Parenthood and the Physical & Mental Health of SGM Parents

Dr. Diana Tordoff shares insights on the health and well-being of LGBTQ parents, revealing the specific stressors and barriers they face while navigating parenthood. Her paper, “Parenthood and the physical and mental health of sexual and gender minority parents: A cross-sectional, observational analysis from The PRIDE Study” can be found in the September 2024 (Vol. 97) issue of Annals of Epidemiology. 

Read the full article here:
https://www.sciencedirect.com/science/article/abs/pii/S1047279724001595

To learn more about or collaborate with The PRIDE Study, visit:
https://pridestudy.org/collaborate

Episode Credits:

• Executive Producer: Sabrina Debas
• Technical Producer: Paula Burrows
• Annals of Epidemiology is published by Elsevier.
  
  
  

Chapters

• 13:43 Behind the Paper

Transcript

Patrick Sullivan: 0:12

Hello, you're listening to EPITalk: Behind the Paper, a monthly podcast from the Annals of Epidemiology. I'm Patrick Sullivan, Editor-in-Chief of the Journal, and in this series we take you behind the scenes of some of the latest epidemiologic research featured in our journal. Today we're here with Dr. Diana Tardoff to discuss her article "Parenthood and the physical and mental health of sexual and gender minority parents: A cross-sectional observational analysis from The PRIDE Study." You can read the full article online in the September 2024 issue of the journal at wwwannalsofepidemiologyorg. Dr Diana Tordoff is an instructor in the Department of Obstetrics and Gynecology at Stanford School of Medicine and an affiliated researcher with the PRIDE Study, which I hope we can talk more about The PRIDE Study. She's an epidemiologist whose research focuses on sexual and reproductive health of LGBTQ populations. Dr. Tordoff, thank you so much for your work and thank you for joining us today.

Diana Tordoff: 1:17

Thank you so much for having me; I'm excited to be here.

Patrick Sullivan: 1:21

So if you could just start by telling us about the purpose of your study, like why this issue and why was it an important question to ask?

Diana Tordoff: 1:29

So in this study, we were interested in how being a parent impacts the health and well-being specifically of LGBTQ people. This type of research has been conducted in the general population as well as specifically for straight and cisgender populations, but not specifically for LGBTQ people. We know that LGBTQ parents face unique stressors and that these might impact their health. So, for example, state legal environments that don't protect LGBTQ parents, difficulty finding LGBTQ parenting communities, experiences of their children experiencing bullying, doing their family structure and more and so we wanted to understand how this might have an impact on both physical or mental health. Also importantly, LGBTQ parents is a population that is large and anticipated to grow a lot in the coming years, so there's two demographic shifts that are happening simultaneously. First is that younger generations are more likely to identify as LGBTQ so 20% of Gen Z versus 4% of Gen X and these younger generations of LGBTQ folks are twice as likely to have or to want to have children compared to prior generations. So it's important to start to better understand this specific subpopulation.

Patrick Sullivan: 2:55

And I'm so glad you mentioned the sort of temporal trend in interest in having children among LGBTQ people, because I think in earlier generations many of us sort of felt like it just wasn't a possibility and I think it's amazing that now there is this sense of the possible and, I think, a broader discussion and planning about having, you know, building families. So thanks for that framing. So to answer this question, you use data from the PRIDE study. Can you talk a little bit about, just from a methods point of view, what kind of study design is this? And then how did you use that data to answer the questions that you were seeking to answer?

Diana Tordoff: 3:32

Absolutely. So, The PRIDE study is a longitudinal cohort study of LGBTQ adults living in the US and its territories. We began data collection in 2017 and are currently in our eighth year of data collection, and the PRIDE study is what we call a dynamic cohort. What this means is that it's a really low barrier for participants to participate in research, and it's also allowed us to reach a very large number of potential participants, and so to date, we've enrolled over 30,000 adults in the study, although year to year, a smaller portion of those complete our annual survey.

Diana Tordoff: 4:11

So for this study, we constructed a cross-sectional sample by pooling data across three years of annual surveys so we took data from 2018 to 2020, which allowed us to create a cross-sectional sample of around 9,600 LGBTQ adults.

Patrick Sullivan: 4:30

So it's really interesting from a methods point of view and I'm encouraging my EPI 530 students to listen to podcasts. So I'll just say it's interesting because you have a prospective cohort that has sort of an open enrollment, but then you're using data from that to essentially construct a cross-sectional study from the annual interviews of people, and so it's an interesting sort of use of data from a prospective cohort design but analyzed in a cross-sectional format. So just nice little methodologic piece. So Can you talk a little bit about some of the barriers to forming families for LGBTQ people? So, just like in general, there are some categories of like financial things and legal things and government things and like access to assisted reproductive technology. So what are some of those barriers that you thought about going in and what were some of the main findings with respect to those barriers?

Diana Tordoff: 5:24

Yeah, absolutely so. As you mentioned, LGBTQ folks do face a variety of barriers. First is, you know, depending on what reproductive anatomy folks have available in their couple or even as a single parent, that really impacts what pathways are available for them to build their families, and many of these pathways are quite expensive. So, whether it's adoption or, you know, assisted reproduction technology like IVF or surrogacy, these are often financially inaccessible to many folks, and also the policy environment has changed dramatically over the last 20 or 30 years, but there are still places where there's discrimination against LGBTQ folks, for example, in the fostering or adoptive systems and even at fertility clinics, who just aren't used to working with LGBTQ couples or who have additional requirements for folks who are LGBTQ. So, for example, at some fertility clinics, if you use a known sperm donor, they require that both the prospective parents as well as the sperm donor undergo psychiatric evaluation, and this type of policy really disproportionately impacts LGBTQ couples rather than straight and cisgender couples, who also sometimes need to use sperm donors based on their fertility situation.

Patrick Sullivan: 6:53

Yeah, I think this is so. Thank you for providing that background for folks who may not think about what the or experience what these barriers are, and I think it ties into really the importance of your question, which is parenthood can have a variety of effect on parents generally, but particularly, why you focus on the physical and mental health of sexual gender minority parents also has to do with this journey towards parenthood and what that's like. So thanks for that context. So what were some of the main findings, then, from your work relative to the kind of barriers and experiences that you're talking about?

Diana Tordoff: 7:27

Yeah. So first, we found that age played a really large factor really across our analyses, both in how we analyze the data as well as the outcomes. So we saw that the proportion of LGBTQ folks who are parents increased with age, which is not surprising. However, we saw that only 2% of participants in their 20s were parents, compared to 18% of those who are in their 30s, 38% of participants who are age 40 and older, and I think we looked at a variety of health outcomes.

Diana Tordoff: 8:01

We focused on chronic health outcomes, common mental health conditions as well as substance use, and our most notable findings reported worse scores on several scales that measure current symptoms, so, for example, worse depressive scores as measured on the PHQ-9, as well as worse scores on the GAZ-7 scale for anxiety and the PCL-6 score for PTSD symptoms. Notably, we did not find differences in lifetime history of diagnoses. So, for example, we did not necessarily see differences in lifetime diagnoses of depression, anxiety and PTSD. I also want to note that this was small but also statistically significant. So in our bivariate analyses, when we looked at severe or moderate depression or anxiety, we found that there was around a 12 to 17% increase in these symptoms and on a continuous scale, this was about a half point increase on each of the scales.

Patrick Sullivan: 9:07

Thanks for that explanation. So you're comparing parents and non-parents among sexual and gender minority people, and so I guess one question that comes to mind is is this an experience of being a parent, or is this a particular experience of being a sexual and gender minority parent? Or is this a particular experience of being a sexual and gender minority parent?

Diana Tordoff: 9:25

That's a great question and we can't necessarily answer that using these data, and it would be nice to have sort of what we think of as a negative control if we had access to cisgender and straight folks. However, we do know from the prior literature that in the general or overall population that parents tend to have worse mental health than non-parents. So this is consistent with the findings, but I think there is likely some additional stressors and additional unique factors impacting parents who are specifically LGBTQ.

Patrick Sullivan: 10:02

And sometimes I wonder you know when you do an analysis like this, that the direction between qualitative and quantitative can go either way, like sometimes we do qualitative work to try and figure out which questions to ask and surveys, you know, and then do mathematical analyses.

Patrick Sullivan: 10:18

But I almost wonder if this is one of those cycles where we need to go back and do some qualitative interviews, maybe with both like sexual and gender minority parents and others, and sort of see what those particular stressors are.

Patrick Sullivan: 10:31

I will say, and I think sometimes the questions we ask are informed by our experiences and by qualitative work and talking to people, but there are definitely hypotheses, I think, about the stresses on sexual and gender minority people that probably you know would be a rich place to start with that including you know, I think it's sort of like published in the literature and not in our communities that there are special kinds of barriers that are faced in schools, with teachers, with classmates, and so I think there's a good reason to think that there might be either differences in these experiences and the level of them, or differences in the mechanism of them, or differences in the kinds of services that are needed to try and support families.

Patrick Sullivan: 11:14

So I'll just sort of use that to go to one last question, which is so what should healthcare professionals and systems, and I would just add like school systems, please like think about in terms of how we support diverse types of families? Are there any specific recommendations or any general recommendations? You would say, like, when you see these findings, what do healthcare providers need to be thinking about, what other systems might need to help to respond to these data?

Diana Tordoff: 11:43

That's a great question, I think in response I'm going to quote my mentor, who is also the co-director of the Pride Study, and she's a clinician I am not, but you know.

Diana Tordoff: 11:52

She says that LGBTQ folks are the same as straight and cisgender folks in sort of what they need and what types of support they need, and you know their hopes and fears for their children.

Diana Tordoff: 12:05

At the same time, LGBTQ people are different from straight and cisgender folks in that they have to navigate more unique life circumstances around family building, interacting with these institutions that really assume like there's a mother and a father and this sort of heteronormative family structure. And at the same time, LGBTQ folks are different from each other and have unique experiences, and there's a lot of diversity of experience in general, but especially related to family building and raising children within the LGBTQ community. And so our next step in this analysis is we're actually looking at the multi-level factors that are influencing the mental health of parents. So in the PRIDE study we have really rich data on community level support, interpersonal experiences of discrimination and social support, as well as individual level factors, as well as individual level factors, and our hope is to better identify some of these mechanisms that are impacting the mental health of parents, so that we can know how to better support them.

Patrick Sullivan: 13:13

And thanks for your plan to sort of move forward into this. Like you know, the question is always like so what can we do? And so I think it's really nice to link up describing the problem or the opportunity with understanding those mechanisms and this pathway to. You know, maybe there's intervention research or RCTs and interventions at a certain time. So, and I think it's the role of descriptive, epi and hypothesis generation and documentation that this sort of launches on a path. So so thank you for talking about your findings and the research process.

Patrick Sullivan: 13:42

I'm going to move to the second part of our discussion, which we call behind the paper, and I think it's so important for our colleagues earlier career colleagues and all of us to sort of hear about how we do work, how we find inspiration, how we sort of manage all the things that it takes to make this work happen. So I have a few questions about this, and I want to start out just about the PRIDE study data, which is a real treasure of a data resource that's longitudinal and addresses this breadth of issues. So if people are interested in these kinds of questions, can people propose to analyze these data? Can they learn more about the study? How would they go about requesting access or being in contact with the PRIDE study management.

Diana Tordoff: 14:23

Absolutely so. The Pride Study loves to collaborate with folks who are outside of Stanford, and so if folks are interested in learning more about the Pride Study, they can go to pridestudy. org/ collaborate and find more information about how they can participate. The PrideIDE study uses an ancillary study process where folks can submit a proposal for their hopes to use PRIDE study data either existing data or to even design a new survey and to date there's been over 30 ancillary studies, with many investigators across the US looking at a large variety of research topics related to LGBTQ folks, and all of this is available on the website. So there's a list of current and completed ancillary studies, so you can see the breadth of the different topics we've already looked at, and then we also have a list of desired ancillary study topics, which are topics that have been identified by our research participants that we have not yet investigated, and then there's, of course, more information about how to request data and to propose an ancillary study on the website as well.

Patrick Sullivan: 15:40

Great, thank you. So for this particular question, can you say a little bit more about- You sort of mentioned that study participants might propose things that are important questions- but for this question about the physical and mental health of sexual and gender minority parents, where did this research question come from and how did it come up in your priorities? You know how does it get worked into all the questions that people want to ask, so where did this one grow out of?

Diana Tordoff: 16:04

So this is part of a larger body of research at the Pride study that's aimed to understand the experience of LGBTQ parents and their health, and so this includes both the family building process itself experiences of pregnancy as well as the experience of people after they become parents, and so this work is being led by Dr. Juno Obedin-Maliver, who is a professor in the Department of Obstetrics and Gynecology and also co-director of the PRIDE study, and we're doing really quite a lot of work really focused on the experiences of parents, including some qualitative work on the experiences of parents, including some qualitative work.

Diana Tordoff: 16:47

So we recently completed focus groups with parents and prospective parents who are assigned male at birth, specifically queer cisgender men, transgender women and non-binary folks assigned male at birth, because this population in particular has been really neglected by the research and in fact, a lot of our early research was focused on the experiences of queer, cisgender women as well as transgender men, and we heard from community- what about us? Like we also want to have families and we actually face a unique set of barriers to building our families and we like want to talk about that and our children, and so we've been doing sort of a lot of work to make our families and we like want to talk about that in our children, and so we've been doing sort of a lot of work to make sure that they also feel represented in the work that we're doing.

Patrick Sullivan: 17:32

Yeah, I really appreciate that and I think it's just so important to say that the experience of parenting of single male or male couple parenting definitely has its own challenges and there are societal biases around and suspicions, you know, I would say, that come out in ways that are harmful.

Patrick Sullivan: 17:48

So you really can think about the components of our diverse communities maybe as having some common, but many, you know, unique barriers to the configurations of parents and how that interacts with societal assumptions. So thank you so much for the attention to that breadth. I want to ask, just in terms of your own work, who or what inspires you to do this work? Because I am a person of sexual and gender minority experience and I think people a lot of times assume that what I'm doing is me-search, somehow like that the questions that are asked are because they're relevant to, like, my experiences and in fact many of them are not and we have different inspirations. So I wonder what inspires you to do this work? It could be career related, it could be non-career related, but, like, what's your path to this work?

Diana Tordoff: 18:37

I love that question, so outside of work, I'm not a big nonfiction reader I'm actually like a sci-fi nerd but the one exception is that I do read a lot about queer history and also queer memoir, and I was originally drawn to the field of public health from reading a lot about HIV and AIDS activists when I was like a little gay teenager, and so I think I'm really grateful for historians, especially folks like Jules Gill- Peterson and Sarah Schulman , who have really documented queer and trans history and, I think, really documenting our struggles and our successes in the past, you know, related to the HIV and AIDS crisis, as well as documenting that, like, queer and trans, families have always existed and loved each other. And I think I find, especially in times like this where there's a lot of backlash, a lot of solace from the fact that actually we've always been here and we've always been doing work to support our health and well-being, and I think that's something I use as to continually inspire me and also sort of ground me in why I do this work.

Patrick Sullivan: 19:47

Thank you. Thank you for that. I'm going to ask one more question which is timely to our topic, and that's to say that you've given us permission to share that you are a new mom, so congratulations, Thank you. And I wonder, like as even as you're doing this work; one, how has it been going back to work and how is it to both do research about these questions while you are also in your own prospective cohort of you know people who are starting families, and so what's it like to be in both of those kind of places at the same time?

Diana Tordoff: 20:19

Absolutely yes, this paper was actually published the same week my kiddo was born. She's now four months, so that was really a fun serendipitous happening.

Patrick Sullivan: 20:29

Like looking at galley proofs while you're trying to like get put the baby bed together, yeah, yeah.

Diana Tordoff: 20:38

Exactly. And I also am a Pride Study participant since 2017.

Diana Tordoff: 20:42

Before I had, you know, any academic or professional relationship with the Pride Study, and so I was really excited to fill out my annual survey this year, because I know that we ask questions about parenthood, and so I got to answer them myself after doing some analyses, which was very sweet, and I just have to say it's been really tender and rewarding to do research on parenthood and family building, also during this period of my life, and I think it really just emphasizes how important this research is.

Diana Tordoff: 21:16

Yeah, as to returning to work, I've only been back a month so, you know, don't have any tips for folks. I feel like I'm still trying to, you know, navigate those waters myself, but I feel really lucky to have many mentors who are also parents, you know, throughout my PhD as well currently and I also am really lucky to have many peers who also are parents, so have had several friends from graduate school also become moms this year, sort of during this early life stage career, and I think that type of community you know, queer academic parents has been really really helpful and special.

Patrick Sullivan: 22:00

Thank you for sharing that and wonderful to just see how, see how. I think this is typical of the LGBTQ community that through our history we've built these communities of support, like as society has shifted around us in positive or negative ways, and so thanks for identifying that as a community that is there to support one another in these important life experiences, that is there to support one another in these important life experiences. Dr. Tordoff, any last thoughts you'd like to share with our listeners, either about this topic or about the process of analyzing and making sense of these data?

Diana Tordoff: 22:37

So one of the things we haven't had the opportunity to talk about in terms of methods was there was a lot of attention paid to the role of age as the confounder in this study and, from an epi perspective, I found that to be one of the most fun aspects of this analysis, which is really trying to figure out how to best approach really severe confounding by age, since parenthood and age are so strongly correlated as well as there being just really large generational differences, age-related differences in both physical and mental health outcomes, and so it's more complicated to, you know, get into in this podcast. So I'm just going to plug that as sort of an epi benefit from reading the study.

Patrick Sullivan: 23:23

Yeah, well, I mean, can you give us a short version, Because I think this is you know again, like I know we have subscribers to the podcast who are in their epi education, so, like, can you just say a little bit more about the framing of that confounding issue with a variable like age and experiences of parenthood, where there is this sort of traveling alongside, right with being in certain ages of kids, for example, and our chronological age get confounded with each other, and so is there enough data in your parent respondents to be able to understand how the experience of having young kids as a 40 year old is different than having young kids as a 25 year old, and that's especially relevant to LGBTQ families, I think because of a lot of societal factors. So what's the approach there to addressing that confounding and you sort of mentioned one of the problems is that there's some sparseness of data, maybe at the extremes of that.

Diana Tordoff: 24:17

Absolutely so.

Diana Tordoff: 24:19

This is the first analysis I've worked on from like an actual manuscript, where there was a full reversal of the association, like a very strong reversal of the association when we adjusted for age, which obviously, when I first ran our regression results, was like a really big red flag and like took some time to really investigate what is going on here.

Diana Tordoff: 24:41

But what's true is that older LGBTQ generations, as a process of general aging and sort of just cohort differences, have lower mental health diagnoses and better mental health symptoms and also worse physical health outcomes, just as natural aging processes, whereas younger LGBTQ folks it's the reverse they tend to have worse mental health symptoms as well as better physical mental health, and so we just saw these really strong reversals in the association between parenthood and these different outcomes, whether or not we accounted for age. And so we ended up using propensity score modeling as a secondary approach to really address this confounding, because we wanted to make sure that we were accounting for it well. And I think what was really reassuring is that when we use multiple different analytic approaches, our results were nearly identical, which really gave me confidence, after sort of seeing this really severe confounding, that we were handling it well and not producing biased estimates.

Patrick Sullivan: 25:51

Yeah, thank you for that insight into the process, because so often papers, when they come out, look tidy, but the process to get there is not always a linear one. So this is a great and generous thing to share about, just like how you dug in and dealt with that.

Diana Tordoff: 26:08

Great and thank you so much to you and the whole team behind EPITalk for having me.

Patrick Sullivan: 26:13

That brings us to the end of this episode. Thank you again, Dr. Tordoff, for joining us today it was so nice to have you on the show and thanks for sharing your work in Annals and sharing some more context about your work on the podcast today. I'm your host, Patrick Sullivan. Thanks for tuning in to this episode and see you next time on EPITalk, brought to you by Annals of Epidemiology, the official journal of the American College of Epidemiology. For a transcript of this podcast or to read the article featured on this episode and more from the journal, you can visit us online at www. annalsofepidemiology. org.