Keywords

Couples, Grief, Lesbians, Pregnancy.

 

Authors

  1. Black, Beth Perry PhD, RN
  2. Fields, Wendy Smith MSN, APRN, FNP-C

Abstract

Abstract: Lesbian couples seek to become parents in a heteronormative world and in the context of complex biological, social, and legal challenges that may constrain same-sex parenting. Because of these constraints and challenges, lesbian couples experiencing a reproductive loss may encounter issues that heterosexual couples typically will not. Prior to pregnancy, lesbians may experience loss and grief because they cannot conceive a child together without the assistance of a third party. Same-sex families are marginalized; simply deciding to become parents leaves them open to criticism and negative judgment. If pregnancy is not achieved or does not end in a live birth, lesbian couples face decisions about how, whether, and who to conceive a subsequent pregnancy. Although laws vary by state, the social (nonbiological) mother may not have legal status as the child's parent; therefore, the decision of which partner to become pregnant is especially significant. In the event of a reproductive loss, the grief of the social mother might not be acknowledged. Lesbian couples will benefit from the care of a nurse who understands and is accepting of the complex contexts within which they face the challenges of reproductive loss.

 

Article Content

Becoming parents poses complex biological, social, and legal challenges for same-sex couples. Despite these challenges, approximately 17% of all same-sex couples seek to become parents (United States Census, 2010). Although the exact number is impossible to determine, a significant portion of the 17% include lesbian couples who wish to have a child born within their relationship who is biologically related to one of the women. The path to pregnancy for lesbian women, however, is different than that of heterosexual women-both biologically and socially-and parenting is fraught with many legal questions not experienced by married heterosexual couples.

  
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In the context of the distinct circumstances of conception, pregnancy, and parenting for lesbian couples, reproductive loss may have unique meaning that may not be fully understood by nurses. Wojnar (2007), in a study of 10 lesbian couples after miscarriage, noted that conception and miscarriage were "so intertwined" that full understanding of these women's experience of loss required first understanding their challenges in conceiving (p. 480). In this article, we describe the biological, social, and legal contexts of reproduction and parenting for lesbian couples in order to illuminate the complexity of reproductive loss for these women. Nurses who are knowledgeable about the possible context within which loss occurs for lesbian couples are better prepared to develop trusting relationships with their patients, with a goal of clear communication, open-mindedness, and nonjudgment afforded to all couples-straight or gay-experiencing this intimate form of loss (Limbo & Kobler, 2010).

 

Reproductive loss refers to a wide spectrum of conditions and events that infer difficulty or failure to achieve or maintain a pregnancy that results in a live birth at term of a healthy infant. These conditions and events include infertility, miscarriage, diagnosis of a severe fetal defect, stillbirth, and neonatal death (Black & Wright, 2012; Price, 2008). Moreover, reproductive loss is a relatively common event in women's lives, with approximately 25% of recognized pregnancies ending in miscarriage (American Society for Reproductive Medicine, 2008) or other forms of reproductive loss. We use the broader term reproductive loss rather than perinatal loss because of its flexibility in addressing the distinct losses experienced by lesbian couples in their efforts to become parents.

 

Reproductive losses can be distressful and even traumatic. The intensity of a loss may be exacerbated by the time and energy spent in trying to conceive, a couple's fertility history, and the amount of outside help needed to conceive (Bennett, Litz, Lee, & Maguen, 2005). Furthermore, the state of the couple's relationship as well as outside influences and expectations about having a child may affect the intensity of the trauma surrounding a loss (Bennett et al.). Several of these traumatizing elements may figure highly in lesbian childbearing, the most obvious of which is the requirement of outside help to conceive. For these couples, the norm-involvement of a third party-is the abnormal heterosexual experience (Peel, 2010), for whom involvement of an outside entity occurs only when pregnancy is elusive or there is a known history of reproductive impairment.

 

Importantly, lesbian childbearing occurs in the context of a heteronormative world in which outside influences may constrain, rather than support, childbearing. Childbearing for lesbian couples is not a social expectation as it is among heterosexual, especially married, couples. The possibility of rejection and lack of support by nonchildbearing peers in the lesbian community, as well as alienation from families of origin and the stigma of raising children in a same-sex family may place significant constraints on lesbians deciding to become parents (McManus, Hunter, & Renn, 2006). Seeking to become pregnant, represents a decision in which the desire to be parents is strong enough to outweigh several significant constraints. This suggests that reproductive losses in lesbian couples can be especially traumatic, as they occur in situations where children are highly desired.

 

Cacciatore and Raffo (2011) described dual insults associated with maternal bereavement in lesbians, who suffer from a lack of social support common among all bereaved parents after the loss of a child, as well as from "chronic invalidation" (p. 175) of their same-sex relationship. This situation of "double-disenfranchisement" (p. 175) is complex. First, lesbians who seek to become parents can be disenfranchised from other lesbians for whom parenthood is understood as inconsistent with lesbian identity. Second, perinatal death per se can result in marginalization. In the context of societal marginalization related to their sexual identity (Cacciatore & Raffo), lesbian couples face significant challenges when pregnancy fails to occur or a loss ensues.

 

Biological Complexities of Reproduction Among Lesbian Couples

A lesbian couple seeking pregnancy has many choices to make and many obstacles to overcome. In contrast to heterosexual couples, pregnancy in this context is always chosen and carefully planned-never an accident or an assumed eventual outcome. Lesbians typically make more lifestyle changes in preparation for pregnancy, and utilize more resources in planning their pregnancies than do straight women (Peel, 2010).

 

If couples seek pregnancy through donor insemination (DI), they must choose between using a known or unknown donor, fresh or frozen sperm, whether to use a sperm bank-and if so, which one-whether to choose an anonymous or "open" donor (whose identity can be released to the child once he or she turns 18), as well as which specific donor to choose. They also decide how much medical assistance they will seek, if any, or whether they will perform their own inseminations at home. Each path offers its own benefits, costs, and risks-medically, legally, financially, and socially. Insemination, such as sexual intercourse, entails some risk of contracting infections; this risk is highest with unscreened fresh specimens obtained from a known donor or through friends or "go-betweens," although sperm banks minimize this risk with a stringent screening protocol (Brill, 2006; Markus, Weingarten, Duplessi, & Jones, 2010). Known donors offer the opportunity for the child to know more about his or her biological father, or even to have ongoing contact with him, but can also pose a legal risk to the lesbian couple, as he may claim parental rights and/or custody. Even the parents of a known donor may seek legal custody of a biological grandchild.

 

The majority of lesbian couples choose DI through a sperm bank because it offers the opportunity to create legally autonomous families (Markus et al., 2010) although minimizing infection risk. This is expensive; DI at home without any medical intervention costs over a thousand dollars per attempt due to the cost of sperm-about $1,000 for a single vial from major sperm banks (California Cryobank, 2013; Genetics & IVF Institute, 2013a, 2013b). Sperm banks charge additional fees for detailed information about the donor's health, education, and family history, and charge higher prices for donors with higher education and/or more desirable health histories (California Cryobank; Genetics & IVF Institute). If needed, medical assistance in the form of ultrasonic follicle monitoring and ovulation induction medication can cost several thousand dollars per cycle. For patients who need even more assistance, IVF costs more than $10,000 per cycle and is rarely covered by insurance.

 

Some lesbians seek pregnancy through intercourse with a man. Reed, Miller, Valenti, and Timm (2011) documented the experiences of Black adolescent lesbians who planned pregnancies while in a committed relationship with another woman by engaging in a sexual relationship with a man they considered a "sperm donor." Consequently, these women are at risk for sexually transmitted infections. This study underscored the high value placed on mothering among Black lesbians, who have higher pregnancy rates than white lesbians and are nearly as likely as white heterosexual women to become pregnant (Reed et al.).

 

The journey to pregnancy for these women can be daunting. Given the significant hurdles lesbians must face in simply becoming pregnant-which are similar to those faced by infertile heterosexual couples-the grief and impact of a reproductive loss on the couple can be especially severe (Peel, 2010).

 

Social Complexities of Reproduction Among Lesbians

Deciding which partner will try to conceive is one of the first and most critical decisions a couple will make. For some couples, the decision may be quite easy at first, for instance, if one woman has always wanted to be a biological mother and the other has not. The extent to which the women have gendered role identities within their relationship may play a key role in this decision. In some lesbian communities or relationships, role identity may be very rigid; women may identify strongly with either the feminine "femme" or the masculine "butch/stud" role, and therefore expectations for who would be an appropriate biological mother may be fixed (Reed et al., 2011). In this situation, infertility may be particularly difficult for the femme-identified partner for whom biological motherhood is part of her essential role. If her partner has a strong "butch/stud" identity, pregnancy for this woman may be out of the question. As one woman wrote in her memoir of becoming a nonbiological lesbian parent, "parenthood is implicitly a gendered binary...Generally speaking, images of motherhood overwhelmingly presuppose not just femaleness, which I grant is reasonable, but femininity-which for some of us gals is less or even unreasonable" (Pagenhart, 2006, p. 39).

 

Nurses and healthcare providers may struggle to understand why the other partner does not attempt pregnancy if one woman in a couple experiences infertility; however, pregnancy and biological motherhood may not be compatible with her gender identity. Similarly, nonbiological motherhood, experienced by some as "lesbian daddyhood," (Pagenhart, 2006; Reed et al., 2011), may be incompatible with a femme-identified woman's gender identity. Gendered division of parenting is what feels right to these couples; one woman sees herself as "mom" while the other may identify as the "dad" (Hequembourg, 2007).

 

As gender roles have become more fluid in society as a whole over the past decades, it has become more common for lesbians to have more fluid gender identities in context of their relationships. Some lesbians with a nuanced gender identity will create new titles for themselves that allow them to break free of the strict male/female and mom/dad binary. As Pagenhart (2006) wrote of her own explanation to children who asked her whether she was a mother or a father, "'I'm going to be a little bit of both...Something other than a mother, but other than father too. I'll be the best parts of a mama, plus the best parts of a papa. Which,' I intoned authoritatively, 'is called a baba'" (p. 56).

 

In some couples, both women may wish to become biological mothers. These couples may take into account a wide range of factors in deciding who will attempt pregnancy, including the women's ages and overall health and the health insurance coverage of each (Renaud, 2007). Some couples may choose to seek pregnancy for both partners, either in tandem or in sequence. Infertility in one woman and not the other poses a paradox in which the infertile woman both grieves her inability to conceive and becomes a parent as a result of the successful pregnancy of her partner. For these women, the loss of the biological mother role may be particularly difficult. In addition to the loss of the experience of pregnancy, childbirth, and (often) the breastfeeding relationship-as any woman who adopts after infertility would-she may additionally suffer from envy or resentment toward her partner who does become pregnant. Unlike in a straight couple adopting after infertility, the lesbian mother in this situation is not the only mom in the house. Her role may feel nebulous and marginal. Miller (2006) wrote of her own experience with infertility followed by her partner's conception and pregnancy:

 

"Mostly, I am sad. I feel left behind in unmarked territory. I am expecting a baby, but I am not pregnant. I will be a mother, but I won't have given birth. I will adopt our baby, legally, but my experience has little or nothing in common with most adoptive parents. There is really no category, no name for what I will be. I am defined by what I am not: a nonbiological mother, the non-birthmother...I don't know what I am...I wanted to get pregnant. I am not mourning the loss of my pregnancy; I am mourning the absence of it...I am involved, supportive, bossy, coaching, protective, but utterly outside" (p. 10).

 

In addition, a social (nonbiological) mother living with a biological mother may feel that she has become the "dad" when she had hoped to be the "mom." Nurses working with such couples should be aware that the nonbiological mother may wish to induce lactation as a way to mitigate this loss. The Newman-Goldfarb protocol, a regimen developed using breast stimulation and galactagogues to induce lactation in adoptive mothers (Newman & Goldfarb, 2002-2013), has been used with success by some lesbian couples to share breastfeeding responsibilities. Nurses and other healthcare providers should support lesbian couples who are seeking information about this option (Wahlert & Feister, 2013). At the same time, the biological mother may experience some reluctance to "share" the mom role with her female partner, requiring the couple to navigate a complex terrain regarding parenting and the sharing of the mother identity (Aizley, 2006). Although lesbian couples may benefit from the absence of traditional gender stereotypes in their relationships and gain flexibility to create more equal partnerships (Mundy, 2013), navigating the complex dynamics of a two-mom family after infertility may create role uncertainty and added strain on the couple.

 

Given the societal marginalization of lesbian families, the necessity to involve a third party to conceive can pose an added strain. Some lesbians may have had negative experiences "coming out" to healthcare providers in the past, and may be reluctant to disclose their sexual orientation although seeking pregnancy, for fear of being judged, treated unkindly, or even of suffering social or legal ramifications within their community. Because in 33 states it is still legal to fire someone for being gay or lesbian, this fear should be acknowledged and respected (National Center for Lesbian Rights, 2013).

 

Homophobia, both societal and internalized, can have a real impact on lesbian couples who are considering or attempting pregnancy. Women may have anxiety about how their families, friends, and communities will react to the news that they are seeking pregnancy, about how they will be treated by the healthcare providers they must involve in their journey, and even about how their potential children will be treated because of their mothers' sexual orientation. As Brill (2006) wrote, "[d]ue to cultural homophobia, internalized homophobia, and the lack of easy access to sperm, women and transmen without biologically male partners have to claim their right and renew their commitment to have children at each step toward getting pregnant" (p. 31).

 

Reproductive Loss in Lesbian Couples

If the couple experiences a reproductive loss requiring extensive interaction in the healthcare system, the trauma they suffer will be intensified if the social mother is treated as if she has no right to access her partner and/or baby. Goodridge (2006) described her experience feeling "illegitimate," after nurses prevented her from seeing her newborn daughter in the NICU. The nurses told her, "You can't be her mother," since her birth mother was in the operating room. Goodridge recounted, "I start to cry. I explain who I am...But they do not believe she is my daughter. Is this what it will always be like, I wonder: trapped in some linoleum purgatory, suspended animation, unable to touch either member of my family?" (p. 33). Nurses can either ease the trauma surrounding this type of loss with kind and sensitive treatment, or exacerbate it by unnecessarily limiting access of women to each other and their baby.

 

For lesbians, then, the route to pregnancy is quite stressful, beginning where a heterosexual couple ends up only after significant difficulty-in an infertility clinic (Peel, 2010; Wojnar, 2007). These women typically invest significant time and energy into figuring out how they will conceive, including where and how to acquire sperm, how to monitor their fertility and ovulation, and even how to perform inseminations at home (Renaud, 2007). Heterosexual couples who require medical assistance and donated gametes to conceive are recognized as facing a loss, both of the "normal"-the private process of conception at home as part of their intimate relationship-as well as the loss of the ability to create a child with a genetic link to both parents. In this sense, lesbian couples attempting pregnancy may already be experiencing feelings of loss and grief that they cannot create their child alone together.

 

Wojnar (2007) noted that although reproductive loss (specifically miscarriage) in lesbian couples resulted in issues not related to sexual orientation, it would be a mistake to "minimize the roles played by sexual orientation and the concomitant impact of social stigmatization and homophobic discourses and practices" (p. 484). We do not wish to pathologize lesbian conception or imply that lesbian pregnancy is unnatural or should not be sought; rather, we believe it is important for nurses and healthcare providers to have sensitivity and understanding of the social context complicating the loss experience of lesbian patients.

 

Legal Complexities of Parenting Among Lesbian Couples

Although an in-depth discussion of legal issues related to same-sex parenting is beyond the scope of this article, we address this issue in order to underscore the stakes that are involved in the decision to become parents, especially in the aftermath of a reproductive loss in lesbian couples. In all couples who seek to become parents, although partners grapple with sadness and grief following a loss, questions of future childbearing may arise. For heterosexual couples, decisions to pursue parenthood are focused on the possibility of future pregnancies, the woman's reproductive health, and the likelihood of a subsequent loss. If pregnancy is not a possibility, avenues to parenthood may include adoption or surrogacy. For lesbian couples, legal constraints, especially questions of parental rights, complicate their path to parenthood.

 

Recognition of parental rights varies across states. In all states, both partners in a legal marriage are presumed to be a child's (biological or adoptive) legal parents. At the time of this writing, 14 states and 3 American Indian Tribal Nations have legal same-sex marriage; one state recognizes out-of-state marriages although same-sex marriages are not performed in that state. Twenty-one other states allow second parent adoption for same-sex couples. Second parent adoption means that an adult who acts as a parent to a child, shares a household with and is in a committed relationship with the legal parent may adopt the child and have full parental rights. Other states allow decisions related to second parent adoption to be made at the county level, so certain states may have counties that recognize second parent same-sex adoption although the state itself does not (National Center for Lesbian Rights, 2012). This leaves lesbian families without any legal second-parent recognition in as many as 15 states; in these places, the social mother lacks legal decision-making power, the ability to cover the child with her health insurance policy, and may suffer many other real day-to-day consequences. In states where second-parent adoption is an option, the family will be able to overcome these obstacles only after spending thousands of dollars to go through a lengthy and invasive process-experienced by many social mothers as a humiliating and insulting experience of being judged. Up-to-date information about each state's laws is available at http://www.nclrights.org.

 

Because of these varying laws, decisions related to parenthood are very complex for same-sex couples. For lesbians, the decision as to which woman becomes pregnant has significant legal repercussions in those states with restrictive same-sex marriage and second-parent adoption laws. After a loss, if the couple decides that the other partner will attempt pregnancy instead, there are significant legal ramifications for the woman who has experienced the original loss. Consider, for example, a woman who had been pregnant and expecting to give birth to a baby whom all would recognize as unquestionably hers. After a loss, if the couple decides that the other partner will now try to conceive, this woman will now be supporting her partner through pregnancy instead and may feel relegated to a marginal role. She may not be recognized as the child's parent and may not be allowed to adopt the child. Even where she does have access to second-parent adoption, she will have to subject herself to strangers' judgments as to whether she is an appropriate parent. Her experience of motherhood is changed dramatically, and not simply because she will not carry the baby, give birth, or breastfeed. Lack of legal recognition of her parental role can pose an additional distressing aspect to the already complex situation of grieving a reproductive loss.

 

Clinical Implications in Caring for Lesbians With Reproductive Loss

Understanding the biological, social, and legal contexts of reproductive loss in lesbian couples allows nurses to recognize more readily points of intervention in caring for these women experiencing loss (see Table 1). Despite these complex contexts surrounding childbearing, however, lesbian couples whose plans for becoming parents are forestalled by loss are in need of the same support and care afforded to all families experiencing loss. The distressing aspects of reproductive loss are well-described in the perinatal and nursing literature; however, research literature on the effect of loss in lesbian couples is still scant. Although little research evidence is currently available to guide practice in this specific situation, nurses can bridge this gap by using two strategies:

  
Table 1 - Click to enlarge in new windowTable 1. Clinical Implications in Caring for Lesbian Couples Experiencing Reproductive Loss

1. use of best practices from the perinatal loss literature that addresses grief and bereavement developed from the experiences of heterosexual couples (e.g., Bacidore, Warren, Chaput, & Keough, 2009; Erlandsson, Warland, Cacciatore, & Radestad, 2013; Limbo & Kobler, 2010; among others); and

 

2. tailoring these practices to the cultural and individual needs of lesbians experiencing reproductive loss.

 

 

Recognizing of course that the meaning of any reproductive loss varies, the loss of a pregnancy planned and achieved in the context of significant biological, social, and legal constraints may be especially distressing in lesbian couples. A knowledgable nurse can help parents anticipate what to expect, accept what they cannot change, and look for alternative ways to honor and respect their parenthood and relationship with their child. Sensitive nursing care for these women, as with all women and their partners, can ease the raw edges of this intimate form of loss.

 

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