Third party reproduction and

the non-nuclear family

Olga van den Akker BSc PhD AFBPsS, C.Psychol

Professor of Health Psychology

Middlesex University

London, UK

New Frontiers of Family - Keynote

Reproductive healthcare services and policy should

reflect the specific, lifetime and shifting needs of the

populations it serves, including future generations

resulting from these innovations

(van den Akker, 2016, Reproductive Health Matters, The Psychologist,

29 (1) 2-5)

Individuals building families using third party

conception should accept difference rather than

shoehorn a non-traditional family into a pseudo-

traditional framework(Smolin, 2016, Surrogacy as the sale of children, Pepperdine Law

Review, 43,265-311)

A few facts about third party conception

• Is increasingly common

• Fulfils a population need•

• Late, solo, single-sex, infertile parents require AC

• Reflects behavioural and lifestyle changes

• Takes place in a socio-cultural context

•

• If not funded, health inequalities exist

• Commercialisation= inequality and commodification

‘Generation’ refers to producing offspring

It is a structural term designating kinship parent-child

(great, grand parent..) nuclear relationships:

it is familiar

In 3rd party AC (non-nuclear families), ‘unfamiliar’ is

introduced unsupported29/04/2016Slide 4

This ‘unfamiliarity’ or ‘difference’

in new generations has led to:

1) Individual psychosocial issues:

2) Societal, policy and practice issues:

3) Global welfare issues:

Non-nuclear family planning:

choreographing, coordinating and contextualising

29/04/2016Slide 5

Preference for traditional – Familiar

• Families using third party

reproduction, emphasize

the importance of genetic

or biological kinship

1) Increase in gestational

surrogacy and

2) a preference in solo and

same sex families to have

at least some biological

link29/04/2016Slide 6

van den Akker, O.B.A. (2007) Human Reproduction Update, 13 (1) 53–62.

Treatment is non-traditional:not genetic – not familiar

• Donor gametes

• Donor embryos

• *Mitochondrial donation

……..the future?

29/04/2016Slide 7van den Akker, O.B.A. (2007) Human Reproduction Update, 13 (1) 53–62.

*

*

*?

Surrogacy is non-traditional:

non biological – not familiar

Donor oocyte/ embryo

CC couple’s embryo

GeneticSM

GestationalSM

GestationalSM

O O O O O O O O OSM genetic baby Donor baby CC couples genetic

baby29/04/2016Slide 8

Surrogacy also offers psychological difference

Research on parent–child

relationships and the

child's psychosocial

development is

inconclusive

– but overprotectiveness,

less parenting self

efficacy etc. are reported.

‘Investment’ / uncertainty

can be high

29/04/2016Slide 9

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State1 State2 State3

SMDI

SMET

IMDI

IMET

van den Akker,O.B.A. (2007) Psychological trait and state characteristics, social support and attitudes to the surrogate pregnancy and baby. Hum. Reprod. 22,8, 2287-2295.

Importance of a Genetic Link: dissonance

What happens if she

thinks a genetic link

is important:

• but she relinquishes

the baby?

• she commissions a

non genetic baby?

29/04/2016Slide 10

0

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100

Important to you

SMDI

SMET

IMDI

IMET

van den Akker,O.B.A. (2007) Psychological traitand state characteristics, social support andattitudes to the surrogate pregnancy and babyHum. Reprod. 22,8, 2287-2295.

OUTCOMES: Children

• Although parental warmth and good attachment-

related behaviours towards commercial surrogate

born children are reported (Golombok et al, 2004; 2006)

• Higher levels of adjustment problems have been

reported in surrogate children compared to gamete

donation children (Golombok et al, 2012)- suggesting effects of Sur

29/04/2016Slide 11

SM prenatal attachment: conflicted

SM: exposed to the pregnancy

& delivery > opportunity for

prenatal attachments

- She is advised not to.

Can she reconcile attachment

with relinquishment? Conflict

-cases of non relinquishment

29/04/2016Slide 12

0

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Easier to relinquish a nongenetic baby

SMDI

SMET

IMDI

IMET

van den Akker (2005) ‘A longitudinal pre pregnancy to post delivery comparison of Genetic and gestational surrogate and intended mothers: Confidence and Gyneology’. J Psychosom. Obst. & Gynaecol. 26,4, 277-284.

IM importance of a Genetic Link: Attachment

IM: does not carry the baby

<misses out on the ability to

bond and form attachments

– She is expected to.

Maternal-foetal sensitivity is

associated with more maternal-

baby sensitivity

- She does not have that or the

genetic link

-consequences for family

functioning? (Maas, et al. (2016) A longitudinal study on

the maternal-fetal relationship and postnatal

maternal sensitivity. JRIP34(2) 110-121)29/04/2016Slide 13

010

20

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Easier to accept a geneticallyrelated baby

SMDI

SMET

IMDI

IMET

van den Akker ,O.B.A. (2007) Psychological trait and state characteristics, social support and attitudes to the surrogate pregnancy and baby. Hum. Reprod. 22,8, 2287-2295.

Adults conceived via gamete donation

reported lower Collective identity orientation

DC offspring: parents are

more likely to disclose AC

origins to genetically linked

than to donor AC children

(Tallandini et al, 2016,

Hum. Reprod.)

How do these children fare

when they grow up?

Problems in constructions of

‘family’ and belonging

29/04/2016Slide 14

Cheek & Briggs (2013) Aspects of Identity Questionnaire (AIQ-IV) . Measurement Instrument Database for the Social Science. Retrieved from www.midss.ie

van den Akker et al (2015) Human Reproduction.

Participants expressed deep sentiments

related to their own needs to trace genetic relatives

• ‘Curiosity’ doesn’t go anywhere near the HUNGER

(emphasis original) to find someone I was

connected to’.

• ‘To see whether we have anything in common’

sounds so casual. It is a case of looking for

CONNECTION (emphasis original). For me, that

was not anything in the zone of curiosity or idle

research; it was visceral’.

• ‘This is my only chance to find blood relatives’.• (van den Akker et al (2015) Human Reproduction)

29/04/2016Slide 15

As shown, the place of the biogenetic

relationship in non-nuclear families at the

individual level is complex, and how it is

‘choreographed’ in society & its laws is a key

theme bridging (or not) policy & practice

(Thompson, 2005)

29/04/2016Slide 16

SOCIAL: Denial of difference: Nrs of Parental

Orders / Births recorded by surr. agencies and

General Register Offices (UK) 1995-2011 (Crawshaw et al, 2012)

• Vietnam / India: culture

bound beliefs that a birth

mother is the ‘real’ mother of

the child (Hibino, 2015). The

Indian government legally

attributes parenthood to those

providing the gametes

• Western cultures: genetics

determine parenthood, even

if governments register births

to birth mothers

Evid. shows non-disclosure is

common Anonymous treatm.29/04/2016Slide 17

0

100

200

300

400

500

600

700

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900

1000

1995-98 1995-2007 1995-2011

Surrogacy Agencies' figures

GRO figures for 4 nations

Legal parenthood is not registered

• Levine (2008) argues that kinship models created by some

non-traditional families use conventional as well as radical

ideas to reference biogenetic connections.

• Parents are changing / constructing

– what is important to not important

– what is legal to illegal

– hiding / denying important facts

• This is evidenced in research where people coped with

cognitive dissonance of the biogenetic distance with the

child by cognitively restructuring new interpretations of third

party AC families (Ragone, 1994; van den Akker, 2007).

29/04/2016Slide 18

HFEA figures (May 2015) of donor,

parent, and DC adult applicants on the register

(needs for genetic information)

For offspring and donors:

policy and accurate health

information and education

are necessary at a global

level, for example

IF made aware

• Increasing awareness led to

increasing registrations

29/04/2016Slide 19

0

50

100

150

200

250

300

2010 2011 2012 2013 2014

UKDL Register: total applicants

OUTCOMES

• People conceived via scientific developments, are

now in turn, using science (DNA) to find genetic

relatives (van den Akker et al, 2015a; and see new paper in HR).•

• Normative concepts of relatedness and

kinship are challenged and these are not

yet adequately addressed / bridged in

research, policy or practice.

29/04/2016Slide 20

Global Issues:

Opportunities for suspect practices

• Ethically suspect

• Socially suspect

• Morally suspect

The infamous 'Baby Gammy' scandal in

Thailand (seeBioNews 765/775) and a

'moral panic' about the rights and wrongs

of commercial surrogate parenthood &

monitoring (child molester).

29/04/2016Slide 21

• A new kind of bio-power (Foucault, 1998) is in the hands of

sufficiently wealthy infertile couples, LGBTQ and single men

and women of all ages who can afford it.

– Eg. A 24 yr old wealthy Japanese man started a ‘baby factory’: fathered 16

children with Thai surrogates over 2 yr period. As soon as they got pregnant,

he requested more; he wanted 10 to 15 babies a year, and wanted to

continue the baby-making process until his death (Rawlinson, 2014).

• The international market in fertility treatment, gamete

donation and surrogacy is a multi-million dollar industry

• The ethics of international baby buying is rarely addressed

(Qadeer, 2010)

29/04/2016Slide 22

Exploitation

29/04/2016Slide 23

• informed consent

• chemical abortions for which they are not fully prepared

• paid minimal fees

• 6% and 26% of CC’s will not take a child born with abnormalities

• BOGOF packages apply

• surrogates are removed from their families to prevent STI’s and to prevent the ‘stigma’ in their local communities of surrogacy (CSR, 2013)

Gender inequalities

• Discrepancy between female / male births

……. …..♀&♂• Illegal abortions for sex selection

29/04/2016Slide 24

Psychosocial inequalities (UK data)

• Surrogate mothers are significantly younger and single

• Some surrogates had never before been pregnant

• 18% of genetic and 20% of gestational surrogates had

experienced PND in a previous pregnancy

• Genetic SM and IM had significantly less time getting to

know each other than gestational SM or IM’s

van den Akker,O.B.A (2003) ‘Genetic and gestational surrogate mothers' experience

of surrogacy’ Journal of Reproductive and Infant Psychology 21, 2 / 145 – 161

29/04/2016Slide 25

Socioeconomic inequalities

Occupational status (%) Sign Education (%) Sign.

Slide 26

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professional manual

SMDI

SMET

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CCET

0102030405060708090

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high medium lowvan den Akker,O.B.A (2005) ‘A longitudinal pre pregnancy to post delivery comparison of Genetic and gestational surrogate and intended mothers: Confidence and Gyneology’.J Psychosomatic Obstetrics and Gynecology, 26,4, 277-284.

Parenthood inequalities

• In liberal, democratic countries – non traditional is commonplace

• Yet in Australia (see BioNews 799): since1990 -In <30 years there were

27 public inquiries and >17 different laws passed (reacting to ‘difference’)

• Parenting is therefore still contextualised in traditional

nuclear family terms.

29/04/2016Slide 27

Choice inequalities

• National statistics reflect behavioural, attitudinal and lifestyle

choices (Barber, 2001)

• Survey evidence shows family building goals are not abating

(Lee et al, 2005).

• There is not enough support for culturally sanctioned third

party family building for people who need to use AC.

• Governments need to react to the lifestyle & attitude shifts they

have encouraged because biologically time runs out & more

people will need treatment (Hansen et al, 2009)

29/04/2016Slide 28

Consequences

• In addition to psychological costs, it can be financially expensive29/04/2016Slide 29

1

it is relatively unsuccessful

can be associated with stigma/ effects on work (van den Akker et al, submitted)

2uncertaintymedicalised conception

3

brings a third party into the process and

can lead to psychological distress and disappointment (Levy-Shiff, et al. 2002).

Disclosure / career inequalities

• Conflict between public and private domains

Disclosing time off from work

– Disclosing ART use

– Disclosing treatment effects

– Disclosing pregnancy

– Disclosing need for maternity/ paternity leave

– Being judged as parent/ employee

• creating concerns about career prospects

• van den Akker, Payne, Lewis (submitted) Catch 22? Disclosing Assisted Reproductive Technology

treatment in the workplace

29/04/2016Slide 30

Risks

Choosing gametes / embryos: LT consequences.

– A California clinic is creating embryos for multiple patients at a time using donor

sperm and donor eggs from young, healthy anonymous donors.

– “anonymous donor embryos” offer infertile patients, especially those who spent

thousands of $ on failed IVF attempts, an “excellent opportunity” to become pregnant.

– The program offers “minimal” wait times and a 100 per cent refund to qualified

recipients .

– Egg and sperm donors are screened for infectious diseases, inherited disorders, mental

illness and “other traits that would be undesirable to most parents,”

Multiple pregnancies: Mothers of AC twins & multiple births are significantly

more likely to experience depression and stress - additional to maternal /

infant health effects.

van den Akker, et al,(in press) Maternal psychosocial consequences of twins and multiple births

following assisted and natural conception: A meta-analysis. RMBOnline

Slide 31

Responsibilities

Implementing national policies requires a full understanding of the

consequences –such as non disclosure effects on child (van den Akker,

2013), yet:

• The UK legislated for anonymous mitochondrial donation (HFEA, 2015)

– However, there is no reason to withhold health information from

individuals (van den Akker, 2016)

– It is a basic human right to have accurate and true information about

one’s health (Gomes de Andrade, 2010)

• Particularly where medical intervention has brought the (third party

conceived) children into the world (van den Akker, 2013)

29/04/2016Slide 32

Summary

Third party conception introduces difference and

inequalities

• Adverse psychological effects in the triads have been

demonstrated

• Research into the psychological consequences of kinship

and identity is only scratching the surface

• Treatments are brought to society via policy and have

implications at economic, cultural, social and psychological

levels

Reproductive health planning should be a priority

• RCOG/BFS/FSRH Fertility Health Summit: Choice not Chance

(https://britishfertilitysociety.org.uk/?post_type=meeting&p=4749#sthash.

VqkhiBBC.dpuf) Recognises risks to young people: Educating School

children in PSE lessons29/04/2016Slide 33

Lifestyle choices

Health care resources

Fund (some)

AC

health inequalities

Success/ Failure/ No opportunity

Psychological support

National drives

encouraging

Resourcing reproduction (micro)

Legislating for social change

29/04/2016Slide 34

Reproductive healthcare services require harmonious

interactions between research, technological innovation policy and

practice

Resourcing reproductive choice (macro)

+ Planning & preventing Reproductive ill health

MAR affects 10% of the population WW

Stressful (Cousineau

and Domar, 2007)

Femininity/ masculinity

Stigma / incompleteness

Treatment

Risks (Mathur, 2015).

Prevention

29/04/2016Slide 35

New kinships

Social change

References

van den Akker, O.B.A. (1999) Organisational selection and assessment of women involved in surrogate

motherhood. Human Reproduction. 14,1, 101-105.

van den Akker,O.B.A (2003) ‘Genetic and gestational surrogate mothers' experience of surrogacy’ Journal of

Reproductive and Infant Psychology 21, 2 / 145 – 161

van den Akker,O.B.A (2005) ‘A longitudinal pre pregnancy to post delivery comparison of Genetic and

gestational surrogate and intended mothers: Confidence and Gyneology’.J Psychosomatic Obstetrics and

Gynecology, 26,4, 277-284.

van den Akker,O.B.A. (2007) Psychological trait and state characteristics, social support and attitudes to the

surrogate pregnancy and baby. Human Reproduction, 22,8, 2287-2295.

van den Akker, O.(2007) Psychosocial aspects of Surrogate Motherhood Hum.Reprod.Update, 13(1), 53-62

van den Akker, O.B.A. (2012) Reproductive Health Psychology. Wiley-Blackwell. ISBN-13: 978-0470683385

van den Akker O.B.A. (2013) For your eyes only: Bio-behavioural and Psychosocial research objectives.

Human Fertility. 16(1): 89–93

van den Akker O.B.A. Crawshaw, M.C, Blyth, E.D and Frith, L.J (2015) Expectations and experiences of

gamete donors and donor-conceived adults searching for genetic relatives using DNA linking through a

voluntary register. Human Reproduction, 30 (1): 111-121.

Barber, J. (2001). "Ideational Influences on the Transition to Parenthood: Attitudes Towards Childbearing and

Competing Alternatives." Social Psychology Quarterly, 64(2): 101-127.

Centre for Social Research (2013) (The Centre for Social Research

(http://www.womenleadership.in/Csr/SurrogacyReport.pdf) India.

Cousineau TM, Domar AD (2007) Psychological impact of infertility. Best Pract Res Clin Obstet

Gynaecol ;21:293-308.

Crawshaw M, Blyth, E and van den Akker O (2012) The changing profile of surrogacy in the UK –

Implications for policy and practice. Journal of Social welfare and family law, 1–11.29/04/2016

Slide 36

References

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Hansen, et al (2009) Childlessness and Psychological Well-Being in Midlife and Old Age: An Examination of

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