of literature in this area; and advocating for systemic change such as in data collection, inclusive imagery and language
Hoffkling et al, 2017: Experiences of pregnant trans men https://doi.org/10.1186/s12884-017-1491-5 Open Access
Summary: 10 transgender men who had given birth were interviewed. Participants often felt erased by the inability of institutions to understand trans male pregnancy in written literature and images, computer systems and intake forms; even when written forms asked for pronouns they were often ignored by staff.
Q24. How can the number and range of sperm donors available to LGBTQIA+ people be increased, including those from racialised ethnic backgrounds?
No evidence found