It is estimated that in 2011 there were 6,120 children under the age of 25 years living with two same-sex parents in Australia [1], with the number of same-sex couple households increasing from around 19,000 to more than 33,000 over the preceding ten years [1, 2]. These figures are a conservative estimate as they 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. Ongoing reforms in Australia around same-sex adoption, surrogacy and fertility treatments will only see this number rise, with a recent national survey on the health and wellbeing of gay, lesbian, bisexual and transgender Australians identifying that 22.1% of respondents have children or step children [3].

Two decades of research from Northern Europe and the United States suggests that the health and wellbeing of children with same-sex attracted parents is no different when compared to children from other family backgrounds, particularly in relation to social and emotional development and educational outcomes [4–6]. Stacey and Biblarz (2001) argue however that a more detailed consideration of the literature identifies a number of areas that do not necessarily follow this commonly acknowledged ‘no difference’ consensus [7]. This includes a focus on sexual orientation, although it is now generally accepted that child sexual orientation is not a measure of quality parenting [7]. In fact, a number of authors agree that simply asking a question that compares the sexual orientation of children with same-sex parents to children with heterosexual parents reinforces a heterosexist viewpoint that stigmatises same-sex families [8].

What the research is beginning to show however is the importance of such stigmatisation, as it is a key factor that impacts on the health and wellbeing of children with same-sex attracted parents [4, 9–15]. Numerous studies have found that when there is perceived stigma, experienced rejection or homophobic bullying, children with same-sex attracted parents are more likely to display problems in their psychosocial development [16–22]. These experiences and their impacts differ globally with children from the US experiencing more homophobia, and associated higher levels of problem behaviour, when compared to children from the Netherlands [17]. The only Australian study to date to consider these issues identified high levels of bullying toward children with same-sex attracted parents but did not consider health outcomes [21].

Previous research has taken a narrow perspective when considering broader aspects of health, limiting data to a few common childhood ailments [23]. Prevention, early intervention, continuity of care and integration of healthcare services are particularly important for child health during early years [24] and it has been suggested that lesbian parents perceive barriers when dealing with the healthcare system in Australia [25]. As such it is important to determine whether potential barriers, such as perceived stigma, have an impact on the physical wellbeing of children with same-sex attracted parents.

When considering child health in same-sex parent families, research on the role of parent gender is conflicted. While some studies suggest that mothers are more emotionally invested in raising children than fathers are in general [26–28], further work suggests that absent fathers may be detrimental to self-rated cognitive and physical competence [29]. Regardless of gender however it is becoming clear that same-sex attracted parents construct their parenting roles more equitably than heterosexual parents and this may be of benefit to family functioning [30]. With this in mind it should be noted that there is a lack of research looking at male same-sex parented families [31], and too often authors extrapolate results from research on lesbian parenting to the whole range of same-sex families [32]. When studies have looked at gay male parents it is usually in the context of a kinship arrangement where the father acts as a sperm donor [33].

Studies to date have often relied on small samples. Such sample sizes limit statistical analysis and the wider application of findings to the broader community. Convenience samples are also commonly used and are often fraught with problems. As participants are self-selecting such studies are open to accusations of bias that might skew results in favour of same-sex parent families and capture only specific subsets of the gay and lesbian community [34]. It is not clear whether such bias is at play in previous samples however, but by employing recruitment strategies that actively seek to reach a broad range of families a more representative sample can be achieved [35]. In some contexts researchers have aimed to overcome limitations of convenience sampling by extrapolating same-sex attracted parents from population surveys [36]. In such cases many assumptions are made as same-sex attraction is presumed based on other demographic characteristics (such as children indicating two parents of the same gender). This limits data to same-sex couple families and does not allow for a broader representation of the community, such as single same-sex attracted parents and co-parenting arrangements to name but two [37]. In Australia current political and cultural discourse does not allow the capturing of sexual orientation in national population surveys. Although household surveys may be of benefit, cost constraints and likely small sample sizes make them impractical and as such the only methodology available to capture child health in the context of same-sex parent families is through convenience sampling. By utilising strategic and broad ranging recruitment techniques however, the best available study population can be achieved under difficult research constraints.

The overall aim of this study was to understand the multidimensional experiences of physical, mental and social wellbeing of children in same-sex parent family contexts, in addition to providing a contemporary policy relevant profile of the diversity and complexity of families and their social and physical environments [38]. The objectives were: to describe the characteristics of a convenience sample of families with at least one same-sex attracted parent; to measure the physical, mental and social wellbeing of children living in this context; and to determine the relationship between perceived stigma and child health and wellbeing.

The full methodology for the Australian Study of Child Health in Same-Sex Families is described in the study protocol [38], while the methods relating to the results presented here are summarised below.

Three hundred and ninety eligible parents made contact with the research team and 315 completed the survey (81%), only two of which used a paper survey. These parents provided data on 500 children.

This is the first study of child health in same-sex parented families in Australia and the largest study of its kind internationally, to date. As such it can be used to understand a broad range of families where at least one parent is same-sex attracted. The findings suggest that there is no evidence to support a difference in parent-reported child health for most measures in these families when compared to children from population samples, which was also found with the previous smaller studies and those of lesbian families [4, 18, 49]. The ACHESS makes a significant contribution to the literature as it succeeded in representing children being raised by same-sex attracted parents from a broader range of family contexts than studies previously. The recruitment of 91 children with male same-sex attracted parents allows for the first time a sample size large enough to enable analysis of child health and wellbeing that includes children growing up with at least one gay male parent. Eleven per cent of children in same-sex couple households had male parents when the Australian census measured in 2011 [1], and as this number grows it is necessary to better understand child health and wellbeing in this context.

Socio-demographically, the parent sample has a high level of education and income, relative to population median income [47], and normative samples. While there is evidence to suggest that maternal education in particular is related to improved child health [50] it is not clear how this translates to same-sex families where the relationship between gender roles and parenting is less clear [30]. This difference in education and income must be considered however when viewing these results, even having adjusted for disparities in statistical analyses. Higher relative income in same-sex families is not surprising however, given that there is often a need to engage in costly and complex medical procedures in order to create a family where the parents are same-sex attracted. Children with male index parents are more commonly born through surrogacy arrangements. However, with commercial surrogacy illegal throughout Australia, and altruistic surrogacy poorly established, these arrangements often take place overseas, and thus parents with lower incomes may be less likely to avail this method. This situation also explains the number of children with a male index parent who were born in the US and India, two of the more commonly accessed territories for this process. Further, despite the fact that Australia is yet to have legislated to ensure marriage equality it appears that family transitions in our sample of same-sex parent families are similar to the general population. For our sample over two thirds of children were born in the context of their parents’ current relationship compared with 65-81% of children, depending on the age of the youngest child, for all families in Australia (2006-7) [51].

Key child health promotion and illness prevention strategies appear to resonate well with our sample of same-sex parent families as seen by the rates of immunisation and breastfeeding. Despite the lack of an easy supply, a number of our male parents strove to ensure that their children receive some breast milk in early life, with a significant proportion of these children born via surrogacy (64%). This is usually achieved via surrogate milk donation and is an indication that same-sex male parents make efforts to support this health strategy for their children.

In comparing CHQ and SDQ scale scores from the ACHESS to population normative data it is possible to understand the multidimensional aspects of child health and wellbeing in a broader context. The three areas where statistically significant differences were seen are general behavior, general health and family cohesion. Population and clinical studies have demonstrated that there are socially and clinically meaningful differences of 5 points on the scales within the CHQ. The small difference seen between the ACHESS sample and the general population on the general behaviour domain was not observed with the behavioural components of the SDQ, which may be related to the origin and development of the two measures, where the CHQ is more related to functioning and the SDQ used as a screening tool. This is an important area for further exploration. The general health scale is a broad concept measured by a single item within the CHQ, however the size of difference is notable. Qualitative interviews accompanying this study might raise themes and issues to enable greater understanding of what could be influencing this finding, possibly related to improved communication via family cohesion. The results for family cohesion are significant. Previous research has suggested that same-sex attracted parents are much more likely to share household duties equally when compared to their heterosexual counterparts, and they make decisions about work/family balance based more on circumstance than preconceived gender-based ideals [30]. Individual suitability rather than societal convention is more likely therefore to inform parenting roles. This has the potential to engender greater family harmony in the long-term.

Whilst children with same-sex attracted parents from our sample demonstrate comparable health to other children across the population, it is clear that they, and their families, are experiencing stigma. Previous work has suggested that stigma and homophobia are related to problem behavior and conduct problems in children with same-sex attracted parents [17, 33, 18]. Our findings support and strengthen the idea that stigma related to parental sexual orientation is associated with a negative impact on child mental and emotional wellbeing. Other family contexts have seen similar associations between stigma and child mental health including race-based stigma in Aboriginal and Torres Strait Islander families, and social stigma in single-parent families [52, 53]. Stigma can be experienced in numerous social contexts, educational settings and healthcare environments. Lesbian parents in Australia have previously described the barriers they perceive when accessing healthcare services and often times have to choose a disclosure strategy to adopt when dealing with practitioners [25]. Instead of feeling accepted when seeking healthcare for their children this perceived stigma can lead to a sense of vulnerability where in fact healthcare services should “be a safe place for lesbians [and gay men] to authentically talk about their relationships with lovers, friends and family [54]”. If the negative impact of perceived stigma on child mental and emotional wellbeing is compounded in a healthcare environment, where parents do not feel free to discuss their family in its entirety, then the health ramifications for children will only be amplified.

This study demonstrates that children with same-sex attracted parents in Australia are being raised in a diverse range of family types. These children are faring well on most measures of child health and wellbeing, and demonstrate higher levels of family cohesion than population samples. Perceived stigma is experienced by children with same-sex attracted parents, which is an issue that requires attention in all settings. In particular this is of importance to healthcare services, where parents seek assistance for their own physical and mental health, as well as that of their children. As perceived stigma already has a negative impact on mental and emotional wellbeing, negative experiences in healthcare settings will serve to exacerbate any problems that these children, and their families, might face. Future work should further explore the ways in which stigma affects the mental health of children with same-sex attracted parents and in particular ways in which these children can be protected from experiences of discrimination. Same-sex families are becoming increasingly visible globally. These results from Australia provide important epidemiological data across health, wellbeing, morbidity and perceived stigma of children with same-sex attracted parents, and an essential contemporary contribution to the current policy-research interface.