Keywords

1 Introduction

In some parts of the world, society accepts women having sexual relations with other women and perceives same-sex marriages and legal rights for lesbian couples as a normal variation. Then, assisted reproduction and pregnancy are apparent consequences.

This chapter will deal with relevant aspects of sexuality in lesbian couples deciding to have children. regardless of sexual orientation, some women want (biological) children, and some do not. Healthcare providers (hcps) should realise that women of sexual minorities may also have reproductive wishes [1]. the chapter wraps up with recommendations on how to give good care to the lesbian couple during pregnancy and beyond.

2 Prevalence of Lesbianism and Professional Acceptance

When assessing the prevalence of homosexual women, it is important to distinguish between sexual behaviour (with whom I have sex), erotic attraction (with whom I want to have sex), self-identification (sexual orientation defined by oneself), affective preference (romantic preference), and social identification (social labelling).

Like earlier estimations from other countries, in a recent Danish national survey with >62.000 randomly selected adult respondents, 0.6% of all women identified as lesbian, and 2.6% as bisexual. A proportion of 8% had had sex with another woman, 3% felt a strong attraction towards women, and 27% did ever feel attracted to a woman [2].

In a study of Commonwealth and American lesbian women who had suffered a pregnancy loss, 27% reported experiences of heterosexism, homophobia, or prejudice from HCPs, and another 8.6% were unsure about this [3]. Midwifery and other HCP-curricula must pay extra attention to a non-biased approach and care of non-heterosexual patients.

3 The Prevalence of Lesbian Motherhood

It is common that lesbian and bisexual females have been pregnant [4]. Thus, 37% of women of these minorities have ever delivered a child [5], with more pregnancies in bisexual than in lesbian women. It is difficult to determine the number of children growing up in ‘rainbow families’.Footnote 1 From the very detailed social registers in Denmark, one may estimate (Table 21.1) that at least 0.2% of all children have two parents of the same gender that are registered or married–but many same-sex couples never get married or registered as partners. Furthermore, some single women are lesbian, which adds to the underestimation of the number of rainbow families. Many models of rainbow families are difficult to read from demographic statistics, such as a single lesbian mother with children with a gay couple.

Table 21.1 Family statistics, Denmark (DK statistics) [6]
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4 Marital and Reproductive Rights

There is a great variety of judicial frameworks concerning marital and reproductive rights for lesbian women, including the parental and adoptive rights for co-mothers/partners. Whereas same-sex marriage and reproductive rights for lesbian women are legally recognised in many countries, other countries still consider same-sex relationships illegal or even punishable by death.

In 1989, Denmark was the first country to allow same-sex civil partnership. Twelve years later, the Netherlands was the first country to institute same-sex marriage. Today, same-sex marriage is legal in many countries (or states) on the Globe. In several countries, legal access to assisted fertilisation, adoption rights, and parental rights have been changed or introduced along with the same-sex marriage law. The legislation on homosexuality ranges from the death penalty to equal rights throughout the world—see Fig. 21.1 for an overview of the situation in December 2020 [7].

Fig. 21.1
A world map represents global legislation for homosexuality. The legislation ranges from the death penalty in some countries to equal rights in others.

Global legislation regarding homosexuality. (Reproduced from ilga.org)

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5 The Decision to Have a Child

Just as some heterosexual couples dearly want children and others do not, the same goes for lesbian couples. Whereas in the heterosexual woman or couple, conception cannot happen ‘accidentally’, for the lesbian woman, it has to be a deliberate decision, and additional steps are needed to achieve a pregnancy.

Fertility clinics offer intrauterine insemination (IUI) to lesbian women in many affluent countries. This method ensures safety regarding screening for various STDs. Most sperm banks also perform donor screening to minimise the risk of major inherited diseases (like cystic fibrosis or spinal muscle atrophy) and other common genetic diseases. Another relevant decision considers using sperm from an anonymous or a known donor (depending on the country’s laws).

The methods to conceive depend on the country where the couple lives. In an online Swedish study, 42% used anonymous donor IUI at a clinic, 28% used known donor insemination outside the clinic setting, 7% used IVF with anonymously donated sperm, one had IVF with identified donated sperm, 14% conceived through sexual intercourse with a male partner, and 1% conceived through sexual intercourse with a man who was not her partner [3].

Knowing that many lesbian women have had sexual experiences with men, one might consider proposing a heterosexual one-night standFootnote 2 for conceiving, but most women are reluctant towards this solution. Relevant reasons not to encourage this solution are the risk of contracting an STD and the limited success rate. In countries where sperm donation is illegal but available for lesbian women, the woman can ‘explain’ a pregnancy as an accident of a one-night stand.

5.1 IUI-D

The conception results after IUI-D (Intrauterine insemination with frozen donor sperm) are the same as in heterosexual women [8].

5.2 Home Insemination

For achieving a pregnancy, one need not consult a fertility clinic. For various reasons, such as reluctance from health professionals to offer treatment to lesbian women, some women prefer to try home insemination.

If a known donor is fathering the child, the biological father’s role afterwards must be considered. In such situations, there is a need of having a contract. See the case story.

Case Story

Minnie (32) and Lisa (37) have been happily married for 3 years. None of them has been pregnant before. Minnie works as an accountant in a large international firm, and Lisa is a schoolteacher. They live in a lovely suburb and are financially stable. During the last year, they have become increasingly confident that they want to have a baby. As Minnie is the younger one, they decide that she should be the biological mother. Minnie is in doubt about whether her fallopian tubes are open. She contacts her gynaecologist because, at age 18, she had appendicitis causing peritonitis. The gynaecologist reluctantly refers Minnie to have a laparoscopy, as she does not support lesbian motherhood.

Minnie’s tubes are open. Due to the unpleasant discussion with the gynaecologist, the couple decides not to be treated by the gynaecologist. They contact Steve, a gay friend, who is willing to be tested for STIs. When all tests are normal, they start home insemination. Since Steve wants to be part of the child’s life, the three sign a contract to guarantee this. After three tries, Minnie is pregnant. During the pregnancy, Minnie, Lisa and Steve encounter many opinions from health professionals, some kind, others less so.

During childbirth, Steve and his mother are nervously pacing the waiting room. A beautiful baby boy is born. As Lisa and Minnie are married, Lisa is automatically granted parenthood. That is not so for Steve since a child cannot have three parents in the country where they live. In the years afterwards, Steve takes care of his son every third weekend and during some holidays. The boy refers to him as ‘Dad’ and to his mothers as Lisa and Minnie.

5.3 IVF

Many lesbian women strongly wish to have children, just like many heterosexual sisters, despite judicial obstacles. In some countries, lesbian women can have IVF with donor sperm. Many other countries limit such reproductive freedom by prohibiting IVF for lesbian couples or single mothers (independent of sexual orientation) that has resulted in cross-border reproductive care (CBRC), the extent and consequences of which are hard to assess [9].

A new option is ‘shared motherhood’ (also called ‘Reception of Oocytes from PArtners (ROPA)’; ‘interspousal egg donation’; or ‘reciprocal IVF’). In this option, one of the mothers goes through ovarian stimulation and ovum pick-up. After fertilisation with donor sperm cells, the embryo is placed in the uterus of the recipient mother, who has been primed with oestrogen and progesterone. Thus, both women are maximally involved in the pregnancy. ROPA is mainly relevant when one of the women has health problems or fertility problems [10]. ROPA has some inborn hazards, such as a high risk for the recipient mother. Egg donation is associated with a higher risk of pregnancy and birth complications, including caesarean section, preterm birth, small-for-gestational age babies, and preeclampsia [11].

5.4 When Artificial Reproductive Techniques Fail

In countries where adoption is possible, heterosexual couples might consider adoption if artificial reproductive techniques fail. Same-sex adoption is legal in many countries, but this is not a possibility in other countries. Furthermore, some donor countries restrict adoptions only to heterosexual couples. The authors recommend readers to be aware of the local legislation and its consequences.

6 Pregnancy and Childbirth

The pregnancies of lesbian women are more susceptible to low birthweight, premature birth, and even stillbirth [12].

This higher risk of complicated pregnancies, including preeclampsia, is linked to a lack of regular pre-conception exposure to paternal seminal fluid [13] (see also Chap. 5).

7 Maternity Care and Midwives’ Area of Responsibility

Throughout the world, countries organise maternity care services in different ways. In many countries, registered midwives or nurse-midwives are the main providers of maternity care for low-risk women. Midwives work with the childbearing family to provide support, care and advice during pregnancy, labour, and postpartum, including advice on sexual and reproductive health. The International Code of Ethics for Midwives [14] says that the midwife should offer equal care to all clients, along with evidence-based professional standards.

Overall, good quality maternity care for lesbian women is carried out just as the care for heterosexual women, focusing on health and well-being and preparing for healthy parenthood. Nevertheless, midwives should be aware that some factors related to sexual orientation make dealing with lesbian couples different from the common situation. Examples are heteronormativity in attitude, documents and registration, and the role of the co-mother.

7.1 Creating a Safe Environment

The understanding that all human beings are heterosexual, often referred to as heteronormativity, is a social norm in our culture. In a heteronormative setting, the lesbian woman is assumed to be heterosexual until she discloses her sexual orientation to the midwife. The decision to reveal one’s sexual orientation may be challenging. Midwives can make women feel welcome and safe by demonstrating awareness about different sexual orientations. An office with a rainbow sticker or a poster with various family constellations signals acceptance and recognition and makes it easier for a lesbian woman or couple to open up. If another woman accompanies a pregnant woman in the antenatal care appointment or at the labour ward, the midwife may politely ask whether the women are partners or friends. Friendly greeting both women can help the couple lower their shoulders.

7.2 Paying Attention to Details

When dealing with lesbian women, midwives should pay attention to details more than average. The use of eye contact, inclusive language, and a welcoming smile may signal that she has a positive attitude. For individuals who have experienced stigmatisation, such details may be important signals of being recognised and respected. Lesbian women often experience that it takes some time before midwives find a way to provide tailored care, and most midwives demonstrate uncertainty in the first encounters [15]. Uncertainty is uncomplicated if there is a positive attitude. However, lesbian couples sometimes meet a midwife who seems more interested in the couple’s sexual orientation rather than focusing on pregnancy and birth in antenatal consultation. Where professional curiosity about health matters serves an HCP well, satisfying personal curiosities with patients of any gender or orientation is always unprofessional.

7.3 Demonstrating Knowledge About Differences

A significant difference between heterosexual couples and lesbian couples planning to start a family is that both women may be able to conceive and give birth to a baby. If both women want to become birth mothers, they sometimes decide to conceive simultaneously, but more often, they take turns becoming pregnant. Midwives should be aware that not all lesbian women want to have a child, or some may want a child but cannot conceive for various reasons, like infertility or age. That may be a challenging subject to bring up when providing antenatal care. Still, the midwife should tactfully address this area as some co-mothers experience jealousy or grief about not being able to conceive and find it difficult to share these feelings with their partner. If that seems too difficult, inviting the co-mother for a ‘partner talk’ could be a solution.

Although underreported in the literature, we mention the possibility for both women to breastfeed the baby. For co-mothers who have previously nursed a baby, re-lactation is possible. For the co-mother who has not given birth, milk production can be stimulated by hormonal treatment and frequent breast pump use (see Chap. 15, Sect 15.7). Addressing, during the pregnancy, the possibility of breastfeeding for the co-mother and properly guiding that process is a sign of real midwifery professionalism.

7.4 Recognising and Including the Co-Mother

In this chapter, we refer to the nonbiological mother as co-mother, nonbirth mother, or social mother.

The fact that, in the lesbian couple, both are a woman may provide a first-hand understanding of pregnancy and labour, especially if the co-mother has previously given birth herself. Still, far from all co-mothers feel comfortable in the labour ward, and a co-mother who has given birth herself may find it challenging to attend her partner’s birth because she is well aware of the pain her partner is experiencing.

In many contexts, co-mothers struggle to find a way to be recognised as the baby’s legal and social mother. Midwives can demonstrate an understanding that families and parenthood may take different forms by avoiding names that position the co-mother as inferior. Referring to her as ‘the other mother’ could be experienced as negative or marginalising.

Furthermore, she can include her when providing information and counselling after birth. For midwives, a way of dealing with this situation is to adjust and adapt language and documentation forms to fit the couples’ situation, e.g. by using the word ‘donor’ rather than ‘father’ when filling out forms and replacing the word ‘father’ with ‘partner’ when conducting birth-preparation courses.

8 How to Guide a Lesbian Couple on Intimacy and Sexuality

During pregnancy and postpartum, the physical and hormonal changes of lesbian and heterosexual women are alike. However, it is unknown how lesbian couples cope with those changes. Some information on sexuality during pregnancy and postpartum might be relevant (combined with some advice). Many lesbian couples enjoy penetrative sex (see Fig. 21.2).

Fig. 21.2
A bar graph indicates the various modes of sexual pleasure enjoyed by lesbian couples. Cunnilingus, with 99.2, is the highest, while strap-on is the lowest at 56.5.

Common Sexual Practices among lesbian women (%). NB Genital scissoring means: genital on genital rubbing or grinding. A strap-on means a dildo attached to the body by a harness [16]

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The dildos used for penetration can cause the transmission of various organisms and STIs [16]. Lesbian women have a higher than average incidence of bacterial vaginosis. Since bacterial vaginosis and vaginal infections can cause premature birth and postpartum infections, it is relevant to integrate information on cleaning sex toys before sharing and using barriers (a good reason to inquire about orientation).

If there is postpartum discharge and the cervical orifice is open, any penetrative or vaginal sex should be discouraged, with the addition that all other sexual activities are allowed.

With the newborn child certainly demanding attention, the lesbian mother/couple should be reminded not to forget intimacy, just as in heterosexual couples. With the breasts being important for lesbian sexual pleasure, breastfeeding might be problematic for those mothers who are confused or ashamed when sexually aroused by nipple stimulation. Independent of sexual orientation, 35–50% of nursing mothers experience breastfeeding as erotic (‘an incredibly intense physical lust’), and some reach orgasm during breastfeeding. But one-quarter feels guilty because of such sexual arousal [17].

9 Offspring of Lesbian Women: Should We Be Concerned?

Although an increasing number of people worldwide express positive attitudes towards homosexual men and lesbian women, people are more reluctant about their reproductive rights and family creation. That reluctance may be related to social norms regarding motherhood and parenting roles [18]. Deviation from the common nuclear family is commonly assumed to increase the risk of children’s psychological health [19]. Research does not support this. In families with two female parents, the absence of a male is not associated with child adjustment problems. However, the homophobia in the surrounding society can represent a problem for the children, although most children make average progress through school.

10 General Recommendations

Include sexuality and sexual orientation as an issue in all maternity care areas, particularly in midwifery education. Health professionals should bear in mind that not all women are heterosexual—if you do not ask—they probably do not tell. Until you know, use gender-neutral wording.

One can do it easy: After ‘Do you have a partner?’, just ask ‘A man or a woman?’

Or a little more careful: ‘I do not know if your partner is a man or a woman, so I want to know if you need me to advice you on contraception?’

Or: ‘Will your partner take part in the birth of your baby? What is the name of your partner?’

Please pay particular attention to verbal and non-verbal language and ask direct questions to both partners to help them both feel acknowledged as parents. Focus on everyday signs of recognition to counterbalance ambiguous situations and feelings of being invisible or overlooked and recognise both mothers by showing an understanding that there are many ways of parenting and family life.

Be also aware not to focus too much on the sexual orientation of the lesbian woman or couple. Many of their questions and problems are common pregnancy or postpartum issues.

Not all minority women are victimised and oppressed, but many women are in some world regions.

All HCPs should be aware of their own assumptions, attitudes, and cultural bias. Meeting the minority woman/couple with an open mind and heart can be a most rewarding experience.