Navigating rough waters: an overview of psychological aspects of surrogacy.

Surrogacy is both the oldest and the most controversial of reproductive innovations. Its documented history goes back at least as far as the Old Testament in which Hagar begot Ishmael with Abraham after his wife, Sarah, failed to conceive (Gem, 16 Authorized [King James] Version). Moreover, artificial insemination (AI), a widely used method for surrogacy arrangements, is neither new nor high tech. It has been available for more than 100 years (Hammer-Burns & Covington, 1999, p. 20) and can be performed without medical assistance using a simple turkey baster (Ciccarelli, 1997; Gallagher, 1989). In the last 25 years, however the commercialization of surrogate mothering and the media firestorm associated with the Baby M case (Matter of Baby M, 1988) have led to a groundswell of interest and controversy about this technology (Ciccarelli, 1997).

Contractual parenting (commonly know as surrogacy) occurs when a couple, the intended parents, contracts with a woman to carry a child for them and to relinquish that child to them after birth (Ciccarelli, 1997; Ragone, 1996). There are two major types of surrogacy arrangements: traditional surrogacy and gestational surrogacy. In traditional surrogacy, the surrogate is impregnated with the sperm of the male partner of the intended parents. In this case, the impregnated woman is both the genetic and birth (i.e., gestational) mother and the intended father is also the genetic father (Ciccarelli, 1997; Ragone, 1996). Gestational carrier surrogacy is used when the female partner of the intended couple has viable eggs but is unable to successfully carry a pregnancy to term. The intended mother's eggs are fertilized with her male partner's sperm in the laboratory using in vitro fertilization (IVF) and the embryo is then implanted in the "surrogate" mother's uterus. In gestational surrogacy, the woman who carries the child has no genetic connection to the child and the intended parents are also the genetic parents (Ciccarelli, 1997; Ragone, 1996).

Some feminist writers have objected to the social construction of the woman who carries the child as the surrogate or surrogate mother. They contend that such terms do not accurately reflect the reality of contractual parenting since the pregnant woman is the actual mother, that is, the gestational or birth mother. Current terminology, they believe, minimizes the value of the gestational mother's role (Hanafin, 1999; Tangri & Kahn, 1993) and delegitimizes her right to a continuing relationship with the child (Jaggar, 1994, p. 379). These issues are important to acknowledge. However, surrogate motherhood reflects the intent of the gestational mother and how she perceives herself and her role (Hanafin, 1999). This term also allows us to distinguish women who bear a child as a result of contractual parenting from other birthmothers. Therefore, we will use the term traditional surrogate for the woman who conceives via AI using the sperm of the father who intends to rear the child and the term gestational surrogate for the woman who carries an embryo that has been conceived via IVF using the intended parents' egg and sperm. The couple that contracts with the surrogate mother is referred to as the intended, social, commissioning or contracting parents, depending on where they are in the surrogate parenting process.

As one can well imagine, the social, psychological, and legal complications increase dramatically as the number of people necessary to conceive a child is increased from the traditional two people (Ciccarelli, 1997).

Review of the literature on contractual parenting reveals a wealth of discussion about the ethical, moral, legal, and psychological implications, but limited empirical data on the psychological and social aspects. Discussion of surrogacy has been ripe with controversy and has assembled some unusual allies. Religious fundamentalists, the Roman Catholic church, and feminists alike have condemned the practice of contractual surrogacy as "baby selling"--one that demeans and threatens women.(e.g., Gibson, 1994; Macklin, 1988; Rothman, 1989; Raymond, 1998; Tangri & Kahn, 1993). The level of controversy engendered by surrogacy, is reminiscent of the abortion controversy in the United States. Surrogacy, like abortion, is controversial precisely because it evokes and often contradicts basic concepts about family, motherhood, and gender roles (Luker, 1984). Conservative groups are fearful that surrogacy will undermine traditional cultural values about the two-parent family with wife primarily responsible for childcare and husband as provider and patriarch (Burr, 2002). On the other hand, many feminists are alarmed about the commodification of women (Tangri & Kahn, 1993) and both groups deplore contractual surrogacy as the selling of babies. Few issues have so deeply divided the feminist community (Behuniak-Long, 1990; Taub, 1992). Pitted against the large group of feminists who oppose contractual surrogacy are others who fear that any limitation of women's reproductive freedom will provide inroads toward curtailment of women's reproductive rights by groups, often religious in nature, that are opposed to women's access to abortion and contraception (e.g., Bartholet, Draper, Resnik, & Geller, 1994; Mahoney, 1988).

Given the level of controversy engendered, one might expect considerable research activity. Yet the research literature is extremely sparse for a number of reasons. First, the absence of funded research on the topic suggests that financial support for research on such a controversial issue may be difficult to secure. Governmental support may be absent when a practice (e.g., abortion, surrogacy) conflicts with the policy of the administration in power. Second, despite the flood of media attention, particularly in the late 1980s and early 1990s, surrogacy arrangements are less common than generally perceived. Historically, there has been no way to track the number of children born as a result of AI. However, since 1992 federal law has mandated that fertility clinics track and report statistics relating to IVF cycles and births (Fertility Clinic Success Rate and Certification Act). The first compilation of these statistics was published by the Centers for Disease Control (CDC, n.d.) in 1995. Unfortunately, this mandate did not include segregating the number of IVF surrogacy births from the total of IVF births. Reporting on IVF surrogacy births became a requirement for fertility clinics in 2003.

Nonetheless, the American Society for Reproductive Medicine has attempted to compile information regarding IVF surrogacy and non-surrogacy births prior to the enactment of the law. According to their statistics, from 1985 through 1999 there were 129,000 babies born as a result of IVF. From 1991 through 1999 there were 1600 babies, included in this total, who were born as result of IVF surrogacy (American Society of Reproductive Medicine, personal communication, June, 2002). The numbers pertaining to IVF births, including surrogacy births, may be low since, prior to enactment of the above mentioned act in 1992, reporting was voluntary. Further, until 2003 reporting regarding surrogacy still was voluntary. In any event, it is clear that contractual parenting is infrequent in comparison with the overall birth rate, even for birth rates involving assisted reproductive technologies.

Third, given the social stigma associated with surrogacy, parties to surrogacy agreements, particularly the contracting couple, relish their privacy and therefore may be unlikely to agree to participate in research (Ciccarelli, 1997; Ragone, 1996). In addition, those who arrange contracts and counsel the parties involved are committed to protecting their privacy for ethical and legal reasons. Low prevalence of surrogacy arrangements and concerns about privacy have led to limited availability of research participants, especially intended parents.

Research information is important to clinical psychologists and other mental health providers because it is difficult to screen, advise, and counsel both surrogate mothers and intended parents if there are no empirical bases for such professional activities, (Hanafin, 1999). Due to lack of empirical data on surrogacy screening and counseling, some clinicians have attempted to glean data from the adoption literature for use in surrogacy. Such comparisons appear inadequate since surrogacy is exceedingly more complex than adoption and has many fewer government laws and regulations structuring it (Hughes, 1990). Research about the ramifications of creating a family through contractual parenting can provide infertile individuals with information that can facilitate informed decisions about their options (Ciccarelli, 1997) and suggestions for improving the surrogacy process for all parties involved.

Examination of two online databases, Psych. Info. and Digital Dissertations (i.e., Dissertation Abstracts), identified only 27 empirical studies (published articles, books, chapters, or doctoral dissertations), from January 1983 to December 2003, that directly studied characteristics and interaction patterns of surrogate mothers; characteristics and interaction patterns of the intended/social parents; and/or attitudes about contractual parenting, surrogate mothers, and intended/social parents (see Table 1).

The research literature primarily describes the motivations and characteristics of surrogate mothers. Many (e.g., Blyth, 1994; Ciccarelli, 1997; Hohman & Hagan, 2001; Migdal, 1989; Preisinger, 1998; Ragone, 1996; and Roher, 1988) are small sample studies of less than 30 surrogate mothers (range of 4 to 28) that primarily analyze qualitative data. A few small studies (Einwohner, 1989; Fischer & Gillman, 1991; Hanafin, 1984; Parker, 1983) assess personality characteristics of surrogate mothers using standardized personality tests. Four studies (Blyth, 1995; Hughes, 1990; Kleinpeter, 2002; Ragone, 1996) examine characteristics or interaction patterns of the intended/social parents and another seven investigate attitudes toward contractual parenting. Finally, we could find only four studies which included comparison or control groups. In three, (Fischer & Gillman, 1991 ; Hanafin, 1984; Resnick, 1990) surrogate mothers were compared to …