The Pregnancy Experience of Gay Couples Expecting a Child Through Overseas Surrogacy

Abstract

This study aims to analyze the emotional experience of pregnancy for gay couples who turn to overseas surrogacy and face a geographical distance from the pregnancy. In-depth interviews were conducted with 16 gay intended fathers, mean age 35.5 years, most of whom expected a child through surrogacy in India. The unborn children’s gestational age ranged from 10 weeks to 32 weeks. A qualitative thematic analysis of the interviews shows that the interviewees felt frustration and anxiety due to their distance from the physical pregnancy and, specifically, their inability to experience the physical presence of the fetus. The resulting emotional disconnect from the developing fetus impacted the development of their parental sense during the pregnancy. The results highlight the importance for the intended parents of establishing a close relationship with the surrogate mother, as is customary in the United States but generally not in countries such as India. The findings support the value of establishing international guidelines for cross-border reproductive services.

Keywords

pregnancy gay couples surrogacy emotionally disconnected cross-border reproductive services

Overseas surrogacy, as part of cross-border reproductive services, is a complex issue that raises an abundance of dilemmas (Thorn, Wischmann, & Blyth, 2012). Yet despite the increasing use of overseas surrogacy, research into the social and psychological ramifications of this practice remains limited. Several factors likely contribute to this paucity of research, including the difficulty of collecting data on the procedure, which has only recently come under government oversight in many countries; the continuing social stigma attached to surrogacy (Poote & van den Akker, 2009), which makes many couples reluctant to participate in studies; and reluctance by funding bodies to support studies on such a controversial topic (Ciccarelli & Beckman, 2005). Much of the existing research is primarily sociological in nature and focuses chiefly on the experience of the surrogate mother and related ethical issues (Palattiyil, Blyth, Sidhva, & Balakrishnan, 2010; van den Akker, 2003). Despite an increased focus over the past decade on the psychological experience of the intended parents and their unique point of view (van den Akker, 2005, 2007a, 2007b), this area is still only beginning to be explored (Blyth, 1995, 2012b; Edelmann, 2004; Ragoné, 1996).

The literature about gay parenting in general and gay couples who employ surrogacy in particular is even scarcer (Tuazon-McCheyne, 2010). The world’s first child born to gay parents through a surrogacy process was born in the mid-1990s in the United States. In 1996, various agencies in the United States, led by the Growing Generations agency in Los Angeles, began to offer surrogacy services for same-sex couples. In the subsequent years, similar organizations appeared in Canada, Thailand, and India, though in other countries gestational surrogacy remains illegal (Bergman, Rubio, Green, & Padron, 2010; Crawshaw, Blyth, & van den Akker, 2012). Indeed, the past two decades have witnessed a “gay baby boom”—a dramatic increase in the number of gays and lesbians who choose to have children (Friedman, 2007). Nevertheless, gay couples who choose surrogacy are still a minority among other emerging nontraditional families (van den Akker, 2005).

The choice of surrogacy over adoption is usually motivated by the desire to raise a healthy child from the moment of birth—that is, a child who has not experienced previous abandonments (Lev, 2006). Another key factor is the complexity and duration of the adoption process, especially for gay couples who, in some countries, are not allowed to adopt at all (Nakash & Herdiman, 2007). However, it appears that couples who choose surrogacy, even heterosexual couples, are motivated previously all by the desire to have a biological and genetic connection to their child (Bergman et al., 2010; Edelmann, 2004; van den Akker, 2000; for a detailed discussion of varied motives for other cross-border fertility treatments, see Blyth, 2012b; Culley et al., 2011).

Israel prohibits the use of surrogacy as well as adoption by gay couples (Israel Government Portal, 2011). Therefore, gay couples in Israel who wish to have a child without having to share parental rights with a third party, as in shared parenting (Mander, 2001), have no choice but to turn to countries that approve surrogacy. A solution of this kind is offered by several Israeli agencies that provide surrogacy services, primarily in the United States and India. The procedure involves finding a donor egg, fertilization of the ovum with the sperm of one of the intended fathers, and implantation in the womb of the host mother. The agency mediates the medical and legal aspects of the entire process, including the relationship between the various parties. Toward the expected childbirth, the intended parents usually fly to the host mother’s home country, where they have the option of joining her in the delivery room. After the birth, in accordance with the laws of the State of Israel, citizenship is given to the newborn and the biological father is officially recognized as the child’s father. Upon their return to Israel, the biological father’s partner may adopt the baby. It should be noted that the high costs of the process—including payments to the agency, the fertility clinic, the egg donor, and the surrogate mother; health care for the surrogate during pregnancy; legal and bureaucratic services; and flights and accommodation—encourage most Israeli couples to choose India for the procedure, as in India, the process is relatively less expensive (Bergman et al., 2010).

Surrogacy overseas is a complex procedure. However, besides the legal and bureaucratic complications, surrogacy overseas has another ramification for the intended parents: Their physical distance from the surrogate mother and the fetus growing inside her. When the intended parents live in the same country as the host mother they can choose how close they wish to be to the surrogate mother during and after the pregnancy (Lev, 2006; MacCallum, Lycett, Murray, Jadva, & Golombok, 2003). Some couples prefer to maintain close ties with their host (open surrogacy), while others prefer complete disconnection (closed surrogacy; Edelmann, 2004; Ragoné, 1996). Surrogacy in which the host mother lives overseas is by nature similar to a closed surrogacy arrangement.

Pregnancy is marked by a variety of physical, hormonal, and metabolic changes as the mother’s body meets the needs of the growing fetus and prepares for the delivery and the coming motherhood. The mother’s swelling belly symbolizes her new status most profoundly, but other external changes occur as well, including swollen veins and changes to skin pigmentation. Internal manifestations of the pregnancy include nausea, vomiting, salivation, constipation, fatigue, shortness of breath, hunger, and excessive emotionality (Raphael-Leff, 2009). The new embryo completely changes the mother’s body as well as her sleeping, eating, mating, and work habits. From its formation, the embryo is there, accompanying and accompanied by its mother even in her most intimate moments, reminding her of their mutual existence (Raphael-Leff, 2001).

As pregnancy develops, in addition to the mother’s physical sensations, hidden thoughts, feelings, and anxieties are revealed. In psychoanalytic terms, pregnancy is characterized by a weakening of the mother’s defense mechanisms, allowing for fantasies and anxieties hitherto repressed and inaccessible to consciousness to occupy conscious thoughts. In the absence of real knowledge of the developing embryo, during the second trimester an imaginary baby representation is developed by the mother based on her conscious and unconscious emotions. With delivery, the imaginary representation departs, enabling the mother to connect with her baby as a new individual. Thus, with the development of the pregnancy, the mother attributes to the fetus both positive and negative characteristics, some of which are based on fetal behavior and some on her fantasies, hopes, desires, and anxieties. To distinguish the real from the imaginary baby, many women tend to give the imaginary baby representation a nickname that will not be used after birth. The naming allows the creation of fantastic tales, as well as placing the fetus in a world of real relationships. The emotional response to pregnancy is also expressed in lush and realistic night dreams that engage issues relating to pregnancy, childbirth, the future child’s identity, and anxieties about motherhood (Raphael-Leff, 2001, 2009).

While fathers do not experience the physical reality of the pregnancy and the fetus in the same way as the pregnant mother, studies show that fathers also experience a variety of unique emotional reactions, including an increase in fantasies, anxieties, and unresolved conflicts. Genesoni and Tallandini (2009) found that fathers experience the pregnancy period as more stressful than either the birth itself or the baby’s first year of life. During pregnancy, the father usually undergoes psychological reorganization, during which he deals with themes relating to his relationship with his partner and his parental identity (Finn & Henwood, 2009). In the absence of an internal physical sense of the fetus, most fathers take a caring and anxious role, which can be expressed, for example, by obsessive preoccupation with their wife’s diet (Raphael-Leff, 2001). In qualitative research on fathers’ dreams during pregnancy, Zayas (1988) found that during the early stages of pregnancy, fathers’ dreams tended to be related to the embryonic environment and feelings of loneliness. With the development of the pregnancy, dreams were more likely to deal with fathers’ anxieties regarding the delivery, their coming fatherhood, and their future care of the infant.

Somatic symptoms during pregnancy, such as weight gain, enhancement or reduction of appetite, and indigestion, are also commonly reported by fathers. This phenomenon, known as Couvade syndrome, usually occurs from the third month of pregnancy until the birth itself, with a peak in the last third of pregnancy. Possible explanations for the syndrome include identification with or envy of the fetus; expressions of anxiety; ambivalent feelings about the coming fatherhood; a social statement about paternity; and jealousy of the maternal role (Brennan, Ayers, Ahmed, & Marshall-Lucette, 2007).

The physical presence of the fetus also has an effect on the emotional response of expectant fathers. Both men and women have been found to communicate with their fetus during the last trimester of pregnancy, and to attribute meaning to embryonic behavior. During this phase, the expectant parents draw conclusions about the coming baby’s temperament, patterns of communication, appearance, and other characteristics based on the seemingly empirical evidence provided by fetal behavior. An encounter with a fetal ultrasound image can strengthen the bond with the fetus for both parents. However, the image of the embryo can also prematurely crush the internal fantasy. One way or another, these abundant fantasies, dreams, and anxieties have a major role in preparing expectant mothers and fathers for parenting (Lederman & Weis, 2009).

For intended parents who expect a child through surrogacy, the experience of pregnancy can be only vicarious. Findings on this question have been mixed. For instance, MacCallum et al. (2003) found that intended parents experienced the pregnancy positively and that levels of anxiety during this period were relatively low. However, Blyth (1995, 2012a) found that intended parents experienced the contract with the surrogate mother as confusing and were anxious about the possibility that the surrogate mother would not safeguard the fetus or her own health (Kleinpeter, 2002). Ragoné (1996) found that, in order to overcome the lack of a genetic connection with the embryo in the surrogate mother’s womb, some intended mothers experience a “pseudopregnancy.” These women accompany the surrogate mother as their “shadow,” attending every medical test and childbirth class. For these women, the surrogate mother is physiologically pregnant, while they are emotionally pregnant. But such experiences can only occur as part of an open surrogacy arrangement. The case of overseas surrogacy is fundamentally different, and the remoteness and alienation from the fetus is a central issue that cannot be ignored.

As suggested previously, over the past decade, cross-border reproductive services have begun to draw increasing research attention (Blyth, 2010, 2011, 2012a, 2012b, 2012c; Hughes & DeJean, 2010; Pennings et al., 2009). Studies concerning overseas surrogacy have addressed various aspects of the process, including changes associated with the transition to parenthood (Bergman et al., 2010); the effect of upcoming fatherhood on how an individual copes with social and political issues (Tuazon-McCheyne, 2010); and ethical issues regarding the potential exploitation of Third World women (Palattiyil et al., 2010; Riggs & Due, 2010). However, the psychological implications of the physical distance between the intended parents and the surrogate mother and fetus during the pregnancy have not been extensively studied (van den Akker, 2007a).

This qualitative study takes a first step toward filling this gap in the literature. We focus on the unique experience of pregnancy for gay couples who are expecting a child through an overseas surrogacy process, by examining how the emotional process is realized in the absence of the physical presence of the fetus.

Method

Participants

Eight gay couples who expected a child through surrogacy took part in the study. An in-depth interview was conducted separately with each of the 16 intended fathers. All the couples were clients of two leading Israeli agencies that provide surrogacy services overseas, using surrogates in the United States and India. Seven of the interviewed couples chose to use a surrogate from India, while only one pair chose the United States.

When the interviews took place, all the couples were expecting their first child or children (one couple expected triplets, one twins, and the rest a single child). The gestational age of the unborn children ranged from 10 weeks to 32 weeks (M = 23.38; SD = 7.33).

Participants ranged in age from 27 years to 47 years (M = 35.5; SD = 5.26). All eight couples had been in a stable gay relationship with joint housekeeping for at least 7 years. Seven of the couples lived in the Tel Aviv metropolitan area, while the eighth couple lived on the coastal plain north of Tel Aviv. Four respondents had a high school education, four had a BA degree, and the rest had master’s degrees. Participants held positions in a variety of professions, including law, academia, art, psychology, communications, high tech, and education. The joint monthly incomes of all eight couples exceeded the average household income in Israel—an unsurprising finding, given the high cost of overseas surrogacy.

Tools

In-depth structured interviews were held with the participants (see the Appendix). Construction of the interview was based on an extensive review of the literature dealing with the psychological experiences of women and their partners during pregnancy. Among the topics covered in the interview were the presence of the pregnancy and fetus in everyday life, fantasies, and dreams about the pregnancy, anxieties, and preparations for parenting. Even though the interview was structured, interviewees were encouraged to raise personal issues and experiences even if these were not directly related to the list of questions.

Procedure

Participants were recruited through two leading Israeli agencies that provide overseas surrogacy services. Preliminary information about the study was given to potential participants through the agencies. An interview was scheduled via a phone call to those couples who expressed interest in taking part in the study. During that phone call, participants were told that the research aimed to study their unique pregnancy experience. In addition, participants were presented with the ethical approval form and were asked to sign a formal agreement, which set out the measures taken to ensure the confidentiality of all responses. The interviews, which lasted about an hour, were carried out in the participants’ homes. The interviews were recorded, with the consent of participants.

It should be noted that we had great difficulty recruiting participants for the study, since many gay couples are apprehensive about the bureaucratic and legal issues involved in bringing surrogate babies into Israel. Many couples also feared revealing the pregnancy to others until tests confirmed that the fetus was healthy and the pregnancy normal. For these reasons, only 20% of the couples initially suggested by the agencies agreed to take part in the research.

After all the respondents had been interviewed, we performed a qualitative analysis of themes that emerged from the interviews, as recommended by Braun and Clarke (2006).

Results

Three main themes emerged from the analysis, all relating to consequences of the distance from the physical presence of the fetus: (a) feelings of frustration and anxiety arising from a perceived loss of control over the process, (b) issues surrounding the formation of a connection with the unborn baby, and (c) issues surrounding the preparation for parenthood. Following convention for describing results from qualitative studies using a relatively small number of participants, the term “many” refers to responses from more than half the sample (in this case, nine or more participants), and the term “some” refers to responses by three to eight participants (Frith, Blyth, Paul, & Berger, 2011).

Frustration and Anxiety

As described previously, the surrogacy agency mediates between the couples and the developing pregnancy in India. At the beginning of each pregnancy, the agency gives the intended parents a calendar showing important dates, including the dates of any ultrasound tests. The agency then forwards to the couple the results of these ultrasounds, as well as other information about the progressing pregnancy. Many of the couples who were interviewed for this study referred to their monitoring of this calendar—and their growing binders of documents and charts—as their experience of pregnancy. Cynically, many of the couples described the process as the exchange of money for ultrasound examinations. As Roy put it, “Pregnancy for me is Google, pregnancy is this folder…my pregnancy is fed on e-mails, reports and Excel tables. This binder is full of formal documents but has no emotionality…You do not see anything or know anything. You travel to India and come back with a child in your hands.”

Ohad, who experienced a miscarriage before the current pregnancy, illustrates the technical and business dimensions of a surrogate pregnancy: “I do not experience pregnancy…documents with pictures are not so different from the contract we signed…when everything is okay, ‘pregnant’ means nothing. Dates have more significance than the length of the fetus. I do not mind it, it even facilitates feelings. When unsuccessful fertilization or a miscarriage occurs, the disappointment is particularly about the time wasted.”

Yair described two recent dreams that also emphasized the technical aspects of an overseas surrogate pregnancy. In his dreams, Yair is on a train in a foreign country and a FedEx messenger delivers the baby to him. The technical dimension, along with the physical distance, contributes to feelings of alienation and detachment from the pregnancy. The interviewees used words like abstract, disembodied, virtual, theoretical, or hidden to describe how pregnancy was missing for them. “Pregnancy,” says Ronen, “is an amorphous process, like a fantasy or fairy tale.” Others cast doubt on the existence of the pregnancy at all, revealing even more extreme feelings—for example, “Sometimes I think that nothing is going on” (Omer), or “We’re not even sure if the ultrasound we received is ours” (Noam). These feelings expressed by many of the interviewees are similar to those of couples or single mothers who employ overseas surrogacy services (Thorn et al., 2012) and are in contrast to those of heterosexual fathers, who experience the pregnancy when they accompany their wives for testing and observe the growing belly (Raphael-Leff, 2009).

The loss of a sense of control is described as the central implication of the distance from the physical pregnancy. As Noam put it, “When it is far away it creates a feeling of lack of control…as men we are not pregnant and control is anyway not in our hands. But with a female spouse there is at least someone on the other side. Here the other is in another continent and most of the time does not really care about us. I guess if she [the surrogate] was our neighbor, it would be different….” Oren’s opinion is even more extreme: “If the surrogate was here, I would not have left her for a minute.” Some interviewees indicated that the absence of a sense of control contributed to the development of potential anxieties. Omer said, “Pregnancy is nine months of uncertainty, we’re waiting every month to get an update regarding the pregnancy’s development. If there was a woman next to me, I could stroke her belly, see that she eats and rests enough…we trusted to fate when we provided our sperm. However, since then we are at the mercy of others. We are not updated or asked for anything.” Roy shares the most difficult moment he experienced during the pregnancy: “We got a message that the surrogate mother had placenta previa. At first we had no idea what that meant…Is she alone? Is she getting enough rest? What is the distance between her home and the hospital? There is great fear when you don’t see or know anything…every time I get a phone call, as long as I do not see the names of the agency representatives on the phone screen I am calm.” Other interviewees expressed anxieties regarding the health of the mother and fetus alongside a strong feeling of being powerless to protect the future of their child.

In the absence of a sense of control, most of the men adopted a strategy of aloofness and emotional detachment, which sometimes led them to relinquish the little control they had. Many of the interviewees did not remember the surrogate mother’s name, even though it was given to them by the agency, and did not ask for photographs of her and her growing belly. “We paid enough money to trust them [the agency],” says Roy cynically. Most reported that they initiated little contact with the agency even around examination dates. Some couples said they followed the calendar closely and expected to receive reports from the agency around key dates, while others completely ignored the calendar and were reminded of the pregnancy taking place overseas when they received an e-mail reporting test results. However, most of the couples sought the aid of a local doctor to clarify the obscure scales provided with the test results.

The Connection With the Unborn Baby

The physical distance from the pregnancy has many consequences, of which the absence of the fetus from the life of the intended parents is perhaps the most central and painful. Many couples described an agonizing feeling that somewhere, in another part of the world, in a foreign belly, was a developing baby who was all theirs. “Even in the belly the baby has a character. As time passes I am anxious to get to know it, but I know I will not,” says Omer. “As men we are naturally not really part of the experience, but heterosexual fathers can feel the child kicking, talk to him and have a relationship with their pregnant wife. The presence of the fetus is much more tangible,” says Alon. Ophir adds, “I lack a relationship with the baby. Receiving an ultrasound report via e-mail is different from experiencing the ultrasound test where the fetal movement is truly there. It's part of a bonding process we don’t have.” Or as Yair put it, “I am about to receive a newborn baby of whom I know hardly anything, including what he went through so far.”

Oren’s dream holds the same pain: “I see a pregnant woman and her tightened belly. The baby's face is visible beneath her belly. It is just below her stomach. I take pictures of her belly and see the shape of his leg and his facial features through the camera.” Oren can detect a fetal entity that has a nature and features, but he cannot touch or feel it. Although he can see, the vision is not direct, but through the camera lens.

Of all the interviewed couples, only Amir and Avi—who decided to undertake the procedure in the United States—established a deep and personal contact with the surrogate mother. This strong connection between the couple and the surrogate mother has its roots in the different cultural environment in which the pregnancy took place. Amir and Avi explain that in the United States, developing such a relationship during the pregnancy and even maintaining it after the birth is quite common. Both men recount how they selected the surrogate mother after visiting her in her home, meeting her husband and children, and experiencing her way of life. They chose her because of her human warmth. Since they first met, Amir and Avi have remained in constant touch with the surrogate mother. They talk about the home that will welcome the child, while the surrogate mother tells them how her belly is growing, how the fetus danced during the last ultrasound test, and how she plays music to the baby. It was actually the surrogate who announced to the couple that she had conceived successfully, rather than a representative of the agency. For all that, Amir says, “We still don’t feel like parents. Perhaps when we get to that moment when we feel the baby move, something will happen.” “I guess there is something about touching and seeing,” Avi concludes.

The absence of the fetus prevents the creation of the “imaginary infant,” whom the parents-to-be can talk to and name. Most couples in the study reported that the physical absence of the fetus was coupled with a spiritual absence. Thus, many couples we interviewed were used to talking about the fetus and not to it. In the same vein, most couples in the study said that they did not refer to the fetus as such, but called it by the name they planned to give the child. In the case of a pregnancy of this kind, the use of the future child’s name hints at the creation of an “imaginary child” rather than an “imaginary infant.” Because the couples have no emotional information that could give them a sense of the nature of the fetus, they invent a future imaginary child, bypassing the stages of the fetus and the pregnancy. Roy thus imagines himself sitting with his son in the park, telling him about flowers and trees. Yair’s incredibly smart child has already finished his master’s degree. For Gilad and Ofir, their children have reached adolescence and are in full rebellion. As for Avi and Amir’s child, he sits playing with dough as the whole family busily makes pasta.

Two elements about the fetus nevertheless capture the imagination and take on increased importance in the absence of all other information: the ultrasound tests and the discovery of the baby’s sex. When the procedure is undertaken in India, all information regarding the sex of the child is kept secret, in accordance with the laws of that state. Gilad and Ofir share their reactions coping with this knowledge gap: “We have elaborate theories about each fetus based on the ultrasound pictures. But it seems like we’ll have to let them be who they are….” From the pictures he has received so far, Omer says that “it looks like a girl.” “Knowing the sex of the fetus helps one crystallize one's dreams. In our dreams, the gender is very real and the stories about each sex differ…You comb a girl’s hair and you show a boy where you served on reserve duty…” says Ohad. Ofir recalls the birth of his nephews and extrapolates: “With my nephews, I was very surprised…There are times when I imagine them [the babies]…but I think that when it happens for real, when I see them, then I’ll have a real shock.” Will that shock be as terrible as Ofir expects it to be? Many of the couples we interviewed wondered about this. Is there an actual price to pay for a lack of experience of pregnancy characterized more by a feeling of solitude than by a connection one cannot ignore? Most couples affirm there is.

The Preparation for Parenthood

The majority of the interviewees affirmed that they always knew they would be parents when the time was right; they simply waited for conditions to be ripe. “We have no biological clock ticking,” Roy says. Gilad explains, “The absence of a biological clock together with the pursuit of a career is what postpones the process.” Nonetheless, for almost all of the interviewees, the feeling of fatherhood was connected to the possibility of touching and connecting with the infant; in its absence, they did not feel like parents. “There is something missing in this pregnancy. Others have the time to get ready [to become parents], while we will be surprised. Nothing has changed in our life. We did not have nausea or dizziness. We did not see or touch any belly grow,” says Ophir. “If I could perceive concrete things, like the baby's pulse or its kicks, then maybe I would feel like a parent,” says Gaby, while Ohad says: “When I hold her for the first time, I’ll feel I am a parent.”

In the absence of an opportunity to stroke the surrogate’s growing belly and to see the fetus moving inside, the couples sought to compensate for their inability to prepare psychologically for parenthood by diving into practical preparations. “It's important to get ready at a spiritual and psychological level,” Alon says. “But most of our preparations are practical in nature, like getting visas for India, booking flights, etc. Even thinking about the nanny or managing everyday life and a baby is basically practical.” Some of these practical preparations involved work/family balance. “I am more concerned about the way life will go on…We both are very ambitious in our jobs and this will have to change,” says Ofir. Alon deliberately began to change his lifestyle almost a year prior to the pregnancy. “I knew that being a father would be the most important thing for me and that it would take up most of my time,” he recounts, “so my position and my job location took a hundred-and-eighty-degree turn.” He nonetheless acknowledges, “I had to renounce my ego. Instead of taking up a managerial position, I had to content myself with a content-related position and every day, I have to remind myself of the reason for it.”

A few interviewees described observing psychological changes in themselves. Yair, for example, who worked as a caregiver, explained that the way he looked at his patients changed during the pregnancy. If, until the pregnancy, he tended to identify with his younger patients, he now found himself identifying with the parents. Practical preparations for parenthood, however, are more common. Almost all couples interviewed had taken legal steps to regularize their status—creating joint surnames, completing any paperwork needed for civil partnership status, and even arranging marriage ceremonies. (Israel formally recognizes same-sex civil partnerships under a law dealing with common-law marriage. Same-sex marriage is prohibited within Israel, but Israeli law recognizes same-sex marriages performed elsewhere.) Several couples renovated their homes or bought new apartments. Other preparations included reading books on parenting and child rearing (but not on pregnancy); discussing diapers, infant formula, and pacifiers with friends who had children; and getting rid of bad habits. Ohad, for example, said he was cutting down on his smoking, with the hope of quitting completely once the child was home. Many interviewees said they were making every effort to expand their circle of friends to include parents with children, in particular those who went through similar experiences.

Discussion

This study aimed to analyze the emotional experience of pregnancy for gay couples who turn to overseas surrogacy and face a geographic distance from the pregnancy and the fetus. Our analysis focused on pregnancy as a period allowing the development of a relationship with the fetus and psychological preparation for parenthood. As described previously, three main themes emerged from our interviews with intended parents. First, most of the interviewees were beset by frustration and anxiety—products of a sense of powerlessness that, in turn, resulted from the geographic and emotional distance between the couples and the surrogate mother. These feelings of anxiety found expression in various ways, including concerns about the health of the surrogate mother (and, therefore, the unborn child), and unease about the integrity of the reproductive services agency—for instance, the impossibility of knowing for sure that the test results they received were actually theirs. Second, the participants expressed difficulty developing a relationship with the fetus—a process that in typical pregnancies occurs naturally for both expectant mothers and fathers, as fetal movements and ultrasound images foster an imaginary representation of the unborn baby. The fact that most of the interviewees were not told the gender of their fetus contributed to this emotional disconnectedness. Only the couple who had chosen surrogacy services in the United States felt close to the surrogate mother and had a strong feeling of being part of the pregnancy. Finally, all the interviewees—including the couple with the American surrogate—shared the feeling that the lack of a physical connection with the fetus hindered their internal development of a parental sense.

The participants’ sense of emotional disconnect related to the pregnancy as well as the fetus itself, expressed in the notion that the pregnancy was represented by a calendar and a binder full of test results. It appears that the geographic remoteness of the pregnant surrogate, and the resulting loss of a sense of control over the process, led the interviewees to minimize the importance of the pregnancy—a status that usually plays a crucial role in preparations for parenthood. Many of the interviewees seemed to deal with their limited control by renouncing even the little control they had—in some cases, even feigning ignorance of the fact that the pregnancy was taking place “somewhere out there.” It appears that similar thought processes led participants to play down the role of the surrogate mother. Previous research and psychoanalytic theory suggest that another factor playing into this response might be envy of the pregnant woman on the part of the fathers-to-be (van den Akker, 2007b). Whether this is the case is beyond the scope of this research.

The inability to develop a relationship with the unborn fetus was the most painful experience described by the interviewees in this study and the one with potentially the strongest ramifications. Without physical or tactile contact with the developing fetus, the interviewees lacked access to the fantasy world normally experienced by expectant parents—the imaginary baby representation through which parents-to-be psychologically and emotionally prepare for the coming birth, making room in their lives for this helpless new member of the family. Instead of an “imaginary infant” whom they could touch and speak to, and with whom they could share their dreams, fears, and expectations, our interviewees created a more substantial “imaginary child” with a real name, defined traits, and a specific character. Meanwhile, their preparations for parenthood revolved around practical, concrete concerns: Who will take paternity leave? Who will pick up the child from day care? Their practical preparations resembled those of other parents, including heterosexual couples: Cutting down on their smoking, moving house, and reorganizing work–family priorities. However, the interviewees were strongly conscious of what they perceived as a missing emotional layer in their preparations for parenthood. This emotional layer, they hoped, would be established once they had a physical connection with their newborn child.

This study focused on gay couples who employ cross-border reproductive services to have children of their own through surrogacy. The individuals concerned are gay men who want to experience fatherhood as heterosexual fathers do—namely, in the context of a traditional style nuclear family comprising two parents and a child or children (rather than, say, shared parenthood agreements, in which the mother and father share parental rights). Correspondingly, their introspective self-descriptions showed that our interviewees did not see themselves primarily as a part of a wider group of people who employ cross-border reproductive services. Rather, they expressed envy of heterosexual fathers who were able to enjoy physical and tactile contact with the developing fetus in their partner’s belly. To some degree, this may reflect an increasing need on the part of the participants for social acceptance and normalcy. As one of the interviewees phrased it, “The hardest thing about coming out of the closet was internalizing that I would not have children. When you understand there is an option, something biological that was hidden wakes up…. The possibility of having a child as a couple, like everyone else, mean we are ‘okay’—a part of society.”

Overall, our findings support other studies (Sanabria, 2013) that suggest that the intended parents would benefit from an emotional connection with the surrogate mother throughout a surrogate pregnancy. Of course, these needs of the intended parents must be weighed against the needs of the surrogate mother. However, recent studies suggest that the surrogate mother, too, can benefit from mutual openness and sharing of emotions (van den Akker, 2007a, 2007b). At the moment, each country has its own set of roles regarding cross-border reproductive services in general and surrogacy services in particular, reflecting different nations’ differing values and culture. The current findings support recommendations by Blyth (2012c), Thorn, Wischmann, and Blyth (2012) and others for the establishment of international guidelines for cross-border reproductive services.

Another issue raised by the current findings involves the need for counseling tailored to gay couples engaged in the surrogacy process. Sanabria (2013), sharing his own surrogacy experience, describes the uncertainty inherent in the process as one of its most frustrating and complex aspects. Aside from the issues surrounding the pregnancy and the connection with the surrogate mother described in this study and others, sources of uncertainty and stress imbue every aspect of the process, from identifying a surrogate mother and making financial arrangements, via the in vitro fertilization conception process and the possibility of failure to conceive (Edelmann, 2004; Schwerdtfeger & Shreffer, 2009), to finally receiving the newborn baby. Health professionals trained to provide counseling designed to meet the needs of the parties involved in surrogacy could help ease the strain and anxiety related to this process. However, the literature focused on such counseling is limited, and literature dealing specifically with the unique situation of gay couples is even scarcer (Ciccarelli & Beckman, 2005; Hanafin, 2006; Pashimi, Ahmadi, & Tabatabaie, 2009). This study adds to others (e.g., Sanabria, 2013) in highlighting the need for trained counselors able to provide relevant and meaningful information relating to legal issues (Dana, 2011; Drabiak, Wegner, Fredland, & Helft, 2007) as well as care to help relieve the uncertainty, frustration, unease, and anxiety arising from the surrogacy process. Our findings—along with those of other studies (see Blyth, 2012b, 2012c; Sanabria, 2013; van den Akker, 2007a)—may help in the development of strategies to counsel couples who cannot experience pregnancy firsthand as they develop their parenting identity.

Finally, our findings highlight the need to further explore the experience of parents who choose unconventional pregnancies, and they suggest interesting avenues for future research. For example, an overseas surrogate pregnancy is similar to adoption in that the intended parents miss out on the progressive physical and psychological effects of pregnancy that normally help the expectant couple prepare for parenthood (Frith et al., 2011). Future studies might examine whether and how the early adaptation to parenthood differs between adoption and surrogacy, where the parents-to-be generally have a biological as well as emotional connection to the child.

The limitations of this study should be noted. We drew our participants from two Israeli agencies that offer surrogacy services in India and in the United States. The population of the study thus excluded prospective parents from cultures other than Israel, and prospective parents who used agencies offering services in other locations, such as Western or Eastern Europe (Pennings et al., 2009). In addition, most of the couples who took part in this study chose to have the procedure take place in India. As mentioned previously, the Indian and American tracks differ significantly in terms of the relationship forged by the parents-to-be with the pregnancy and the surrogate mother. In India, the agency serves as a mediator throughout the process, whereas in the United States, the intended parents select the surrogate mother and can establish a close connection with her; they also assume a much greater role in the progression of the pregnancy. Since the majority of our participants resorted to surrogacy in India, our findings should be seen as a reflection of this choice.

Nevertheless, this study helps us understand a growing phenomenon: Unable or unwilling to adopt and reluctant to go through the difficulties and complexity of shared parenthood, an increasing number of gay couples in Israel now turn to overseas surrogacy. Amid the public debate about this particular path to parenthood, it is difficult to find many studies that focus on the parents’ experience of this complicated process. It should also be pointed out that the participants in this study belong to a minority population struggling for its rights, notably in the fields of matrimony and parenthood. This study aims to give this population a voice and allow its members to share their unique experience.

Footnotes

Appendix

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Bergman

Rubio

R. J.

Green

R. J.

Padron

. (2010). Gay men who become fathers via surrogacy: The transition to parenthood. Journal of GLBT Family Studies, 6, 111–141. doi:110.1080/15504281003704942

Blyth

(1995). “Not a primrose path”: Commissioning parents’ experience of surrogacy arrangements in Britain. Journal of Reproductive and Infant Psychology, 13, 185–196.

Blyth

(2010). Fertility patients’ experiences of cross-border reproductive care. Fertility and Sterility, 94, e11–e15.

Blyth

(2011). One parent or five—more of the same from the Commission on Parenthood's Future. BioNews, 631.

Blyth

(2012a). Access to genetic and birth origins information for people conceived following third party assisted conception in the United Kingdom. The International Journal of Children's Rights, 20, 300–318.

Blyth

(2012b, July). Crossing borders for fertility care: Where should the line be drawn? Retrieved from http://www.varta.org.au/crossing-borders-for-fertility-care/

Blyth

(2012c). Guidelines for infertility counselling in different countries: Is there an emerging trend? Human Reproduction, 27, 2046–2057.

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101.

Brennan

Ayers

Ahmed

Marshall-Lucette

(2007). A critical review of the Couvade syndrome: The pregnant male. Journal of Reproductive and Infant Psychology, 25, 173–189. doi:110.1080/02646830701467207

10.

Ciccarelli

J. C.

Beckman

L. J.

(2005). Navigating rough waters: An overview of psychological aspects of surrogacy. Journal of Social Issues, 61, 21–43.

11.

Crawshaw

Blyth

van den Akker

O. B. A.

(2012). The changing profile of surrogacy in the UK—Implications for national and international policy and practice. Journal of Social Welfare and Family Law, 34, 1–11. doi:10.1080/09649069.09642012.09750478

12.

Culley

Hudson

Rapport

Blyth

Norton

Pacey

(2011). Crossing borders for fertility treatment: Motivations, destinations and outcomes of UK fertility travellers. Human Reproduction, 26, 2373–2381.

13.

Dana

A. R.

(2011). The state of surrogacy laws: Determining legal parentage for gay fathers. Duke Journal of Gender Law and Policy, 18, 353–390.

14.

Drabiak

Wegner

Fredland

Helft

P. R.

(2007). Ethics, law, and commercial surrogacy: A call for uniformity. Journal of Law, Medicine, & Ethics, 35, 300–309.

15.

Edelmann

R. J.

(2004). Surrogacy: The psychological issues. Journal of Reproductive and Infant Psychology, 22, 123–136. doi:110.1080/0264683042000205981

16.

Finn

Henwood

(2009). Exploring masculinities within men's identificatory imaginings of first-time fatherhood. British Journal of Social Psychology, 48, 547–562. doi:510.1348/014466608X014386099

17.

Friedman

(2007). First comes love, then comes marriage, then comes baby carriage: Perspectives on gay parenting and reproductive technology. Journal of Infant, Child & Adolescent Psychotherapy, 6, 111–123.

18.

Frith

Blyth

Paul

M. S.

Berger

(2011). Conditional embryo relinquishment: Choosing to relinquish embryos for family-building through a Crhistian embryo ‘adoption’ program. Human Reproduction, 26, 3327–3338.

19.

Genesoni

Tallandini

M. A.

(2009). Men's psychological transition to fatherhood: An analysis of literature 1989-2008. Birth, 36, 305–317. doi:310.1111/j.1523-1536X.2009.00358.x

20.

Hanafin

(2006). Surrogacy and gestational carrier participants. In Hammer Burns

Covington

S. N.

(Eds), Infertility counseling (pp. 375–388). Pearl River, NY: Parthenon.

21.

Hughes

DeJean

(2010). Cross-border fertility services in North America: A survey of Canadian and American providers. Fertility and Sterility, 94, e16–e19.

22.

Israel Government Portal. (2011). Guide to infertility, adoption and surrogacy. Retrieved from http://www.gov.il/FirstGov/TopNav/Situations/SSituationsInLife/SFerSurAdop/SFSurrogacyEntitlement/ (In Hebrew).

23.

Kleinpeter

C. B.

(2002). Surrogacy: The parents’ story. Psychological Reports, 91, 135–145. doi:110.2466/pr2460.2002.2491.2461.2201

24.

Lederman

Weis

(2009). Psychosocial adaptation to pregnancy. New York, NY: Springer.

25.

Lev

A. I.

(2006). Gay dads: Choosing surrogacy. Lesbian & Gay Psychology Review, 7, 73–77.

26.

MacCallum

Lycett

Murray

Jadva

Golombok

(2003). Surrogacy: The experience of commissioning couples. Human Reproduction 18, 1334–1342. doi:1310.1093/humrep/deg1253

27.

Mander

(2001). Fatherhood today: Variations on a theme. Psychodynamic Counselling, 7, 141–158. doi:110.1080/135333300110041255

28.

Nakash

Herdiman

(2007). Surrogacy. Journal of Obstetrics and Gynaecology, 27, 246–251. doi:210.1080/01443610701194788

29.

Palattiyil

Blyth

Sidhva

Balakrishnan

(2010). Globalization and cross-border reproductive services: Ethical implications of surrogacy in India for social work. International Social Work, 53, 686–700.

30.

Pashimi

Ahmadi

S. A.

Tabatabaie

S. M. S.

(2009). The need for counseling surrogate mothers before practicing surrogacy. Medical Journal of Reproduction and Infertility, 9, 361–372.

31.

Pennings

Autin

Decleer

Delbaere

Delbeke

Delvigne

… Vandekerckhove

(2009). Cross-border reproductive care in Belgium. Human Reproduction, 24, 3108–3118.

32.

Poote

van den Akker

O. B. A.

(2009). British women’s attitudes to surrogacy. Human Reproduction, 24, 139–145.

33.

Ragoné

(1996). Chasing the blood tie: Surrogate mothers, adoptive mothers and fathers. American Ethnologist, 23, 352–365. doi:10.1525/ae.1996.1523.1522.1502a00090

34.

Raphael-Leff

(2001). Pregnancy: The inside story. Northvale, NJ: Jason Aronson.

35.

Raphael-Leff

(2009). Psychological processes of childbearing. London, England: The Anna Freud Center.

36.

Riggs

D. W.

Due

(2010). Gay men, race privilege and surrogacy in India. Outskirts Online Journal: Feminisms along the Edge, 22. Retrieved from http://www.outskirts.arts.uwa.edu.au/volumes/volume-22/riggs

37.

Sanabria

(2013). When adoption in not an option: Counseling implications related to surrogacy. Journal of Gay & Lesbian Social Services, 25, 269–286. doi:10.1080/10538720.2013.806880

38.

Schwerdtfeger

K. L.

Shreffer

K. M.

(2009). Trauma of pregnancy loss and infertility among mothers and involuntary childless women in the United States. Journal of Loss and Trauma, 14, 211–277.

39.

Thorn

Wischmann

Blyth

(2012). Cross-border reproductive services—suggestions for ethically based minimum standards of care in Europe. Journal of Psychosomatic Obstetrics & Gynecology 33, 1–6.

40.

Tuazon-McCheyne

. (2010). Two dads: Gay male parenting and its politicization—a cooperative inquiry action research study. The Australian and New Zealand Journal of Family Therapy, 31, 311–323. doi: http://dx.doi.org/310.1375/anft.1331.1374.1311

41.

van den Akker

O. B. A.

(2000). The importance of a genetic link in mothers commissioning a surrogate baby in the UK. Human Reproduction, 15, 110–117.

42.

van den Akker

O. B. A.

(2003). Genetic and gestational surrogate mothers’ experience of surrogacy. Journal of Reproductive and Infant Psychology, 21, 145–161.

43.

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 genealogy. Journal of Psychosomatic Obstetrics and Gynecology, 26, 277–284.

44.

van den Akker

O. B. A.

(2007a). Psychological trait and state characteristics, social support and attitudes to the surrogate pregnancy and baby. Human Reproduction, 22, 2287–2295.

45.

van den Akker

O. B. A.

(2007b). Psychosocial aspects of surrogate motherhood. Human Reproduction Update, 13, 53–62.

46.

Zayas

L. H.

(1988). Thematic features in the manifest dreams of expectant fathers. Clinical Social Work Journal, 16, 282–296.