Expert Commentary

Gestational diabetes is on the increase in the United States. That trend will likely continue if recent recommendations by an international task force are adopted.^1,2 Those recommendations include a switch to a 75-g, 2-hour oral glucose tolerance test that meets or exceeds any of these thresholds: 1) fasting, 92 mg/dL, 2) 1 hour, 180 mg/dL, 3) 2 hours, 153 mg/dL. Use of these new thresholds will increase the rate of gestational diabetes to about 15% of the population.

Traditionally, insulin has been prescribed to treat gestational diabetes when medical nutrition therapy fails to achieve the desired level of glucose control, but insulin must be administered by injection and carries the inherent risk of hypoglycemia if caloric intake is not appropriately matched. The oral agent glyburide, a sulfonylurea, also carries a risk of hypoglycemia. Another oral drug, metformin, a biguanide, carries no risk of hypoglycemia. It would be highly desirable if oral antidiabetic agents could be used in pregnancy.

Randomized trials of glyburide and metformin have demonstrated efficacy similar to that of insulin, although some treated patients needed additional insulin when predetermined maximal doses did not control the glucose level.^3,4

In this latest trial, the two oral agents produced similar glucose levels among gravidas in whom either drug was effective. However, the failure rate of metformin (35%) was significantly higher than that of glyburide (16%). In this study, the likelihood of failure was similar to that described in the MiG trial for metformin (46%) and in a large case series for glyburide (16%).⁵

Do oral agents cross the placenta?

An important consideration in regard to these oral agents is safety. Although an in vitro study of isolated perfused placental cotyledons showed little transplacental passage of glyburide,⁶ and the original randomized trial of glyburide³ found that the drug could not be identified in cord blood of exposed newborns, a recent publication from the National Institute of Child Health and Human Development Obstetric-Fetal Pharmacology Research Unit Network demonstrated that the average fetal glyburide level was 70% of the maternal level.⁷ Metformin also crosses the placenta and is concentrated in the fetal compartment, with the fetal level approximately double that of the maternal circulation.⁸

In published reports to date, no significant increase in adverse outcomes has been reported with metformin or glyburide. A number of questions remain unanswered, however.

For example, the role of in utero programming on the development of problems such as insulin resistance syndrome in later life has drawn a great deal of attention. Just as exposure to hyperglycemia in utero has been shown to predispose to the development of glucose intolerance⁹ in adulthood, might exposure to an insulin sensitizer such as metformin, or an insulin secretagogue such as glyburide, have long-lasting effects on offspring? Studies of animal models are needed, as well as long-term follow-up of exposed humans, to establish the safety of these agents in gestational diabetes.

Gestational diabetes is on the increase in the United States. That trend will likely continue if recent recommendations by an international task force are adopted.^1,2 Those recommendations include a switch to a 75-g, 2-hour oral glucose tolerance test that meets or exceeds any of these thresholds: 1) fasting, 92 mg/dL, 2) 1 hour, 180 mg/dL, 3) 2 hours, 153 mg/dL. Use of these new thresholds will increase the rate of gestational diabetes to about 15% of the population.

Traditionally, insulin has been prescribed to treat gestational diabetes when medical nutrition therapy fails to achieve the desired level of glucose control, but insulin must be administered by injection and carries the inherent risk of hypoglycemia if caloric intake is not appropriately matched. The oral agent glyburide, a sulfonylurea, also carries a risk of hypoglycemia. Another oral drug, metformin, a biguanide, carries no risk of hypoglycemia. It would be highly desirable if oral antidiabetic agents could be used in pregnancy.

Randomized trials of glyburide and metformin have demonstrated efficacy similar to that of insulin, although some treated patients needed additional insulin when predetermined maximal doses did not control the glucose level.^3,4

In this latest trial, the two oral agents produced similar glucose levels among gravidas in whom either drug was effective. However, the failure rate of metformin (35%) was significantly higher than that of glyburide (16%). In this study, the likelihood of failure was similar to that described in the MiG trial for metformin (46%) and in a large case series for glyburide (16%).⁵

Do oral agents cross the placenta?

An important consideration in regard to these oral agents is safety. Although an in vitro study of isolated perfused placental cotyledons showed little transplacental passage of glyburide,⁶ and the original randomized trial of glyburide³ found that the drug could not be identified in cord blood of exposed newborns, a recent publication from the National Institute of Child Health and Human Development Obstetric-Fetal Pharmacology Research Unit Network demonstrated that the average fetal glyburide level was 70% of the maternal level.⁷ Metformin also crosses the placenta and is concentrated in the fetal compartment, with the fetal level approximately double that of the maternal circulation.⁸

In published reports to date, no significant increase in adverse outcomes has been reported with metformin or glyburide. A number of questions remain unanswered, however.

For example, the role of in utero programming on the development of problems such as insulin resistance syndrome in later life has drawn a great deal of attention. Just as exposure to hyperglycemia in utero has been shown to predispose to the development of glucose intolerance⁹ in adulthood, might exposure to an insulin sensitizer such as metformin, or an insulin secretagogue such as glyburide, have long-lasting effects on offspring? Studies of animal models are needed, as well as long-term follow-up of exposed humans, to establish the safety of these agents in gestational diabetes.

Gestational diabetes is on the increase in the United States. That trend will likely continue if recent recommendations by an international task force are adopted.^1,2 Those recommendations include a switch to a 75-g, 2-hour oral glucose tolerance test that meets or exceeds any of these thresholds: 1) fasting, 92 mg/dL, 2) 1 hour, 180 mg/dL, 3) 2 hours, 153 mg/dL. Use of these new thresholds will increase the rate of gestational diabetes to about 15% of the population.

Traditionally, insulin has been prescribed to treat gestational diabetes when medical nutrition therapy fails to achieve the desired level of glucose control, but insulin must be administered by injection and carries the inherent risk of hypoglycemia if caloric intake is not appropriately matched. The oral agent glyburide, a sulfonylurea, also carries a risk of hypoglycemia. Another oral drug, metformin, a biguanide, carries no risk of hypoglycemia. It would be highly desirable if oral antidiabetic agents could be used in pregnancy.

Randomized trials of glyburide and metformin have demonstrated efficacy similar to that of insulin, although some treated patients needed additional insulin when predetermined maximal doses did not control the glucose level.^3,4

In this latest trial, the two oral agents produced similar glucose levels among gravidas in whom either drug was effective. However, the failure rate of metformin (35%) was significantly higher than that of glyburide (16%). In this study, the likelihood of failure was similar to that described in the MiG trial for metformin (46%) and in a large case series for glyburide (16%).⁵

Do oral agents cross the placenta?

An important consideration in regard to these oral agents is safety. Although an in vitro study of isolated perfused placental cotyledons showed little transplacental passage of glyburide,⁶ and the original randomized trial of glyburide³ found that the drug could not be identified in cord blood of exposed newborns, a recent publication from the National Institute of Child Health and Human Development Obstetric-Fetal Pharmacology Research Unit Network demonstrated that the average fetal glyburide level was 70% of the maternal level.⁷ Metformin also crosses the placenta and is concentrated in the fetal compartment, with the fetal level approximately double that of the maternal circulation.⁸

In published reports to date, no significant increase in adverse outcomes has been reported with metformin or glyburide. A number of questions remain unanswered, however.

For example, the role of in utero programming on the development of problems such as insulin resistance syndrome in later life has drawn a great deal of attention. Just as exposure to hyperglycemia in utero has been shown to predispose to the development of glucose intolerance⁹ in adulthood, might exposure to an insulin sensitizer such as metformin, or an insulin secretagogue such as glyburide, have long-lasting effects on offspring? Studies of animal models are needed, as well as long-term follow-up of exposed humans, to establish the safety of these agents in gestational diabetes.

Breast tenderness is a common side effect of postmenopausal hormone therapy (HT); generally, it is dose-dependent. In this study by Crandall and colleagues, investigators assessed self-reported breast tenderness at the beginning of the WHI and after 12 months of HT, exploring any association between that tenderness and the risk of breast cancer. Here is what they found:

• Among women who reported no breast tenderness at study entry, the incidence of breast tenderness after 12 months was three times higher in those assigned to HT than in those assigned to placebo (36.1% vs 11.8%; P <.001).
• Women who reported the onset of breast tenderness after starting HT were older and more likely to be black or Hispanic than were women who did not.
• More than 75% of women who reported new breast tenderness (most often rated as mild) had been assigned to HT.
• Women taking HT who reported new breast tenderness had a risk of breast cancer 48% higher than those who did not report this complaint (P=.02).
• New-onset breast tenderness in women assigned to the placebo group was not associated with an elevated risk of breast cancer.

Does breast tenderness reflect an increase in cell proliferation?

Earlier studies have linked breast tenderness in women taking CEE plus MPA to high mammographic density, an independent risk factor for breast cancer. They have also established a link between estrogen-progestin therapy and breast cell proliferation. Therefore, as Crandall and colleagues observe, “breast discomfort may be a clinical manifestation of increased proliferation that is manifest radiographically as increased breast density.”

Keep in mind that the original WHI estrogen-progestin trial demonstrated that CEE plus MPA is associated with eight additional cases of breast cancer per 10,000 woman-years—a modest increase in risk. Although the study by Crandall and colleagues suggests that new-onset breast tenderness further increases the risk of breast cancer among users of estrogen-progestin therapy, the absolute magnitude of this increased risk is modest.

New-onset breast tenderness has a sensitivity and specificity similar to those of the Gail model for predicting the risk of invasive breast cancer. In this study, based on a mean follow-up of 5.6 years, the sensitivity and specificity of new-onset breast tenderness were 41% and 64%, respectively, and the positive predictive value was 2.7%. In comparison, using a threshold risk of breast cancer of 1.67% over 5 years, the Gail model has sensitivity, specificity, and a positive predictive value of 44%, 66%, and 6.6%, respectively.

Breast tenderness is a common side effect of postmenopausal hormone therapy (HT); generally, it is dose-dependent. In this study by Crandall and colleagues, investigators assessed self-reported breast tenderness at the beginning of the WHI and after 12 months of HT, exploring any association between that tenderness and the risk of breast cancer. Here is what they found:

• Among women who reported no breast tenderness at study entry, the incidence of breast tenderness after 12 months was three times higher in those assigned to HT than in those assigned to placebo (36.1% vs 11.8%; P <.001).
• Women who reported the onset of breast tenderness after starting HT were older and more likely to be black or Hispanic than were women who did not.
• More than 75% of women who reported new breast tenderness (most often rated as mild) had been assigned to HT.
• Women taking HT who reported new breast tenderness had a risk of breast cancer 48% higher than those who did not report this complaint (P=.02).
• New-onset breast tenderness in women assigned to the placebo group was not associated with an elevated risk of breast cancer.

Does breast tenderness reflect an increase in cell proliferation?

Earlier studies have linked breast tenderness in women taking CEE plus MPA to high mammographic density, an independent risk factor for breast cancer. They have also established a link between estrogen-progestin therapy and breast cell proliferation. Therefore, as Crandall and colleagues observe, “breast discomfort may be a clinical manifestation of increased proliferation that is manifest radiographically as increased breast density.”

Keep in mind that the original WHI estrogen-progestin trial demonstrated that CEE plus MPA is associated with eight additional cases of breast cancer per 10,000 woman-years—a modest increase in risk. Although the study by Crandall and colleagues suggests that new-onset breast tenderness further increases the risk of breast cancer among users of estrogen-progestin therapy, the absolute magnitude of this increased risk is modest.

New-onset breast tenderness has a sensitivity and specificity similar to those of the Gail model for predicting the risk of invasive breast cancer. In this study, based on a mean follow-up of 5.6 years, the sensitivity and specificity of new-onset breast tenderness were 41% and 64%, respectively, and the positive predictive value was 2.7%. In comparison, using a threshold risk of breast cancer of 1.67% over 5 years, the Gail model has sensitivity, specificity, and a positive predictive value of 44%, 66%, and 6.6%, respectively.

Breast tenderness is a common side effect of postmenopausal hormone therapy (HT); generally, it is dose-dependent. In this study by Crandall and colleagues, investigators assessed self-reported breast tenderness at the beginning of the WHI and after 12 months of HT, exploring any association between that tenderness and the risk of breast cancer. Here is what they found:

• Among women who reported no breast tenderness at study entry, the incidence of breast tenderness after 12 months was three times higher in those assigned to HT than in those assigned to placebo (36.1% vs 11.8%; P <.001).
• Women who reported the onset of breast tenderness after starting HT were older and more likely to be black or Hispanic than were women who did not.
• More than 75% of women who reported new breast tenderness (most often rated as mild) had been assigned to HT.
• Women taking HT who reported new breast tenderness had a risk of breast cancer 48% higher than those who did not report this complaint (P=.02).
• New-onset breast tenderness in women assigned to the placebo group was not associated with an elevated risk of breast cancer.

Does breast tenderness reflect an increase in cell proliferation?

Earlier studies have linked breast tenderness in women taking CEE plus MPA to high mammographic density, an independent risk factor for breast cancer. They have also established a link between estrogen-progestin therapy and breast cell proliferation. Therefore, as Crandall and colleagues observe, “breast discomfort may be a clinical manifestation of increased proliferation that is manifest radiographically as increased breast density.”

Keep in mind that the original WHI estrogen-progestin trial demonstrated that CEE plus MPA is associated with eight additional cases of breast cancer per 10,000 woman-years—a modest increase in risk. Although the study by Crandall and colleagues suggests that new-onset breast tenderness further increases the risk of breast cancer among users of estrogen-progestin therapy, the absolute magnitude of this increased risk is modest.

New-onset breast tenderness has a sensitivity and specificity similar to those of the Gail model for predicting the risk of invasive breast cancer. In this study, based on a mean follow-up of 5.6 years, the sensitivity and specificity of new-onset breast tenderness were 41% and 64%, respectively, and the positive predictive value was 2.7%. In comparison, using a threshold risk of breast cancer of 1.67% over 5 years, the Gail model has sensitivity, specificity, and a positive predictive value of 44%, 66%, and 6.6%, respectively.

Whether testing for GDM is justified has been a source of contention for more than 20 years. The identification of people who are afflicted with any disease is most useful when treatment is known to produce a benefit. Until recently, evidence that treatment of GDM provides maternal, fetal, or neonatal benefit has been observational. This lack of definitive data has been particularly striking in cases involving glucose intolerance not severe enough to require initial treatment with anything more than diet.

Two blinded, randomized, controlled trials published within the past 5 years—one from Australia (the Australian Carbohydrate Intolerance Study in Pregnant Women [ACHOIS study]¹ ) and the other from the Maternal–Fetal Medicine Units (MFMU) Network (cited above)—provide evidence that treatment of less severe GDM does reduce the incidence of adverse maternal and perinatal outcomes.

Details of the trials

Both studies randomized women who had mild GDM to a treatment group and a group that received only routine prenatal care. Treatment consisted of changes in diet, with the addition of insulin if certain maternal glycemic thresholds were met during the course of pregnancy.

Although sample size and results of the 50-g 1-hour glucose screening test and fasting glucose tolerance test were similar in both studies, comparison between the trials is difficult because of differences in:

• maternal prepregnancy body mass indices
• selection of candidates for glucose tolerance testing
• glucose loads during the glucose tolerance test (75 and 100 g in the ACHOIS and MFMU studies, respectively)
• glycemic thresholds and number of exceeded thresholds needed to define GDM
• percentage of patients requiring insulin in addition to diet treatment (20% and 8% in the ACHOIS and MFMU studies, respectively).

Absent from both studies is reporting of daily blood glucose values, which would have facilitated analysis of the nature of the relationship between maternal glucose concentrations and clinical outcomes.

Nonetheless, after adjusting for confounders, both studies found a reduction in the rate of macrosomia, preeclampsia, and maternal weight gain among women in the study group, compared with the control group.

Whether testing for GDM is justified has been a source of contention for more than 20 years. The identification of people who are afflicted with any disease is most useful when treatment is known to produce a benefit. Until recently, evidence that treatment of GDM provides maternal, fetal, or neonatal benefit has been observational. This lack of definitive data has been particularly striking in cases involving glucose intolerance not severe enough to require initial treatment with anything more than diet.

Two blinded, randomized, controlled trials published within the past 5 years—one from Australia (the Australian Carbohydrate Intolerance Study in Pregnant Women [ACHOIS study]¹ ) and the other from the Maternal–Fetal Medicine Units (MFMU) Network (cited above)—provide evidence that treatment of less severe GDM does reduce the incidence of adverse maternal and perinatal outcomes.

Details of the trials

Both studies randomized women who had mild GDM to a treatment group and a group that received only routine prenatal care. Treatment consisted of changes in diet, with the addition of insulin if certain maternal glycemic thresholds were met during the course of pregnancy.

Although sample size and results of the 50-g 1-hour glucose screening test and fasting glucose tolerance test were similar in both studies, comparison between the trials is difficult because of differences in:

• maternal prepregnancy body mass indices
• selection of candidates for glucose tolerance testing
• glucose loads during the glucose tolerance test (75 and 100 g in the ACHOIS and MFMU studies, respectively)
• glycemic thresholds and number of exceeded thresholds needed to define GDM
• percentage of patients requiring insulin in addition to diet treatment (20% and 8% in the ACHOIS and MFMU studies, respectively).

Absent from both studies is reporting of daily blood glucose values, which would have facilitated analysis of the nature of the relationship between maternal glucose concentrations and clinical outcomes.

Nonetheless, after adjusting for confounders, both studies found a reduction in the rate of macrosomia, preeclampsia, and maternal weight gain among women in the study group, compared with the control group.

Whether testing for GDM is justified has been a source of contention for more than 20 years. The identification of people who are afflicted with any disease is most useful when treatment is known to produce a benefit. Until recently, evidence that treatment of GDM provides maternal, fetal, or neonatal benefit has been observational. This lack of definitive data has been particularly striking in cases involving glucose intolerance not severe enough to require initial treatment with anything more than diet.

Two blinded, randomized, controlled trials published within the past 5 years—one from Australia (the Australian Carbohydrate Intolerance Study in Pregnant Women [ACHOIS study]¹ ) and the other from the Maternal–Fetal Medicine Units (MFMU) Network (cited above)—provide evidence that treatment of less severe GDM does reduce the incidence of adverse maternal and perinatal outcomes.

Details of the trials

Both studies randomized women who had mild GDM to a treatment group and a group that received only routine prenatal care. Treatment consisted of changes in diet, with the addition of insulin if certain maternal glycemic thresholds were met during the course of pregnancy.

Although sample size and results of the 50-g 1-hour glucose screening test and fasting glucose tolerance test were similar in both studies, comparison between the trials is difficult because of differences in:

• maternal prepregnancy body mass indices
• selection of candidates for glucose tolerance testing
• glucose loads during the glucose tolerance test (75 and 100 g in the ACHOIS and MFMU studies, respectively)
• glycemic thresholds and number of exceeded thresholds needed to define GDM
• percentage of patients requiring insulin in addition to diet treatment (20% and 8% in the ACHOIS and MFMU studies, respectively).

Absent from both studies is reporting of daily blood glucose values, which would have facilitated analysis of the nature of the relationship between maternal glucose concentrations and clinical outcomes.

Nonetheless, after adjusting for confounders, both studies found a reduction in the rate of macrosomia, preeclampsia, and maternal weight gain among women in the study group, compared with the control group.

Optimal screening for breast cancer is a topic of debate and interest for physicians in many disciplines who play a role in diagnosis and management of this disease. Through improvements in early detection and treatment, we now see longer survival in women who have breast cancer. The burden of disease remains high, however, with one of every eight women in the United States being given a diagnosis of invasive breast cancer.¹

Historically, physicians relied on CBE to identify masses. With the advent of mammography, however, and increasing evidence of its efficacy in detecting malignancy, mammography became the new norm for screening, and remains the gold standard for detection of breast cancer. It is clear that mammography can detect some types of lesions long before they can be palpated on clinical exam.

Mammography isn’t perfect

The sensitivity of mammography to detect breast cancer ranges from 68% to 88%, depending on the patient’s menopausal status, breast density, and other characteristics. Certain types of breast cancer, such as invasive lobular carcinoma, are more difficult to detect with mammography. Many major medical organizations, including ACOG and the American Cancer Society, continue to recommend CBE as a component of the screening process. Most ObGyns value their role in screening women for cancer and generally believe that CBE is an important element of well-woman care. In addition, as Barton and colleagues point out, some women are more accepting of CBE than of mammography.²

CBE took 8 to 10 minutes

The Chiarelli study is a large, well-designed study that included women 50 to 69 years old who participated in breast-screening programs in Ontario. Women were screened by mammography alone or mammography combined with CBE. Examinations were standardized and performed by well-trained and certified nurses, and the CBE took an average of 8 to 10 minutes.

Surveys of American women suggest that most of them would accept the possibility of undergoing biopsy for a negative finding for the sake of improving detection of breast cancer. The study by Chiarelli and colleagues supports the current practice of ObGyns and other primary care providers who perform CBE as a component of screening, and is congruent with our patients’ wish to optimize the sensitivity of screening.

To be effective, however, the quality of our exams must be consistent with those described in the study. In a published review, CBE in the community setting did not yield the same sensitivity reported in randomized trials.³ We must remain cognizant of the goals of CBE and educate our patients about the benefits, limitations, and risks of screening.

Optimal screening for breast cancer is a topic of debate and interest for physicians in many disciplines who play a role in diagnosis and management of this disease. Through improvements in early detection and treatment, we now see longer survival in women who have breast cancer. The burden of disease remains high, however, with one of every eight women in the United States being given a diagnosis of invasive breast cancer.¹

Historically, physicians relied on CBE to identify masses. With the advent of mammography, however, and increasing evidence of its efficacy in detecting malignancy, mammography became the new norm for screening, and remains the gold standard for detection of breast cancer. It is clear that mammography can detect some types of lesions long before they can be palpated on clinical exam.

Mammography isn’t perfect

The sensitivity of mammography to detect breast cancer ranges from 68% to 88%, depending on the patient’s menopausal status, breast density, and other characteristics. Certain types of breast cancer, such as invasive lobular carcinoma, are more difficult to detect with mammography. Many major medical organizations, including ACOG and the American Cancer Society, continue to recommend CBE as a component of the screening process. Most ObGyns value their role in screening women for cancer and generally believe that CBE is an important element of well-woman care. In addition, as Barton and colleagues point out, some women are more accepting of CBE than of mammography.²

CBE took 8 to 10 minutes

The Chiarelli study is a large, well-designed study that included women 50 to 69 years old who participated in breast-screening programs in Ontario. Women were screened by mammography alone or mammography combined with CBE. Examinations were standardized and performed by well-trained and certified nurses, and the CBE took an average of 8 to 10 minutes.

Surveys of American women suggest that most of them would accept the possibility of undergoing biopsy for a negative finding for the sake of improving detection of breast cancer. The study by Chiarelli and colleagues supports the current practice of ObGyns and other primary care providers who perform CBE as a component of screening, and is congruent with our patients’ wish to optimize the sensitivity of screening.

To be effective, however, the quality of our exams must be consistent with those described in the study. In a published review, CBE in the community setting did not yield the same sensitivity reported in randomized trials.³ We must remain cognizant of the goals of CBE and educate our patients about the benefits, limitations, and risks of screening.

Optimal screening for breast cancer is a topic of debate and interest for physicians in many disciplines who play a role in diagnosis and management of this disease. Through improvements in early detection and treatment, we now see longer survival in women who have breast cancer. The burden of disease remains high, however, with one of every eight women in the United States being given a diagnosis of invasive breast cancer.¹

Historically, physicians relied on CBE to identify masses. With the advent of mammography, however, and increasing evidence of its efficacy in detecting malignancy, mammography became the new norm for screening, and remains the gold standard for detection of breast cancer. It is clear that mammography can detect some types of lesions long before they can be palpated on clinical exam.

Mammography isn’t perfect

The sensitivity of mammography to detect breast cancer ranges from 68% to 88%, depending on the patient’s menopausal status, breast density, and other characteristics. Certain types of breast cancer, such as invasive lobular carcinoma, are more difficult to detect with mammography. Many major medical organizations, including ACOG and the American Cancer Society, continue to recommend CBE as a component of the screening process. Most ObGyns value their role in screening women for cancer and generally believe that CBE is an important element of well-woman care. In addition, as Barton and colleagues point out, some women are more accepting of CBE than of mammography.²

CBE took 8 to 10 minutes

The Chiarelli study is a large, well-designed study that included women 50 to 69 years old who participated in breast-screening programs in Ontario. Women were screened by mammography alone or mammography combined with CBE. Examinations were standardized and performed by well-trained and certified nurses, and the CBE took an average of 8 to 10 minutes.

Surveys of American women suggest that most of them would accept the possibility of undergoing biopsy for a negative finding for the sake of improving detection of breast cancer. The study by Chiarelli and colleagues supports the current practice of ObGyns and other primary care providers who perform CBE as a component of screening, and is congruent with our patients’ wish to optimize the sensitivity of screening.

To be effective, however, the quality of our exams must be consistent with those described in the study. In a published review, CBE in the community setting did not yield the same sensitivity reported in randomized trials.³ We must remain cognizant of the goals of CBE and educate our patients about the benefits, limitations, and risks of screening.

The original indication for cervical cerclage, as devised more than 50 years ago, included both historical and contemporaneous findings:

• 1) a history of second-trimester loss involving painless cervical dilatation in the absence of infection, bleeding, amniorrhexis, and fetal demise
  
• 2) asymptomatic cervical changes in the current pregnancy.
  

Although our understanding of cervical insufficiency has undergone many revisions and reinterpretations in the intervening years, we still lack an accepted diagnostic test or proven criteria for diagnosis. Cerclage is placed in 1% of all pregnancies in the United States, but there is no consensus on indications, and the effectiveness is still a matter of debate.¹ Cerclage placement based on ultrasonographic (US) measurement of cervical length has been proposed as the solution to this clinical quagmire, in the wake of evidence suggesting that cervical length may act as a surrogate for cervical competence.

A patient-level meta-analysis of four randomized trials of cervical cerclage, published in 2005, reconfirmed the original indication for cerclage. In women who had a cervical length below 25 mm, cerclage reduced the rate of preterm birth at less than 35 weeks’ gestation only if they had a history of preterm birth.² This finding prompted the question: Would such women represent a truly homogeneous population in terms of therapeutic response to cerclage?

The Owen trial attempts to answer this specific question.

Details of the trial

Women who had a cervix shorter than 25 mm and a history of preterm birth and who were pregnant with a singleton gestation were eligible. Candidates for elective cerclage based on history, or for emergency cerclage based on cervical dilatation of at least 2 cm with visible membranes, were excluded from the study—possibly reducing the generalizability of the findings.

For the remaining 302 participants, cerclage appeared to have an overall benefit when survival analysis took the duration of gestation into consideration. But only women who had a cervical length below 15 mm had a significant reduction in the primary outcome (preterm birth at less than 35 weeks’ gestation) with cerclage. These results are somewhat reminiscent of the findings of a randomized comparison of cerclage and 17α-hydroxyprogesterone caproate in women who had a short cervix (measured by US), in which cerclage proved to be superior only when cervical length was less than 15 mm.³

Why the 15-mm cutoff isn’t definitive

Despite these findings, the 15-mm measurement cannot be assumed to be completely prescriptive because it was selected somewhat arbitrarily. Furthermore, it may be inadvisable to wait for cervical length to decrease below 15 mm. In pregnancies in which cervical length is below 5 mm, there is a significantly higher expression of intra-amniotic inflammation than in those in which cervical length is 6 to 25 mm, according to another recent study.⁴ Women who have a very short cervix may be far along the inflammatory cascade and may have already entered the irreversible phase of parturition, reducing the efficacy and even the advisability of cerclage. A positive fetal fibronectin test (as a marker of inflammation and choriodecidual disruption) and an increased level of interleukin-8 in cervical mucus reportedly identified a subgroup of women with a short cervix who would not benefit from cerclage—and who might even be harmed by it.^5,6

Because preterm birth is such a complex disorder, it is unlikely that one intervention will be effective in all women—even within a certain stratum of cervical length. Rather, it may be necessary to identify subsets of pregnant women amenable to targeted or tailored intervention.

The original indication for cervical cerclage, as devised more than 50 years ago, included both historical and contemporaneous findings:

• 1) a history of second-trimester loss involving painless cervical dilatation in the absence of infection, bleeding, amniorrhexis, and fetal demise
  
• 2) asymptomatic cervical changes in the current pregnancy.
  

Although our understanding of cervical insufficiency has undergone many revisions and reinterpretations in the intervening years, we still lack an accepted diagnostic test or proven criteria for diagnosis. Cerclage is placed in 1% of all pregnancies in the United States, but there is no consensus on indications, and the effectiveness is still a matter of debate.¹ Cerclage placement based on ultrasonographic (US) measurement of cervical length has been proposed as the solution to this clinical quagmire, in the wake of evidence suggesting that cervical length may act as a surrogate for cervical competence.

A patient-level meta-analysis of four randomized trials of cervical cerclage, published in 2005, reconfirmed the original indication for cerclage. In women who had a cervical length below 25 mm, cerclage reduced the rate of preterm birth at less than 35 weeks’ gestation only if they had a history of preterm birth.² This finding prompted the question: Would such women represent a truly homogeneous population in terms of therapeutic response to cerclage?

The Owen trial attempts to answer this specific question.

Details of the trial

Women who had a cervix shorter than 25 mm and a history of preterm birth and who were pregnant with a singleton gestation were eligible. Candidates for elective cerclage based on history, or for emergency cerclage based on cervical dilatation of at least 2 cm with visible membranes, were excluded from the study—possibly reducing the generalizability of the findings.

For the remaining 302 participants, cerclage appeared to have an overall benefit when survival analysis took the duration of gestation into consideration. But only women who had a cervical length below 15 mm had a significant reduction in the primary outcome (preterm birth at less than 35 weeks’ gestation) with cerclage. These results are somewhat reminiscent of the findings of a randomized comparison of cerclage and 17α-hydroxyprogesterone caproate in women who had a short cervix (measured by US), in which cerclage proved to be superior only when cervical length was less than 15 mm.³

Why the 15-mm cutoff isn’t definitive

Despite these findings, the 15-mm measurement cannot be assumed to be completely prescriptive because it was selected somewhat arbitrarily. Furthermore, it may be inadvisable to wait for cervical length to decrease below 15 mm. In pregnancies in which cervical length is below 5 mm, there is a significantly higher expression of intra-amniotic inflammation than in those in which cervical length is 6 to 25 mm, according to another recent study.⁴ Women who have a very short cervix may be far along the inflammatory cascade and may have already entered the irreversible phase of parturition, reducing the efficacy and even the advisability of cerclage. A positive fetal fibronectin test (as a marker of inflammation and choriodecidual disruption) and an increased level of interleukin-8 in cervical mucus reportedly identified a subgroup of women with a short cervix who would not benefit from cerclage—and who might even be harmed by it.^5,6

Because preterm birth is such a complex disorder, it is unlikely that one intervention will be effective in all women—even within a certain stratum of cervical length. Rather, it may be necessary to identify subsets of pregnant women amenable to targeted or tailored intervention.

The original indication for cervical cerclage, as devised more than 50 years ago, included both historical and contemporaneous findings:

• 1) a history of second-trimester loss involving painless cervical dilatation in the absence of infection, bleeding, amniorrhexis, and fetal demise
  
• 2) asymptomatic cervical changes in the current pregnancy.
  

Although our understanding of cervical insufficiency has undergone many revisions and reinterpretations in the intervening years, we still lack an accepted diagnostic test or proven criteria for diagnosis. Cerclage is placed in 1% of all pregnancies in the United States, but there is no consensus on indications, and the effectiveness is still a matter of debate.¹ Cerclage placement based on ultrasonographic (US) measurement of cervical length has been proposed as the solution to this clinical quagmire, in the wake of evidence suggesting that cervical length may act as a surrogate for cervical competence.

A patient-level meta-analysis of four randomized trials of cervical cerclage, published in 2005, reconfirmed the original indication for cerclage. In women who had a cervical length below 25 mm, cerclage reduced the rate of preterm birth at less than 35 weeks’ gestation only if they had a history of preterm birth.² This finding prompted the question: Would such women represent a truly homogeneous population in terms of therapeutic response to cerclage?

The Owen trial attempts to answer this specific question.

Details of the trial

Women who had a cervix shorter than 25 mm and a history of preterm birth and who were pregnant with a singleton gestation were eligible. Candidates for elective cerclage based on history, or for emergency cerclage based on cervical dilatation of at least 2 cm with visible membranes, were excluded from the study—possibly reducing the generalizability of the findings.

For the remaining 302 participants, cerclage appeared to have an overall benefit when survival analysis took the duration of gestation into consideration. But only women who had a cervical length below 15 mm had a significant reduction in the primary outcome (preterm birth at less than 35 weeks’ gestation) with cerclage. These results are somewhat reminiscent of the findings of a randomized comparison of cerclage and 17α-hydroxyprogesterone caproate in women who had a short cervix (measured by US), in which cerclage proved to be superior only when cervical length was less than 15 mm.³

Why the 15-mm cutoff isn’t definitive

Despite these findings, the 15-mm measurement cannot be assumed to be completely prescriptive because it was selected somewhat arbitrarily. Furthermore, it may be inadvisable to wait for cervical length to decrease below 15 mm. In pregnancies in which cervical length is below 5 mm, there is a significantly higher expression of intra-amniotic inflammation than in those in which cervical length is 6 to 25 mm, according to another recent study.⁴ Women who have a very short cervix may be far along the inflammatory cascade and may have already entered the irreversible phase of parturition, reducing the efficacy and even the advisability of cerclage. A positive fetal fibronectin test (as a marker of inflammation and choriodecidual disruption) and an increased level of interleukin-8 in cervical mucus reportedly identified a subgroup of women with a short cervix who would not benefit from cerclage—and who might even be harmed by it.^5,6

Because preterm birth is such a complex disorder, it is unlikely that one intervention will be effective in all women—even within a certain stratum of cervical length. Rather, it may be necessary to identify subsets of pregnant women amenable to targeted or tailored intervention.

The selective estrogen receptor modulators (SERMs) tamoxifen and raloxifene have been shown to reduce the risk of primary invasive breast cancer, as has the selective tissue estrogenic activity regulator tibolone. Tamoxifen and raloxifene are approved for use in high-risk women—although raloxifene is approved for this indication in postmenopausal women only. Tibolone is not available in the United States and is therefore not included in this discussion, although it was included in the review by Nelson and associates.

In the United States, tamoxifen is usually prescribed as adjuvant endocrine therapy after treatment of estrogen-receptor–positive breast cancer in both premenopausal and post-menopausal women. Raloxifene is most often prescribed for the prevention and treatment of osteoporosis in postmenopausal women. Use of these agents as chemoprophylaxis in women who have no history of breast cancer is less common, largely because of the risks and side effects of these drugs.

The increase in venous thromboembolism is of particular concern for women who have an elevated risk of this outcome, including overweight women and those of advanced age. The elevated risk of malignant and benign gynecologic disease associated with tamoxifen is of concern in all women who have an intact uterus.

Details of the review

Nelson and colleagues performed a systematic review, funded by the Agency for Health-care Research and Quality, that involved the aggregation of findings from seven placebo-controlled trials and one head-to-head, randomized, clinical trial involving women who had no history of preinvasive or invasive breast cancer. In the process, they focused on harms as well as benefits associated with use of these chemoprophylactic agents.

Tamoxifen and raloxifene reduced the risk of invasive breast cancer by 7 to 10 cases in every 1,000 women annually. These agents reduced the risk of estrogen-receptor–positive malignancy, but not estrogen-receptor–negative tumors, noninvasive cancer, or breast cancer–related mortality.

Tamoxifen and raloxifene were similarly effective in premenopausal and postmenopausal populations; both drugs also reduced the rate of osteoporotic fracture.

Most of the participants in the prevention trials were white and relatively healthy. Therefore, the relevance of these findings to women of other racial and ethnic groups and to women who have chronic disease or other morbidity is uncertain.

Aromatase inhibitors are being assessed for chemoprophylaxis, so we should have information on their risk-benefit ratio in the near future.

The selective estrogen receptor modulators (SERMs) tamoxifen and raloxifene have been shown to reduce the risk of primary invasive breast cancer, as has the selective tissue estrogenic activity regulator tibolone. Tamoxifen and raloxifene are approved for use in high-risk women—although raloxifene is approved for this indication in postmenopausal women only. Tibolone is not available in the United States and is therefore not included in this discussion, although it was included in the review by Nelson and associates.

In the United States, tamoxifen is usually prescribed as adjuvant endocrine therapy after treatment of estrogen-receptor–positive breast cancer in both premenopausal and post-menopausal women. Raloxifene is most often prescribed for the prevention and treatment of osteoporosis in postmenopausal women. Use of these agents as chemoprophylaxis in women who have no history of breast cancer is less common, largely because of the risks and side effects of these drugs.

The increase in venous thromboembolism is of particular concern for women who have an elevated risk of this outcome, including overweight women and those of advanced age. The elevated risk of malignant and benign gynecologic disease associated with tamoxifen is of concern in all women who have an intact uterus.

Details of the review

Nelson and colleagues performed a systematic review, funded by the Agency for Health-care Research and Quality, that involved the aggregation of findings from seven placebo-controlled trials and one head-to-head, randomized, clinical trial involving women who had no history of preinvasive or invasive breast cancer. In the process, they focused on harms as well as benefits associated with use of these chemoprophylactic agents.

Tamoxifen and raloxifene reduced the risk of invasive breast cancer by 7 to 10 cases in every 1,000 women annually. These agents reduced the risk of estrogen-receptor–positive malignancy, but not estrogen-receptor–negative tumors, noninvasive cancer, or breast cancer–related mortality.

Tamoxifen and raloxifene were similarly effective in premenopausal and postmenopausal populations; both drugs also reduced the rate of osteoporotic fracture.

Most of the participants in the prevention trials were white and relatively healthy. Therefore, the relevance of these findings to women of other racial and ethnic groups and to women who have chronic disease or other morbidity is uncertain.

Aromatase inhibitors are being assessed for chemoprophylaxis, so we should have information on their risk-benefit ratio in the near future.

The selective estrogen receptor modulators (SERMs) tamoxifen and raloxifene have been shown to reduce the risk of primary invasive breast cancer, as has the selective tissue estrogenic activity regulator tibolone. Tamoxifen and raloxifene are approved for use in high-risk women—although raloxifene is approved for this indication in postmenopausal women only. Tibolone is not available in the United States and is therefore not included in this discussion, although it was included in the review by Nelson and associates.

In the United States, tamoxifen is usually prescribed as adjuvant endocrine therapy after treatment of estrogen-receptor–positive breast cancer in both premenopausal and post-menopausal women. Raloxifene is most often prescribed for the prevention and treatment of osteoporosis in postmenopausal women. Use of these agents as chemoprophylaxis in women who have no history of breast cancer is less common, largely because of the risks and side effects of these drugs.

The increase in venous thromboembolism is of particular concern for women who have an elevated risk of this outcome, including overweight women and those of advanced age. The elevated risk of malignant and benign gynecologic disease associated with tamoxifen is of concern in all women who have an intact uterus.

Details of the review

Nelson and colleagues performed a systematic review, funded by the Agency for Health-care Research and Quality, that involved the aggregation of findings from seven placebo-controlled trials and one head-to-head, randomized, clinical trial involving women who had no history of preinvasive or invasive breast cancer. In the process, they focused on harms as well as benefits associated with use of these chemoprophylactic agents.

Tamoxifen and raloxifene reduced the risk of invasive breast cancer by 7 to 10 cases in every 1,000 women annually. These agents reduced the risk of estrogen-receptor–positive malignancy, but not estrogen-receptor–negative tumors, noninvasive cancer, or breast cancer–related mortality.

Tamoxifen and raloxifene were similarly effective in premenopausal and postmenopausal populations; both drugs also reduced the rate of osteoporotic fracture.

Most of the participants in the prevention trials were white and relatively healthy. Therefore, the relevance of these findings to women of other racial and ethnic groups and to women who have chronic disease or other morbidity is uncertain.

Aromatase inhibitors are being assessed for chemoprophylaxis, so we should have information on their risk-benefit ratio in the near future.

The author reports no financial relationships relevant to this article.

CASE 1: Refusal to treat—is it legal?

Two lesbians in South Carolina, together for 7 years, seek insemination services from their HMO gynecology service. The doctors at that service decline to inseminate them—saying that they do not offer this service to lesbians because they believe that only heterosexual, married women should have children—and refer them to another physician outside the HMO. The couple pays $8,000 out of pocket to conceive their son. Because it is legal to discriminate against homosexuals in South Carolina, the doctors cannot be sued, and ACOG cannot discipline the doctors.

Currently, 25% to 45% of clinics in the United States report that they refuse to inseminate lesbians.^1,2 What can we do to end such discrimination?

“Physicians and other health care professionals have the duty to refer patients in a timely manner to other providers if they do not feel that they can in conscience provide the standard reproductive services that their patients request.” So says Committee Opinion #385 of the American College of Obstetricians and Gynecologists (ACOG).³ This formal opinion implies that a physician who objects to same-sex couples may refer a lesbian patient to another physician for insemination, thereby communicating his or her discrimination to the patient.

In addition, ACOG’s Committee on Underserved Women released Committee Opinion #428, endorsing “equitable treatment for lesbians and their families, not only for direct health care needs but also for indirect health care issues; this should include the same legal protections afforded married couples.”⁴ The opinion does not endorse access to civil marriage, per se.

And although ACOG includes a nondiscrimination clause in its Code of Professional Ethics stating that the “principle of justice requires strict avoidance of discrimination on the basis of race, color, religion, national origin, or any other basis that would constitute illegal discrimination,” sexual orientation and gender identity are not specified.

To remain consistent with its mission of “advancing women’s health,” ACOG must include sexual orientation and gender identity in its nondiscrimination statement and endorse access for same-sex couples to civil marriage—not just “equitable treatment.”

In 44 states, laws mandating so-called equitable treatment deny the families of lesbian couples the legal and financial protections of civil marriage that are deemed essential to the health of families headed by heterosexual couples.

In 30 states, ACOG’s nondiscrimination policy, as written, could be interpreted to permit gynecologists to discriminate on the basis of sexual orientation in their practices.

The American Society for Reproductive Medicine issued a statement affirming that there is no justification for denying same-sex couples assisted reproductive technologies.⁵

Both the American Academy of Pediatrics (AAP) and the American Psychiatric Association (APA) prohibit discrimination on the basis of sexual orientation and endorse civil marriage for same-sex couples in richly evidence-based policy statements. Both organizations affirm that:

• homosexuality is natural, immutable, and noncontagious
• the children of homosexual parents develop with outcomes equal to those of heterosexual parents
• the families of same-sex couples need the same protections that their heterosexual counterparts enjoy.

The American Medical Association (AMA) issued policy statements prohibiting discrimination based on sexual orientation and gender identity because of documented health disparities that arise from discrimination.

In this article, I present evidence to support these positions; provide examples of how the current ACOG statement contributes to disparities; and challenge ACOG to clarify the wording of its opinions.

There is no scientific rationale for any discrimination against same-sex families. There is abundant scientific evidence that these families are harmed by discriminatory laws and treatment.

Civil unions, domestic partnerships do not equal civil marriage

ACOG Committee Opinion #428 makes it clear that “equitable treatment” does not affect religious rules about marriage ceremonies: Marriage licenses must be solemnized either in a religious ceremony performed by a clergy member, or in a civil ceremony performed by a judge, justice of the peace, or elected official.⁴ The Committee Opinion recognizes that domestic partnerships and civil unions do not provide the same rights as a state civil marriage license, and notes that neither is portable to all other states or recognized by the United States government.⁴

 

The opinion further acknowledges that marriage has a uniquely universal dignity and recognition in our society and grants the couple access to more than 1,000 federal rights deemed important for the health of its partners and their families.⁴

ACOG Committee Opinion #385 concedes that to refer a homosexual patient seeking insemination or surrogacy services does indeed communicate the physician’s discriminatory attitude to the patient and may cause harm.³ The AMA prohibits such discrimination by requiring that physicians only offer those services that they can provide to all patients without discrimination. This would allow a physician to refuse to do any procedure that is deemed unconscionable—but any service provided to some must be provided to all.

How the first trimester may influence sexual orientation

Fetal brain circuitry is permanently organized during the first trimester of pregnancy under the influence of various hormones and hormonelike substances, conferring an innate sexual orientation and gender identity, which children gradually come to recognize.⁶ Any subtle or not-so-subtle exposure to androgenic substances during early gestation of a 46 XX fetus can influence neural patterns in the phenotypic female child. These patterns may manifest as more aggressive play activity and masculinized somatic skeletal structure, neural structure, behavioral and biophysiologic skills, or gynephilic sexual orientation, and possibly confer a male gender identity.^7-11

Congenital adrenal hyperplasia (CAH) demonstrates the biological effects of prenatal hormones on sexual orientation and gender identity. CAH is a condition in which an enzyme (21-hydroxylase) in the cortisone synthesis pathway is missing or dysfunctional, resulting in buildup of precursor androgens in the fetal blood. Female infants with CAH can be born with virilization of their external genitals or ambiguous genitalia.

Since 1968, 13 published studies have revealed that 20% to 50% of females who have CAH will identify as lesbian or bisexual in adulthood.¹⁰ A smaller percentage will come to recognize a male gender identity, particularly when their CAH is the more severe salt-wasting type.¹¹

Homosexual orientation is also more frequent among women who had prenatal exposure to the complex steroid diethylstilbestrol,¹² and among those who have polycystic ovarian syndrome (PCOS).¹³ Further evidence of the influence of prenatal androgen exposure on female sexual orientation is seen among females who gestated with a fraternal male co-twin.¹⁴ These girls are reported to have more aggressive play patterns during childhood and are more likely to identify as lesbian later in life.

Female-to-male transgender individuals have been shown to have higher adult androgen levels, a higher incidence of PCOS, and a greater likelihood of a history of CAH.^15,16

It is unclear whether all homosexual females or female-to-male transsexuals were influenced by some form of first-trimester androgen excess. There are many endogenous and exogenous sources of androgen-like substances. They include maternal adrenal steroids arising from a high level of stress, anabolic steroids ingested from poultry or beef, and subclinical variations of fetal 21-hydroxylase concentration or efficiency, for example.

Homosexuality is not a disorder

The APA backs evidence that homosexuality cannot be spread by exposure or influence, nor can it be “repaired” or eradicated by disciplinary treatment. In fact, published evidence shows that the mental health and development of children are significantly harmed by parental, familial, and school peer rejection, whereas developmental parameters are much improved by their parents’ celebration of the youth’s diversity and the school’s enforcement of its diversity policy.¹⁷ Still, recognition of one’s sexual orientation can be difficult because of legal and social proscriptions against homosexuality.

Although most homosexuals have experienced some form of discriminatory treatment in their lives—be it verbal or physical abuse, or different treatment at their school or job or by existing federal and state laws—most still report a full and rewarding life.¹⁸ Experiences of discrimination, however, are potent psychic stressors for which many seek counseling and support, and which may undermine mental and physical health.^19,20 Such discrimination may lie at the root of the documented higher rates of obesity, smoking, and alcoholism among lesbians compared with heterosexual women reported in the Women’s Health Initiative and the Nurses Health Study.^21,22

Most young people, including those who will realize that they are gay, are raised with a strong appreciation for family and cultural traditions and an anticipation of adulthood with a career and marriage.²³ Although marriage systems may differ, marriage across world cultures is a publicly acknowledged, highly respected, singular union, designed to create kinship obligations and sharing of resources between two adults and protect any children that they may produce.

 

Like heterosexual women, many lesbians desire to create families secured by civil marriage laws. These families need and deserve the same protections established by law to support and protect families headed by heterosexual couples. The marriage license is a state-regulated contract between two individuals. Each couple must then separately have the license solemnized, either by a designated state official (civil marriage) or by a clergy member (religious marriage).

All of the states with laws that permit civil marriage for same-sex couples have explicitly endorsed a religious right for clergy to refuse to certify same-sex couples’ licenses according to their beliefs.

Married parents provide a greater sense of security

In comparison with mere cohabitation, marriage confers more health benefits to the couple and has been correlated with a lower rate of cardiac disease²⁴ and cancer risk factors,²⁵ and with greater longevity.²⁶ Marriage also provides greater security to any children in the family unit.²⁷ When federal and state laws treat homosexual families differently than heterosexuals, this discrimination conveys a lower societal respect to all members of the family, but especially to the children.²⁸ When children eventually learn that their parents—unlike other children’s parents—are not allowed to marry, they may lose some faith in their parents and be subject to bullying.²⁹

The AAP reported significant, reliable evidence that lesbian and gay parents are as fit, effective, and successful as heterosexual parents.²⁸ The organization also confirmed research showing that children of same-sex couples are as emotionally healthy and socially well-adjusted and at least as educationally and socially successful as children raised by heterosexual parents.²⁸

The APA issued a pamphlet that states:

• Both heterosexual behavior and homosexual behavior are normal aspects of human sexuality. Both have been documented in many different cultures and historical eras. Despite the persistence of stereotypes that portray lesbian, gay, and bisexual people as disturbed, several decades of research and clinical experience have led all mainstream medical and mental health organizations in this country to conclude that these orientations represent normal forms of human experience.³⁰

Case studies in discrimination

In 44 states, “equitable treatment” for same-sex couples, reflected in local law, entails denial of civil marriage and the family protections it confers. In nine states, equitable treatment means prohibition of adoption by same-sex couples. In 30 states, equitable treatment includes discrimination in housing or jobs based on sexual orientation and gender identity.

Consider the following vignettes, all possible (as is Case 1) under current laws in the geographic areas specified:

CASE 2

A Massachusetts lesbian married to a same-sex spouse who bore the couple’s children is offered a job promotion managing the Arkansas branch of her company. She has to decline the promotion because her company cannot continue her family’s medical insurance in Arkansas. Nor would she have legal custody of her children in that state or be able to adopt them there.

CASE 3

A married lesbian is hit by a car while crossing the street at a medical conference in Dallas. The funeral home refuses to release her body to her spouse for burial near their home in Connecticut. The decedent’s brother is called because he is the closest legal relative under Texas law, but since he never approved of his sister’s lesbian sexual orientation, he has her body transported to his family’s plot in Virginia.

CASE 4

A physician who is a lesbian is recruited to a state university in Michigan in 2003. She moves there with her domestic partner and their two adopted children, one of whom has cerebral palsy, and is promoted to the rank of associate professor in 2007. The next year, the Michigan Supreme Court interprets a 2004 constitutional amendment to mean that state institutions are prohibited from providing domestic partner benefits to same-sex couples. This leaves her stay-at-home spouse and their children without health insurance.

In each case, “equitable treatment” that is legal nevertheless injures the stability, integrity, and health of families, and ACOG’s Code of Professional Ethics fails to serve its mission of promoting women’s and family health.

AAP, APA endorse civil marriage

After reviewing 25 scientific articles on families parented by same-sex couples and the development of children in those families, the AAP concluded in 2006 that:

• These data have demonstrated no risk to children as a result of growing up in a family with one or more gay parents. Conscientious and nurturing adults, whether they are men or women, heterosexual or homosexual, can be excellent parents. The rights, benefits, and protections of civil marriage can further strengthen these families.²⁸

 

The APA in 2004 endorsed civil marriage.³¹ For its part, the AMA has taken historic social and political stands endorsing nondiscrimination in school education programs for youth, in youth scouting organizations, in medical education, and in insurance coverage. The AMA also issued support of legislation to allow adoption by same-sex partners and co-parents. The AMA seeks to reduce the health disparities suffered because of unequal treatment of minor children and same-sex parents by supporting equality in laws affecting the health care of members of same-sex partner households and their dependent children.³² The AMA also issued a nondiscrimination clause that states:

• The AMA reaffirms its longstanding policy that there is no basis for the denial to any human being of equal rights, privileges, and responsibilities commensurate with his or her individual capabilities and ethical character because of an individual’s sex, sexual orientation, gender, gender identity, or transgender status, race, religion, disability, ethnic origin, national origin, or age [emphasis mine].³²

Just as ACOG expects to be consulted for testimony in any legislation or court proceeding about gynecologic and obstetric issues, the expertise of the APA and AAP in the areas of child and family mental health are indisputable.

We should take a principled stand on this matter

The AMA Principles of Medical Ethics stipulate that “a physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.” Our scientific ACOG community possesses access to knowledge that the lay community does not have. We have a responsibility to reflect the evidence in our ACOG policies and share the information in our communities for the health and well-being of our patients.

When society is broadly misinformed about issues related to homosexuality and frequently votes in ways that harm lesbians and their families, ACOG—whose mission is “advancing women’s health”—should take an unequivocally principled stand, as the AAP and the APA have already done.

The endorsement of civil marriage per se and inclusion of sexual orientation and gender identity in the nondiscrimination clause in no way oppose any of ACOG’s values but, rather, reflect and support ACOG’s mission for America’s women.

In the past, ACOG did not at first endorse “equitable treatment” for women who had unintended pregnancy. ACOG took the highly controversial but principled stand of endorsing women’s self-determination or “choice” to continue or abort an early gestation. ACOG endorsed what scientific evidence had proved to be healthiest for the woman and her family, and should do so now again.

ACOG could accomplish its mission for women’s health more fully if it would reconvene the Committees on Ethics and on Underserved Women and ask the committees to unambiguously prohibit all discrimination based on sexual orientation and gender identity, and endorse equal access to civil marriage across the country for the health of lesbian couples and parents. ACOG also should revise the Code of Professional Ethics to include sexual orientation and gender identity in the nondiscrimination clause.

The author reports no financial relationships relevant to this article.

CASE 1: Refusal to treat—is it legal?

Two lesbians in South Carolina, together for 7 years, seek insemination services from their HMO gynecology service. The doctors at that service decline to inseminate them—saying that they do not offer this service to lesbians because they believe that only heterosexual, married women should have children—and refer them to another physician outside the HMO. The couple pays $8,000 out of pocket to conceive their son. Because it is legal to discriminate against homosexuals in South Carolina, the doctors cannot be sued, and ACOG cannot discipline the doctors.

Currently, 25% to 45% of clinics in the United States report that they refuse to inseminate lesbians.^1,2 What can we do to end such discrimination?

“Physicians and other health care professionals have the duty to refer patients in a timely manner to other providers if they do not feel that they can in conscience provide the standard reproductive services that their patients request.” So says Committee Opinion #385 of the American College of Obstetricians and Gynecologists (ACOG).³ This formal opinion implies that a physician who objects to same-sex couples may refer a lesbian patient to another physician for insemination, thereby communicating his or her discrimination to the patient.

In addition, ACOG’s Committee on Underserved Women released Committee Opinion #428, endorsing “equitable treatment for lesbians and their families, not only for direct health care needs but also for indirect health care issues; this should include the same legal protections afforded married couples.”⁴ The opinion does not endorse access to civil marriage, per se.

And although ACOG includes a nondiscrimination clause in its Code of Professional Ethics stating that the “principle of justice requires strict avoidance of discrimination on the basis of race, color, religion, national origin, or any other basis that would constitute illegal discrimination,” sexual orientation and gender identity are not specified.

To remain consistent with its mission of “advancing women’s health,” ACOG must include sexual orientation and gender identity in its nondiscrimination statement and endorse access for same-sex couples to civil marriage—not just “equitable treatment.”

In 44 states, laws mandating so-called equitable treatment deny the families of lesbian couples the legal and financial protections of civil marriage that are deemed essential to the health of families headed by heterosexual couples.

In 30 states, ACOG’s nondiscrimination policy, as written, could be interpreted to permit gynecologists to discriminate on the basis of sexual orientation in their practices.

The American Society for Reproductive Medicine issued a statement affirming that there is no justification for denying same-sex couples assisted reproductive technologies.⁵

Both the American Academy of Pediatrics (AAP) and the American Psychiatric Association (APA) prohibit discrimination on the basis of sexual orientation and endorse civil marriage for same-sex couples in richly evidence-based policy statements. Both organizations affirm that:

• homosexuality is natural, immutable, and noncontagious
• the children of homosexual parents develop with outcomes equal to those of heterosexual parents
• the families of same-sex couples need the same protections that their heterosexual counterparts enjoy.

The American Medical Association (AMA) issued policy statements prohibiting discrimination based on sexual orientation and gender identity because of documented health disparities that arise from discrimination.

In this article, I present evidence to support these positions; provide examples of how the current ACOG statement contributes to disparities; and challenge ACOG to clarify the wording of its opinions.

There is no scientific rationale for any discrimination against same-sex families. There is abundant scientific evidence that these families are harmed by discriminatory laws and treatment.

Civil unions, domestic partnerships do not equal civil marriage

ACOG Committee Opinion #428 makes it clear that “equitable treatment” does not affect religious rules about marriage ceremonies: Marriage licenses must be solemnized either in a religious ceremony performed by a clergy member, or in a civil ceremony performed by a judge, justice of the peace, or elected official.⁴ The Committee Opinion recognizes that domestic partnerships and civil unions do not provide the same rights as a state civil marriage license, and notes that neither is portable to all other states or recognized by the United States government.⁴

 

The opinion further acknowledges that marriage has a uniquely universal dignity and recognition in our society and grants the couple access to more than 1,000 federal rights deemed important for the health of its partners and their families.⁴

ACOG Committee Opinion #385 concedes that to refer a homosexual patient seeking insemination or surrogacy services does indeed communicate the physician’s discriminatory attitude to the patient and may cause harm.³ The AMA prohibits such discrimination by requiring that physicians only offer those services that they can provide to all patients without discrimination. This would allow a physician to refuse to do any procedure that is deemed unconscionable—but any service provided to some must be provided to all.

How the first trimester may influence sexual orientation

Fetal brain circuitry is permanently organized during the first trimester of pregnancy under the influence of various hormones and hormonelike substances, conferring an innate sexual orientation and gender identity, which children gradually come to recognize.⁶ Any subtle or not-so-subtle exposure to androgenic substances during early gestation of a 46 XX fetus can influence neural patterns in the phenotypic female child. These patterns may manifest as more aggressive play activity and masculinized somatic skeletal structure, neural structure, behavioral and biophysiologic skills, or gynephilic sexual orientation, and possibly confer a male gender identity.^7-11

Congenital adrenal hyperplasia (CAH) demonstrates the biological effects of prenatal hormones on sexual orientation and gender identity. CAH is a condition in which an enzyme (21-hydroxylase) in the cortisone synthesis pathway is missing or dysfunctional, resulting in buildup of precursor androgens in the fetal blood. Female infants with CAH can be born with virilization of their external genitals or ambiguous genitalia.

Since 1968, 13 published studies have revealed that 20% to 50% of females who have CAH will identify as lesbian or bisexual in adulthood.¹⁰ A smaller percentage will come to recognize a male gender identity, particularly when their CAH is the more severe salt-wasting type.¹¹

Homosexual orientation is also more frequent among women who had prenatal exposure to the complex steroid diethylstilbestrol,¹² and among those who have polycystic ovarian syndrome (PCOS).¹³ Further evidence of the influence of prenatal androgen exposure on female sexual orientation is seen among females who gestated with a fraternal male co-twin.¹⁴ These girls are reported to have more aggressive play patterns during childhood and are more likely to identify as lesbian later in life.

Female-to-male transgender individuals have been shown to have higher adult androgen levels, a higher incidence of PCOS, and a greater likelihood of a history of CAH.^15,16

It is unclear whether all homosexual females or female-to-male transsexuals were influenced by some form of first-trimester androgen excess. There are many endogenous and exogenous sources of androgen-like substances. They include maternal adrenal steroids arising from a high level of stress, anabolic steroids ingested from poultry or beef, and subclinical variations of fetal 21-hydroxylase concentration or efficiency, for example.

Homosexuality is not a disorder

The APA backs evidence that homosexuality cannot be spread by exposure or influence, nor can it be “repaired” or eradicated by disciplinary treatment. In fact, published evidence shows that the mental health and development of children are significantly harmed by parental, familial, and school peer rejection, whereas developmental parameters are much improved by their parents’ celebration of the youth’s diversity and the school’s enforcement of its diversity policy.¹⁷ Still, recognition of one’s sexual orientation can be difficult because of legal and social proscriptions against homosexuality.

Although most homosexuals have experienced some form of discriminatory treatment in their lives—be it verbal or physical abuse, or different treatment at their school or job or by existing federal and state laws—most still report a full and rewarding life.¹⁸ Experiences of discrimination, however, are potent psychic stressors for which many seek counseling and support, and which may undermine mental and physical health.^19,20 Such discrimination may lie at the root of the documented higher rates of obesity, smoking, and alcoholism among lesbians compared with heterosexual women reported in the Women’s Health Initiative and the Nurses Health Study.^21,22

Most young people, including those who will realize that they are gay, are raised with a strong appreciation for family and cultural traditions and an anticipation of adulthood with a career and marriage.²³ Although marriage systems may differ, marriage across world cultures is a publicly acknowledged, highly respected, singular union, designed to create kinship obligations and sharing of resources between two adults and protect any children that they may produce.

 

Like heterosexual women, many lesbians desire to create families secured by civil marriage laws. These families need and deserve the same protections established by law to support and protect families headed by heterosexual couples. The marriage license is a state-regulated contract between two individuals. Each couple must then separately have the license solemnized, either by a designated state official (civil marriage) or by a clergy member (religious marriage).

All of the states with laws that permit civil marriage for same-sex couples have explicitly endorsed a religious right for clergy to refuse to certify same-sex couples’ licenses according to their beliefs.

Married parents provide a greater sense of security

In comparison with mere cohabitation, marriage confers more health benefits to the couple and has been correlated with a lower rate of cardiac disease²⁴ and cancer risk factors,²⁵ and with greater longevity.²⁶ Marriage also provides greater security to any children in the family unit.²⁷ When federal and state laws treat homosexual families differently than heterosexuals, this discrimination conveys a lower societal respect to all members of the family, but especially to the children.²⁸ When children eventually learn that their parents—unlike other children’s parents—are not allowed to marry, they may lose some faith in their parents and be subject to bullying.²⁹

The AAP reported significant, reliable evidence that lesbian and gay parents are as fit, effective, and successful as heterosexual parents.²⁸ The organization also confirmed research showing that children of same-sex couples are as emotionally healthy and socially well-adjusted and at least as educationally and socially successful as children raised by heterosexual parents.²⁸

The APA issued a pamphlet that states:

• Both heterosexual behavior and homosexual behavior are normal aspects of human sexuality. Both have been documented in many different cultures and historical eras. Despite the persistence of stereotypes that portray lesbian, gay, and bisexual people as disturbed, several decades of research and clinical experience have led all mainstream medical and mental health organizations in this country to conclude that these orientations represent normal forms of human experience.³⁰

Case studies in discrimination

In 44 states, “equitable treatment” for same-sex couples, reflected in local law, entails denial of civil marriage and the family protections it confers. In nine states, equitable treatment means prohibition of adoption by same-sex couples. In 30 states, equitable treatment includes discrimination in housing or jobs based on sexual orientation and gender identity.

Consider the following vignettes, all possible (as is Case 1) under current laws in the geographic areas specified:

CASE 2

A Massachusetts lesbian married to a same-sex spouse who bore the couple’s children is offered a job promotion managing the Arkansas branch of her company. She has to decline the promotion because her company cannot continue her family’s medical insurance in Arkansas. Nor would she have legal custody of her children in that state or be able to adopt them there.

CASE 3

A married lesbian is hit by a car while crossing the street at a medical conference in Dallas. The funeral home refuses to release her body to her spouse for burial near their home in Connecticut. The decedent’s brother is called because he is the closest legal relative under Texas law, but since he never approved of his sister’s lesbian sexual orientation, he has her body transported to his family’s plot in Virginia.

CASE 4

A physician who is a lesbian is recruited to a state university in Michigan in 2003. She moves there with her domestic partner and their two adopted children, one of whom has cerebral palsy, and is promoted to the rank of associate professor in 2007. The next year, the Michigan Supreme Court interprets a 2004 constitutional amendment to mean that state institutions are prohibited from providing domestic partner benefits to same-sex couples. This leaves her stay-at-home spouse and their children without health insurance.

In each case, “equitable treatment” that is legal nevertheless injures the stability, integrity, and health of families, and ACOG’s Code of Professional Ethics fails to serve its mission of promoting women’s and family health.

AAP, APA endorse civil marriage

After reviewing 25 scientific articles on families parented by same-sex couples and the development of children in those families, the AAP concluded in 2006 that:

• These data have demonstrated no risk to children as a result of growing up in a family with one or more gay parents. Conscientious and nurturing adults, whether they are men or women, heterosexual or homosexual, can be excellent parents. The rights, benefits, and protections of civil marriage can further strengthen these families.²⁸

 

The APA in 2004 endorsed civil marriage.³¹ For its part, the AMA has taken historic social and political stands endorsing nondiscrimination in school education programs for youth, in youth scouting organizations, in medical education, and in insurance coverage. The AMA also issued support of legislation to allow adoption by same-sex partners and co-parents. The AMA seeks to reduce the health disparities suffered because of unequal treatment of minor children and same-sex parents by supporting equality in laws affecting the health care of members of same-sex partner households and their dependent children.³² The AMA also issued a nondiscrimination clause that states:

• The AMA reaffirms its longstanding policy that there is no basis for the denial to any human being of equal rights, privileges, and responsibilities commensurate with his or her individual capabilities and ethical character because of an individual’s sex, sexual orientation, gender, gender identity, or transgender status, race, religion, disability, ethnic origin, national origin, or age [emphasis mine].³²

Just as ACOG expects to be consulted for testimony in any legislation or court proceeding about gynecologic and obstetric issues, the expertise of the APA and AAP in the areas of child and family mental health are indisputable.

We should take a principled stand on this matter

The AMA Principles of Medical Ethics stipulate that “a physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.” Our scientific ACOG community possesses access to knowledge that the lay community does not have. We have a responsibility to reflect the evidence in our ACOG policies and share the information in our communities for the health and well-being of our patients.

When society is broadly misinformed about issues related to homosexuality and frequently votes in ways that harm lesbians and their families, ACOG—whose mission is “advancing women’s health”—should take an unequivocally principled stand, as the AAP and the APA have already done.

The endorsement of civil marriage per se and inclusion of sexual orientation and gender identity in the nondiscrimination clause in no way oppose any of ACOG’s values but, rather, reflect and support ACOG’s mission for America’s women.

In the past, ACOG did not at first endorse “equitable treatment” for women who had unintended pregnancy. ACOG took the highly controversial but principled stand of endorsing women’s self-determination or “choice” to continue or abort an early gestation. ACOG endorsed what scientific evidence had proved to be healthiest for the woman and her family, and should do so now again.

ACOG could accomplish its mission for women’s health more fully if it would reconvene the Committees on Ethics and on Underserved Women and ask the committees to unambiguously prohibit all discrimination based on sexual orientation and gender identity, and endorse equal access to civil marriage across the country for the health of lesbian couples and parents. ACOG also should revise the Code of Professional Ethics to include sexual orientation and gender identity in the nondiscrimination clause.

The author reports no financial relationships relevant to this article.

CASE 1: Refusal to treat—is it legal?

Two lesbians in South Carolina, together for 7 years, seek insemination services from their HMO gynecology service. The doctors at that service decline to inseminate them—saying that they do not offer this service to lesbians because they believe that only heterosexual, married women should have children—and refer them to another physician outside the HMO. The couple pays $8,000 out of pocket to conceive their son. Because it is legal to discriminate against homosexuals in South Carolina, the doctors cannot be sued, and ACOG cannot discipline the doctors.

Currently, 25% to 45% of clinics in the United States report that they refuse to inseminate lesbians.^1,2 What can we do to end such discrimination?

“Physicians and other health care professionals have the duty to refer patients in a timely manner to other providers if they do not feel that they can in conscience provide the standard reproductive services that their patients request.” So says Committee Opinion #385 of the American College of Obstetricians and Gynecologists (ACOG).³ This formal opinion implies that a physician who objects to same-sex couples may refer a lesbian patient to another physician for insemination, thereby communicating his or her discrimination to the patient.

In addition, ACOG’s Committee on Underserved Women released Committee Opinion #428, endorsing “equitable treatment for lesbians and their families, not only for direct health care needs but also for indirect health care issues; this should include the same legal protections afforded married couples.”⁴ The opinion does not endorse access to civil marriage, per se.

And although ACOG includes a nondiscrimination clause in its Code of Professional Ethics stating that the “principle of justice requires strict avoidance of discrimination on the basis of race, color, religion, national origin, or any other basis that would constitute illegal discrimination,” sexual orientation and gender identity are not specified.

To remain consistent with its mission of “advancing women’s health,” ACOG must include sexual orientation and gender identity in its nondiscrimination statement and endorse access for same-sex couples to civil marriage—not just “equitable treatment.”

In 44 states, laws mandating so-called equitable treatment deny the families of lesbian couples the legal and financial protections of civil marriage that are deemed essential to the health of families headed by heterosexual couples.

In 30 states, ACOG’s nondiscrimination policy, as written, could be interpreted to permit gynecologists to discriminate on the basis of sexual orientation in their practices.

The American Society for Reproductive Medicine issued a statement affirming that there is no justification for denying same-sex couples assisted reproductive technologies.⁵

Both the American Academy of Pediatrics (AAP) and the American Psychiatric Association (APA) prohibit discrimination on the basis of sexual orientation and endorse civil marriage for same-sex couples in richly evidence-based policy statements. Both organizations affirm that:

• homosexuality is natural, immutable, and noncontagious
• the children of homosexual parents develop with outcomes equal to those of heterosexual parents
• the families of same-sex couples need the same protections that their heterosexual counterparts enjoy.

The American Medical Association (AMA) issued policy statements prohibiting discrimination based on sexual orientation and gender identity because of documented health disparities that arise from discrimination.

In this article, I present evidence to support these positions; provide examples of how the current ACOG statement contributes to disparities; and challenge ACOG to clarify the wording of its opinions.

There is no scientific rationale for any discrimination against same-sex families. There is abundant scientific evidence that these families are harmed by discriminatory laws and treatment.

Civil unions, domestic partnerships do not equal civil marriage

ACOG Committee Opinion #428 makes it clear that “equitable treatment” does not affect religious rules about marriage ceremonies: Marriage licenses must be solemnized either in a religious ceremony performed by a clergy member, or in a civil ceremony performed by a judge, justice of the peace, or elected official.⁴ The Committee Opinion recognizes that domestic partnerships and civil unions do not provide the same rights as a state civil marriage license, and notes that neither is portable to all other states or recognized by the United States government.⁴

 

The opinion further acknowledges that marriage has a uniquely universal dignity and recognition in our society and grants the couple access to more than 1,000 federal rights deemed important for the health of its partners and their families.⁴

ACOG Committee Opinion #385 concedes that to refer a homosexual patient seeking insemination or surrogacy services does indeed communicate the physician’s discriminatory attitude to the patient and may cause harm.³ The AMA prohibits such discrimination by requiring that physicians only offer those services that they can provide to all patients without discrimination. This would allow a physician to refuse to do any procedure that is deemed unconscionable—but any service provided to some must be provided to all.

How the first trimester may influence sexual orientation

Fetal brain circuitry is permanently organized during the first trimester of pregnancy under the influence of various hormones and hormonelike substances, conferring an innate sexual orientation and gender identity, which children gradually come to recognize.⁶ Any subtle or not-so-subtle exposure to androgenic substances during early gestation of a 46 XX fetus can influence neural patterns in the phenotypic female child. These patterns may manifest as more aggressive play activity and masculinized somatic skeletal structure, neural structure, behavioral and biophysiologic skills, or gynephilic sexual orientation, and possibly confer a male gender identity.^7-11

Congenital adrenal hyperplasia (CAH) demonstrates the biological effects of prenatal hormones on sexual orientation and gender identity. CAH is a condition in which an enzyme (21-hydroxylase) in the cortisone synthesis pathway is missing or dysfunctional, resulting in buildup of precursor androgens in the fetal blood. Female infants with CAH can be born with virilization of their external genitals or ambiguous genitalia.

Since 1968, 13 published studies have revealed that 20% to 50% of females who have CAH will identify as lesbian or bisexual in adulthood.¹⁰ A smaller percentage will come to recognize a male gender identity, particularly when their CAH is the more severe salt-wasting type.¹¹

Homosexual orientation is also more frequent among women who had prenatal exposure to the complex steroid diethylstilbestrol,¹² and among those who have polycystic ovarian syndrome (PCOS).¹³ Further evidence of the influence of prenatal androgen exposure on female sexual orientation is seen among females who gestated with a fraternal male co-twin.¹⁴ These girls are reported to have more aggressive play patterns during childhood and are more likely to identify as lesbian later in life.

Female-to-male transgender individuals have been shown to have higher adult androgen levels, a higher incidence of PCOS, and a greater likelihood of a history of CAH.^15,16

It is unclear whether all homosexual females or female-to-male transsexuals were influenced by some form of first-trimester androgen excess. There are many endogenous and exogenous sources of androgen-like substances. They include maternal adrenal steroids arising from a high level of stress, anabolic steroids ingested from poultry or beef, and subclinical variations of fetal 21-hydroxylase concentration or efficiency, for example.

Homosexuality is not a disorder

The APA backs evidence that homosexuality cannot be spread by exposure or influence, nor can it be “repaired” or eradicated by disciplinary treatment. In fact, published evidence shows that the mental health and development of children are significantly harmed by parental, familial, and school peer rejection, whereas developmental parameters are much improved by their parents’ celebration of the youth’s diversity and the school’s enforcement of its diversity policy.¹⁷ Still, recognition of one’s sexual orientation can be difficult because of legal and social proscriptions against homosexuality.

Although most homosexuals have experienced some form of discriminatory treatment in their lives—be it verbal or physical abuse, or different treatment at their school or job or by existing federal and state laws—most still report a full and rewarding life.¹⁸ Experiences of discrimination, however, are potent psychic stressors for which many seek counseling and support, and which may undermine mental and physical health.^19,20 Such discrimination may lie at the root of the documented higher rates of obesity, smoking, and alcoholism among lesbians compared with heterosexual women reported in the Women’s Health Initiative and the Nurses Health Study.^21,22

Most young people, including those who will realize that they are gay, are raised with a strong appreciation for family and cultural traditions and an anticipation of adulthood with a career and marriage.²³ Although marriage systems may differ, marriage across world cultures is a publicly acknowledged, highly respected, singular union, designed to create kinship obligations and sharing of resources between two adults and protect any children that they may produce.

 

Like heterosexual women, many lesbians desire to create families secured by civil marriage laws. These families need and deserve the same protections established by law to support and protect families headed by heterosexual couples. The marriage license is a state-regulated contract between two individuals. Each couple must then separately have the license solemnized, either by a designated state official (civil marriage) or by a clergy member (religious marriage).

All of the states with laws that permit civil marriage for same-sex couples have explicitly endorsed a religious right for clergy to refuse to certify same-sex couples’ licenses according to their beliefs.

Married parents provide a greater sense of security

In comparison with mere cohabitation, marriage confers more health benefits to the couple and has been correlated with a lower rate of cardiac disease²⁴ and cancer risk factors,²⁵ and with greater longevity.²⁶ Marriage also provides greater security to any children in the family unit.²⁷ When federal and state laws treat homosexual families differently than heterosexuals, this discrimination conveys a lower societal respect to all members of the family, but especially to the children.²⁸ When children eventually learn that their parents—unlike other children’s parents—are not allowed to marry, they may lose some faith in their parents and be subject to bullying.²⁹

The AAP reported significant, reliable evidence that lesbian and gay parents are as fit, effective, and successful as heterosexual parents.²⁸ The organization also confirmed research showing that children of same-sex couples are as emotionally healthy and socially well-adjusted and at least as educationally and socially successful as children raised by heterosexual parents.²⁸

The APA issued a pamphlet that states:

• Both heterosexual behavior and homosexual behavior are normal aspects of human sexuality. Both have been documented in many different cultures and historical eras. Despite the persistence of stereotypes that portray lesbian, gay, and bisexual people as disturbed, several decades of research and clinical experience have led all mainstream medical and mental health organizations in this country to conclude that these orientations represent normal forms of human experience.³⁰

Case studies in discrimination

In 44 states, “equitable treatment” for same-sex couples, reflected in local law, entails denial of civil marriage and the family protections it confers. In nine states, equitable treatment means prohibition of adoption by same-sex couples. In 30 states, equitable treatment includes discrimination in housing or jobs based on sexual orientation and gender identity.

Consider the following vignettes, all possible (as is Case 1) under current laws in the geographic areas specified:

CASE 2

A Massachusetts lesbian married to a same-sex spouse who bore the couple’s children is offered a job promotion managing the Arkansas branch of her company. She has to decline the promotion because her company cannot continue her family’s medical insurance in Arkansas. Nor would she have legal custody of her children in that state or be able to adopt them there.

CASE 3

A married lesbian is hit by a car while crossing the street at a medical conference in Dallas. The funeral home refuses to release her body to her spouse for burial near their home in Connecticut. The decedent’s brother is called because he is the closest legal relative under Texas law, but since he never approved of his sister’s lesbian sexual orientation, he has her body transported to his family’s plot in Virginia.

CASE 4

A physician who is a lesbian is recruited to a state university in Michigan in 2003. She moves there with her domestic partner and their two adopted children, one of whom has cerebral palsy, and is promoted to the rank of associate professor in 2007. The next year, the Michigan Supreme Court interprets a 2004 constitutional amendment to mean that state institutions are prohibited from providing domestic partner benefits to same-sex couples. This leaves her stay-at-home spouse and their children without health insurance.

In each case, “equitable treatment” that is legal nevertheless injures the stability, integrity, and health of families, and ACOG’s Code of Professional Ethics fails to serve its mission of promoting women’s and family health.

AAP, APA endorse civil marriage

After reviewing 25 scientific articles on families parented by same-sex couples and the development of children in those families, the AAP concluded in 2006 that:

• These data have demonstrated no risk to children as a result of growing up in a family with one or more gay parents. Conscientious and nurturing adults, whether they are men or women, heterosexual or homosexual, can be excellent parents. The rights, benefits, and protections of civil marriage can further strengthen these families.²⁸

 

The APA in 2004 endorsed civil marriage.³¹ For its part, the AMA has taken historic social and political stands endorsing nondiscrimination in school education programs for youth, in youth scouting organizations, in medical education, and in insurance coverage. The AMA also issued support of legislation to allow adoption by same-sex partners and co-parents. The AMA seeks to reduce the health disparities suffered because of unequal treatment of minor children and same-sex parents by supporting equality in laws affecting the health care of members of same-sex partner households and their dependent children.³² The AMA also issued a nondiscrimination clause that states:

• The AMA reaffirms its longstanding policy that there is no basis for the denial to any human being of equal rights, privileges, and responsibilities commensurate with his or her individual capabilities and ethical character because of an individual’s sex, sexual orientation, gender, gender identity, or transgender status, race, religion, disability, ethnic origin, national origin, or age [emphasis mine].³²

Just as ACOG expects to be consulted for testimony in any legislation or court proceeding about gynecologic and obstetric issues, the expertise of the APA and AAP in the areas of child and family mental health are indisputable.

We should take a principled stand on this matter

The AMA Principles of Medical Ethics stipulate that “a physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.” Our scientific ACOG community possesses access to knowledge that the lay community does not have. We have a responsibility to reflect the evidence in our ACOG policies and share the information in our communities for the health and well-being of our patients.

When society is broadly misinformed about issues related to homosexuality and frequently votes in ways that harm lesbians and their families, ACOG—whose mission is “advancing women’s health”—should take an unequivocally principled stand, as the AAP and the APA have already done.

The endorsement of civil marriage per se and inclusion of sexual orientation and gender identity in the nondiscrimination clause in no way oppose any of ACOG’s values but, rather, reflect and support ACOG’s mission for America’s women.

In the past, ACOG did not at first endorse “equitable treatment” for women who had unintended pregnancy. ACOG took the highly controversial but principled stand of endorsing women’s self-determination or “choice” to continue or abort an early gestation. ACOG endorsed what scientific evidence had proved to be healthiest for the woman and her family, and should do so now again.

ACOG could accomplish its mission for women’s health more fully if it would reconvene the Committees on Ethics and on Underserved Women and ask the committees to unambiguously prohibit all discrimination based on sexual orientation and gender identity, and endorse equal access to civil marriage across the country for the health of lesbian couples and parents. ACOG also should revise the Code of Professional Ethics to include sexual orientation and gender identity in the nondiscrimination clause.

Cerebral palsy occurs in approximately two of every 1,000 live births in the United States and causes major social and economic hardship for affected children and their families.^1,2

Preterm birth is among the most significant risk factors for CP. Although they constitute fewer than 3% of births in the United States, infants born before 34 weeks’ gestation account for nearly one of every four new cases of CP.³

To date, few, if any, obstetric interventions have proved to be effective for preventing or reducing the likelihood or consequences of CP. During the 1990s, several observational studies found an association between treatment with magnesium sulfate during pregnancy and a reduction in the risk of CP among infants born preterm or at low birth weight. However, other observational series failed to confirm this association. As a result, considerable controversy clouded this issue.

Since that time, several randomized, controlled trials have explored the association. The overarching purpose of this meta-analysis by Conde-Agudelo and Romero is to assess the impact of magnesium sulfate for neuroprotection against CP among infants born before 34 weeks’ gestation.

Reasons this meta-analysis is credible

Conde-Agudelo and Romero conducted this review in concordance with a prospectively prepared protocol and followed Quality of Reporting of Meta-analyses (QUOROM) guidelines. Their search strategy and literature review were comprehensive and included all relevant studies in this arena. In addition, they utilized rigorous inclusion criteria and assessed heterogeneity in the various study designs and populations.

Besides including pooled relative risks in the results of the meta-analysis, they also calculated the number needed to treat (NNT), a measure of utility that is important to the clinician and clinical research. In this analysis, the number of women who were at risk of preterm delivery before 34 weeks’ gestation who needed to be treated with magnesium sulfate rather than placebo to prevent one case of CP was 52 (95% confidence interval, 31–154).

Last, the authors provided a measure of the impact of the use of magnesium sulfate on the public health and economic sectors, placing the problem and intervention in a broader, highly relevant context.

No revelations about magnesium in multiple versus singleton gestations

The trials included in this meta-analysis had limitations, of course. As a result, Conde-Agudelo and Romero were unable to estimate the direction and magnitude of the effect of magnesium sulfate on the risk of CP among multiple versus singleton gestations. Nor were they able to comment on the relative influence of the various dosing and treatment protocols employed in the primary trials. Therefore, this analysis cannot be used to advocate a specific dosage or protocol.

Cerebral palsy occurs in approximately two of every 1,000 live births in the United States and causes major social and economic hardship for affected children and their families.^1,2

Preterm birth is among the most significant risk factors for CP. Although they constitute fewer than 3% of births in the United States, infants born before 34 weeks’ gestation account for nearly one of every four new cases of CP.³

To date, few, if any, obstetric interventions have proved to be effective for preventing or reducing the likelihood or consequences of CP. During the 1990s, several observational studies found an association between treatment with magnesium sulfate during pregnancy and a reduction in the risk of CP among infants born preterm or at low birth weight. However, other observational series failed to confirm this association. As a result, considerable controversy clouded this issue.

Since that time, several randomized, controlled trials have explored the association. The overarching purpose of this meta-analysis by Conde-Agudelo and Romero is to assess the impact of magnesium sulfate for neuroprotection against CP among infants born before 34 weeks’ gestation.

Reasons this meta-analysis is credible

Conde-Agudelo and Romero conducted this review in concordance with a prospectively prepared protocol and followed Quality of Reporting of Meta-analyses (QUOROM) guidelines. Their search strategy and literature review were comprehensive and included all relevant studies in this arena. In addition, they utilized rigorous inclusion criteria and assessed heterogeneity in the various study designs and populations.

Besides including pooled relative risks in the results of the meta-analysis, they also calculated the number needed to treat (NNT), a measure of utility that is important to the clinician and clinical research. In this analysis, the number of women who were at risk of preterm delivery before 34 weeks’ gestation who needed to be treated with magnesium sulfate rather than placebo to prevent one case of CP was 52 (95% confidence interval, 31–154).

Last, the authors provided a measure of the impact of the use of magnesium sulfate on the public health and economic sectors, placing the problem and intervention in a broader, highly relevant context.

No revelations about magnesium in multiple versus singleton gestations

The trials included in this meta-analysis had limitations, of course. As a result, Conde-Agudelo and Romero were unable to estimate the direction and magnitude of the effect of magnesium sulfate on the risk of CP among multiple versus singleton gestations. Nor were they able to comment on the relative influence of the various dosing and treatment protocols employed in the primary trials. Therefore, this analysis cannot be used to advocate a specific dosage or protocol.

Cerebral palsy occurs in approximately two of every 1,000 live births in the United States and causes major social and economic hardship for affected children and their families.^1,2

Preterm birth is among the most significant risk factors for CP. Although they constitute fewer than 3% of births in the United States, infants born before 34 weeks’ gestation account for nearly one of every four new cases of CP.³

To date, few, if any, obstetric interventions have proved to be effective for preventing or reducing the likelihood or consequences of CP. During the 1990s, several observational studies found an association between treatment with magnesium sulfate during pregnancy and a reduction in the risk of CP among infants born preterm or at low birth weight. However, other observational series failed to confirm this association. As a result, considerable controversy clouded this issue.

Since that time, several randomized, controlled trials have explored the association. The overarching purpose of this meta-analysis by Conde-Agudelo and Romero is to assess the impact of magnesium sulfate for neuroprotection against CP among infants born before 34 weeks’ gestation.

Reasons this meta-analysis is credible

Conde-Agudelo and Romero conducted this review in concordance with a prospectively prepared protocol and followed Quality of Reporting of Meta-analyses (QUOROM) guidelines. Their search strategy and literature review were comprehensive and included all relevant studies in this arena. In addition, they utilized rigorous inclusion criteria and assessed heterogeneity in the various study designs and populations.

Besides including pooled relative risks in the results of the meta-analysis, they also calculated the number needed to treat (NNT), a measure of utility that is important to the clinician and clinical research. In this analysis, the number of women who were at risk of preterm delivery before 34 weeks’ gestation who needed to be treated with magnesium sulfate rather than placebo to prevent one case of CP was 52 (95% confidence interval, 31–154).

Last, the authors provided a measure of the impact of the use of magnesium sulfate on the public health and economic sectors, placing the problem and intervention in a broader, highly relevant context.

No revelations about magnesium in multiple versus singleton gestations

The trials included in this meta-analysis had limitations, of course. As a result, Conde-Agudelo and Romero were unable to estimate the direction and magnitude of the effect of magnesium sulfate on the risk of CP among multiple versus singleton gestations. Nor were they able to comment on the relative influence of the various dosing and treatment protocols employed in the primary trials. Therefore, this analysis cannot be used to advocate a specific dosage or protocol.