Infertility is a rising healthcare issue impacting individuals both male and female. [1]In addition to infertility, changes in societal norms have also played a role in the acceptance of surrogacy. In today’s progressive society, both men and women recognize infertility as a healthcare problem, and parenthood is no longer restricted to the heterosexual community. Innovations in artificial reproductive techniques have empowered individuals of every gender to experience parenthood, with surrogacy emerging as a practical alternative.
Surrogacy, an assisted reproduction method, involves intended parents assigning conception and birth to a surrogate mother. It addresses infertility, medical conditions, and supports same-sex couples. While it offers solutions for diverse situations, it carries risks during preimplantation, prenatal, and neonatal stages.[2] Surrogacy is an increasingly frequent form of family building and allows individuals to become parents despite an infertility diagnosis or a biological impossibility. Positive outcomes for both the surrogacy child and the surrogate mother have been reported, including in cases of same-sex male couples and single persons.[3]
Surrogacy was made legal in India by the Surrogacy Regulation Act of 2002. There are two main types of surrogacy: altruistic and commercial. Altruistic surrogacy means the surrogate receives no money for carrying the child. On the other hand, commercial surrogacy involves paying the surrogate, which includes making a profit, while compensated surrogacy only covers the expenses and lost wages acquired by the surrogate.[4] Commercial surrogacy was legal in India between 2002 and 2015. India was the most preferred nation for surrogacy by foreigners.[5] Tragically, the demand for surrogacy was seized upon by intermediaries who established a network linking the healthcare system with women willing to become surrogates. This resulted in the exploitation of these women, as they were often subjected to unfair treatment, inadequate compensation, and sometimes even coercion or manipulation to participate in surrogacy arrangements. [6]
Commercial surrogacy became a significant 2.5 billion dollars industry in India, with Australians accounting for an estimated 40 percent of the clientele. Ethically, surrogate mothers and the children they carry are vulnerable, especially in commercial arrangements, where there are often significant financial disparities between the commissioning parents and the surrogates. This creates a power dynamic where the surrogates may feel compelled to agree to terms and conditions that are not in their best interests due to financial need or lack of bargaining power. Additionally, the focus on financial gain may overshadow concerns for the well-being and rights of the surrogate and the child, leading to potential exploitation and neglect of their rights and welfare.[7]
The practice of surrogacy was largely unregulated internationally and even in India. In 2015, the Indian government opposed commercial surrogacy, leading to the drafting of the Surrogacy Regulation Bill in 2016. After amendments, it was passed by the Lok Sabha in 2018 and further discussed by the Rajya Sabha in 2019. The final version, along with the Assisted Reproductive Technology Regulation Act, was passed into law on December 25, 2021, and came into effect on January 25, 2022. The amended act allows only charitable surrogacy, aiming to prevent exploitation by those with financial resources. It explicitly prohibits commercial surrogacy and the buying and selling of human gametes (reproductive cells) and embryos.
The limited social research available suggests that India has emerged as a leading destination for surrogacy, driven by high demand, particularly from foreigners, and the abundant supply of surrogate mothers, often from economically disadvantaged backgrounds.[8] Despite increasing media and scientific attention and the proliferation of specialized clinics and agencies, surrogacy remains largely taboo and poorly understood, often associated with stigma and misconceptions, such as allegations of women’s adultery.
Many infertile women in developing countries consider that, without children, their lives are without hope.[9] In many cultures, childless women suffer discrimination, stigma and ostracism. The establishment of advanced infertility centers comes with a high cost, leading to a limited number of such centers in low- and middle-income countries, with many remaining in the private sector. However, for infertile women in these regions, there is hope in the introduction of affordable infertility services.
Although male infertility has been found to be the cause of a couple’s failure to conceive in about 50% of cases, the social burden “falls disproportionately on women”. [10] Stigma surrounding male infertility often stems from societal perspectives and norms. Men facing infertility may feel hesitant to discuss it due to societal attitudes. There’s a common belief that male infertility challenges masculinity, impacting men’s mental health. Additionally, discussing infertility can lead to feelings of inadequacy and shame, as it may be seen as a sign of diminished capability, aligning with societal norms and stereotypes. Consequently, many men may avoid discussing their infertility struggles due to fear of judgment or perceived social stigma.
The psychology of surrogate mothers is a complex and multifaceted topic that involves understanding their motivations, experiences, and emotional well-being throughout the surrogacy process. Surrogate mothers may have various reasons for choosing to become surrogates, including altruism, financial incentives, or a combination of both. Understanding these motivations is crucial for comprehending their psychological dynamics.
Research indicates that the majority of surrogacy arrangements are carried out successfully. Additionally, most surrogate mothers are highly motivated and typically experience little difficulty in separating from the children born as a result of the arrangement.[11] Surrogacy families tend to maintain positive relationships with the surrogate mother over time. Children born through surrogacy also typically feel positive about their surrogate mother and their unique birth circumstances.[12]
Research indicates that children born to surrogate mothers generally do not face negative consequences due to their mother’s decision to be a surrogate, regardless of whether the surrogate uses her own egg or not.[13] Also, Surrogacy mothers tend to have more positive relationships with their children, and surrogacy fathers typically experience lower levels of parenting stress compared to parents who conceive naturally. These findings suggest that surrogacy can lead to positive outcomes for both parents and children involved in the process.[14]
While surrogacy can have positive outcomes, surrogate mothers also face challenges. Research indicates that surrogate mothers often experience higher levels of depression compared to mothers in a comparison group, both during pregnancy and post-birth. Factors such as low social support during pregnancy, keeping surrogacy a secret, and facing criticism from others have been linked to higher levels of depression in surrogate mothers after giving birth. Additionally, surrogate mothers may have less prenatal bonding with the fetus, interacting less with and thinking less about the unborn child. These findings highlight the importance of addressing the psychological well-being and support needs of surrogate mothers throughout the surrogacy process. [15]
Surrogacy introduces a complex dynamic involving genetic, gestational, and social parenting, which can lead to identity and role confusion in children born through this process. Children may grapple with questions about their biological origins, their relationship with the surrogate mother, and their place within their family structure. This complexity can potentially impact a child’s sense of self and understanding of their identity.
Research has shown that children born through surrogacy exhibit higher levels of adjustment difficulties at age seven compared to children conceived by gamete donation. Additionally, mothers who chose to keep their child’s origins a secret experienced elevated levels of distress. However, it’s important to note that maternal distress had a more negative impact on children who were aware of their origins.[16]
What challenges can be faced
While the 2021 Bill aims to safeguard the well-being of surrogate mothers, it also raises concerns about their livelihood. it’s important to consider the broader implications of such policies. While safety measures are crucial, it’s also essential to balance them with the rights and well-being of all parties involved, including surrogate mothers, intended parents, and children born through surrogacy.
By banning commercial surrogacy, the bill restricts a source of income for many low-income Indian women who relied on surrogacy as a means of livelihood. Additionally, the prohibition on single unmarried women from commissioning surrogacy further limits opportunities for both intended parents and surrogates. Advocates for commercial surrogacy argue that surrogate mothers should have the right to receive compensation for their services, considering the duration and effort involved. However, under altruistic surrogacy, surrogate mothers are only provided with basic medical expenses, which may not adequately compensate them for their contribution.
Way Further
The above discussion highlights the crucial need for robust psychological support and counseling services for surrogates, especially in the postpartum phase. Surrogacy entails unique emotional challenges, making it essential to provide surrogates with resources to navigate these complexities effectively. Offering emotional support through avenues like social circles, support groups, and professional counseling can empower surrogates to develop effective coping strategies and transition back into their lives more smoothly. By prioritizing comprehensive psychological care, we can ensure that surrogates receive the support they need to navigate the emotional aspects of their surrogacy journey with resilience and confidence.[17][18]
[1] Narayan, Gaurang, Hara Prasad Mishra, Tarun Kumar Suvvari, Ishika Mahajan, Mrinal M. Patnaik, Sahil Kumar, Nidhal A Amanullah, and Smruti Mishra. 2023. “The Surrogacy Regulation Act of 2021: A Right Step Towards an Egalitarian and Inclusive Society?” Cureus, April.
[2] Cui, Weiyuan. 2010. “Mother of Nothing: The Agony of Infertility.” Bulletin of the World Health Organization 88 (12): 881–82.
[3] Igreja, Ana Rita, and Miguel Ricou. 2019. “Surrogacy: Challenges and Ambiguities.” The New Bioethics 25 (1): 60–77. https://doi.org/10.1080/20502877.2019.1564007.
[4] Surrogacy Regulation Act, 2021
[5] A Critical Analysis of The Surrogacy (Regulation) Bill, 2020 – (lawwallet.in)
[6] Narayan G, Mishra H, Suvvari T, et al. (April 20, 2023) The Surrogacy Regulation Act of 2021: A Right Step Towards an Egalitarian and Inclusive Society?. Cureus 15(4): e37864.
[7]Gracias, Carlos Sebastian. 2020. “Reproductive Surrogacy in Ireland — an Ethical and Legal Context.” Irish Journal of Medical Science (1971 -) 190 (3): 1063–70. https://doi.org/10.1007/s11845-020-02402-4.
[8] Rozée, V., and S. Unisa. “Surrogacy as a growing practice and a controversial reality in India: exploring new issues for further researches.” J Womens Health, Issues Care 4 6 (2015): 2.
[9] Cui W. (2010). Mother or nothing: the agony of infertility. Bulletin of the World Health Organization, 88(12), 881–882.
[10] Tnn. 2019. “In Almost 50% Infertility Cases, the Reason Is Male Infertility!” The Times of India, January 14, 2019.
[11] Söderström‐Anttila, Viveca, Ulla‐Britt Wennerholm, Anne Loft, Anja Pinborg, Kristiina Aittomäki, Liv Bente Romundstad, and Christina Bergh. 2015. “Surrogacy: Outcomes for Surrogate Mothers, Children and the Resulting Families—a Systematic Review.” Human Reproduction Update, October, dmv046.
[12] Jadva, Vasanti, Lucy Blake, Polly Casey, and Susan Golombok. 2012. “Surrogacy Families 10 Years on: Relationship With the Surrogate, Decisions Over Disclosure and Children’s Understanding of Their Surrogacy Origins.” Human Reproduction 27 (10): 3008–14.
[13] Jadva, Vasanti, and Susan Imrie. 2013. “Children of Surrogate Mothers: Psychological Well-being, Family Relationships and Experiences of Surrogacy.” Human Reproduction 29 (1): 90–96.
[14] Golombok, Susan, Fiona MacCallum, Clare Murray, Emma Lycett, and Vasanti Jadva. 2005. “Surrogacy Families: Parental Functioning, Parent–child Relationships and Children’s Psychological Development at Age 2.” Journal of Child Psychology and Psychiatry 47 (2): 213–22.
[15] Lamba, Nishtha, Vasanti Jadva, K.S. Kadam, and Susan Golombok. 2018. “The Psychological Well-being and Prenatal Bonding of Gestational Surrogates.” Human Reproduction 33 (4): 646–53. https://doi.org/10.1093/humrep/dey048.
[16]Golombok, Susan, Lucy Blake, Polly Casey, Gabriela Román, and Vasanti Jadva. 2012. “Children Born Through Reproductive Donation: A Longitudinal Study of Psychological Adjustment.” Journal of Child Psychology and Psychiatry 54 (6): 653–60.
[17] A Psychologist Explores The Complex Emotional Costs Of Surrogacy (forbes.com)
[18] Ana Rita Igreja & Miguel Ricou (2019) Surrogacy: Challenges and Ambiguities, The New Bioethics, 25:1, 60-77.