Different Countries, Different Surrogate Experiences
Is the experience of being a surrogate the same in the United States as it is in Canada, the United Kingdom, India, or Thailand? Short answer, no.
Longer answer: A recently published article in the Journal of Neonatal Surgery (1) examined the psychological, physical, and socio-cultural aspects of surrogacy in several countries around the world.
In this article, I will review the authors’ findings, discuss my interpretation of the data, and summarize lessons learned that can be applied in any country to help surrogacy be the best possible experience for everyone involved.
Altruistic versus Commercial Surrogacy
When discussing surrogacy in different countries, the first distinction is always whether the surrogacy arrangements are altruistic or commercial. The authors of this publication do the same in their introduction, and I have to point out that the term ‘commercial’ is biased and unnecessary.
Altruistic assumes pure, humanistic intent. Commercial connotates cold, financial arrangements. Also, commercial implies a business that is built on the backs of poor, disadvantaged women who are - according to the anti-surrogacy mob - the only ones who would decide to become surrogates under such an arrangement. Nothing could be further from the truth, and thankfully, the authors generally come to the same conclusion that women who pursue commercial surrogacy under ethical conditions are not only satisfied but enriched by the situation.
I would wholeheartedly argue that ‘commercial’ should be replaced with ‘compensated.’ Compensation does not imply the abusive and coercive industrial practice that commercial does, and, also, it makes common sense that the surrogate should be directly compensated for her role in the journey.
After all, no one would dream of asking the doctors, embryologists, lawyers, nurses, midwives, coordinators, or literally anyone else involved in altruistic surrogacy to work without compensation. So, why should the surrogate?
Another issue I have with the altruistic versus compensated (I will be using my terminology from now on in this article) comparison is that the altruistic path is often not without compensation. What I mean by this is an altruistic surrogate may not be directly compensated for the journey, but say she wants money for new clothes, food for her and her family, a vacation to relax, massages, and anything else that can be described as ‘medical’ or ‘necessary’ for her well being, then it is paid for by the intended parents (IPs) in altruistic arrangements. I have absolutely no issue with this at all. I think surrogates should get everything and anything they want during this time. Frankly, that goes for all pregnant women. However, I think in calling such an arrangement ‘altruistic’ we are canonizing it as a more virtuous and ideal alternative to compensated surrogacy, when in reality, they are more alike than different.
Country Variations: UK, Canada, USA, and India
The next section of the publication focuses on characteristics that are specific to each of the following countries: UK, Canada, USA, and India.
Both the authors are from the IFTM University in Moradabad, India, so it’s not surprising that they focus most on this country. However, I believe they have been erroneously narrow in their selection of countries. Of their list, only the USA has compensated surrogacy. They have left out Mexico, Colombia, Cyprus, Georgia, and Albania, all countries that permit compensated surrogacy and international IPs. Despite this, the authors do highlight some interesting features of the countries they cover that I would like to discuss in more detail.
United Kingdom
The UK has an established history of altruistic surrogacy, with follow up studies over a decade after deliveries demonstrating that the vast majority of surrogates had sustained, amicable, and satisfactory relationships with their IPs.
One aspect that the authors mentioned but didn’t elaborate on was a perceived lack of social support by some surrogates during their pregnancy.
While there was no evidence to substantiate this claim, I believe this may be due to the fact that the altruistic system in the UK, while in existence for years, is still underdeveloped from a communication and information perspective. By this I mean that there are not robust resources for IPs or potential surrogates to engage with each other in order to really understand and navigate the process. The system is opaque and actually infrequently used as most British IPs opt to go internationally as the journeys are faster and more transparent given the infrastructure that can develop with compensated surrogacy.
Canada
In many ways, altruistic surrogacy in Canada is what the UK aspires to. There is more infrastructure, agencies, and support for IPs and surrogates, so it is a more appealing destination for domestic and international IPs.
Most interesting, the authors highlight that Canadian surrogates have expressed a sentiment of exploitation for not being compensated. That’s right, surrogates in altruistic arrangements feel they should be compensated. I agree (see above). In fact, all arrangements, if ethically done, are altruistic and should include compensation. It should really just be called ethical surrogacy and not altruistic or compensated.
United States of America
The USA is the only country described that has compensated surrogacy, and the research that has been done shows that it is overwhelmingly positive for surrogates. There is little to no difference in the experience for surrogates in the USA compared with countries that have robust altruistic surrogacy. Except for the important fact that the women get paid.
India
As mentioned above, the authors are Indian academics, and so they focus more on the situation in their country. Let me say, the situation is not great from what they describe.
Before the Indian Surrogacy Regulation Act of 2021, surrogates were often illiterate, paid less than $10,000 USD, financially motivated, kept in ‘surrogacy hotels’ away from their families, forced to have cesarean sections that were not medically necessary, and often left their communities out of shame after their surrogacy journey. It sounds horrific.
After the 2021 legislation, surrogacy has been more strictly regulated and controlled, limiting it to domestic IPs that meet the following criteria:
Heterosexual couples who have been married for at least 5 years
Women between 23 and 50 and men between 25 and 55 years of age
No previous children, even through adoption
In order to qualify as a surrogate, the criteria were set to:
Between the ages of 25 and 35
Married
At least one child of their own
Physically and mentally fit as determined by their physician
Additionally, surrogates were not permitted to participate in traditional surrogacy arrangements where they would use their own egg, and they were limited to 3 transfer attempts. Also, the surrogate retains the right to terminate the pregnancy if she changes her mind.
While these changes have improved the mental health of surrogates in India, the authors state the regulations are not well enforced, international arrangements are still occurring, and there is still significant shame and psychological burden on Indian surrogates that is very different from their counterparts’ experience in the UK, Canada, and the USA.
What Would Improve Indian Surrogates’ Mental Health and Experience?
Although the authors state their suggestions for improving the surrogate experience are for all countries, it does seem like they are leveraging the Indian history and surrogate experience more in their findings.
However, I am aligned with all their suggestions to ensure ethical and psychologically sound surrogacy journeys:
Disclosure: Surrogates should be comfortable and open with family and friends regarding their journey.
Multiples: Surrogates should not be subjected to more than 2 embryo transfers per pregnancy attempt, as multiples (triplets or higher) significantly increase medical complexities and often result in challenging journeys for the surrogate, IPs, and the newborn children. Note: In India, up to 5 embryos can be transferred per pregnancy attempt, while in the U.S. the max is 2 embryos and even this is increasingly rare.
Husband: The husband has to be on board and supportive of the surrogacy journey.
Financial Coercion: Obviously this is a big no, but this has to be said given the recent history in India and some other countries around the world.
Legality: The ‘clandestine’ (aka illegal) surrogacy arrangements of international IPs that the authors state are still occurring in India and Thailand is unacceptable and leads to significant stress and psychological impact on the surrogate.
Communication: Open and frequent communication between IPs and surrogates before, during, and after the birth.
Counseling: As with communication, professional mental health support should be available at all times of the journey for all parties involved.
This ethical framework is an excellent guideline from which to navigate any international or domestic, altruistic or compensated surrogacy arrangement.
What is the Way Forward for Ethical Surrogacy?
The authors conclude two things for the future of surrogacy:
More research
Global regulation
Frankly, I could not agree more.
Research into every aspect of the surrogacy journey is still lacking. It’s not just the psychological or experiential aspect for surrogates, as was the focus of this paper, but also the medical, mental, social, legal, and cultural aspects that warrant more investigation.
Lastly, global regulation would be a dream come true. This would allow the ethical standards to be transparent and enforced in every country, allowing everyone on a journey to engage and have the experience that they want.
This would also safeguard surrogacy for future generations, as the more controversies there are where shortcuts and crimes are committed, both ethically and legally, the more surrogacy is at risk of being completely banned. It would be such a loss for all gay intended parents like myself if surrogacy were no longer an option for having a family, and so it should be protected with international guidelines to safeguard everyone involved.
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