TECHNICAL REPORT

Promoting the Well-Being of ChildrenWhose Parents AreGay or Lesbian

abstractExtensive data available from more than 30 years of research revealthat children raised by gay and lesbian parents have demonstratedresilience with regard to social, psychological, and sexual health de-spite economic and legal disparities and social stigma. Many studieshave demonstrated that children’s well-being is affected much moreby their relationships with their parents, their parents’ sense ofcompetence and security, and the presence of social and economicsupport for the family than by the gender or the sexual orientation oftheir parents. Lack of opportunity for same-gender couples to marryadds to families’ stress, which affects the health and welfare of allhousehold members. Because marriage strengthens families and, inso doing, benefits children’s development, children should not bedeprived of the opportunity for their parents to be married. Pathsto parenthood that include assisted reproductive techniques, adop-tion, and foster parenting should focus on competency of theparents rather than their sexual orientation. Pediatrics 2013;131:e1374–e1383

INTRODUCTION

The mission of the American Academy of Pediatrics (AAP) is to promoteoptimal physical, mental, and social health and well-being for all in-fants, children, adolescents, and young adults. Historically, the AAPhas worked, through its educational, research, advocacy, and policyefforts, to highlight the powerful connection between children’s well-being and the functioning of their most enduring source of support andinfluence—their parents. It is vital that pediatricians understand theunique and complex characteristics of their patients’ families andsupport them to ensure optimal development of children.

All children have the same needs for, and the right to, nurturing,security, and social stability. Children whose parents are gay and les-bian have historically been subjected to laws, social policies, anddisapproving attitudes that create social distance and ostracism andchallenge the stability of their families as well as their optimal socialand psychological development. This technical report provides thescientific rationale, based on the current available evidence, to supportthe recommendations outlined in the policy statement “Promotingthe Well-Being of Children Whose Parents are Gay or Lesbian”1: sup-port for marriage equality, including repeal of the federal Defense of

Ellen C. Perrin, MD, MA, Benjamin S. Siegel, MD, and theCOMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD ANDFAMILY HEALTH

KEY WORDScivil marriage, adoption, foster care, nurturing children, gayparents, lesbian parents, health disparities, legal disparities,same sex, same gender, marriage equality

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave filed conflict of interest statements with the AmericanAcademy of Pediatrics. Any conflicts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content ofthis publication.

The guidance in this report does not indicate an exclusivecourse of treatment or serve as a standard of medical care.Variations, taking into account individual circumstances, may beappropriate.

All technical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

www.pediatrics.org/cgi/doi/10.1542/peds.2013-0377

doi:10.1542/peds.2013-0377

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Marriage Act and similar public poli-cies that limit access to federal ben-efits associated with civil marriagefor gay and lesbian couples, and theright of gay and lesbian adults toadopt and provide foster care for eli-gible children.

Children depend on their parents forguidance, nurturing, protection, sup-port, and love. Their resiliency derivesfrom their sense of permanence, se-curity, and unconditional attachment.As a consequence of this central valueto their children, modern societies havedeveloped the legal and social contractof marriage to ensure the permanentcommitment of parents to each otherand to their children, and thus toprovide an optimal environment forchildren to thrive. The value of childrento society is reflected also in the manypublic policies and programs that aredesigned to ensure adequate resourcesand support to parents who are raisinga child alone, by choice or circum-stance, and to families that because ofphysical or mental illness, abuse, ne-glect, and/or financial difficulty, cannotfunction successfully in their capacityas parents. Families created by gay andlesbian adults are no exception to thesebroad social policies.

Because of the value of marriage to thesociety, there are few legal restrictionson who can marry. The only legal limi-tations to marriage equality for con-senting adults in the United States arefor adults who are certified as mentally/emotionally incompetent, for whommarriage would lead to a polygamousrelationship, who are of minor age, whoare related by blood, or who are thesame gender (in a majority of thestates). Even a history of child abuse,domestic violence, or other criminalactivity does not disqualify adults fromcivil marriage. Despite conflicts basedon individuals’ political and religiousbeliefs, it is important to recognize thatlaws restricting competent adults of

the same gender from codifying theircommitment to each other and theirchildren via civil marriage may resultnot only in pain and hardship fortheir children but also in legal, eco-nomic, psychological, social, andhealth disparities that can no longerbe justified.

DIVERSE FAMILIES

The 2003 report of the AAP Task Forceon the Family stated that: “No partic-ular family constellation makes pooror good outcomes for children in-evitable.”2 The report continued: “Astable, well-functioning family thatconsists of 2 parents and children ispotentially the most secure, support-ive, and nurturing environment inwhich children may be raised. Thatchildren can be successfully broughtto adulthood without this basic func-tioning unit is a tribute to those in-volved who have developed the skilland resiliency to overcome a difficultand fundamental challenge.”2

Families are diverse, complex, andchanging. Most US public policy is builton the presumption that the majority offamilies are composed of a marriedmother and father raising their bi-ological children. In contrast, the 2010US Census revealed that the proportionof children living with 2 married bi-ological parents had declined to 65.3%,down from 69.2% in 2001.3 See Table 1for further elucidation of family typesbased on the 2010 Census.

Determining the number of childrenbeing raised by lesbian and gay parentsis challenging, because most surveys

do not ask about parents’ sexual ori-entation. Starting with the 2000 Cen-sus, gay and lesbian couples have hadthe option to identify themselves asspouses.4 The 2010 Census identified131 729 self-reported married same-gender households and 514 735 same-gender unmarried partner householdslocated in essentially all counties ofthe United States.4–6

Thirty-one percent of same-gendercouples who identified as spousesand 14% of those who identified asunmarried partners indicated that theywere raising children, more than 111 000in all.5 In addition to these parents,many single gay men and lesbians arealso raising children. Combined, cur-rent estimates suggest that almost 2million children younger than 18years are being raised by at least 1gay or lesbian parent in the UnitedStates.6,7

Families with a gay or lesbian parent(or parents) are, themselves, a diversegroup.8,9 For example, 55% to 59% ofsame-gender couples with childrenidentify as white compared with 70%to 73% of married heterosexual cou-ples with children.7 Same-gender cou-ples, like heterosexual couples, maybecome parents by having children inprevious heterosexual relationships orthrough fostering, adoption, donor in-semination, and/or surrogacy.10

LEGAL DISPARITIES CREATED BYSTATE LAWS

Regulations and laws about the rightsand responsibilities of parenthood areprimarily state specific, resulting in

TABLE 1 Children in the United States 2010: Family Status

Family Status Number of Children(Millions)a

Children in theUnited States, %

Children in 2-parent households 51.456 73.0Children with married parents living together 48.516 65.3Children with unmarried parents 2.940 3.9Children with single/separated parents 20.263 27.1Children being raised by 1 or more grandparents 2.595 3.5a Total number of children in the United States: 74.630 million.

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great variability among the states.Many legal and social disparities existfor same-gender couples and theirchildren.11

� A critical disparity for children ofunmarried parents is the absenceof the protections reflected in di-vorce law. Thus, in the event of thedissolution of the couple’s rela-tionship, these families lack theprotections that exist for childrenwhose parents are married, suchas:

1. Access to the courts for a legallystructured arrangement for dis-solution of the relationship;

2. A court-approved legal arrange-ment for visitation rights and/or custody of children; and

3. Entitlement for children to fi-nancial support from and on-going relationships with bothparents.

� The majority of states prohibit,by statute or state constitutionalamendment, recognition of same-gender marriage.12 A few statesextend other forms of relationshiprecognition, such as civil union ordomestic partnership.

� A few states, either by statute, reg-ulation, or legal interpretation, re-strict or prohibit foster parentingby same-gender couples and/orlesbians and gay men.

� Laws regarding joint adoption bysame gender couples, whereinboth individuals become the legalparents of a biologically unrelatedchild, vary from state to state.13

Joint adoption by lesbian and gaycouples is expressly prohibited ina few states, granted by law infewer than half, and not addressedby statutes in most states.

� Only in states that recognize civilmarriage or other forms of domes-tic relationships can a lesbian orgay spouse or partner be recognized

as a legal parent or step-parent tothe child(ren) she or he is helpingraise. In the majority of states, thisis not a legal option.

� In the United States (but not inmuch of Europe), sperm and eggdonors may choose to remainanonymous and take on no legalresponsibility for any childrenborn. In a few states, a donormay be considered a legally recog-nized parent and have related re-sponsibilities. A few states havelaws ensuring that both parentsare legally recognized as “pre-sumed parents” of the child.

� Most states lack a formal mecha-nism to ensure basic rights andresponsibilities to nonbiological,nonadoptive coparents. Such lawsare important to children whenadult couple relationships are indissolution and appropriate cus-tody is under consideration.

� Legal arrangements with a surro-gate carrier are available in onlya few states to gay men who wishto have a biologically related child.

� In the event of death of a spouse,partner, or parent, state laws donot provide for Social Security orveteran’s survivor benefits for thesurviving spouse/partner and chil-dren.

LEGAL DISPARITIES CREATED BYFEDERAL LAWS AND REGULATIONS

Restrictions against civil marriage forsame-gender couples, such as thefederal Defense of Marriage Act (Pub LNo. 104-199 [1996]) and replications ofit in state statutes and constitutions,deny these couples and their childrennumerous other protections and ben-efits deemed valuable by society andgovernment to which heterosexualmarried couples and their childrenhave access. Under the Defense ofMarriage Act, these benefits are not

available to couples of the same gen-der even if they are legally married ina state that recognizes same-gendermarriage. The US Government Ac-countability Office has identified a totalof 1138 federal statutory provisions inwhich marital status was a factor indetermining or receiving rights, ben-efits, and protections. These have beenoutlined elsewhere in detail14; a fewexamples are presented here:

� Legal recognition of a couple’scommitment to and responsibilityfor one another and legal recogni-tion of a child’s relationship toboth parents and joint parentingrights;

� Tax-exempt employer-sponsoredhealth and other insurance ben-efits for spouse/partner andnonbiological/not jointly adoptedchildren;

� Ability to consent to medical careor authorize emergency medicaltreatment of nonbiological/not jointlyadopted children;

� The ability to travel with a child if itwill require proof of being a legalparent;

� The ability to file joint income taxreturns and take advantage offamily-related deductions, includ-ing the ability to use the child taxcredit, child and dependent caretax credit, dependency exemption,earned income tax credit, and giftand estate tax exemption; and

� A surviving parent’s right to thecustody of and care for, and child-ren’s right to maintain a relation-ship with, a nonbiological or notlegally recognized parent in theevent of the death of the other par-ent.

HEALTH DISPARITIES

� Because children cannot legallyconsent to medical treatment, thelack of uniform legal recognition of

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lesbian and gay parents results inparents being prohibited from ac-companying their child(ren) andmaking medical decisions for themin routine and even emergencysituations. Parents may even bebarred from visiting their child inthe hospital if their parental statusis ambiguous.

� Another challenge for same-gendercouples and their families is ob-taining health insurance. As a re-sult of the federal Defense ofMarriage Act, employers are notrequired to, although some chooseto, offer health benefits to same-gender spouses or partners orchildren of lesbian and gayemployees, even if those workersare legally married in their state.As a result, same-gender couplesare 2 to 3 times less likely to havehealth insurance than are hetero-sexual couples.7,15 This disparityaffects children directly, becausethe vast majority of children (morethan 84%) have the same healthinsurance status as their parents(public or private insurance oruninsured16). Evidence that healthinsurance coverage is directly as-sociated with health status is un-deniable.17

� Even when employers do makehealth insurance benefits avail-able to same-gender spouses,partners, and related children,these families are faced withan economic disadvantage com-pared with their heterosexualcounterparts. Such benefits areconsidered by the Internal Reve-nue Code to be taxable or “im-puted” income to the employeeunless the spouse or partner orchild qualifies as a legal depen-dent. In addition, employers mustalso pay taxes on this imputed in-come for their share of theemployee’s payroll tax.

� Lesbian- and gay-headed families areat greater peril than heterosexual-headed families when a parentloses a job or takes a cut in pay.The Consolidated Omnibus BudgetReconciliation Act of 1995 (COBRA[Pub L No. 99-272]) provides work-ers and their families who losetheir health benefits the capacityto continue group health benefitsprovided by their employer grouphealth plan for limited periods oftime. However, the COBRA, as fed-eral legislation, does not requireemployers, even those who providebenefits for same-gender spouses/partners and their dependents, tooffer lesbian and gay employees theopportunity to enroll their spouses,partners, or children.

� Additional challenges exist in theprovision of health care. Physi-cians, hospitals, and other healthcare professionals and environ-ments may not offer a welcom-ing environment for same-genderparents and their children. Thereaction a family may encoun-ter ranges from acceptance todisdain: sometimes pediatriciansand others encountered in healthcare settings or institutions mayexpress stigmatizing attitudes orrefuse to recognize an unmarriedparent, especially when that par-ent is part of a gay or lesbiancouple. Among respondents ina survey of gay and lesbian pa-rents in New York, 42% reportedthat dislike of lesbian and gay peo-ple was a barrier to accessinghealth care and reported a lackof appropriately trained, compe-tent professionals to deliver healthcare to lesbian and gay people.18

According to the October 2011 re-port, All Children Matter: How Le-gal and Social Inequalities HurtLGBT Children, “a family may shyaway from scheduling a child’s

doctor’s visit in an effort to shieldhim or her from hostile questionsor misunderstandings. For parentswho must rely on medical profes-sionals with unknown attitudes to-ward lesbian and gay patients,concerns linger about treatmentof them and their children, whichcan make care more difficult toobtain.”7 Some parents report wor-ries about being blamed for theirchild’s physical or emotional disor-ders because of their sexual orien-tation or family constellation.19

CHILDREN’S DEVELOPMENTALTRAJECTORY AND PSYCHOLOGICALOUTCOMES

Many factors confer risk to children’shealthy development and adult out-comes, such as poverty, parental de-pression, parental substance abuse,divorce, and domestic violence, butthe sexual orientation of their parentsis not among them. Many studies haveassessed the developmental and psy-chosocial outcomes of children whoseparents are gay or lesbian and notethat a family’s social and economicresources and the strength of therelationships among members of thefamily are far more important vari-ables than parental gender or sexualorientation in affecting children’s de-velopment and well-being.20 A largebody of scientific literature demon-strates that children and adolescentswho grow up with gay and/or lesbianparents fare as well in emotional,cognitive, social, and sexual function-ing as do children whose parents areheterosexual.21–37 Although the meth-odologic challenges are daunting inaddressing phenomena as complexand multifactorial as children’s long-term developmental and psychosocialoutcomes, the literature accumulatedover more than 30 years, taken to-gether, provides robust, reliable, andvalid assurance about the well-being

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of children raised by parents of thesame gender.28,29

The first review of available data re-garding the well-being of children liv-ing with lesbian or gay parentsconcluded that “While research onthese topics is relatively new….thereis no evidence that the development ofchildren with lesbian and gay parentsis compromised in any significant re-spect relative to that among childrenof heterosexual parents in otherwisecomparable circumstances.”30

Another early review summarized 23articles published before 2000 that,together, described 615 offspring oflesbian mothers and gay fathers and387 controls by using a variety ofpsychological tests and interviews. Theconclusion drawn from these studieswas that children raised by gay andlesbian parents did not systematicallydiffer from other children in emotional/behavioral functioning, sexual orien-tation, experiences of stigmatization,gender role behavior, or cognitivefunctioning.31

A more recent comprehensive reviewof the experiences of gay and lesbianparents and their children reaffirmedthat most children raised by lesbianand gay parents are developmentallyand socially well-adjusted and that thesocietal presence of stigma, hetero-sexism, family circumstance, struc-ture, and process are more importantinfluences on children’s developmentaltrajectory than is the gender or sexualorientation of their parents.32

Much of this early research aboutchildren with gay and lesbian parentswas, by necessity, based on relativelysmall convenience samples. Never-theless, more than 100 scientificpublications over 30 years, taken to-gether, have demonstrated that chil-dren’s well-being is affected muchmore by their relationships withtheir parents, their parents’ sense ofcompetence and security, and the

presence of social and economic sup-port for the family than by the genderor the sexual orientation of theirparents.20,33,34

Increasing recognition and acceptanceof lesbian and gay parents has allowedfor larger, community-based and na-tional studies in the United States andEurope. Three studies are of particularnote. Using data obtained in a largeUS population-based survey, the Na-tional Longitudinal Study of AdolescentHealth, the 44 adolescents who re-ported being raised by 2 women ina “marriage-like” family arrangementwere compared with a random sam-ple of 44 adolescents raised by het-erosexual parents.35,36 There were nodifferences noted in measures of self-esteem, depression, anxiety, schoolconnectedness, and school success.The authors concluded that “adoles-cents were functioning well and theiradjustment was not associated withfamily type.” In both groups of adoles-cents, those who described a “closerrelationship with their parents” re-ported less delinquent behavior andsubstance abuse; that is, the quality ofparent-adolescent relationships betterpredicted adolescent outcomes thandid family type.

Another community-wide study wasbased on data from a cohort of 14 000mothers of children born withina particular county in England during1 year.37 The study examined thequality of parent-child relationshipsand socioemotional and gender de-velopment in a community sample of5- to 7-year-old children with lesbianmothers. Thirty-nine lesbian motherfamilies were compared with 74 two-parent heterosexual families and 60families headed by single heterosex-ual mothers. No differences werefound in maternal warmth, emotionalinvolvement, enjoyment of motherhood,frequency of conflicts, supervisionof the child, abnormal behaviors

reported by parents or teachers inthe child, children’s self-esteem, orpsychiatric disorders. Both mothersand teachers reported more behav-ioral problems among children insingle-parent families than amongchildren who had 2 parents in thehome, irrespective of their sexualorientation.

A recent publication was based ona large national sample of US adultswho were asked whether their parentshad ever had a relationship witha person of the same gender whilethey were growing up and whetherthey had ever lived with that parentwhile the parent was involved in sucha relationship.38 Parents who weresaid to have had a same-gender re-lationship were categorized as lesbianor gay parents, although their sexualorientation was not directly deter-mined. In comparison with those whodid not report that a parent had hada same-gender relationship, a numberof adverse outcomes were identified,including being on public assistance,being unemployed, and having poorereducational attainment. Extensive cri-tique of this study39–44 has pointed outthat:

� It is well known that family insta-bility, and in particular divorce, isa risk factor for children,45,46 andalmost all of the respondentswhose parent had had a same-gender relationship had also ex-perienced the divorce of theirparents.

� These data reflect an era whenstigmatization and discriminationtoward same-gender couples andtheir children were strong andwere likely to have contributedto less-than-optimal child-rearingenvironments.40

� Respondents were certainly notchildren “raised by” lesbian orgay parents, because only halfwere living with these parents,

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and the sexual orientation of theparents was not determined.41,42

� The great variability in the formand characteristics of both same-gender and heterosexual relation-ships, combined with the smallnumber of those relationships,even in a large data set like thisone, makes it impossible to sortout true evidence of causality.43

A longstanding longitudinal study ofchildren born to lesbian parents in theUnited States provides further insightinto the well-being of children raisedfrom birth by lesbian parents. TheNational Longitudinal Lesbian FamilyStudy began in 1986, enrolling 154lesbian mothers who became preg-nant through donor insemination (70birth mothers, 70 comothers, and 14single mothers). These mothers havebeen enrolled in the study for morethan 17 years, maintaining a retentionrate of 92%. Recent publications de-scribe the outcome of 78 adolescentoffspring at age 17 (39 girls and 39boys) on the basis of mothers’ andadolescents’ reports and comparingthem with national standardizationsamples. The mothers’ reports abouttheir 17-year-old sons and daughtersindicated that they had high levels ofsocial, school/academic, and totalcompetence and fewer social prob-lems, rule breaking, and aggressiveand externalizing behavior comparedwith their age-matched counterpartsin the Achenbach Child BehaviorChecklist’s standardization sample.There were no differences betweenoffspring who were conceived byknown or anonymous donors or be-tween offspring whose parents werestill together and those whose moth-ers had separated.47 An accompany-ing editorial noted, “Can these datareassure those who fear that homo-sexual relationships with or withoutchildren will herald the end of thefamily as we know it? Our experience

tells us of the resilience of childrenwho are loved and know that love. …And when we see these moms or dadswith their kids in our practice, we callthem families.”48

The self-reported quality of life of theadolescents in this sample was similarto that reported by a comparablesample of adolescents with hetero-sexual parents.49 Lesbian parentsreported that they planned to exposetheir children to male role models asan important child-rearing strategy.Half of both the girls and the boys hadidentified a male role model in theirlives. There were no significant asso-ciations between gender role traits,adolescent psychological adjustment,gender of the adolescent, and thepresence or absence of male rolemodels.50

More data are available to documentthe well-being of children whoseparents are lesbian than of thosewhose parents are gay men, becausethe numbers of gay men parentinghave, until recently, been small. Recentstudies affirm that families createdby gay men resemble closely thosecreated by lesbians.51 For example,a recent study assessed child de-velopment and parenting among 27lesbian, 29 gay, and 50 heterosexualcouples who had adopted a child.52

Lesbian and gay parents were similarin a variety of parenting character-istics to their heterosexual counter-parts. Children in all family typeswere functioning similarly and had fewbehavior problems. Average scoresfor internalizing, externalizing, andtotal behavior problems reported byparents and teachers were similar topopulation averages for the child de-velopment instruments. In particular,there were no differences among thefamily types in children’s adjustment,parenting stress, parent disciplinetechniques, and couple adjustment. Asin previous studies, teachers’ ratings

of behavior noted that behavior prob-lems were more likely in children withsingle parents than with 2 parents,irrespective of their sexual orientation.Instead, “parents who reported lessparenting stress, use of more effectivedisciplinary techniques and who hadgreater happiness in their couplerelationships had children who weredescribed as well off.”51

Some authors have investigated chil-dren’s academic performance as anindicator of their well-being. Two ar-ticles compared the academic achi-evement of children whose parentswere gay or lesbian with childrenwhose parents were heterosexual. Al-though the studies were performedwith different methodologies and indifferent population groups, bothrevealed similar academic achieve-ment in the 2 groups. Using an anal-ysis of US Census data to perform thefirst large-sample, nationally repre-sentative analysis of educational out-comes, the author concluded that“children of same-sex couples areas likely to make normal progressthrough school as the children ofmost other family structures.”53 An-other study demonstrated that loweracademic achievement was relatedmore to the number of family tran-sitions experienced by children thanto the sexual orientation of theirparents.54

A few publications have suggested lesspositive outcomes for children raisedby same-gender parents. For example,a small study from Australia55 hassometimes been cited in support ofthe proposition that children raised bylesbians and gay men are less well-adjusted than those raised by het-erosexual couples. The study wasbased on a comparison of teachers’reports about 58 children in each of 3groups of parents: married, hetero-sexual cohabiting, and gay or lesbiancohabiting. A primary goal of the

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study was to understand possibledisadvantages to children’s schooland social performance on the basisof the marriage versus cohabitationof their parents. It is critical to notethat:

� At the time of the research, mar-riage was available only to hetero-sexual parents, and therefore, allgay or lesbian couples were, bydefinition, cohabiting.

� There is strong evidence providedin the article that the children withgay or lesbian parents were se-verely stigmatized in their schoolsand communities.

� Most of the children with gay orlesbian parents had experiencedthe divorce of their heterosexualbirth parents, in many casesshortly before the time of study,thus potentially adding to thechildren’s stress.45,46

The study’s findings included consid-erable variation in the ratings givenby teachers with regard to the child-ren’s school behavior and perfor-mance. For example, children with gayor lesbian parents were rated asperforming less well in language andmath but better in social studies andas having a better attitude towardlearning, compared with the childrenbeing raised by cohabiting or marriedheterosexual parents. The deleteriouseffects of divorce and of stigmatiza-tion on children’s development aredescribed by the author as likelycontributors to the areas of poorerperformance of the children with gayor lesbian parents. Overall, theauthor’s conclusions emphasized thebenefits of marriage: “married cou-ples seem to offer the best envi-ronment for a child’s social andeducational development.”55 In an-other article, the same author reporteda comparison of cohabiting adultsof the same and of different gendersand concluded that, in substantial

ways, the relationships of cohabitingadults are similar, whether the part-ners are of the same or differentgenders.56

A 2012 commentary has describedvarious shortcomings of the aforemen-tioned research in support of adop-tion rights and marriage equality forsame-gender couples.57 In general,this critique pointed out that moststudies have included small and se-lective samples; have rarely reportedlongitudinal data and, therefore, havereported only short-term outcomes;and often have not included a com-parison group. While agreeing withthe imperfections of past research inthis area, others have pointed out theintrinsic complexities of this researchagenda40 and commented that, de-spite these imperfections, it is likelythat the extensive research effortsthat have been carried out would havedocumented serious and significantdamages if they existed. In addition, itis important to note that all past re-search about children growing upwith gay or lesbian parents has takenplace in the context of pervasive so-cial stigma and includes a majority ofchildren whose parents were eithersingle or divorced, each of which canbe expected to contribute to pooroutcomes for children.39

Although studies of uncommon andvaried phenomena are difficult toperform and yield incomplete andimperfect results, there is an emerg-ing consensus, based on an extensivereview of the scientific literature, thatchildren growing up in householdsheaded by gay men or lesbians are notdisadvantaged in any significant re-spect relative to children of hetero-sexual parents. Indeed, the fact thatmost data suggest that children growup successfully in families created bygay and lesbian parents despite thealmost-universal family disruption andsocial stigma they have experienced

attests to the resilience of thesefamilies. Greater acceptance and sup-port of these families will provide anenvironment even more conducive tosuccessful social and emotional de-velopment.

Over the past decade, 11 countrieshave recognized marriage equalityand, thus, allow marriage between 2partners of the same gender: Argen-tina, Belgium, Canada, Denmark, Ice-land, Netherlands, Norway, Portugal,Spain, South Africa, and Sweden. Therehas been no evidence that children inthese countries have experienced dif-ficulties as a result of these socialchanges.

WHEN MARRIAGE IS NOT ANOPTION

The AAP recognizes that some childrenare members of families headed bya single parent or by 2 parents who donot choose to be legally married andthat it is possible for these parentsto overcome the challenges involvedin raising children in these circum-stances. The AAP also acknowledgesthat some children have been removedfrom severely challenged families andare in temporary custody of a stateagency or a related adult. There is noevidence that restricting these children’saccess to loving and nurturing adoptiveor foster care homes on the basis ofgender or sexual orientation of theparents is in their best interests.52,58

MARRIAGE MATTERS

The AAP Task Force on the Familyreported that “married men andwomen are physically and emotionallyhealthier and are less likely to engagein health risk behaviors, such as al-cohol or drug abuse, than are un-married adults.”2 Both men andwomen live longer when married,presumably in part because they havehealthier lifestyles, eat better, and

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monitor each other’s health.2 Theytend to have relationships with morepeople and social institutions, whichincreases their level of social support.It has been well established that per-manently married parents can createthe best environment for children’sdevelopment.2,59

Marriage supports permanence andsecurity (the basic ingredients for thehealthy development of children).Marriage is also the official societalmechanism for conferring rights,benefits, and protections that supportcouples as spouses and parents andtheir children financially and legally.In a survey of married same-gendercouples in Massachusetts, the firststate to allow civil marriage for same-gender couples, 24% of the respond-ents noted that their children hadpreviously been explicitly teased ortaunted about having a gay or lesbianparent, but 93% of respondents statedthat marriage has made their childrenhappier and better off.60 Eighty-fourpercent of parents stated that theirbeing married made them feel morecomfortable working with their child(ren)’s teachers at school.

CONCLUSIONS

On the basis of this comprehensivereview of the literature regardingthe development and adjustment of

children whose parents are the samegender, as well as the existing evidencefor the legal, social, and health bene-fits of marriage to children, the AAPconcludes that it is in the best inter-ests of children that they be able topartake in the security of permanentnurturing and care that comes withthe civil marriage of their parents,without regard to their parents’ gen-der or sexual orientation.

Marriage equality can help reducesocial stigma faced by lesbian and gayparents and their children, therebyenhancing social stability, acceptance,and support. Children who are raisedby married parents benefit from thesocial and legal status that civil mar-riage conveys to their parents.

When marriage of their parents is nota viable option, children should notbe deprived of the opportunity fortemporary foster care or adoption bysingle parents or couples, irrespectiveof their sexual orientation. Publicpolicy and community support are vitalto the success of children in thesecircumstances.

Pediatricians working to eliminatedisparities and establish support,stability, and security of all familiesthrough marriage equality and legalparental recognition honor the AAPmission to promote the optimal phy-sical, mental, and social health and

well-being of all infants, children,adolescents, and young adults.

ACKNOWLEDGMENTThe authors and the committee thankJames G. Pawelski, MS, for his valuablecontributions to the development of thistechnical report.

LEAD AUTHORSEllen C. Perrin, MD, MABenjamin S. Siegel, MD

COMMITTEE ON PSYCHOSOCIALASPECTS OF CHILD AND FAMILYHEALTH, 2012–2013Benjamin S. Siegel, MD, ChairpersonMary I. Dobbins, MDArthur Lavin, MDGerri Mattson, MDJohn Pascoe, MD, MPHMichael Yogman, MD

LIAISONSRonald T. Brown, PhD – Society of PediatricPsychologyMary Jo Kupst, PhD – Society of PediatricPsychologyD. Richard Martini, MD – American Academy ofChild and Adolescent PsychiatryBarbara Blue, MSN, RN, CPNP, PMHNP-BC –

National Association of Pediatric NursePractitionersTerry Carmichael, MSW – National Associationof Social Workers

CONSULTANTGeorge J. Cohen, MD

STAFFStephanie Domain, MS, CHES

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