Mental health professionals are being confronted by the new forms of reproductive technology. Specifically, the surrogate mother, herself, challenges many of our assumptions about human behavior. In this new arena psychologists have had to question personal and theoretical beliefs regarding bonding, attachment, loss, pregnancy and family. We are being called upon to collect data, predict behavior, and counsel participants in the varying options available to creating families.In an attempt to understand behavior and the effects of surrogate parenting, two studies were conducted. They explored the perceptions of women volunteering to serve as both the gestational and biological mother to the purpose of relinquishing their parenting rights to an infertile couple.The first of the studies included 89 surrogates who were participating in a surrogate mother program in the Los Angeles area. The program's staff psychologist collected demographic information and statements regarding their motivations to be a surrogate during an interview. The MMPI was also collected and 376 items were used. The second of these studies included follow-up surveys which were mailed to surrogate mothers who had relinquished a child and to adoptive couples who had received a child through the surrogate process. The survey consisted of 25 questions, both short answer and likert scale, that addressed their reactions to and thoughts about their surrogacy experience. Surrogate Mother ProfileThe demographics of the 89 surrogate mothers can be summarized as follows. The women had a mean age of 28 years and a mean of 2.0 children. The mean number of years of formal education was 13. A ratio of five to one of the women were anglo. Of the sample, four to one were currently married and three to one had full-time employment. The vast majority of the sample had been raised in a Christian faith, with 25% being Catholic. The Black and Asian population and the Jewish heritage were nearly absent from this sample.Abortion and adoption occurred in the histories of the sample. Only three participants had adoption as part of their history. Of these, one was adopted, one had placed a child for adoption, and one had siblings who were adopted. Of the surrogate mother sample, 37% had abortion in their history. Thirteen percent of the women had had more than one abortion. For some, unresolved feelings regarding these terminations were a factor in their desire to be a surrogate.The motivations to become a surrogate mother are summarized in table one. Enjoyment of the pregnant state and the desire to be pregnant again were cited by the vast majority of surrogate mothers. These women uniformly described their previous pregnancies as relatively easy. Being pregnant seemed to provide an opportunity to feel special and to feel a sense of wholeness. They also felt empathy for childless couples, an empathy increased by prior contact with an infertile couple's pain and by the importance of children in their own lives. A third motivation was the desire to do something remarkable with their lives and make a unique contribution. Many perceived being a surrogate as providing a sense of accomplishment. Financial gain was also cited but consistently was not the primary motivating factor. The surrogates described the fee as becoming less important as their relationship with the adoptive couple increased. Of the participants, 12% indicated that being a surrogate mother was an attempt to compensate for a prior loss in their history. The most obvious examples were the surrogates who earlier had voluntarily terminated a pregnancy and believed that creating a child for someone else may help them resolve feelings regarding the termination. The mean scores and ranges of the MMPI are presented in figure 1. The profiles were typically unremarkable with most scores falling within one standard deviation of the midline. Only 7.9% of the surrogate mothers had a clinical score above the 70th percentile. Overall, 2.3% had two clinical scores elevated above the 70th percentile. Of the clinical scores, scale 1 had the lowest mean. Scale 0 had the widest range of the clinical scores, from the 30th percentile to the 78th percentile. The correction scale was especially notable and overall was the most elevated scale. Furthermore, 73.9% of the profiles had a F-K score of -11 or less. Because the MMPI was taken during the women's screening process for acceptance into the program the K score and the F-K score might be interpreted as the surrogate mothers' tendency to be guarded and/or deny emotions in the hopes of making a good impression.The individual MMPI profiles revealed no critical pattern typical for this sample. Elevations of scales 1, 2, 8, 7 were notably absent from the profiles. Scales 0, 6, 9, 4 and 5 were more present but were not significantly elevated. In summary, it can be stated that surrogate mothers of this sample do not exhibit pathology according to the MMPI. However, given the limitations of this measure, we must use other instruments and techniques to understand the dynamics of the women who choose to be surrogate mothers. Extensive clinical interviews and participation in support group meetings, and additional tests are valuable tools in assessing surrogates. It is important to explore both conscious and unconscious motivations so to assess whether being a surrogate serves as a functional or dysfunctional purpose for the participant and her family. Thorough assessment will prevent collusion with pathology, exploitation, or unhealthy degrees of denial.Follow-up Study Of the participants in the study described above, 37 have relinquished the child to the adoptive parents and are at least 10 months post-partum. Follow-up questionnaires were mailed to 37 surrogates, 20 of whom responded. A similar follow-up questionnaire was mailed to the 37 sets of adoptive parents who had received children from these surrogate mothers. Of the adoptive couples, 16 responded. The responses are summarized in table two.The 20 surrogates who responded to the questionnaire ranged from 10 months to 3 years post-partum. Their emotional adjustment since the relinquishment of the child demonstrates two components. The first component being feelings reported for approximately two weeks after birth. Four of the surrogate mothers reported post-partum blues. Two of them mentioned longer term concerns. One expressed concern about her daughter's adjustment to the relinquishment of the child and the other expressed a concern about what the child might feel toward the surrogate in the future. Secondly, surrogates reported missing the contact with the adoptive parents and their special role as a surrogate mother. some surrogates grieved the loss of pregnancy itself because it was expected to be their last pregnancy. Additionally, several surrogates reported that convincing others that she felt at peace with the relinquishment caused periodic frustration. The questioning ad doubts expressed by some friends, family, and acquaintances as to why she was not noticeably grieving were bothersome.Grieving over the separation from the child was notably absent. The attachment was most often greater to the couple than to the child. The surrogates' perception that it was always "their child" is often based on the fact that the child would not have come into being if it were not for the particular couple's desire. the belief that the baby; was always the couple's child minimized feelings of loss. Surrogates consistently described their feelings of attachment for this child as different than their feelings for their other children. Affection and care was expressed, but the bonding was described as similar to attachment for a friend's or relative's child. All of the surrogates reported positive feelings since the birth of the child. These included feeling satisfied, fulfilled, resolved, and better about themselves. All felt surrogacy was beneficial for themselves. Five reported an increase in confidence and an enrichment of their lives. Another nine reported a stronger marriage and greater appreciation of family and children. Five to two of the respondents were able to articulate a clear positive influence on their lives by being a surrogate mother -- for example, increased marital communication, being inspired to pursue further education and increased individuation from extended family. They also reported that their immediate family had adjusted better than their extended family.When the surrogates thought of the child they reported thinking mostly of the adoptive couple's happiness. They also expressed curiosity at how the child looks and how he or she has developed. Of the 20 surrogates who responded, six to one perceived the child clearly as the couple's child. Only 3 of the surrogates perceived the child as still shared by the couple and by themselves. Overall, of the 20 who responded, there was a minimal amount of emotional discomfort reported by the surrogate mothers in relation to themselves and their children.The adoptive couples similarly reported very little emotional discomfort due to their having worked with a surrogate mother. Of the 16 couples, three reported stress and discomfort concerning the artificial insemination process and anxiety regarding achieving a conception and three others reported that they had wished they had been more involved in the pregnancy. The adoptive couple consistently reported that the child's genetic connection to only one parent had very little influence on how they related to the child in general. Of the fathers, three reported feeling a greater sense of closeness and understanding because of their genetic relation to the child. All of the couples reported that they perceived the child as their child, not as the surrogate's child or as a child they feel is shared with the surrogate. It could be hypothesized that the surrogates' and couples' shared perception that the child is the couple's child demonstrates denial which helps to minimize discomfort. Both surrogates and couples reported that they felt they had sufficient contact with the other party. The twenty surrogates who responded all had post-partum contact through the child's first birthday. Of the nine surrogates for whom over two years or more had passed, all but one had contact through the second year. Typically, the adoptive parents sent cards and photos at Christmas and/or the child's birthday. Fourteen of the surrogates who participated in the study reported that they had met face-to-face with the couple and child at least once after saying good-bye at the hospital. Only one couple reported any degree of fear that the surrogate will make uninvited contact. Within this group of adoptive parents, 15 couples stated that they plan to tell the child of its adoption, and one couple was uncertain as to what they would do.The adoptive couples and the surrogate mothers seemed to agree on several points in this follow-up survey. None of the adoptive couples or the surrogate mothers regretted their decision to participate in the program. Additionally, they both reported that knowing each other was beneficial to their experience. In the surrogates' reports, as well as in the couples' reports, the appreciation, warmth, sharing, and knowledge of each other were helpful in making the experience meaningful and enable the surrogate to more easily relinquish the child. They also predicted that knowing each other benefitted the children involved. The couples and the surrogates both want surrogate parenting legalized so there will be appropriate restrictions and regulations on the process. For instance, both sample groups felt that surrogate mothers should have a psychological evaluation prior to participation in such a program.These studies are a beginning of necessary longitudinal studies on surrogates, their families, and the children. the data presented agrees with the minimal literature to date suggesting that surrogate mothers do not exhibit pathological personalities and appear to function well both before and after the birth. It further suggests that contact between the individual and the families who have come together to create this child should be open. The contact appears to provide a positive and communicative environment for all participants. Furthermore, the open relationship helps to minimize secrecy and denial which are detrimental to the children. New reproductive alternatives are now established, but it is mandatory that we proceed with caution. Mental health professionals can assume a significant role in evaluating, monitoring, and counseling within the new programs. Psychologists can be helpful in preventing exploitation. The psychology professional must assess for each individual where surrogacy constitutes a constructive life step or where it is a collusion with pathology. However, in order to assist attorneys, physicians, and families, we need to reassess the values, beliefs and assumptions of our culture and of our profession regarding acceptable ways to create families. History suggests that forms of surrogacy have provided acceptable alternatives in different cultures and at different times in our history. Perhaps surrogacy will become another behavior that we will come to understand as not pathological, but as one that broadens the continuum and definition of what humans can think and feel. Specifically, surrogacy may expand our knowledge about varying degrees of attachment behavior between biological mother an child. We may now have to question what is commonly perceived in our society as an absolute attachment that every woman feels to every child she carries. The road ahead is indeed a challenging one. Above all else, we must proceed with the children's best interest as our primary concern.TABLE I Categorized Responses to the Interview Question, "Why do you want to become a surrogate mother?" Percentage of Women in the Surrogate Mother Sample Who Gave Each Response
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