Surrogacy families

In 1986, the case of "Baby M" in the USA caught the world's attention when her surrogate mother, Mary Beth Whitehead, refused to give up the baby to William and Elizabeth Stern, a couple who had paid her $10,000 to carry their child. Although Mary Beth Whitehead had signed a legal contract stating that she would relinquish the baby, she felt unable to let her go, which resulted in a high-profile legal battle between the surrogate mother and the intended parents that has influenced the practice of surrogacy to this day. This was the first surrogacy dispute in the USA and it centered on who should have custody of the child. Mary Beth Whitehead had conceived Baby M using her own egg and the intended father's sperm, a practice known as traditional or genetic surrogacy, and a key argument of her legal team was that it was not in the child's best interest to be separated from her biological mother. On the side of the intended parents, the argument focused on whether or not a surrogacy contract was enforceable by law. Custody was awarded initially to the intended parents in a New Jersey court. On appeal, however, the New Jersey Supreme Court ruled that the surrogacy contract was invalid on the grounds that payment to a surrogate mother was "Illegal, perhaps criminal, and potentially degrading to women," and that the surrogate mother and the intended father were the legal parents of the child. Although custody was awarded to the Sterns – as this was considered to be in the best interest of Baby M – Mary Beth Whitehead was given visitation rights. As a result of this case, many American states and countries around the world banned commercial surrogacy.

Another notable case took place in the UK in 1985. Britain's first commercial surrogate mother, Kim Cotton, gave birth to a baby girl for a childless couple. As with Baby M, the surrogate mother had been inseminated with the sperm of the intended father. When it was reported that the surrogacy arrangement had involved a payment to Kim Cotton of £6,500, the authorities intervened, taking the baby into the care of the state. When the surrogate then sold her story to the press for more than double the amount she had received for having the baby, a media frenzy ensued, focusing on the apparent callousness of the surrogate mother. As the Guardian newspaper on July 1, 1985, put it, "How will baby Cotton feel when she learns that her unknown mother did not give her up sadly, out of necessity, but gladly, for money?" In the court case that followed, the judge awarded custody of the baby, known as "Baby Cotton," to the intended parents. As a result of this case, legislation was rushed through the British Parliament to outlaw commercial surrogacy. In the UK, surrogate mothers are entitled to obtain only genuine expenses associated with the pregnancy. In practice, though, the definition of what counts as a genuine expense remains unclear in law, and it is not unusual for payments of up to £15,000 to be made to surrogate mothers by intending parents. Such a sum is not very far removed from that which is paid to surrogates in the USA in commercial surrogacy arrangements. However, unlike the USA, the UK maintains unenforceable surrogacy contracts; the surrogate mother and her husband (if she is married) are always the legal parents of the child – even in cases of gestational surrogacy (see below) – until legal parenthood is transferred by court to the intended parents.

The introduction of egg donation in 1983 paved the way for another form of surrogacy, gestational surrogacy, whereby the child is conceived using the egg of the intended mother (or an egg donor) and the sperm of the intended father (or sperm donor) and the resulting embryo is implanted in the surrogate mother. Thus, the surrogate hosts the pregnancy but does not have a genetic connection to the child. In a Californian legal case in 1990, a gestational surrogate was refused custody of a child to whom she had given birth on the grounds that she had simply hosted the pregnancy. This set the scene for the upsurge in gestational surrogacy in the USA that we see today. No one knows exactly how many babies have been born through gestational surrogacy worldwide, but estimates point to more than 1,000 per year in the USA, alone (Armour, 2012). Although not every American state allows surrogacy, some do, and some allow surrogates to be paid, with surrogates commonly earning around $30,000 for their services.

In many other countries, any form of surrogacy remains illegal. However, in recent years, there has been a dramatic rise in the number of people traveling abroad for surrogacy. This is owing to the prohibitive cost of surrogacy, with agencies in the USA, for example, often charging more than $100,000, and also to the difficulties involved in finding surrogates in countries where payment is not permitted. Countries such as India, Russia, Mexico, Poland, Thailand and Ukraine are just some of the destinations that have become popular for surrogacy, with those who can afford it also traveling to the USA.

Although gestational surrogacy is a recent phenomenon, traditional surrogacy dates back to biblical times. As described in the Old Testament, Sarah, who was infertile, encouraged her husband Abraham to embark upon a sexual relationship with her maid Hagar, with the intention of producing a child to be raised as Sarah's own. In due course, Hagar gave birth to a son. However, as highlighted by Haberman (2014), the difficulties that ensued between Hagar and Sarah paralleled those experienced more than 4,000 years later between Mary Beth Whitehead and the Sterns. Other problems may also arise today, especially when intended parents and surrogate mothers take matters into their own hands, as occurred in the case of Amy and Scott Kehoe, who found an egg donor, a sperm donor and a surrogate mother through the Internet who gave birth to twins in the USA in 2009. One month later, the twins were removed from them by court order after it transpired that Amy Kehoe had been diagnosed with a severe psychiatric disorder and had previous drug charges. The surrogate mother was so concerned about the welfare of the twins that she took legal steps to recover them (Ghevaert, 2010). There have also been instances of intended parents changing their mind. In 2011, a 20-year-old genetic surrogate mother, who already had two children of her own, was abandoned with twins after the intended parents split up (thestar.com; Vukets, 2011). And in Thailand in 2014, a scandal erupted when an intended couple returned home to Australia with a healthy twin, leaving the other twin, who had Down Syndrome, with the surrogate mother.

Although surrogacy has become more widespread – and attitudes toward it have become less negative – surrogacy remains the most controversial form of assisted reproduction, raising a number of ethical concerns. Those opposed to surrogacy have argued that surrogacy is unacceptable because the child is treated as a commodity to be bought and sold, with payment to a surrogate viewed by some as tantamount to baby selling. Another objection to surrogacy is the potential for exploitation inherent in a situation in which economically disadvantaged women have babies for women who are more affluent than themselves; this is particularly seen to be true in cases in which the decision to embark upon surrogacy is driven largely by payment. Surrogacy also raises questions relating to procreative liberty: should women who wish to host a pregnancy for another woman be allowed to do so? It is interesting to note that feminist thought on surrogacy is divided, with some viewing surrogacy as the ultimate exploitation of women and others insisting that women should have autonomy over their reproductive lives and thus be free to act as paid surrogates should they so wish. Cross-border surrogacy has raised additional ethical concerns regarding the potential exploitation of surrogate mothers living in poverty in developing countries. In India, for example, where commercial surrogacy was legalized in 2002, Western couples access surrogates from poor backgrounds, who enter into surrogacy arrangements because of the large financial incentives involved. For couples seeking surrogacy in India, the cost can be as little as one-quarter of the US rate (DasGupta and DasGupta, 2014). Although the surrogate is paid only a small proportion of the fee charged by the clinic, it is equivalent to 10 years' income for her (Pande, 2009), enough to educate her children or buy a house, which would not otherwise have been within the realms of possibility for her family (DasGupta and DasGupta, 2014). Indian surrogates often live in "surrogacy houses" away from their family during the pregnancy, and rarely meet the couple whose child they gestate.

An issue that has been of principal concern and is of particular relevance to this book is whether or not surrogacy has an adverse effect on the well-being of children born in this way (Brazier, Campbell, and Golombok, 1998). As discussed in Chapter 4, developments in assisted reproductive technologies have resulted in new family forms in which genetic parenthood is dissociated from social parenthood. Children conceived by egg donation lack a genetic relationship with their mother, children conceived by sperm donation lack a genetic relationship with their father and children conceived by embryo donation are genetically unrelated to both parents. However, these children are born to the parents who raise them. With surrogacy, the mother who gives birth to the child and the mother who parents the child are not the same. Furthermore, in the case of genetic surrogacy, in which the surrogate mother's egg is used, the surrogate mother is not only the gestational mother, but also the genetic mother of the child.

It may be expected from the findings of research on families created by egg, sperm or embryo donation that the outcomes for parents and children in surrogacy families are equally positive. However, surrogacy differs from other types of assisted reproduction in ways that could conceivably result in greater problems for surrogacy families than for families created by more traditional assisted reproduction procedures involving gamete or embryo donation. First of all, intended parents must live through the 9 months of pregnancy with the uncertainty of whether or not the surrogate mother will relinquish the child. Furthermore, as the intended mother is not, herself, pregnant, prenatal bonding with the child may be absent or diminished. Secondly, the intended parents must establish a mutually acceptable relationship with the surrogate mother during the pregnancy and ensure that this relationship does not break down. Not only is this situation likely to produce anxiety in the intended parents, but it may also put a strain on their relationship, especially if one partner is more in favor of the surrogacy arrangement than the other. From the perspective of the intended mother, who is unable herself to give birth, the relationship with the fertile and (often younger) surrogate mother, to whom she is indebted, may result in feelings of inadequacy, depression and low self-esteem. Thirdly, there is a great deal of prejudice against the practice of surrogacy, and intended parents may experience disapproval from family, friends and their wider social world. Unlike other forms of assisted reproduction, in which the mother experiences pregnancy and thus it is not essential for the parents to be open about the circumstances of their child's conception, couples who become parents through surrogacy have to explain the arrival of their newborn baby.

All these factors have the potential to impact negatively on not only the psychological well-being of the intended parents but also the way in which they parent their children. Moreover, the need to resort to surrogacy, in itself, may interfere with the intended parents' quality of parenting. Couples whose children are born through surrogacy may view the process as an inferior route to parenthood or may feel less confident as parents. Specific aspects of the surrogacy arrangement may also influence intended couples' psychological well-being and parenting quality. Greater difficulties may arise in situations in which the surrogate mother is the genetic mother of the baby, because intended mothers, who are neither the genetic nor the gestational mother of their children, may feel greater insecurity in their mothering role. This is sometimes the experience of adoptive mothers (Grotevant and Kohler, 1999). Whether the surrogate mother is known or unknown to the commissioning parents prior to embarking upon the surrogacy arrangement may also impact on parenting. Better outcomes may be expected when the surrogate mother is a relative or a friend, because of the longevity and closeness of the relationship. However, this may blur relationships within the family, such that a sister who becomes a surrogate mother may become unduly involved with the child and thus weaken the status of the intended mother. A further factor that may influence parenting is whether the surrogate mother remains in contact with the family as the child grows up. It has been suggested that contact with the surrogate mother may benefit the child by providing the child with a greater understanding of his or her origins. However, the ongoing involvement of the surrogate mother with the family may have an undermining effect on the parenting of the intended couple. The most crucial question of all is how the children will feel about having been relinquished by the surrogate mother, especially in cases in which she is their genetic mother, and in cases in which she has received a large sum of money in return.

In the studies described below, the term "surrogacy family" refers to the family in which a child born through surrogacy grows up, and "surrogacy parents" and "parents" are used interchangeably to describe the parents who raise a child born through surrogacy, irrespective of whether or not they are the genetic parents of that child. The term "gestational surrogate" is used when the surrogate mother hosts the pregnancy and has no genetic link to the child. The term "genetic surrogate" is used when the surrogate mother's egg is used in the child's conception and thus she has a genetic link to the child. The children born as a result of surrogacy are referred to as "surrogacy children," and the surrogate mothers' own children are referred to as "surrogates' children."

Studies of surrogacy families

In spite of the contentious nature of surrogacy and the adverse publicity it has attracted around the world, surprisingly little empirical research has been conducted to determine its impact on surrogate mothers, surrogacy parents and, most importantly, children. In a questionnaire-based study of the psychological adjustment of children in different types of assisted reproduction families, Shelton, Boivin, Hay, et al. (2009) compared a group of 21 5- to 9-year-old children born through gestational surrogacy with 378 children born through IVF, 182 through donor insemination, 153 through egg donation and 27 through embryo donation. The questionnaires completed by mothers and fathers ranged from those designed to assess conduct problems and attention deficit hyperactivity disorder to measures of anxiety, depression, peer problems and pro-social behavior. The children born through surrogacy did not differ from children in the other types of assisted reproduction families, for any of the measures. Neither did they show raised levels of conduct or peer problems when their scores were compared with general population norms.

In the only in-depth investigation, a group of 42 families created by surrogacy was included in the UK Longitudinal Study of Assisted Reproduction Families (see Chapter 4 for further discussion of this study). The families were recruited when the children were around 1 year of age through the General Register Office of the UK Office for National Statistics, which keeps a record of all families formed through surrogacy when legal parentage is granted to the intended parents. In order to reach families in which legal parentage had not yet been granted, those families with children of the same age who were members of the only UK surrogacy agency in existence at the time (known as Childlessness Overcome Through Surrogacy [COTS]) were also asked to take part. Although it was not possible to calculate an exact participation rate, it was estimated that more than 60 percent of the eligible surrogacy families with 1-year-old children throughout the UK were recruited to take part in the research. Approximately two-thirds of the families had used a genetic surrogate, with the remaining third having used a gestational surrogate. Around 70 percent of the surrogates had been unknown to the intended parents prior to the surrogacy arrangement, whereas the other surrogates had been relatives or friends. The surrogacy families were compared with a matched group of 51 egg donation families (who had been recruited through fertility clinics) and a matched group of 80 natural conception families (who had been recruited through maternity wards), all of whom had had planned pregnancies. For both of these family types, all eligible families were asked to take part and more than 70 percent agreed. The egg donation families were included as a comparison group (in addition to the natural conception families), in order to control for the experience of female infertility and the involvement of a third party in the birth of the child.

The first assessment was carried out at around the time of the child's first birthday and focused on three aspects of family functioning using in-depth, standardized interviews and questionnaires: the parents' psychological well-being and marital satisfaction; the quality of their parenting; and the temperament of their children (Golombok, Murray, Jadva, et al., 2004). Both mothers and fathers took part in the research. Contrary to the concerns that have been expressed about the potentially negative consequences of surrogacy for family functioning, the differences identified between the surrogacy families and the other family types indicated greater psychological well-being and adaption to parenthood by the mothers and fathers of children born through surrogacy than by the comparison group of natural conception parents. Both mothers and fathers in surrogacy families reported lower levels of stress associated with parenting than did those with naturally conceived children, and mothers also showed lower levels of depression . With respect to parent–child relationships, the findings were again more positive for the surrogacy parents than for the natural conception parents. Mothers and fathers in surrogacy families showed greater warmth and attachment-related behavior toward their infants, and greater enjoyment of parenthood, than did natural conception parents. The surrogacy fathers were also more satisfied with the parental role. The only exception to this positive pattern of findings was that the surrogacy mothers and fathers showed higher levels of emotional over-involvement with their infants. However, this reflected only a slight degree of over-involvement, rather than a dysfunctional level. Interestingly, the egg donation parents were similar to the surrogacy parents in terms of the quality of their relationships with their children. However, the egg donation mothers, like the natural conception mothers, showed higher levels of depression than did the surrogacy mothers, possibly owing to physical consequences of the pregnancy. No differences in infant temperament were identified between the three family types.

Aspects of the surrogacy arrangement were also examined. An important question is whether it makes a difference if the surrogate mother is also the genetic mother of the child. It appears not, as no differences were found in the quality of the surrogacy parents' parenting according to whether or not the surrogate was the genetic mother of the child. However, the nature of the relationship between the surrogacy parents and the surrogate mother did seem to make a difference. When the surrogate mother was a relative or a friend, as opposed to someone who was unknown to the surrogacy parents prior to the surrogacy arrangement, the surrogacy mothers showed more positive parenting.

The families were revisited when the children were aged 2 years (Golombok, MacCallum, Murray, et al., 2006). Once again, the focus of the research was on the psychological well-being of the parents, the quality of the parent–child relationships and the psychological development of the children. At this phase of the study, the quality of parent–child relationships was examined using the Parent Development Interview (Slade, Belsky, Aber, et al., 1999), an interview technique designed to assess the nature of the emotional bond between a parent and the child. In line with the findings when the children were 1 year old, the surrogacy mothers appeared to have more positive thoughts and feelings about their toddlers than did the natural conception mothers. They showed higher levels of pleasure in their children and greater feelings of competence as parents, and lower levels of anger, guilt and disappointment with their children. No differences were found between the surrogacy and natural conception fathers in terms of their relationships with their children. However, the surrogacy fathers reported lower levels of parenting stress. The egg donation mothers and fathers were similar to the mothers and fathers in surrogacy families in terms of their thoughts and feelings about their children, although the surrogacy fathers again showed lower levels of parenting stress. The surrogacy children did not differ from either the natural conception children or the egg donation children with respect to their social, emotional or cognitive development.

The families were followed up for a third time when the children were 3 years old (Golombok, Murray, Jadva, et al., 2006). The findings were consistent with those of the earlier phases of the study. Where differences in parent–child relationships were identified, these showed more positive relationships in terms of both warmth and interaction among mothers in surrogacy families than among their counterparts in natural conception families. Once again, the egg donation mothers were similar to the surrogacy mothers with respect to the quality of their relationships with their children. The children showed positive psychological adjustment, with no differences between children born through surrogacy, egg donation or natural conception.

The next phase of the study took place when the children were aged 7 years (Golombok, Readings, Blake, et al., 2011), the age by which children develop a more sophisticated understanding of the absence of a genetic or gestational link to their parents (Gregg, Solomon, Johnson, et al., 1996 ; Williams and Smith, 2010; Richards, 2000). In the earlier phases of the study, the children were too young to be fully aware of the circumstances of their birth. In addition to an interview assessment of mother–child relationships, an observational assessment of mother–child interaction was carried out at this phase of the research to examine the quality of dynamic interactions between mothers and children that could not be captured by interview or self-report. No differences were found in the quality of mother–child relationships between the surrogacy families and either the natural conception or the egg donation families, as assessed by interview. However, the surrogacy mothers showed less positive interaction with their children in the observational assessment than did the natural conception mothers. Once again, the egg donation mothers were similar to the surrogacy mothers on this measure. Thus, the more positive parent–child relationships shown by the surrogacy, than by the natural conception, mothers when the children were in their preschool years was no longer apparent when the children were 7 years old. Nevertheless, the surrogacy families were not experiencing difficulties. They did not show more negative parent–child relationships than did the natural conception families. Instead, the differences identified reflected more subtle differences in patterns of mother–child interaction.

The psychological adjustment of the children was measured when the children were aged 7 years, and again at the age of 10, using the Strengths and Difficulties Questionnaire completed by mothers and the children's teachers (Goodman, 1994 , 1997 , 2001), and the surrogacy children's scores compared with those of children conceived by gamete donation (i.e. the scores of the egg donation children were combined with those of the donor insemination children described in Chapter 4 [Golombok, Blake, Casey, et al., 2013]). At 7 years of age, the surrogacy children showed higher levels of adjustment problems than did the children conceived by gamete donation as rated by mothers but not teachers. Interestingly, this finding parallels that of internationally adopted children at the age of 7 (Stams, Juffer, Rispens, et al., 2000), which Juffer and van IJzendoorn (2005) attributed to internationally adopted children's need to struggle with identity issues earlier than domestically adopted children, due to their difference in appearance from their parents. Surrogacy children may similarly face identity issues at an early age: not only are they born to a surrogate mother, which makes them different from other children, but they may also remain in contact with their surrogate mother as they grow up. It is important to emphasize, however, that the surrogacy children in this study were generally well-adjusted at the age of 7, with scores within the normal range. Also, the raised levels of psychological problems shown by the surrogacy children disappeared by the age of 10, which, again, was consistent with the decline in difficulties shown by internationally adopted children by adolescence.

The sample sizes in this study were relatively small and may have been biased toward the inclusion of well-functioning families. Furthermore, some families were lost over time. However, the study also had a number of advantages, including an in-depth, multi-method approach involving interview, observational and questionnaire measures, as well as data collection from mothers, fathers, children and teachers; thus, the potential for participants to present the family in an artificially positive light was reduced. Moreover, almost 80 percent of the surrogacy families who enrolled in the research were still taking part 10 years later. As the first study worldwide to investigate parenting and child development in surrogacy families, the results must be replicated – ideally in other countries and cultures – before general conclusions can be drawn. Nevertheless, the findings of this initial study are reassuring and indicate that some of the fears that have been expressed about the consequences of surrogacy for children are based on speculation, rather than fact.

A question that often crops up whenever surrogacy is discussed is how the parents and surrogate mother get on with each other during the pregnancy and after the child is born. The most commonly voiced concern is that the surrogate mother will refuse to hand over the baby. In fact, this rarely occurs. The cases that have hit the headlines have given a false impression of the frequency with which surrogate mothers change their minds. As part of the UK Longitudinal Study of Assisted Reproduction Families, intended parents were interviewed about the nature of their relationship with the surrogate mother at all five phases of the research; that is, when their children were aged 1 year (MacCallum, Lycett, Murray, et al., 2003) until their children were aged 10 (Jadva, Blake, Casey, et al., 2012). When the children were aged 1 year, the 42 sets of parents were asked to report on their relationship with the surrogate mother both during the pregnancy and after their children were born. During the pregnancy, the large majority of intended mothers saw the surrogate mother at least once per month – often accompanying her to medical appointments – with intended fathers having less contact. This is in line with the findings of Ragoné (1994), who found, in a study in the USA, that the role of the intended father during pregnancy was de-emphasized, whereas the intended mother formed a strong bond with the surrogate mother and was very involved in the pregnancy. For the most part, intended parents in the UK study reported a harmonious relationship with the surrogate mother. Where this was not the case, there was minor conflict or a lack of communication, rather than major conflict or hostility. Most of the intended mothers (but only one-third of the intended fathers) were present at the birth. In spite of concerns to the contrary, all of the surrogate mothers relinquished the baby to the intended parents without difficulty, with the exception of one woman who did so after some hesitation. Likewise, all of the intended mothers had no difficulty accepting the baby, although one woman reported minor problems initially.

In the year following the birth, almost all of the mothers and fathers met with the surrogate mother at least once, and most described their relationship with her in positive terms. However, the frequency of contact between the parents and the surrogate mothers decreased over time, particularly in cases in which they had not known each other prior to the surrogacy arrangement and the surrogate mother's egg had been used to conceive the child. By the time the children were 10 years old, 60 percent of the parents were still in contact with the surrogate mother and, for the large majority, this relationship remained positive. As one mother put it: "In my experience it's been extremely positive. I've got a lovely friend that you know … words can't express how I feel about [surrogate mother] because she's just been brilliant the whole way through." Thus, fears were allayed that difficulties would develop between the parents and the surrogate mother as the child grew up, or that the involvement of the surrogate mother would interfere with the mother's confidence as a parent. However, those who had lost contact may have done so intentionally as a result of difficulties between the surrogate mother and the family.

The nature of the relationship between surrogate mothers and their surrogacy children was of particular interest, especially in cases in which the surrogate mother had been the genetic mother or a friend or relative of the family. In the year following the birth, three-quarters of the surrogate mothers saw the baby. Although most of the parents were happy about this, a few had mixed feelings. Where there was no contact between the surrogate mother and the baby, this was usually by mutual agreement or because the surrogate mother did not want contact. There were no reported cases of contact being denied by the parents. Not surprisingly, the frequency of contact between the children and their surrogate mothers mirrored that of their parents and declined as they grew older, with 60 percent of children remaining in contact with their surrogate mothers by the age of 10. Interestingly, children who were genetically related to their surrogate mother were less likely to keep in touch with her than were those who lacked a genetic link. This may have been deliberate on the part of the parents, in order to distance the surrogate mother from the child.

Surrogacy parents are much more open with their children about the circumstances of their birth than are parents of children conceived by egg, sperm or embryo donation. All of the parents in the UK Longitudinal Study of Assisted Reproduction Families planned to tell their children about the surrogacy (MacCallum, Lycett, Murray, et al., 2003), and the large majority did so by the time their children reached 7 years of age (Jadva, Blake, Casey, et al., 2012). However, by the child's age of 7, the majority of parents whose children had been born through genetic surrogacy had told their children that they had been carried by another woman, but had not disclosed the use of the surrogate mother's egg (Readings, Blake, Casey, et al., 2011); almost half of these parents had still not disclosed this information by the time their children turned 10 (Jadva, Blake, Casey, et al., 2012). Thus, these children were unaware that their surrogate mother was also their genetic mother. As one mother put it, "We've made it like bread in the oven, 'she just kept you warm until you were ready to come out,' so no, it hasn't come up that biologically she's not mine."

Some mothers were worried about rejection by their children. As one mother said:

I think the one thing that is in the back of my mind and haunts me slightly is if ever one of my girls might turn around and say to me 'You're not my mum.' I think that would cut very, very deep. But that hasn't happened so far … and I don't believe that they would say that … because we have a very good relationship … a very close relationship so I don't think it would enter their mind but it's in my mind … rightly or wrongly.

When children were interviewed at the age of 7 years and at the age of 10, the majority showed some understanding of surrogacy, at least to the extent that they had been born to a woman who was not their mother. As one child put it, "Well my mum's womb, I think … well it was broken, so [surrogate mother] carried me instead of my mum." Most of the children who were in contact with their surrogate mother said that they liked her, describing her as "nice" or "kind." For example, one child said "She was really kind about … like carrying me in her tummy" and another said, "I think she is kind and she's lovely and funny." Two-thirds wished to see her more often and the remainder felt that the level of contact was just right, with the exception of only one child, who wished to see her less. Despite the widespread opinion that children would be distressed by the knowledge that they had been born through surrogacy, this did not appear to be a big issue for the children in the study, with the majority feeling neutral or indifferent about this. The view of this 10-year-old was typical of the other children in the study: "I feel fine. I don't feel bad or cross in any way. It's just pretty much nature so I can't do anything about it. I wouldn't like to do anything about it." Nevertheless, the oldest children in the study were only 10 years old. They may feel differently as they grow up.

Some of the children also understood their relationship to the surrogate mother's own children. One father described it as follows:

Since he was very young, he understood that the surrogate's children were his half siblings. He has known that. He has so absolutely known that. In fact, when he did a family tree at school, he put a little dog leg and [surrogate mother and children] as part of his family tree. And even more interestingly … the surrogate's child also put him as her half-brother.

As yet, no studies have been carried out of the views of older children born through surrogacy. It remains to be seen how children will feel as they enter adolescence, when issues relating to identity become more significant, and whether payment to the surrogate mother for her services will make a difference to the reactions of the child. The situation may become even more complex for children whose surrogate mother lives in a different country or speaks a different language, as is becoming increasingly common with the growing use of surrogate mothers in India and other countries.  

Studies of surrogate mothers and their families

Some of the most contested ethical questions regarding surrogacy relate to the surrogate mother. Is the surrogate mother in a position to give truly informed consent if she has never done this in the past and is therefore unaware of what it feels like to relinquish a baby she has carried for 9 months and who may also be her genetic child? Do surrogate mothers feel regret once they have handed over the baby? Do they experience psychological distress or long-term psychological problems? What is the impact of surrogacy on the surrogate mother's own family, including her partner and her children?

In order to examine the psychological consequences of surrogacy for surrogate mothers, 34 women who had given birth to a surrogacy child in the UK were administered a standardized interview one year after the birth of the child and completed a questionnaire assessment of post-natal depression (Jadva, Murray, Lycett, et al., 2003). More than 70 percent of those who were asked to participate agreed to do so. None of the women reported experiencing any doubts about handing over the baby to the intended parents. When asked to recollect their feelings and experiences, around one-third of the women reported feeling upset in the weeks following the hand-over, although only one woman described feeling severely depressed. One year later, only two women (6 percent) reported psychological difficulties arising from their experiences of surrogacy, and none obtained a score on the post-natal depression questionnaire that was indicative of clinical depression. Neither was there a difference in depression scores between the genetic and gestational surrogate mothers, which suggests that the surrogate mothers did not experience long-term psychological problems, even in cases in which they were genetically related to the surrogacy child. Thus, the psychological difficulties experienced by surrogate mothers were not severe and tended to dissipate with time; this lends little support to the expectation that surrogate mothers will experience psychological problems following the relinquishment of the child. The study found a great deal of variation in the frequency of contact between the surrogate mother and the baby following the hand-over. Whereas one-third of the surrogate mothers had seen the baby at least once a month, one-quarter had not had any contact. Not one of the surrogate mothers felt as if the surrogacy child was their own – a factor that might have helped them to relinquish the baby to the intended parents. For almost two-thirds of the surrogate mothers, information was also available from the parents, as they were participants in the UK Longitudinal Study of Assisted Reproduction Families. Interestingly, the accounts of the surrogate mothers were almost identical to those of the parents, thus validating the parents' reports of positive relationships with the surrogate mothers.

In the only investigation of the long-term outcomes of surrogacy for surrogate mothers and surrogate mothers' own children, 34 surrogate mothers (20 of whom had taken part in the previous study 1 year after the birth of the surrogacy child) and 36 of their children (aged 12 to 25 years) were interviewed between 5 and 15 years after the mother had given birth to a surrogacy child (Jadva and Imrie, 2014a, b; Jadva, Imrie and Golombok, 2014; Imrie and Jadva, 2014). The findings challenged the widespread expectation that difficulties would arise in the relationship between the surrogate mother and the intended parents as time went on, and instead painted a largely positive picture of the relationships formed between surrogate mothers and the families they helped to create. In three-quarters of surrogacy arrangements, the surrogate mothers had stayed in touch with the children they had carried for another couple, and generally saw them once or twice a year. In addition, almost half of the surrogate mothers' own children were in contact with the surrogacy child, whom many described as a sibling or half-sibling, irrespective of genetic relation. However, others did not appear to ascribe any significance to their genetic or gestational relatedness to the surrogacy child, and yet others created their own terminology to describe this new form of relationship, including "surrosister" and "tummy-sister" (Jadva and Imrie, 2014b).

Only half of the surrogate mothers' children were interviewed, and thus the views of the other half are not known. This is partly because the children were asked to participate by their mothers and some mothers felt disinclined to ask children who had left home. However, this is the first study to examine surrogacy from the perspective of surrogate mothers' own children, and it sheds light on their experiences and views. Despite fears to the contrary, it appears that these children were not adversely affected by their mothers' involvement in surrogacy. Indeed, the large majority were positive about this and felt proud of their mother for helping a woman who was unable to have children, herself. As a child of a genetic surrogate mother said: "I think it's amazing … It's quite, I dunno, it's like … it's difficult for a woman to like give away a child that she's given birth to and I just think it's … fantastic that my mum can, and make people so happy." Similarly, a child of a gestational surrogate mother stated: "I think it's a really nice thing to do for someone, obviously if they can't have children and they really want a child that's a bad thing, so if someone else is able to do that for you and help you through it then it's something that is compassionate really."  

Conclusions

Surrogacy is not without its difficulties. Although uncommon, the surrogate mother may change her mind and decide to keep the baby, as occurred in the case of Baby M. Intended parents may also change their mind and leave surrogates, literally, holding the baby. Nevertheless, the findings from the few studies of surrogacy that currently exist indicate that families formed in this way are generally functioning well, suggesting that the absence of a gestational link between the parents and the child does not jeopardize the development of positive family relationships or positive child adjustment. It is interesting to note that surrogacy and egg donation families appear to show similarly positive outcomes. As the key distinguishing factor between these two family types (especially in the case of genetic surrogacy) is whether or not there is a gestational relationship with the child, this provides further support for the conclusion that a gestational link is not essential for positive family functioning. Moreover, there is evidence that harmonious relationships can ensue between surrogate mothers' families and the families these surrogates help to create. What is not yet known is how these relationships will play out over time and, crucially, how children born through surrogacy will feel about their origins later in their lives. 

- © Susan Golombok, 2015, published by Cambridge University Press, reproduced with permission. 'Modern Families: Parents and Children in New Family Forms' is one of the winners of the British Psychological Society's Book Award.

Full reference list available in the book.