Flourishing Families: Promoting Public Health and Reproductive Justice for All by Protecting and Supporting LGBTQ+ Families in Policy and Practice

We are researchers, practitioners, and advocates working with and for LGBTQ+ people (lesbian, gay, bisexual, transgender, queer or questioning, or people whose identities are outside dominant groups of heterosexual sexual identities). We observe with alarm the medical and scientific establishment’s muted responses to the onslaught of executive orders narrowly targeting LGBTQ+ people and broadly endangering reproductive health and autonomy. Efforts to relegate sexual and gender minorities to invisible, second-class status are the opening salvo in a broader attack upon the rights, autonomy, and dignity of women; racial, ethnic, and religious minorities; immigrants; and people with disabilities.

The current assault on the reproductive rights and medical autonomy of women and LGBTQ+ people is ironically cloaked under the guise of promoting their well-being. Orders intended to end legal recognition of transgender and nonbinary people (e.g., limiting access to identity documents, health care, services, and facilities); permitting discrimination on the basis of sexual orientation, gender identity, and gender expression (SOGIE); halting foreign medical aid; and reinstating the abortion “gag rule” abroad are clearly harmful.¹ Perhaps less apparent are the pernicious motives underlying plans to improve access to in vitro fertilization (IVF) for “loving and longing mothers and fathers.”² All evidence indicates that such policies will deliberately exclude hopeful parents who are LGBTQ+ or otherwise deemed unfit to produce “beautiful” babies.² The aim: to selectively promote the reproduction of people with traits deemed “desirable” while hindering the reproduction of people with so-called “undesirable” traits.

Such reproductive governance will codify discrimination, entrench existing inequities, and, coupled with outdated parentage laws, leave many LGBTQ+ or queer parents and their children legally vulnerable (“LGBTQ+” and “queer” are used interchangeably herein). An especially insidious aspect of this regressive reproductive crusade is its effort to (re)define the concept of family and to weaponize the nuclear family—described as “the greatest form of governance known to humankind”³—as a primary vehicle of social and economic oppression. US law derives from English common law, in which the family as a legal structure existed to secure patrilineal inheritance, yielding the “presumption of legitimacy” for marital children. Under “coverture,” aspects of which existed in the United States until the 1970s, married women had no autonomous legal existence. The nuclear family enables capitalism by privatizing and devaluing caregiving labor, thereby disadvantaging many women as wage arners. The campaign to define family narrowly as heterosexual, cisgender, dyadic, and procreative pathologizes and disadvantages childless, childfree, single-parent, multiparent, extended, chosen, and Tribal families. Moreover, this narrow family model excludes the vast majority of US families, which are diverse and flexible in structure.⁴

As researchers and medical, health, and legal professionals specializing in LGBTQ+ reproduction, parenting, and families, we have witnessed firsthand the struggle for recognition and against oppression, the fostering of resiliency, and the cultivation of well-being, pride, and joy within LGBTQ+ families. We have studied reproductive technologies from donor insemination⁵ to the stratifications of assisted reproduction (including gamete donation and IVF).^6,7 We have advised on US policy relating to family, reproduction, and health care⁸ and witnessed the heartbreak of genetically unrelated parents denied access to children they parented since birth.⁹ We have worked with thousands of people raised by LGBTQ+ parents, who are directly experiencing the harmful impact of anti-LGBTQ+ policy and rhetoric and increasingly fear for their families’ safety. We have assisted tens of thousands of LGBTQ+ people through planning, conceiving, gestating, and birthing babies into loving families.¹⁰ “Pride” as celebrated by racial and sexual minority communities denotes “a collective sense of self-worth,” while “joy”—contra fleeting “happiness”—signifies “the ability to affirm the goodness of life even in the midst of sorrow.”^11,12 Evocatively, children often are described as their families’ “pride and joy.”

From the depth of our expertise, we wish to signal a reminder, a warning, and a call to action for all whose mandate is to promote public health and well-being.

FIRST, THE REMINDER

The concept of family is integral to the queer community, and children raised by LGBTQ+ parents and same-sex couples fare similarly to children raised by cisgender, heterosexual-couple parents.

Family Is Central to LGBTQ+ Communities

Family—which we define broadly as relationships of care over time that may or may not involve genetic ties, sexual intimacy, reproduction, or child-rearing and may include individuals of varying ages within or across generations—has always been a central structure supporting queer well-being throughout history, whether recognized or not.¹³ LGBTQ+ people embrace family so fundamentally as to claim the Sister Sledge song, “We Are Family” as a cultural anthem. LGBTQ+ families are often referred to as “chosen families,” evoking the ways in which LGBTQ+ communities create families, which transcend heteronormative, biologically based family structures.¹⁴

Narrow conceptions of family result in concrete harms in the context of federal policies. In a 2020 report, The Center for American Progress urged federal policymakers to understand that the failure to “fully recognize that chosen families exist causes real harm … from the insult of not being recognized to not being included in or covered by certain benefits or programs.”¹⁵ Defining family informs a wide range of policies and practices, including determining access to employment benefits, custodial rights, survivorship benefits, housing access, and more. Many LGBTQ+ families include children: currently, nearly one in five US LGBTQ+ adults (18%) are parenting children younger than 18 years—a total of 2.6 million families. Because Black LGBTQ+ adults are more likely than White adults to be parenting (23% vs 17%), and LGBTQ+ parents are more likely to experience poverty (33%) than LGBTQ+ nonparents (21%), policies impacting LGBTQ+ parents and their children disproportionately impact families of color and poor families.¹⁶ Queer families promote lifelong well-being, providing a crucial source of support and means of survival amid pervasive homophobia and transphobia and rejection and abuse inflicted by families of origin.¹⁷ Our professional and personal experiences of queer family inform our recognition of the importance of defining “family” broadly to include nongenetic kinship and diverse family structures.

The Kids Are Alright

The data are crystal clear: the quality and security of familial relationships matter for children’s well-being; the gender or sexual orientation of their parent(s) does not. Regardless of how measured—whether in population-based samples or among subsets of families, such as those created through assisted reproduction—children raised by LGBTQ+ parents and same-sex couples fare similarly to children raised by cisgender, heterosexual-couple parents in health, quality of family relationships, and outcomes in adulthood.¹⁸ Queer people build families in diverse ways, parenting children born through assisted reproduction, adopted privately or from foster care, and originated during previous different-sex relationships, within a variety of family structures. These kids are alright. Indeed, LGBTQ+ families and the providers who serve them are “ahead of the curve” in some respects. Surviving eras of invisibility and forced “passing,” criminalization, and violence has led queer families to value trust, honesty, and intentionality.

The benefits of these qualities, especially honesty, in LGBTQ+ families support donor-conceived person advocates’ call for early disclosure of donor-assisted reproduction. The Sperm Bank of California—a nonprofit originally created to serve lesbian couples and single women being refused care elsewhere—has always supported parents sharing “donor origin stories” with children and created the first open-identity option enabling interested adult donor-conceived persons to identify and possibly contact donors, potentially facilitating parental openness. Discussing donor conception openly—in contrast to historically common practices of secrecy—prevents the disruption associated with “late discovery” in adulthood and encourages children to feel comfortable about their origins, ultimately fostering positive psychological outcomes.¹⁹ Consistent with the data, the American Society of Reproductive Medicine (ASRM) updated recommendations that providers encourage parents of donor-conceived persons disclose early and often,²⁰ and clarified its definition of “infertility” in 2023 to facilitate access to care for LGBTQ+ hopeful parents.²¹

NEXT, THE WARNING

The expansion of knowledge, human rights, and civil liberties underlying advances in public health and well-being are under threat.

We must take the authors and supporters of regressive policies at their word: the family is a unit of governance. Particularly following the Dobbs decision and the ensuing retrogression of reproductive rights, attacks on LGBTQ+ people must be understood—and resisted—as steps toward the goal of stripping the civil and human rights of women, minorities, and people with disabilities. Regressive and sexist policies restricting reproductive choice and targeting LGBTQ+ people—particularly gender minorities—have proliferated for years and have at their roots the harmful social structures of misogyny, heteronormativity, and cisnormativity.

These efforts to codify inequity have intensified to unprecedented levels in legislation, and related press and social media discourse advance patently unscientific claims that support eliminating abortion, abolishing gender, reducing sex to a binary by fiat, and codifying narrow definitions of terms such as “family,” “mother,” and “father,” exacerbating vulnerabilities associated with outdated state parentage laws. To obscure the faulty bases and harmful impact of such policies, it is necessary to defund and devalue science and expertise in favor of misinformation and disinformation (i.e., “alternative facts”). Tellingly, the administration has moved to halt SOGIE data collection and research. The ultimate goal of these policies is to prevent LGBTQ+ people from full and open engagement in civic life. This crusade will not end with LGBTQ+ people. As the US Supreme Court recognized in Bostock v Clayton County (590 US 644 [2020]), sexism underlies homophobia and transphobia. This obsession with the immutable biological reality of sex serves to reinforce the reduction of women to reproductive and caregiving roles within nuclear families, threatening to roll back progress to a time—not so distant—when women were not recognized as full legal persons.

FINALLY, THE CALL TO ACTION

Professional organizations and individual professionals must speak and act to support the LGBTQ+ community and to defend science and science-based policy. In addition, public health professionals must support the modernization of state parentage laws to protect nongenetic family relationships.

Organizations Must Defend Science

It is crucial that reproductive and family policy incorporate gender-neutral language and expansive, inclusive definitions of terms such as “infertility” and “family.” The leadership of organizations such as ASRM—which advocates on behalf of professionals and patients, funds multidisciplinary research, promotes ethical practice, and provides evidence-based information—is critical at this moment. For two decades, ASRM has consistently and repeatedly affirmed its support of providing assisted reproductive services to lesbian and gay hopeful parents. Ten years ago, ASRM similarly indicated support for transgender prospective parents, stating that “[p]rograms should treat all requests for assisted reproduction without regard to gender identity.”^22(p1111) When the White House issued an executive order in January 2025 declaring that the US government thenceforth would “recognize two sexes, male and female,” and asserting that “gender identity … does not provide a meaningful basis for identification,”²³ ASRM responded swiftly, issuing a press release and evidence-based factsheet explaining gender and its differentiation from sex.²⁴ When the administration sought policy recommendations regarding IVF, ASRM expressed readiness to “engag[e] with the administration and Congress,” and urged— based upon its “deep expertise”—that medical decisions should be “made by patients and physicians, not by bureaucrats, politicians, or insurance companies,” that treatment should “meet … modern standards of care,” and that policy solutions should be “inclusive of all patients who need care.”²⁵

While such professional policy statements are urgently necessary, simply letting people through the clinic door is not enough. Providing ethical, evidence-based care to sexual and gender minority patients requires population-specific data collection and research. For example, applying routine infertility treatment protocols to same-sex female couples seeking donor conception substantially increases risk during pregnancy without significantly increasing the likelihood of achieving pregnancy.⁵ It is important for professional organizations to step forward to ensure that SOGIE data collection and cross-disciplinary research continue and to respond swiftly and decisively to disingenuous efforts to mischaracterize research documenting the negative impacts of discrimination and minority stress. Crucially, groups that historically have supported and worked in coalition with the LGBTQ+ community must not abandon us in this critical moment by cheerleading carve-outs for IVF in policies that erode reproductive rights or that expand access to reproductive health care for a subset of “desirable” prospective parents.

State Parentage Laws Must Protect Nongenetic Families

We and countless others have documented the flourishing of LGBTQ+ families, finding consistently that despite coping with prejudice and minority stress, children raised in these families are at least as healthy and resilient as children raised in so-called “traditional” families. Given the consistent and compelling body of evidence accumulated over decades demonstrating positive outcomes for children born through assisted reproduction reared by LGBTQ+ parents, it is deeply troubling that LGBTQ+ family advocacy organizations such as Children of Lesbians and Gays Everywhere (COLAGE) must continue to fight for parentage reform, even in the wake of US Supreme Court decisions legalizing same-sex marriage nationwide and guaranteeing same-sex married couples the full rights and privileges of marriage. Parentage, the legal relationship between parent and child, establishes crucial rights and responsibilities. Outdated laws in numerous US states fail to provide simple, accessible pathways for genetically unrelated parents to secure their legal relationships to their children, subjecting many to costly, intrusive processes such as adoptive “home studies.”⁴ This leaves many genetically unrelated parents and their children vulnerable in contexts such as divorce, the death of a genetically related parent, or family policing system involvement.

Few heterosexual parents are obliged to adopt their children born through assisted reproduction or to travel with copies of marriage and birth certificates to ensure their family relationships will be recognized in emergencies. Few children of heterosexual parents feel compelled to vigilantly consider whether, when, and with whom to share information about their families to avoid discrimination. These unfortunately common experiences for LGBTQ+ families underline the urgent need to enact legislation such as the Uniform Parentage Act (2017), which recognizes the diverse ways modern families are formed and creates clear, accessible pathways to parentage.²⁶ Children should not have to fear losing their parents and siblings, nor parents fear separation from children they planned for, care for, and desperately love—their “pride and joy.”

Individual Actions as a Form of Support

Individuals researching and working with LGBTQ+ individuals and families and all those tasked with the promotion of public health must stand up and stand fast in the current moment. The following are actions they must take to accomplish this:

• •First and foremost, treat LGBTQ+ individuals and families with dignity and respect: use gender-inclusive language.
• •Model allyship by sharing pronouns.
• •Avoid making assumptions about familial relationships or structure, including that genetic ties are necessary for relationships to be “real” or healthy.
• •Build coalitions; bring an intersectional and interdisciplinary lens to gender, reproduction, and family.
• •Refuse to anticipate or comply with discriminatory policies, particularly capricious diktats unlikely to survive legal challenges.
• •Connect with local advocates.
• •Show up to actions, advocacy, and community-building events.
• •Harness expertise in op-eds and legislative testimony.
• •Contact representatives to support modernizing outdated parentage laws.
• •Challenge narratives that privilege some families while pathologizing others.
• •Oppose discriminatory laws intended to restrict the rights of LGBTQ+ people and policies that hinder or selectively facilitate reproductive choice and access to health care.
• •Support policies that promote self-determination and reproductive choice for all.

Everyone should be free to determine and pursue their own family building plans, including whether, when, how, and with whom to build a family.