Vincent C. Smith, MD, MPH, Jonathan S. Litt, MD, MPH, ScD, and Molly Fraust Wylie, MA

In the United States, the traditional family structure of a man, a woman, and one or more of their biological or adopted children is changing. More commonly, members of the Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning (LGBTQ) community are choosing to become parents. According to a 2010 census, 37% of LGBT-identified individuals have had a child, and 19% of same-sex couples are raising children. LGBTQ–headed families represent a small but growing portion of NICU families.

There is very little beyond personal anecdotes to characterize the experience of LGBTQ-headed families in the NICU.
What is clear from these stories is that being in an LBGTQ-headed family affects the NICU experience for the family as well as for the health care providers. Some of the experiences were positive, and some were negative. Most NICU providers have limited training about and experience with the unique needs and issues for LGBTQheaded in a NICU setting. There are some national and local resources available to support LGBTQ-headed families and staff who care for them.

Definitions and terminology

• Gender identity is a self-perceived understanding of one’s gender. Terms often used to describe gender
  identity include female, male, nonbinary, gender-fluid, and queer. The term “cisgender” is when the gender
  matches the sex assigned at birth. The term “transgender” is when gender does not match the sex assigned
  at birth.
• Gender expression is the outward presentation of one’s gender identity. Terms often used to describe gender
  expression include femme, butch, female/male presenting, and gender non-conforming.
• Sexual orientation is an enduring pattern of romantic and/or sexual desirability to persons of the same or
  different gender. Sexual orientation has three components-attraction, behavior, and identity. Attraction
  refers to the gender that one finds romantically and/or sexually attractive. Behavior refers to with whom
  one engages in romantic and/or sexual relationships. Identity refers to the self-perceived understanding
  of one’s orientation and is typically linked to public expression and social engagement. Terms often used
  to describe sexual orientation include lesbian, gay, bisexual, questioning, and straight.
• Heteronormativity is a term used to describe the world view that promotes heterosexuality as the normal
  or preferred sexual orientation.

Insights into and suggestions for interacting with LBGTQ-headed families in the NICU

Insight: Most families will be LGBTQ headed because the children are often not LGBTQ.

Suggestion: Try not to apply typical heteronormative (male/female) paradigm to same-sex couples.

Insight: For LGBTQ-headed families, parental roles and functions may not be based on biology.

Suggestion: Keep an open mind about which parent is doing what tasks. Don’t assume that anything in regard to parenting roles. Follow the family’s lead. Staff should refrain from assuming that based on a more traditional masculine or feminine appearance or manner that they know what role the LGBTQ person plays in the relationship or in parenting their child.

Insight: The language we use is very important. For some staff, it can be hard to know how to refer to LGBTQ individuals, the proper pronouns to use, and what identifiers are acceptable.

Suggestion: Ask LGBTQ individuals how they want to be referred, which pronouns are appropriate for them, and which identifiers are acceptable.

Insight: Some cultural norms can be unintentionally marginalizing for LGBTQ-headed families. Forms and handouts that refer to “mother” and “father” can be inadvertently exclusionary.

Suggestion: Review all forms and written materials for inclusive language. For example, use the word “parent” instead of “mother” or “father.”

Insight: Much of the family’s experience will be shaped by interpersonal interactions. Families interact with various staff members from the time they are on the premises to when they are about to return home.

Suggestion: It is important to train all staff that may interact with the family. This includes clinical providers, front desk staff, security, valets, and environmental services staff.

Insight: Overall, the staff do an amazing job with all families.

Suggestion: When staff do not do an amazing job do not ignore it and move on. Instead, try to understand what happened and how it can be prevented from happening again. Use the opportunity as a teachable moment and turn a negative into a positive. Keep in mind that an “isolated event” could be indicative of an underlying problem. Apologize at the beginning for any faux pas that could arise, and provide the family with a standing invitation to correct
any gaffe that arises.

Insight: Generally, LGBTQ parents appreciate kindness and a genuine desire by the staff to provide them with the highest level of care. When kindness, caring, and good intent are obvious, many LGBTQ parents can overlook incidental faux pas.

Suggestion: Staff can be open about what they do not know and express a willingness to learn. It is helpful to explain to the LGBTQ individuals about the amount of experience that one has caring for LGBTQ-headed families. Express an eagerness and openness to learn any insight that the LGBTQ family volunteers to share without insisting that the family educate one about LGBTQ culture.

Final insight: Do not forget that we owe it to all families to provide excellent medical care, a safe and comfortable environment, as well as dignity and respect.

TAKE HOME POINTS

1. The makeup of American families is changing, with more LGBTQ individuals becoming parents.
2. LBGTQ-headed families expressed gratitude for thoughtful, sensitive care. When kindness, caring, and good intent are obvious, many LGBTQ-headed families can overlook incidental faux pas.
3. Avoid making assumptions about LGBTQ individuals based on physical appearance and/or manner.
4. There are ever-increasing opportunities to improve how we care for all types of families in our NICUs. Each family provides an opportunity to refine the care we provide.

Selected national resources

1. National Network of LGBTQ Family Groups available at https://www.familyequality.org/family-support/national-network-lgbtq-family-groups/ accessed 9/14/19
2. Gay Parent Magazine available at https://www.gayparentmag.com/support-groups accessed 9/14/19
3. PFLAG (Parents, Families, and Friends of Lesbians and Gays) is the United States’ first and largest organization uniting families and allies with people who are LGBTQ available at https://www.pflag.org/ accessed 9/14/19
4. Children of LGBT Parents available at https://www.glaad.org/resources/ally/8 accessed 9/14/19

Disclosure: The National Perinatal Association www.nationalperinatal.org is a 501c3 organization that provides education and advocacy around issues affecting the health of mothers, babies, and families.