With the repeal of the “Don’t Ask, Don’t Tell” policy in 2011 and the marriage equality Supreme Court decision in 2015, same-sex couples and LGBTQ families in the military can now openly access services to become pregnant. Accessing specialty services in the military can be a challenge, particularly at remote locations or when primary care physicians are not knowledgeable about the process.
Behavioral Health Consultants (BHCs) and other mental health professionals in primary care have a unique opportunity to advocate for the reproductive health needs of LGBTQ families and provide education to primary care providers and leaders. Mental health providers also can anticipate and begin to address some of the added pressures LGBTQ individuals may experience navigating this system. This knowledge and cultural competence will improve readiness for the individual service member and their family and by proxy, the unit. Below are three major stressors related to reproductive services and some proactive strategies for supporting the LGBTQ families in your care.
Stressor: Lack of provider knowledge and information
Fertility information is often targeted to and tailored for straight families and resources for LGBTQ individuals are harder to find. For example, one study showed that only 31 percent of fertility websites included any reference to LGBTQ families. This disparity of knowledge and information is evident at many touchpoints of care from informational websites to primary care clinics. TRICARE covers some assisted reproductive procedures and services. There are six military treatment facilities (MTFs) that offer comprehensive fertility treatment, including intrauterine insemination, for all service members including LGTBQ individuals: Madigan Army Medical Center (Joint Base Lewis-McChord, Washington), Womack Army Medical Center (Fort Bragg, North Carolina), Walter Reed National Military Medical Center (Bethesda, Maryland), San Antonio Military Medical Center (Joint Base San Antonio, Texas), Naval Medical Center San Diego (San Diego, California), and Tripler Army Medical Center (Honolulu, Hawaii).
- LGBTQ families may benefit from being connected to resources and other sources of information:
- If a service member expresses having difficulty with receiving a referral for reproductive services, encourage them to ask for a second opinion and/or consider calling the fertility clinic directly.
- Encourage service members to join social media groups where there’s helpful sharing of information (e.g., queer parenting or military-specific fertility pages).
- Integrated mental health providers should make efforts to increase accessibility of fertility-related information:
- Consider developing a list or patient handout with specific information relevant to LGBTQ families.
- If at a primary care site, spot check primary care providers for their knowledge of how to refer for reproductive services. Consider offering brief training and handouts for providers.
Stressor: Microaggressions in military and medical settings
Microaggressions are casual, everyday slights and snubs that serve to remind marginalized individuals of their marginalized status. For example, to begin an appointment, a medical support assistant might address a transperson using the wrong gender pronouns. These microaggressions are often casual and unintentional, but can be harmful to the individual who experiences them. Sexual orientation microaggressions have been described as “death by a thousand cuts” as repeated exposure negatively impacts mental health. Widespread microaggressions show a lack of concern for inclusion and suggest that an environment may be unsafe for historically marginalized individuals. There are a number of areas, including reproductive health services, where simple changes in procedures and knowledge may have important psychological impacts for LGBTQ families.
Paperwork. Intake paperwork at fertility clinics is often tailored to straight couples. You might see frequent language referring to “how long you’ve been trying” and references to male and female partners. It can be frustrating to work around this information that doesn’t fit your situation.
Additional steps. There are some additional steps that couples using donor sperm or eggs must take at most military fertility clinics. For example, many fertility clinics require an additional psychological evaluation/information session for couples using donor material. Because LGBTQ couples often rely on donor material, it can feel like additional scrutiny and judgment that straight couples typically do not receive before becoming parents.
Provider comments throughout Labor and Delivery tours. Providers and other staff may also use language tailored to straight couples, which leave out lots of individuals who give birth outside of traditional relationships. You might hear staff refer to “mommies and daddies.”
- Integrated mental health providers should make efforts to shape the environment of care and make processes more affirming:
- Review administrative paperwork at your clinics for exclusive language.
- Use on-the-spot corrections if you hear other providers use inappropriate language in clinical meetings.
- Recommend LGBTQ affirming training for clinic staff.
- Ask service members about their experience with microaggressions and encourage them to use hospital patient advocates if necessary.
- Link service members with patient advocates if they experience discrimination in medical settings.
Stressor: Financial and legal stress
Financial well-being is a key aspect of personal well-being and behavioral health. MTFs cover most fertility procedures at no cost, but sperm, eggs, and/or surrogacy services can be expensive. Purchasing sperm from a sperm bank can range in cost from $1,000-$5,000 per cycle. Purchasing eggs can range from $20,000-40,000. Surrogacy costs between $90,000 to $130,000. Using a known donor may also incur some costs, including medical procedures for retrieving and evaluating the material. Using a known donor should also include a legal agreement, which might then incur legal costs.
In addition to increased financial burden, LGBTQ service members may experience legal and administrative stress associated with legal protection. In a same-sex couple, both parents don’t automatically have the same legal status and parenting rights. According to a 2017 Supreme Court ruling, same-sex parents may list themselves on the birth certificate. However, many states do not recognize the birth certificate as conferring parental rights. Most non-birth parents must go through the process of second-parent or step-parent adoption if a state does not recognize a same-sex parent name on the birth certificate, which can be challenging and resource-intensive.
- Encourage compassion and logistical support surrounding extra steps LGBTQ individuals may have to take in order have financial and legal safety for their families.
- If LGBTQ service members express financial concerns, encourage them to use Morale, Welfare, and Recreation (MWR) financial advising services and do their own research on low-interest fertility specific loans.
LGBTQ Military Resources
- Military One Source article Legal and Financial Considerations for Lesbian and Gay Service Members
- Army Military Parental Leave Program
Dr. Baisley is a contracted psychologist and subject matter expert in the Clinical Care Branch at the Psychological Health Center of Excellence. She served in the Army and has worked in DoD and VA settings. She continues to join in efforts to ensure health care access and support for all who have served.
The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.