Understanding Multilevel Predictors Affecting Family Formation Among Sexual and Gender Minority Couples

In September, Cindy Veldhuis, PhD, received her first R01 grant. The project is titled, “Understanding multilevel predictors affecting family formation among sexual and gender minority couples.” Co-investigators include Oluwateniola (Teni) Brown, MD, assistant professor of Obstetrics and Gynecology, Maria Pyra, PhD, MPH, assistant professor of Medical Social Sciences, and Ricky Hill, PhD, research assistant professor at the Institute for Sexual and Gender Minority Health and Wellbeing. 

External co-investigators include Brittany Charlton, MSc, ScD, Harvard Medical School, Harvard Pilgrim Health Care, and Harvard T.H. Chan School of Public Health and Abbie Goldberg, PhD, Clark University. 

What are the aims of the project?  

Most research on decisions whether or not to have children focuses on micro-level factors like income and job security. However, we know that during times of high national stress (like the Great Recession and 9/11), rates of having children dropped.  A sole focus on micro-level factors situates family formation within individuals and ignores structurally- and historically-produced inequities driving disparities. The goal of the study is thus to take a multi-level approach to understanding family formation desires and plans among sexual and gender minority couples (SGM).  

Almost 40 percent of SGM people wish to parent but may face insurmountable barriers causing thwarted family plans. Becoming a parent for SGM people is not as straightforward as for cisgender heterosexual couples. It is complex, expensive and often uncertain as it may involve adoption, fostering and reproductive technologies—all of which are vulnerable to state-level policies. We are thus particularly interested in how the confluence of systemic/structural racism, sexism (e.g., threats to reproductive rights), and trans/homophobia (e.g., anti-trans legislation) may affect how SGM couples are making decisions about whether, how, and when to have children.  To capitalize on a dynamic social context that uniquely supports a natural experiment of the health and wellbeing impacts of sociopolitical change, we will fill gaps in knowledge by conducting a prospective mixed-methods study among SGM couples. This project will produce the first investigation of how multi-level factors prospectively influence SGM couples’ family formation. 

What are your next steps? 

We are currently forming a community advisory board to advise on all aspects of the study from design to recruitment to interpretation of findings. Once our community advisory board is formed, we will begin focus groups to help shape a large-scale survey of sexual and gender minority couples and what they perceive as influences on their family formation plans. 

What do you hope will come out of this funded research? 

This work is anticipated to have a significant public health impact by revealing for the first time the multi-level needs of SGM couples as they form families, thereby informing future intervention efforts to reduce entrenched disparities.  

There is a dearth of research on family formation planning among SGM, which is reflected in challenges for SGM couples in finding culturally competent family planning care. Data suggests that SGM couples, particularly same-gender couples, are often not asked about family formation plans in healthcare settings and that healthcare providers are underprepared to provide culturally competent support. Our goal with this study is thus largely to inform clinical care—across fields like obstetrics and gynecology, psychology, and nursing—in how to: help SGM couples plan families, discuss the unique issues and concerns SGM couples may have in a culturally informed way and how to deliver care that is inclusive of these needs.  

If our hypothesis that structural stigma plays a role in family planning is borne out, the importance of considering the broader context surrounding SGM couples and their decision-making processes should scaffold culturally competent care. Being unable to have children due to infertility or recurrent pregnancy loss has mental health impacts—less understood are the wellbeing impacts of not being able to have children for other reasons, particularly when family formation is thwarted at the structural level. If our hypothesis that multi-level barriers to family planning have impacts on couple functioning and/or mental health, then this will have direct implications for clinical care and supporting SGM couples through these processes (e.g., referrals to psychotherapy or support groups; ensuring that psychotherapy is inclusive of these potential impacts). Our data can elucidate how to intervene with SGM families experiencing high levels of stressors—like from structural stigma—to ensure healthy family outcomes.