Abstract

The present article aims to bridge the gaps or deepen the debate to discuss the relationship between homoparenthood and health. This essay is anchored in specific literature. We seek to work on the following questions throughout the text: (i) How is the central theme of this discussion historically outlined? (ii) How does homoparenthood appear in scientific health production in general? (iii) What sociopolitical dimensions emerge around homoparenthood-health relationships? and (iv) What are the limitations and possibilities for exercising reproductive rights between same-sex couples? Among the conclusions, we underscore the challenge of facing the strangeness of homoparenthood against the idea of the so-called called “normal” family based on heteronormative logic. Even in countries with some legal apparatus assuring the rights to homoparental families, their members suffer prejudice, discrimination, and violence.

Key words:
Homoparenthood; Family; Health

Introduction

Homoparenthood is a term created in 1997 by the Association of Gay and Lesbian Parents¹1 Gross M. Histoire des revendications homoparentales en France. Bull d'Histoire Politique 2010; 18(2):113-123. in France and designates any family situation with at least one adult who self-identifies as homosexual and is raising one or more children¹1 Gross M. Histoire des revendications homoparentales en France. Bull d'Histoire Politique 2010; 18(2):113-123.. Ribeiro et al.²2 Ribeiro CR, Gomes R, Moreira MCN. A paternidade e a parentalidade como questões de saúde frente aos rearranjos de gênero. Cien Saude Colet 2015; 20(11):3589-3598., based on Zambrano³3 Zambrano E. Parentalidades "impensáveis": pais/mães homossexuais, travestis e transexuais. Horiz Antropol 2006; 12(26):123-147., observe that homoparenthood is established from at least four situations:

[...] by children born in a previous heterosexual relationship, by legal or informal adoption, through new reproductive technologies that enable the birth of biological children, and by co-parenting, in which care for the child is exercised jointly and equitably by the partners²2 Ribeiro CR, Gomes R, Moreira MCN. A paternidade e a parentalidade como questões de saúde frente aos rearranjos de gênero. Cien Saude Colet 2015; 20(11):3589-3598.(p.3592).

In the 1990s, in France, homoparenthood emerged at the crossroads of changing attitudes towards same-gender attraction, scientific progress in assisted reproduction, and the transformation of social attitudes vis-à-vis the family¹1 Gross M. Histoire des revendications homoparentales en France. Bull d'Histoire Politique 2010; 18(2):113-123..

Although the expression homoparenthood is subject to criticism, as mentioned by Zambrano³3 Zambrano E. Parentalidades "impensáveis": pais/mães homossexuais, travestis e transexuais. Horiz Antropol 2006; 12(26):123-147. and Cecílio et al.⁴4 Cecílio MS, Scorsolini-Comim F, Santos MA. Produção científica sobre adoção por casais homossexuais no contexto brasileiro. Estud Psicol 2013; 3(18):507-516., we will use this expression to highlight parenting involving gays or lesbians.

The discussion about homoparenthood is relatively expanding in the international health sector in general, although this discussion in this area is still very incipient⁵5 Gomes R, Toma TS, Silva JL, Domene FM, Silva A. A homoparentalidade como questão da saúde coletiva: uma revisão de escopo. Rev Saude Publica 2023; 57:80. at the national level. Although the topic in question may be perceived as recent, Gross¹1 Gross M. Histoire des revendications homoparentales en France. Bull d'Histoire Politique 2010; 18(2):113-123. observes that gay parents have existed since the very existence of same-gender attraction. The author argues that gay people have married or are married and live their same-gender attraction more or less clandestinely, or their attraction to people of the same sex was only discovered after having children within a heterosexual union.

Based on international data, Vecho and Schneider⁶6 Vecho O, Schneider B. Attitudes envers l'homoparentalité: Une comparaison entre psychologues français et québécois. Can J Behav Sci 2015; 47(1):102-112. note that statistics that attempt to quantify the number of same-sex families still need to be more accurate. By way of illustration, the authors present data from 2007 from the United States, which records that same-sex parenting involves between 2 and 14 million children. They also note that the 2011 census data in Quebec, Canada, revealed that 1,410 children lived in a family of a same-sex couple married or in common law marriage.

Even in countries with legislation that protects the rights of homoparental families, such families struggle to exercise their rights. Challenges are not limited only to issues of homoparenthood but also same-gender attraction issues that precede them⁷7 Scali T, D'Amore S. Défis et besoins des intervenants psychosociaux en planning familial face à la thématique de l'homoparentalité. Dans Thérapie Familiale 2016; 2(37):187-204..

In Canada, a country that implemented significant legislative changes to put an end to all legal discrimination against same-sex couples and homoparental families, studies reveal ongoing discrimination against parents and children in these families, causing them to feel stress that can affect their health and well-being⁸8 Lavoie K, Greenbaum M. Regards sur les familles homoparentales: s'ouvrir à leurs réalités pour mieux répondre aux besoins des enfants. Nouvelles Pratiques Soc 2012; 24(2):140-150.. Besides prejudice and discrimination, invisibility and silence are the most frequent obstacles for members of a homoparental family in this country.

To fill gaps or deepen the debate related to the subject in question, our discussion aims to discuss aspects that involve the relationship between homoparenthood and health. To this end, anchored in specific literature, we will follow an essayistic path, an exploratory exercise about a topic or object of discussion to find a new perspective on the subject⁹9 Tobar F, Yalour MR. Como fazer teses em saúde pública: conselhos e ideias para formular projetos e redigir teses e informes de pesquisas. Rio de Janeiro: Fiocruz; 2002.. Along this path, we will mainly highlight issues related to kinship and family and how these issues resonate in health.

Discussing the relationships between homoparenthood and health, we will formulate the following questions: (i) How is the central theme of this discussion historically outlined? (ii) How does homoparenthood appear in scientific health production in general? (iii) What sociopolitical dimensions emerge around homoparenthood-health relationships? and (iv) What are the limitations and possibilities for exercising reproductive rights between same-sex couples?

Theme historicization in the field of health

Homoparenthood can be interpreted as a resignification of a naturalized and naturalizing logic of procreation and biogenetic affiliation in families composed of male-female pairs, especially when we remember that informal same-sex unions and the upbringing of children by gays and lesbians have long existed in society, even if they were not given visibility and legal support.

The search to understand homoparenthood in its contemporary complexity - as an outcome of the growing visibility of same-gender attraction and the questioning of traditional family concepts and norms - led researchers to investigate the terminologies used to approach the issue initially. The relative lack of consensus results from political emphases, theoretical orientations from different disciplinary fields, and social and geographic contexts where the problem is investigated. Thus, while English, North American, and Canadian studies use terminologies such as gay families, lesbian families, same-sex couples, gay parenthood, and lesbian motherhood¹⁰10 Imrie S, Golombok S. Impact of new family forms on parenting and child development. Annual Rev Develop Psychol 2020; 2:295-316.^,1111 Luce J. Beyond expectation: lesbian/Bi/queer women and assisted reproduction. Toronto: University of Toronto Press; 2010., in Brazil, mainly in Law and Medicine, in the early 2000s, the term homoaffectivity was used to soften political debates seeking to affirm rights¹²12 Machin R. Homoparentalidade e adoção:(re) afirmando seu lugar como família. Psicol Soc 2016; 28:350-359.. Over time, and especially from the perspective of socio-anthropological studies, the term homoparenthood was taken from the French homoparentalité to make the topic’s visibility strategic. Also, the use of this denomination is based on repositioning the debate in the face of ideologies rooted in the socially prevalent heteronormative family.

The historicization of the field of research on homoparenthood explains how different disciplinary fields, such as Medicine, Psychology, Psychoanalysis, Anthropology, Sociology, and Law, chose guiding questions for investigations and conceptual references. Commonly, given the interdisciplinary nature of research and the tenuous boundaries between these fields, research themes and objects tend to converge into large groups. Gato and Fontaine¹³13 Gato J, Fontaine AM. Homoparentalidade no masculino: uma revisão da literatura. Psicol Soc 2014; 26:312-322. argue that the initial studies from the 1970s onwards focused on the parental behavior and practices of lesbian mothers and gay fathers, the psychological development of their children, and the attitudes of the heterosexual community towards homoparenthood.

Regarding parental behavior, the review by Gato and Fontaine¹³13 Gato J, Fontaine AM. Homoparentalidade no masculino: uma revisão da literatura. Psicol Soc 2014; 26:312-322. points to the agreement between hetero- and homoparenthood, with some of the studies indicating the preference for homoparental families in aspects such as division of domestic labor, quality of relationships with children, and marital life. The psychological development of children belonging to such families has been a widely explored topic in Anglo-Saxon literature, mainly based on the contributions of longitudinal research on children in families with same-sex parents by Susan Golombok¹⁴14 Golombok S. Parenting in new family forms. Current Opinion Psychol 2017; 15:76-80.. These studies represented essential advances in reconfiguring social fears related to such families, as they explain that children in these “new family types” experience positive parenting, are well adjusted to the developmental stages, and the family structure is less important for children’s adaptation than family processes¹⁰10 Imrie S, Golombok S. Impact of new family forms on parenting and child development. Annual Rev Develop Psychol 2020; 2:295-316.^,1414 Golombok S. Parenting in new family forms. Current Opinion Psychol 2017; 15:76-80..

More recently, expressive studies and discussions in the Brazilian health field around homoparenthood reflect the expanded public debate from the early 2010s. In 2011, a decision by the Federal Supreme Court recognized same-sex common law marriages, allowing these couples to have a legally formalized adoption with registration of dual motherhood or fatherhood¹⁵15 Supremo Tribunal Federal (STF). Supremo reconhece união homoafetiva [Internet]. 2011 [acessado 2015 dez 14]. Disponível em: http://www.stf.jus.br/portal/cms/verNoticiaDetalhe.asp?idConteudo=178931.
http://www.stf.jus.br/portal/cms/verNoti... . In 2013, the medical standard regulating the practice’s operation in the country provided couples of women and men access to reproductive technologies (RT)¹⁶16 Conselho Federal de Medicina (CFM). Resolução nº 2.013/2013 [Internet]. [acessado 2015 abr 9]. Disponível em: http://www.portalmedico.org.br/resolucoes/CFM/2013/2013_2013.pdf.
http://www.portalmedico.org.br/resolucoe... .

In this decade, national studies focus on how these gay and lesbian couples build a parenting project, what are the paths to making it viable, and how they manage to become parents in light of the legal implications in the medical and family law fields¹²12 Machin R. Homoparentalidade e adoção:(re) afirmando seu lugar como família. Psicol Soc 2016; 28:350-359.^,1717 Vitule C, Couto MT, Machin R. Casais de mesmo sexo e parentalidade: um olhar sobre o uso das tecnologias reprodutivas. Interface (Botucatu) 2015; 19:1169-1180.

18 Costa PA. Homoparentalidade: que famílias, que experiências? In: Leal I, Pimenta F, Marques M, coordenadoras. Intervenção em Psicologia clínica e da saúde: modelos e práticas. Lisboa: Placebo; 2012. p. 115-128.^-1919 Vilhena J, Souza ACB, Uziel AP, Zamora MH, Novaes JV Que família? Provocações a partir da homoparentalidade. Rev Mal-Estar Subjetividade 2011; 11(4):1639-1658.. These studies signal a cultural change regarding the paths to build a family, whether through access to biomedicine and reproductive technologies (RT) or adoption. Furthermore, the paths to exercising parenthood are surrounded by distinct institutional (im)possibilities (operated by law and health). In this sense, investigations during this period seek to establish which force correlations influence the realization of these couples’ experience of forming families with children.

Scientific health production in focus

In order to map the scientific production about homoparenthood in the field of health in general, we adopted the strategy of searching for review articles on the subject as we understand that this type of article can provide us with a mapping on the subject. In this sense, we conducted two brief surveys. The first was on Google Scholar (https://scholar.google.com.br) on August 10, 2023. This survey identified six reviews²⁰20 Biasutti CM, Nascimento CRR, Gato J, Bortolozzo ML. Same-sex parenting in Brazil and Portugal: An integrative review. Res Soc Develop 2022; 11(16):e357111638227.

21 Ferreira EPP, Fernandes MFSF, Bragança RAP, Maceiras M. Midwife's interventions to promote positive experiences for female homosexual couples during pregnancy: a scoping review. J Nurs Edu Practice 2022; 12(9):54-62.

22 Leal D, Gato J, Coimbra S, Freitas D, Tasker F. Social support in the transition to parenthood among Lesbian, gay, and bisexual persons: a systematic review. Sexuality Res Soc Policy 2021; 18:1165-1179.

23 Mata JJ, Santos MA, Scorsolini-Comin F. Conjugalidade e parentalidade em casais homossexuais e heterossexuais: revisão integrativa da literatura. Pensando Famílias 2020: 24(2):32-45.

24 Santos AB, Bossi TJ. A Vivência da parentalidade por casais homossexuais: revisão sistemática de teses e dissertações. Pensando Famílias 2022: 26(1):152-166.

25 Santos YGS, Scorsolini-Cominb F, Santos MA. Homoparentalidade masculina: revisando a produção científica. Psicol Reflex Crítica 2013; 26(3):572-582.^-2626 Viana FDC, Leite CB, Torres CMG, Martins VF, Barbosa GS, Diniz JA, Ramos FS. Considerações sobre a homoparentalidade adotiva: uma revisão integrativa da literatura. Rev Casos Consultoria 2022; 13(1):e13129319. in the 2020-2023 defined period. The second survey was run on the BVS Regional Portal (https://bvsalud.org) on August 18, 2023, without a search year filter, and identified four other reviews⁴4 Cecílio MS, Scorsolini-Comim F, Santos MA. Produção científica sobre adoção por casais homossexuais no contexto brasileiro. Estud Psicol 2013; 3(18):507-516.^,2626 Viana FDC, Leite CB, Torres CMG, Martins VF, Barbosa GS, Diniz JA, Ramos FS. Considerações sobre a homoparentalidade adotiva: uma revisão integrativa da literatura. Rev Casos Consultoria 2022; 13(1):e13129319.

27 Lucio FPS, Araújo EC. A maternidade de mães lésbicas na perspectiva da enfermagem: revisão integrativa. Rev Eletr Enf 2017; 19:a08.^-2828 Ruiz JM, Borges CAP, Hueb MFD, Tilio R, Scorsolini-Comin F. Gender and adoption in the brazilian context: an integrative review of the scientific literature. Trends Psychol 2019; 27(2):293-308., one of which had already been found in the first survey²⁴24 Santos AB, Bossi TJ. A Vivência da parentalidade por casais homossexuais: revisão sistemática de teses e dissertações. Pensando Famílias 2022: 26(1):152-166..

Regarding the analysis context, most reviews consider national and international production. As an exception, we identified one review focusing on the Brazilian context²⁸28 Ruiz JM, Borges CAP, Hueb MFD, Tilio R, Scorsolini-Comin F. Gender and adoption in the brazilian context: an integrative review of the scientific literature. Trends Psychol 2019; 27(2):293-308., and another establishes comparisons between the Brazilian and Portuguese²⁰20 Biasutti CM, Nascimento CRR, Gato J, Bortolozzo ML. Same-sex parenting in Brazil and Portugal: An integrative review. Res Soc Develop 2022; 11(16):e357111638227. contexts.

Most studies address gay and lesbian families together. Two studies limit the analysis to questions about lesbians, focusing on the area of nursing in addressing pregnancy and prenatal care²¹21 Ferreira EPP, Fernandes MFSF, Bragança RAP, Maceiras M. Midwife's interventions to promote positive experiences for female homosexual couples during pregnancy: a scoping review. J Nurs Edu Practice 2022; 12(9):54-62. and lesbian motherhood²⁷27 Lucio FPS, Araújo EC. A maternidade de mães lésbicas na perspectiva da enfermagem: revisão integrativa. Rev Eletr Enf 2017; 19:a08.. One study focuses on gay people’s family issues²⁵25 Santos YGS, Scorsolini-Cominb F, Santos MA. Homoparentalidade masculina: revisando a produção científica. Psicol Reflex Crítica 2013; 26(3):572-582.. When the LGBT community is mentioned in the texts, they mainly appear as support to homoparental families²⁰20 Biasutti CM, Nascimento CRR, Gato J, Bortolozzo ML. Same-sex parenting in Brazil and Portugal: An integrative review. Res Soc Develop 2022; 11(16):e357111638227.

21 Ferreira EPP, Fernandes MFSF, Bragança RAP, Maceiras M. Midwife's interventions to promote positive experiences for female homosexual couples during pregnancy: a scoping review. J Nurs Edu Practice 2022; 12(9):54-62.^-2222 Leal D, Gato J, Coimbra S, Freitas D, Tasker F. Social support in the transition to parenthood among Lesbian, gay, and bisexual persons: a systematic review. Sexuality Res Soc Policy 2021; 18:1165-1179..

Regarding the theoretical-conceptual approach, two reviews highlight that their primary sources are anchored in Psychoanalysis, Anthropology, and Law²⁵25 Santos YGS, Scorsolini-Cominb F, Santos MA. Homoparentalidade masculina: revisando a produção científica. Psicol Reflex Crítica 2013; 26(3):572-582.^,2727 Lucio FPS, Araújo EC. A maternidade de mães lésbicas na perspectiva da enfermagem: revisão integrativa. Rev Eletr Enf 2017; 19:a08., while two reviews base their analyses on psychological aspects⁴4 Cecílio MS, Scorsolini-Comim F, Santos MA. Produção científica sobre adoção por casais homossexuais no contexto brasileiro. Estud Psicol 2013; 3(18):507-516.^,2424 Santos AB, Bossi TJ. A Vivência da parentalidade por casais homossexuais: revisão sistemática de teses e dissertações. Pensando Famílias 2022: 26(1):152-166..

Among the main conclusions of the reviews, we highlight the following: (a) feelings related to the family of same-sex couples and belonging to it is unrelated to sexual orientation²⁴24 Santos AB, Bossi TJ. A Vivência da parentalidade por casais homossexuais: revisão sistemática de teses e dissertações. Pensando Famílias 2022: 26(1):152-166.; (b) progress in the legal field promoted advances in the rights of homosexual families²⁴24 Santos AB, Bossi TJ. A Vivência da parentalidade por casais homossexuais: revisão sistemática de teses e dissertações. Pensando Famílias 2022: 26(1):152-166.; (c) raising children in same-sex families does not differ from raising children in so-called conventional families²⁸28 Ruiz JM, Borges CAP, Hueb MFD, Tilio R, Scorsolini-Comin F. Gender and adoption in the brazilian context: an integrative review of the scientific literature. Trends Psychol 2019; 27(2):293-308.; (d) when establishing a family, gay men receive less support from the family than lesbians and lesbians receive less support than heterosexual women²²22 Leal D, Gato J, Coimbra S, Freitas D, Tasker F. Social support in the transition to parenthood among Lesbian, gay, and bisexual persons: a systematic review. Sexuality Res Soc Policy 2021; 18:1165-1179.; (e) gays are sometimes seen as incapable of being parents because of stereotypes about their gay identity²²22 Leal D, Gato J, Coimbra S, Freitas D, Tasker F. Social support in the transition to parenthood among Lesbian, gay, and bisexual persons: a systematic review. Sexuality Res Soc Policy 2021; 18:1165-1179.; (f) adoption can be a way to establish parenthood for homosexual couples²³23 Mata JJ, Santos MA, Scorsolini-Comin F. Conjugalidade e parentalidade em casais homossexuais e heterossexuais: revisão integrativa da literatura. Pensando Famílias 2020: 24(2):32-45.^,2626 Viana FDC, Leite CB, Torres CMG, Martins VF, Barbosa GS, Diniz JA, Ramos FS. Considerações sobre a homoparentalidade adotiva: uma revisão integrativa da literatura. Rev Casos Consultoria 2022; 13(1):e13129319. and (g) health professionals must be better prepared for prenatal care for lesbians²¹21 Ferreira EPP, Fernandes MFSF, Bragança RAP, Maceiras M. Midwife's interventions to promote positive experiences for female homosexual couples during pregnancy: a scoping review. J Nurs Edu Practice 2022; 12(9):54-62.^,2727 Lucio FPS, Araújo EC. A maternidade de mães lésbicas na perspectiva da enfermagem: revisão integrativa. Rev Eletr Enf 2017; 19:a08..

Regarding the focus of discussion, whether centrally or secondarily, production on the subject calls into question the hegemony of the heteronormative family so that homoparenthood can be considered. This questioning occurs mainly with arguments that there are no differences in caring for children between heterosexual and same-gender couples. Longitudinal studies of children raised by same-gender couples have attested that there are no psychological impairments in these children.

We should further investigate same-sex families and open space for their opinions in the scientific debate in order to move forward in the discussion on taking the heteronormative family as a reference, as some reviews state. As Bourdieu²⁹29 Bourdieu P. Des familles sans nom. Actes Recherche Sci Soc 1996; 113:3-5. observes, unusual family configurations, through the questions they promote, can reveal principles of vision hitherto unseen, “like the glasses we look for when we have them on our nose and which, established in things and bodies, ensure an unquestionably obvious status to the ways of being or doing, those of the so-called normal family, thus represented as absolute norms”²⁹29 Bourdieu P. Des familles sans nom. Actes Recherche Sci Soc 1996; 113:3-5.(p.3).

Seeking to understand the establishment of the family of same-gender couples and other family schemes that deviate from the hegemonic norm, production must advance in discussing the family and kinship concepts. Weston³⁰30 Weston K. Families we choose: lesbians, gays, kinship. New York/Oxford: Columbia University Press; 1997. notes that families should not be confused with genealogically defined relationships. According to the author, in the United States, gays and lesbians consider the family to be the chosen one, involving people you can count on emotionally and materially. Choosing who is a relative may include friends, lovers, co-parents, adopted children, children from previous heterosexual relationships, and those conceived through alternative insemination³⁰30 Weston K. Families we choose: lesbians, gays, kinship. New York/Oxford: Columbia University Press; 1997.. On the other hand, “a lover’s biological or adoptive parents may not be classified as relatives, depending on their attitudes of ‘rejection’ or ‘acceptance’”³⁰30 Weston K. Families we choose: lesbians, gays, kinship. New York/Oxford: Columbia University Press; 1997.(p.112).

Advancing the discussion on the family and kinship concepts, we can also include Sahlins’ analyses³¹31 Sahlins M. What Kinship Is-And Is Not. Chicago: The University of Chicago Press; 2013., which conceives kinship as a matter of “mutuality of being”, in which - in a logic of intersubjective belonging - they are people who are intrinsic to each other’s existence. The author observes that several forms of kinship formation appear in the logic of “mutuality”, whether through “consanguineous” or “affinal” routes, and group descent arrangements.

Besides the relationships between family and kinship not explored in-depth in the reviews analyzed, we also observed that issues related to the assisted reproduction method should be discussed. When it appears, this method is mentioned only to establish parenthood, together with adoption, without going in depth. We will discuss these issues below to fill this gap.

Sociopolitical dimensions surrounding homoparenthood-health relationships

Social movements are conceived as sociopolitical actions built by collective stakeholders from different classes and social strata. They can contribute to developing and transforming civil society, involving different areas, such as education and health³²32 Gohn MG. Teorias dos Movimentos Sociais: paradigmas clássicos e contemporâneos. São Paulo: Loyola; 1997.^,3333 Gomes R. Participação dos movimentos sociais na saúde de gays e lésbicas. Cien Saude Colet 2021; 26(6):2291-2300.. Adam³⁴34 Adam BD. Epistemic fault lines in biomedical and social approaches to HIV prevention. J Int AIDS Soc 2011; 14(Supl. 2):S2. observes that the success of social movements can result in robust agendas within the scope of political demands.

With the AIDS epidemic, the so-called “new social movements” emerged with different forms of involvement with science³³33 Gomes R. Participação dos movimentos sociais na saúde de gays e lésbicas. Cien Saude Colet 2021; 26(6):2291-2300.. An example of alliances between biomedicine and social movements that resulted in the transformation of medical practice in treating AIDS is the extensive study by Epstein³⁵35 Epstein S. The Construction of Lay Expertise: AIDS Activism and the Forging of Credibility in the Reform of Clinical Trials. Sci Techn Human Values 1995; 20(4):408-437..

In some countries, the achievements of gays and lesbians in the field of health can be attributed to the alliances established between these stakeholders’ movements and other movements, such as AIDS activism and feminism³³33 Gomes R. Participação dos movimentos sociais na saúde de gays e lésbicas. Cien Saude Colet 2021; 26(6):2291-2300.. According to Green et al.³⁶36 Green JN, Quinalha R, Caetano, Fernandes M. Apresentação. 40 anos do movimento LGBT brasileiro. In: Green JN, Quinalha R, Caetano, Fernandes M, organizadores. História do Movimento LGBT no Brasil. São Paulo: Alameda; 2018. p. 9-13., the gay movement emerged in some countries in the late 1960s, and the current LGBTI+ movement is already four decades old in Brazil.

Gomes³³33 Gomes R. Participação dos movimentos sociais na saúde de gays e lésbicas. Cien Saude Colet 2021; 26(6):2291-2300. observes that - although the participation of social movements in struggles for the health of gays and lesbians began in the first years of the last century - in the 21^st century, in some countries, political demands emerged in social agendas, while in others, only meager rights’ concessions were achieved. This author affirms that the Ministry of Health should continually undertake political actions to guarantee health rights for all gender identities and sexual orientations.

More significant potential for mobilization aimed at non-hegemonic sexual rights was possible in some countries, as gay and lesbian movements aligned themselves with the demands of other gender identities, such as bisexuals and transgenders³²32 Gohn MG. Teorias dos Movimentos Sociais: paradigmas clássicos e contemporâneos. São Paulo: Loyola; 1997..

French society is an example to be mentioned regarding the recognition of homoparenthood. Since 1980, this topic has emerged as an object of social and human sciences, and the Association des Parents Gays et Lesbiens (APGL) played an essential political role in this regard¹1 Gross M. Histoire des revendications homoparentales en France. Bull d'Histoire Politique 2010; 18(2):113-123.. Since 1986, the APGL has focused on gays and lesbians who have or intend to have and raise children (APGL, 2013).

In Brazil, the LGBT movement has been active for more than four decades, influencing politics in different areas, including health³⁷37 Quinalha R. Movimento LGBTI+: Uma breve história do século XIX aos nossos dias. Belo Horizonte: Autêntica; 2018.^,3838 Ferreira BO, Nascimento M. A construção de políticas de saúde para as populações LGBT no Brasil: perspectivas históricas e desafios contemporâneos. Cien Saude Colet 2022; 27(10):3825-3834.. Some relevant achievements over this period were the National Comprehensive LGBT Health Policy, launched in 2011, the recognition of same-sex marriage, established in 2013 by Resolution No. 175 of the National Council of Justice, and the Federal Supreme Court’s criminalization of homophobia, equivalent to the crime of racism, in 2019.

Likewise, the Yogyakarta Principles³⁹39 Princípios de Yogyakarta mais 10. Princípios e obrigações estatais adicionais sobre a aplicação da legislação internacional de direitos humanos em relação à orientação sexual, identidade de gênero, expressão de gênero e às características sexuais que complementam os Princípios de Yogyakarta. 2017., an international document that recognizes rights violations based on sexual orientation or gender identity as human rights violations, includes, in principle 24, State obligations regarding the right to establish a family⁴⁰40 Bandeira K. Comissão da Câmara pauta projeto que proíbe casamento homoafetivo [Internet]. O Globo; 2023. [acessado 2023 set 24]. Disponível em: https://oglobo.globo.com/brasil/noticia/2023/09/19/comissao-da-camara-pauta-projeto-que-proibe-casamento-homoafetivo.ghtml.
https://oglobo.globo.com/brasil/noticia/... , regardless of sexual orientation or gender identity, which means, in the international human rights setting, recognizing the multiple families and possible parental schemes.

Recognizing homoparental families has been an agenda of the LGBT movement and specific groups, such as the Brazilian Association of Homotransaffective Families. However, we should emphasize that although there have been significant achievements in recent decades, we also live with ongoing attempts at regression, such as Bill No. 5,167, of 2009, contrary to same-sex marriage, to be voted on in the National Congress, with the justification of that “to approve homosexual marriage is to deny how all men are born in this world and attacks the existence of human species”⁴⁰40 Bandeira K. Comissão da Câmara pauta projeto que proíbe casamento homoafetivo [Internet]. O Globo; 2023. [acessado 2023 set 24]. Disponível em: https://oglobo.globo.com/brasil/noticia/2023/09/19/comissao-da-camara-pauta-projeto-que-proibe-casamento-homoafetivo.ghtml.
https://oglobo.globo.com/brasil/noticia/... . It is worth noting that, unlike other countries where same-sex marriage resulted from a specific law, in the Brazilian case, no law allows and regularizes same-sex marriage. However, STF’s decision to recognize common law marriage in 2011 and CNJ’s decision that determined that registry offices were obliged to perform same-sex marriages in 2013 grant rights to couples before Brazilian law and justice.

Thus, the debate on same-sex marriage, homoparenthood, and other possible family arrangements concerns not only legal issues but, as Grossi⁴¹41 Grossi M. Parceria civil: realidade ou utopia? In: Mello L. Novas famílias: conjugalidade homossexual no Brasil contemporâneo. Rio de Janeiro: Garamond; 2005. already called our attention, a “political clash” in which different “citizenship conceptions” are at play.

Limits and possibilities for exercising reproductive rights among homoparental couples

The political, cultural, and legislative transformations around decriminalizing same-gender attraction, the equality of same-sex couples for civil marriage, the demand for recognition of child adoption, and the access to reproductive technologies in different societies in recent decades were generated by changes in paradigms and mentalities, whose essential reference is fighting for the recognition of equal rights for LGBT groups. In this context, we underscore the reference to the principle of equal rights for citizens, which is more relevant than the supposed praise for “difference”⁴²42 Almeida MV. A chave do armário. Homossexualidade, casamento, família. Florianópolis: Ed. UFSC; 2010..

Although we have seen in different societies significant advances toward recognizing the rights of gay people to establish parenthood and non-discrimination based on sexual orientation in the last decades, the heterosexual couple’s centrality still prevails in several areas. Furthermore, the emergence of conservative and far-right political positions has grown in different countries, and they question these rights and have sought to establish an agenda to revoke these achievements.

In this sense, access to parental rights may still involve legal and social uncertainties for many same-sex couples who intend to exercise their right or even those who have already formed a family⁴³43 Park N, Schmitz RM, Slauson-Blevins K. "It Takes a Lot of Planning": Sexual Minority Young Adult Perceptions of Gay and Lesbian Parenthood. J Family Issues 2020; 41(10):1785-1809.. These rights understood within human rights as reproductive rights are anchored in the recognition of the fundamental right to autonomy necessary for the exercise of the reproductive capacity of every couple and individual; in other words, deciding freely and responsibly about having or not having children and how many, choosing the appropriate time for reproduction and how it will occur⁴⁴44 Manifesto da Campanha por uma Convenção Interamericana dos Direitos Sexuais e dos Direitos. Rev Estud Feministas 2007; 15(1):1-24..

These groups’ building parenthood involves different processes from those in heterosexual couples. It can also be seen as a product of these contexts’ different institutional reproduction possibilities. Thus, it is configured as a co-producer of these family forms, such as access to public policies, which provide the adoption or access to reproductive technologies and national health systems¹⁷17 Vitule C, Couto MT, Machin R. Casais de mesmo sexo e parentalidade: um olhar sobre o uso das tecnologias reprodutivas. Interface (Botucatu) 2015; 19:1169-1180.. The literature on the subject has highlighted that parenting projects for sexual minorities are based on a mature and reflected decision and, therefore, with a commitment to parenting, to the extent that they need to seek ways to make a family that does not occur directly from the exercise of sexuality⁴³43 Park N, Schmitz RM, Slauson-Blevins K. "It Takes a Lot of Planning": Sexual Minority Young Adult Perceptions of Gay and Lesbian Parenthood. J Family Issues 2020; 41(10):1785-1809.^,4545 R, Maria M, López GF. Meeting-Abstract: Families with Lesbian Mothers and Gay Fathers in Spain after the Legislative Change: From Legal to Real Equality. Culture Health Sexuality 2011; 13(Supl. 1):S1-S179.^,4646 Riskind R, Patterson C. Parenting intentions and desires among childless lesbian, gay, and heterosexual individuals. J Family Psychol 2010; 24(1):78-81.. In this sense, by moving away from the discussion of sexual procreation and biogenetic affiliation forms, these groups bring new contributions to the social debate.

Some questions surrounding the construction of this project can be expressed as how they would like to have a child, if they would like to adopt, who would participate in this process (doing it alone or with a partner), and whether they would like to be genetically/biologically involved in parentage⁴⁷47 Carvalho PGC. Homoparentalidade feminina: nuances da assistência à saúde durante concepção, gravidez, parto e pós-parto [tese]. São Paulo: Faculdade de Saúde Pública, Universidade de São Paulo; 2018.^,4848 Fonseca C. Homoparentalidade: novas luzes sobre o parentesco. Estud Fem 2008; 16(3):769-783.. The answers to these questions can establish different trajectories for their implementation and involve more significant limitations or possibilities.

The literature has revealed that access to reproductive technologies for the construction of homoparenthood among women has been increasing in most countries that recognize this right, such as the United Kingdom, United States, Brazil, Canada, and Australia⁴⁹49 Mamo L. Queering reproduction: achieving pregnancy in the age of technoscience. Durham & London: Duke University Press; 2007.^,5050 Luce J. Beyond expectation: lesbian/Bi/queer women and assisted reproduction. Toronto: University of Toronto Press; 2010.. In some countries, this access occurs through national health systems, as in the United Kingdom and Canada, or through the private sector, as in the USA. In Brazil, the 2013 Federal Council of Medicine resolution explicitly mentions access to reproductive technologies for same-sex couples. However, the practice was already performed in some clinics, as some studies have recorded¹⁷17 Vitule C, Couto MT, Machin R. Casais de mesmo sexo e parentalidade: um olhar sobre o uso das tecnologias reprodutivas. Interface (Botucatu) 2015; 19:1169-1180.^,5151 Correa MEC. Duas mães? Mulheres lésbicas e maternidade [tese]. São Paulo: Faculdade de Saúde Pública, Universidade de São Paulo; 2012.. Another critical element in this situation was the permission of the Federal Council of Medicine to implement the technique known as ROPA (Reception of Ovules by the Partner). Through this technique, both women participate in the process of in vitro fertilization, and one donates ovules so that the other can get pregnant. The technique allows the biological connection of both with the child to be generated¹⁷17 Vitule C, Couto MT, Machin R. Casais de mesmo sexo e parentalidade: um olhar sobre o uso das tecnologias reprodutivas. Interface (Botucatu) 2015; 19:1169-1180..

More significant restrictions are identified in establishing male homoparenthood through access to reproductive technologies, as this involves the practice of surrogate pregnancy (or temporary transfer of the uterus), which has legal restrictions in several countries. Some of them allow the practice for heterosexual couples but restrict the participation of same-gender couples, such as in Russia and Ukraine. In other countries, it is regulated and authorized for heterosexual couples, same-gender couples, and even single people, such as in some states in the United States and Mexico, Belgium, South Africa, and Colombia. Some countries prohibit remuneration for this practice, such as Australia, the United Kingdom, and Canada⁵²52 Olavarría ME. La gestación para otros en México. Parentesco, tecnología y poder. Ciudad de México: Gedisa-Universidad Autónoma Metropolitana; 2018.^,5353 Parry B. Surrogate Labour: Exceptional for Whom? Economy Soc 2018; 47(2):214-233.. In Brazil, regulation is defined by the Federal Council of Medicine (CFM resolution No. 2,320/2022). Since the first resolution in 1992, only intra-family surrogacy has been allowed, with exceptions that must be screened by the CFM, and practice commercialization is prohibited.

The diverse context of international regulations and limited access to the practice for gay couples means that many need to leave their country of residence to undergo the procedure. The increasing “pilgrimage” in search of reproductive services has been linked to internationalized health services, with the establishment of reproductive connectivity networks that adapt to national and regional laws, technological development, and people mobility, bringing new issues and challenges within the exercise of rights.

Furthermore, it is crucial to consider that some of these possibilities of access to reproductive rights for same-sex couples may represent economic barriers, reinforcing social and health inequalities, as they involve costs to be incurred through private services as they are not available in national health systems⁴³43 Park N, Schmitz RM, Slauson-Blevins K. "It Takes a Lot of Planning": Sexual Minority Young Adult Perceptions of Gay and Lesbian Parenthood. J Family Issues 2020; 41(10):1785-1809..

Regarding adoptions, studies have shown that even in contexts where adoption is legal for gay or lesbian couples and people, legal and social assistance professionals’ prejudice, and homophobia vis-à-vis their ability to exercise parenthood can represent practical obstacles to the exercise of their rights⁴³43 Park N, Schmitz RM, Slauson-Blevins K. "It Takes a Lot of Planning": Sexual Minority Young Adult Perceptions of Gay and Lesbian Parenthood. J Family Issues 2020; 41(10):1785-1809.^,5454 Farr D, Goldberg A. Sexual orientation, gender identity, and adoption law. Family Court Rev 2018; 56(3):374-383..

Final considerations

Including the debate on homoparenthood in the health field, in general, can raise several questions so that actions can be planned and implemented. One challenge is facing the strangeness of this theme to the idea of the so-called “normal” family based on heteronormative logic. Even in countries with some legal apparatus that ensures rights to homoparental families, their members suffer prejudice, discrimination, and violence.

One of the strategies for coping with this situation comes with developing investigations that show, for example, that children raised within these families do not show developmental differences compared to those in heterosexual families. This is the response from researchers in the field of health that somehow seeks, by disseminating knowledge, to achieve some success in the long term by thinking about the family under the logic of diversity.

Another strategy that can bring advances in recognizing homoparenthood in the social order is the alignment that can be established between actions in the health sector and those promoted by social movements or social activism. In some countries, such as Brazil, this alignment around AIDS, for example, has historically produced opportunities for rights to be guaranteed to those infected with HIV. In the case of homoparenthood, if health professionals wish to undertake alignments with other social sectors, it is necessary to map the potential political stakeholders who can join the discussion on the rights of homoparental families to comprehensive health care for their family members.

Regardless of these strategies, the health sector faces an internal challenge of reflecting on the training of its professionals to address the issue in question. What skills are needed for these professionals to recognize the health needs of homoparental families? How do we accommodate the demands of these families? How do we customize health protocols for these families?

These questions, among others, motivate us to continue debating the possible relationships between homoparenthood and health in general.

References

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