Division of Primary Care, Public and Occupational Health, Public Health Building, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
Correspondence: Division of Primary Care, Public and Occupational Health, Public Health Building, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK. E-mail: O.B.A.van-den-Akker{at}bham.ac.uk
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Abstract |
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Key words: cognitive dissonance/family/genetic/infertility/surrogate
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Introduction |
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Surrogacy arrangements vary considerably. In some cases, the surrogate mother carries a baby who is biologically related to the commissioning parents, as a result of IVF using the commissioning woman's egg (IVF-S), and her partner's spermatozoa (gestational surrogacy; ASRM, 1990). In other cases, the child may be related genetically to the surrogate mother and not to the mother who adopts and brings up the child (genetic surrogacy; ASRM, 1990). To date, only two exploratory studies of British commissioning couples' experiences of surrogacy have been carried out (Snowdon, 1994; Blyth, 1995
). Parents who decide on surrogacy as a means of creating their families differ from others in terms of experiencing infertility and infertility treatment. They do not conform to the norm, and they do not give birth to the child they bring up. Additionally, in many cases these parents are both not related genetically to the children born as a result of surrogacy (van den Akker, 1999c
).
This fragmentation of reproductive function has several interesting consequences. First, it separates sex from reproduction; second, it separates motherhood from pregnancy; and third, it separates the unity of one couple into the involvement of a third person within the potential family relationship. The first fragmentation has been a consequence of contraception for decades, the second separates genes from biological and gestational relatedness, whereas the third challenges the kinship ideology of family, which can only be reasserted upon relinquishment of the baby by the surrogate and her completion of the arrangement. Reasons for the apparent discomfort with redefining `family' as a result of the unorthodox achievement of family status (i.e. conception and gestation) are not clear, but a presumed fragility of a family relationship not supported by genetic relatedness has been discussed (Snowdon, 1994). The traditional structural functionalist theory posits the traditional family in the established pattern (institutionalized and legitimized) for intimate relationships and child-rearing. Diversity from this norm in biological and social terms, is seen as deviant (Bernardes, 1993
, 2000
). Function, in functionalist theory, relates to activities which are seen as necessary for the maintenance of the family within society and necessary for the maintenance of the species (Smith, 1995
). Current research of the family, however, reports a lack of uniformity in structure and function observed within the diverse forms of family studied. The term post-modern family was coined by Stacey `to signal the contested, ambivalent, and undecided character of contemporary gender and kinship arrangements' (Stacey, 1990, p. 17). Single, gay, divorced, remarried, unmarried partnered, adoptive and reproductively assisted families are commonplace today, yet have little resemblance to the traditional nuclear family. Thus, post-modern family theorists, in contrast to the traditional theorists, argue that family diversity is now permanent, commonplace (Bernardes, 1993
) and not alternative.
However, although there may be a theoretical shift in what constitutes a family, this does not appear to have filtered through to the culture itself, hence the apparent cognitive dissonance associated with the creation of non-traditional families (van den Akker, unpublished observations). Within social psychology, there is a long history of work following the premise that people are motivated toward a resolution of cognitive inconsistencies. People may distort their memories or modify their attitudes so that they fit better with their behaviour (Festinger, 1957). If they do not, they are in a state of cognitive dissonance, which is a state in which one cognition does not follow from another. The `following from' is of course culturally defined. Since both the British and American cultures are still bound by traditional kinship ideologies, deviations from those ideologies using surrogacy may lead to discomfort or cognitive dissonance. This may be particularly important if there is only a partial or no genetic link in the resultant family.
American research suggests that people involved in reproductive technologies and surrogacy, appear to highlight and disclose those aspects which resemble ordinary family ideology, and ignore those which are incongruous with traditional family or kinship ideology (Ragone, 1994). Ragone also notes that `the ideas and beliefs that surrogates express, and programs reinforce, are culturally sanctioned'. In other words, they do not express or reinforce aspects of surrogacy which go against `culturally palatable ways'. British research, on the other hand suggests disclosure of aspects of surrogacy which are incongruous with traditional family ideology are not ignored (Blyth, 1995
). Blyth states that couples' attempts to achieve `normality' were not accompanied by strategies to deny difference. Ragone's (1994) interpretation of the couples she studied is that some biological (male) relatedness is generally achieved in surrogacy, leading to the birth of a (partly genetic) child which transforms the couple into a traditional family. In Britain, commissioning parents try to establish surrogacy as an acceptable form of creating a family (Blyth, 1995
), as they become a surrogate family. Thus cognitive dissonance should be important in the American, but not British, families created through surrogacy.
Research on adoption has argued for the benefits of disclosure (Howe et al., 2000) allowing for a cognitively consistent state, and the same benefits are said to apply to DI (Brandon, 1979
). A recent study of adoptive parents' intention to disclose and actual disclosure, suggests that nearly all adoptive parents do this for adoption, but would not for DI, egg donation, IVF or surrogacy (van den Akker, manuscript in preparation). Other research on DI has demonstrated that in many cases couples do not plan to tell their children of their genetic origins (Humphrey and Humphrey, 1986
; Schover et al., 1992
), and even fewer intend to do so following delivery of the child (Amuzu et al., 1990
; Brewaeys et al., 1993
). It was also found (Cook et al., 1995
) that the reasons for the difficulty in disclosing genetic origins in DI families are those which distinguish DI from adoption. Among the reasons were that DI parents had difficulty acknowledging the father's infertility, they also believed they were protecting the child and feared that the child could reject the father. Additionally, they did not know what the best timing and manner of telling was, and they had little information to give the child, as DI donor identities were protected.
In surrogacy cases, although there is some overlap with both adoption and DI, different issues apply. Here, theoretically, the genes can come from the commissioning or adoptive mother or the surrogate mother, they may come from the husband or from a male donor, and each can be combined with all other possibilities. In practice, the commissioning husband's genetic contribution is usually made, and the majority of gestational surrogates use the commissioning mother's eggs. However, the majority of genetic surrogacy arrangements do not employ IVF. Here the commissioning husband contributes his spermatozoa to the surrogate mother for fertilization with her egg (van den Akker, 1999a).
The lack of, or the ambiguous genetic and biological relationships between parents and children in families created through surrogacy raises a number of issues for parents and children, for psychologists interested in families and family relationships, as well as medico-legal issues about `ownership' and contractual arrangements between surrogate mothers and the commissioning parents. Some of the psychological issues which have been identified include the separation of genetic/gestational and social/interpersonal links between parents and children (Snowdon, 1994). This exposes the parents, children and society to a new interpretation of the family and gives a new existential burden to those using the new reproductive freedom. This freedom is accompanied by new fears; are test tubes mixed up, who is the donor, are the adopted, donor or surrogate children reflections of our own identity? Where is the tradition, predictability, familiarity, and how can cognitive consistency be accomplished? This study focuses on the importance of a genetic link in genetic and gestational surrogacy as this will impact on society's future interpretation of the family.
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Materials and methods |
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Questionnaire
The questionnaire consisted of five parts; part 1 obtained social and demographic information about participants and enquired in detail about their infertility, and what they did to overcome their childlessness. Other questions enquired about types of treatment, reasons for choosing each option and issues of a genetic link, based on previous pilot work and an extensive search through the relevant literature. These were semi-structured with open-ended sections for further comments. Examples of open-ended questions were: `How much does it mean to you to have a baby?.....'; `How much does it mean to your partner to have a baby?.....'; `How would you feel if you never had a baby?.....'; `How would your partner feel if he never had a baby?.....'. Examples of semi-structured questions are: `Have you considered a surrogacy arrangement? YES/NOT SURE/NO', Why?.....'. Parts 2 to 5 were standardized psychological questionnaires and were presented elsewhere (van den Akker, 1999b).
Sample
Twenty-nine sub/infertile women completed all questionnaires. Their ages ranged between 29 and 47 years, with a mean (± SD) age of 37.20 ± 5.55 years. Partners' ages ranged from 29 to 55 years (mean 38.96 ± 6.28 years). Socio-economic groupings were varied, with nine women being housewives, and two women belonging to professional (group 1), nine to managerial (2) and eight to skilled (3) groups; one woman was unskilled. Partners' socio-economic groupings were similar, ranging from six professional, 10 managerial, 10 skilled and three unskilled. Educational achievements were also fairly distributed between the sample, with nine high (degree +), nine medium (professional qualification) and 11 low (schooling). Nineteen women originally belonged to the Church of England, three were Catholics, two reported `other' religions, and five did not respond to this question. However, only 12 out of the 24 with religion were currently practising their faith; 17 described themselves as not practising any religion.
All women were married (n = 28) or living with their partner (n = 1), and had been trying to conceive for between 1 and 25 years (the mean number of years sub/infertile was 9.25 ± 5.93 years). Fourteen women had never been pregnant, five had conceived once, seven twice, and one woman had been pregnant three times, one four times and one six times. Twenty-one of the 29 women had never produced a live child of their own, seven had one, and one had borne three live children. Of the 15 women who had been pregnant, five reported one miscarriage, three reported two miscarriages, and one woman reported three and one six miscarriages. One woman had two terminations for medical reasons, and three women had a termination for social reasons. One woman did not answer this question.
Procedure
All questionnaires were delivered to the participating clinics and agencies, and were accompanied by a letter explaining the nature of the study, and a contact number in case of uncertainty or assurances. A stamped addressed envelope (SAE) was also provided. All clinics and one of the agencies added the address labels, to ensure that none of this confidential information left their premises. The questionnaires were then sent by post from the original centres, and returned anonymously to the researcher in the SAE provided. The participants recruited from the other agency were approached individually following the annual general meeting, and each member was given an explanation about the nature of the study. If they agreed to participate, the questionnaire, covering letter and SAE were left with them, to be taken home and completed in their own time.
Two main sets of findings are reported here: (i) the women's feelings and reactions to infertility; and (ii) the women's reactions to and feelings about surrogacy and a genetic link.
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Results |
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Of the sub/infertile women studied, all said their lives were incomplete and were dominated by their search for ways of obtaining the status of familyhood. For 17%, childlessness had a major effect on their marital relationship, for 31% this had some effect, and for 52% it had no effect on their relationship. Their desperation is further demonstrated in Table I, by their varied attempts to have a baby, and by their reasons for considering surrogacy. As can be seen from Table I
, 24% had failed other options and 52% had no alternative choice. The remainder chose surrogacy to have a genetic link. All participants were asked if they intended to or had continued a surrogacy arrangement, and the majority said they would or had (90%), one subject was not sure, and two did not think they would continue to pursue this option.
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Discussion |
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The results raise some important issues for psychological notions of `the family', and the development of family relationships (Snowdon, 1994). Like adoption, surrogacy enables women to become mothers and hence bring up children and create families of their own. They differ, however, from families created in more conventional ways, in terms of parenthood, because these mothers have not given birth to their children. In many cases, the children are also not genetically related to the product of both their parents. Surrogacy, therefore, as a means of creating families is unique and, like adoption, it involves another personthe woman who bears the child.
However, unlike adoption, in surrogacy one or both parents may have a genetic link with the baby. Cooper (1997) discussed the ethical issues involved in procreation using assisted reproductive techniques in general. She points out that, as with DI, the child has rights to know about its genetic origins and has rights regarding information about the processes involved in its conception. These issues have been addressed in this study. First, participants were asked if a biological link was important to them; and second, they were asked if they would tell their child how it was conceived. The results suggest a complicated mixture of responses from those who were and who were not in a position to use their own genetic material. These two issues will be discussed separately.
The importance of a biological link
In this study, all male partners were fertile, allowing for a male genetic link. The majority of women who used their own genetic material believed this link to be important to themselves and their partners. However, for women using a donor egg (that of the surrogate), only 31% (4/13) believed that a genetic link was important, which contrasts to the women's ratings of their male partners [69% (9/13) thought that it was important]. Thus, women show an unequivocal desire to have a family; and they logically accept the best form of familyhood that is practically possible for them, particularly since they all have at least a partial (male) genetic link. The pragmatism about a genetic relationship was also expressed by the commissioning mothers studied in Blyth's (1995) pioneering work on surrogacy in the UK. The women's perception of their partners' responses in this study may follow the same logic because all could use their own genetic material.
However, this practical logic does not explain the cognitive inconsistencies observed following the questions asked about adoption. The cognitive dissonance observed in the present study, with 59% who believed a genetic link was important also considering adoption, was replicated in a population of sub/infertile women opting for adoption (van den Akker, unpublished observations). One would have expected women who could not use their genetic material (the majority did not think a genetic link was important) to find adoption a possibility, but not those who could use their own genetic material (the majority did think a genetic link was important). These issues need to be addressed in counselling couples opting for alternative methods to become a family (Edelmann et al., 1994). Other studies (Ragone, 1994
) have suggested that couples using adoption cannot easily emphasize aspects of traditional kinship ideology (there is no pregnancy and no genetic link), whereas with surrogacy they can (be it only partially genetic in some cases). Further research is needed to clarify the relative contributions of a genetic link (obtained through surrogacy) and culturally sanctioned practices (through the adoption route) to cognitive conflict or dissonance. Clearly, some cognitive restructuring to realign the dissonance between genetics and family ideologies is required.
Disclosure of methods used to create a family
Two investigations (Cook et al., 1995; McWhinnie, 1995
) compared the disclosure practices of families created through a number of techniques. None of the DI families had disclosed the origins to the child. The reasons ranged from difficulty coming to terms with the father's infertility, the timing and method of telling, and because they lacked information about the genetic origins of the child. However, perhaps the most important aspect of non-disclosure concerns the maintaining of a secret for a lifetime from children, family and friends. Their behaviour suggests a dissonance between practice and attitudes. DI families were happy to utilize DI, but unhappy to disclose it.
Blyth's (1995) commissioning couples in surrogate arrangements unequivocally disclosed or intended to disclose the child's genetic and gestational origins. In fact, unlike Ragone's (1994) American data, Blyth's results stressed how his couples' attempted to `normalize' this form of creating a family, and they lacked the need to deny the gestational/genetic differences. The vast majority of commissioning participants in this study, would also disclose surrogacy to a resultant child, confirming Blyth's (1995) results. However, only 69% would disclose adoption, 62% IVF and 35% donor egg or sperm conceptions. The donor egg and sperm results are comparable to other studies (e.g. see Cook et al., 1995 above). One could argue that in donation, the lack of genetic history available makes it practically impossible to disclose virtually anything. Alternatively, donation deviates from the kinship ideology postulated earlier (Ragone, 1994) because it relies on the contribution of a third person. This additional third party involvement is incongruous or dissonant with traditional kinship ideology, and could result in coping through denial or non-disclosure. However, surrogacy, like any other form of donation, involves a third party and would also seem to go against kinship ideology and against disclosure.
The fact that surrogacy, unlike other options, appears to be generally disclosed and does not result in cognitive dissonance or denial in British studies, may be explained by differences in surrogacy practices between the USA and the UK. The UK children are likely to know their genetic/gestational or gestational surrogate mother. Our practice of surrogacy is largely based on faith in each other and compassion (van den Akker, 1998a), and unlike the USA, contractual involvement is ineffective. It is possible that couples need to stay in touch following an arrangement, so that the friendships which have developed over a year-long period are maintained. The results of Blyth (1995) and the present study strongly indicate that this may be the difference between the UK and American experiences. The British couples tend to stay in touch, they continue to meet following the adoption and relinquishment process, and they may be returning the compassion received from the surrogate for her willingness to carry and relinquish a baby.
These reasons may be pertinent, and warrant further investigation in view of the predicted increase in these practices in the UK, particularly for surrogacy, and the increased demands made by grown-up donor offspring about their genetic heritage. Only one psycho-analytical study (Lester, 1995) has addressed the boundary and the boundary confusions between the surrogate and commissioning mothers. Complex interpersonal states can evolve between these women, and their resultant view of ownership of the child. One worry for 23% of commissioning mothers was a fear of non-relinquishment of the surrogate baby. This was despite the finding that half the commissioning women had expected to get on well with their surrogates, probably because they chose one another. Compassion was also shown by some commissioning mothers for the emotions of the surrogate upon relinquishment of the baby. Less is known about the man's feelings in this area, although some tension between the commissioning male partner's feelings towards the surrogate's male partner has been reported (Blyth, 1995
). The social stigma attached to a surrogacy arrangement was another concern voiced in this study by commissioning mothers (albeit very few), and may reflect reports of the public's declining support for surrogacy (Brook et al., 1992
). Alternatively, it may be a reflection of the prevailing cultural belief in the traditional structural functionalist view of the family. Furthermore, because of the relative novelty of this practice, we do not know what the long-term plans, benefits and effects of contact between these mothers are, for them and for their children.
What is certain though, is that some re-defining of family is necessary. Acceptance of a post-modern theory of family will enable a more honest approach into a future where many more surrogacy arrangements will take place, as the 70% studied here demonstrated. This need for re-definition is not only due to the escalation of unorthodox infertility treatments, but is also seen by the increasing fragmentation of traditional families in society, and the subsequent restructuring of alternative families and family memberships. A societal acceptance of new families should allow for cognitive consistency in those attempting the formation of non-traditional families. The ideology of family will remain possible in practice for as long as people intend to have and bring up children. The differential make-up of families in the new millennium in fact confirms the overall aim: to continue to create families, not to threaten these.
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Acknowledgments |
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Notes |
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References |
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Submitted on February 1, 2000; accepted on May 5, 2000.