US Surrogates’ Motivations and Satisfaction – A key to read the social context

The Social Context for Surrogates’ Motivations and Satisfaction” (2014) is an article written by Zsuzsa Berend, sociologist of UCLA.

Berend starts this article talking about one of the persistent surrogacy fears related to surrogacy; what about if the surrogate, who carries for the IP, regrets her decision when the process is completed? (Teman, 2008) As I’ve already shown in a previous blogpost “My Bun, Her Oven” An Anthropological Review, how Elly Teman has analyzed why the large portion of the thoughts express a sense of discomfort with surrogacy. In sum: gestational surrogacy (GS) reveals the strong cultural assumption in Western society that women “naturally” develop instinctive bonds and love with the babies in their bellies, and they won’t give the babies away unless they are desperate, forced, or out of their minds.

Berend article
Within the substantial literature on surrogacy that has analyzed this practice for over 20 years, there are just few longer-term data results on it. On the Reproductive BioMedicine Online, Imrie and Jadva (2014) have published a long-term study on surrogates ‘experiences. This research has found that most of the surrogates were satisfied with the relationship they had with the intended parents (IPs) and have shown no regrets for their journey as surrogates. (I will discuss about it in the future).

Berend has conducted a decennial research on surromomonline (SMO), one of the largest US surrogacy support website until the early 2000s. She has analyzed how US surrogates collectively defined their experience, reading which kind of expectations they had about their journey. The sociologist, noticed that there has been a change throughout the years: in the early 2000s, surrogates expressed the desired for an ongoing friendship with the intended parents. While, over time, surrogates have presented a different representation of the relationships with the IPS. In some cases, they did not have any contact after the delivery or have reported to feel abandoned by the IPs. Berend found that the surrogates constructed some social explanations to describe why the parents acted in the way the acted. Such as, the parents wanted to bond with the newborn or simply because they were new busy parents.

This paper is interesting because Berend suggests to keep separated the meaning of the relationship from the meaning of satisfaction. She explained that meanings are social, while satisfactions are personal feelings that involve individual interpretations of different experiences. In general, the degree of the satisfaction is related to our expectations. What does it mean being satisfied and how can we understand when and if we are satisfied? Berend said that we make a kind of comparison with our previous experience, referring to a range of practical expectations constructed on our prior knowledge. Following her thoughts, if these expectations are satisfied, we feel satisfied. As Berend asks: “[…] how do we know what to expect in new social relationships such as surrogacy?” (2014:399). Within surrogacy, satisfaction is harder to define, because it is the outcome of an intricate set of evaluation about what the relationship could be and what in concrete is.

US surrogates of SMO blog discussed about the relationship with the IPs, emphasizing that surrogacy doesn’t mean having new friends; it is more to help someone to create their own family. Related to that, there were a lot of advice for avoiding having high expectations about the relationship the surrogates could have with the IPs, during before and after the birth. In literature (Berend,2016; Teman, 2010), the most common way to stay in touch are: some periodical emails, some pictures exchanged through social media and, less often, some presents sent between them. What does it mean to stay in touch and how to stay in touch? I will analyze the meaning of that during my research.

Often surrogacy is a hybrid of contractual and gift relationship, and gifts and relationships are not terminated in the same way that contractual relations are.” (2014:400).

Berend continues her article paying attention to the other main question of the study: the surrogates’ motivations. What are the reasons why some women become surrogates? In their research, Imrie and Jadva found that most answers were, wanting to help a couple and the pleasure of being pregnant. These were similar answers that other researchers received in other cultural contexts. The most popular motivations find in literature are the payment, the desire to help a childless couple and the enjoyment of the pregnancy. For more information, I suggest to read this article.

References
Berend Z., 2016, The Online World of Surrogacy, Berghahn Books, New York – Oxford.
Carries J., 1991, Gift, commodities, and social relations: a maussian view of exchange. Sociol. Forum 6, 119 -136.

Imrie S. and Jadva V., 2014, The Long-term experiences of surrogates: relationship and contact with surrogacy families in genetic and gestational surrogacy arrangements. Reprod. Biomed.

Teman E., 2008, The Social Construction of Surrogacy research: An Anthropological critique of the psychological scholarship on surrogate motherhood. Doc Sci. Med. 67, 1104-1112.

Teman, E., 2010. Birthing a Mother. The Surrogate Body and the Pregnant Self, The University of California Press, Berkeley, CA.

“What Egg Donation is All About”. An Interview with Leslie, Medical assistant & Senior Egg Donor Coordinator at WFI

Leslie began her journey at the Western Fertility Institute as an intern in April, last year. Throughout the process she became a Medical Assistant in April, and a Senior Egg Donor Program Coordinator. As Leslie said, she had a “very big teacher, Quiana”. She was taught about fertility and surrogacy during her internship; before that, she never thought about working in this field.

A medical assistant helps nurses and doctors, and has several other functions. Leslie spends most of her time doing blood work. As she said, taking blood is not just a routine job: “I am kind of a confidant for surrogates and egg donors. I try to construct a personal relationship with them. I know their journey, their troubles, their history…”.

blood

She continuously follows the journey of the egg donors. Leslie is by their side for all the steps of the procedure. There are many reasons why a woman enters in the egg donation process. As Leslie pointed out: “Whatever the reason why a woman is making this act, she needs to be informed more about the process of the egg donation. She is giving a part of herself away, it is a part of them”. She makes sure they are informed of the possible connections that egg donation can construct.

As she explained to me, every donor receives a different protocol. In general, the medication that a donor has to follow takes about 10 days. Every 1 or 2 days, the donor has to make a blood analysis at WFI in order to see if the follicles are growing (2mm each day). When the eggs are “ready”, the egg retrieval occurs. At WFI they are performed every Wednesday and Friday. The whole procedure takes about 2 hours: 30 minutes to prepare the patient for the surgery, 15 minutes for the retrieval itself, and the time left for the recovery. “We wait until the patient feels comfortable, we control the situation and make sure everything is fine”. Leslie follows donors throughout all the journey.

test tube

She works also with the surrogates, but the relationships she constructs with them are quite different. If a donor is going to WFI every 2 days, the surrogates spend less time at the clinic. The relationship that Leslie is building with the donors is more intense because they spend more time together talking about egg donation, the medications, but also about the everyday life. She said that probably this connection she feels is related with the age and the experience that the patient has. In comparison to the donors, the surrogate already knows what a pregnancy is, they know what to expect from it. “They had experienced the gestation, so they know what will happen to their body. Yes, they ask a lot of question about the medication, and in general, about all the medical procedures. I make sure donors understand what egg donation is all about. I make donors understand the procedure. I try to explain to them all the information I know; it is a way to keep them more involved. They can trust us. They become basically family with us”.

I asked Leslie her favorite aspect of her job, she mentioned: “My favorite part is connecting with people. I love helping people with their journey. I am part of their story, I am helping them to create a family”.

Sonia, a 3rd Party Coordinator: A Liaison Between Different Subjects

Sonia is the first employee of Western Fertility Institute that I have interviewed. I entered her office while she was filling out some documents for a gay couple. With 20 years of experience in the medical field, she mentioned she did not have any idea the extent the fertility industry had grown and the number of people that were becoming a part of it.

Sonia is currently a 3rd party coordinator at the Western Fertility Institute.
As a coordinator, Sonia wears many hats. She works with a vast variety of different people including, intended parent(s), egg donor and surrogates. She doesn’t just interact with them, she becomes the liaison between different figures within and out of WFI.  

foto so

She follows and takes care about different aspects of the pathway, from the first match between parties throughout the journey and delivery. Communication is one of the important skills she needs to manage during the months. Every part of the process is separated from one another, but everything is interconnected, like in a puzzle. Anxiety, anticipation, timing, waiting, joy and happiness are just some of the emotions she has to balance with each patient she is working with.

Every story is different; every patient has their own reason why they’re here. Sometimes the IPs keep the surrogate updated. Sometimes not. I have to work and make sure that everything is going well, for all the parties involved in the process.”

I asked Sonia, what is it that she loves most about her job, she replied: “My favorite part is when the Intended Parents get the news they are having a baby”.

Comments on Berend’s interview: Money, Contract & Relationship

With the interview with sociologist Zsuzsa Berend of UCLA, we have touched the heart of some thematic nodes that are often at the center of numerous debates. In this new article, I briefly comment the aspects I found most interesting and useful for my research.
The most common type of surrogacy in the United States is gestational surrogacy – GS (Perkins KM, Boulet SL, Jamieson DJ, Kissin MD, 2016), that it has been practiced for three decades (Twine 2015). Is money the most relevant resource in the surrogacy experiences? To try to answer this common question, I would like to focus my attention on 3 different aspects: money, the contract and the relationship.

1. Money
Money is seen as something that gives more power to those who possess it and guarantees them to acquire a privileged position within the surrogacy pathway. In other words, who owns the money is seen as the one who has advantages over those who enter in the circuit and have a lower economic position than the intended parents. Quite on the contrary, Berend (2016) decade-long ethnographic research on US surrogates has revealed that surrogates (mostly married, white, middle-class women) discuss their choices, resources and voice their opinions about agencies, clinics, and practices. Her findings show how surrogates define choice and resources in a way that contradict the “taken-for-granted” notions about vulnerability and the role of money within the arrangement of surrogacy. Berend talking about money: “Obviously, it is a resource because people that don’t have the money can’t probably start the surrogacy process, but also people with money cannot even end up with a baby if the surrogate doesn’t put her resources, her generosity, her fertility and all the other skills that they are so proud of, into providing the baby for this couple”. Money clearly is not the only resource in these exchanges.

2. Contract
As Berend (Ibidem) has pointed out during the years, “the contract became more and more sophisticated”. How the surrogates see the contract? Following the answer of Berend “They don’t think of this as something that people force on them, they very much want to understand what contracts entail and act to have their own contract”. But one of the most fascinating points she found is that the surrogates saw the contract like the basis of a social relationship with the intended parents (IPs), like the test of a character and the compatibility.

3. Relationship
In this view, the contract plays an important role, not only for legal purposes, but because it became clue of the future relationship and communication. The Surrogates desire to transform the surrogacy journey into a mutual gift-giving relationship, during the contract phases, allows the ability for both parties to understand the type of relationship they will have and the type of people they will be dealing with.
I think these 3 aspects play an important role during the surrogacy pathway. This is why I’ve decide to focus my attention on them during the first part of my fieldwork.

 

References
Berend. Z. (2016). The Online World of Surrogacy, New York: Berghahn Books.

Twine, F. W., (2015), Outsourcing the Womb:Race, Class, and Gestational Surrogacy in a Global Market. Second Edition. New York and London: Routledge.

Perkins KM., Boulet SL., Jamieson DJ, Kissin DM., (2016), National Assisted Reproductive Technology Surveillance System (NASS) Group. Trends and Outcomes of gestational surrogacy in The United States, Fertility and Sterility: 106; 435-42 e 2.

 

“The Online World of Surrogacy”

Surrogacy is considered to be an assisted reproductive technology by the World Health Organization (Zegers-Hochschild et al., 2009). Nevertheless, this practice is one of the most controversial procedures in the field of assisted reproduction. What are the reasons why this procedure is at the center of a series of political and cultural battles?

There are numerous preconceptions that exist around this practice. It has been argued that surrogacy may exploit women from a more economically disadvantaged background (Blyth, 1994). For example, the women may enter into a surrogacy arrangement because of financial hardship without being fully aware of the potential risks (Brazier et.al., 1998). The media tends to report only the negative aspects of surrogacy: in where the surrogate refuses to relinquish the child (as the “Baby M” case – New Jersey Supreme Court, 1987) or in which the surrogates have changed their mind after the delivery. In sum, surrogacy is depicted and especially criticized as an exploitative practice, in which the women are not completely free and self-conscious about their decisions.

As many researchers pointed out, and as anthropologist, I suggest that it is essential: A) to consider the local context in which surrogacy takes place; B) to consider the experiences and the positions of the different subjects involved in these journeys because they can be so different in relation to various socio-cultural and economic contexts.

There are two main motivations that drove me to interview Zsuzsa Berend, sociologist of University of California – Los Angeles (UCLA):

1. We know little about the women who have chosen to take part into this pathway. Berend spent more than 10 years studying the website http://www.surromomsonline.com, analyzing the meaning and the mutual knowledge everyday constructed by the surrogates. Her book is a way to know more about their thoughts, their point of view and their experiences.

2. Berend offers some unique perspective of surrogacy in the U.S.

The Online World of Surrogacy” is the last book of Zsuzsa Berend. The title anticipates the object of her book, as well as the methodology she used for conducting research on the surrogates’ journey. Although in the last years surrogacy has become a hot topic, there are not many studies that have focused their attention on the surrogates’ lives.

My questions focused on what I’ve found important to highlight for reading the surrogates’ experiences from a scientific and a different point of view, including the contract, the gift-giving narrative, the surrogate’s agency and the relationship between the ‘altruistic” and “commercial” dimension of surrogacy.

In your book, you paid a lot of attention to the contract. Can you explain to us the reasons why you deiced to do that?

The contract, I think, grew as a chapter because I realized as I was writing how significant it is in their own imagination, not just legally but also in terms of the relationship, how they really think that this is the way to figure out the relationship, to make sure that it is going to work. And as they said that the contract is such a negotiation throughout that contract phase, are just so difficult that if people survived that, well then, they come out of it as stronger partners in the journey. But what I also found throughout my ten or so years doing this research, is that the contract became more and more sophisticated, and they added more and more. Both sides, it seems, and of course the legal professionals became more specialized Contracts have gotten much longer, much more intricate, with many more issues that really need to be negotiated, restrictions on the surrogates, conditions on the surrogates, termination of the pregnancy, and some of these things were so important for the surrogates: pregnancy terminations, embryo transfer practices, they became a lot more important, a lot more prominent for them over time. Money issues are important, too, especially items such as lost wages and childcare in case of complication during pregnancy. Women may lose money if lost wages are capped, for example.

People who are generally against surrogacy, depict the contract as a tool designed to force women to accomplish a “task”, based on the fact they have signed it. What does your research reveal about surrogates’ experiences?

In their understanding, the contract, is this binding manifestation of something that they think honorable and responsible people should all work out anyways. And even if the contract is not legally binding, they always encourage everyone to have such a contract, knowing that it is not going to be good for legal purposes, it is still certainly worth going through for the purposes of the journey, the purpose of clarifications, and the purposes of knowing exactly where you stand and what you want and what you agree to. So, in that sense they are just as adamant that contracts are important as the intended parents are. They don’t think of this as something that people force on them, they very much want to understand what contracts entail and act to have their own contract.

There is a complex meaning around the concept of the gift-giving. Often, the common sense tends to describe just the baby as the gift of life. What did you finding can add to this discussion?

I think, it would be very simplistic to think of the baby as the precious gift, because when you actually read all the things that they are talking about, it is a whole long list of things that they include and obviously first of all, it starts with the willingness to carry for this couple. Because they always say that the money itself it is not enough, so there must be some other good motivations, and some generosity, some compassion, some other element that goes into wanting to be a surrogate. So, their ability to gestate, of course, is a kind of a gift in a way because they always think about their own children like gifts, so they don’t think that people can own children or can buy children.

When they talk about their own children as a gift, then you also think about children in general may be gifts and the ability to produce them is a gift, and their generosity to carry for others is a gift. And then it is more and more complicated as they actually are doing the surrogacy, because then all the bodily involvement, and anything that is difficult to go through become the surrogates’ gift to the intended parents. But then they talk about the gift of trust that they are receiving the gift of trust, because the intended parents are trusting them to carry “their baby”, and surrogates are honored to be trusted to gestate the baby It becomes very interesting, a mutual kind of gift-giving narrative and practices around to this mutual gift-giving.

In the surrogacy agreements, there are many different forms of power that play a role during the journey. How can you describe the power play of money and the surrogate’s agency?

Surrogates think about their ability to gestate and to give birth, as following all the rules and all the medical procedures, the protocols as kind of a resource, as a skill, not something that is given but like a combination of skills and abilities that is pretty valuable and pretty impressive. Their fertility is a biological fact but using it to carry other people’s children is a purposeful activity. The fact that they will do that, the fact that they will follow the protocol even if that it means shots, and medication, and various procedures that are invasive and take time to go to medical appointments, they think of all those things as somehow this package that are resources that the intended parents, some of the intended parents don’t have, so they are lacking resources. This is this interesting reversal: the surrogate can do things for this couple that the couple can’t do themselves and surrogates are very proud of that, and they take agency [personality] very seriously. And they would say: “I know my body, I know I can do that. The doctor said this, but I know my body better”. So, they have a lot of stories in which they underline their agency, as well as their ability, and their resources as they see. They do think of themselves as powerless at all. They also say that surrogates need to be informed and knowledgeable and be their own advocates, rather than simply rely on doctors’ or other professionals’ advice or opinion.

Many critics say that money is the most important resource to analyze this practice?

A lot of the people think about the money as the most relevant resource in this domain because it does cost a lot for couples: to pay the surrogates, pay clinics and doctors and legal experts. But what it is missing here is that money by itself can’t buy babies and there is a lot of truth in the surrogates’ point of view which is that that here is the couple that spend a lot of money in treatments, IVF, and various things and clearly, they still don’t have a baby. So, money is clearly not the only resource. And of course, the intended parents, the mothers offer their stories of years and years of treatments, many IVF procedures and the baby … and the money is not the only important resource. Obviously, it is a resource because people that don’t have the money can’t probably start the surrogacy process, but also people with money cannot even end up with a baby if the surrogate doesn’t put her resources, her generosity, her fertility and all the other skills that they are so proud of into providing the baby for this couple. And obviously, in their understanding, the IPs see the surrogate like a key component during the surrogacy process.

Did you analyze the relationship between altruistic and commercial dimension of surrogacy?

In these kind of relationships, where the intimate and the financial components are so interrelated, I think there is more of a continuum rather than opposition. In general altruism coexists with commercial practices. When money changes hand there is still a space for altruism and vice versa. In this kind of interactions and relationships, that involve bodily commodities (as some people called it) it is always going to be a kind of coexistence of altruism and commodified exchange, of gift and money, because these are not standard produced goods. There are all kinds of risks involved in these kinds of practices that people can’t put a price tag on. I know it sounds a little cheesy, but there are economists like Kenneth Arrow, for example, that write about how certain risks don’t have a monetary price, or compensation amount and can’t express this kind of risk in monetary terms.

BerendOnline

Barend’s answers are useful to observe and understand the surrogacy practice from a different point of view.

Berend also has an impressive range of publications within the field, as listed below:

Berend, Z. (2010). “Surrogate Losses: Understandings of Pregnancy Loss and Assisted Reproduction among Surrogate Mothers,” Medical Anthropology Quarterly, 24, 240-262.

Berend, Z. (2012). “The Romance of Surrogacy,” Sociological Forum, 27, 913-936.

Berend, Z. (2012) “Surrogate Losses: Surrogate Mothers, Pregnancy Loss, and Assisted Reproduction,” in Understanding Reproductive Loss: International perspectives on life, death and fertility. Earle, S., Komaromy, C. & Layne L. L. (Eds). Ashgate Publishing Company, Burlington, VT, 93-104.

Berend, Z. (2014). “The Social Context for Surrogates’ Motivations and Satisfaction,” Commentary, Reproductive Biomedicine Online, 29, 399-401.

Berend, Z. (2016). “We Are All Carrying Someone Else’s Child:” Relatedness and Relationships in Third-Party Reproduction.” American Anthropologist, 118, 24-36.

Berend, Z. (2016). “Labor of Love” and Emotion Work: surrogacy arrangements in the US. An ethnographic account.” In: Handbook of Gestational Surrogacy: International Clinical Practice & Policy Issues. Sill, E. S. (Ed.). Cambridge University Press.

Berend. Z. (2016). The Online World of Surrogacy, New York: Berghahn Books.

Berend. Z. & Teman. E. “Surrogate Non-Motherhood: Israeli and US Surrogates Speak About Kinship and Parenthood,” With Elly Teman. Anthropology & Medicine, forthcoming.

For further information: https://www.opendemocracy.net/beyondslavery/zsuzsa-berend/online-world-of-surrogacy

References

• Berend. Z. (2016). The Online World of Surrogacy, New York: Berghahn Books.

• Blyth E., (1994), “I wanted to be investigating. I wanted to be able to say ‘I’ve done something interesting with my life’”, Interviews with surrogate mothers in Britain., J. Reprod. Infant. Psychol., 12, 198-198.

• Brazier M., Campbell A., and Golombok S. (1998), Surrogacy: review for health ministers of current arrangements for ppayments and regulation. No. CM 4068, Department of health, London.

• Zegers-Hoschchild, Fernando, G. David Adamson, Jaques de Mouzon, Osamu, Ishihara, Ragaa Mansour, Karl-Gosta Nygren, Elisabeth Sullivan, and Sheryl Vanderpoel (on behalsf of ICMASRT and WHO). 2009. “International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the Worls Health Organization (WHO) Revised Glossary of ART Terminology. “Human Reproduction 24(11):2683-2687.