Views of Swedish commissioning parents relating to the exploitation discourse in using transnational surrogacy

The future of surrogacy: a review of current global trends and national landscapes

The practice of surrogacy is frequently the subject of media, scientific, social, regulatory and policy attention. Although it is, for many, an accepted form of assisted reproduction for those who would otherwise not be able to have children, surrogacy often generates strong feeling, particularly where there is any possibility of exploitation. Therefore, there is disagreement about how it should be regulated. In some countries, surrogacy is prohibited in any form, although this does not stop people using it. In others, it is unregulated but still practised. In some nations it is regulated in either a 'commercial' or an 'altruistic' model. This review article considers the possible regulatory future of surrogacy, initially from a UK perspective considering a recent review of the legal framework in a country where surrogacy works well (although some cross borders to access it), and then through an assessment of global trends and other national perspectives. It concludes that the international regulation of surrogacy, although potentially desirable, is unlikely. This being the case, it would be preferable for individual nations to regulate surrogacy so it can be undertaken in ways that are safe, ethical and protective of the best interests of children, surrogates, intended parents and families.

Commercial surrogacy: Landscapes of empowerment or oppression explored through integrative review

The surge in demand for surrogacy treatments, combined with regulatory loopholes, has spurred the widespread adoption of global commercial surrogacy. This phenomenon poses potential risks to all involved parties, including surrogates and children, encompassing ethical, legal, physical, and psychological concerns. Although commercial surrogacy is under discussion in various jurisdictions, some countries may reintroduce legislation on the matter. In addressing this intricate landscape, the researchers performed an integrative review of existing literature with the intention of providing guidance to researchers and policymakers. The researchers emphasized notable legal and ethical challenges linked to commercial surrogacy. Surrogates often experience disempowerment and oppression, exacerbated by the contractual nature of these arrangements, perpetuating structural inequalities. Children born through commercial surrogacy, especially internationally, risk losing cultural heritage and future benefits. Banning commercial surrogacy may drive it underground, harming surrogates. Reconsidering prohibitions without penalizing surrogates could mitigate downstream issues and safeguard them from exploitation.

Commercial Surrogacy: An Overview

OBJECTIVE

 Surrogacy is the process in which a woman carries and delivers a baby to other person or couple, known as intended parents. When carriers are paid for surrogacy, this is known as commercial surrogacy. The objective of the present work is to review the legal, ethical, social, and cultural aspects of commercial surrogacy, as well as the current panorama worldwide.

METHODS

 This is a review of the literature published in the 21st century on commercial surrogacy.

RESULTS

 A total of 248 articles were included as the core of the present review. The demand for surrogate treatments by women without uterus or with important uterine disorders, single men and same-sex male couples is constantly increasing worldwide. This reproductive treatment has important ethical dilemmas. In addition, legislation defers widely worldwide and is in constant change. Therefore, patients look more and more for treatments abroad, which can lead to important legal problems between countries with different laws. Commercial surrogacy is practiced in several countries, in most of which there is no specific legislation. Some countries have taken restrictive measures against this technique because of reports of exploitation of carriers.

CONCLUSION

 Commercial surrogacy is a common practice, despite important ethical and legal dilemmas. As a consequence of diverse national legislations, patients frequently resort to international commercial surrogacy programs. As of today, there is no standard international legal context, and this practice remains largely unregulated.

The Liberal Social Values of Swedish Healthcare Providers in Women’s Healthcare: Implications for Clinical Encounters in a Diversified Sexual and Reproductive Healthcare

Objectives: Women’s healthcare is a potential source of cross-cultural conflicts. Diverging values between healthcare providers and patients challenges the provision of culturally sensitive care and meeting migrant women’s needs. The aim is to investigate healthcare providers’ values in relation to sexual and reproductive rights, gender equality, migration and religion in Swedish sexual and reproductive healthcare.

Methods: A national cross-sectional study was carried out. The questionnaire was distributed through a non-probability sample to midwives or other nurses, gynaecologists and obstetricians, and hospital social workers (n = 1,041). Through descriptive statistics, we mapped their values, comparing healthcare provider data to external representative population survey data.

Results: Healthcare providers in sexual and reproductive healthcare displayed homogeneous liberal social values, being permissive towards sexual and reproductive rights and restrictive against gender-based violence. They were for gender equality, expressed low anti-immigrant sentiments, and had even more liberal values than the Swedish population and a demographically comparative sub-population.

Conclusion: Individuals with very liberal values are selected to work in Swedish sexual and reproductive healthcare. Healthcare providers need self-reflexivity to avoid conflicts in clinical encounters in a diversified society.

Outsourcing problems or regulating altruism? Parliamentary debates on domestic and cross-border surrogacy in Finland and Norway

This article employs the concept of respectability and the discursive representation of gender equality policies to discuss how surrogacy is represented in Nordic parliamentary debates and policy documents. The article’s objective is to study how respectability, problems and equality are represented and discursively and rhetorically produced through a comparative study of Finnish and Norwegian political discourses on domestic unpaid surrogacy and cross-border commercial surrogacy. The article uses rhetorical and discursive analysis to analyse the Finnish and Norwegian Parliaments’ bills, members’ initiatives and proceedings from 2002 to 2018. Finland’s policy on surrogacy has evolved from an unregulated and permissive approach towards a more restrictive one, with discourses focusing on medicalisation, equality, altruism and safety concerning domestic surrogacy and problems and risks concerning cross-border surrogacy. Norway’s policy on surrogacy has been restrictive consistently, with discourses focusing on surrogacy as a transnational social problem involving exploitation of women and children, and biocentrism. Analysing surrogacy regulation in Nordic welfare states, the author concludes that policies and parliamentary debates in both countries have expressed expectations for inclusive health policies and social security for families. Cross-border surrogacy is characterised as an unwanted consequence of globalisation and marketisation of reproduction. Surrogate mothers’ respectability is constructed through rhetoric on differences in terms of nationality, class and binary representations of female caring and instrumentalism.

Surrogacy among Filipinos who have struggled with infertility: A discourse analysis

Surrogacy continues to be practiced to address infertility in the Philippines; however, discussions on the method are sparse, given its limited accessibility and morally questionable procedures that may concern potential parents in a developing country. Using discourse analysis, the researchers interviewed ten (10) Filipino Roman Catholics who were struggling with infertility, to uncover how they construct the idea of surrogacy. The study shows the discourses on surrogacy are often approached in a detached manner, where potential parents describe the method as a last choice or one that is never considered. They articulate this position by highlighting the emotional factors surrogacy would entail; the women, in particular, described the involvement of another individual as “taking over” the role of the mother. Participants placed themselves in positions of both power and vulnerability, reconciling the split between surrogacy as a compassionate act or a transactional business. The ambiguous role of faith was also negotiated by the participants, where they argued for surrogacy using alternative teachings or through God-given “free will”. The discourses present considerations for the continued practice of surrogacy among key players in reproductive health in developing countries, recognizing the concerns of infertile couples to enable informed decision-making and policy creation.

Constructions of surrogates, egg donors, and mothers: Swedish gay fathers’ narratives

The study explored in detail how Swedish gay fathers (through surrogacy) talked about the surrogate mother and the egg donor. Thirteen semi-structured interviews with 22 gay fathers were conducted and analysed using critical discursive analysis. The surrogates were primarily constructed as a close family member, but occasionally in terms of their instrumental function. They were often described as active and independent, but occasionally as vulnerable or exploited. The egg donors were in some interviews constructed as close family members, while others talked about them as distant acquaintances. Further, donors were constructed either as a significant individual (for the fathers), or as an instrumental provider of the oocyte. While some participants constructed the surrogate and/or donor as their child’s mother(s), others were more reluctant or ambivalent about the mother construct. In conclusion, the participants engaged in rhetorical work that shed a positive light on surrogacy, and their own decisions were depicted as solid, ethical and genuine. The participants’ positive framing can be understood as the production of a counter discourse, in relation to an ongoing debate in Sweden, in which surrogacy is constructed as exploitation, dehumanization and prostitution.

Surrogacy relationships: a critical interpretative review

Based on a critical interpretative review of existing qualitative research investigating accounts of 'lived experience' of surrogates and intended parents from a relational perspective, this article proposes a typology of surrogacy arrangements. The review is based on the analysis of 39 articles, which belong to a range of different disciplines (mostly sociology, social psychology, anthropology, ethnology, and gender studies). The number of interviews in each study range from as few as seven to over one hundred. Countries covered include Australia, Canada, Greece, India, Iran, Israel, Italy, Mexico, Norway, Russia, Sweden, UK, Ukraine, and the USA. Most studies focus only on surrogacy practices in one country (although often with intended parents from other countries), and some include several countries (e.g. interviewees from several countries or fieldwork in different field-sites). The proposed typology goes beyond the division between altruistic versus commercial, and traditional versus gestational surrogacy, in order to inform further research and to contribute to bioethical and policy debates on surrogacy in a transnational context. Four types of relations are identifiable: open, restricted, structured, and enmeshed. The criteria which influence these relationships are: the frequency and character of contact pre- and post-birth; expectations of both parties; the type of exchange involved in surrogacy arrangements; and cultural, legal, and economic contexts. The theoretical contribution of the article is to further the development of a relational justice approach to surrogacy.

Being questioned as parents: An interview study with Swedish commissioning parents using transnational surrogacy

This study sought to explore how Swedish parents who had commissioned surrogacy abroad experienced the process of parenthood recognition. The study consisted of in-depth interviews with five couples and 10 individuals representing 10 additional couples who had used surrogacy abroad, mainly in India. The construction of motherhood and fatherhood in the Swedish system contradicts how parenthood is defined in the surrogacy process. This study found that the formal recognition of parenthood involved a complex and frustrating process where the presumption of fatherhood and step-child adoption as grounds for parenthood make people feel questioned as parents, negatively affecting parental welfare. Policy makers need to take into account the consequences of an unregulated situation regarding surrogacy, and focus more on the child-parent relationship when regulating surrogacy.

Reproductive and sexual Health of surrogate mothers, developing a care program: a protocol for mixed methods study

Background

Gestational surrogacy is one of the options for women whom pregnancy is contraindicated. Despite of increasing demand for gestational surrogacy, its various aspects are controversial. The unique nature of surrogacy causes surrogate mothers to face a variety of problems such as, ethical confusion, psychological disturbance and reproductive health matters. Therefore, it is necessary to develop a comprehensive care program for reproductive and sexual health providing specific care at prenatal and pregnancy as well as delivery and postpartum period in socio- cultural context of Iran.

Methods

This research is an exploratory study with the qualitative-quantitative sequencing design (mixed) that is consisted of three sequential phases. In the first phase, following a qualitative approach, the researcher will explain needs of reproductive and sexual health in surrogate mothers. In the second phase, a primary reproductive and sexual health care program is designed for surrogate mothers in which, in addition to using the qualitative study results, related papers and texts will be also used. In the third phase of the study, reproductive and sexual health care program will be evaluated by RAND method (RAM).

Discussion

The results of this mixed method study are expected to lead to the development of a reproductive and sexual health care program meeting the needs of surrogate mothers and are in accordance with the cultural conditions of the research community, ultimately leading to improvement in reproductive and sexual health of surrogate mothers.

Surrogate mother - praiseworthy or stigmatized: a qualitative study on perceptions of surrogacy in Assam, India

Background: Surrogacy is a reproductive practice that has been strongly marketed in India as a solution for childless couples. As a result, the number of surrogacy clinics is increasing. Meanwhile, a global discourse on surrogacy, originating from a Western perspective, has characterized surrogacy as being exploitative of women in low-income settings, where poverty drives them to become surrogate mothers.

Objective: This study explored perspectives on surrogacy from men and women in Assam, an Indian state known to be a low-income setting. Surrogacy arrangements in Assam are still uncommon. It can be expected that the dominant global discourses on surrogacy will be unfamiliar to the general population, and the objective was also to position the results within the divergent global discourses of surrogacy.

Methods: In order to explore local views on surrogacy, we conducted individual interviews and focus group discussions with people from various socioeconomic groups in Assam.

Results: Our findings reveal that people in Assam perceive surrogacy as a good option for a childless couple, as it would result in a child who is a ‘blood’ relation – something highly desirable for sociocultural reasons. However, the part played by the surrogate mother complicates local views on surrogacy. Most people consider payment to the surrogate mother contrary to societal norms. A surrogate mother is also often judged in a moral light, either as a ‘bad mother’ for selling her child, or as a ‘noble woman’ who has helped a childless couple and deserves payment for her services.

Conclusions: In order to decrease the stigmatization of women, a regulatory policy is needed that will take into account the complex understandings of surrogacy and perceptions of surrogate mothers in Indian society. In policy, the possible effect of the dominant exploitation discourse needs to be modulated by local understandings of this reproduction method.

Cross-border surrogacy: Experiences of heterosexual and gay parents in Sweden

INTRODUCTION

Surrogacy is a controversial method of assisted reproduction that is not permitted in many countries. While there is some evidence that families following surrogacy seem to fare well, there is limited knowledge about the experiences of parents who turn to cross-border surrogacy. The aim of the present study was therefore to investigate the experiences of heterosexual parents and gay fathers who chose cross-border surrogacy to have a child.

MATERIAL AND METHODS

This cross-sectional survey describes the experiences of 30 families (18 heterosexual parent and 12 gay father families). Participants were recruited through a website for a Swedish surrogacy interest group. The participants were requested individually to complete a postal questionnaire including study-specific questions on their experiences of disclosure and the Swedish Parenting Stress Questionnaire.

RESULTS

All couples but one were still living together and had a child (3 months to 5 years). Parenting stress levels were generally low and were not related to sexual orientation. While almost all parents were open about the child's mode of conception in contacts with health care, gay fathers were significantly more open about using surrogacy in contacts with preschool (P = 0.004) and child recreational activities (P = 0.005) compared with heterosexual parents. A majority described being treated positively or "as any other parent" in these contexts.

CONCLUSIONS

Heterosexual and gay parents reported low levels of parenting stress and generally experienced positive or neutral reactions to their parenthood in contacts with healthcare providers, in preschool, and in the child's recreational activities.

Accounting for the money-made parenthood of transnational surrogacy

In the last decade, transnational surrogacy has attracted world-wide attention for making babies and pregnancies exchangeable with money. Involuntarily childless couples and individuals travel abroad and pay to have the desired child and to become parents. Acknowledging the importance of asking into the consequences of this monetization of reproduction, the author takes issue with universalistic assumptions about money and markets, and their presumed universal effects on social relations. Instead, it is argued that we need to explore how money works, and, by extension, how transnational surrogacy works out and becomes viable to people as a way to become parents. Putting together insights from economic sociology, and the assisted reproductive technology and parenting culture literature, the author employs the notion of accounting to grasp how people make sense of the money involved in making them parents. Based on a study involving 21 interviews with Norwegian gay and straight couples and single men and women seeking surrogacy abroad, the author explores how money is accounted for in three cases, set in three different countries; India, the United States and Canada. The analysis shows how money is accounted for in particular ways to confirm parenthood. These ways differ depending on the local context and transnational relations; ultimately making differentiated monetized parenthood. This is of significance when we try to conceptualize contemporary parenthood and how money seemingly sustains parenthood in ever more radical ways.

Attitudes toward surrogacy among doctors working in reproductive medicine and obstetric care in Sweden

INTRODUCTION

The aim of this study was to investigate attitudes and opinions towards surrogacy among physicians working within obstetrics and reproductive medicine in Sweden.

MATERIAL AND METHODS

Physicians working within medically assisted reproduction (MAR), antenatal care and obstetrics were invited to participate in a cross-sectional nationwide survey study. The study-specific questionnaire measured attitudes and experiences in three domains: attitudes towards surrogacy, assessment of prospective surrogate mothers, and antenatal and obstetric care for surrogate mothers.

RESULTS

Of the 103 physicians who participated (response rate 74%), 63% were positive or neutral towards altruistic surrogacy being introduced in Sweden. However, only 28% thought that it should be publicly financed. Physicians working at fertility clinics were more positive towards legalization as well as public financing of surrogacy compared than were those working within antenatal and delivery care. The majority of the physicians agreed that surrogacy involves the risk of exploitation of women's bodies (60%) and that there is a risk that the commissioning couple might pay the surrogate mother "under the table" (82%). They also expressed concerns about potential surrogate mothers not being able to understand fully the risks of entering pregnancy on behalf of someone else.

CONCLUSION

There is a relatively strong support among physicians working within obstetrics and reproductive medicine for the introduction of surrogacy in Sweden. However, the physicians expressed concerns about the surrogate mothers' health as well as the risk of coercion. Further discussions about legalization of surrogacy should include views from individuals within a wide field of different medical professions and laymen.

Survey shows that Swedish healthcare professionals have a positive attitude towards surrogacy but the health of the child is a concern

AIM

In February 2016, Sweden upheld its ban on surrogacy following a Government enquiry. This survey investigated attitudes towards surrogacy among primary health professionals working with children and their experiences of working with families following surrogacy abroad.

METHODS

From April to November 2016, nurses, physicians and psychologist working in primary child health care in four counties in Sweden were invited to participate in a cross-sectional online survey about surrogacy.

RESULTS

The mean age of the 208 participants was 49.2 years (range 27-68) and nearly 91% were women. Approximately 60% supported legalised surrogacy. Wanting a conscience clause to be introduced in Sweden was associated with not supporting surrogacy for any groups, while personal experiences of infertility and clinical experiences with families following surrogacy were associated with positive attitudes towards surrogacy for heterosexual couples. The majority (64%) disagreed that surrogate children were as healthy as other children, and many believed that they risked worse mental health (21%) and social stigmatisation (21%).

CONCLUSION

We found that 60% supported legalised surrogacy, but many expressed concerns about the children's health and greater knowledge about the medical and psychosocial consequences of surrogacy is needed.