A surrogacy journey aims to create a family. In the process, it creates bonds between an egg donor, a surrogate, an intended parent or parents, and the child or children conceived through the contribution of all participants. Although these participants often begin as strangers to one another, their collaboration creates a new person. As such, it affects the unborn child, whose identity and birth story will always be linked to the donor and the surrogate; the donor and her offspring, who will always be genetically half-linked to the child; the surrogate and her family; and the intended parents themselves. When donor, surrogate and intended parents are all mature, emotionally balanced, realistic about surrogacy and psychologically prepared for it—the potential rewards are priceless. But if one or more of the participants is emotionally unstable, insincere in their motivation, unrealistic in their expectations, or unprepared for the challenges ahead, the heartfelt dream of surrogacy may easily transform into a heartbreaking ordeal.
The psychological screening of egg donors and surrogates and the psychoeducational meeting with intended parents aim to protect all those involved in the surrogacy journey: donors or surrogates and their families, intended parents and theirs, and future children conceived through the assistance of collaborative reproduction. Through these meetings, the mental health professional uses their knowledge and expertise to (1) assess psychological factors such as psychopathology, problematic personality traits, motivation, resilience, and adaptability; (2) explore past or present life circumstances which may affect the person’s participation in the surrogacy experience (3) foresee emotional or relationship problem areas; and (4) determine the best fit between parties. The mental health professional also educates participants on the common psychological challenges of surrogacy, counsels them on possible ways to navigate those challenges, equips them with the tools necessary for making decisions along the way, and prepares them for the effects of surrogacy on their future relationships—with one another, with their loved ones and most importantly, with their children.
Psychological Screening of Potential Surrogates and Egg Donors
The first goal of screening the donor or surrogate is to ascertain whether she is psychologically suited to donate or participate in the surrogacy. The second goal is to ensure that the process is a positive and healthy one for her and her family. A final goal is to help her and her partner (if she has one) understand the psychological consequences of surrogacy so that she can make informed decisions along the way.
A typical donor or surrogate evaluation includes five elements:
1. Clinical interview
2. Behavioral observations
3. Psychological testing
4. Couple’s interview (with her partner, if she has one)
5. Psychosocial education
In the clinical interview the psychologist collects information about a potential egg donor or surrogate’s mental health, her family of origins’ mental health, her emotional and cognitive capacity to give informed consent, her ability to make choices free of coercion or pressure (financial or emotional), and her thoughtfulness in making future choices affecting her and her family. Further, the clinical interview explores the candidate’s motivation and goals, empathy, resilience, psychological flexibility, maturity and judgment, coping skills, and assertiveness. The evaluation delves into the candidate’s social, sexual, financial, legal and psychiatric history. It investigates her history of trauma and loss; of possible sexual, substance, emotional or physical abuse; and it assesses the current levels of stress in her life, as well as future changes or anticipated stressors which may affect her ability to donate or carry through with the surrogacy plan in a responsible, reliable and healthy way.
Throughout the clinical interview, the mental health professional will use their specialized training to observe, assess and interpret the candidate’s behavior—sometimes only informally, sometimes also by administering a formal Mental Status Exam—to add another layer of information about her psychological status and level of functioning.
The psychological test is one of the most important aspects of the assessment process. An objective, standardized, and normed psychometric instrument such as the Minnesota Multiphasic Personality Inventory (MMPI) or the Personality Assessment Inventory (PAI) measures psychopathology and personality traits, further supporting the clinician’s impressions and confirming the presence or absence of significant mental health issues.
If the egg donor or surrogate has a life partner, they will be asked to join the evaluation for a couple’s interview. Participating in a collaborative reproduction relationship affects not only the candidate, but her partner and family as well. They will be called to make sacrifices, to look after her, and to walk alongside on the unknown and sometimes unpredictable path of surrogacy. Therefore, the psychological screening must confirm that the couple has a healthy relationship and a strong support system. Surrogates and their partners, in particular, must be prepared to educate friends, family, and strangers about surrogacy. They may have to combat the potential stigma of surrogacy and, at the same time, that of carrying a baby for a gay man or same-sex couple. For many, this will be the first time experiencing homophobia on a personal level. Consequently, both surrogate and partner need to be prepared and confident in their own ability, as well as that of their children, to cope with it.
The screening of surrogates focuses in depth on their and their partners’ ability to work collaboratively with the intended parents, and on their needs and expectations from the relationship with the IPs before conception, during pregnancy, post-birth, and in the long-term. Often, in a subsequent joint session with the intended parents, the mental health professional will ensure that all stakeholders’ expectations, needs, motivations and communication styles are congruent. Discordant expectations, conflicting needs and miscommunication may later become the roadblocks that obstruct a successful surrogacy journey, and avoiding them from the very start is one of the main goals of the psychological screening.
Finally, the meeting with the surrogate or egg donor aims to educate. Therefore, it includes a detailed discussion of the medical protocol, from the first steps of egg donation, through childbirth and postpartum, to the distant future, where there is a child—and eventually an adult—whom they’ve helped bring into the world. Both the candidate and her partner need to understand the medical and psychological risks involved, the ethical and emotional choices they may have to make, and the potential short-term disruptions and long-term implications to their and their family’s lives. In the process of education, the mental health professional often serves as a “devil’s advocate,” raising worst-case scenarios and presenting all possible risks. The goal is not to scare the surrogate or egg donor away, but to ensure that both she and her partner understand the consequences of their decision so they enter the surrogacy journey with open eyes and with an informed and genuine commitment.
Psychoeducational Meeting with the Intended Parents
Unlike the meetings with surrogates or donors, the psychological session with the intended parents is less of an evaluation and more of a psychoeducational consultation. Typically, it does not include psychological testing or formal assessment. The psychologist is not trying to determine if the IPs are worthy of becoming parents. Like most people, they too have a right to build a family without a gatekeeper judging whether they’re suitable. Instead, the evaluative component, to the extent that there is one, focuses on the intended parents’ ability to navigate the surrogacy journey. Are they comfortable with the concept of surrogacy? Do they understand its emotional implications? Are their expectations realistic? Will they be able to maintain a healthy and respectful relationship with the surrogate or the egg donor and her family? Can they balance their own needs with hers?
When the egg donor or the surrogate is known to the intended parents—whether a friend or a family member—the mental health professional has to explore additional questions. Are the intended parents truly comfortable with the surrogate or donor, or are they collaborating with her only out of convenience? Do they both feel equally positive about her? If she is not the right fit, would they feel comfortable turning her down? Is she agreeing to become a donor or surrogate from a place of true generosity, and not obligation or subtle coercion? Are there unresolved conflicts that may be playing out in the relationship with her or her partner? Will they be able to communicate in healthy ways? How would the donation or surrogacy change their future relationship with her? How would their other friends or family members respond to the process? How might their future child be affected by it?
Finally, just like the donor or surrogate screening, the consultation with the intended parents aims to educate them on the medical process and its psychological implications; on the typical experience of surrogates, donors and intended parents; on the possible choices IPs need to make, and on how to make then from an ethical, well-informed, and authentic place. Commonly, the mental health professional will also explore issues relating to parenting children conceived through egg-donation and surrogacy; outlining relevant research findings and offering the intended parents suggestions and resources. Often, the educational discussion focuses on the unique circumstances of the intended parent’s life: whether, for instance, they are trans, single, or from a background that may affect their experience during and after the surrogacy journey.
Qualifications of Mental Health professionals
Evaluating donors and surrogates is a complex and high-risk clinical endeavor. It requires the hand of a seasoned mental health specialist who is at once versed in reproductive medicine and experienced in conducting third-party psychological evaluations. Therefore, best practices in surrogacy postulate that a qualified clinician must have been trained and supervised by the Mental Health Professional Group (MHPG) of the American Society for Reproductive Medicine (ASRM) and that the PAI or MMPI must be performed by a licensed clinical psychologist with training and experience in psychological testing in general, and in the application of psychometrics to collaborative reproduction in particular.
Often, the mention of meeting a mental health professional provokes as much dread in egg donors, surrogates and partners as in intended parents. Many fear that the clinician will label them “crazy,” find them unqualified for the journey, or unfit for parenthood. Nevertheless, the psychological screening, when done ethically, throughly, and professionally, safeguards the integrity of the entire surrogacy process and protects all parties from undue harm now and in the future. And as such, it helps ensure that the birth story a child will be told one day, is a story of love, generosity and interconnectedness.