Teen pregnancy experiences of sexual minority women

Abstract

Study Objective

Sexual minority women are more likely than heterosexual peers to have a teen pregnancy, though little is known about origins of this disparity. Our objective was to describe teen pregnancy experiences among sexual minority women and elucidate potential risk factors.

Design

As a part of the Sexual Orientation and Pregnancy Experiences (SLOPE) Study, indepth semi-structured interviews and surveys were conducted.

Setting

Across the United States.

Participants

Interviews were conducted with ten sexual minority cisgender females, ages 2166, who experienced a teen pregnancy.

Main Outcome Measures

Interview transcripts were analyzed using immersion/crystallization and template organizing style approaches. The themes were contextualized using survey data and organized into a conceptual model.

Results and Conclusions

Participants first became pregnant between ages 12–19 years; all pregnancies were described as unintentional. Half of pregnancies resulted from sexual assault. Most of the remaining pregnancies resulted from consensual sex with a boyfriend or regular partner with whom the participant reported inconsistent or no contraceptive use. Five primary themes emerged from participants’ interviews: 1) sexuality, 2) life history and contextual factors prior to pregnancy, 3) abuse and assault, 4) reactions to the pregnancy, and 5) pregnancy outcomes. Future research should assess each theme to explore its contribution to the higher burden of teen pregnancies among sexual minority compared to heterosexual women; such data can inform public health prevention campaigns and evidenced-base curricula for healthcare providers caring for adolescents.

INTRODUCTION

Compared to heterosexual women, sexual minority women are at an elevated risk of experiencing a teen pregnancy (before age 20 years)^1–11. Research has begun to explore factors that may explain this disparity. For example, sexual minority women have a younger age of sexual initiation compared to heterosexual women, which is a risk factor for teen pregnancy¹². There may also be risk factors that are unique to sexual minority women such as sexual orientation-related discrimination (e.g., bullying, assault)^3,13. While this emerging research suggests potential origins of this teen pregnancy disparity, little is known about the underlying causes.

To fill this gap, we examined sexual minority women’s experiences with teen pregnancy as a part of the larger SexuaL Orientation and Pregnancy Experiences (SLOPE) Study. The aim of this analysis was to describe the experiences of sexual minority women who became pregnant as teens to understand potential risk factors. These findings can help to formulate next steps for research, which can then aid public health practitioners in creating well-informed prevention campaigns and contribute to evidence-based curriculum to enable better training of healthcare providers caring for teens.

METHODS

Study Population

The SLOPE Study aims to elucidate pregnancy experiences of sexual and gender minorities including the experiences of sexual minority teens, transmasculine individuals, and healthcare providers. For the current analysis, we analyzed data from all SLOPE participants who were cisgender sexual minority women, ages 21–66 years (N=10). Data are still being collected among other subgroups. To capture a diverse range of experiences, participants were recruited from multiple sources including support networks, clinics, community centers, homeless shelters, college LGBTQ groups, clinics serving at-risk youth, and various events targeting sexual minorities. Online methods such as social media posts, targeted advertisements, and emails to community partners were also used for recruitment.

To be eligible, participants must have been at least 18 years old and residing in the United States at the time of the study session. Participants must have reported same-sex attractions or same-sex partners or identified as a sexual minority (e.g., gay, lesbian, bisexual, queer) at some point in their life. Finally, participants also must have become pregnant before the age of 20 years.

Researchers

The authors of this study brought diverse perspectives, which informed this work. BMC is an assistant professor trained in epidemiology. Her work focuses on sexual orientation-related reproductive health disparities and she identifies as a white queer cisgender woman. BNC is a bi-racial queer sociologist who focuses on sexuality and gender. MSC is a white cisgender lesbian who trained in pediatrics and does clinic work and research around adolescent reproductive health. SLKW is a white queer bisexual cisgender female assistant professor trained in developmental psychology, gender and women’s studies, and social epidemiology, with expertise in LGBTQ health and qualitative methods.

Prior to engaging in analysis, the researchers assumed that the pregnancies would primarily be unintentional and that participants might describe cognitive dissonance between not wanting to get pregnant and not using contraception. The researchers also expected that many participants would identify as bisexual; have limited economic resources; and report experiences of abuse, sexual violence, and bullying.

Procedure

Study sessions were conducted between March and August 2017 in person or remotely via telephone or videoconference. Participants chose the location of the study session (e.g., researchers’ offices, at home or work, at a community center) based on comfort and privacy. All participants gave informed consent prior to participating. Study sessions lasted approximately 90 minutes and consisted of a 60-minute semi-structured qualitative interview followed by a 30-minute quantitative survey. All interviews were digitally recorded and professionally transcribed verbatim. Survey data were collected via electronic tablets using REDCap. Participants were offered $20 compensation in addition to travel/parking vouchers to the study session. Considering the sensitivity of some study measures (e.g., childhood abuse), a safety plan was in place during all study sessions. Participants were also provided with a resource list that included mental health and support resources related to reproductive health and sexual minorities. This study was approved by the Institutional Review Board at Boston Children’s Hospital.

Interview Protocol

The interview protocol was semi-structured and developed specifically for the current study. Interview questions asked participants to describe their sexual orientation and teen pregnancy experience in their own words. Participants were prompted to discuss stressors (e.g., bullying) they experienced before their pregnancies as well as coping mechanisms (e.g., drugs, alcohol) they used. If participants experienced more than one pregnancy as a teenager, they were instructed to answer interview questions as they related to their first pregnancy.

Survey Measures

Surveys were used descriptively to provide context for the qualitative data and therefore assessed sociodemographic characteristics including date of birth, race/ethnicity, sex assigned at birth, current income, current zip code; contraceptive use prior to the pregnancy; stressful events including abuse during childhood and teen years as well as bullying; sexual orientation dimensions across the lifecourse including identity, attraction, and sexual contact. Many items were adapted from the Growing Up Today Study, a longitudinal cohort study with sexual orientation-related teen pregnancy data ⁴.

Analytic Methodology

Interview transcripts were analyzed by BNC and SLKW using immersion/crystallization¹⁴ and template organizing style approaches¹⁵. Immersion/crystallization involves examination of the data in detail and identification of meaningful patterns by immersion in the data [e.g., reading interview transcripts¹⁴]. Template organizing style arranges text using codes and a codebook¹⁵. To create a codebook, the first five interview transcripts were selected and reviewed for emergent and iterative themes. The codebook was tested using three additional transcripts and then reviewed and revised to ensure that codes and sub-codes were clear and consistent and reflected the data across interviews. The final codebook contained 153 codes and sub-codes. The web-based program Dedoose was used to code the interview transcripts. SLKW and BNC met regularly during the coding process to review and resolve issues that arose. Using the impact calculator and co-occurrence features in Dedoose, the most common and co-occurring codes were identified. These codes were aggregated into five larger themes, which were organized into a conceptual model. Data from participants’ surveys were used to contextualize qualitative interview data.

RESULTS

Sociodemographic Profile of Participants

We interviewed ten sexual minority, cisgender women who became pregnant prior to the age of 20. All participants reported that their pregnancies were unintentional, and half disclosed their pregnancies were the result of sexual assault. For participants who became pregnant from a consensual sexual encounter, the majority did so with a boyfriend or regular sexual partner. These participants had been with their partner for at least one year, were typically close in age to their partners, and reported inconsistent or absent contraceptive use. Participants reported first becoming pregnant between age 12–19 years. Six participants resided in the Northeast at the time of the study sessions, three resided in the South, and one resided in the Midwest. Four participants reported a current low income (pre-tax household annual income <$40,000) and six participants reported medium income ($40,000-$99,999). Five identified themselves as White, two as African American, and three as more than one racial/ethnic identity (i.e., combinations of White, Black, Hispanic, American Indian or Alaska Native, and Jewish).

Interview Themes

Commonalities emerged across the ten interviews, which we organized into five primary themes: 1) sexuality, 2) life history and contextual factors prior to pregnancy, 3) abuse and assault, 4) reactions to the pregnancy, and 5) pregnancy outcomes. A conceptual model of the themes with corresponding codes and sub-codes is shown in Figure 1.

Figure 1.

Conceptual Model of Sexual Minority Women’s Teen Pregnancy Experiences

Theme 1: Sexuality

Sexual Identity and Attractions

Based on the interviews and surveys, nine participants identified as a sexual minority at the time of the study session with seven identifying as bisexual and two as lesbian. One lesbian participant described always being exclusively attracted to women and the other lesbian participant discussed her history of sexual trauma influencing her decision to exclusively date women. One participant identified as heterosexual at the time of the study session and reported having same-sex partners in the past.

Four participants described their sexual orientation at the time of the pregnancy as being different from their current sexual orientation (e.g., identifying as bisexual at the time of the pregnancy and then identifying as lesbian at the time of the study session). Two participants identified as heterosexual at the time of their pregnancy. All participants reported first feeling attracted to females, having female partners, or identifying as a sexual minority while they were teenagers or even younger.

Sexual Orientation Disclosure

When asked whether they disclosed their sexual orientation to others, participants gave a range of responses. By the time of the study session, most participants had “come out” to at least one person. However, at the time of the pregnancy, the majority of participants did not disclose their sexual orientation to others. For some, they felt shame surrounding their sexual orientation identity:

When I was in high school, I had, like, an idea. I was always attracted to women, but I was just kinda scared to say it, so at the time, I would say, I was straight but I always had an attraction for women. Like, ever since middle school, I remember being attracted to women, but I was just too afraid to, like, admit it and I was, like, a little bit ashamed of it…

Others were concerned about the lack of social acceptance: “No, we weren’t a couple, but we kept it secret because she was bisexual as well, and we both just wasn’t comfortable, I guess, letting the world know.”

Other participants felt comfortable disclosing their sexual orientation or perceived that others automatically knew their sexual orientation identity. For those who came out later into adulthood, growing older and shifting social mores made them feel comfortable disclosing their identity. A bisexual participant who became pregnant at age 16 years offered:

As I got older, I was kinda just, like, ‘You know what? Like, I’m getting older, it’s my life. You know, if I do like women, I like women, there’s nothing wrong with it....there’s a lot of supportive people now about the LGBTQ community.’…that kinda just, like, gave me more, like, it helped me out more to come out.

However, some participants continued to not disclose their sexual orientation identity to others. A bisexual participant who first became pregnant at age 15 years and went on to have another pregnancy stated she was concerned disclosing her sexual orientation might be confusing for her young child. Another participant rejected the idea of labels and rarely uses them in her daily life.

Connection Between Sexual Minority Identity and Teen Pregnancy

Only one participant explicitly made a connection between her sexual minority identity and becoming pregnant as a teenager; she became pregnant after being sexually assaulted because of her sexual orientation.

Theme 2: Life History and Contextual Factors

Positive Factors

All participants identified positive factors prior to and during their pregnancy. Each participant was enrolled in school and had housing at the time they became pregnant. Half of participants found school and school-related activities to be an affirmative presence in their lives. In response to the question “Can you recall anything that was really good that was happening at the time [of your pregnancy]?” one 19-year-old participant who was enrolled in college, responded, “I was in school. That was the good part. I was doing really well. I graduated in two years so I was taking a lot of classes. And passing all of them and I was just focused on that.” Half of participants held jobs, which they viewed as a positive factor in their lives and helped to alleviate the financial stresses they faced. Most participants said that family, friends, or their community were positive or “good things.” Those who could name positive relationships with friends were more likely to report feeling happy overall prior to the pregnancy. Other examples of positive forces in participants’ lives included: being a successful track and field athlete, being politically active, and generally feeling stress-free. In response to the question above, one participant replied, “All I recall is like the best time of my life. That’s what I recall. You live with your parents. They take care of everything, and you haven’t got a worry in your mind.”

Negative Factors

All participants also identified negative factors prior to and during their pregnancy. Most reported having a negative relationship with one or more family members at the time of pregnancy. Many participants described experiencing sexual and/or physical trauma in their childhood or adolescence (see Theme 3: Abuse and Assault for more details). Half of participants stated that either one or both of their parents were absent from their lives or neglectful. One participant recounted, “I mean my dad was pretty much absent from my life, and my mom was like verbally and emotionally abusive and I had no money because I was a teenager.” Another participant, who had been abused and impregnated by her father, stated:

My mother did not want me. She said she wished she never had me. I was a mistake. Like, still to this day, I don’t talk to her. I got emancipated when I was [age] 15. I’ve been on my own since.

Participants who reported experiencing parental neglect also mentioned their parents often used drugs or alcohol. One participant reflected:

My mom was an alcoholic. She had this boyfriend, her boyfriend’s son was staying with us. I was like [age] 7, he was like [age] 13, he was just doing weird stuff to me, and my mom was too drunk to realize.

The majority of participants discussed feeling as though they were on their own or had to take care of their own needs. It was often unclear whether participants had felt this way in their childhood or whether these feelings emerged once they became aware of their pregnancy, but it was a consistent feeling for most participants.

Half of participants cited financial concerns as a stressor prior to and during their pregnancy. Some participants reported their limited finances played a significant role in their decision to terminate their pregnancy. One participant discussed her constraints:

It was scary. That was, it was just scary because I was only 16 years old and I knew I couldn’t, like, I just couldn’t take care of a child at such a young age. You know, I didn’t have much money. My parents are, you know, they aren’t financially as stable as, you know, to bring in another child into the world, and I was just, like, “I can’t do this.”

Theme 3: Abuse and Assault

Abuse During Childhood

All but one participant experienced some form of physical, emotional, or sexual abuse in their childhood (before age 11 years) by adults both in and outside of the participants’ families. Four participants reported being touched in a sexual way by an adult or older child. Three participants disclosed that an adult forced them into a sexual activity by threatening them, holding them down, or hurting them in some way. Participants reported these experiences on the surveys and some also described them in more detail during the interview. One participant described being assaulted at a party in early adolescence:

So it was, technically, it’s a trio of people. Two people committed the actual assault and one person just sort of didn’t stop it. So when you’re [age] 12, you’re a child so it doesn’t really matter like whether or not you eventually say yes. You’re a kid. So I had a trio of guys take me into a room and coerce me.

Another participant recounted experiencing sexual abuse from members of her family, “I had been a victim of sexual abuse from my dad, and from a couple of my brothers, and also from my mom.” Additionally, the majority of participants experienced physical abuse, including being punched, kicked, or hit so hard it left a bruise based on survey reports.

Abuse During Adolescence

The majority of participants also experienced physical, emotional, or sexual abuse during their adolescence, between the ages of 11–17 years. Half of participants experienced sexual abuse or assault during that stage of their life, including four participants who reported being sexually assaulted more than once. Three of those participants became pregnant, or thought it was likely they became pregnant, as a result of an assault. One bisexual participant had a boyfriend with whom she was sexually active, but was also assaulted at a party by an acquaintance, and was unsure who impregnated her.

Sexual Assault and Alcohol

Two participants were coerced or incapacitated through the use of alcohol for the purposes of having sex. One bisexual participant recounted, “…it was his birthday, and you know I was [age] 15, so he was like, ‘Just have a drink’ and I just got really drunk. And from there I didn’t know what really happened.” A lesbian participant, who was assaulted outside of a gay bar, noted she thought intoxication played a role in being targeted. She stated: “At the time, I was drunk…I didn’t realize until I stood up how drunk I was. And we were coming out of the bar, and these guys started hassling us….” Other participants reported using drugs or alcohol during their adolescence but did not connect their substance use to their pregnancy.

Bullying and Discrimination

A number of participants recounted instances of bullying and discrimination, ranging from the spread of rumors and gossip meant to embarrass the participant to physical violence. A couple participants explained that after being sexually assaulted, they withdrew from others and were subsequently harassed by peers. For example, one explained that because her father had abused her, she isolated herself from others and rarely talked, making her a target of violence from her peers for being “an oddball.” Other participants recalled being teased and harassed because of their sexual orientation, because they were sexually active, or because they were pregnant.

Theme 4: Reactions to the Pregnancy

Self-Reactions and Disclosure

As mentioned above, none of the participants reported actively trying to get pregnant. All but one reported feeling confused, fearful, or sad upon finding out they were pregnant. One stated, “I was scared like a baby having a baby, basically. I didn’t know what to do. I didn’t have family support or anything like that. I had to figure it out on my own.” Another said, “I was upset…I was scared, I didn’t know what to do…I didn’t know how to feel. I was upset at myself because I didn’t know what I was gonna do.” Others expressed feelings of disappointment in themselves, anger, and denial.

All participants hid their pregnancy for at least some period of time. Most participants eventually told a family member. Half of participants confided in friends or told the person with whom they were in a relationship. Two participants first disclosed their pregnancy to a healthcare provider or other adult.

Reactions From Others

Reactions to the participant’s pregnancy ranged from supportive to negative. For almost half of participants, a family member or partner played some role in the pregnancy decision process. One participant reflected:

I got pregnant at [age] 15, and I hid it for like two months. And then my mom....bought [me] a test and it was positive. And she kept saying, ‘Oh you’re not gonna have the baby, you’re not gonna have this baby, you’re only [age] 15.’”

Another participant who was married as a teen recalled her husband being adamant that she have an abortion.

Other participants experienced stigma and anger when they disclosed their pregnancy to family members. One participant stated, “My mother, she wasn’t really that supportive, she was more ashamed of me. So, it was just very lonely. I found that it was a very lonely, dark time”. Another participant’s sister reacted with anger, “[My family] were all shocked. My sister was actually a little mad at me. She was, like, ‘How could you slip up like that?’ You know, like, she was just angry.” In rare cases, families were supportive or even happy upon hearing about the pregnancy. One participant reported that her mother was excited about the prospect of having a grandchild.

Half of participants disclosed their pregnancies to their partners, who mostly reacted with fear or similar negative responses; some offered emotional support or resource assistance. In one case, a participant from the Midwest chose to raise her twins with the help of her girlfriend at the time.

Those participants who told friends subsequently received acceptance or support; none of the friends reacted negatively. Only a few participants discussed reactions from their broader community, all of which involved ridicule. For example, one participant recounted: “Everybody knew. I was in high school. I was pregnant…Some people like made fun of me because I was pregnant.”

Theme 5: Pregnancy Outcome

Two participants carried their pregnancies to term and raised their children, and one participant had a miscarriage. The other seven participants had abortions.

For the two participants who carried their pregnancies to term, both discussed hardships related to being a teen parent, especially related to finances. One participant moved out of her mother’s house and lived in her car for several months. Neither participant reported regret around their decision to raise their children.

All participants who had an abortion expressed relief after the procedure. Some participants also reflected on their nuanced decision to have an abortion. For example, one participant from the Northeast said, “I feel bad because she [referring to her daughter] coulda had a sibling.” One participant from the South also mentioned that she continues to reflect on her decision, by wondering how her life would have been different if she had made another choice: “There’s always that what if? I ended up having three boys and I always wonder, what if that one was a girl?” Two participants reported that they felt more mature and prepared to take greater precautions as a result of becoming pregnant.

DISCUSSION

The aim of the current study was to describe the experiences of ten cisgender, sexual minority women who became pregnant as teenagers. Five primary themes emerged from the interview transcript analysis.

The first theme was related to the participant’s sexuality. A few participants described their sexual orientation identity at the time of the pregnancy, as well as during the study session, as “lesbian” but most participants described their sexual orientation identity as “bisexual.” This aligns with past research showing that, compared to heterosexual women, sexual minority women (particularly bisexual) are at an increased risk for teen pregnancy^{2,4,5,10,16,17}. Bisexual women may be at the highest risk of having a teen pregnancy for many reasons, including having more regular male partners and experiencing more sexual victimization than lesbians^17,18. Many participants described not disclosing their sexual orientation at the time of their pregnancy due to feeling shame and internalized homophobia. Research among sexual minority men has described how individuals who feel internalized homophobia are more likely to engage in sex¹⁹; however, this has not been fully explored among sexual minority women. Nonetheless, it is possible that some of the shame participants in the current study felt around their sexual minority identity informed their decision not to disclose their identities and to engage in behaviors that resulted in pregnancy.

In the second and third themes, participants described both positive and negative factors in their lives at the time of their pregnancies. Many of these experiences are known risk factors for teen pregnancy, including physical and sexual abuse^3,5,17. In the current study, one participant explicitly described the connection between being sexually assaulted because of her sexual orientation and becoming pregnant as a result. While other participants did not directly discuss the connection between their sexual orientation and pregnancy, nearly all participants reported during the interviews and on the surveys a history of physical and sexual abuse, which is a teen pregnancy risk factor. A number of participants also became pregnant after being sexually assaulted. Though it is unclear whether these assaults were related to their sexual minority status, sexual minority women do experience more assault than heterosexual women²⁰.

In the fourth theme, participants described experiencing a number of reactions to their pregnancies, the majority of which were negative. Previous research has indicated that experiencing an unintended pregnancy, particularly for teenagers, is stressful and can result in feeling shame and disappointment²¹. Participants also commonly described bullying and discrimination from peers, both of which are teen pregnancy risk factors^3,5,22. These reactions seem to be universal in the face of teen pregnancy, and do not particularly relate to the participant’s sexual orientation.

In the fifth theme, participants discussed the process of making decisions about their pregnancies. For example, participants discussed the experience of raising their children, including many of the struggles that teen parents often face like financial constraints and difficulty completing their education²³. A number of participants who had an abortion discussed the complex feelings that accompanied their decisions and spoke about how it was the right choice²⁴. As in the fourth theme, these processes again seem to be universal around teen pregnancy and did not specifically relate to the participant’s sexual orientation.

A number of study limitations should be mentioned. The sample was small and was also recruited using convenience methods, in part due to sexual minorities making up less than a quarter of the U.S. population²⁵ and teen pregnancy being a relatively rare outcome²⁶. Therefore, the sample may not represent the realities of all sexual minority women who experienced teen pregnancy. However, thematic saturation was reached during analysis, suggesting that the sample was large enough to meet the research goal. Participants were primarily from the Northeastern and Southern U.S. and reported a low- or middle-income level, limiting the ability to draw conclusions about sexual minority women from other U.S. geographic regions and those with a higher income level. A number of participants were older, which may have affected their ability to clearly recall experiences that happened during adolescence. Finally, the sample was limited to cisgender women; future research should examine the pregnancy experiences of transgender and cisgender male adolescents. Despite limitations, this study is one of the first of its kind to qualitatively describe sexual minorities’ experiences of teen pregnancy.

Themes that emerged from the interviews in this study highlight potential areas for future research on sexual minority teen pregnancy experiences. Namely, it would be useful to further investigate how sexual orientation disclosure, sexual minority-related shame, and abuse may be associated with teen pregnancy. Regarding clinical practice with sexual minority women, medical and mental health providers should be knowledgeable about the higher likelihood of teen pregnancy among sexual minority compared to heterosexual women, and potential risk factors. It is particularly important for healthcare providers to avoid further stigmatizing sexual minority adolescents who experience pregnancies and may already be experiencing stigma based on being a sexual minority. Instead, healthcare providers can offer support and connect sexual minority women to resources that are specifically geared toward this population.

In conclusion, sexual minority women have a range of experiences related to being pregnant as teenagers. Such experiences highlight areas for future research as well as the need for more resources to address feelings of internalized homophobia and shame as well as experiences of physical and sexual abuse among sexual minority adolescents. Finally, these data can be used to inform public health prevention campaigns as well as evidenced-base curricula for healthcare providers caring for adolescents.