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This article was first published in Fertility and Sterility.

All of my gay friends have gotten married in the last few years, and are now looking to the next step: starting a biological family.

Gay marriage has been legal in the entire US since 2015, and in individual states since 2004. At the same time these civil rights battles were being fought and won, advances in infertility treatments, IVF, egg and sperm donation, and surrogacy have become more common, more affordable, and are even covered by insurance in some states.

The U.S. is one of the only locations in the world where egg and sperm donation is not only legal but also relatively easy to accomplish. Additionally, gestational surrogates can be compensated well beyond just medical expenses. Lastly, it is also legal for LGBTQ people to pursue these options in the U.S. Unfortunately, that is not the case in many other countries, even in countries where gay marriage itself has been legal for a long time.

The U.S. Centers for Disease Control and Prevention (CDC) publishes an annual report detailing the numbers, types and success rates of infertility procedures in the U.S. From these data we know that the number of IVF cycles using donated eggs has jumped dramatically from just 1,802 cycles in 1992 to over 20,000 cycles in 2015.

Of these “egg donor recipient” IVF cycles we don’t know how many were intended to treat female infertility, and how many were used to conceive children for gay male couples or single men. IVF cycles that have an “absent female partner” are reported under the category “other,” which also includes several other medical conditions.

It turns out that there is actually a lot we don’t know about how LGBTQ folks choose another individual to reproduce with. What we do know is that the journey to biological parenthood for the LGBTQ community is becoming a significant part of modern human culture.

Amazingly, only about half of fertility clinics that belong to the Society for Assisted Reproductive Technology (SART) include any LGBTQ content at all on their websites (1).

How Do LGBTQ individuals choose a reproductive partner?

Like a dating website, egg donor websites display photos, medical histories, eye color, height, ethnicity or race, education level, personal interests, and family histories.

We know a lot about egg donor choice in infertile women, because some scientists have thought to ask the right questions. For example, we know that in the last decade, infertile women have started pursuing characteristics such as intelligence and athletic abilities over the appearance or genetic background of the egg donor (2).

Due to availability (and legality) of tissue donation and surrogacy, LGBTQ individuals can now choose reproductive partners separately from the partners they engage in relationships with, and we have the opportunity to understand what the LGBTQ set of preferences for reproductive purposes are. These phenomena have been extensively studied in heterosexual individuals (3–4), and the heteronormative set of standards for “physical attractiveness” informs the idealized images used in advertising (5).

Several studies have characterized the sexual attraction of some gay men to men in their late teens and early twenties, with physical attractiveness prioritized over status (6–7). (Use caution interpreting these results, there are many sub-groups in gay culture, and these studies do not stratify based on sub group identification, and treat all gay men as if one belonging to one homogenous group). There is very little published evidence examining gay intended parents behaviors and choices with respect to either tissue donation or surrogacy. I could only find ONE abstract (from a conference proceedings (8)) that characterized the attitudes of very small number of gay male intended parents with respect to the number of embryos transferred into their gestational carrier during a gestational surrogacy/egg donation IVF cycle.

The lack of academic publications indicates that we do not yet have good theoretical, comparative, or experimental approaches to ask how LGBTQ folks choose reproductive partners. This is not the only understudied aspect of human sexuality we still don’t understand how or why homosexuality is maintained in human populations.

Same-Sex Attraction, is it a “Paradox”?

Straight people are the majority, but gay men, lesbians, bisexuals, and transgender people account for a significant minority of people — a recent survey found 7 percent of women and 8 percent of men in the U.S. identify as L, G, B, or T. Same-sex attraction is a “paradox” in evolutionary terms. In theory, same-sex attraction should become more scarce every year, because gay people reproduce less than straight people (or have less “reproductive fitness”), yet it persists readily in human populations despite its apparent reproductive disadvantages. So, is it really a paradox? Or are we shoehorning the study of same-sex attraction with the biased idea that it should be a “paradox?”

Of course, gay people have always had some level of reproduction, for cultural or religious reasons. Different-sex relationships at a relatively young age are a common path to parenthood for LGB men and women. One analysis shows that LGBTQ individuals are younger than non-LGBTQ individuals when they have their first child (22.5 years compared to 24.1 years respectively), and individuals in same-sex couples who were previously married are much more likely to have biological or stepchildren than those who were never married (23.5% compared to 9.5% respectively). The same analysis shows that for LGBTQ couples with children, the proportion who have adopted children has nearly doubled from 10% to 19% between 2000 and 2009. Again, these data are not broken out by IVF/ infertility treatment and tissue donation, but, one has to assume that is one were to ask, we would find significant concordance.

In the biological sciences, it can sometimes be difficult to perform this kind of research. The geographic data in the study above suggest that many same-sex couples with children live in states with limited or no legal protections for their families. Heteronormative bias, language, and assumptions can creep into even the best-designed studies. In many countries homosexuality is criminally prosecuted, biasing the individuals who will participate in studies like these to favor Western, white, and wealthy individuals. The research itself can be politically exploited because fertility- who can have babies, and when, and how- is culturally organized into systems of power that reward some people and suppress others.

Some evidence exists that there is an inherited genetic basis for same-sex attraction; we know that a gay man is more likely than a straight man to have a gay biological brother, and lesbians are more likely to have gay sisters (9–11). However, despite years of study, there is limited evidence to explain the genetic mechanisms that govern the inheritance of same-sex attraction (12–14).

One hypothesis suggests that LGBTQ folks might make up for a lack of biological children by boosting the reproductive success of their close relatives. There is evidence that X-linked genes associated with homosexuality in men provides a fitness boost in female relatives (termed sexual antagonism). In other words, women that are related to gay men have significantly more children than women not related to gay men (15), thereby compensating for the reduced reproduction of their homosexual relatives.

There is a competing theory as well; called “overdominance.” The concept of over dominance is simply that getting two of certain (unknown) genes (i.e. homozygous alleles) may result in the person being homosexual but that only getting one of those genes (i.e. a heterozygous allele) may somehow create a genetic advantage resulting in more offspring (16), therefore, these alleles persist in the population.

Sexual selection, the concept that females choose mates based on traits that they arbitrarily consider beautiful (17), could also play an un-recognized role in the mechanisms of the inheritance of homosexuality. What if the male relatives of gay men are simply irresistible to women, increasing the fitness of a gay individual’s close male relatives? Could female preference, instead of the standard male:male competition model, be the driving force behind the persistence of homosexuality? Perhaps we need to broaden the view of mate selection to include a model where families, or even societies as a whole are chosen by women, due to the fitness signals that having a gay relative (or living in a society that has gay members) gives. Those signals could indicate a larger familial or social stability — this society or this family structure can amply support individuals who have essentially no reproductive fitness.

In one recent example, we have seen the entrenched “male competition” bias neatly turned around by female choice (18). The concept that sperm race to the egg, that the “first to the finish line” achieves fertilization, is being replaced by evidence that the egg as an equal and active player in fertilization.

The hypotheses presented above are not mutually exclusive to the established theory of X-linked sexual antagonism. Predictions about the inheritance and fitness effects of alleles can be tested in same-sex couples that are undergoing assisted reproduction to directly test these hypotheses, and many more. One recent study predicts that nearly 400 million people may be alive as a result of assisted reproductive technologies by 2100. The figure accounts for three percent of the world’s projected population, and includes not only those conceived through IVF but also their descendants (19).

Not only could new studies and ideas be tested in this population but also the studies that form the foundation of what we think we know can be confirmed. There are many limitations with the studies reviewed above, for example just 61 pairs of twins were sampled in the study that is most often cited as evidence of a genetic component of homosexuality, very few of these studies have ever been independently replicated, and there are other methodological concerns beyond sample sizes, particularly with the studies proclaiming to have found “the gay gene” (20).

Perhaps we can even solve the apparent paradox of the inheritance of same-sex attraction. We know that when alleles gain even a weak advantage or disadvantage they can rapidly spread through a population. Here is just one example from contemporary medicine; genes for a larger fetal head circumference would have been strongly selected against before the advent of Caesarean sections, because a fetal head that can’t fit through the birth canal would have likely caused the death of both mother and child in labor. Since C-sections have become widespread in certain populations we do see some evidence for a real increase in the rate of the head fetal head size being too big for the birth canal or “fetopelvic disproportion” (21).

In theory, use of assisted reproduction in LGBTQ populations could quickly produce large evolutionary effects, because reproductive success is directly influences. We know that genetic traits have been influenced in infertile heterosexual couples undergoing assisted reproduction (22), for example, the growth rate of fetuses, gene expression in the placenta, the birthweight of newborns and body weight at 2 years of age (23).

The art of ART (assisted reproductive technologies). Where are LBTQ Expressions of In/fertility?

Infertility seems to be a ripe topic for artistic expression engaged in the politics of sexuality and human rights- yet, expressions of LGBTQ parentage are rare.

The existence of ancient expressions of fertility -Mesolithic Goddess figurines, Venus/ Aphrodite, Demeter, as well a numerous contemporary examples make it clear that fertility has long been a topic explored and celebrated in art.

Infertility (and the prevention of pregnancy) on the other hand is somewhat taboo. The societal consequences of infertility include depression, anxiety, ostracism, physical abuse, and suicide.

The standard view of queer art tends to focus on the depiction of homoeroticism, queer bodies, queer sex, and of themes dealing with AIDS or post-identity politics. Erotic homosexuality is thought to be represented as far back in human history as Mesolithic art and petroglyphs through to present day (24). However, artistic expressions of the journey to achieve LGBTQ parenthood are very difficult to come by.

For example, the European Society of Human Reproduction and Embryology (ESHRE) recently held the world’s first arts festival dedicated to “fertility, infertility, modern families and the science of making babies.” The website for the “Art at ESHRE” exhibit reveals that all of the featured artists are heteronormative presenting cis-couples.

LGBTQ intended parents also experience failed IVF cycles, the heartbreak and roller coaster of frozen embryo transfer, the grief and devastation of miscarriage or fetal demise (through use of ART, gay men are now experiencing miscarriage and fetal loss in new and unique ways,) and the joys and frustrations of long sought and hard-won parenthood. They struggle with the concept of having the “perfect family.” They experience issues of parental legitimacy, body dysmorphia and general distrust of the medical establishment for marginalizing and neglecting their bodies.

For example, transwomen, and masculine presenting women may want to have their own genetic children, and elect to undergo hormonal stimulation and oocyte-retrievals. They need particular care to feel comfortable when being stimulated with high levels of reproductive hormones, and during the multiple ultrasounds and procedures on organs and body parts that might not match the gender they are presenting as, and that they might not even be comfortable with having still.

Consider another example: there are thousands of examples of artistic expressions of women nursing and breastfeeding (a Breastfeeding Art Instagram account, for example has thousands upon thousands of followers and images). Inclusive intersectional representation is now warranted. Transwomen have recently been induced to lactate (25) for the first time (anecdotal evidence indicates that it has occurred before but this is the first time that it was documented). Induced two parent co-nursing (i.e. nursing by the non- carrying mother) in queer families, and supplemental nursing systems (SNS) involving a bottle or syringe attached to a tube placed at the nipple of parents who are unable to lactate are all strategies to help parents achieve their own personal nursing goals, yet underrepresented in the art celebrating breastfeeding.

How could an infertility art festival, such as the one at ESHRE, purport to feature “modern families” but yet not include any LGBTQ expressions of parenting?

It is challenging to find any artistic expression (beside photography of individuals) that explores, celebrates, and illuminates LGBTQ parenting- never mind artistic expression that helps us to understand reproductive partner preference in LGTBQ populations.

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Lee Paje uses tondos to defy stereotypes by naturalizing queer narratives, in this case by offering a simple portrait of an unconventional family. In 2016, in the U.K. a beautiful commemorative stamp by artist and United Nations postal administration (UNPA) art director Sergio Baradat, promoted equal rights for LGTQ parents.

Each in their own right- homosexuality, queerness, and infertility are all or have all been taboo topics.

In conclusion, because this is an emerging field of treatment, LGBTQ specific content is not only underrepresented on fertility clinics websites, but also in the scientific literature, and in artistic representation of all kinds.

Additionally, the examination of sexual selection and reproductive partner choice in the context of reproductive tissue donation could be expanded in the biological sciences to examine their role as factors influencing evolutionary change in LGBTQ populations, and in the arts and humanities to illuminate and examine aspects of the inner life of LGBTQ individuals, the history of our culture, and the politics and mores during this socio-political moment.

Assisted reproduction may be influencing human evolution in this specific population that is enjoying increased reproductive fitness during this current historical and political moment and thematically, LGBTQ parenthood journeys have been undertreated in contemporary art- leaving open a wide playing field to treat these topics. Finally, further study of the set of LGBTQ preferences for reproductive purposes is warranted to design user-specific digital art assets for egg and sperm donor catalogues and fertility clinic websites.

Dr. Carol Lynn Curchoe, Founder ART Compass

At ART Compass we support IVF professionals with lab information management and those #TTC. Find out more at www.artcompass.io

References:

1. Wu, H.Y. et al. Lesbian, gay, bisexual, transgender (LGBT) content on reproductive endocrinology and infertility clinic websites. Fertility and Sterility, Volume 106, Issue 3, e366

2. Shopping for an Egg Donor: Is Beauty, Brains, or Health Most Important?

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6. Kenrick, Douglas T., Keefe, Richard C., Bryan, Angela, Barr, Alicia, Brown, Stephanie. Age preferences and mate choice among homosexuals and heterosexuals: A case for modular psychological mechanisms. Journal of Personality and Social Psychology, Vol 69(6), Dec 1995, 1166–1172

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20. Rice G, Anderson C, Risch N, Ebers G. Male homosexuality: absence of linkage to microsatellite markers at Xq28. Science. 1999 Apr 23; 284(5414):665–7.

21. Philipp Mitteroecker, Simon M. Huttegger, Barbara Fischer and Mihaela Pavlicev. Cliff-edge model of obstetric selection in humans. PNAS. December 5, 2016. 201612410

22. Hans Ivar Hanevik Dag O. Hessen Arne Sunde Jarle Breivik. Can IVF influence human evolution? Human Reproduction, Volume 31, Issue 7, 1 July 2016, Pages 1397–1402,

23. Kleijkers SH, Eijssen LM, Coonen E, Derhaag JG, Mantikou E, Jonker MJ, Mastenbroek S, Repping S, Evers JL, Dumoulin JC et al. Differences in gene expression profiles between human preimplantation embryos cultured in two different IVF culture media. Hum Reprod 2015;10:2303–2311.

24. Barthes, J., Crochet, P.-A., & Raymond, M. (2015). Male Homosexual Preference: Where, When, Why? PLoS ONE, 10(8), e0134817. http://doi.org/10.1371/journal.pone.0134817

25. Reisman Tamar and Goldstein Zil. Case Report: Induced Lactation in a Transgender Woman. Transgender Health. Jun 2018. Volume: 3 Issue 1: January 1, 2018. http://doi.org/10.1089/trgh.2017.0044

Founder www.artcompass.io | Scientist. Teacher. Author.

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