Desire for Parenthood and Associated Trends in Czech Lesbian Women.

The research sample consists of 318 women in total; of whom, 172 (54.08%) were single lesbian women and 73 lesbian couples, 146 women (45.91%). The sample included 100% of lesbian women who from April 2009 to April 2017 visited our clinic and were registered here. Our clinic is called Centrum MEDIOL, and we provide a full spectrum of healthcare services in the field of sexual medicine and marital counseling. In terms of time, the sample was divided into 2 groups: group A included women who were patients of our clinic between 1 April 2009 and 31 March 2013, that is the first 4 years of the monitored period, whereas group B comprised women who were our patients from 1 April 2013 to 31 March 2017, that is the other 4 years of the monitored period. The purpose was to examine the trend of development in this area after legalization of the registered partnership of the some sex couples in 2006 and the adoption of antidiscrimination laws in 2009. 15 , 27 , 28 All study procedures were approved by the Ethical Review Board of Centrum MEDIOL. Group A included 151 (from n = 318, ie, 47.48%) women, whereas group B comprised 167 women (n = 318, 52.52%). As far as age is concerned, the average age in group A was 35.95 ± 7.9 years, ME 38; in group B, the average age was 35.64 ± 7.97 years, ME 37. In terms of education, the sample was structured as follows – elementary education: 3.31% in group A as opposed to 5.39% in group B; secondary education without school-leaving qualification: 8.61% in group A as opposed to 11.98% in group B; secondary education with school-leaving qualification: 29.8% in group A as opposed to 35.33% in group B; bachelor's degree: 11.25% in group A as opposed to 14.37% in group B; master's degree: 47.02% in group A as opposed to 32.93% in group B. Place of residence: rural 17.88% in group A as opposed to 17.37% in group B; urban up to 20,000 inhabitants: 8.61% in group A as opposed to 13.76% in group B; urban from 20,001 to 50,000 inhabitants: 5.96% in group A as opposed to 5.39% in group B; urban from 50,001 to 100,000 inhabitants: 8.61% in group A as opposed to 6.59% in group B; urban from 100,001 to 500,000 inhabitants: 38.41% in group A as opposed to 37.13% in group B; urban over 500,000 inhabitants: 20.53% in group A as opposed to 19.76% in group B. Data collection was performed by analyzing medical history (medical and personal history), which is a standard part of documentation in our clinic and also includes information concerning reproduction and reproduction planning and information about sexual identity, orientation, and behavior of a person. Based on the analysis of the medical history data, we have obtained information in both group on whether women already have a child or whether they want a child. If they already were mothers, it was examined how they had fulfilled their desire, and if the father was known, whether he had wanted to be or was specified in the birth certificate and whether he had wanted to take part in the upbringing of the child. All monitored women gave a written consent to anonymous use of the data for scientific and research purposes. Statistical processing of the results was made using the Statistica programme v. 10.0. (Statistica, Tulsa). The assessment of the differences between the monitored subsamples was performed in a non-parametric way using contingency tables with the application of the goodness of fit test – chi-squared. The level of statistical significance was tested at P  ≤ .05; P  ≤ .01.

Table 1 presents the basic characteristics of the research sample of homosexual women in terms of single life or partnership, in terms of their desire for a child, and in terms of previous parenthood. Table 1 Description of the research sample Variables Group “A” Group “B” χ 2 P n % n % Number of women total 151 100 167 100 Of whom single 97 64.24 75 44.91 11.934 0.01 Of whom women in couples 54 35.76 92 55.09 11.934 0.01 Number of women who already have a child 61 40.39 73 43.71 0.358 ns Number of women who already have or want to have a child 117 77.48 141 84.43 2.501 ns Number of women who do not want to have a child 34 22.52 26 15.57 2.501 ns Description of the research sample In the research sample, group A included 97 (n = 151, 64%) single women and 54 (n = 151, 36%) women in partnership, whereas group B comprised 75 (n = 167, 45%) single women and 92 (n = 167, 55%) women in partnership. A significant change was observed in both parameters, the number of single women significantly decreased and the number of women in partnership significantly increased in the monitored period. At the time of data collection, of the total number of 151 women in group A, 61 (40.4%) women already had a child, while of the total number of 167 women in group B, 73 (43.7%) already had a child. The table also suggests that most homosexual women already had a child or desired to have a child, specifically 117 (n = 151, 77.5%) women in group A vs 141 (n = 167, 84.4%) in group B. The percentage of lesbians who did not desire to have a child decreased during the monitored period, specifically in group A, 34 women (n = 151, 22.5%) do not want to have a child, while in group B, the number was 26 (n = 167, 15.6%). The following table analyzes the methods of conception in 61 women in group A and 73 women in group B. The methods of fulfilling the desire for a child are listed in the table by the frequency of their occurrence reflecting their popularity (see Table 2 ). Table 2 Use of different methods of conception Variables Group “A” Group “B” χ 2 P n % n % Number of women 61 100 73 100 Child from a previous relationship 19 31.15 20 27.40 0.228 ns Clinically assisted reproduction – anonymous donor 12 19.57 22 30.14 1.925 ns Home IUI – known donor 15 24.59 14 19.18 0.575 ns Clinically assisted reproduction – known donor 8 13.11 8 9.59 0.148 ns Coitus outside the relationship for the purpose of conception 6 9.84 4 5.47 0.916 ns Home IUI – anonymous donor 1 1.64 3 4.11 0.699 ns Assisted reproduction performed abroad 0 0 2 2.74 1.695 ns Use of different methods of conception A total of 19 women in group A had a child from their previous relationship (n = 61, 31.2%); in group B, it was 20 women (n = 73, 27.4%). Clinically assisted reproduction with an anonymous donor was used by 12 women in group A (n = 61, 19.6%) as opposed to 22 women in group B (n = 73, 14%). In this method, the greatest change was observed, albeit statistically insignificant. The third most frequently used method is home intrauterine insemmination with a known donor, which was performed by 15 women in group A (n = 61, 24.6%) and 14 women in group B (n = 73, 19.2%). Clinically assisted reproduction with a known donor was used by 8 women in group A (n = 61, 13.1%) and by 8 women in group B (n = 73, 9.6%). Coitus outside the relationship for the purpose of child conception was used by 6 women in group A (n = 61, 9.8%) and 4 women in group B (n = 73, 5.5%). Home intrauterine insemmination by sperm from an anonymous donor was performed by only 1 woman in group A (n = 61, 1.6%) and 3 women in group B (n = 73, 4.1%). Assisted reproduction performed abroad was not selected by any women in group A and by 2 women in group B (n = 73, 2.7%). The text that follows includes a detailed analysis of the methods of conception in the order as specified in Table 2 . It is assumed that a certain proportion of lesbians had previously been in a heterosexual relationship. In the research sample, only 1 woman from group B (n = 20, 5.00%) confirmed deliberate heterosexual relationship of convenience as a means of child conception as opposed to 2 women from group A (n = 19, 10.53%) (see Table 3 ). The other women with a child (17 in group A and 19 in group B) used a different method of child conception (eg, home intrauterine insemmination or coitus outside the relationship for the purpose of child conception). Table 3 Child from a previous relationship Variables Group “A” Group “B” χ 2 P n % n % Number of women 19 100 20 100 Relationship for the purpose of conception 2 10.53 1 5.00 0.421 ns Child from a previous relationship Currently, the most popular and most used method of conception among lesbians is assisted reproduction with an anonymous sperm donor (see Table 4 ), which was used by 12 women in group A (n = 61, 19.6%) and 22 women in group B (n = 73, 30.1%). Table 4 Clinically assisted reproduction with an anonymous donor Variables Group “A” Group “B” χ 2 P n % Number of women 12 100 22 100 Family member 2 16.97 7 31.82 0.921 ns Friends and acquaintances 10 83.33 15 68.18 0.921 ns Clinically assisted reproduction with an anonymous donor In this case, in both groups the “fictitious” partner was an acquaintance or a friend. In group A, friends and acquaintances accounted for 83.3% (n = 12, ie, in 10 cases) vs 68.2% (n = 22, ie, in 15 cases) in group B. Family members, mostly related to the other woman in the couple accounted for 16.7% (n = 12, ie, 2 women) in group A vs 31.8% of women (n = 22, ie, 7 women) in group B. In both cases involving an allegedly anonymous donor whether it be a family member or a friend, there were changes in time, although statistically insignificant. The formerly popular home insemination with a known sperm donor (see Table 5 ) is gradually losing popularity; in group A, this method was favored by 24.6% (n = 61, ie, 15 cases) of all methods used vs 19.18% (n = 73, ie, 14 women) in group B. Table 5 Home IUI with a known donor Variables Group “A” Group “B” χ 2 P n % Number of women 15 100 14 100 Relative of the other woman 5 33.33 4 28.57 0.075 ns Donor for compensation 3 20.00 1 7.14 1.005 ns Friend donor 7 46.67 9 64.28 0.915 ns Number of women 15 100 14 100 Heterosexual donor 6 40.00 3 21.43 1.159 ns Homosexual donor 9 60.00 11 78.57 1.159 ns Number of women 15 100 14 100 The man wants to take part in upbringing 10 66.67 11 78.57 0.511 ns Number of women 15 100 14 100 The man wants to be specified in the birth certificate 2 13.33 5 33.33 1.979 ns Home IUI with a known donor In the terms of this method, the least popular way is searching for donor adds for a financial compensation; this was the case of only 20% (3 women) in group A and only 1 woman in group B (7.14%). There was also a gradual but not significant decrease in the number of donors who are at the same time family members from 33.3% (5 cases of 15) in group A to 28.6% (4 women of 14) in group B. Acquaintances are the most frequent sperm donors both in group A (n = 15, 46.7% ie, in 7 cases) and in 9 cases in group B (n = 14, 64.28%). In terms of donors’ sexual orientation, there was a gradual decrease in the percentage of donors with heterosexual orientation. While in group A, the proportion of heterosexual sperm donors was 40% (n = 15, 6 cases) to 60% (n = 15, 9 cases) of homosexual donors, in group B, the proportion of homosexual donors is greater, but not statistically significant, that is 21.4% (n = 14, 3 cases) heterosexual donors vs 78.6% (n = 14, 11 cases) homosexual donors. The percentage of donors who want to be in contact with the child and take part in upbringing in some form is gradually increasing: in group A, this applied to 66.7% of donors (n = 15, 10 cases) vs 78.6% (n = 14, 11 cases) of donors in group B. An interesting fact is that most of them did not insist on being specified as fathers in the birth certificate. But, also in this respect, a slight decrease was observed. The percentage of those who required their name to be specified in the birth certificate was 13.3% in group A and even 33.3% in group B. A slight decrease was also observed in the selection of clinically assisted reproduction with a known sperm donor (see Table 6 ): 13.1% in group A as opposed to 9.6% in group B. Family members were selected only in 1 case (12.5%) in group A and 2 cases (25%) in group B, while other men (friends and acquaintances) who represented the other choice were selected as follows: 87.5% in group A vs 75% in group B. Table 6 Clinically assisted reproduction with an known donor Variables Group “A” Group “B” χ 2 P n % Number of women 8 100 8 100 Family member donor 1 12.50 2 25.00 0.41 ns Other donors 7 87.50 6 75.00 0.41 ns Number of women 8 100 8 100 Homosexual donors 3 37.50 6 75.00 2.286 ns Heterosexual donors 5 62.50 2 25.00 2.286 ns Number of women 8 100 8 100 The man wants to be specified in the birth certificate 5 62.50 7 87.50 1.333 ns The man does not want to be specified in the birth certificate 3 37.50 1 12.50 1.333 ns Number of women 8 100 8 100 The man wants to take part in upbringing 6 75.00 7 87.50 0.41 ns Number of women 8 100 8 100 Donor for compensation 1 12.50 0 0 Clinically assisted reproduction with an known donor In this case, sperm for compensation was donated by only 1 man in group A (12.5%), while in group B, this option was not used by any woman. There is also a preference of homosexual donors at the expense of heterosexual donors. There was a marked increase in the proportion of homosexual donors, specifically 37.5% in group A as opposed to 75% in group B, which resulted in a decrease in the proportion of heterosexual donors, that is 62.5% in group A and 25% in group B. In their desire for fatherhood, most predominantly homosexual donors wanted to be specified in the birth certificate as the father, specifically 62.5% in group A as opposed to 87.5% in group B, and accordingly, the number of donors who wanted to take part in upbringing increased, 75% in group A as opposed to 87.5% in group B. Probably, the greatest loss in popularity was observed in having sexual intercourse outside the partnership for the purpose of child conception (see Table 7 ). In group A, this method was used by 6 women (9.84%) and by 4 women (5.47%) in group B. Table 7 Coitus outside the relationship for the purpose of conception Variables Group “A” Group “B” χ 2 P n % Number of women 6 100 4 100 Random partner 3 50.00 2 50.00 0 ns Pretended relationship 2 33.33 1 25.00 0.079 ns Sex with a known partner 1 16.67 1 25.00 0.104 ns Coitus outside the relationship for the purpose of conception In terms of partner selection for the purpose of coitus outside the relationship, a random sexual partner (one-night stand) was selected by the same proportion of women in both groups, that is 50%. In group A, a known partner was selected by 16.7% vs 25% in group B; while pretended relationship with a man for the purpose of conception was selected by 33.3% of women in group A vs 25% of women in group B. Another method that showed a shift in popularity was home vaginal insemination by sperm from an anonymous donor ordered in another EU country where this is legal. In group A, this method was selected by 1 woman (1.64%) as opposed to 3 women (4.11%) in group B. The costly procedure is an assisted reproduction in another EU country (whether in the EU or outside) where this is legal also for same-sex couples. Regarding the fact that the costs are usually at least 5–10 times higher than that of assisted reproduction in the CR, this is the least popular method and is used primarily by financially secure lesbians (used only by 2 women in group B). In this case, the donor was always anonymous.

Pavel Turcan: Conceptualization, Investigation, Formal Analysis, Writing - Review & Editing; Martin Prochazka: Writing - Review & Editing; Pavel Pokorny: Investigation; Jana Kvintova: Investigation, Writing - Review & Editing; Martin Sigmund Investigation, Writing - Review & Editing; Eva Sedlata Juraskova: Writing - Review & Editing

Lesbians, just as heterosexual women, show identical tendencies in terms of their desire for a child. Therefore, it is not surprising that the vast majority of homosexual women want to become mothers. The percentage of those who fulfill their desire slightly increases over time. However, this fact is in consistence with the increasing number of heterosexual women who want to remain without children. There has also been an increase in the number of part of “rainbow families,” where homosexual women pair with gay men who also desire a child. As a result, new non-conventional family models emerge. These are, for example, families with 2 mothers or 2 fathers, or 1 mother and 2 fathers, and so on, where these persons share child care. 51 , 52 Therefore, we as the providers of medical services should be prepared for this fact and should abandon the idea of one and only traditional heterosexual model. We shall be ready to provide lesbians and other members of sexual minorities with adequate help, advice, and subsequent care. We shall adopt a professional attitude without bias and prejudice and answer their questions and concerns relating to their desire to become parents and to help them fulfill their personal and relational needs. We confirm that the percentage of Czech lesbians who have a child or want to have a child has increased which corresponds with the prevalence in Western Europe.

The present study provides an overview of the current situation but also the trends in development relating to the desire for parenthood and ways of its fulfillment on a sample of 318 Czech homosexual women who in a period of 8 years visited our clinic. So far, no extensive research study on a similar topic has been published in the CR. Few works have been published on qualitative examination of a small sample of already existing lesbian parents. 15 So far, the largest published quantitative research on parental desires in the LGBTQ population included 408 respondents but comprised the entire LGBTQ community without detailed data. 29 As per a study by the Public Opinion Research Centre (Centrum pro výzkum veřejného mínění) of 2004, 5.2% of heterosexual women are not planning to become mothers. This number is gradually increasing in the CR, and it is assumed that this trend will continuously move to levels typical for contemporary Western Europe, that is 10–20% of childless women in the population. Compared with heterosexual women, this number decreases in lesbian population and it may be assumed that it will further decrease. 30 In the present study, the number of women who do not want to have children has decreased since 2009, but the current percentage still corresponds with the prevalence in Western Europe (decrease from 23% to 16%). 31 , 32 , 33 The decreasing percentage of single lesbians and lesbian couples who do not have a child or do not wish to have a child corresponds with the contemporary trend that has started in the CR since the so-called Velvet Revolution of 1989. 5 This positive trend follows a model long time accepted in Western countries as a natural manifestation of societal normalization and acceptance of lesbian and other sexual minority families. 1 , 14 , 15 Usually, we perceive motherhood from physiological and psychological point of view as a signal of the adulthood and mature functioning capacities. For women in general, including lesbians, motherhood is a profound foundation of adult identity. 34 Lesbian mothers may feel more normalized in the role of women that is expected by society. 2 Motherhood links lesbians, as well as heterosexual women, to the continuity of society and their own continuity, too. Having a child can also mean fulfilling a loving relationship. For some women, including lesbians, having a biological child fulfills the need for genetic connection to their children. 35 For others, it is more important to personally experience being pregnant, giving birth, and breastfeeding their child rather than having direct biological and genetic link with their child. 35 , 36 , 37 Acceptance of parental role signals an important manifestation of generativity connected with adulthood. It is a unique fulfillment of one's intimity. In our culture, child birth changes the partners' dyad to a family triad and is considered a very important and serious moment in any relationship. The value of having a “child” has now gained in importance from the emotional and societal point of view. In general, having a child is highly valuable in the society and has a profound meaning within the partnership. 38 Partners themselves can understand the moment of deciding to become parents as pivotal, strengthening their relationship. 39 Some authors, however, point out to partnership risks associated with parenthood. Child birth and child care require new role distribution within the family, including the house chore distribution. It influences the overall family functioning and brings about many important developmental changes and moments of crises. Very often, 1 or both partners may experience temporary dissatisfaction within the relationship. 40 Moreover, for lesbians or lesbian couples, it is more difficult to “come out as a lesbian family” and deal with problems and issues related to that (minority stress, lack of support from their families and society, as mentioned above, and so on.) 2 , 5 Choosing to be mothers in a heteronormative societal context means many challenges for homosexual women. 41 , 42 Concerning the total percentage of lesbians who already have a child, the present sample is consistent with the results of similar studies in other countries, especially in the United States and Western Europe, which confirms that at least 1/3 of lesbians are at the same time biological mothers. Leaving aside children from a previous heterosexual relationship and taking into consideration conception by a single lesbians or a lesbian couple, Czech lesbians do not deviate in terms of the methods selected – clearly the most frequent form is artificial insemination or IVF by sperm from an anonymous donor. 5 , 43 The increasing accessibility of assisted reproductive methods makes conception for lesbians far less complicated than in the past. Donor sperm can be used for various alternate modes of insemination, including vaginal insemination, intrauterine insemination, or IVF. Vaginal insemination can be undertaken either in a medically supervised procedure in a clinical setting or as self-insemination at home. 41 , 44 There is also a clear increasing tendency of mixed gay and lesbian parental couples with a growing interest of gay fathers in upbringing and being specified as fathers in the birth certificate. 45 This leads to the development of new non-conventional models where gay and lesbian couples take care of the child together. 46 , 47 The benefit of the present study is the observation of the increasing trend in the preferences concerning the methods of conception from 2009 to 2017 in favor of clinically assisted reproductions with anonymous or known donors. A positive aspect of the present study is that the methods that represent a health risk (such as an accidental conception outside the relationship) are from a long-term perspective the least popular methods. In this case, there is a higher risk of sexually transmitted diseases (eg, AIDS), absence of knowledge about the donor's health, risk of transmission of a genetically conditioned disease, and son on. 2 Another positive feature is the increase in tolerance toward LGBTQ among the Czech population, as also suggested by the demographic data of both groups. Group A was significantly dominated by women with higher education who were able to cope with more difficult conditions at an early stage after the change of the political regime when societal acceptance of LGBTQ was insufficient and possibilities to conceive the child for lesbians were more difficult. Moreover, women with higher education were better informed about the possibilities of conception and usually better financially secured. Group B had a greater proportion of women with elementary education and secondary and vocational education. With the growing tolerance of society, together with better awareness of the possibilities of conception, more women with lower education began to consider parenthood. Regarding the higher population density and shorter distances in the CR, the differences between the urban and rural environment are less significant; nevertheless, there has been an increase in the number of lesbians with children in towns up to 20,000 inhabitants. In accordance with some research studies, tolerance toward LGBTQ is greater in smaller towns compared with the capital city, which is home to one tenth of the entire Czech population. 27 Although the CR has the highest tolerance toward the LBGT community of all postcommunist countries, 19 the development of the situation is not as positive and political will does not often match the opinions of the public. Although most of the Czech population is supportive of the enactment of same-sex marriage, the Parliament keeps on postponing the bill and the enactment is not in sight. 48 Another possibility for lesbian couples is child adoption as part of substitute family care, but as per the laws applicable in the CR, this is currently not allowed, as was mentioned in the introduction. An interesting finding is that none of the lesbian couples who used the assisted reproduction method showed the so-called shared lesbian motherhood in which the ovum of one partner is fertilized by means of IVF and then the embryo is introduced into the uterus of the other partner. In western countries, this is becoming more popular. Therefore, this sort of development can be expected in the future. 28 Currently, progress is observed not only in the use of various available methods, but the easier access to lesbian motherhood increases the number of lesbians who want to have a child and at the same time require adequate counseling and follow-up care from Medici professionals and medical staff. 49 Medical doctors in the CR and other postcommunist countries have little information about lesbian conception and not all have a real insight into the issue. 50 This study is a part of an extensive research focused on a long-term monitoring of these parameters. The results may be affected by the relatively low absolute number of women and also by the fact that not all single lesbians or lesbian couples visit medical facilities similar to our clinic that focus on sexual medicine, reproduction, and partner and family therapy. In any case, the sample comprised 100% lesbians who visited our clinic during the monitored period. Despite the fact that the differences between the groups in the monitored period did not show almost any statistical significance, there were increasing or decreasing trends concerning the methods of child conception.

Worldwide, there are more homosexual women who are choosing to have children in the context of a same-sex relationship than ever before. In developed western democracies, the fulfillment of lesbian desire for motherhood is natural. In other countries, however, this is not or has not been the case. In the Czech Republic (CR), the situation started to change only after the so-called Velvet Revolution in 1989. The revolution resulted in the fall of the communist regime. The change of the social climate and the amendments to some acts began to transform the situation, which gradually started to resemble that in western countries. 1 For individuals as well as couples, the desire for and the fulfillment from being a parent are both natural part of human evolution. Regardless of sexual orientation, parenthood is regarded as a continuation, fulfillment, and transition to a different level of any relationship between 2 people. In this aspect, medical doctors and other healthcare professionals often hesitate or do not know how to help people from sexual minority groups become parents. Members of the sexual minority groups, including lesbians, are no being provided with the adequate help from the healthcare professionals only because the latter lack knowledge and adequate information about the sources of help. 2 , 3 , 4 , 5 The objective of the present retrospective study is to examine the desire of Czech lesbians for children and its fulfillment and the methods of conception that they have to use to achieve this desire. The findings presented in this article focus on the changes among 2 groups of lesbians in the monitored parameters over 8 years divided in 2 follow-up periods of 4 years. The preferences in methods of conception were closely analyzed. Recently, there has been an increase in the number of single lesbians and lesbian couples who desire to conceive a child. However, the path to achieving their dream is more difficult compared with that of heterosexual women. 6 , 7 The situation in the CR only follows the trends that have long been seen in other countries in Western Europe, America, Australia, and other parts of the world. 2 , 8 , 9 The legal standards applicable in the CR do not allow single homosexual women or lesbian couples to conceive a child by means of assisted reproduction, yet they have an opportunity to have their desire fulfilled. 10 In some countries, assisted reproduction is also available for lesbian couples; it is even possible for both women in the couple to be specified as mothers in the birth certificate. In the CR, this is not allowed by applicable laws. Currently, lawmakers are considering adoption of a child by the other partner in a homosexual pair (ie, also lesbian and gay couples) in cases where one person in the pair already has a child. The purpose is to provide the other partner with a possibility to adopt the child (stepchild adoption). Therefore, this does not mean substitute family care adoption. However, this has so far been quite problematic, even though it is often to the detriment of the child. 11 Therefore, the possibilities of lesbian family planning vary in different countries. In this area, lesbians in the CR do not have the same rights and opportunities as heterosexual single women or heterosexual couples, still they have several possibilities to fulfill their desire for parenthood. 12 , 13 To achieve their desire, single lesbians and lesbian couples select several possible ways noted previously mentioned. The objective of the present retrospective study is to examine the desire of Czech lesbians for children and its fulfillment, the possibilities that they have to achieve this desire, and the changes of the monitored parameters over time. 14