Conservative estimates show that in 2011 there were more than 33,000 same-sex couples living together in Australia, an increase from around 19,000 ten years earlier [1, 2]. The number of children living in these families almost doubled over the same period and it is now estimated that that there are around 6,120 children under the age of 25 years living with two same-sex parents . These figures do not capture children living with same-sex attracted single parents, or parents who are reluctant to self-identify as same-sex attracted due to fear of stigma and discrimination. The recent Private Lives 2 report, a national survey of the health and wellbeing of gay, lesbian, bisexual and transgender Australians, identified that 22.1% of respondents reported having children or step children . In the Australian context ongoing reforms allowing same-sex adoption and increased access to surrogacy and fertility treatments for same-sex couples  suggest that the number of children growing up in same-sex parent households is also likely to grow.
Same-sex attracted adults are known to be at increased risk of psychological disorders, and it has been suggested that discriminatory policies may be associated with mental health outcomes for this population . Furthermore, experiences of discrimination vary depending on where they live [6, 7]. Given that same-sex attracted people are increasingly raising children it is important to determine how this context impacts on child health and wellbeing. This paper aims to highlight the findings from research to date on the health and wellbeing of children with same-sex attracted parents and describes an Australian study that aims to measure the health and wellbeing of children aged 0–17 years, with a particular focus on the dimensions of importance to children within this familial context.
In order to define the conceptual framework and population context, we have selected the World Health Organization definition of health, where health is “the complete physical, mental and social wellbeing of children and not merely the absence of disease or infirmity” . In relation to the potential population denominator, we have defined same-sex families for the purpose of this research to maximize comparability internationally, as ‘any family in which at least one parent is same-sex attracted’.
Over the last two decades reviews of the literature from Northern Europe and the United States on the health and wellbeing of children with same-sex attracted parents have suggested that there is no difference when these children are compared to children from other family backgrounds with respect to social, emotional, developmental and educational outcomes; the so called ‘no difference consensus’ [9–11]. Stacey and Biblarz in 2001 were among the first to argue that a closer inspection of the literature identifies a number of areas that do not immediately follow the generally accepted ‘no difference’ hypothesis , including child sexual orientation and gender role behavior [13–21]. Health care professionals no longer view homosexuality as a negative health outcome however. While conservative aspects of society may dispute this, as do some authors in the field , other authors on child health and wellbeing in same-sex families maintain that child sexual orientation is not a marker of quality of parenting . In fact, it has been argued that asking a question that compares the sexual orientation of children with same-sex parents to children with heterosexual parents reinforces a heteronormative viewpoint that stigmatises same-sex families further .
Increasingly research on child health and wellbeing in same-sex families has begun to consider stigma and discrimination. The findings from this research demonstrate that the experiences of stigmatisation is one area that is consistently associated with the health and wellbeing of children with same-sex attracted parents [9, 15, 17, 23–27]. Frequently, studies have found that when there is perceived stigma, experiences of rejection or homophobic bullying, children with same-sex attracted parents are more likely to display problems in their psychosocial development [7, 14, 28–32]. The experience of discrimination is by no means universal. Bos et al’s 2008 study comparing children in the US and the Netherlands suggests that children in the US sample experience much more homophobia than the Netherlands and that this homophobia is related to higher levels of problem behaviors by comparison to the Dutch sample . This cultural context appears to play an important role. In 1993 Javaid showed that US children with heterosexual parents display high levels of prejudice towards homosexuality, and Gershon et al. in 1999 demonstrated that in the USA there is a strong link between perceived stigma and poor self-esteem for children with same-sex parents [14, 30]. Interestingly however, countries that are considered to be more liberal in their attitudes towards homosexuality (the United Kingdom, the Netherlands, Belgium and Canada – all of which currently allow same-sex marriage or civil partnerships) do not appear to identify as many significant differences in teasing between children with same-sex attracted parents and children with heterosexual parents [33–35]. Currently Australia does not recognise same-sex marriages, and Queensland has recently wound back legislation to remove civil partnerships from that state’s statutes . How this lack of political recognition of same-sex families impacts on the stigma perceived by children is not yet known. Of some concern however is research from 2001 conducted by Ray and Gregory. They found high levels of bullying experienced by Australian children from same-sex families. Much more detailed investigation is required however, taking into account different socioeconomic and cultural settings .
A holistic view
When considering the health and wellbeing of children with same-sex attracted parents 40 relevant studies were conducted between January 1990 and March 2011, the first by Javaid in 1993  and the most recent a report from the fifth wave of the National Longitudinal Lesbian Family Study in the USA . Australian research from 2008 has suggested that lesbian parents perceive barriers when dealing with the healthcare system . Given the benefits of effective interactions with health care providers, particularly in the very early years of childhood where prevention and early intervention, continuity of care and integration of services are central , it is important to establish whether potential barriers, which might include perceived stigma, have an impact on the physical wellbeing of children with same-sex attracted parents.
Of the 40 studies described above only five have considered physical aspects of health and wellbeing and these have only presented crude figures pertaining to a handful of common childhood ailments . It is clear that a more comprehensive approach to understanding health and wellbeing is required to fully capture the complete health experience of children with same-sex attracted parents.
The influence of parental gender and parenting has been another area of enquiry, and in this context Stacy and Biblarz, who reviewed the existing literature in 2001, suggest that, rather than sexual orientation, parental gender may play a role in child health and wellbeing, highlighting research that scores both lesbian and heterosexual mothers better in measures of effective parenting than heterosexual fathers . They argue that mothers are more emotionally invested in raising children than fathers are in general, which has been supported by other authors [41–43] and includes research by Gatrell (2005, 2010) and Golombok (2010) [40, 44, 45]. The research conducted by Golombok et al. in 1997 suggests that absent fathers may be detrimental to self-rated cognitive and physical competence . One area that many authors are in agreement on however is that there is a lack of research looking at male same-sex parented families . While it cannot be assumed that the findings described by Stacey and Biblarz suggest children with gay male parents would perform poorly in their health and wellbeing outcomes, Cameron (2009) argues that all too often authors erroneously extrapolate results from research on lesbian parenting to the whole range of same-sex families  and as such outcomes from lesbian headed families should not be directly applied to gay male families. Only seven studies have considered gay fathers. One of these studies, conducted in 2010 in the Netherlands, compared children with gay biological fathers to children with heterosexual, married, biological fathers and found that overall there was no difference in child wellbeing. When the gay fathers perceived stigma however their children did show poorer psychological outcomes . It should be noted that this research looked at families where gay men donated sperm as part of a kinship arrangement and the children were not being raised in mother absent families. To date there is no substantial research looking at the health and wellbeing of children residing from birth with gay male parents and conclusions cannot therefore be drawn about their health and wellbeing in this setting.
Representing the population
Overall, the 40 studies suggest that many of the factors that might be expected to have an influence on child health and wellbeing hold true for children with same-sex attracted parents, such as family relationships - parental relationships with each other and their children; family income; parental education; and socioeconomic status [10, 44, 50, 51]. It is often assumed that in developed countries same-sex parent families are well educated and fall into higher socioeconomic status groupings. This assumption is supported by much of the literature that has recruited families using convenience sampling techniques. The few studies that have been able to employ a more representative sampling method, identifying same-sex parent families from broader population surveys, have found no difference in income, SES and years of education when comparing the same-sex parent families to the heterosexual parent families [34, 52–54]. One study even suggests that same-sex parent families may have lower income, SES and fewer years of education . It is these factors, set in a broader social context, that require further study to elicit the effect of the lived environment on the health and wellbeing of children with same-sex attracted parents. In the Australian setting this would involve seeking participation from ethnic minority and rural same-sex attracted parents, and those from low socioeconomic groups.
It has been argued that there should be a greater focus on child health and wellbeing in the context of same-sex parent families with a number of recent studies no longer making direct comparisons to heterosexual parent families [15, 31, 37, 56]. While it is important to identify how the children in these families are fairing and what factors ensure their optimal health and wellbeing, measuring health and wellbeing using instruments that have population level normative data gives a baseline from which epidemiological analysis can evolve. Taking these factors into account it is suggested that the focus should be on issues relating to stigma, as this has been shown to have a significant impact on health and wellbeing .
Most of the quantitative studies utilise standardised tools for data collection, although there is a wide variety in the specific tools chosen. The only tool to have been used widely, across differing research collaborations, is the Child Behavior Check List (CBCL) [35, 37, 43, 44, 50, 51, 57]. Recent research has suggested that other tools, such as the Strengths and Difficulties Questionnaire (SDQ), can effectively provide substantial added value when compared with the CBCL and may be preferred by both parents and preventive child health care professionals . None of the tools used however have allowed detailed measurement of physical wellbeing and as such other validated instruments should be considered for use in conjunction with those described to date in the literature.
The current study
In light of the above research, its strengths and limitations, the questions that remain unanswered relate to understanding the multidimensional experience of physical, mental and social wellbeing of children with same-sex attracted parents, as well as the complexity of the family contexts and social and physical environments in which children are based. It is essential that the measurement instruments are standardised, gold standard and the recruitment methods are comprehensive and transparent. We would add that the issues of stigma and discrimination for these children and their families is a new dimension that hasn’t adequately been captured and a contemporary exploration of this and its facets needs to be included.
Every effort should be made to recruit a diverse sample from the broad range of all families in the gay, lesbian, bisexual and transgender community to ensure maximum representation, and the possibility to extrapolate results to the wider context. In particular attempts should be made to recruit gay male parents and their children, as this growing sub-population requires much greater consideration.