Episode 145: Family Planning for the LGBTQIA+ - a podcast by Rio Bravo Family Medicine Residency Program

from 2023-07-28T12:00

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Episode 145: Family Planning for the LGBTQIA+

Future Dr. Hoque explains how to assist with family planning for the LGBTQIA+ community. Some principles such as avoiding unintended pregnancies and reducing and early treatment of STIs are discussed.  

Written by Ashfi Hoque, MBA, MS4, Ross University School of Medicine. 

You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

Arreaza: Welcome to episode 145 of the Rio Bravo qWeek podcast. My name is Hector Arreaza, a faculty member of the Rio Bravo Family Medicine Residency Program.

Ashfi: Hello everyone, I am Ashfi Hoque a 4th-year medical student at Ross University School of Medicine. I am from Long Beach, California. Patient advocacy and patient-centered care have always been a priority of mine. I’ve volunteered for years at the LGBT+ center in Weho and Long Beach. Today we will be discussing Family Planning for everyone while learning ways to become LGBTQIA+ inclusive. 

Arreaza: Yes, family planning is important, and I’m glad you included all types of families. I believe medical care must be offered to everyone, and I also believe in freedom of conscience, that’s why I can freely express that I support traditional family for me. Why did you choose this topic?

Ashfi: I chose this topic because my partner recently went to get her physical. Her provider had an extensive conversation about family planning and even discussed the anticipated cost of freezing her oocytes. I really loved the way this provider went about the conversation so I started researching ways I can support my community and also teach others to provide Queer inclusive medical care. 

What is LGBTQIA+?

LGBTQIA+ stands for Lesbian, Gay, Bisexual, Trans, Queer, Intersex, Asexual, etc. The community will be referenced as the Queer community, an umbrella term for people who are not heterosexual or not cisgender. There are many inequalities that the community faces and we can do our due diligence to educate ourselves continuously and be aware that terminology and health needs may change. We have another Rio Bravo episode, Caring for LGBTQ+ Patients on Episode 103, that discusses healthcare disparities, but during this episode, we will be diving into an introduction to bridging health gaps, creating health equity, and building trust with the community. 

A 2023 Global Survey found that the self-identified Queer community represents 9% of the population, while the true estimate may be higher due to safety concerns. While diabetics are 10-13% of the population. These statistics show that as a medical provider, you'll encounter Queer patients more often than you think. One of the healthcare issues that Queer folks face is a lack of family planning.

What is Family Planning?

The World Health Organization (WHO) defines family planning as “the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through the use of contraceptive methods and the treatment of involuntary infertility.”

Family planning serves three critical needs: 

  1. Avoiding unintended pregnancies
  2. Reducing sexually transmitted diseases (STDs)
  3. Early treatment of STDs to reduce rates of infertility

When discussing family planning for patients, here are some examples of questions you can ask. 

  • What name may I use to address you?
  • What are your pronouns?
  • What is your gender? (Only if necessary for care, what is your assigned sex at birth?)
  • Are you sexually active?
  • What is the gender(s) of your partner(s)?
  • Are you concerned about unintended pregnancy?
  • Are you currently using any contraceptive measures?
  • Are you taking any precautions to reduce STI/STD such as physical barriers like condoms, dental dams, or any harm reduction such as PrEP?
  • What kind of STI/STD screening are you requesting?
  • Do you need me to request additional labs such as oral or anal swabs?

Those questions must be asked in a natural, non-judgmental way. While STD/STI screening and treatment is part of family planning, the part that we tend to neglect is the desire for Queer folks to build a family. 

Why is Family Planning Important for the LGBTQIA+ community?

The Queer community gained the legal right to marry eight years ago, in 2015. They did not have the nationwide right to adopt until the last state, Mississippi, overturned the unconstitutional restrictions for the Queer community to adopt in 2016. 

A UCLA study in 2018 titled, “How many same-sex couples in the US are raising children?” reported cis-heterosexual couples: 3% are raising at least one adopted child and 95% are raising biological children while same-sex couples: 21.4% are raising at least one adopted child and 68% have a biological child. 

When it comes to family planning, there is more than adoption for Queer people. Queer folks are not offered the same pregnancy planning options, such as cis hetero-couples who are experiencing infertility or cis-women planning for advanced maternal age pregnancy. However, the options are quite similar. These options require specific types of planning, and that information can be provided to patients by their primary care doctor. A couple needs to know their options and consider the long-term financial planning necessary for surrogacy, in vitro fertilization (IVF), or donor insemination. The main difference for many Queer couples is the method of conception needed. Depending on sexual orientation and gender identity, patients may have varying reproductive needs as part of their family planning. We cannot make assumptions about how family planning should look and need to remember this journey looks different from person to person and couple to couple.

How to approach family planning with the LGBTQIA+ community? 

Basic tenants of providing medical care for queer patients: 

Clinics specializing in Queer family planning found patient-centered care leads to better outcomes. The best approach is to be mindful, conscious, and to communicate without assumptions. We have to start with providers building trust, being honest, showing sensitivity assisting with reproductive services, and working towards being more knowledgeable about Queer parenthood. A provider could ask questions such as: 

  • Would you like information about family planning?
  • What do you imagine your future family to look like?
  • Would you like to see options and potential costs?
  • Would you need a referral for a specialist?

Or it can be as simple as being honest about your scope of knowledge by stating, “I am not well versed in LGBTQIA+ community issues but what ways can I support you?” It is ethically appropriate to transition care to a physician with better knowledge if you feel unable to assist a person from the LGBTQ+ community. Make sure to do it in a polite and respectful way.

Gender inclusive: 

With more people openly identifying as non-binary and trans, there is a need for a gender-neutral approach to discussing a patient’s biological and reproductive needs. 

First, we will avoid assuming gender identity based on the biological sex of a patient. Episode 14 of Rio Bravo does a great job of breaking down gender diversity and the difference between gender identity and biological sex. For transgender and nonbinary patients, providing care for medical transitioning often includes conversations about family planning before starting HRT. It is common to ask patients about to begin HRT if they would like to freeze their sperm or eggs. 

Second, we want to avoid assuming anything based on what reproductive organs a patient has. We can ask a patient about their intention to start a family. Avoid asking if a trans patient has received transitional surgery (bottom surgery) unless it is completely necessary for the care we are providing. Instead, it is appropriate to ask the patient if birthing is an option? Have you given birth before? Were there any complications? Is there any current hormonal treatment? This mindful strategy is also useful for patients who may have limitations in: producing oocytes or sperm, the ability to house a fetus in utero, or implantation and fertility. 

Third, we are going to address our underlying beliefs and assumptions about gendered parenthood. Parenthood is almost always thought of as motherhood and fatherhood, but this can be alienating for transgender patients. There are many possible ways of being a parent, and to be inclusive let’s consider the possibility of a masculine woman or transmasculine man being a birthing parent or of a transgender woman being the mother of a child without giving birth to the child. There are many more scenarios we can discuss at another point. In the interest of time, we are going to shift into discussing family planning for lesbian and gay people and couples. 

Sexuality inclusive:

For homosexual cis-gendered people who are single or in relationships, family planning can look similar to couples facing infertility issues. When having family planning conversations with these patients, a provider should ask broad, unassuming questions. If you have established that a queer person or couple wants a child, then you can ask if they have a family plan. 

If the patient or couple has a plan, follow the couple’s lead. If the patient(s) do not have a plan, then you can begin to ask questions like: Do you have someone in mind to be a birth giver? Do you have a sperm donor? Do you have an egg donor? These questions are a great transition into discussing the following options for family planning.

What are the options for having a newborn and the financial and ethical cost?

Having a child can cost up to $100k, and this does not even include the cost of childcare. Infertility treatment is not covered by regular insurance, so patients need either infertility insurance or private financing to cover the cost of treatment. However, fertility insurance does not cover same-sex couples. There is a large emotional, physical, and ethical cost to deciding which route to choose. Let’s discuss options and obstacles.

1. Donor Insemination: The most affordable route is having a birth-giving parent who is fertile with a known sperm donor. This method can be as simple as using a syringe to inseminate the uterus-carrying person, but we need to consider necessary attorney fees to terminate the parental rights of the sperm donor. Sperm from a sperm bank requires an extensive workup including STD panel, HIV, and genetic disorder screening. The sperm donor gives up all parental rights during the process. The price of these procedures is constantly changing and depends on location.

California Cryobank costs start at $1200 for anonymous donors and $1900 for identification disclosure donor which the child will receive information about the donor at age 18. Selecting a donor can include specifics such as race, talents, education, hobbies, physical attributes, and showing donor baby photos. There are two common insemination processes:

  • Intracervical insemination: semen inside the cervical opening and covers the cervix
  • Intrauterine insemination: semen is inserted through the cervix and placed directly into the cavity

The next option jumps up in cost significantly.

2. Freezing Eggs (Oocyte Cryopreservation):Pacific Fertility Center Los Angeles, reports a single cycle of egg freezing can cost $6-10k per freezing cycle and may need multiple cycles without medication. The medications are typically around $3-6k depending on how much your body needs. Storage is an additional cost of $700-$1,000 a year. This is an option for parents planning pregnancy during advanced ages.

3. In Vitro Fertilization (IVF): It is a process where an oocyte is collected similarly to freezing eggs but fertilized with a partner’s or donor’s sperm.Pacific Fertility Center Los Angeles reports it costs $8-13k per cycle of fertilization. It is an option for those who have issues with infertility, previous pelvic inflammatory diseases, surgeries, and issues with implantations.

4. Surrogacy: This is the process of hiring a professional birthing surrogate to carry an embryo. This is an alternative option for couples who decline or cannot carry a pregnancy. The surrogate has no legal rights or biological relation to the fetus. Family Tree Surrogacy reports it costs about $45-65k.

5. Adoption: Foster care adoption in California can be $1-5k. American Cost of Adoption, reports the cost of adoption for infants in California $40-70k including the medical expenses for the birth-giving person and legal expenses for the process. Versus adopting an infant from another country due lack of resources and poverty may better their lives or cause a higher demand for infants which may be an ethical issue. Also, transcultural adoption where the race of the parents and the children are different, and navigating culture and race with the children. Adoptees have reported having racial identity crises.

With all these studies, it is well documented that providers will not be perfect at giving care to the Queer community. These studies do not represent every queer person and do not take the intersectionality of race, class, or gender identity into consideration. It is our job as providers to be supportive of all types of patients in order to increase their access to proper medical care. 

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Conclusion: Now we conclude episode number 145, “Family Planning for the LGBTQIA+.” Future Dr. Hoque explained how queer people can be included in family planning conversations, even before heterosexual couples. She described some options such as donor insemination, freezing eggs, IVF, and adoption. Dr. Arreaza explained that it is important to ask reproductive questions in a natural, non-judgmental way to all your patients, and refer to another professional when needed. 

This week we thank Hector Arreaza and Ashfi Hoque. Audio editing by Adrianne Silva.

Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! 

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References:

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  22. Royalty-free music used for this episode: "Rain in Spain." Downloaded on October 13, 2022, from https://www.videvo.net/ 

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