Commissioning Parents’ Experiences with International Surrogacy: A Qualitative Study

Commissioning Parents’ Experiences with International Surrogacy: A Qualitative Study Abstract The purpose of this qualitative study was to explore the experiences of commissioning parents (CPs) who travel abroad for surrogacy, paying attention to motivations, processes, and sources of social support. The authors recruited 10 CPs and used semistructured, in-depth interviews to illicit storytelling. Data analysis revealed primary themes around CPs’ experiences pre-surrogacy, during surrogacy, and post-surrogacy. International surrogacy was described as a long and arduous journey only undertaken after multiple failed attempts at “natural” conception. Prior to traveling abroad, CPs engaged in trade-off decision making, weighing their reproductive assistance options. CPs were primarily motivated to undertake international surrogacy by health complications and legal restrictions in their home country. CPs emphasized strenuous relationships in both the destination country and at home, and they worried about disclosure to family, friends, and children. The mental health and social needs of CPs were neglected throughout and should be incorporated in future interventions to address stigmatization. assisted reproductive technology, commissioning parents, cross-border reproduction, intended parents, transnational surrogacy It is estimated that between 12 and 90.4 million women are likely to seek medical intervention when failing to conceive after engaging in 12 months of unprotected sexual intercourse (Boivin, Bunting, Collins, & Nygren, 2007). Medical intervention may include infertility-related tourism, which is one of the most popular services identified by medical tourism companies (Alleman, 2011). Infertility-related medical tourism includes international surrogacy, which is the act of commissioning parents (CPs) traveling across borders to find a woman who agrees, under a contractual agreement, to carry and deliver a baby for the CPs, who will raise the child (Kirby, 2014). International surrogacy represents an important area of involvement for social workers, especially as it pertains to CPs’ social and emotional well-being. People who rely on international surrogacy come from a variety of industrialized countries, including Australia, Canada, France, Germany, and the United States (Pande, 2010). Most CPs who seek out surrogacy are heterosexual couples in which the female partner is infertile (Deonandan, Loncar, Rahman, & Omar, 2012; Mahajan & Marwah, 2012; Vora, 2009). Other CPs may include same-sex couples or single parents (Dar et al., 2015). Previous research has outlined several reasons why CPs choose to travel abroad for surrogacy; however, more research is needed to explore the lived experiences of CPs. CPs are motivated to use surrogacy for a variety of reasons, particularly the strong desire to raise a biological child despite reproductive health issues (Hammarberg, Stafford-Bell, & Everingham, 2015; Vora, 2009). At a Canadian fertility clinic, a study of 256 CPs found that a variety of medical conditions can cause couples to seek out gestational surrogacy, including recurrent implantation failure (22.3 percent), maternal medical condition (16.0 percent), uterine malformations or Asherman’s syndrome (13.3 percent), uterine agenesis or Mayer–Rokitansky–Küster–Hauser syndrome (12.9 percent), and recurrent pregnancy loss (11.7 percent) (Dar et al., 2015). CPs are often motivated to travel abroad for surrogacy because of legal restrictions in their country of origin, a lack of clinics that provide surrogacy services, or the inability to afford the high costs associated with surrogacy in their home countries (Pennings et al., 2008). In the United Kingdom, where surrogacy contracts are not enforced by law, Culley et al. (2011) found that CPs were motivated to travel abroad for reproductive assistance because of donor shortages, perceived success rates overseas, and displeasure with medical care in their home country. Throughout the surrogacy process, legal concerns must be considered. Deomampo (2015) talked to 39 CPs who described the experience of trying to bring their newborn home as “stressful, bewildering, and maddening.” Requirements for citizenship, nationality, and legal parenthood varied between countries of origin, with some countries placing credence on genetic ties and others valuing the gestational link between surrogate and child. CPs were required to wade through large amounts of paperwork and wait for weeks to months to obtain citizenship for their child. Because international surrogacy is a relatively new trend, many countries have no clear guidelines and are continuously modifying their response, thereby creating a moving target for CPs (Deomampo, 2015). Even though CPs have reported legal difficulties related to the international surrogacy process, many do not seek out legal counsel. Rodino, Goedeke, and Nowoweiski (2014) found that only 32.6 percent of their Australian and New Zealander study sample had sought legal advice regarding citizenship prior to traveling overseas. Legal advice is important to ensure CPs’ legal rights as parents and protect against criminal prosecution through extraterritorial sanctions. Furthermore, CPs rarely sought out formal sources of emotional support and counseling. Most participants who had completed international surrogacy agreed that their medical needs had been met and that treatment had been safe, 91.2 percent and 89.4 percent, respectively (Rodino et al., 2014). However, only 57.9 percent agreed that their emotional needs had been met. The relationship between CPs and international surrogates is important to understand. Typically, CPs do not choose a particular surrogate but are matched to a surrogate by the director of a clinic. After an initial interview with the surrogate, there is little to no contact between the CPs and the surrogate, because clinic staff closely mediate the relationship (Vora, 2009). A qualitative study examining the experiences of eight gay Israeli couples using international surrogacy discovered that CPs felt frustration and anxiety from a perceived loss of control over the process (Ziv & Freund-Eschar, 2014). Furthermore, the CPs expressed unease and doubt over whether the surrogacy agencies were being honest with them, and the participants were concerned about the surrogate’s health. There is a substantial lack of research on commercial surrogacy, and the research that does exist tends to be conceptual or quantitative in nature. Existing qualitative research has examined motivations for traveling abroad for surrogacy, issues of citizenship, and attachment to the fetus. Of particular relevance to this study is the importance of examining relationships that provide social and emotional support to CPs before, during, and after the international surrogacy process. Our purpose was to explore the lived experiences of CPs who travel abroad for surrogacy, paying attention to motivations, processes, and sources of social support. One research question guided this study: What are the lived experiences of CPs in the international surrogacy process? METHOD This qualitative study took an interpretative phenomenological approach (IPA) with the goal of exploring the phenomenon of international surrogacy from the perspective of CPs (Creswell, 2009). This allows for deeper meanings to be observed through prolonged interactions and captures participants’ specific language to describe their experiences (Padgett, 2008). The goal of IPA is to describe the underlying structures of an experience by the researchers through interpretation of findings (Moustakas, 1994). Participant Recruitment and Screening Participants for this study were recruited between January and June 2015 using purposive sampling techniques (Padgett, 2008). Google and Facebook searches were completed to identify international surrogacy networking nonprofits and support groups. The search terms “global surrogacy” and “international surrogacy” were used to identify these prospective partners. Staff of various international surrogacy networking nonprofits were contacted to assist with recruitment, and four contacts agreed to circulate the study information to members in their Facebook group. These four contacts serve CPs in Australia, Canada, England, Germany, Israel, Japan, Madagascar, and the United States. Prospective participants were provided with the contact information for the researchers, and interested CPs contacted the researchers directly by e-mail. Those living in high-income countries and age 18 years and older, who had crossed borders to participate in commercial gestational surrogacy arrangements within the last five years, were permitted to participate. All the individuals who contacted the researchers met these eligibility criteria and were, therefore, included in this research study. In total, 10 CPs participated in this study, a sample size typical for phenomenological research (Padgett, 2008). Of the 10 CPs who participated, half identified as women and half as men (for demographic information, see Table 1). All participants were married at the time of surrogacy, including six in heterosexual marriages and four in same-sex marriages. One member from each couple participated in this research study. All participants lived in high-income countries, with the majority coming from Australia and the United States. Most participants traveled to Mexico, Thailand, or India for surrogacy; however, two participants engaged in the process in the United States. Table 1: Participant Demographics (N = 10) Gender Relationship Status Home Country Surrogacy Country Female Heterosexual marriage Germany Mexico Male Heterosexual marriage Australia Mexico Female Heterosexual marriage Australia Thailand Male Same-sex marriage United States India Female Heterosexual marriage Australia Thailand Male Same-sex marriage Israel United States Male Same-sex marriage United States India Female Heterosexual marriage United States India Female Heterosexual marriage United States Mexico Male Same-sex marriage England United States Gender Relationship Status Home Country Surrogacy Country Female Heterosexual marriage Germany Mexico Male Heterosexual marriage Australia Mexico Female Heterosexual marriage Australia Thailand Male Same-sex marriage United States India Female Heterosexual marriage Australia Thailand Male Same-sex marriage Israel United States Male Same-sex marriage United States India Female Heterosexual marriage United States India Female Heterosexual marriage United States Mexico Male Same-sex marriage England United States Table 1: Participant Demographics (N = 10) Gender Relationship Status Home Country Surrogacy Country Female Heterosexual marriage Germany Mexico Male Heterosexual marriage Australia Mexico Female Heterosexual marriage Australia Thailand Male Same-sex marriage United States India Female Heterosexual marriage Australia Thailand Male Same-sex marriage Israel United States Male Same-sex marriage United States India Female Heterosexual marriage United States India Female Heterosexual marriage United States Mexico Male Same-sex marriage England United States Gender Relationship Status Home Country Surrogacy Country Female Heterosexual marriage Germany Mexico Male Heterosexual marriage Australia Mexico Female Heterosexual marriage Australia Thailand Male Same-sex marriage United States India Female Heterosexual marriage Australia Thailand Male Same-sex marriage Israel United States Male Same-sex marriage United States India Female Heterosexual marriage United States India Female Heterosexual marriage United States Mexico Male Same-sex marriage England United States Data Collection In-depth interviews were conducted by the first two authors of this article, using a semistructured interview guide. Interview guide questions were open-ended and encouraged participants to convey their surrogacy stories. Participants were permitted to guide the conversation, covering topics of most importance to them. Examples of interview guide items include (a) “Tell me about your journey to have your child”; (b) “Talk to me about how prepared you were”; (c) “What do you wish you would have known prior to traveling for surrogacy?”; and (d) “What are your recommendations for others planning to travel abroad for surrogacy services?” Interviews were conducted on Skype and lasted approximately 109 minutes on average. A consent form was e-mailed to participants prior to the interview for review, and each participant provided verbal informed consent prior to the start of the Skype interview. Following the interview, each participant was e-mailed a $10 Amazon gift card; however, one participant declined the incentive. There were no pre-existing relationships between the interviewers and participants. This research study was approved by the institutional review board at the University of Utah and the Ohio State University. Data Analysis Data analysis focused on discovering common themes in participants’ experiences and the conditions of those experiences (Padgett, 2008). To accomplish this goal, we followed the Stevick–Colaizzi–Keen method of phenomenological analysis (as cited in Moustakas, 1994). First, verbatim transcripts were read line-by-line several times with the goal of understanding CPs’ experiences with international surrogacy. Next, all germane statements were coded and recorded. All nonrepetitive statements were listed. Then, the statements were clustered into categories that were grouped into themes with similar meanings or descriptions of the experience. Finally, themes were synthesized into a description ofinternational surrogacy, and verbatim excerpts were used to highlight each theme. The first two authors performed the analysis separately and then verified the descriptions for accuracy as a team. RESULTS International surrogacy was a long and arduous journey for CPs. This often included many years of failed in vitro fertilization (IVF) procedures followed by an investigation of options and surrogacy attempts in multiple destination countries. Common elements of the surrogacy process included meeting the medical staff, undergoing medical tests and procedures, choosing a surrogate and possibly also egg donor, meeting the surrogate, communicating with and receiving updates from the surrogacy clinic or agent, and navigating laws to bring the newborn (or newborns) home. Social and emotional factors frequently affected the surrogacy process, as the CPs were heavily influenced by levels of social support (or lack thereof) provided by family, friends, and community members. Even after the process was complete, CPs continued to confront residual issues, such as whether to disclose surrogacy to the child. Through data analysis, it was evident that participants’ narratives were divided by time frames and stages of the process. Therefore, we present our results in three sections that consider CPs’ experiences prior to, during, and following their participation in international surrogacy. Prior to the Journey Motivations Prior to traveling abroad for surrogacy, CPs participated in a process of trade-off decision making, weighing their reproductive assistance options. Two primary drivers that encouraged CPs to seek surrogacy abroad were (1) health complications that made it difficult or impossible for “natural” conception and (2) legal restrictions imposed in their home country. The most frequently cited motivation for engaging in international surrogacy was related to difficulty becoming pregnant, particularly among heterosexual CPs. All heterosexually partnered participants reported that it was impossible to have biological children on their own, and health complications included failed IVF attempts, miscarriages, and infertility. One Australian participant stated, I had six attempts here in Australia with IVF, and . . . I had two miscarriages and an ectopic pregnancy by this stage. . . . [The physician] said that my adenomyosis was so severe . . . my uterus was never going to stretch beyond nine weeks. Participants were also motivated by legal restrictions around adoption and surrogacy in their home countries. Participants considered all options, including adoption, before deciding to engage in international surrogacy. Both heterosexual and same-sex coupled participants expressed frustration with the adoption system for multiple reasons including the high cost, lengthy process, and loss of privacy. In addition to these barriers to adoption, same-sex coupled participants perceived discrimination based on their sexual orientation. An American participant stated, “I think [the adoption agency was] just giving me the run-around because I was a gay male. . . . So it was kind of very disheartening. . . . For about a year, I was really upset.” This is not surprising as many countries do not allow gay couples to adopt (Zanghellini, 2011). The discrimination experienced during the adoption process is a unique challenge for same-sex couples. Sources of Information and Support All participants described a variety of sources they used to research surrogacy, including the Internet, Facebook, other CPs, books, surrogacy agencies and clinics, online forums, health care providers, and surrogacy conferences. These sources of information were instrumental in allowing CPs to make an informed choice about their participation in international surrogacy, including the destination country and selected clinic. Participants reported extensively investigating international surrogacy for many years prior to engaging in the process. Participants found some social support through the surrogacy community, Facebook groups, online forums, and nonprofit organizations, such as Families Through Surrogacy and Surrogacy Australia. However, most participants reported that they received relatively little support from their friends, family, and community members. Many participants stated that negative publicity and societal disapproval of surrogacy affected the opinions of their loved ones. Participants discussed the importance of education at all levels, including the education of loved ones. Family, friends, and community members were often unaware of surrogacy as a reproductive option. A participant stated, “My husband’s father had a little bit of hesitation at first. . . . He didn’t even know that these medical things could be done. . . . But that only took him a couple of days to be educated, and then he came around.” One participant refrained from talking to his parents about his desire to participate in surrogacy, because he had not yet come out as gay. Another participant refrained from telling friends and family until later in the process, having experienced a history of failed IVF attempts and not wanting to be forced to “share bad news.” Embarking on the Journey Medical Process Following failed IVF, adoption attempts, and participating in a careful examination of all options available, CPs decided to embark on their international surrogacy journey. A gay Israeli man who traveled to the United States with his husband to complete surrogacy described his process: “We went to the States, we had our embryos, and then we transferred two embryos, one made of my sperm and one from my partner’s sperm. And then two weeks later we found out we were pregnant.” The desire of both partners to contribute genetic material and have an equal probability of being the biological father affected their surrogacy process. In a different scenario, a heterosexual Australian woman traveled to Thailand with her husband to complete surrogacy and used her own eggs. She said, We saw [the surrogate] every second day ’cause she was coming in to have bloods to make sure that her uterus lining was going up while my eggs were developing as well and then if it looked like hers was going to go too quickly and my eggs weren’t developing, they could slow it down slightly so that we were right on time with each other. Medical Staff in the Destination Country Participants described important interactions with medical staff and the surrogate during the surrogacy process. CPs indicated relatively positive experiences with medical staff and reported medical staff to be informative regarding the process, adequately answering all CP questions. For example, an Australian participant stated, “I did not come away feeling that this was a third-rate country at all. On the contrary . . . they’re quite advanced.” Difficulties tended to emerge in relationship to agents who acted as middlemen between the fertility clinic and the CPs. One American participant indicated that an embryo was lost in transit, which was trau-matic because she was unable to produce any more embryos. This resulted in the participant depending on an egg donor agency, which “went on to embezzle ten and a half thousand dollars.” Relationship with Surrogate The relationship with the surrogate differed based on the destination country and agency regulations; however, there was typically minimal contact with the surrogate. A participant who engaged in surrogacy in Thailand stated, I really wanted to have a much closer relationship with my surrogate, and it just makes me sad that she will never know that . . . we made sure that we spent a lot of time with her, let her spend time with the baby and communicated to her. . . . That was the most amazing thing that anyone could have done, and it was quite an emotional farewell for that reason. All CPs engaged in surrogacy in low-income countries, except for two participants who chose to complete the process in the United States. These two CPs described being closer to the surrogate than those who engaged in the process in low-income countries. For example, one Israeli participant stated, “We were in touch with the surrogate throughout the process. . . . We bought a ticket for her and her husband to come over to Israel, and they spent a week with us here.” The other participant who engaged in international surrogacy in the United States indicated that he and his husband purposely chose the United States for an open process and to maintain a relationship with the surrogate. This UK resident stated, We wanted one [surrogate mother] who was very open . . . we headed out there this summer and spent one week with them in California. And the kids Skype with her frequently. And we send messages to each other. And they call her tummy mummy. Social Support Some participants had a limited amount of social support during the actual surrogacy process. Often, participants only confided in a select few family members or friends about their plans because of fear of a negative response. One participant from Germany did not intend to tell her family at all and instead planned on claiming that the child was adopted. In some cases, when participants eventually did disclose that they were using surrogacy, they received a positive and supportive response, as was the case for the following participant who noted that her friends and family have been supportive: I was very nervous . . . it wasn’t until . . . 26 weeks that I actually told anyone apart from my closest friends that we were doing surrogacy, and I was really nervous about how people were going to respond. . . . I’ve been very surprised by how [positive] everyone’s been. Coming Home Citizenship The citizenship process represented another difficulty for many CPs, which varied based on the CPs’ home country, presumably stemming from embassies’ fears that newborns were being trafficked. A participant from the United States stated, “She [the vice consulate] made her final decision and escalated it to Hague as an illegal adoption, so . . . the last year has been fighting and proving that we didn’t steal them [the twins].” One German CP described her international surrogacy process as chaotic with failed attempts in Ukraine and Thailand before the birth of a child in Mexico. This CP had also chosen not to mention the word “surrogate” for fear that the German government would not grant citizenship to the child. She stated, “We didn’t mention the word ‘surrogate mother,’ just someone is pregnant with my husband’s baby. Yeah, legally that’s fine, because she’s the mother so we are talking about the mother of the child.” This participant indicated that surrogacy is equated with sex work in Germany and similarly stigmatized. For this reason, some CPs are likely to maintain anonymity regarding their participation in international surrogacy, which can be isolating especially as it pertains to social support. Social Support Several participants feared negative reactions and felt that their communities were unsupportive of surrogacy. This was attributed to negative media attention, a lack of understanding of the experience of infertility, and a lack of knowledge about surrogacy in general. One participant noted that the media’s portrayal of surrogates as living in dormitories and engaging in multiple, consecutive surrogate pregnancies contributed to her community’s negative perception of surrogacy. She indicated that this portrayal did not accurately reflect her surrogate’s experience. This was most apparent in Germany, where all forms of surrogacy are prohibited. The community reaction was less negative in countries where surrogacy is partially legal (for example, where altruistic surrogacy is legal). Only two participants reported receiving overwhelmingly positive reactions from their communities. One participant attributed these reactions to her enthusiastic attitude toward surrogacy: “Whenever I talk about surrogacy it’s the most amazing positive experience of my life and it’s, you know, our dreams of having a baby here so all we’ve ever heard is ‘Congratulations,’ ‘That’s fantastic,’ ‘That’s amazing.’” Another participant stated, “We sort of took the approach [of disclosure to family] that it takes a village and the more extended family members, the more family members they [children] have to love them, the better.” Issues of Disclosure to Child Even after CPs return home, they must make decisions regarding disclosure to the child. Several participants indicated that they were open, or intended to be open, with their children about how they were born. For example, one participant stated, “I think we want to tell our child later on, because we think that everybody has a right to know about his own identity.” However, CPs questioned the right time to be transparent with children about their birth story. Participants also reported a desire for children to have the opportunity to meet their surrogate mother and have an ongoing relationship with her: We chose our surrogate because we wanted one who was very open, who would want to know the kids, who would want to see the kids over the summer when we came back. . . . We know some couples who want to have their kids and never let their kids know who it was and this and that. That wasn’t us. That wasn’t what we wanted. Several participants reported that they have an ongoing relationship with their surrogate. Others reported a desire for the opportunity to maintain a relationship with their surrogate; however, this choice is not entirely in their control. For example, a participant stated, If we want to have some contact with her [the surrogate] in the future, which I would like, the kids to meet her in the future, they have to go through the agency. . . . It’s not that easy for us to reach out to her. We have to go through the agency, and they can accommodate that if the babies in the future want to see the surrogate mom. However, agencies typically limited the CPs’ relationship with the surrogate. This was attributed to the importance of maintaining the surrogate’s privacy, but also, according to the surrogacy agency, to limit potential financial exploitation of CPs. For example, CPs reported that agencies warned them about surrogates’ requests for increased compensation. DISCUSSION It is curious as to why individuals prize genetic kinship, crossing borders to achieve it, over kinship through adoption. Scholars have theorized that genetic kinship is valorized as it is viewed as “natural” (Riggs & Due, 2010). For example, women unable to reproduce may be stigmatized for not fulfilling cultural norms and expectations around gender and pregnancy (Whiteford & Gonzalez, 1995). Others have theorized that gay and lesbian couples may idealize genetic kinship in response to societal heteronormativity, attempting to become the “idealised homonormative couple” (Hosking & Ripper, 2012). The participants in this study, though, emphasized that adoption is a lengthy process that involves high costs, both direct financial costs and indirect personal costs related to lengthy time commitments and invasions of privacy. Although this conversation is beyond the scope of our article, it is important to understand the privileging of certain types ofkinship, as well as racial and national privilege in contextualizing international surrogacy transactions. Our findings are consistent with previous research on motivations to participate and on issues related to the surrogacy process. These results highlight the medical and social complexities involved in the surrogacy process. Specifically, many CPs faced medical and social challenges, leading them to seek out international surrogacy. In the surrogacy process, additional medical and social complications arose that were not addressed by medical staff in the destination country. Relationships between CPs and surrogates were heavily mediated by clinic staff, and most CPs reported that this can be distressing. Consistent with previous studies, motivations for pursuing international surrogacy were related to health complications. For example, heterosexual couples have cited medical problems as their primary motivation for surrogacy (Hammarberg et al., 2015). Dar et al. (2015) found that medical conditions that prohibit “natural” conception or pregnancy, such as Asherman’s syndrome, lead to women seeking out surrogacy. Several women in our sample sought out surrogacy after failed attempts to conceive “naturally.” Our study was the first to establish that restrictions around adoption (for example, ban on same-sex couple adoptions) and surrogacy largely influenced many of the participants. The international surrogacy process has not been heavily documented in the academic literature, and knowledge regarding the process primarily comes from news outlets and anecdotal accounts. Rodino et al. (2014) found that most individuals who had completed cross-border reproductive care reported that while their medical needs had been met by international fertility clinics, their emotional and mental health needs were largely neglected. Our study participants generally expressed positive experiences with fertility clinics, but physical needs were emphasized over emotional and mental health ones. In addition, difficulties did arise with the middlemen between the clinic and CPs, which can result in exploitation. CPs expressed availability of minimal social support, as surrogacy was typically disclosed to only a few friends or family members. Most participants in this study reported minimal contact with their surrogate. Many participants wished they had more contact with the surrogate and reported feelings of disappointment or worry. Fathers in the Ziv and Freund-Eschar (2014) study expressed similar sentiments of concern and worriedness about their surrogate’s health. Whereas most participants in the Ziv and Freund-Eschar (2014) study expressed feelings of disconnect from the fetus, participants in this study did not express those same emotions. A 10-year follow-up study in the United Kingdom found positive results when CPs and offspring maintained a relationship with the surrogate (Jadva, Blake, Casey, & Golombok, 2012). However, both CPs and surrogates in that study resided in the United Kingdom, presumably making it easier to maintain contact. Limitations This study’s analysis provides insight into the motivations and process of international surrogacy arrangements from the CPs’ perspectives. Despite the strength and thoroughness of these results, no study is without limitations. First, the sample size of this study was relatively small. However, small sample sizes are consistent with typical phenomenological studies (Creswell, 2009; Padgett, 2008). Our participants’ experiences are not meant to represent all CPs who seek surrogacy abroad. Although this study captured the experiences of both heterosexual and same-sex male couples, a more detailed look into the experiences of single and lesbian-coupled CPs may be appropriate. With regard to theoretical saturation, all participants in this study fit the established criteria, participants were sought out who would provide atypical data, and the possibility of generating different data in the process of data analysis was exhausted (Creswell, 2009). Future research should explore the experiences of other atypical CPs to find deviations in the aforementioned surrogacy motivations and processes. Second, this study limited participation to only those living in high-income countries. This was intentional to understand the experiences of CPs who cross borders for assisted reproduction services. Whereas it may be less common for individuals in low-income countries to seek out international surrogacy services, our knowledge would be enhanced from understanding motivations and experiences of CPs in this context. Finally, this study only focused on CPs who had completed the surrogacy process. Future research would benefit from a longitudinal investigation into experiences throughout the process, instead of relying on retrospective data. Direct ethnographic observation of CPs at fertility clinics may also be beneficial for future research. Implications This study found that CPs seek international surrogacy services for two primary reasons: medical issues, such as the inability to conceive “naturally” or through IVF; and legal restrictions around surrogacy or adoption in their home countries. CPs, coping with their own inability to conceive and navigating international surrogacy options, would benefit from support prior to the start and routinely throughout the process of surrogacy. Social workers are poised to provide this support. CPs are not guaranteed to have a child at the end of the surrogate pregnancy. For example, medical complications with the surrogate, conception, and pregnancy can leave CPs without a biological child. These realities can be difficult for some to handle. Sanabria (2013) and Dar et al. (2015) recommend professional mental health services for any person seeking surrogacy services. Social workers can provide guidance to individuals and couples, ensuring that they are fully informed about the various decisions to be made in the surrogacy process. Social workers can also connect CPs with various coping resources (for example, support groups) and legal counsel and assist them in the emotional processes associated with surrogacy (Sanabria, 2013). Social workers from host countries are uniquely adept at establishing rapport with CPs, connecting them to the proper legal services, and ensuring the safe return of CPs and children. With regard to legal barriers that prevent surrogacy or adoption in CPs’ home countries, progressive social policies can curb the rate of individuals from high-income countries seeking out international surrogates. Specifically, host countries need to recognize that individuals and couples deserve equal access to adoption regardless of sexual orientation. Thus, social workers can advocate for equitable adoption and surrogacy policies. If a strong connection to the surrogate is desired, CPs should have the ability to make this lasting bond if surrogates agree. Although this can be quite difficult to achieve in present international surrogacy arrangements (because of vast social, class, and cultural disparities between CPs and surrogates), this is much more easily achieved when surrogacy is available in CPs’ home countries. Advocating for ethical, transparent regulation of surrogacy should be a priority for both CPs and surrogates. Informed consent for all parties involved in the surrogacy process must be paramount. Social workers should mediate and establish the boundaries for relationships and ensure informed consent for all parties. REFERENCES Alleman , B. ( 2011 ). Medical tourism services available to residents of the United States . Journal of General Internal Medicine , 26 , 492 – 497 . Google Scholar CrossRef Search ADS PubMed Boivin , J. , Bunting , L. , Collins , J. A. , & Nygren , K. ( 2007 ). International estimates of infertility prevalence and treatment-seeking: Potential need and demand for infertility medical care . Human Reproduction , 22 , 1506 – 1512 . Google Scholar CrossRef Search ADS PubMed Creswell , J. W. ( 2009 ). Research design: Qualitative, quantitative, and mixed methods approaches ( 3rd ed. ). Thousand Oaks, CA : Sage Publications . Culley , L. , Hudson , N. , Rapport , F. , Blyth , E. , Norton , W. , & Pacey , A. A. ( 2011 ). Crossing borders for fertility treatment: Motivations, destinations and outcomes of UK fertility travelers . Human Reproduction , 26 , 2373 – 2381 . Google Scholar CrossRef Search ADS PubMed Dar , S. , Lazer , T. , Swanson , S. , Silverman , J. , Wasser , C. , Moskovtsev , S. I. , et al. . ( 2015 ). Assisted reproduction involving gestational surrogacy: An analysis of the medical, psychosocial and legal issues: Experience from a large surrogacy program . Human Reproduction , 30 , 345 – 352 . Google Scholar CrossRef Search ADS PubMed Deomampo , D. ( 2015 ). Defining parents, making citizens: Nationality and citizenship in transnational surrogacy . Medical Anthropology , 34 , 210 – 225 . Google Scholar CrossRef Search ADS PubMed Deonandan , R. , Loncar , M. , Rahman , P. , & Omar , S. ( 2012 ). Measuring reproductive tourism through an analysis of Indian ART clinic websites . International Journal of General Medicine , 2012 , 763 – 773 . Google Scholar CrossRef Search ADS Hammarberg , K. , Stafford-Bell , M. , & Everingham , S. ( 2015 ). Intended parents’ motivations and information and support needs when seeking extraterritorial compensated surrogacy . Reproductive BioMedicine Online , 31 , 689 – 696 . Google Scholar CrossRef Search ADS PubMed Hosking , G. , & Ripper , M. ( 2012 ). In the best interests of the (silenced) child: The mobilisation of children of lesbian and gay parents to reinforce heteronormativity . Australian Feminist Studies , 27 , 177 – 188 . Google Scholar CrossRef Search ADS Jadva , V. , Blake , L. , Casey , P. , & Golombok , S. ( 2012 ). Surrogacy families 10 years on: Relationship with the surrogate, decisions over disclosure and children’s understanding of their surrogacy origins . Human Reproduction , 27 , 3008 – 3014 . Google Scholar CrossRef Search ADS PubMed Kirby , J. ( 2014 ). Transnational gestational surrogacy: Does it have to be exploitative? American Journal of Bioethics , 14 ( 5 ), 24 – 32 . Google Scholar CrossRef Search ADS PubMed Mahajan , T. , & Marwah , V. ( 2012 ). Birthing a market: A study on commercial surrogacy . New Delhi : Sama—Resource Group for Women and Health . Moustakas , C. ( 1994 ). Phenomenological research methods . Thousand Oaks, CA : Sage Publications . Google Scholar CrossRef Search ADS Padgett , D. K. ( 2008 ). Qualitative methods in social work research ( 2nd ed. ). Thousand Oaks, CA : Sage Publications . Pande , A. ( 2010 ). Commercial surrogacy in India: Manufacturing a perfect mother worker . Journal of Women in Culture and Society , 35 , 969 – 992 . Google Scholar CrossRef Search ADS Pennings , G. , de Wert , G. , Shenfield , F. , Cohen , J. , Tarlatzis , B. , & Devroey , P. ( 2008 ). ESHRE task force on ethics and law 15: Cross-border reproductive care . Human Reproduction , 23 , 2182 – 2184 . Google Scholar CrossRef Search ADS PubMed Riggs , D. W. , & Due , C. ( 2010 ). Gay men, race privilege and surrogacy in India. Outskirts Online Journal, 22. Retrieved from http://www.outskirts.arts.uwa.edu.au/volumes/volume-22/riggs Rodino , I. S. , Goedeke , S. , & Nowoweiski , S. ( 2014 ). Motivations and experiences of patients seeking cross-border reproductive care: The Australian and New Zealand context . Fertility and Sterility , 102 , 1422 – 1431 . Google Scholar CrossRef Search ADS PubMed Sanabria , S. ( 2013 ). When adoption is not an option: Counseling implications related to surrogacy . Journal of Gay & Lesbian Social Services , 25 , 269 – 286 . Google Scholar CrossRef Search ADS Vora , K. ( 2009 ). Indian transnational surrogacy and the commodification of vital energy . Subjectivity: International Journal of Critical Psychology , 28 ( 1 ), 266 – 278 . Whiteford , L. M. , & Gonzalez , L. ( 1995 ). Stigma: The hidden burden of infertility . Social Science & Medicine , 40 ( 1 ), 27 – 36 . Google Scholar CrossRef Search ADS Zanghellini , A. ( 2011 ). Gay surrogacy, intentionality and Tahitian parenting . Griffith Law Review , 20 , 1 – 30 . Google Scholar CrossRef Search ADS Ziv , I. , & Freund-Eschar , Y. ( 2014 ). The pregnancy experience of gay couples expecting a child through overseas surrogacy . Family Journal , 23 , 158 – 166 . Google Scholar CrossRef Search ADS © 2018 National Association of Social Workers This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health & Social Work Oxford University Press

Commissioning Parents’ Experiences with International Surrogacy: A Qualitative Study

Health & Social Work, Volume Advance Article (3) – Jun 12, 2018

Loading next page...
 
/lp/oxford-university-press/commissioning-parents-experiences-with-international-surrogacy-a-ZoQid4xQ0V
Publisher
Oxford University Press
Copyright
© 2018 National Association of Social Workers
ISSN
0360-7283
eISSN
1545-6854
D.O.I.
10.1093/hsw/hly018
Publisher site
See Article on Publisher Site

Abstract

Abstract The purpose of this qualitative study was to explore the experiences of commissioning parents (CPs) who travel abroad for surrogacy, paying attention to motivations, processes, and sources of social support. The authors recruited 10 CPs and used semistructured, in-depth interviews to illicit storytelling. Data analysis revealed primary themes around CPs’ experiences pre-surrogacy, during surrogacy, and post-surrogacy. International surrogacy was described as a long and arduous journey only undertaken after multiple failed attempts at “natural” conception. Prior to traveling abroad, CPs engaged in trade-off decision making, weighing their reproductive assistance options. CPs were primarily motivated to undertake international surrogacy by health complications and legal restrictions in their home country. CPs emphasized strenuous relationships in both the destination country and at home, and they worried about disclosure to family, friends, and children. The mental health and social needs of CPs were neglected throughout and should be incorporated in future interventions to address stigmatization. assisted reproductive technology, commissioning parents, cross-border reproduction, intended parents, transnational surrogacy It is estimated that between 12 and 90.4 million women are likely to seek medical intervention when failing to conceive after engaging in 12 months of unprotected sexual intercourse (Boivin, Bunting, Collins, & Nygren, 2007). Medical intervention may include infertility-related tourism, which is one of the most popular services identified by medical tourism companies (Alleman, 2011). Infertility-related medical tourism includes international surrogacy, which is the act of commissioning parents (CPs) traveling across borders to find a woman who agrees, under a contractual agreement, to carry and deliver a baby for the CPs, who will raise the child (Kirby, 2014). International surrogacy represents an important area of involvement for social workers, especially as it pertains to CPs’ social and emotional well-being. People who rely on international surrogacy come from a variety of industrialized countries, including Australia, Canada, France, Germany, and the United States (Pande, 2010). Most CPs who seek out surrogacy are heterosexual couples in which the female partner is infertile (Deonandan, Loncar, Rahman, & Omar, 2012; Mahajan & Marwah, 2012; Vora, 2009). Other CPs may include same-sex couples or single parents (Dar et al., 2015). Previous research has outlined several reasons why CPs choose to travel abroad for surrogacy; however, more research is needed to explore the lived experiences of CPs. CPs are motivated to use surrogacy for a variety of reasons, particularly the strong desire to raise a biological child despite reproductive health issues (Hammarberg, Stafford-Bell, & Everingham, 2015; Vora, 2009). At a Canadian fertility clinic, a study of 256 CPs found that a variety of medical conditions can cause couples to seek out gestational surrogacy, including recurrent implantation failure (22.3 percent), maternal medical condition (16.0 percent), uterine malformations or Asherman’s syndrome (13.3 percent), uterine agenesis or Mayer–Rokitansky–Küster–Hauser syndrome (12.9 percent), and recurrent pregnancy loss (11.7 percent) (Dar et al., 2015). CPs are often motivated to travel abroad for surrogacy because of legal restrictions in their country of origin, a lack of clinics that provide surrogacy services, or the inability to afford the high costs associated with surrogacy in their home countries (Pennings et al., 2008). In the United Kingdom, where surrogacy contracts are not enforced by law, Culley et al. (2011) found that CPs were motivated to travel abroad for reproductive assistance because of donor shortages, perceived success rates overseas, and displeasure with medical care in their home country. Throughout the surrogacy process, legal concerns must be considered. Deomampo (2015) talked to 39 CPs who described the experience of trying to bring their newborn home as “stressful, bewildering, and maddening.” Requirements for citizenship, nationality, and legal parenthood varied between countries of origin, with some countries placing credence on genetic ties and others valuing the gestational link between surrogate and child. CPs were required to wade through large amounts of paperwork and wait for weeks to months to obtain citizenship for their child. Because international surrogacy is a relatively new trend, many countries have no clear guidelines and are continuously modifying their response, thereby creating a moving target for CPs (Deomampo, 2015). Even though CPs have reported legal difficulties related to the international surrogacy process, many do not seek out legal counsel. Rodino, Goedeke, and Nowoweiski (2014) found that only 32.6 percent of their Australian and New Zealander study sample had sought legal advice regarding citizenship prior to traveling overseas. Legal advice is important to ensure CPs’ legal rights as parents and protect against criminal prosecution through extraterritorial sanctions. Furthermore, CPs rarely sought out formal sources of emotional support and counseling. Most participants who had completed international surrogacy agreed that their medical needs had been met and that treatment had been safe, 91.2 percent and 89.4 percent, respectively (Rodino et al., 2014). However, only 57.9 percent agreed that their emotional needs had been met. The relationship between CPs and international surrogates is important to understand. Typically, CPs do not choose a particular surrogate but are matched to a surrogate by the director of a clinic. After an initial interview with the surrogate, there is little to no contact between the CPs and the surrogate, because clinic staff closely mediate the relationship (Vora, 2009). A qualitative study examining the experiences of eight gay Israeli couples using international surrogacy discovered that CPs felt frustration and anxiety from a perceived loss of control over the process (Ziv & Freund-Eschar, 2014). Furthermore, the CPs expressed unease and doubt over whether the surrogacy agencies were being honest with them, and the participants were concerned about the surrogate’s health. There is a substantial lack of research on commercial surrogacy, and the research that does exist tends to be conceptual or quantitative in nature. Existing qualitative research has examined motivations for traveling abroad for surrogacy, issues of citizenship, and attachment to the fetus. Of particular relevance to this study is the importance of examining relationships that provide social and emotional support to CPs before, during, and after the international surrogacy process. Our purpose was to explore the lived experiences of CPs who travel abroad for surrogacy, paying attention to motivations, processes, and sources of social support. One research question guided this study: What are the lived experiences of CPs in the international surrogacy process? METHOD This qualitative study took an interpretative phenomenological approach (IPA) with the goal of exploring the phenomenon of international surrogacy from the perspective of CPs (Creswell, 2009). This allows for deeper meanings to be observed through prolonged interactions and captures participants’ specific language to describe their experiences (Padgett, 2008). The goal of IPA is to describe the underlying structures of an experience by the researchers through interpretation of findings (Moustakas, 1994). Participant Recruitment and Screening Participants for this study were recruited between January and June 2015 using purposive sampling techniques (Padgett, 2008). Google and Facebook searches were completed to identify international surrogacy networking nonprofits and support groups. The search terms “global surrogacy” and “international surrogacy” were used to identify these prospective partners. Staff of various international surrogacy networking nonprofits were contacted to assist with recruitment, and four contacts agreed to circulate the study information to members in their Facebook group. These four contacts serve CPs in Australia, Canada, England, Germany, Israel, Japan, Madagascar, and the United States. Prospective participants were provided with the contact information for the researchers, and interested CPs contacted the researchers directly by e-mail. Those living in high-income countries and age 18 years and older, who had crossed borders to participate in commercial gestational surrogacy arrangements within the last five years, were permitted to participate. All the individuals who contacted the researchers met these eligibility criteria and were, therefore, included in this research study. In total, 10 CPs participated in this study, a sample size typical for phenomenological research (Padgett, 2008). Of the 10 CPs who participated, half identified as women and half as men (for demographic information, see Table 1). All participants were married at the time of surrogacy, including six in heterosexual marriages and four in same-sex marriages. One member from each couple participated in this research study. All participants lived in high-income countries, with the majority coming from Australia and the United States. Most participants traveled to Mexico, Thailand, or India for surrogacy; however, two participants engaged in the process in the United States. Table 1: Participant Demographics (N = 10) Gender Relationship Status Home Country Surrogacy Country Female Heterosexual marriage Germany Mexico Male Heterosexual marriage Australia Mexico Female Heterosexual marriage Australia Thailand Male Same-sex marriage United States India Female Heterosexual marriage Australia Thailand Male Same-sex marriage Israel United States Male Same-sex marriage United States India Female Heterosexual marriage United States India Female Heterosexual marriage United States Mexico Male Same-sex marriage England United States Gender Relationship Status Home Country Surrogacy Country Female Heterosexual marriage Germany Mexico Male Heterosexual marriage Australia Mexico Female Heterosexual marriage Australia Thailand Male Same-sex marriage United States India Female Heterosexual marriage Australia Thailand Male Same-sex marriage Israel United States Male Same-sex marriage United States India Female Heterosexual marriage United States India Female Heterosexual marriage United States Mexico Male Same-sex marriage England United States Table 1: Participant Demographics (N = 10) Gender Relationship Status Home Country Surrogacy Country Female Heterosexual marriage Germany Mexico Male Heterosexual marriage Australia Mexico Female Heterosexual marriage Australia Thailand Male Same-sex marriage United States India Female Heterosexual marriage Australia Thailand Male Same-sex marriage Israel United States Male Same-sex marriage United States India Female Heterosexual marriage United States India Female Heterosexual marriage United States Mexico Male Same-sex marriage England United States Gender Relationship Status Home Country Surrogacy Country Female Heterosexual marriage Germany Mexico Male Heterosexual marriage Australia Mexico Female Heterosexual marriage Australia Thailand Male Same-sex marriage United States India Female Heterosexual marriage Australia Thailand Male Same-sex marriage Israel United States Male Same-sex marriage United States India Female Heterosexual marriage United States India Female Heterosexual marriage United States Mexico Male Same-sex marriage England United States Data Collection In-depth interviews were conducted by the first two authors of this article, using a semistructured interview guide. Interview guide questions were open-ended and encouraged participants to convey their surrogacy stories. Participants were permitted to guide the conversation, covering topics of most importance to them. Examples of interview guide items include (a) “Tell me about your journey to have your child”; (b) “Talk to me about how prepared you were”; (c) “What do you wish you would have known prior to traveling for surrogacy?”; and (d) “What are your recommendations for others planning to travel abroad for surrogacy services?” Interviews were conducted on Skype and lasted approximately 109 minutes on average. A consent form was e-mailed to participants prior to the interview for review, and each participant provided verbal informed consent prior to the start of the Skype interview. Following the interview, each participant was e-mailed a $10 Amazon gift card; however, one participant declined the incentive. There were no pre-existing relationships between the interviewers and participants. This research study was approved by the institutional review board at the University of Utah and the Ohio State University. Data Analysis Data analysis focused on discovering common themes in participants’ experiences and the conditions of those experiences (Padgett, 2008). To accomplish this goal, we followed the Stevick–Colaizzi–Keen method of phenomenological analysis (as cited in Moustakas, 1994). First, verbatim transcripts were read line-by-line several times with the goal of understanding CPs’ experiences with international surrogacy. Next, all germane statements were coded and recorded. All nonrepetitive statements were listed. Then, the statements were clustered into categories that were grouped into themes with similar meanings or descriptions of the experience. Finally, themes were synthesized into a description ofinternational surrogacy, and verbatim excerpts were used to highlight each theme. The first two authors performed the analysis separately and then verified the descriptions for accuracy as a team. RESULTS International surrogacy was a long and arduous journey for CPs. This often included many years of failed in vitro fertilization (IVF) procedures followed by an investigation of options and surrogacy attempts in multiple destination countries. Common elements of the surrogacy process included meeting the medical staff, undergoing medical tests and procedures, choosing a surrogate and possibly also egg donor, meeting the surrogate, communicating with and receiving updates from the surrogacy clinic or agent, and navigating laws to bring the newborn (or newborns) home. Social and emotional factors frequently affected the surrogacy process, as the CPs were heavily influenced by levels of social support (or lack thereof) provided by family, friends, and community members. Even after the process was complete, CPs continued to confront residual issues, such as whether to disclose surrogacy to the child. Through data analysis, it was evident that participants’ narratives were divided by time frames and stages of the process. Therefore, we present our results in three sections that consider CPs’ experiences prior to, during, and following their participation in international surrogacy. Prior to the Journey Motivations Prior to traveling abroad for surrogacy, CPs participated in a process of trade-off decision making, weighing their reproductive assistance options. Two primary drivers that encouraged CPs to seek surrogacy abroad were (1) health complications that made it difficult or impossible for “natural” conception and (2) legal restrictions imposed in their home country. The most frequently cited motivation for engaging in international surrogacy was related to difficulty becoming pregnant, particularly among heterosexual CPs. All heterosexually partnered participants reported that it was impossible to have biological children on their own, and health complications included failed IVF attempts, miscarriages, and infertility. One Australian participant stated, I had six attempts here in Australia with IVF, and . . . I had two miscarriages and an ectopic pregnancy by this stage. . . . [The physician] said that my adenomyosis was so severe . . . my uterus was never going to stretch beyond nine weeks. Participants were also motivated by legal restrictions around adoption and surrogacy in their home countries. Participants considered all options, including adoption, before deciding to engage in international surrogacy. Both heterosexual and same-sex coupled participants expressed frustration with the adoption system for multiple reasons including the high cost, lengthy process, and loss of privacy. In addition to these barriers to adoption, same-sex coupled participants perceived discrimination based on their sexual orientation. An American participant stated, “I think [the adoption agency was] just giving me the run-around because I was a gay male. . . . So it was kind of very disheartening. . . . For about a year, I was really upset.” This is not surprising as many countries do not allow gay couples to adopt (Zanghellini, 2011). The discrimination experienced during the adoption process is a unique challenge for same-sex couples. Sources of Information and Support All participants described a variety of sources they used to research surrogacy, including the Internet, Facebook, other CPs, books, surrogacy agencies and clinics, online forums, health care providers, and surrogacy conferences. These sources of information were instrumental in allowing CPs to make an informed choice about their participation in international surrogacy, including the destination country and selected clinic. Participants reported extensively investigating international surrogacy for many years prior to engaging in the process. Participants found some social support through the surrogacy community, Facebook groups, online forums, and nonprofit organizations, such as Families Through Surrogacy and Surrogacy Australia. However, most participants reported that they received relatively little support from their friends, family, and community members. Many participants stated that negative publicity and societal disapproval of surrogacy affected the opinions of their loved ones. Participants discussed the importance of education at all levels, including the education of loved ones. Family, friends, and community members were often unaware of surrogacy as a reproductive option. A participant stated, “My husband’s father had a little bit of hesitation at first. . . . He didn’t even know that these medical things could be done. . . . But that only took him a couple of days to be educated, and then he came around.” One participant refrained from talking to his parents about his desire to participate in surrogacy, because he had not yet come out as gay. Another participant refrained from telling friends and family until later in the process, having experienced a history of failed IVF attempts and not wanting to be forced to “share bad news.” Embarking on the Journey Medical Process Following failed IVF, adoption attempts, and participating in a careful examination of all options available, CPs decided to embark on their international surrogacy journey. A gay Israeli man who traveled to the United States with his husband to complete surrogacy described his process: “We went to the States, we had our embryos, and then we transferred two embryos, one made of my sperm and one from my partner’s sperm. And then two weeks later we found out we were pregnant.” The desire of both partners to contribute genetic material and have an equal probability of being the biological father affected their surrogacy process. In a different scenario, a heterosexual Australian woman traveled to Thailand with her husband to complete surrogacy and used her own eggs. She said, We saw [the surrogate] every second day ’cause she was coming in to have bloods to make sure that her uterus lining was going up while my eggs were developing as well and then if it looked like hers was going to go too quickly and my eggs weren’t developing, they could slow it down slightly so that we were right on time with each other. Medical Staff in the Destination Country Participants described important interactions with medical staff and the surrogate during the surrogacy process. CPs indicated relatively positive experiences with medical staff and reported medical staff to be informative regarding the process, adequately answering all CP questions. For example, an Australian participant stated, “I did not come away feeling that this was a third-rate country at all. On the contrary . . . they’re quite advanced.” Difficulties tended to emerge in relationship to agents who acted as middlemen between the fertility clinic and the CPs. One American participant indicated that an embryo was lost in transit, which was trau-matic because she was unable to produce any more embryos. This resulted in the participant depending on an egg donor agency, which “went on to embezzle ten and a half thousand dollars.” Relationship with Surrogate The relationship with the surrogate differed based on the destination country and agency regulations; however, there was typically minimal contact with the surrogate. A participant who engaged in surrogacy in Thailand stated, I really wanted to have a much closer relationship with my surrogate, and it just makes me sad that she will never know that . . . we made sure that we spent a lot of time with her, let her spend time with the baby and communicated to her. . . . That was the most amazing thing that anyone could have done, and it was quite an emotional farewell for that reason. All CPs engaged in surrogacy in low-income countries, except for two participants who chose to complete the process in the United States. These two CPs described being closer to the surrogate than those who engaged in the process in low-income countries. For example, one Israeli participant stated, “We were in touch with the surrogate throughout the process. . . . We bought a ticket for her and her husband to come over to Israel, and they spent a week with us here.” The other participant who engaged in international surrogacy in the United States indicated that he and his husband purposely chose the United States for an open process and to maintain a relationship with the surrogate. This UK resident stated, We wanted one [surrogate mother] who was very open . . . we headed out there this summer and spent one week with them in California. And the kids Skype with her frequently. And we send messages to each other. And they call her tummy mummy. Social Support Some participants had a limited amount of social support during the actual surrogacy process. Often, participants only confided in a select few family members or friends about their plans because of fear of a negative response. One participant from Germany did not intend to tell her family at all and instead planned on claiming that the child was adopted. In some cases, when participants eventually did disclose that they were using surrogacy, they received a positive and supportive response, as was the case for the following participant who noted that her friends and family have been supportive: I was very nervous . . . it wasn’t until . . . 26 weeks that I actually told anyone apart from my closest friends that we were doing surrogacy, and I was really nervous about how people were going to respond. . . . I’ve been very surprised by how [positive] everyone’s been. Coming Home Citizenship The citizenship process represented another difficulty for many CPs, which varied based on the CPs’ home country, presumably stemming from embassies’ fears that newborns were being trafficked. A participant from the United States stated, “She [the vice consulate] made her final decision and escalated it to Hague as an illegal adoption, so . . . the last year has been fighting and proving that we didn’t steal them [the twins].” One German CP described her international surrogacy process as chaotic with failed attempts in Ukraine and Thailand before the birth of a child in Mexico. This CP had also chosen not to mention the word “surrogate” for fear that the German government would not grant citizenship to the child. She stated, “We didn’t mention the word ‘surrogate mother,’ just someone is pregnant with my husband’s baby. Yeah, legally that’s fine, because she’s the mother so we are talking about the mother of the child.” This participant indicated that surrogacy is equated with sex work in Germany and similarly stigmatized. For this reason, some CPs are likely to maintain anonymity regarding their participation in international surrogacy, which can be isolating especially as it pertains to social support. Social Support Several participants feared negative reactions and felt that their communities were unsupportive of surrogacy. This was attributed to negative media attention, a lack of understanding of the experience of infertility, and a lack of knowledge about surrogacy in general. One participant noted that the media’s portrayal of surrogates as living in dormitories and engaging in multiple, consecutive surrogate pregnancies contributed to her community’s negative perception of surrogacy. She indicated that this portrayal did not accurately reflect her surrogate’s experience. This was most apparent in Germany, where all forms of surrogacy are prohibited. The community reaction was less negative in countries where surrogacy is partially legal (for example, where altruistic surrogacy is legal). Only two participants reported receiving overwhelmingly positive reactions from their communities. One participant attributed these reactions to her enthusiastic attitude toward surrogacy: “Whenever I talk about surrogacy it’s the most amazing positive experience of my life and it’s, you know, our dreams of having a baby here so all we’ve ever heard is ‘Congratulations,’ ‘That’s fantastic,’ ‘That’s amazing.’” Another participant stated, “We sort of took the approach [of disclosure to family] that it takes a village and the more extended family members, the more family members they [children] have to love them, the better.” Issues of Disclosure to Child Even after CPs return home, they must make decisions regarding disclosure to the child. Several participants indicated that they were open, or intended to be open, with their children about how they were born. For example, one participant stated, “I think we want to tell our child later on, because we think that everybody has a right to know about his own identity.” However, CPs questioned the right time to be transparent with children about their birth story. Participants also reported a desire for children to have the opportunity to meet their surrogate mother and have an ongoing relationship with her: We chose our surrogate because we wanted one who was very open, who would want to know the kids, who would want to see the kids over the summer when we came back. . . . We know some couples who want to have their kids and never let their kids know who it was and this and that. That wasn’t us. That wasn’t what we wanted. Several participants reported that they have an ongoing relationship with their surrogate. Others reported a desire for the opportunity to maintain a relationship with their surrogate; however, this choice is not entirely in their control. For example, a participant stated, If we want to have some contact with her [the surrogate] in the future, which I would like, the kids to meet her in the future, they have to go through the agency. . . . It’s not that easy for us to reach out to her. We have to go through the agency, and they can accommodate that if the babies in the future want to see the surrogate mom. However, agencies typically limited the CPs’ relationship with the surrogate. This was attributed to the importance of maintaining the surrogate’s privacy, but also, according to the surrogacy agency, to limit potential financial exploitation of CPs. For example, CPs reported that agencies warned them about surrogates’ requests for increased compensation. DISCUSSION It is curious as to why individuals prize genetic kinship, crossing borders to achieve it, over kinship through adoption. Scholars have theorized that genetic kinship is valorized as it is viewed as “natural” (Riggs & Due, 2010). For example, women unable to reproduce may be stigmatized for not fulfilling cultural norms and expectations around gender and pregnancy (Whiteford & Gonzalez, 1995). Others have theorized that gay and lesbian couples may idealize genetic kinship in response to societal heteronormativity, attempting to become the “idealised homonormative couple” (Hosking & Ripper, 2012). The participants in this study, though, emphasized that adoption is a lengthy process that involves high costs, both direct financial costs and indirect personal costs related to lengthy time commitments and invasions of privacy. Although this conversation is beyond the scope of our article, it is important to understand the privileging of certain types ofkinship, as well as racial and national privilege in contextualizing international surrogacy transactions. Our findings are consistent with previous research on motivations to participate and on issues related to the surrogacy process. These results highlight the medical and social complexities involved in the surrogacy process. Specifically, many CPs faced medical and social challenges, leading them to seek out international surrogacy. In the surrogacy process, additional medical and social complications arose that were not addressed by medical staff in the destination country. Relationships between CPs and surrogates were heavily mediated by clinic staff, and most CPs reported that this can be distressing. Consistent with previous studies, motivations for pursuing international surrogacy were related to health complications. For example, heterosexual couples have cited medical problems as their primary motivation for surrogacy (Hammarberg et al., 2015). Dar et al. (2015) found that medical conditions that prohibit “natural” conception or pregnancy, such as Asherman’s syndrome, lead to women seeking out surrogacy. Several women in our sample sought out surrogacy after failed attempts to conceive “naturally.” Our study was the first to establish that restrictions around adoption (for example, ban on same-sex couple adoptions) and surrogacy largely influenced many of the participants. The international surrogacy process has not been heavily documented in the academic literature, and knowledge regarding the process primarily comes from news outlets and anecdotal accounts. Rodino et al. (2014) found that most individuals who had completed cross-border reproductive care reported that while their medical needs had been met by international fertility clinics, their emotional and mental health needs were largely neglected. Our study participants generally expressed positive experiences with fertility clinics, but physical needs were emphasized over emotional and mental health ones. In addition, difficulties did arise with the middlemen between the clinic and CPs, which can result in exploitation. CPs expressed availability of minimal social support, as surrogacy was typically disclosed to only a few friends or family members. Most participants in this study reported minimal contact with their surrogate. Many participants wished they had more contact with the surrogate and reported feelings of disappointment or worry. Fathers in the Ziv and Freund-Eschar (2014) study expressed similar sentiments of concern and worriedness about their surrogate’s health. Whereas most participants in the Ziv and Freund-Eschar (2014) study expressed feelings of disconnect from the fetus, participants in this study did not express those same emotions. A 10-year follow-up study in the United Kingdom found positive results when CPs and offspring maintained a relationship with the surrogate (Jadva, Blake, Casey, & Golombok, 2012). However, both CPs and surrogates in that study resided in the United Kingdom, presumably making it easier to maintain contact. Limitations This study’s analysis provides insight into the motivations and process of international surrogacy arrangements from the CPs’ perspectives. Despite the strength and thoroughness of these results, no study is without limitations. First, the sample size of this study was relatively small. However, small sample sizes are consistent with typical phenomenological studies (Creswell, 2009; Padgett, 2008). Our participants’ experiences are not meant to represent all CPs who seek surrogacy abroad. Although this study captured the experiences of both heterosexual and same-sex male couples, a more detailed look into the experiences of single and lesbian-coupled CPs may be appropriate. With regard to theoretical saturation, all participants in this study fit the established criteria, participants were sought out who would provide atypical data, and the possibility of generating different data in the process of data analysis was exhausted (Creswell, 2009). Future research should explore the experiences of other atypical CPs to find deviations in the aforementioned surrogacy motivations and processes. Second, this study limited participation to only those living in high-income countries. This was intentional to understand the experiences of CPs who cross borders for assisted reproduction services. Whereas it may be less common for individuals in low-income countries to seek out international surrogacy services, our knowledge would be enhanced from understanding motivations and experiences of CPs in this context. Finally, this study only focused on CPs who had completed the surrogacy process. Future research would benefit from a longitudinal investigation into experiences throughout the process, instead of relying on retrospective data. Direct ethnographic observation of CPs at fertility clinics may also be beneficial for future research. Implications This study found that CPs seek international surrogacy services for two primary reasons: medical issues, such as the inability to conceive “naturally” or through IVF; and legal restrictions around surrogacy or adoption in their home countries. CPs, coping with their own inability to conceive and navigating international surrogacy options, would benefit from support prior to the start and routinely throughout the process of surrogacy. Social workers are poised to provide this support. CPs are not guaranteed to have a child at the end of the surrogate pregnancy. For example, medical complications with the surrogate, conception, and pregnancy can leave CPs without a biological child. These realities can be difficult for some to handle. Sanabria (2013) and Dar et al. (2015) recommend professional mental health services for any person seeking surrogacy services. Social workers can provide guidance to individuals and couples, ensuring that they are fully informed about the various decisions to be made in the surrogacy process. Social workers can also connect CPs with various coping resources (for example, support groups) and legal counsel and assist them in the emotional processes associated with surrogacy (Sanabria, 2013). Social workers from host countries are uniquely adept at establishing rapport with CPs, connecting them to the proper legal services, and ensuring the safe return of CPs and children. With regard to legal barriers that prevent surrogacy or adoption in CPs’ home countries, progressive social policies can curb the rate of individuals from high-income countries seeking out international surrogates. Specifically, host countries need to recognize that individuals and couples deserve equal access to adoption regardless of sexual orientation. Thus, social workers can advocate for equitable adoption and surrogacy policies. If a strong connection to the surrogate is desired, CPs should have the ability to make this lasting bond if surrogates agree. Although this can be quite difficult to achieve in present international surrogacy arrangements (because of vast social, class, and cultural disparities between CPs and surrogates), this is much more easily achieved when surrogacy is available in CPs’ home countries. Advocating for ethical, transparent regulation of surrogacy should be a priority for both CPs and surrogates. Informed consent for all parties involved in the surrogacy process must be paramount. Social workers should mediate and establish the boundaries for relationships and ensure informed consent for all parties. REFERENCES Alleman , B. ( 2011 ). Medical tourism services available to residents of the United States . Journal of General Internal Medicine , 26 , 492 – 497 . Google Scholar CrossRef Search ADS PubMed Boivin , J. , Bunting , L. , Collins , J. A. , & Nygren , K. ( 2007 ). International estimates of infertility prevalence and treatment-seeking: Potential need and demand for infertility medical care . Human Reproduction , 22 , 1506 – 1512 . Google Scholar CrossRef Search ADS PubMed Creswell , J. W. ( 2009 ). Research design: Qualitative, quantitative, and mixed methods approaches ( 3rd ed. ). Thousand Oaks, CA : Sage Publications . Culley , L. , Hudson , N. , Rapport , F. , Blyth , E. , Norton , W. , & Pacey , A. A. ( 2011 ). Crossing borders for fertility treatment: Motivations, destinations and outcomes of UK fertility travelers . Human Reproduction , 26 , 2373 – 2381 . Google Scholar CrossRef Search ADS PubMed Dar , S. , Lazer , T. , Swanson , S. , Silverman , J. , Wasser , C. , Moskovtsev , S. I. , et al. . ( 2015 ). Assisted reproduction involving gestational surrogacy: An analysis of the medical, psychosocial and legal issues: Experience from a large surrogacy program . Human Reproduction , 30 , 345 – 352 . Google Scholar CrossRef Search ADS PubMed Deomampo , D. ( 2015 ). Defining parents, making citizens: Nationality and citizenship in transnational surrogacy . Medical Anthropology , 34 , 210 – 225 . Google Scholar CrossRef Search ADS PubMed Deonandan , R. , Loncar , M. , Rahman , P. , & Omar , S. ( 2012 ). Measuring reproductive tourism through an analysis of Indian ART clinic websites . International Journal of General Medicine , 2012 , 763 – 773 . Google Scholar CrossRef Search ADS Hammarberg , K. , Stafford-Bell , M. , & Everingham , S. ( 2015 ). Intended parents’ motivations and information and support needs when seeking extraterritorial compensated surrogacy . Reproductive BioMedicine Online , 31 , 689 – 696 . Google Scholar CrossRef Search ADS PubMed Hosking , G. , & Ripper , M. ( 2012 ). In the best interests of the (silenced) child: The mobilisation of children of lesbian and gay parents to reinforce heteronormativity . Australian Feminist Studies , 27 , 177 – 188 . Google Scholar CrossRef Search ADS Jadva , V. , Blake , L. , Casey , P. , & Golombok , S. ( 2012 ). Surrogacy families 10 years on: Relationship with the surrogate, decisions over disclosure and children’s understanding of their surrogacy origins . Human Reproduction , 27 , 3008 – 3014 . Google Scholar CrossRef Search ADS PubMed Kirby , J. ( 2014 ). Transnational gestational surrogacy: Does it have to be exploitative? American Journal of Bioethics , 14 ( 5 ), 24 – 32 . Google Scholar CrossRef Search ADS PubMed Mahajan , T. , & Marwah , V. ( 2012 ). Birthing a market: A study on commercial surrogacy . New Delhi : Sama—Resource Group for Women and Health . Moustakas , C. ( 1994 ). Phenomenological research methods . Thousand Oaks, CA : Sage Publications . Google Scholar CrossRef Search ADS Padgett , D. K. ( 2008 ). Qualitative methods in social work research ( 2nd ed. ). Thousand Oaks, CA : Sage Publications . Pande , A. ( 2010 ). Commercial surrogacy in India: Manufacturing a perfect mother worker . Journal of Women in Culture and Society , 35 , 969 – 992 . Google Scholar CrossRef Search ADS Pennings , G. , de Wert , G. , Shenfield , F. , Cohen , J. , Tarlatzis , B. , & Devroey , P. ( 2008 ). ESHRE task force on ethics and law 15: Cross-border reproductive care . Human Reproduction , 23 , 2182 – 2184 . Google Scholar CrossRef Search ADS PubMed Riggs , D. W. , & Due , C. ( 2010 ). Gay men, race privilege and surrogacy in India. Outskirts Online Journal, 22. Retrieved from http://www.outskirts.arts.uwa.edu.au/volumes/volume-22/riggs Rodino , I. S. , Goedeke , S. , & Nowoweiski , S. ( 2014 ). Motivations and experiences of patients seeking cross-border reproductive care: The Australian and New Zealand context . Fertility and Sterility , 102 , 1422 – 1431 . Google Scholar CrossRef Search ADS PubMed Sanabria , S. ( 2013 ). When adoption is not an option: Counseling implications related to surrogacy . Journal of Gay & Lesbian Social Services , 25 , 269 – 286 . Google Scholar CrossRef Search ADS Vora , K. ( 2009 ). Indian transnational surrogacy and the commodification of vital energy . Subjectivity: International Journal of Critical Psychology , 28 ( 1 ), 266 – 278 . Whiteford , L. M. , & Gonzalez , L. ( 1995 ). Stigma: The hidden burden of infertility . Social Science & Medicine , 40 ( 1 ), 27 – 36 . Google Scholar CrossRef Search ADS Zanghellini , A. ( 2011 ). Gay surrogacy, intentionality and Tahitian parenting . Griffith Law Review , 20 , 1 – 30 . Google Scholar CrossRef Search ADS Ziv , I. , & Freund-Eschar , Y. ( 2014 ). The pregnancy experience of gay couples expecting a child through overseas surrogacy . Family Journal , 23 , 158 – 166 . Google Scholar CrossRef Search ADS © 2018 National Association of Social Workers This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Health & Social WorkOxford University Press

Published: Jun 12, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off