Abstract

The aim of this article is to present the state of the art, in the field of public health, on cis homoparental reproduction, from 28 studies addressing barriers to reproduction by homoparental couples for legal, ethical, technical or economic reasons, in addition to prejudice and discrimination. Six studies addressed facilitators, such as receptiveness in services, availability of conception and contraceptive methods and training of health professionals. The results show that the discussion has focused more on the barriers than on the facilitating factors. This may indicate a continuing need to problematise the hegemonic model of a heterosexual, nuclear family.

Key words:
Sexual and gender minorities; Family; Reproduction; Health; Review

Introduction

The right to sexual and reproductive health is a Human Right recognised in legal documents. Among the international frameworks, two United Nations (UN) conferences stand out. The International Conference on Population and Development (ICPD), held in 1994 in Cairo, stated that reproductive rights are a basic right of individuals and couples. In this sense, ways must be ensured to fulfil this right, with a view to reproductive decision making free from discrimination, coercion and violence. The following year, in Beijing, the 4^th World Conference on Women reaffirmed the ICPD agreements and advanced the definition of sexual and reproductive rights, to establish them as Human Rights¹1 Brasil. Ministério da Saúde (MS). Saúde sexual e saúde reprodutiva. Brasília: MS; 2013..

In 2013 Brazil’s Ministry of Health published a Primary Care Handbook on sexual and reproductive health, reaffirming individual reproductive and sexual rights based on these international conferences and other movements in favour of the rights to sexual health and reproductive health. The handbook stresses that, although these rights have been formally instituted at UN international conferences, it has to be asserted that they extend universally to population groups whose human rights have historically been violated because of their sexual orientation or gender identity¹1 Brasil. Ministério da Saúde (MS). Saúde sexual e saúde reprodutiva. Brasília: MS; 2013..

Documents drafted in Brazil relating to its citizens’ sexual and reproductive rights include prominently the 1988 Federal Constitution, the 1984 Comprehensive Women’s Health Care Programme (Programa de Assistência Integral à Saúde da Mulher, PAISM), Law No. 9.263/1996, which regulates family planning, the 2004 National Comprehensive Women’s Health Care Policy (Política Nacional de Atenção Integral à Saúde da Mulher) and the 2005 National Sexual and Reproductive Rights Policy (Política Nacional dos Direitos Sexuais e dos Direitos Reprodutivos)¹1 Brasil. Ministério da Saúde (MS). Saúde sexual e saúde reprodutiva. Brasília: MS; 2013..

Sexual rights began to be discussed in the late 1980s, with the participation of gay, lesbian and feminist movements. Reproductive rights were more difficult to debate, especially with regard to homosexuals²2 Silva Netto MCF. Planejamento familiar nas famílias LGBT: desafios sociais e jurídicos do recurso à reprodução humana assistida no Brasil. Belo Horizonte: Fórum; 2021.. One barrier to this debate’s progressing was the hegemonic model of the family, which requires this institution to be nuclear, monogamous, heterosexual and procreative in purpose³3 Zambrano E. Parentalidades "impensáveis": pais/mães homossexuais, travestis e transexuais. Horiz Antrop 2006; 12(26):123-147.. On the other hand, it can be seen that, as long as the State approaches sexual and reproductive rights with a view to encouraging individual freedom and autonomy, and encouraging responsibility, couples - whether hetero- or homo-affective - will be able to carry out their plans for parenthood²2 Silva Netto MCF. Planejamento familiar nas famílias LGBT: desafios sociais e jurídicos do recurso à reprodução humana assistida no Brasil. Belo Horizonte: Fórum; 2021..

Brazil’s legal recognition of the right to homoparenthood means that ways are being considered to make this right workable²2 Silva Netto MCF. Planejamento familiar nas famílias LGBT: desafios sociais e jurídicos do recurso à reprodução humana assistida no Brasil. Belo Horizonte: Fórum; 2021.. These, as highlighted by Zambrano (2006)³3 Zambrano E. Parentalidades "impensáveis": pais/mães homossexuais, travestis e transexuais. Horiz Antrop 2006; 12(26):123-147., can include joint and equal coparenting by partners in situations where children are incorporated from a heterosexual relationship prior to setting up the family, legal or informal adoption and use of new reproductive technologies.

As regards reproduction between same-sex couples, which is the scope of this study, resolutions by Brazil’s Federal Medical Council ensure access to human assisted reproduction technology (HART) for heterosexual, homosexual and transgender people, without requiring any specific marital status²2 Silva Netto MCF. Planejamento familiar nas famílias LGBT: desafios sociais e jurídicos do recurso à reprodução humana assistida no Brasil. Belo Horizonte: Fórum; 2021..

Despite these advances, which purportedly guarantee the reproductive rights of homoparental families, this population’s reproductive health demands and needs are complex and it is important that Brazilian national health system (SUS) be adapted to meet them effectively, comprehensively and with quality¹1 Brasil. Ministério da Saúde (MS). Saúde sexual e saúde reprodutiva. Brasília: MS; 2013.. In this respect, it is necessary, at the very least, to discuss the subject and one of the first steps in that direction is to map what the specialised national and international literature has to say about this . Such mapping will make it possible, among other things, to examine issues with a view to informing the debate.

In view of the foregoing, this article is intended to present the state of the art, as identified in the global scientific literature in the collective health or public health fields, as regards cisgender homoparental reproduction.

Methods

This scoping review draws on the methodological framework of the Joanna Briggs Institute⁴4 Munn Z, Pollock D, Khalil H, Alexander L, McInerney P, Godfrey CM, Peters M, Tricco AC. What are scoping reviews? Providing a formal definition of scoping reviews as a type of evidence synthesis. JBI Evid Synth 2022; 20(4):950-952.. The report followed the recommendations of the PRISMA Extension for Scoping Reviews⁵5 Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, Moher D, Peters MDJ, Horsley T, Weeks L, Hempel S, Akl EA, Chang C, McGowan J, Stewart L, Hartling L, Aldcroft A, Wilson MG, Garritty C, Lewin S, Godfrey CM, Macdonald MT, Langlois EV, Soares-Weiser K, Moriarty J, Clifford T, Tunçalp Ö, Straus SE. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467-73.. A research protocol was developed beforehand and registered in the Open Science Framework (OSF)⁶6 Gomes R, Silva JL, Toma TS, Silva A, Domene FM. Protocolo: a homoparentalidade como questão da saúde coletiva: uma revisão de escopo. OSF 2022. DOI: DOI 10.17605/OSF.IO/QXSDU.
https://doi.org/10.17605/OSF.IO/QXSDU.... .

This article addresses part of the results of the larger review “Homoparenthood as a collective health issue: a scoping review”, which investigated the global scientific production, in the collective health or public health field, on homoparenthood⁷7 Gomes R, Toma TS, Silva JL, Domene FM, Silva A. Homoparenting as a public health issue: a scoping review. Rev Saude Publica 2023; 57:80..

The guiding question in review - “What aspects of cisgender homoparental reproduction are addressed in the global scientific production in the collective or public health field?” - was formulated with the help of the acronym PCC (Population: cisgender homoparental families; Concept: global scientific production on reproduction; Context: collective or public health).

Inclusion and exclusion criteria

Our inclusion criteria allowed primary and secondary studies, documents, reports, dissertations or theses, available in English, French, Portuguese or Spanish, that addressed issues relating to legislation, policies, programmes, access and fertility and reproductive services for cisgender homoparental families, in the collective health or public health context. In this article, a minor change was made from the original protocol, by including studies published in French. Studies in other health contexts or addressing non-cisgender homoparental families were excluded.

Data sources and search strategies

The following databases were searched in July and September 2022: PubMed, Virtual Health Library (Biblioteca Virtual em Saúde, BVS ), SciELO, Scopus, Web of Science, Dimensions and the Brazilian Digital Library of Theses and Dissertations (Biblioteca Digital Brasileira de Teses e Dissertações, BDTD). MeSH (Medical Subject Headings) terms were used in PubMed and DeCS (Health Sciences Descriptors) terms in the VHL, with adaptations in other databases. Details of the search strategies and descriptors used can be found in Chart 1.

Selection of studies

The Rayyan QCRI⁸8 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan - a web and mobile app for systematic reviews. Syst Rev 2016; 5(1):210. literature review manager was used to select studies. After duplicates were excluded, studies were selected by two reviewers, independently reading titles and abstracts against the inclusion and exclusion criteria. Divergences were resolved by seeking consensus between the two reviewers or were resolved by a third reviewer. Dissertations and theses were selected manually by reading the abstracts. Eligible studies were read in full by two reviewers, not in a duplicate manner, and validated by a third reviewer. The references cited in included studies were checked so as to include other eligible studies not retrieved in the searches.

Data extraction

The following information was extracted from the included studies: i) author and year of publication; ii) objective; iii) study design; iv) study population; v) number of participants; vi) participants’ age; vii) sex/gender; viii) race/colour; ix) family characteristics; x) country where the study was conducted; xi) study location; xii) approach focus and central theme; xiii) outcomes or thematic categories; xiv) findings; xv) limitations; xvi) gaps; xvii) conclusion; xviii) funding; xix) conflict of interest; and xx) authors’ institutional affiliation. The first articles were extracted independently by three reviewers, until the process achieved homogeneity (calibration). Data were then extracted by two reviewers, not in a duplicate manner, and validated by a third reviewer.

Data analysis

The extracted data were analysed with an eye to the reproductive health of cisgender homoparental families in the public and collective health context. The studies’ findings were examined using the content analysis technique adapted by Gomes⁹9 Gomes R. Análise e interpretação de dados de pesquisa qualitativa. In: Minayo MCS, organizadora. Pesquisa social: teoria, método e criatividade. Petrópolis: Vozes; 2007. p. 79-108. and described by Bardin¹⁰10 Bardin L. Análise de conteúdo. Lisboa: Edições 70; 1979.. The results are presented in narrative form. The studies were not evaluated for methodological quality, considered as an optional step in scoping reviews, as this was not an exclusion criterion¹¹11 Peters MDJ, Godfrey C, McInerney P, Soares CB, Khalil H, Parker D. Scoping reviews. In: Aromataris E, Munn Z, editors. Joanna Briggs Institute Reviewer's Manual. Adelaide: JBI; 2017..

Results and discussion

The searches retrieved 1,350 records and, after excluding duplicates, 725 records were screened in the Rayyan manager, by titles and abstracts. Of 47 eligible reports read in full, 29 were included. An additional 42 records were screened, from the survey of theses and dissertations and the reference lists of studies included; of these, 34 eligible papers were read in full and also included. In this way, 63 studies were selected and this article will examine the 31 that addressed the issue of reproduction in cisgender homoparental families. The selection process is shown in Figure 1, and the 18 eligible studies excluded are listed in Chart 2.

General characteristics of the studies

Of the 31 studies included¹³13 Albuquerque GA, Belém JM, Cavalcante Nunes JF, Leite MF, Quirino GS. Planejamento reprodutivo em casais homossexuais na Estratégia Saúde da Família. Rev APS 2018; 21(1):104-111.

14 Belaisch Allart J. L'accès à l'Assistance Médicale à la Procréation, la gestation pour autrui, l'homoparentalité. Gynecol Obstet Fertil 2012; 40:3-7.

15 Carvalho PGC, Cabral CDS, Ferguson L, Gruskin S, Diniz CSG. 'We are not infertile': challenges and limitations faced by women in same-sex relationships when seeking conception services in São Paulo, Brazil. Cult Health Sex 2019; 21(11):1257-1272.

16 Chapman R, Wardrop J, Zappia T, Watkins R, Shields L. The experiences of Australian lesbian couples becoming parents: deciding, searching and birthing. J Clin Nurs 2012; 21(13-14):1878-1885.

17 Fantus S. Experiences of gestational surrogacy for gay men in Canada. Cult Health Sex 2021; 23(10):1361-1374.

18 Gregg I. The health care experiences of lesbian women becoming mothers. Nurs Womens Health 2018; 22(1):40-50.

19 Guérin JF. Assistance médicale à la procréation pour toutes : les éléments du débat. Rev Prat 2018; 68(5):483-486.

20 Hayman B, Wilkes L, Halcomb EJ, Jackson D. Marginalised mothers: lesbian women negotiating heteronormative healthcare services. Contemp Nurse 2013; 44(1):120-127.

21 Hayman B, Wilkes L, Halcomb E, Jackson D. Lesbian women choosing motherhood: the journey to conception. J GLBT Fam Stud 2015; 11(4):395-409.

22 Imaz E. Same-sex parenting, assisted reproduction and gender asymmetry: reflecting on the differential effects of legislation on gay and lesbian family formation in Spain. Reprod Biomed Soc Online 2017; 4:5-12.

23 Juntereal NA, Spatz DL. Breastfeeding experiences of same-sex mothers. Birth 2020; 47(1):21-28.

24 Klein DA, Malcolm NM, Berry-Bibee EN, Paradise SL, Coulter JS, Keglovitz Baker K, et al. Quality primary care and family planning services for LGBT clients: a comprehensive review of clinical guidelines. LGBT Health 2018; 5(3):153-170.

25 Klittmark S, Garzón M, Andersson E, Wells MB. LGBTQ competence wanted: LGBTQ parents' experiences of reproductive health care in Sweden. Scand J Caring Sci 2019; 33(2):417-426.

26 Lavoie K, Greenbaum M. Regards sur les familles homoparentales: s'ouvrir à leurs réalités pour mieux répondre aux besoins des enfants. Nouv Prat Soc 2013; 24(2):140-150.

27 Lucio FPS, Araújo EC. A maternidade de mães lésbicas na perspectiva da enfermagem: revisão integrativa. Rev Eletronica Enferm 2017; 19:1-11.

28 Malmquist A, Nelson KZ. Efforts to maintain a "just great" story: Lesbian parents' talk about encounters with professionals in fertility clinics and maternal and child healthcare services. Fem Psychol 2014; 24(1):56-73.

29 McManus AJ, Hunter LP, Renn H. Lesbian experiences and needs during childbirth: guidance for health care providers. J Obstet Gynecol Neonatal Nurs 2006; 35(1):13-23.

30 Nau JY. De l'homoparentalité légalisée. Rev Med Suisse 2011; 7(281):372-373.

31 Nimbi FM, Viozzi E, Tripodi F, Simonelli C, Baiocco R. Could educational programs in sexology have an influence on attitudes towards same-sex marriage and parenting? Sexologies 2020; 29(3):e77-e83.

32 Norton W, Hudson N, Culley L. Gay men seeking surrogacy to achieve parenthood. Reprod Biomed Online 2013; 27(3):271-279.

33 O'Neill KR, Hame HP, Dixon R. Perspectives from lesbian women: their experiences with healthcare professionals when transitioning to planned parenthood. Divers Equal Heal Care 2013; 10(4):213-222.

34 Obem MK. A (in)visibilidade de famílias homoafetivas durante atendimentos nos serviços de saúde [tese]. Rio Grande do Sul: Universidade Federal de Santa Maria; 2018.

35 Ross LE, Steele LS, Epstein R. Lesbian and bisexual women's recommendations for improving the provision of assisted reproductive technology services. Fertil Steril 2006; 86(3):735-738.

36 Rozental A, Malmquist A. Vulnerability and acceptance: lesbian women's family-making through assisted reproduction in Swedish public health care. J GLBT Fam Stud 2015; 11(2):127-150.

37 Silva DA. Enfim mães! Da experiência da reprodução assistida à experiência da maternidade lésbica [tese]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2013.

38 Silva JL, Costa MJF, Távora RCO, Valença CN. Planejamento para famílias homoafetivas: releitura da saúde pública brasileira. Rev Bioet 2019; 27(2):276-280.

39 Singer RB. Improving prenatal care for pregnant lesbians. Int J Child Educ 2012; 27(4):1-37.

40 Vecho O, Schneider B. Attitudes envers l'homoparentalité: une comparaison entre psychologues franços et québécois. Can J Behav Sci 2015; 47(1):102-112.

41 Weber S. Parenting, family life, and well-being among sexual minorities: nursing policy and practice implications. Issues Ment Health Nurs 2008; 29(6):601-618.

42 Wells MB, Lang SN. Supporting same-sex mothers in the Nordic child health field: a systematic literature review and meta-synthesis of the most gender equal countries. J Clin Nurs 2016; 25(23):3469-3483.^-4343 Werner C, Westerståhl A. Donor insemination and parenting: concerns and strategies of lesbian couples. A review of international studies. Acta Obstet Gynecol Scand 2008; 87(7):697-701., sixteen (51.6%) were primary studies, two (6.5%) were opinion articles, one (3.2%) was a dossier, two (6.4%) were trials and ten (32.3%) were reviews. The primary studies were qualitative (n = 13), mixed methods (n = 1) and quantitative evaluation (n = 2) studies. Authors cited the reviews as review (n = 2), integrative literature review (n = 1), clinical guidelines review (n = 1), literature review (n = 1), systematic literature review and meta-synthesis (n = 1) and narrative review (n = 4).

The authors of just over half the studies (51.6%) gave no information on conflicts of interest, while 41.9% reported no conflicts. In two studies, conflicts were reported: one author of one review²⁴24 Klein DA, Malcolm NM, Berry-Bibee EN, Paradise SL, Coulter JS, Keglovitz Baker K, et al. Quality primary care and family planning services for LGBT clients: a comprehensive review of clinical guidelines. LGBT Health 2018; 5(3):153-170. was a member of the advisory board of Gilead Sciences, Inc. and Merck; the author of the other study¹⁹19 Guérin JF. Assistance médicale à la procréation pour toutes : les éléments du débat. Rev Prat 2018; 68(5):483-486. was a consultant on ethical issues at the Unilabs company. About 38% of studies received funding, 11% did not and 50% provided no information in this regard.

The studies examined the formation of lesbian homoparental families (61.3%), gay families (6.4%) or both homoparental family formations (32.3%) (Figure 2). Study sample size ranged from 8 to 1,735 participants and ages, from 23 to 58 years.

The primary studies, including also those cited in the reviews, were conducted in Australia, Brazil, Canada, Spain, the United States of America, Finland, France, Italy, Norway, New Zealand, Portugal, the United Kingdom, Sweden and Switzerland. Two reviews²⁹29 McManus AJ, Hunter LP, Renn H. Lesbian experiences and needs during childbirth: guidance for health care providers. J Obstet Gynecol Neonatal Nurs 2006; 35(1):13-23.^,3939 Singer RB. Improving prenatal care for pregnant lesbians. Int J Child Educ 2012; 27(4):1-37. did not state which countries the primary studies were conducted in.

Barriers to reproduction and reproductive health of cis same-sex couples

The themes of 28 of the included studies were found to relate to the barriers faced by cis same-sex couples wanting to have children in identifying or accessing reproductive health services. The barriers related to legal, ethical and technical issues involved in human assisted reproductive technology, surrogacy and sperm donation; financial matters; prejudices, discrimination and stigma; and health personnel’s homophobic attitudes and limited understanding of same-sex couples’ needs.

One of the barriers to assisted reproduction has to do with legal, ethical and technical issues. In some countries, such as France, insemination as a means of enabling reproduction is anchored in two rationales. The first is that such procedures constitute a therapeutic remedy for clinically confirmed infertility or subfertility and is not a response to any form of desire to have a child. Demand for assisted reproduction from homosexual couples does not necessarily obey that logic¹⁴14 Belaisch Allart J. L'accès à l'Assistance Médicale à la Procréation, la gestation pour autrui, l'homoparentalité. Gynecol Obstet Fertil 2012; 40:3-7.^,1919 Guérin JF. Assistance médicale à la procréation pour toutes : les éléments du débat. Rev Prat 2018; 68(5):483-486.^,3030 Nau JY. De l'homoparentalité légalisée. Rev Med Suisse 2011; 7(281):372-373.^,4040 Vecho O, Schneider B. Attitudes envers l'homoparentalité: une comparaison entre psychologues franços et québécois. Can J Behav Sci 2015; 47(1):102-112.. Jean-François Guerin (2018) found that most homosexual women reported being unable to consider having sex with a man. The second rationale for insemination, which is connected with the first, concerns the fact that this procedure is intended exclusively for heterosexual couples¹⁹19 Guérin JF. Assistance médicale à la procréation pour toutes : les éléments du débat. Rev Prat 2018; 68(5):483-486..

A 2008 narrative review signalled that public policies in the United States continued to resist any restructuring of the sexual and reproductive rights of lesbians and gays⁴¹41 Weber S. Parenting, family life, and well-being among sexual minorities: nursing policy and practice implications. Issues Ment Health Nurs 2008; 29(6):601-618.. An anthropological essay from Spain, concludes about the differences between female and male couples: women, whether single or married to another woman, can access artificial insemination and in-vitro fertilisation with no legal impediments; male couples, on the other hand, are prevented from accessing fatherhood by biological means (because their gender is not reproductive), through adoption (their sexual orientation makes them ineligible in most countries) or through assisted reproductive technologies (they can only access fatherhood by involving a woman, who will have the legal filiation ties). The study also notes that surrogacy is considered an illegal procedure in Spain²²22 Imaz E. Same-sex parenting, assisted reproduction and gender asymmetry: reflecting on the differential effects of legislation on gay and lesbian family formation in Spain. Reprod Biomed Soc Online 2017; 4:5-12..

A 2013 narrative document review focused on legal issues faced by gay men who choose to become parents through surrogacy. Prominent among its findings were that surrogacy remains illegal in many European countries, including Germany, France, Spain, the United Kingdom and Italy, while countries such as India and Ukraine impose few restrictions and accept the practice of commercial surrogacy when paid for by the intended parents. Commercial surrogacy is also acceptable in the United States³²32 Norton W, Hudson N, Culley L. Gay men seeking surrogacy to achieve parenthood. Reprod Biomed Online 2013; 27(3):271-279..

One difficulty for Canadian gay parents was finding surrogates who were open to talking to same-sex prospective parents, with surrogates refusing on heteronormative assumptions of reproduction and fertility. Fertility clinics have helped intended parents with sperm donation, but fertility clinic policies sometimes prohibit gay men from donating sperm in the same room due to sanitation and sperm mixing concerns¹⁷17 Fantus S. Experiences of gestational surrogacy for gay men in Canada. Cult Health Sex 2021; 23(10):1361-1374..

One review found that lesbian couples who needed sperm, ultrasounds, laboratories and experienced personnel are often alone medically and financially. Heterosexuals may get financial assistance to reproduce, but members of sexual minorities often go without medical, government, employer or social assistance. While reproductive health is covered by heterosexual spouses’ employment benefits, not all jobs extend the same benefits to same-sex partners. Moreover, there are restrictive policies on reproductive and fertility health coverage, to benefit heterosexual couples trying to conceive³⁹39 Singer RB. Improving prenatal care for pregnant lesbians. Int J Child Educ 2012; 27(4):1-37.. Another literature review highlighted three primary legal issues that must be addressed with lesbian couples - the legal relationship between the women, the legal relationship between the child and the non-pregnant mother and the legal rights and obligations of the donor. Although many facilities are beginning to recognise relationships between same-sex partners, many remain bound by state laws or facility policies (or both) that require a legal or blood relative to be designated as next of kin. The law is often confusing about who can be recognised as the legal next of kin and, even with appropriate documentation, lesbian couples can encounter difficulties²⁹29 McManus AJ, Hunter LP, Renn H. Lesbian experiences and needs during childbirth: guidance for health care providers. J Obstet Gynecol Neonatal Nurs 2006; 35(1):13-23..

The narrative review by Silva et al. published in 2019³⁸38 Silva JL, Costa MJF, Távora RCO, Valença CN. Planejamento para famílias homoafetivas: releitura da saúde pública brasileira. Rev Bioet 2019; 27(2):276-280. focused on Brazilian legislation with regard to assisted reproduction, family formations in the same-sex population and family planning. It finds that the legal nature of family planning-related factors has been widely debated to determine whether or not family planning is a fundamental right. While family planning is supported by Brazilian legislation, the same is not true of assisted reproduction.

Even when legal discrimination disappears, couples may encounter unexpected barriers. In Canada, for example, while there is no legal impediment to assisted reproduction for homosexual couples, they have to cope with prejudice and discrimination in health services, schools and communities²⁶26 Lavoie K, Greenbaum M. Regards sur les familles homoparentales: s'ouvrir à leurs réalités pour mieux répondre aux besoins des enfants. Nouv Prat Soc 2013; 24(2):140-150..

In Brazil, for example, lesbians have limited access to public services, because they are beyond the scope of the protocol for receiving reproductive technology treatment, added to which are the financial barriers to accessing private services¹⁵15 Carvalho PGC, Cabral CDS, Ferguson L, Gruskin S, Diniz CSG. 'We are not infertile': challenges and limitations faced by women in same-sex relationships when seeking conception services in São Paulo, Brazil. Cult Health Sex 2019; 21(11):1257-1272.. Also in Brazil, three studies have reported heteronormative barriers, both in the imaginations of health professionals who stipulate that biological reproduction is impossible for these couples, disregarding other alternative means of forming a family¹³13 Albuquerque GA, Belém JM, Cavalcante Nunes JF, Leite MF, Quirino GS. Planejamento reprodutivo em casais homossexuais na Estratégia Saúde da Família. Rev APS 2018; 21(1):104-111., and in the configuration of reproduction clinics designed for heterosexual families, whose environments feature only photographs of cisgender couples of men and women³⁴34 Obem MK. A (in)visibilidade de famílias homoafetivas durante atendimentos nos serviços de saúde [tese]. Rio Grande do Sul: Universidade Federal de Santa Maria; 2018.. Some lesbian couples could not participate in choosing the assisted reproduction technology and reported a lack of information, a lack of receptiveness in response to their anguish and, at times, dubious looks, although they considered the process as a whole in a positive light, either because they underwent the procedure and valued the experience of motherhood more than the difficulties of the process or also because the clinic did not deny care in view of their sexuality at variance with the hegemonic norm³⁷37 Silva DA. Enfim mães! Da experiência da reprodução assistida à experiência da maternidade lésbica [tese]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2013.. There were also situations where clinics denied care, explaining that it was because the family formation differed from the standard served by the service³⁴34 Obem MK. A (in)visibilidade de famílias homoafetivas durante atendimentos nos serviços de saúde [tese]. Rio Grande do Sul: Universidade Federal de Santa Maria; 2018..

Stigmatisation can contribute to difficult access. A review in Australia indicated that six lesbian couples reported difficulties in the process of becoming mothers, because of stigmatisation and prejudice on the part of health professionals, even after the country’s legislation change in 2002 to ensure lesbians access to reproductive technology²⁷27 Lucio FPS, Araújo EC. A maternidade de mães lésbicas na perspectiva da enfermagem: revisão integrativa. Rev Eletronica Enferm 2017; 19:1-11.. Also in Australia, there were situations where lesbian couples travelled to another state to access fertility services, which were unavailable in their state of origin²⁰20 Hayman B, Wilkes L, Halcomb EJ, Jackson D. Marginalised mothers: lesbian women negotiating heteronormative healthcare services. Contemp Nurse 2013; 44(1):120-127.^,2121 Hayman B, Wilkes L, Halcomb E, Jackson D. Lesbian women choosing motherhood: the journey to conception. J GLBT Fam Stud 2015; 11(4):395-409.. In another Australian study, all participants started their search for fertility clinics to conceive by consulting a general practitioner, which was not always reported as a positive experience. One example cited is of a couple who changed clinics during treatment and were very frustrated with the process of having to obtain a new referral, although the reason for their infertility was obvious¹⁶16 Chapman R, Wardrop J, Zappia T, Watkins R, Shields L. The experiences of Australian lesbian couples becoming parents: deciding, searching and birthing. J Clin Nurs 2012; 21(13-14):1878-1885.. One review included in that article highlighted the issue of finding a provider to provide services during insemination as among the barriers¹⁸18 Gregg I. The health care experiences of lesbian women becoming mothers. Nurs Womens Health 2018; 22(1):40-50.. The author reported that one problem that emerged in several of the studies evaluated, particularly those in Australia, was finding a provider for referral to a fertility specialist. In the United States and Australia, referral to specialists often requires a documented diagnosis of infertility. The review explains that such a diagnosis is complicated for lesbian women, because they are not making monthly attempts to achieve pregnancy with a male partner¹⁸18 Gregg I. The health care experiences of lesbian women becoming mothers. Nurs Womens Health 2018; 22(1):40-50..

In this regard, even in cases where the right to assisted reproduction is guaranteed, lesbians may encounter frustrations. Three qualitative studies in Sweden identified discomfort and stigma experienced by cisgender same-sex couples in their relations with reproductive services and health professionals. Interviewees reported that medical procedures originally tailored for different-sex couples did not always meet the needs of same-sex couples. By asserting a difference between heterosexuals with fertility problems and themselves as “completely healthy lesbian women”, one participant made a clear distinction between the two groups’ points of departure. This vulnerability was illustrated in relation to the treatment offered, where lesbian couples asserted a need for “other types of treatments”, adapted more specifically to them as patients³⁶36 Rozental A, Malmquist A. Vulnerability and acceptance: lesbian women's family-making through assisted reproduction in Swedish public health care. J GLBT Fam Stud 2015; 11(2):127-150.. The Swedish participants described different kinds of inappropriateness and mistreatment in reproductive health care. They reported that reproductive health professionals were unaware of LGBTQ (Lesbian, Gay, Bisexual, Transvestite, Transsexual and Queer) matters, as well as of means of impregnation, all of which was described as tiring and uncomfortable. Personnel showed their lack of knowledge, for example, by asking irrelevant questions and being unable to evaluate participants’ responses. Several participants felt that midwives did not know how to work through the emotions arising from a difficult path to pregnancy, often involving infertility and miscarriages, or about the difficulties arising from this difficult path in intimate relationships. Participants described how they questioned the inappropriate treatment openly, had to explain themselves and/or their situation repeatedly to professionals and how they were obliged to educate professionals about pathways to pregnancy and the rules and legislation on assisted reproduction²⁵25 Klittmark S, Garzón M, Andersson E, Wells MB. LGBTQ competence wanted: LGBTQ parents' experiences of reproductive health care in Sweden. Scand J Caring Sci 2019; 33(2):417-426.. One lesbian couple were planning to get pregnant with the help of the Swedish public healthcare system and one of the mothers-to-be called a fertility clinic to make an appointment. She said that, on the phone, despite her clarity and frankness, she was misunderstood or ignored when asking for help to get onto the insemination waiting list. The woman at the clinic didn’t want to “understand anything”. The participant stressed that “it took ages to explain” and that she didn’t “know how many times” she had to explain. Like a number of other couples, they argued that hostile treatment at Swedish fertility clinics was the only reason they contacted a well-known lesbian-friendly fertility clinic in Denmark. Their account presented the poor treatment as a consequence of heteronormativity; it alleged that fertility clinic staff lacked knowledge about how to respond to lesbian couples as future mothers²⁸28 Malmquist A, Nelson KZ. Efforts to maintain a "just great" story: Lesbian parents' talk about encounters with professionals in fertility clinics and maternal and child healthcare services. Fem Psychol 2014; 24(1):56-73..

A study in New Zealand found that the power imbalance left some lesbian participants unable to express concerns about their treatment and the power they held over their reproductive opportunities. Thus, they were effectively silenced. One participant’s difficulties had to do with the nurses, who were “horrible” when providing treatment and care for her and her partner. She also met with homophobic attitudes from a social worker who was assessing them for fertility assistance at a clinic they were hoping to use. The participant stated that the balance of power led her to submit to mistreatment, so as not to hinder the process they were trying to get through. The feeling that, on the heteronormative worldview, she and her partner were not “doing things right” was added to a sensation of being perpetually marginalised, which placed undue stress on the relationship. The process the participant was undergoing at the time included invasive procedures, as well as depending on nurses for clear and honest information, which she did not receive. Some participants felt additional pressure relating to the feeling of being under constant scrutiny and judgment by the heterosexual community, particularly health professionals³³33 O'Neill KR, Hame HP, Dixon R. Perspectives from lesbian women: their experiences with healthcare professionals when transitioning to planned parenthood. Divers Equal Heal Care 2013; 10(4):213-222..

There are other important issues in reproductive care for lesbian couples that must be taken into account in order to achieve equity and comprehensive care. A study in the United States reported that lesbian couples needed to decide and agree on the conception process and who would be the mother of the pregnancy, because she would consequently become the predominant mother to provide the child with human milk. Gestational mothers can also carry the non-gestational mother’s egg, and services can offer that choice. The study noted that each family’s lactation experience is different, but all mothers believed that clinical support could be improved to support same-sex mothers better. Many mothers voiced the opinion that health professionals could be more respectful and informed about lactation care. They reported that personnel needed to know more about what they went through to get pregnant. Mothers often felt that professionals dismissed their real health concerns and approached them as a pregnancy issue, rather than listening to their needs. They knew little or nothing about induced lactation or breastfeeding²³23 Juntereal NA, Spatz DL. Breastfeeding experiences of same-sex mothers. Birth 2020; 47(1):21-28..

Another issue that arises in acquisition of donor sperm is choosing between anonymous and known donors²³23 Juntereal NA, Spatz DL. Breastfeeding experiences of same-sex mothers. Birth 2020; 47(1):21-28.. Whether or not it is possible to choose anonymous, open-identity or known donors differed widely between the countries evaluated in the studies. Anonymous donors were often chosen out of concern for the non-biological mother, in order to strengthen her role as mother⁴³43 Werner C, Westerståhl A. Donor insemination and parenting: concerns and strategies of lesbian couples. A review of international studies. Acta Obstet Gynecol Scand 2008; 87(7):697-701.. A study in Australia cited the logistic and ethical challenges of finding a donor. These challenges involved issues of using a known or unknown donor, retaining sperm and/or eggs for future children, donor availability for multiple families, and identification and parental rights of donors. Most participants conceived using an unidentified donor and ensured that subsequent children had the same donor. Simply locating a donor proved difficult¹⁶16 Chapman R, Wardrop J, Zappia T, Watkins R, Shields L. The experiences of Australian lesbian couples becoming parents: deciding, searching and birthing. J Clin Nurs 2012; 21(13-14):1878-1885.. Lesbian couples in Norway sought assisted reproduction in Denmark, so that the sperm donor would remain anonymous⁴²42 Wells MB, Lang SN. Supporting same-sex mothers in the Nordic child health field: a systematic literature review and meta-synthesis of the most gender equal countries. J Clin Nurs 2016; 25(23):3469-3483.. One narrative review addressing donor insemination technique found that the challenges of finding a donor, deciding on the desired level of interaction with the donor and deciding how much and when to tell the child about their origins were key issues that should be discussed before insemination. The search for a donor is influenced by the outcome of the couple’s decision as to whether or not to use a known or anonymous donor and what role, if any, the donor is to play in the child’s life²⁹29 McManus AJ, Hunter LP, Renn H. Lesbian experiences and needs during childbirth: guidance for health care providers. J Obstet Gynecol Neonatal Nurs 2006; 35(1):13-23..

Factors facilitating rights and reducing discrimination

Six studies addressed possible facilitating factors that would help lower or eliminate these barriers: reproductive health services adapted to welcome all sexual orientations openly and non-judgmentally; conception and contraceptive methods available and supplied also to the LGBT population and an informed approach to reproductive options; strategies to facilitate sperm donation; and service environments modified without the assumption that all users are heterosexual.

A review of clinical guidelines provided a summary of recommendations on provision of primary care and family planning services for the LGBT population. Seven guidelines underlined the importance of reproductive health services that meet the needs of all sexual orientations, of providers informed of the specific sexual and reproductive health needs of LGBT people and of services modified to meet individual needs. Ten guidelines included clinical recommendations on pregnancy prevention adapted to LGBT populations. They emphasised the importance of contraceptive methods, including emergency contraception, being available and provided to all who want them, regardless of sexual orientation, as well as of avoiding assumptions that lesbian women are not (or will not be) sexually active with men, which may result in pregnancy. Nine guidelines discussed pregnancy planning and fertility services, encouraging providers to counsel LGBT people, including lesbian or bisexual women and transgender clients, as to their reproductive options. The recommendations were that fertility counselling and services be made available to lesbians, including details on fertility preservation methods and the various manners of having a child and integrating them into the family. The guidelines also recommended that, before initiating any hormone therapy or surgery, doctors discuss reproductive options with people, including the implications of gender transition on future fertility²⁴24 Klein DA, Malcolm NM, Berry-Bibee EN, Paradise SL, Coulter JS, Keglovitz Baker K, et al. Quality primary care and family planning services for LGBT clients: a comprehensive review of clinical guidelines. LGBT Health 2018; 5(3):153-170..

A study in Canada proposed broad measures regarding fertilisation for lesbians and gays: 1) involve all parties desired by users, including partners, known sperm donors and co-parents; 2) provide affordable fertility services to known sperm donors, including gay men; 3) expand selection of sperm donors, particularly with regard to donors from diverse ethnic and cultural backgrounds and open-identity donors; 4) minimise service costs and communicate a consistent fee structure; 5) provide opportunities for women to make informed choices about interventions consistent with their known or presumed fertility; 6) offer infertility support that is specific to lesbian and bisexual women (e.g., specialised groups) or provided by individuals knowledgeable about issues relevant to lesbian and bisexual women; 7) provide cues that the service is lesbian and bisexual positive; 8) Strive for a unified standard of care across all geographic regions and facilitate access for women living outside large urban centres; 9) whenever possible, offer specialised services or services in partnership with the lesbian and gay community; 10) help lesbian and bisexual women to connect with other relevant services and supports³⁵35 Ross LE, Steele LS, Epstein R. Lesbian and bisexual women's recommendations for improving the provision of assisted reproductive technology services. Fertil Steril 2006; 86(3):735-738..

Some studies included gave a voice to cisgender same-sex couples in order to understand, from their perspectives, what could facilitate their family-building. One review addressed lesbian couples who actively sought out parenting groups with other lesbian couples in order to discuss and think about issues specific to their situation. Future mothers raised important issues for quality reception in healthcare services: open and non-judgmental attitudes; appointments, posters and forms free of the assumption that all users are heterosexual; knowledge about the situation of lesbian women; and recognition of the co-mother⁴³43 Werner C, Westerståhl A. Donor insemination and parenting: concerns and strategies of lesbian couples. A review of international studies. Acta Obstet Gynecol Scand 2008; 87(7):697-701.. A Swedish qualitative study reported that participants expressed thoughts about what kind of care and support they would like to have and how professionals could be more inclusive of prospective and new parents. They said that they would feel supported if health professionals could reflect on the limitations of the health system and legislation, and they approved the attitudes of personnel when they tried to help them find solutions and access care. Participants reported wanting to be understood and supported when some of them chose to go abroad for help with assisted reproduction. They also said that it would be supportive if health professionals expressed sympathy regarding normative and exclusive arrangements, restrictive legislation that excludes LGBTQ people who wish to become parents, and for the questions put to LGBTQ people needing to undergo psychosocial assessments in order to access assisted reproductive care²⁵25 Klittmark S, Garzón M, Andersson E, Wells MB. LGBTQ competence wanted: LGBTQ parents' experiences of reproductive health care in Sweden. Scand J Caring Sci 2019; 33(2):417-426..

An evaluation study in Italy investigated the differences between two groups of Italian health professionals, one trained and the other untrained, by sexology educational programmes, which influence how well gays’ and lesbians’ same-sex marriage and parenting needs are met. Healthcare professionals who participated in these programmes reported significantly lower levels of homophobia towards gays and lesbians as compared with those who did not participate. The participating group also showed lower levels of total and benevolent sexism, although no significant differences were reported in levels of hostile sexism, with both groups returning low average scores on this subscale. Both groups achieved high average scores on both variables, homophobia and benevolent sexism, and displayed positive overall attitudes to gays’ and lesbians’ marriage and parenting rights, while the group that participated in sexology educational programmes reported significantly higher scores than the non-participating group. The participating group scored significantly higher on same-sex adoption, artificial insemination and in-vitro fertilisation for lesbians³¹31 Nimbi FM, Viozzi E, Tripodi F, Simonelli C, Baiocco R. Could educational programs in sexology have an influence on attitudes towards same-sex marriage and parenting? Sexologies 2020; 29(3):e77-e83..

Lavoie and Greenbaum (2013)²⁶26 Lavoie K, Greenbaum M. Regards sur les familles homoparentales: s'ouvrir à leurs réalités pour mieux répondre aux besoins des enfants. Nouv Prat Soc 2013; 24(2):140-150. described a project of a Canadian association for homoparental families, involving family members, educators, community activists and researchers. The project, operating since 2009, is described as a knowledge transfer project designed to raise awareness and support health and education professionals working with these families and to contribute to social recognition for homoparenthood.

Final remarks

In the literature reviewed, the discussion evidently focuses more on barriers and difficulties in homosexual couples’ using assisted human reproduction technology than on related facilitating factors. This may indicate that - in the context in which the studies were conducted - there is still a need to problematise the hegemonic model of nuclear, heterosexual family.

Other evidence of this is that, even in countries where assisted reproduction by homosexual couples is legal, awareness among health professionals still needs to be raised in order for this right to be guaranteed to such couples, and social measures are needed to reinforce social recognition for the rights of homoparental families.

In that none of the studies reviewed questioned the right of access to assisted reproduction as a means to homoparenthood, the academic consensus that this right is assured also constitutes evidence.

Among the limitations of this review is the fact that the “grey literature” publications were not searched. No studies on the subject were excluded for reasons of language.

One gap observed in the literature reviewed was a lack of studies of families of gay men in discussions of reproduction by cis same-sex couples. Future studies may ratify or rectify the hypothesis that, regardless of whether couples are homosexual or heterosexual, the mechanical association between women and reproduction remains.

Lastly, discussion on the subject discussed here needs to shift from the academic world to the more general social universe. Alignment between academia and social movements can be a powerful strategy for sexual and reproductive rights not only to become a political agenda in the collective health field, but also gain feasibility through programmatic strategies in this field. The case of AIDS, nationally and internationally, attests to the efficacy and effectiveness of that alignment.

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