December 30, 2024 • 27 mins
Dr. Diana Tordoff shares insights on the health and well-being of LGBTQ parents, revealing the specific stressors and barriers they face while navigating parenthood. Her paper, “Parenthood and the physical and mental health of sexual and gender minority parents: A cross-sectional, observational analysis from The PRIDE Study” can be found in the September 2024 (Vol. 97) issue of Annals of Epidemiology.
Read the full article here:
https://www.sciencedirect.com/science/article/abs/pii/S1047279724001595
To learn more about or collaborate with The PRIDE Study, visit:
https://pridestudy.org/collaborate
Episode Credits:
- Executive Producer: Sabrina Debas
- Technical Producer: Paula Burrows
- Annals of Epidemiology is published by Elsevier.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Patrick Sullivan (00:12):
Hello, you're listening to EPITalk
Paper, a monthly podcast fromthe Annals of Epidemiology.
I'm Patrick Sullivan,Editor-in-Chief of the Journal,
and in this series we take youbehind the scenes of some of the
latest epidemiologic researchfeatured in our journal.
Today we're here with Dr.
(00:35):
Diana Tardoff to discuss herarticle "Parenthood and the
physical and mental health ofsexual and gender minority
parents (00:41):
A cross-sectional observational analysis from The
PRIDE Study.
" You can read the full articleonline in the September 2024
issue of the journal atwwwannalsofepidemiologyorg.
Dr Diana Tordoff is aninstructor in the Department of
Obstetrics and Gynecology atStanford School of Medicine and
(01:01):
an affiliated researcher withthe PRIDE Study, which I hope we
can talk more about The PRIDEStudy.
She's an epidemiologist whoseresearch focuses on sexual and
reproductive health of LGBTQpopulations.
Dr.
Tordoff, thank you so much foryour work and thank you for
joining us today.
Diana Tordoff (01:17):
Thank you so much for having me; I'm excited to
be here.
Patrick Sullivan (01:21):
So if you could just start by telling us
about the purpose of your study,like why this issue and why was
it an important question to ask?
Diana Tordoff (01:29):
So in this study, we were interested in how being
a parent impacts the health andwell-being specifically of
LGBTQ people.
This type of research has beenconducted in the general
population as well asspecifically for straight and
cisgender populations, but notspecifically for LGBTQ people.
We know that LGBTQ parents faceunique stressors and that these
(01:53):
might impact their health.
So, for example, state legalenvironments that don't protect
LGBTQ parents, difficultyfinding LGBTQ parenting
communities, experiences oftheir children experiencing
bullying, doing their familystructure and more and so we
wanted to understand how thismight have an impact on both
(02:15):
physical or mental health.
Also importantly, LGBTQ parentsis a population that is large
and anticipated to grow a lot inthe coming years, so there's
two demographic shifts that arehappening simultaneously.
First is that youngergenerations are more likely to
identify as LGBTQ so 20% of GenZ versus 4% of Gen X and these
(02:40):
younger generations of LGBTQfolks are twice as likely to
have or to want to have childrencompared to prior generations.
So it's important to start tobetter understand this specific
subpopulation.
Patrick Sullivan (02:55):
And I'm so glad you mentioned the sort of
temporal trend in interest inhaving children among LGBTQ
people, because I think inearlier generations many of us
sort of felt like it just wasn'ta possibility and I think it's
amazing that now there is thissense of the possible and, I
think, a broader discussion andplanning about having, you know,
(03:17):
building families.
So thanks for that framing.
So to answer this question, youuse data from the PRIDE study.
Can you talk a little bit about, just from a methods point of
view, what kind of study designis this?
And then how did you use thatdata to answer the questions
that you were seeking to answer?
Diana Tordoff (03:32):
Absolutely.
So, The PRIDE study is alongitudinal cohort study of
LGBTQ adults living in the USand its territories.
We began data collection in2017 and are currently in our
eighth year of data collection,and the PRIDE study is what we
call a dynamic cohort.
What this means is that it's areally low barrier for
(03:54):
participants to participate inresearch, and it's also allowed
us to reach a very large numberof potential participants, and
so to date, we've enrolled over30,000 adults in the study,
although year to year, a smallerportion of those complete our
annual survey.
So for this study, weconstructed a cross-sectional
(04:14):
sample by pooling data acrossthree years of annual surveys so
we took data from 2018 to 2020,which allowed us to create a
cross-sectional sample of around9,600 LGBTQ adults.
Patrick Sullivan (04:30):
So it's really interesting from a methods
point of view and I'mencouraging my EPI 530 students
to listen to podcasts.
So I'll just say it'sinteresting because you have a
prospective cohort that has sortof an open enrollment, but then
you're using data from that toessentially construct a
cross-sectional study from theannual interviews of people, and
(04:50):
so it's an interesting sort ofuse of data from a prospective
cohort design but analyzed in across-sectional format.
So just nice littlemethodologic piece.
So Can you talk a little bitabout some of the barriers to
forming families for LGBTQpeople?
So, just like in general, thereare some categories of like
financial things and legalthings and government things and
(05:13):
like access to assistedreproductive technology.
So what are some of thosebarriers that you thought about
going in and what were some ofthe main findings with respect
to those barriers?
Diana Tordoff (05:24):
Yeah, absolutely so.
As you mentioned, LGBTQ folksdo face a variety of barriers.
First is, you know, dependingon what reproductive anatomy
folks have available in theircouple or even as a single
parent, that really impacts whatpathways are available for them
to build their families, andmany of these pathways are quite
(05:47):
expensive.
So, whether it's adoption or,you know, assisted reproduction
technology like IVF or surrogacy, these are often financially
inaccessible to many folks, andalso the policy environment has
changed dramatically over thelast 20 or 30 years, but there
(06:07):
are still places where there'sdiscrimination against LGBTQ
folks, for example, in thefostering or adoptive systems
and even at fertility clinics,who just aren't used to working
with LGBTQ couples or who haveadditional requirements for
folks who are LGBTQ.
So, for example, at somefertility clinics, if you use a
(06:31):
known sperm donor, they requirethat both the prospective
parents as well as the spermdonor undergo psychiatric
evaluation, and this type ofpolicy really disproportionately
impacts LGBTQ couples ratherthan straight and cisgender
couples, who also sometimes needto use sperm donors based on
their fertility situation.
Patrick Sullivan (06:53):
Yeah, I think this is so.
Thank you for providing thatbackground for folks who may not
think about what the orexperience what these barriers
are, and I think it ties intoreally the importance of your
question, which is parenthoodcan have a variety of effect on
parents generally, butparticularly, why you focus on
the physical and mental healthof sexual gender minority
parents also has to do with thisjourney towards parenthood and
(07:16):
what that's like.
So thanks for that context.
So what were some of the mainfindings, then, from your work
relative to the kind of barriersand experiences that you're
talking about?
Diana Tordoff (07:27):
Yeah.
So first, we found that ageplayed a really large factor
really across our analyses, bothin how we analyze the data as
well as the outcomes.
So we saw that the proportionof LGBTQ folks who are parents
increased with age, which is notsurprising.
However, we saw that only 2% ofparticipants in their 20s were
(07:49):
parents, compared to 18% ofthose who are in their 30s, 38%
of participants who are age 40and older, and I think we looked
at a variety of health outcomes.
We focused on chronic healthoutcomes, common mental health
conditions as well as substanceuse, and our most notable
findings reported worse scoreson several scales that measure
(08:14):
current symptoms, so, forexample, worse depressive scores
as measured on the PHQ-9, aswell as worse scores on the
GAZ-7 scale for anxiety and thePCL-6 score for PTSD symptoms.
Notably, we did not finddifferences in lifetime history
of diagnoses.
(08:35):
So, for example, we did notnecessarily see differences in
lifetime diagnoses of depression, anxiety and PTSD.
I also want to note that thiswas small but also statistically
significant.
So in our bivariate analyses,when we looked at severe or
moderate depression or anxiety,we found that there was around a
(08:58):
12 to 17% increase in thesesymptoms and on a continuous
scale, this was about a halfpoint increase on each of the
scales.
Patrick Sullivan (09:07):
Thanks for that explanation.
So you're comparing parents andnon-parents among sexual and
gender minority people, and so Iguess one question that comes
to mind is is this an experienceof being a parent, or is this a
particular experience of beinga sexual and gender minority
parent?
Or is this a particularexperience of being a sexual and
gender minority parent?
Diana Tordoff (09:25):
That's a great question and we can't
necessarily answer that usingthese data, and it would be nice
to have sort of what we thinkof as a negative control if we
had access to cisgender andstraight folks.
However, we do know from theprior literature that in the
general or overall populationthat parents tend to have worse
(09:48):
mental health than non-parents.
So this is consistent with thefindings, but I think there is
likely some additional stressorsand additional unique factors
impacting parents who arespecifically LGBTQ.
Patrick Sullivan (10:02):
And sometimes I wonder you know when you do an
analysis like this, that thedirection between qualitative
and quantitative can go eitherway, like sometimes we do
qualitative work to try andfigure out which questions to
ask and surveys, you know, andthen do mathematical analyses.
But I almost wonder if this isone of those cycles where we
need to go back and do somequalitative interviews, maybe
(10:25):
with both like sexual and genderminority parents and others,
and sort of see what thoseparticular stressors are.
I will say, and I thinksometimes the questions we ask
are informed by our experiencesand by qualitative work and
talking to people, but there aredefinitely hypotheses, I think,
about the stresses on sexualand gender minority people that
(10:46):
probably you know would be arich place to start with that
including you know, I think it'ssort of like published in the
literature and not in ourcommunities that there are
special kinds of barriers thatare faced in schools, with
teachers, with classmates, andso I think there's a good reason
to think that there might beeither differences in these
experiences and the level ofthem, or differences in the
(11:08):
mechanism of them, ordifferences in the kinds of
services that are needed to tryand support families.
So I'll just sort of use that togo to one last question, which
is so what should healthcareprofessionals and systems, and I
would just add like schoolsystems, please like think about
in terms of how we supportdiverse types of families?
(11:31):
Are there any specificrecommendations or any general
recommendations?
You would say, like, when yousee these findings, what do
healthcare providers need to bethinking about, what other
systems might need to help torespond to these data?
Diana Tordoff (11:43):
That's a great question, I think in response
I'm going to quote my mentor,who is also the co-director of
the Pride Study, and she's aclinician I am not, but you know
.
She says that LGBTQ folks arethe same as straight and
cisgender folks in sort of whatthey need and what types of
support they need, and you knowtheir hopes and fears for their
(12:03):
children.
At the same time, LGBTQ peopleare different from straight and
cisgender folks in that theyhave to navigate more unique
life circumstances around familybuilding, interacting with
these institutions that reallyassume like there's a mother and
a father and this sort ofheteronormative family structure
(12:25):
.
And at the same time, LGBTQfolks are different from each
other and have uniqueexperiences, and there's a lot
of diversity of experience ingeneral, but especially related
to family building and raisingchildren within the LGBTQ
community.
And so our next step in thisanalysis is we're actually
looking at the multi-levelfactors that are influencing the
(12:49):
mental health of parents.
So in the PRIDE study we havereally rich data on community
level support, interpersonalexperiences of discrimination
and social support, as well asindividual level factors, as
well as individual level factors, and our hope is to better
identify some of thesemechanisms that are impacting
the mental health of parents, sothat we can know how to better
(13:10):
support them.
Patrick Sullivan (13:13):
And thanks for your plan to sort of move
forward into this.
Like you know, the question isalways like so what can we do?
And so I think it's really niceto link up describing the
problem or the opportunity withunderstanding those mechanisms
and this pathway to.
You know, maybe there'sintervention research or RCTs
and interventions at a certaintime.
So, and I think it's the roleof descriptive, epi and
(13:34):
hypothesis generation anddocumentation that this sort of
launches on a path.
So so thank you for talkingabout your findings and the
research process.
I'm going to move to the secondpart of our discussion, which we
call behind the paper, and Ithink it's so important for our
colleagues earlier careercolleagues and all of us to sort
of hear about how we do work,how we find inspiration, how we
(13:55):
sort of manage all the thingsthat it takes to make this work
happen.
So I have a few questions aboutthis, and I want to start out
just about the PRIDE study data,which is a real treasure of a
data resource that'slongitudinal and addresses this
breadth of issues.
So if people are interested inthese kinds of questions, can
people propose to analyze thesedata?
Can they learn more about thestudy?
(14:17):
How would they go aboutrequesting access or being in
contact with the PRIDE studymanagement.
Diana Tordoff (14:23):
Absolutely so.
The Pride Study loves tocollaborate with folks who are
outside of Stanford, and so iffolks are interested in learning
more about the Pride Study,they can go to pridestudy.
org/ collaborate and find moreinformation about how they can
participate.
The PrideIDE study uses anancillary study process where
(14:46):
folks can submit a proposal fortheir hopes to use PRIDE study
data either existing data or toeven design a new survey and to
date there's been over 30ancillary studies, with many
investigators across the USlooking at a large variety of
research topics related to LGBTQfolks, and all of this is
(15:09):
available on the website.
So there's a list of currentand completed ancillary studies,
so you can see the breadth ofthe different topics we've
already looked at, and then wealso have a list of desired
ancillary study topics, whichare topics that have been
identified by our researchparticipants that we have not
(15:30):
yet investigated, and thenthere's, of course, more
information about how to requestdata and to propose an
ancillary study on the websiteas well.
Patrick Sullivan (15:40):
Great, thank you.
So for this particular question, can you say a little bit more
about- You sort of mentionedthat study participants might
propose things that areimportant questions- but for
this question about the physicaland mental health of sexual and
gender minority parents, wheredid this research question come
from and how did it come up inyour priorities?
You know how does it get workedinto all the questions that
(16:01):
people want to ask, so where didthis one grow out of?
Diana Tordoff (16:04):
So this is part of a larger body of research at
the Pride study that's aimed tounderstand the experience of
LGBTQ parents and their health,and so this includes both the
family building process itselfexperiences of pregnancy as well
as the experience of peopleafter they become parents, and
(16:24):
so this work is being led by Dr.
Juno Obedin-Maliver, who is aprofessor in the Department of
Obstetrics and Gynecology andalso co-director of the PRIDE
study, and we're doing reallyquite a lot of work really
focused on the experiences ofparents, including some
qualitative work on theexperiences of parents,
(16:46):
including some qualitative work.
So we recently completed focusgroups with parents and
prospective parents who areassigned male at birth,
specifically queer cisgender men, transgender women and
non-binary folks assigned maleat birth, because this
population in particular hasbeen really neglected by the
research and in fact, a lot ofour early research was focused
on the experiences of queer,cisgender women as well as
(17:10):
transgender men, and we heardfrom community- what about us?
Like we also want to havefamilies and we actually face a
unique set of barriers tobuilding our families and we
like want to talk about that andour children, and so we've been
doing sort of a lot of work tomake our families and we like
want to talk about that in ourchildren, and so we've been
doing sort of a lot of work tomake sure that they also feel
(17:31):
represented in the work thatwe're doing.
Patrick Sullivan (17:32):
Yeah, I really appreciate that and I think
it's just so important to saythat the experience of parenting
of single male or male coupleparenting definitely has its own
challenges and there aresocietal biases around and
suspicions, you know, I wouldsay, that come out in ways that
are harmful.
So you really can think aboutthe components of our diverse
(17:52):
communities maybe as having somecommon, but many, you know,
unique barriers to theconfigurations of parents and
how that interacts with societalassumptions.
So thank you so much for theattention to that breadth.
I want to ask, just in terms ofyour own work, who or what
inspires you to do this work?
(18:14):
Because I am a person of sexualand gender minority experience
and I think people a lot oftimes assume that what I'm doing
is me-search, somehow like thatthe questions that are asked
are because they're relevant to,like, my experiences and in
fact many of them are not and wehave different inspirations.
So I wonder what inspires youto do this work?
It could be career related, itcould be non-career related, but
(18:35):
, like, what's your path to thiswork?
Diana Tordoff (18:37):
I love that question, so outside of work,
I'm not a big nonfiction readerI'm actually like a sci-fi nerd
but the one exception is that Ido read a lot about queer
history and also queer memoir,and I was originally drawn to
the field of public health fromreading a lot about HIV and AIDS
activists when I was like alittle gay teenager, and so I
(19:00):
think I'm really grateful forhistorians, especially folks
like Jules Gill- Peterson andSarah Schulman , who have really
documented queer and transhistory and, I think, really
documenting our struggles andour successes in the past, you
know, related to the HIV andAIDS crisis, as well as
documenting that, like, queerand trans, families have always
(19:23):
existed and loved each other.
And I think I find, especiallyin times like this where there's
a lot of backlash, a lot ofsolace from the fact that
actually we've always been hereand we've always been doing work
to support our health andwell-being, and I think that's
something I use as tocontinually inspire me and also
(19:44):
sort of ground me in why I dothis work.
Patrick Sullivan (19:47):
Thank you.
Thank you for that.
I'm going to ask one morequestion which is timely to our
topic, and that's to say thatyou've given us permission to
share that you are a new mom, socongratulations, Thank you.
And I wonder, like as even asyou're doing this work; one, how
has it been going back to workand how is it to both do
research about these questionswhile you are also in your own
(20:10):
prospective cohort of you knowpeople who are starting families
, and so what's it like to be inboth of those kind of places at
the same time?
Diana Tordoff (20:19):
Absolutely yes, this paper was actually
published the same week my kiddowas born.
She's now four months, so thatwas really a fun serendipitous
happening.
Patrick Sullivan (20:29):
Like looking at galley proofs while you're
trying to like get put the babybed together, yeah, yeah.
Diana Tordoff (20:38):
Exactly.
And I also am a Pride Studyparticipant since 2017.
Before I had, you know, anyacademic or professional
relationship with the PrideStudy, and so I was really
excited to fill out my annualsurvey this year, because I know
that we ask questions aboutparenthood, and so I got to
answer them myself after doingsome analyses, which was very
(21:00):
sweet, and I just have to sayit's been really tender and
rewarding to do research onparenthood and family building,
also during this period of mylife, and I think it really just
emphasizes how important thisresearch is.
Yeah, as to returning to work,I've only been back a month so,
(21:22):
you know, don't have any tipsfor folks.
I feel like I'm still trying to, you know, navigate those
waters myself, but I feel reallylucky to have many mentors who
are also parents, you know,throughout my PhD as well
currently and I also am reallylucky to have many peers who
also are parents, so have hadseveral friends from graduate
(21:46):
school also become moms thisyear, sort of during this early
life stage career, and I thinkthat type of community you know,
queer academic parents has beenreally really helpful and
special.
Patrick Sullivan (22:00):
Thank you for sharing that and wonderful to
just see how, see how.
I think this is typical of theLGBTQ community that through our
history we've built thesecommunities of support, like as
society has shifted around us inpositive or negative ways, and
so thanks for identifying thatas a community that is there to
support one another in theseimportant life experiences, that
(22:23):
is there to support one anotherin these important life
experiences.
Dr.
Tordoff, any last thoughtsyou'd like to share with our
listeners, either about thistopic or about the process of
analyzing and making sense ofthese data?
Diana Tordoff (22:37):
So one of the things we haven't had the
opportunity to talk about interms of methods was there was a
lot of attention paid to therole of age as the confounder in
this study and, from an epiperspective, I found that to be
one of the most fun aspects ofthis analysis, which is really
trying to figure out how to bestapproach really severe
(22:57):
confounding by age, sinceparenthood and age are so
strongly correlated as well asthere being just really large
generational differences,age-related differences in both
physical and mental healthoutcomes, and so it's more
complicated to, you know, getinto in this podcast.
(23:18):
So I'm just going to plug thatas sort of an epi benefit from
reading the study.
Patrick Sullivan (23:23):
Yeah, well, I mean, can you give us a short
version, Because I think this isyou know again, like I know we
have subscribers to the podcastwho are in their epi education,
so, like, can you just say alittle bit more about the
framing of that confoundingissue with a variable like age
and experiences of parenthood,where there is this sort of
traveling alongside, right withbeing in certain ages of kids,
(23:46):
for example, and ourchronological age get confounded
with each other, and so isthere enough data in your parent
respondents to be able tounderstand how the experience of
having young kids as a 40 yearold is different than having
young kids as a 25 year old, andthat's especially relevant to
LGBTQ families, I think becauseof a lot of societal factors.
(24:07):
So what's the approach there toaddressing that confounding and
you sort of mentioned one ofthe problems is that there's
some sparseness of data, maybeat the extremes of that.
Diana Tordoff (24:17):
Absolutely so.
This is the first analysis I'veworked on from like an actual
manuscript, where there was afull reversal of the association
, like a very strong reversal ofthe association when we
adjusted for age, whichobviously, when I first ran our
regression results, was like areally big red flag and like
(24:38):
took some time to reallyinvestigate what is going on
here.
But what's true is that olderLGBTQ generations, as a process
of general aging and sort ofjust cohort differences, have
lower mental health diagnosesand better mental health
symptoms and also worse physicalhealth outcomes, just as
(24:59):
natural aging processes, whereasyounger LGBTQ folks it's the
reverse they tend to have worsemental health symptoms as well
as better physical mental health, and so we just saw these
really strong reversals in theassociation between parenthood
and these different outcomes,whether or not we accounted for
(25:20):
age.
And so we ended up usingpropensity score modeling as a
secondary approach to reallyaddress this confounding,
because we wanted to make surethat we were accounting for it
well.
And I think what was reallyreassuring is that when we use
multiple different analyticapproaches, our results were
nearly identical, which reallygave me confidence, after sort
(25:44):
of seeing this really severeconfounding, that we were
handling it well and notproducing biased estimates.
Patrick Sullivan (25:51):
Yeah, thank you for that insight into the
process, because so often papers, when they come out, look tidy,
but the process to get there isnot always a linear one.
So this is a great and generousthing to share about, just like
how you dug in and dealt withthat.
Diana Tordoff (26:08):
Great and thank you so much to you and the whole
team behind EPITalk for havingme.
Patrick Sullivan (26:13):
That brings us to the end of this episode.
Thank you again, Dr.
Tordoff, for joining us todayit was so nice to have you on
the show and thanks for sharingyour work in Annals and sharing
some more context about yourwork on the podcast today.
I'm your host, Patrick Sullivan.
Thanks for tuning in to thisepisode and see you next time on
EPITalk, brought to you byAnnals of Epidemiology, the
(26:35):
official journal of the AmericanCollege of Epidemiology.
For a transcript of thispodcast or to read the article
featured on this episode andmore from the journal, you can
visit us online at www.
annalsofepidemiology.
org.
Hello, you're listening to EPITalk
Paper, a monthly podcast fromthe Annals of Epidemiology.
I'm Patrick Sullivan,Editor-in-Chief of the Journal,
and in this series we take youbehind the scenes of some of the
latest epidemiologic researchfeatured in our journal.
Today we're here with Dr.
(00:35):
Diana Tardoff to discuss herarticle "Parenthood and the
physical and mental health ofsexual and gender minority
parents (00:41):
A cross-sectional observational analysis from The
PRIDE Study.
" You can read the full articleonline in the September 2024
issue of the journal atwwwannalsofepidemiologyorg.
Dr Diana Tordoff is aninstructor in the Department of
Obstetrics and Gynecology atStanford School of Medicine and
(01:01):
an affiliated researcher withthe PRIDE Study, which I hope we
can talk more about The PRIDEStudy.
She's an epidemiologist whoseresearch focuses on sexual and
reproductive health of LGBTQpopulations.
Dr.
Tordoff, thank you so much foryour work and thank you for
joining us today.
Diana Tordoff (01:17):
Thank you so much for having me; I'm excited to
be here.
Patrick Sullivan (01:21):
So if you could just start by telling us
about the purpose of your study,like why this issue and why was
it an important question to ask?
Diana Tordoff (01:29):
So in this study, we were interested in how being
a parent impacts the health andwell-being specifically of
LGBTQ people.
This type of research has beenconducted in the general
population as well asspecifically for straight and
cisgender populations, but notspecifically for LGBTQ people.
We know that LGBTQ parents faceunique stressors and that these
(01:53):
might impact their health.
So, for example, state legalenvironments that don't protect
LGBTQ parents, difficultyfinding LGBTQ parenting
communities, experiences oftheir children experiencing
bullying, doing their familystructure and more and so we
wanted to understand how thismight have an impact on both
(02:15):
physical or mental health.
Also importantly, LGBTQ parentsis a population that is large
and anticipated to grow a lot inthe coming years, so there's
two demographic shifts that arehappening simultaneously.
First is that youngergenerations are more likely to
identify as LGBTQ so 20% of GenZ versus 4% of Gen X and these
(02:40):
younger generations of LGBTQfolks are twice as likely to
have or to want to have childrencompared to prior generations.
So it's important to start tobetter understand this specific
subpopulation.
Patrick Sullivan (02:55):
And I'm so glad you mentioned the sort of
temporal trend in interest inhaving children among LGBTQ
people, because I think inearlier generations many of us
sort of felt like it just wasn'ta possibility and I think it's
amazing that now there is thissense of the possible and, I
think, a broader discussion andplanning about having, you know,
(03:17):
building families.
So thanks for that framing.
So to answer this question, youuse data from the PRIDE study.
Can you talk a little bit about, just from a methods point of
view, what kind of study designis this?
And then how did you use thatdata to answer the questions
that you were seeking to answer?
Diana Tordoff (03:32):
Absolutely.
So, The PRIDE study is alongitudinal cohort study of
LGBTQ adults living in the USand its territories.
We began data collection in2017 and are currently in our
eighth year of data collection,and the PRIDE study is what we
call a dynamic cohort.
What this means is that it's areally low barrier for
(03:54):
participants to participate inresearch, and it's also allowed
us to reach a very large numberof potential participants, and
so to date, we've enrolled over30,000 adults in the study,
although year to year, a smallerportion of those complete our
annual survey.
So for this study, weconstructed a cross-sectional
(04:14):
sample by pooling data acrossthree years of annual surveys so
we took data from 2018 to 2020,which allowed us to create a
cross-sectional sample of around9,600 LGBTQ adults.
Patrick Sullivan (04:30):
So it's really interesting from a methods
point of view and I'mencouraging my EPI 530 students
to listen to podcasts.
So I'll just say it'sinteresting because you have a
prospective cohort that has sortof an open enrollment, but then
you're using data from that toessentially construct a
cross-sectional study from theannual interviews of people, and
(04:50):
so it's an interesting sort ofuse of data from a prospective
cohort design but analyzed in across-sectional format.
So just nice littlemethodologic piece.
So Can you talk a little bitabout some of the barriers to
forming families for LGBTQpeople?
So, just like in general, thereare some categories of like
financial things and legalthings and government things and
(05:13):
like access to assistedreproductive technology.
So what are some of thosebarriers that you thought about
going in and what were some ofthe main findings with respect
to those barriers?
Diana Tordoff (05:24):
Yeah, absolutely so.
As you mentioned, LGBTQ folksdo face a variety of barriers.
First is, you know, dependingon what reproductive anatomy
folks have available in theircouple or even as a single
parent, that really impacts whatpathways are available for them
to build their families, andmany of these pathways are quite
(05:47):
expensive.
So, whether it's adoption or,you know, assisted reproduction
technology like IVF or surrogacy, these are often financially
inaccessible to many folks, andalso the policy environment has
changed dramatically over thelast 20 or 30 years, but there
(06:07):
are still places where there'sdiscrimination against LGBTQ
folks, for example, in thefostering or adoptive systems
and even at fertility clinics,who just aren't used to working
with LGBTQ couples or who haveadditional requirements for
folks who are LGBTQ.
So, for example, at somefertility clinics, if you use a
(06:31):
known sperm donor, they requirethat both the prospective
parents as well as the spermdonor undergo psychiatric
evaluation, and this type ofpolicy really disproportionately
impacts LGBTQ couples ratherthan straight and cisgender
couples, who also sometimes needto use sperm donors based on
their fertility situation.
Patrick Sullivan (06:53):
Yeah, I think this is so.
Thank you for providing thatbackground for folks who may not
think about what the orexperience what these barriers
are, and I think it ties intoreally the importance of your
question, which is parenthoodcan have a variety of effect on
parents generally, butparticularly, why you focus on
the physical and mental healthof sexual gender minority
parents also has to do with thisjourney towards parenthood and
(07:16):
what that's like.
So thanks for that context.
So what were some of the mainfindings, then, from your work
relative to the kind of barriersand experiences that you're
talking about?
Diana Tordoff (07:27):
Yeah.
So first, we found that ageplayed a really large factor
really across our analyses, bothin how we analyze the data as
well as the outcomes.
So we saw that the proportionof LGBTQ folks who are parents
increased with age, which is notsurprising.
However, we saw that only 2% ofparticipants in their 20s were
(07:49):
parents, compared to 18% ofthose who are in their 30s, 38%
of participants who are age 40and older, and I think we looked
at a variety of health outcomes.
We focused on chronic healthoutcomes, common mental health
conditions as well as substanceuse, and our most notable
findings reported worse scoreson several scales that measure
(08:14):
current symptoms, so, forexample, worse depressive scores
as measured on the PHQ-9, aswell as worse scores on the
GAZ-7 scale for anxiety and thePCL-6 score for PTSD symptoms.
Notably, we did not finddifferences in lifetime history
of diagnoses.
(08:35):
So, for example, we did notnecessarily see differences in
lifetime diagnoses of depression, anxiety and PTSD.
I also want to note that thiswas small but also statistically
significant.
So in our bivariate analyses,when we looked at severe or
moderate depression or anxiety,we found that there was around a
(08:58):
12 to 17% increase in thesesymptoms and on a continuous
scale, this was about a halfpoint increase on each of the
scales.
Patrick Sullivan (09:07):
Thanks for that explanation.
So you're comparing parents andnon-parents among sexual and
gender minority people, and so Iguess one question that comes
to mind is is this an experienceof being a parent, or is this a
particular experience of beinga sexual and gender minority
parent?
Or is this a particularexperience of being a sexual and
gender minority parent?
Diana Tordoff (09:25):
That's a great question and we can't
necessarily answer that usingthese data, and it would be nice
to have sort of what we thinkof as a negative control if we
had access to cisgender andstraight folks.
However, we do know from theprior literature that in the
general or overall populationthat parents tend to have worse
(09:48):
mental health than non-parents.
So this is consistent with thefindings, but I think there is
likely some additional stressorsand additional unique factors
impacting parents who arespecifically LGBTQ.
Patrick Sullivan (10:02):
And sometimes I wonder you know when you do an
analysis like this, that thedirection between qualitative
and quantitative can go eitherway, like sometimes we do
qualitative work to try andfigure out which questions to
ask and surveys, you know, andthen do mathematical analyses.
But I almost wonder if this isone of those cycles where we
need to go back and do somequalitative interviews, maybe
(10:25):
with both like sexual and genderminority parents and others,
and sort of see what thoseparticular stressors are.
I will say, and I thinksometimes the questions we ask
are informed by our experiencesand by qualitative work and
talking to people, but there aredefinitely hypotheses, I think,
about the stresses on sexualand gender minority people that
(10:46):
probably you know would be arich place to start with that
including you know, I think it'ssort of like published in the
literature and not in ourcommunities that there are
special kinds of barriers thatare faced in schools, with
teachers, with classmates, andso I think there's a good reason
to think that there might beeither differences in these
experiences and the level ofthem, or differences in the
(11:08):
mechanism of them, ordifferences in the kinds of
services that are needed to tryand support families.
So I'll just sort of use that togo to one last question, which
is so what should healthcareprofessionals and systems, and I
would just add like schoolsystems, please like think about
in terms of how we supportdiverse types of families?
(11:31):
Are there any specificrecommendations or any general
recommendations?
You would say, like, when yousee these findings, what do
healthcare providers need to bethinking about, what other
systems might need to help torespond to these data?
Diana Tordoff (11:43):
That's a great question, I think in response
I'm going to quote my mentor,who is also the co-director of
the Pride Study, and she's aclinician I am not, but you know
.
She says that LGBTQ folks arethe same as straight and
cisgender folks in sort of whatthey need and what types of
support they need, and you knowtheir hopes and fears for their
(12:03):
children.
At the same time, LGBTQ peopleare different from straight and
cisgender folks in that theyhave to navigate more unique
life circumstances around familybuilding, interacting with
these institutions that reallyassume like there's a mother and
a father and this sort ofheteronormative family structure
(12:25):
.
And at the same time, LGBTQfolks are different from each
other and have uniqueexperiences, and there's a lot
of diversity of experience ingeneral, but especially related
to family building and raisingchildren within the LGBTQ
community.
And so our next step in thisanalysis is we're actually
looking at the multi-levelfactors that are influencing the
(12:49):
mental health of parents.
So in the PRIDE study we havereally rich data on community
level support, interpersonalexperiences of discrimination
and social support, as well asindividual level factors, as
well as individual level factors, and our hope is to better
identify some of thesemechanisms that are impacting
the mental health of parents, sothat we can know how to better
(13:10):
support them.
Patrick Sullivan (13:13):
And thanks for your plan to sort of move
forward into this.
Like you know, the question isalways like so what can we do?
And so I think it's really niceto link up describing the
problem or the opportunity withunderstanding those mechanisms
and this pathway to.
You know, maybe there'sintervention research or RCTs
and interventions at a certaintime.
So, and I think it's the roleof descriptive, epi and
(13:34):
hypothesis generation anddocumentation that this sort of
launches on a path.
So so thank you for talkingabout your findings and the
research process.
I'm going to move to the secondpart of our discussion, which we
call behind the paper, and Ithink it's so important for our
colleagues earlier careercolleagues and all of us to sort
of hear about how we do work,how we find inspiration, how we
(13:55):
sort of manage all the thingsthat it takes to make this work
happen.
So I have a few questions aboutthis, and I want to start out
just about the PRIDE study data,which is a real treasure of a
data resource that'slongitudinal and addresses this
breadth of issues.
So if people are interested inthese kinds of questions, can
people propose to analyze thesedata?
Can they learn more about thestudy?
(14:17):
How would they go aboutrequesting access or being in
contact with the PRIDE studymanagement.
Diana Tordoff (14:23):
Absolutely so.
The Pride Study loves tocollaborate with folks who are
outside of Stanford, and so iffolks are interested in learning
more about the Pride Study,they can go to pridestudy.
org/ collaborate and find moreinformation about how they can
participate.
The PrideIDE study uses anancillary study process where
(14:46):
folks can submit a proposal fortheir hopes to use PRIDE study
data either existing data or toeven design a new survey and to
date there's been over 30ancillary studies, with many
investigators across the USlooking at a large variety of
research topics related to LGBTQfolks, and all of this is
(15:09):
available on the website.
So there's a list of currentand completed ancillary studies,
so you can see the breadth ofthe different topics we've
already looked at, and then wealso have a list of desired
ancillary study topics, whichare topics that have been
identified by our researchparticipants that we have not
(15:30):
yet investigated, and thenthere's, of course, more
information about how to requestdata and to propose an
ancillary study on the websiteas well.
Patrick Sullivan (15:40):
Great, thank you.
So for this particular question, can you say a little bit more
about- You sort of mentionedthat study participants might
propose things that areimportant questions- but for
this question about the physicaland mental health of sexual and
gender minority parents, wheredid this research question come
from and how did it come up inyour priorities?
You know how does it get workedinto all the questions that
(16:01):
people want to ask, so where didthis one grow out of?
Diana Tordoff (16:04):
So this is part of a larger body of research at
the Pride study that's aimed tounderstand the experience of
LGBTQ parents and their health,and so this includes both the
family building process itselfexperiences of pregnancy as well
as the experience of peopleafter they become parents, and
(16:24):
so this work is being led by Dr.
Juno Obedin-Maliver, who is aprofessor in the Department of
Obstetrics and Gynecology andalso co-director of the PRIDE
study, and we're doing reallyquite a lot of work really
focused on the experiences ofparents, including some
qualitative work on theexperiences of parents,
(16:46):
including some qualitative work.
So we recently completed focusgroups with parents and
prospective parents who areassigned male at birth,
specifically queer cisgender men, transgender women and
non-binary folks assigned maleat birth, because this
population in particular hasbeen really neglected by the
research and in fact, a lot ofour early research was focused
on the experiences of queer,cisgender women as well as
(17:10):
transgender men, and we heardfrom community- what about us?
Like we also want to havefamilies and we actually face a
unique set of barriers tobuilding our families and we
like want to talk about that andour children, and so we've been
doing sort of a lot of work tomake our families and we like
want to talk about that in ourchildren, and so we've been
doing sort of a lot of work tomake sure that they also feel
(17:31):
represented in the work thatwe're doing.
Patrick Sullivan (17:32):
Yeah, I really appreciate that and I think
it's just so important to saythat the experience of parenting
of single male or male coupleparenting definitely has its own
challenges and there aresocietal biases around and
suspicions, you know, I wouldsay, that come out in ways that
are harmful.
So you really can think aboutthe components of our diverse
(17:52):
communities maybe as having somecommon, but many, you know,
unique barriers to theconfigurations of parents and
how that interacts with societalassumptions.
So thank you so much for theattention to that breadth.
I want to ask, just in terms ofyour own work, who or what
inspires you to do this work?
(18:14):
Because I am a person of sexualand gender minority experience
and I think people a lot oftimes assume that what I'm doing
is me-search, somehow like thatthe questions that are asked
are because they're relevant to,like, my experiences and in
fact many of them are not and wehave different inspirations.
So I wonder what inspires youto do this work?
It could be career related, itcould be non-career related, but
(18:35):
, like, what's your path to thiswork?
Diana Tordoff (18:37):
I love that question, so outside of work,
I'm not a big nonfiction readerI'm actually like a sci-fi nerd
but the one exception is that Ido read a lot about queer
history and also queer memoir,and I was originally drawn to
the field of public health fromreading a lot about HIV and AIDS
activists when I was like alittle gay teenager, and so I
(19:00):
think I'm really grateful forhistorians, especially folks
like Jules Gill- Peterson andSarah Schulman , who have really
documented queer and transhistory and, I think, really
documenting our struggles andour successes in the past, you
know, related to the HIV andAIDS crisis, as well as
documenting that, like, queerand trans, families have always
(19:23):
existed and loved each other.
And I think I find, especiallyin times like this where there's
a lot of backlash, a lot ofsolace from the fact that
actually we've always been hereand we've always been doing work
to support our health andwell-being, and I think that's
something I use as tocontinually inspire me and also
(19:44):
sort of ground me in why I dothis work.
Patrick Sullivan (19:47):
Thank you.
Thank you for that.
I'm going to ask one morequestion which is timely to our
topic, and that's to say thatyou've given us permission to
share that you are a new mom, socongratulations, Thank you.
And I wonder, like as even asyou're doing this work; one, how
has it been going back to workand how is it to both do
research about these questionswhile you are also in your own
(20:10):
prospective cohort of you knowpeople who are starting families
, and so what's it like to be inboth of those kind of places at
the same time?
Diana Tordoff (20:19):
Absolutely yes, this paper was actually
published the same week my kiddowas born.
She's now four months, so thatwas really a fun serendipitous
happening.
Patrick Sullivan (20:29):
Like looking at galley proofs while you're
trying to like get put the babybed together, yeah, yeah.
Diana Tordoff (20:38):
Exactly.
And I also am a Pride Studyparticipant since 2017.
Before I had, you know, anyacademic or professional
relationship with the PrideStudy, and so I was really
excited to fill out my annualsurvey this year, because I know
that we ask questions aboutparenthood, and so I got to
answer them myself after doingsome analyses, which was very
(21:00):
sweet, and I just have to sayit's been really tender and
rewarding to do research onparenthood and family building,
also during this period of mylife, and I think it really just
emphasizes how important thisresearch is.
Yeah, as to returning to work,I've only been back a month so,
(21:22):
you know, don't have any tipsfor folks.
I feel like I'm still trying to, you know, navigate those
waters myself, but I feel reallylucky to have many mentors who
are also parents, you know,throughout my PhD as well
currently and I also am reallylucky to have many peers who
also are parents, so have hadseveral friends from graduate
(21:46):
school also become moms thisyear, sort of during this early
life stage career, and I thinkthat type of community you know,
queer academic parents has beenreally really helpful and
special.
Patrick Sullivan (22:00):
Thank you for sharing that and wonderful to
just see how, see how.
I think this is typical of theLGBTQ community that through our
history we've built thesecommunities of support, like as
society has shifted around us inpositive or negative ways, and
so thanks for identifying thatas a community that is there to
support one another in theseimportant life experiences, that
(22:23):
is there to support one anotherin these important life
experiences.
Dr.
Tordoff, any last thoughtsyou'd like to share with our
listeners, either about thistopic or about the process of
analyzing and making sense ofthese data?
Diana Tordoff (22:37):
So one of the things we haven't had the
opportunity to talk about interms of methods was there was a
lot of attention paid to therole of age as the confounder in
this study and, from an epiperspective, I found that to be
one of the most fun aspects ofthis analysis, which is really
trying to figure out how to bestapproach really severe
(22:57):
confounding by age, sinceparenthood and age are so
strongly correlated as well asthere being just really large
generational differences,age-related differences in both
physical and mental healthoutcomes, and so it's more
complicated to, you know, getinto in this podcast.
(23:18):
So I'm just going to plug thatas sort of an epi benefit from
reading the study.
Patrick Sullivan (23:23):
Yeah, well, I mean, can you give us a short
version, Because I think this isyou know again, like I know we
have subscribers to the podcastwho are in their epi education,
so, like, can you just say alittle bit more about the
framing of that confoundingissue with a variable like age
and experiences of parenthood,where there is this sort of
traveling alongside, right withbeing in certain ages of kids,
(23:46):
for example, and ourchronological age get confounded
with each other, and so isthere enough data in your parent
respondents to be able tounderstand how the experience of
having young kids as a 40 yearold is different than having
young kids as a 25 year old, andthat's especially relevant to
LGBTQ families, I think becauseof a lot of societal factors.
(24:07):
So what's the approach there toaddressing that confounding and
you sort of mentioned one ofthe problems is that there's
some sparseness of data, maybeat the extremes of that.
Diana Tordoff (24:17):
Absolutely so.
This is the first analysis I'veworked on from like an actual
manuscript, where there was afull reversal of the association
, like a very strong reversal ofthe association when we
adjusted for age, whichobviously, when I first ran our
regression results, was like areally big red flag and like
(24:38):
took some time to reallyinvestigate what is going on
here.
But what's true is that olderLGBTQ generations, as a process
of general aging and sort ofjust cohort differences, have
lower mental health diagnosesand better mental health
symptoms and also worse physicalhealth outcomes, just as
(24:59):
natural aging processes, whereasyounger LGBTQ folks it's the
reverse they tend to have worsemental health symptoms as well
as better physical mental health, and so we just saw these
really strong reversals in theassociation between parenthood
and these different outcomes,whether or not we accounted for
(25:20):
age.
And so we ended up usingpropensity score modeling as a
secondary approach to reallyaddress this confounding,
because we wanted to make surethat we were accounting for it
well.
And I think what was reallyreassuring is that when we use
multiple different analyticapproaches, our results were
nearly identical, which reallygave me confidence, after sort
(25:44):
of seeing this really severeconfounding, that we were
handling it well and notproducing biased estimates.
Patrick Sullivan (25:51):
Yeah, thank you for that insight into the
process, because so often papers, when they come out, look tidy,
but the process to get there isnot always a linear one.
So this is a great and generousthing to share about, just like
how you dug in and dealt withthat.
Diana Tordoff (26:08):
Great and thank you so much to you and the whole
team behind EPITalk for havingme.
Patrick Sullivan (26:13):
That brings us to the end of this episode.
Thank you again, Dr.
Tordoff, for joining us todayit was so nice to have you on
the show and thanks for sharingyour work in Annals and sharing
some more context about yourwork on the podcast today.
I'm your host, Patrick Sullivan.
Thanks for tuning in to thisepisode and see you next time on
EPITalk, brought to you byAnnals of Epidemiology, the
(26:35):
official journal of the AmericanCollege of Epidemiology.
For a transcript of thispodcast or to read the article
featured on this episode andmore from the journal, you can
visit us online at www.
annalsofepidemiology.
org.
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