Pathways to parenthood: Utilizing surrogacy for gay and heterosexual couples with agencies and clinics
Masterscriptie Preventieve Jeugdhulp en Opvoeding Pedagogische Wetenschappen en Onderwijskunde Universiteit van Amsterdam X. L. Schouten 10186530 Begeleiding: H. M. W. Bos Tweede beoordelaar: L. van Rijn-van Gelderen Amsterdam, June, 2017
Table of Contents Abstract ... 4 Introduction………...………..5 Methods ... 8 Procedure ... 9 Participants ... 10 Research instruments ... 11 Data analysis ... 12 Results ... 13
Satisfaction with the agency ... 13
Satisfaction with the clinics ... 14
Positive experiences with agencies ... 15
Negative experiences with agencies ... 18
Positive experiences with clinics ... 21
Negative experiences with clinics ... 23
Discussion ... 25 References ... 33 Table 1 ………..37 Table 2……….……..38 Table 3………..……….39 Table 4……….………..40
Table 5………..41 Table 6………..42 Table 7……….……….43
Abstract
The purpose of this study is to better understand the satisfaction and experiences that gay intended parents who opt for conception through surrogacy have with their respective
agencies and clinics in relation to the Sexual Minority Stress Model. This study is explorative, employing a mixed-methods approach through a combination of quantitative and qualitative methodologies. Data were collected by using an online survey (ngay = 147, nheterosexual = 52).
According to the experiences of the gay participants, many clinics remain heteronormative. Whereas, no significant difference was found for satisfaction with the agencies and clinics. This study reveals that agencies and clinics should learn to acknowledge the normalcy and positive value of same-sex relationships to improve the heteronormative situations in the clinics.
In the past it was often assumed that gay men were uninterested in becoming parents; however, the number of gay men raising children today is increasing (Gates, 2013). Gates estimated in 2013 that 20 percent of gay men aged 50 or younger living alone or with a same sex spouse or partner in the United States (U.S.), were raising children under the age of 18. It can be deduced that young gay men today are expecting to raise children when they get older. According to the research conducted by Gates and colleagues (2007) in the U.S., 52% of the gay male participants who not have children, would like to have a child.
For gay men interested in parenthood, there are options. In the U.S., most gay fathers who became parents after coming out, adopted their children (Gates, 2013). Another route to parenthood for gay men after coming out, is to co-parent with a lesbian couple or single woman by donating sperm and raising the child together. A third option is surrogacy. A study carried out in the Netherlands showed that 49.1% of gay men would like to have a child through surrogacy (Bos & Tornello, 2016).
Surrogacy—which is well-regulated in the U.S., where the proposed study has been carried out—is a technique in which an individual or a couple, the intended parent(s),
contracts a woman to carry a child for them (Bergman, Rubio, Green, & Padrón, 2010). There are two types of surrogacy arrangements: (1) genetic (traditional) surrogacy, which takes place when the surrogate is impregnated with the sperm of one of the male partners through insemination (Nakash & Herdiman, 2007); and (2) gestational surrogacy or in vitro
fertilization (IVF) surrogacy, which occurs when a female donor’s egg is fertilized by one of the male partner’s sperm in the laboratory using IVF. The resulting embryo is transferred to the surrogate’s womb, where she only carries the child and has no genetic relation to it (Nakash & Herdiman, 2007).
Even though surrogacy is well regulated in the U.S. the legislation of surrogacy differs across countries. In some countries, surrogacy is forbidden (e.g., France) but in other
countries non-commercial surrogacy is allowed (e.g., United Kingdom (U.K.), the
Netherlands). Non-commercial surrogacy means that the intended parents can compensate surrogates for their expenses but makes it illegal to advertise for a surrogate or for individuals to solicit themselves as surrogates. Despite the fact that non-commercial surrogacy is allowed, gay couples have many obstacles to overcome in order to receive access to these clinics. Gestational surrogacy proves especially difficult for gay couples. According to legislation in the Netherlands, clinics can only conduct gestational surrogacy for medical reasons—if the intended mother does not have a womb, for example (Bos & Van Rooij, 2011; Boele-Woelki, Curry-Summer, Schrame, & Vonk, 2011).
When these gay couples would like to implement gestational surrogacy they must travel abroad to countries without legal barriers to gestational surrogacy, where their sexual
orientation does not matter (Vonk & Boele-Woelki, 2012). There are certain States in the U.S. that forbid denying intended parents access to surrogacy services on the grounds of sexual orientation (Bos & Van Rooij, 2011). The technical procedure is not the only aspect of surrogacy that presents a challenge. Surrogacy is a difficult and emotional procedure for both the intended parents and the surrogate mother. To become a surrogate mother in the U.S. you have to fulfill certain conditions requiring a psychological test, interviews and a full
examination of their genetic history (Bergman et al., 2010). Once the surrogate mother has been screened and approved for surrogacy the next step in this procedure is to carefully match the intended parents with their surrogate mother.
Most gay men who choose surrogacy as their preferred pathway to parenthood did so because of the promise of a genetic link to their child by either themselves or their partner. Additionally appealing is the opportunity for these parents to raise a child from birth - which is not always the case in adoption. Adoption is complicated for parents because adopted children often struggle psychologically later in life with feelings of abandonment by their
birth parents (Lev, 2006). Many gay couples also prefer to be the only parents of a child, which is not possible in a co-parenting arrangement with a lesbian couple or a single woman (Lev, 2006).
Heterosexual couples who opt for surrogacy do so because of a medical inability (e.g., because they does not have an uterus) to reproduce via traditional heterosexual reproductive methods (MacCallum, Lysett, Murray, Jadva, & Golombok, 2003). Whereas homosexual couples simply do not possess the necessary reproduction anatomy to accomplish procreation in the first place (MacCallum et al., 2003). Similar to gay couples aspiring to be parents, heterosexual couples choose surrogacy because they also prefer to have a genetic link to their child (Nakash & Herdiman, 2007).
Although gay couples and heterosexual couples might have different reasons to opt for surrogacy, they will likely have similar experiences throughout the surrogacy process. The attitude from society towards surrogacy is slowly becoming less negative but still is the most controversial form of assisted reproduction, which can cause stress to any prospective parent (Bergman et al., 2010). The reasons for society’s negative perception of surrogacy are varied. People are typically less familiar with surrogacy, or Artificial Reproduction Technology (ART), as a method of conception. Due to this lack of information, the media often reports negative surrogacy stories, focused on unacceptable or illegal surrogacy practices (Van den Akker, Camara, & Hunt, 2016).
Surrogacy presents challenges to all parents independent of sexual identity. An overwhelming aspect of surrogacy is the inability of parents to have any control over the health of the baby or the surrogate due to hormones being used as well as other variables outside their control. An added stressor can be the anxiety of the possibility that the surrogate would like to keep the child (Damelio & Sorensen, 2008).
Gay fathers may face additional stressors in the form of rejection. It is likely that others will challenge the reasoning for a gay couple or an individual gay man for simply wanting to have a child. The Sexual Minority Stress Model explains that these kind of stressors are attributed to being a member of a sexual minority group, which can have a large impact on the mental health status of individuals who identify as homosexual (Meyer, 2007). One can also experience these kinds of negative reactions and treatment from institutions. For the purpose of this proposed study, I will assume that gay men confront homophobic stigmatization from agencies and clinics—both of whom have a key role in arranging the surrogacy procedure. Therefore, it is likely that gay men might feel less satisfied by agencies and clinics in comparison to heterosexual individuals who received support from agencies and clinics throughout the surrogacy process (Hendricks & Testa, 2012).
The aim of the proposed study is to investigate the level of satisfaction with surrogacy agencies and clinics, found by individuals who became a parent for the first time through surrogacy. The second aim of this study is to take a deeper look into the experiences of those gay and heterosexual individuals who opt for surrogacy with their respective agencies and clinics. Especially significant will be in finding whether the type of experiences had by gay parents utilizing these surrogacy institutions differed from heterosexual parents. It should be taken into account that these differences that we might describe have to do with other variables like sexual orientation, gender, country and surrogacy type.
Methods
This research study is explorative, employing a mixed-methods approach through a combination of quantitative and qualitative methodologies. Specifically, the mixed-methods ‘concurrent quant + QUAL’ approach is used during this research (Fleming & Parker, 2007; Johnson, Onwuegbuzi, & Turner, 2007). Although the methodology has a quantitative component, the main focus has been on the qualitative part, and it should be noted that the
quantitative and qualitative data was collected at the same time. The quantitative approach allows for a comparison between the level of satisfaction homosexual and heterosexual individuals feel with surrogacy agencies and clinics. In contrast, the qualitative approach has been especially useful in insight into a participant’s private experiences. This qualitative data reflects the experience of each individual throughout the surrogacy procedure with particular focus on agencies and clinics.
Procedure
Both quantitative and qualitative data has already been collected through an online survey with Men Having Babies (MHB). MHB is a non-profit organization that was originally intended as a peer support network, but soon expanded to promote, inform and guide individuals interested in the surrogacy procedure. The majority of those interested are homosexual, though heterosexual individuals also utilize MHB.
The online survey was developed by MHB over five years ago, and the organization began collecting data on March 12th, 2012. Data collection remains ongoing and for this research study data has been used from 2012 until March 3th, 2017. The online survey is linked directly to the MHB website. Although, when it was initially launched in 2012, it was sent to everyone on their mailing list. Since the survey’s inception, the organization has been mentioning it repeatedly on their regular e-blasts and newsletters. Last year they ran a
promotion (advertisement) on Facebook to encourage more people to become involved with the study. Many providers (agencies and clinics) have also asked their past clients to submit these online surveys.
Participants who fill out the online survey do not receive compensation because MHB does not allow this, though MHB does encourage everyone to spread the word about this research project. That said, MHB strongly discourages service providers from applying any pressure on their clients or attempting them to reward them in any way for submitting positive
reviews. If MHB is notified about such practices they consider removing these service providers from the directory. The participants are aware that the information is used by academics for research studies. MHB explains that this research project is carried out in conjunction with researchers worldwide—such as the Centre for Family Research at Cambridge University and the University of Amsterdam—before a participant begins the online survey. MHB also emphasizes that all information is collected anonymously. Participants
The data of this thesis reflects the response of 889 individuals to the online survey. This research study will focus on the first surrogacy experiences of the participants (i.e., first journey; n = 199), because later experiences might be influenced by previous surrogacy journeys. Additionally, single parents (n =103) were excluded from the study because their experiences might be influenced by their lack of a partner, which would likely impact their level of satisfaction with their respective agencies and clinics. As a result of these
inclusion/exclusion criteria, the analytic sample consists of 147 gay and 52 heterosexual parents (15 men and 37 women). It should be noted that only one intended parent of each couples filled out the online survey.
The demographics of the sample are shown in Table 1. The average age of first journey parents in our sample was 40.41 years old (SD=6.07) and ranged in age from 26 to 59 years old. Almost all participants completed a bachelors or higher educational degree. Roughly half (52.8%) of the first journey parents were from the USA, the other 47.2% came from different countries such as Israel, France and Spain. Available data focused on the surrogacy procedure (see also Table 1). revealed that most parents opted for gestational surrogacy (93.45%) with a known (40.9%) or unknown egg donor (50.9%). The profiles (social demographics and information about the surrogacy procedure) of gay and heterosexual parents only differed significantly with respect to age and surrogacy type. Gay parents were younger in comparison
to the heterosexual parents (Mgay parents=39.09, SDgay parents=5.98, Mheterosexual parents=42.10,
SDheterosexual parents=6.05), F = 5.20 and p = .024. Gay parents also opted for gestational
surrogacy more often than heterosexual parents (gay parents: 98.0%, heterosexual parents: 80.4%), χ2 = 19.05 and p < .000.
Research instruments
Satisfaction with the agencies. To evaluate participant satisfaction with the agency, participants were asked: “Please, rate the surrogacy agency you used in the following areas: (1) effective contribution to the success of journey, (2) responsiveness and support throughout journey, (3) surrogate screening and matching, and (4) accommodation of international
parents (this was only asked to those individuals not residing in the U.S.). Additionally they were also asked to rate their satisfaction with the agency overall. In response to the questions, the participants were asked to rank their answers from 1(“not satisfied at all”) to 10 (“very satisfied”).
Satisfaction with the clinics. Participants were asked the abovementioned four questions in relation to their experiences with the clinics. Again, in response to the questions, the participants were asked to rank their answers from 1(“not satisfied at all”) to 10 (“very satisfied”) and these items are used as single-items.
Experiences with agencies. Participants were asked to describe their experiences with an agency based on the following open-ended question: “Would you like to comment or write a review about your surrogacy agency?”
Experiences with clinics. Participants were asked to describe their experiences with a clinic based on the following open-ended question: “Would you like to add comments or write a review about your fertility clinic?”
Data analysis
In order to gain access to this study it was necessary to co-sign a confidentiality agreement with MHB. The data was analyzed by using SPSS. Utilizing SPSS two groups (gay and heterosexual parents) were tested using an Analysis of Covariance (ANCOVA) test with age and surrogacy type as control variables. Age and Surrogacy type were used as control variables because the social demographic results had shown that the two groups (gay and heterosexual participants) differences on these two variables. These control variables are used to make sure that the differences we find are attributed to these two groups.
The open-ended questions that have made up the qualitative dataset have been analyzed using the MAXQDA program. Coding the data for research was completed last year, which served as the first step towards analyzing the qualitative data. Coding is a process of
identifying aspects of the data that relate to the research questions (Braun & Clarke, 2013). The selective coding approach was selected as the coding method, which caused data
reduction and selected only the data that is pertinent to the research question. When the code system was finished, the responses to the open-ended questions were examined using
interpretative phenomenological analysis (IPA). This methodology examines participant’s responses for themes that emerge from the data. If some responses were unclear, making their coding more difficult, an impartial colleague was available, with which to discuss these doubts. All the responses were coded under two categories: either a positive or negative experience with clinics and agencies. These two major categories were divided in six or seven subthemes as shown in Table 2. As a result the mechanism of experiences between gay and heterosexual parents could be described.
After the coding was complete, the next step was to define the verbal counting of these themes (Sandelowski, 2001). This was done utilizing the recommendation of Sandelowski (Sandelowski, 2001). In the results when a theme was mentioned, the following terms were
used as a numerical reference to the themes in question: “few” refers to 10 or less participants, “some” refers to 11 to 21 participants and “many” refers to more than 22 participants.
Results Satisfaction with the agency
Table 3 shows mean scores and standard deviations for parental satisfaction with the agencies, separately for gay and heterosexual parents. Parents were asked how satisfied they were with the: (a) success of the journey, (b) responsiveness and support throughout the journey, (c) surrogate screening and matching, and (d) accommodation for international parents.
Success of the journey. The overall mean score of satisfaction with the success of the journey was 8.88 (SD = 1.99). The mean score for gay parents was 8.92 (SD = 1.85). For heterosexual parents, the mean score was 8.81 (SD = 2.34). After controlling for age and surrogacy type, gay and heterosexual parents did not differ significantly on the variable satisfaction with, F = 0.00 and p = .972.
Responsiveness and support throughout the journey. The overall mean score of
satisfaction with the responsiveness and support throughout the journey was 8.57 (SD = 2.36). The mean score for gay parents was 8.60 (SD = 2.17). For heterosexual parents, the mean score was 8.64 (SD = 2.63). After controlling for age and surrogacy type there was no significant difference between satisfaction with responsiveness and support between gay and heterosexual parents, F = 0.21 and p = .647.
Surrogate screening and matching. The overall mean score of satisfaction with the surrogate screening and matching was 8.90 (SD = 2.09). The mean score for gay parents was 8.89 (SD = 2.05). The score for heterosexual parents was a little bit higher (M= 9.02, SD = 2.28). After controlling for age and surrogacy type the differences between gay and
Accommodation for international parents. International parents also rated how satisfied they were with their accommodation. The overall mean score on this variable was 8.62 (SD = 2.28). After controlling for age and surrogacy type gay parents and heterosexual parents did not differ significantly on this variable. The mean score for gay parents was 8.64 (SD = 2.71) and was 8.60 (SD = 2.11) for heterosexual parents, F = 0.00 and p = .982.
Satisfaction with the clinics
Table 3 shows the mean scores and standard deviations for parental satisfaction with the clinics. Parents were asked how satisfied they were with the: (a) quality of medical services throughout their journey, (b) responsiveness and support throughout the journey, (c) surrogate screening and matching, and (d) accommodation for international parents.
Quality of medical services. The overall mean score of satisfaction for the quality of medical services was 9.44 (SD = 129). The mean score for gay parents was 9.44 (SD = 1.34). For heterosexual parents, the average score was 9.45 (SD = 1.26). After controlling for age and surrogacy type, gay and heterosexual parents did not differ significantly on the variable satisfaction with, F = 0.02 and p = .903.
Responsiveness and support throughout the journey. The overall mean score of
satisfaction with the responsiveness and support throughout the journey was 8.42 (SD = 2.11). The mean score for gay parents was 8.43 (SD = 2.13) and for heterosexual parents, the
average score was 8.41 (SD = 2.07). After controlling for age and surrogacy type there was no significant difference between satisfaction with responsiveness and support between gay and heterosexual parents, F = 0.14 and p = .705.
Surrogate screening and matching. The overall mean score of satisfaction with the surrogate screening and matching was 8.69 (SD = 2.02). The mean score for gay parents was 8.66 (SD = 1.97) and the score for heterosexual parents was a little bit higher (M = 8.83, SD =
2.27). After controlling for age and surrogacy type the differences between gay and heterosexual parents was not significant, F = 0.01 and p = .928.
Accommodation for international parents. International parents also rated how satisfied they were with the accommodation. The overall mean score on this variable was 8.86 (SD = 2.29). After controlling for age and surrogacy type gay parents and heterosexual parents did not differ significantly on this variable. For gay parents 8.82 (SD = 2.34) for and 9.00 (SD = 2.15) for heterosexual parents, F = 0.07 and p = .799.
Positive experiences with agencies
The positive experiences with agencies were divided into eight themes: (1) overall satisfaction, (2) great match, (3) quick response/accessibility, (4) medically informative, (5) just friendly or gay friendly, (6) emotional support, (7) clarity/transparency concerning costs and (8) guidance/support in legal paperwork (Table 4). For gay men the three most mentioned themes were: great match, emotional support and guidance/support completing legal
paperwork. The three topics least mentioned by gay men were: overall satisfaction with the agencies, medically informative and just friendly or gay friendly. However, for heterosexual people the three most mentioned themes were: emotional support, quick
response/accessibility, and great match. The three topics least mentioned by heterosexual people were: just friendly or gay friendly, overall satisfaction and medically informative.
Overall satisfaction with the agency. A few participants described their own experiences with the agency as “satisfied” throughout their pathway to parenthood. One participant (male, 41, heterosexual) wrote: “Excellent agency, I would highly recommend them”. Another participant (male, 33, gay) wrote about his experience: “All was perfect, nothing else to say!” Gay participants mentioned this theme slightly more than heterosexual participants. These participants, which consisted of both gay and heterosexual participants, all chose gestational surrogacy and typically came from countries other than the United States.
Great match. Many participants described their match with their surrogate as great. Most responses with this theme described that their matching procedure was personal, and they were assured throughout the process that their match would go through. The matches were based on the personalities and preferences of the surrogate and the intended parents. One participant (male, 43, gay) said: “They matches people based on personality and preferences, and does not just match based on whoever is next in line, which was our previous
experience.” Another participant (male, 40, heterosexual) wrote: “The surrogate work and match was the best ever and we still have connection with her one year and half later”. Gay participants mentioned this theme more often than heterosexual participants. Additionally, these participants (gay and heterosexual) tended to choose gestational surrogacy more often and tended to hail from the United States, rather than other countries.
Quick response/accessibility. Some participants were very fond of the manner in which the agencies maintained contact with them throughout the process. One participant (male, 32, gay) remarked that there seemed to be “no question too big or small and the agency always came back to us quickly despite the time difference”. Others appreciated the great
involvement of the agencies (male, 44, heterosexual), reflecting that, “they truly care and are available around the clock 24/7 to answer any question”. Heterosexual participants
mentioned this theme slightly more than gay participants. The majority of these participants (gay and heterosexual) opted for gestational surrogacy and came from the United States.
Medically informative. Some of the participants described the agency as knowledgeable about the medical process and were upfront about the expectations of the procedure. One participant (male, 45, gay) wrote: “They were upfront about the process and expectations”. Another participant (female, 50, heterosexual) observed that, “This agency was more knowledgeable than other places we interviewed”. Gay participants mentioned this topic more often than heterosexual participants. All of these participants (gay and heterosexual)
chose gestational surrogacy and the majority of them came from countries other than the United States.
Just friendly or gay friendly. A few described the agencies as having friendly staff or admitted to feeling very welcome despite their sexual orientation. One participant (male, 29, gay) wrote: “They were very accommodating to us as a gay international couple”. Another participant (female, 54, heterosexual) remarked that, “despite us being on the other side of the world and in a different time zone, our agency was always available and we had total
confidence in them”. Gay participants mentioned this friendliness more often than
heterosexual participants. The majority of these participants (gay and heterosexual) chose to employ gestational surrogacy and came more often than not from countries other than the United States.
Emotionally supportive. Many participants felt that they were treated like family by their agency. According to the participants, many agencies were committed and supportive
throughout the entire surrogacy process. One participant (male, 47, gay) wrote: “We were always treated like family and not just a business client”. Another participant (male, 48, heterosexual) described the staff at his agency to be “caring, friendly, understanding and they seemed to have an intuition into your thoughts and feelings”. Gay participants mentioned this emotional support in their responses more often than heterosexual participants. The majority of these participants (gay and heterosexual) chose to employ gestational surrogacy and came more often than not from countries other than the United States.
Clarity/transparency concerning costs. Some described the service and help they received from the agencies as worthy of the cost. One participant (male, 34, gay) wrote about his experience: “The agency gave a good price, and included the law services, which saved a lot of money”. Another participant (female, 34, heterosexual) wrote: “Throughout the process I always did a cross check on the costs that were in the contract and the ones that we were
paying everything was correct and exactly what was expected”. Gay participants mentioned the clarity of costs more often than heterosexual participants. The majority of these
participants (gay and heterosexual) chose to employ gestational surrogacy and often came from countries other than the United States.
Guidance/Support in legal paperwork. Many felt supported throughout the legal paperwork procedure. International participants were particularly pleased with the guidance they received while tackling the legal paperwork, describing the agencies as professional and supportive. One participant (male, 38, gay) described that their agency was “always honest, clear and explained every detail” when it came to paperwork and expense proceedings. Another participant (female, 42, heterosexual) dictated a similar experience, explaining that her agency was “supportive and responsive to all our questions including legal paperwork”. Gay participants mentioned the legal support in their responses more often than heterosexual participants. The majority of these participants (gay and heterosexual) chose to employ gestational surrogacy and came more often than not from countries other than the United States.
Negative experiences with agencies
The negative experiences with agencies were divided into six resounding themes: (1) difficult/slow process, (2) unequal treatment of clients, (3) lack of clarity concerning the costs, (4) difficult/long matching time, (5) not helpful and (6) not responsive (Table 5). For gay men, the three most mentioned themes were: lack of clarity concerning the costs, not helpful and difficult/slow process. The three topics least mentioned by gay men were: unequal treatment of clients, difficult/long matching time and not responsive. The focus of responses did not differ severely for heterosexual participants, as the three most mentioned themes were: not helpful, not responsive, and difficult/slow process. The three topics least mentioned by
heterosexual people were: unequal treatment of clients, difficult/long matching time and lack of clarity concerning the costs.
Difficult/slow process. Some of the participants wrote about the difficulties they faced during the surrogacy process. One participant (female, 33, heterosexual) explained that she and her partner, “ran into some issues at the time of the birth where our paperwork was not acknowledged by the hospital administration”. Another participant (male, 45, gay) said he faced a, “very difficult process with limited to no help from the agency”. Gay participants mentioned the difficult and slow process in their responses more often than heterosexual participants. The majority of these participants (gay and heterosexual) chose to employ gestational surrogacy and came from countries other than the United States.
Unequal treatment of clients. A few participants said their agency or surrogate did not treat them equally. One participant (Male, -, gay) remarked that his “first matched surrogate ended up deciding not to work with a same sex couple”. Only gay participants mentioned this frustration with feeling a lack of equality between themselves and their agency or surrogate. Both of these participants (gay and heterosexual) chose to employ gestational surrogacy and came from countries other than the United States.
Lack of clarity concerning the costs. Some of the participants remarked that the agencies did not help them when they were facing high medical costs, and they felt
particularly surprised by the extra costs during the process. One participant (male, 36, gay), “felt that the agency surprised us with additional legal fees towards the end of the process, which lacked transparency”. Another participant (female, 35, heterosexual) wrote that, “the agency scammed us big time. After two-and-half years our dream of a family has still not been realized”. Gay participants mentioned the lack of clarity about costs in their responses more often than heterosexual participants. The majority of these participants (gay and
heterosexual) chose to employ gestational surrogacy and came from countries other than the United States.
Difficult/ long matching time. A few participants responded negatively about the long and difficult matching time with an appropriate surrogate. One participant (Female, 46, couple, heterosexual) remarked that, “the first carrier we were recommended and paired with turned out to be unsuitable due to medical reasons which we did not find out about until 3 months after we began the process”. Another participant (male, 39, gay) described that his
“biggest issue was the time it took to match us with a surrogatefor almost three years”. Gay
participants mentioned their difficulty matching slightly more than heterosexual participants. The majority of these participants (gay and heterosexual) chose to employ gestational
surrogacy and came from countries other than the United States.
Not helpful. Some of the participants felt like there was little assistance from the agencies when they faced difficulties during the process. One participant (male, 47, gay) admitted to feeling, “that the agency was, however, not helpful when we started facing difficulties with our surrogate, it appeared that the psychological screening had been conducted several years before the contract”. Another participant (female, 43, heterosexual) remarked that, “the background checks promised for any surrogacy candidate were not done as explained when signing on with ART”. Gay participants mentioned their difficulty matching slightly more than heterosexual participants. The majority of these participants (gay and heterosexual) chose to employ gestational surrogacy and came from countries other than the United States.
Not responsive. A few participants wrote about the lack of responsiveness during the process on the part of the agency. One participant (male, 48, heterosexual) explained that his contact at the agency was, “not very supportive, on the contrary, she even was able to put some spanners in the process”. Another participant (male, 39, gay) complained that, “for the amount of money we paid them it would have been nice for them to have checked on us”.
Heterosexual participants mentioned this theme more often than gay participants. All of these participants (gay and heterosexual) chose to employ gestational surrogacy and the majority of them came from the United States.
Positive experiences with clinics
The positive experiences with clinics were divided in six themes namely, (1) overall satisfaction, (2) always available, (3) clear explanation of the process, (4) professional/ emotional support, (5) easy to work with and (6) gay friendly (Table 6). Gay men and heterosexual participants mentioned the same three topics the most and the least. The three most mentioned themes were: professional/emotional support, easy to work with and always available. The three topics least mentioned across the board were: overall satisfaction with clinic, gay friendly and clear explanation of the process.
Overall satisfaction. A few participants described their experiences with the clinics as satisfying overall. One participant (male, 37, gay) commented that, “they were amazing and the first transfer worked. We highly recommended them.” Only gay participants mentioned this theme. These participants chose to use gestational surrogacy and came from the United States.
Always available. Some of the participants described that they experienced good
communication with the staff and that they were always available. One participant (male, 48, gay) explained that, “the doctor even gave us his personal cell phone number and (even though we tried not to) we used it!” Another participant (female, 34, heterosexual)
commented that the, “guidance from them was so great that we able to do it with e–mail and Skype calls”. Gay participants mentioned this theme more often than heterosexual
participants. The majority of these participants (gay and heterosexual) chose to employ gestational surrogacy and came from the United States.
Clear explanation of the process. A few participants felt like the people who work within the clinics explained the procedure and process clearly, which made it understandable for them. One participant (male, 38, couple, gay) was thankful that, “their information was clear and they were very communicative both to us and our surrogate”. Another participant (male, 39, gay) wrote that, “throughout the process, the staff was helpful and made sure we were looped”. Gay participants mentioned this theme more often than heterosexual
participants. The majority of these participants (gay and heterosexual) chose to employ gestational surrogacy and came from the United States.
Professional/emotional support. Many participants appreciated the kindness and helpfulness of the clinics throughout the process. One participant (male, 36, gay) explained that the clinic staff, “were very supportive and friendly during the entire process and always very responsive while waiting for the pregnancy results”. Another participant (female, 46, heterosexual) commented that her doctor “was very professional but also human and gave us straight forward advice”. Gay participants mentioned this theme more often than
heterosexual participants. The majority of these participants (gay and heterosexual) chose to employ gestational surrogacy and came from the United States.
Easy to work with. Some of the participants described the cooperation between the intended parents, surrogate and doctors as “smooth”, commenting that the clinic staff and surrogates were straightforward with their advice. One participant (male, 38, gay) was thankful that the clinic staff “accommodated all our personal needs, especially because we are international parents form Brazil and they were always there for us when we asked and needed something”. Another participant (female, 46, heterosexual) observed: “They were very professional but also human and gave us straight forward advice”. Gay participants
participants (gay and heterosexual) chose to employ gestational surrogacy and came from the United States.
Gay friendly. A few gay participants felt that the staff of the clinic were comfortable with their sexual orientation and they felt welcomed. One participant (male, 52, couple, gay) remarked that, “the people we dealt with were all very welcoming and helpful to us as a same-gender couple”. Only gay participants mentioned this theme. All gay participants employed gestational surrogacy and came from the United States.
Negative experiences with clinics
The negative experiences with clinics were divided in six themes: (1) lack of clarity concerning the costs, (2) bad management, (3) a bit distant, (4) the institutional aspects were heteronormative and (5) lack of communication (Table 7). For gay men, the three most mentioned themes were: lack of clarity concerning the costs, lack of communication and the institutional aspects were heteronormative. Less mentioned topics by gay men were: bad management and a bit distant. However, for heterosexual people the three most mentioned themes were: bad management, a bit distant, and lack of communication. Less mentioned topics by heterosexual people were: lack of clarity concerning the costs and the institutional aspects were heteronormative.
Lack of clarity concerning the costs. Some of the participants described that they were dissatisfied with the transparency represented by the clinics regarding the costs. There were some hidden costs, which were not explained before the start of the procedure. One
participant (male, 54, heterosexual) criticized that “the clinic needed to be better managed and there were many hidden costs”. Another participant (male, 37, gay) explained that his, “only complaint is that I had to be very careful that they were not charging us for services we were already getting from our surrogacy agency”. Gay participants mentioned this theme more often than heterosexual participants. The majority of these participants (gay and
heterosexual) chose to employ gestational surrogacy type and came from the United States more than other countries.
Bad management. A few participants wrote about organizational problems and understaffed clinics. One participant (female, 43, heterosexual) remarked that, “numerous mistakes were made in several different departments, including medical errors”. Another participant explained that there was a shortcoming of the administrative organization of the clinic given the, “lack of response, where as a result too many e-mails are left unanswered and too many staff members approximate information”. Gay participants and heterosexual participants mentioned this theme equally. The majority of these participants (gay and heterosexual) chose to employ gestational surrogacy type and came from the United States more than other countries.
A bit distant. A few participants wrote about the lack of responsiveness from the staff. One participant (female, 36, heterosexual) remarked that, “they were not sensitive to the intended mother by treating the surrogate like an IVF patient”. Another participant (male, 55, gay) described the clinic staff as, “somewhat cold in their interaction with us and extremely expensive”. Heterosexual participants mentioned this theme slightly more than gay
participants. The majority of these participants (gay and heterosexual) chose to employ gestational surrogacy type and came from the United States more than other countries.
The institutional aspects were heteronormative. A few participants described how some aspect of the clinics were still too heteronormative. Some staff members were surprised to find same-sex couples (especially men) opting for surrogacy. One participant (male, 52, gay) simply stated that, “a few of the institutional aspects of the organization are still a bit heteronormative”. Another participant (male, -, gay) candidly explained that, “as a same sex couple not everyone has the experience of that, so there were occasional light oversights, each of us got asked who the mother or wife was and then had to say it is the man that stood
next to me!” Only gay participants mentioned this theme. All of these participants chose to employ gestational surrogacy type and came from the United States.
Lack of communication. Some participants described how frustrating it was that there was little to no communication with the clinics. They also were frustrated that due to this lack of communication, problems were left unsolved. One participant (male, 40, gay) complained about one particular clinic staff member, remarking that the “person repeatedly avoided our emails, literally lied on several occasions, was superficially nice but actually very dismissive and all in all gave the impression of a depressed, burn-out employee who is there to punch the ticket and go home”. Another participant (female, 36, heterosexual) was frustrated that the “surrogate had to relay information and questions received by clinic to the intended mother instead of contacting her directly”. Gay participants mentioned this theme more often than heterosexual participants. The majority of these participants (gay and heterosexual) chose to employ gestational surrogacy type and came from the United States more than other
countries.
Discussion
Deciding to become a parent as a gay couple can bring unique challenges. In order to better understand the challenges faced by gay parents, participants in this study rated their satisfaction and described their experiences with agencies and clinics throughout the process of becoming a parent via surrogacy. Although gay and heterosexual couples seemed to have faced similar experiences in their path to parenthood through surrogacy (e.g., society’s negative perception towards surrogacy) (Bergman et al., 2010), gay fathers may face
additional stressors in the form of rejection (Meyer, 2007). The Sexual Minority Stress Model explains that these kind of stressors are attributed to being a member of a sexual minority group, which can have a large impact on the mental health status of individuals who identify themselves as homosexual (Hendricks & Testa, 2012; Meyer, 2007). Gay couples can
experience these kinds of negative reactions and treatment from institutions, as well as individuals (Hendricks & Testa, 2012). This research study assumed that gay men would confront homophobic stigmatization from agencies and clinics—both of which have a key role in arranging the surrogacy procedure. Due to the potential for homophobic
stigmatization, it was hypothesized that gay men might feel less satisfied with agencies and clinics in comparison to heterosexual individuals, who might have received more support from agencies and clinics throughout the surrogacy process (Hendricks & Testa, 2012).
The gay participants in this research study were slightly younger than the heterosexual participants. The best explanation for this discrepancy in age has to do with the tendency for heterosexual couples to try and conceive a child in other ways before opting for surrogacy (MacCallum et al., 2003). Results indicate that overall, both gay and heterosexual were very satisfied with their agencies and clinics. That said, after analyzing the experiences of gay and heterosexual participants with their respective agencies and clinics, it seems that some gay participants felt as though they were not being treated equally to the heterosexual individuals involved in the surrogacy process (Corbett, Frecker, Shapiro, & Yudin, 2013). The
overarching theme illustrated by gay participants is that clinics retain an inclination towards heteronormativity (Corbett et al., 2013). The gay participants who voiced this in this study were attempting gestational surrogacy and therefore more depended on the clinics (Nakash & Herdiman, 2007).
This study was conducted utilizing a quantitative approach. Though it was hypothesized that there may be a difference in satisfaction levels between gay and heterosexual participants with their respective agencies and clinics, the quantitative data reveals that there was no significant difference. Both gay and heterosexual participants checked an eight or higher for the question inquiring about their satisfaction with the agencies and clinics. That said, there still existed differences. Most of the time heterosexual participants were just slightly more
pleased with their agencies and clinics. Additionally, only gay participants were pleased with the ‘success of the journey’ in regards to their experience with their agency and were more pleased overall with the ‘responsiveness and support from the clinics and agencies throughout the journey’ on average.
In terms of conception, there were no differences, as all of the participants journeys resulted in a baby. The questionnaire designed by MHB was sent to these participants after the process of surrogacy had ended, which likely impacted the responses received in a few ways. First, since each of the participants were able to a conceive a child through surrogacy, each participant that completed a questionnaires was, speculatively, in a happy place due to the fact that he or she held a newborn in their arms (Erez & Schenkman, 2016). Second, this questionnaire was completed after the surrogacy process had been accomplished, meaning that the stressors they had to overcome during the process had been resolved and were in the past. In other words, any stress they had during the process (e.g., the anxiety resulting from the possibility that the surrogate would want to keep the child) was no longer present (Damelio & Sorensen, 2008).
Although the gay participants gave high scores on the ‘responsive and supportive nature of the clinics and agencies throughout the journey’, the expectation was otherwise according to the Sexual Minority Stress Model (Meyer, 2007). It was expected that gay participants would feel less satisfied by agencies and clinics than heterosexual participants in terms of the support they received from them (Hendricks & Testa, 2012). One could assume that given the timing of the questionnaire, they were in a happier place and therefore gave higher scores.
The experiences of the participants with the surrogacy agencies and clinics were divided into positive and negative experiences. These positive and negative experiences were divided in several major themes. After coding the open-ended questions, the fact remained that overall, gay and heterosexual participants were satisfied with their agencies and clinics. Gay
and heterosexual participants are pleased with the emotional support they received from the agencies and were satisfied with their respective surrogate matches. Gay participants were pleased with the emotional support they received, which contradicts what the Sexual Minority Stress Model would have hypothesized (Hendricks & Testa, 2012). Given the results of this study, it seems that the problems attributed to the surrogacy process from the perspective of gay participants do not have a connection to the lack of emotional support they get from the agencies.
The negative experiences between gay and heterosexual participants were also alike. Both of these groups wrote about the lack of transparency concerning the cost of the surrogacy process that some agencies maintained. Additional feedback illustrates that both groups felt that sometimes the agencies were not as helpful as they should have been. Only the gay participants remarked about the inequality that clinics and agencies showed various clients. The feeling of inequality can be explained through the Sexual Minority Stress Model (Meyer, 2007). This feeling can cause excess anxiety for gay participants that heterosexual participants do not experience due to the fact that they are not a member of a minority group (Hendricks & Testa, 2012).
Gay and heterosexual participants were both pleased with the professionalism and emotional support they received from the clinics. Also they were both satisfied with the help they received from the staff during the process, the consistency towards professionalism and emotional support made the process easier for them; however, when analyzing the negative experiences with clinics there was one main difference between the satisfaction level between gay and heterosexual participants. Gay participants experienced institutional aspects of the organization that were heteronormative. This means that overall, gay participants experienced less understanding, and felt more discriminated against, by the staff throughout the process (Corbett et al., 2013). For example, during the intake at the clinics, the staff would ask for the
‘wife’ even though there were two men standing in front of them. Another example is that the sperm of gay participants was subjected to additional tested, making these participants feel as though they were being treated differently than their heterosexual counterparts.
The feeling that some of the institutional aspects were heteronormative can be explained with the Sexual Minority Stress Model (Hendricks & Testa, 2012; Meyer, 2007). It should be noted that the gay participants who reported feeling like they were treated differently by the clinics used gestational surrogacy as their pathway to parenthood. One could assume that by using gestational surrogacy these gay participants were therefore more dependent on the clinics than with traditional surrogacy (Friedman, 2007; Nakash & Herdiman, 2007). By using gestational surrogacy gay participants had more contact with the staff and thereby felt more alienated than the heterosexual participants (Corbett et al., 2013).
The limitations of this study should be acknowledged. First, each item in this study is used as a single-item. This is not surprising for this type of research study since the validity
remains sufficient for this type of sample (Bergkvist & Rossiter, 2007). Single-item
measurements are more often used in gay parenting research. In big national survey research studies about gay parenting it is common to use single-items measurements (e.g., Bos, Knox, van Rijn-van Gelderen, & Gartrell, 2016).
Another constraint is the limited power to pick up a mean difference in the research study. By using a post hoc analysis the statistical power has been computed due to sample size, mean and standard deviation (Faul, Erdfelder, Buchner, & Lang, 2009). After a post hoc power calculation for the single-items—which represented the satisfaction with the agency— there exists a limited power between .06 and .10. For the post hoc power calculation for the single-items—which represented the satisfaction with the clinics—the power is limited between .06 and .13. Due to the fact there is a limited power, one should look with a critical eye towards the results.
It should be acknowledged that in this research study the heterosexual participants were not divided into male and female groups. This is due to the fact that the group was too small with only 15 men and 37 women. Additionally, the online questionnaire only focused on the experiences of the participants after the process for surrogacy had ended. The initial
questionnaires were collected and considered without conducting further interviews to seek clarification about any questions that perhaps were in need of more explanation. The information, therefore, came from only one source: the intended parents.
Future research should focus more on the experiences of gay parents by utilizing multiple questionnaires, or allowing for follow-up interviews. This method would provide a more comprehensive image of the experiences these gay parents had since it will allow them to expand on their feedback and clarify their answers. One should also involve the agencies and clinics by asking them about their experiences with their gay and heterosexual clients. This way we can have a realistic and more accurate impression of what is going on in these clinics and what they need to do in order to make it less heteronormative for same-sex couples.
This research study gives us an overall impression of the experiences and satisfaction of gay and heterosexual participants with surrogacy agencies and clinics. The experiences of gay participants give us insightful information about what is still needed during the long and difficult process of surrogacy. Clearly gay couples are in need of a more gay friendly
approach from clinics. It is important that clinics learn an affirmative approach towards same-sex couples. The staff of these clinics can learn to acknowledge the normal and positive value of same-sex relationships. Also, from an institutional aspect, the organization of the
administrative procedures should become more gender neutral. In this way, all couples that choose to pursue surrogacy feel welcomed. Clinics can achieve this by learning an affirmative approach towards same-sex couples.
In all, this study provides insight into the experiences of gay and heterosexual participants during their surrogacy process. The aim of this research study was to understand whether gay men were confronted with homophobic stigmatization from agencies and clinics. According to the experiences of participants with the agencies, this assumption fails to prove correct. The only time when a gay couple was treated differently was due to a surrogate refusing to work with a same-sex couple. Perhaps this is due to the fact that other gay couples lead most of the agencies, which creates an environment where gay couples do not feel as if they are treated much differently than heterosexual couples.
The experiences of gay participants with their respective clinics confirm that stereotype that gay men are confronted with homophobic stigmatization in clinics. Even so, some gay participants felt as though they were treated differently by the staff due to the institutional aspects of the clinics. Clinics can expand their understanding of the difficulties that same-sex couples face and focus on becoming less heteronormative in their organizational nature (Langdridge, 2008).
Surrogacy is available for same-sex couples in the majority of the United States, which is not the same as in the Netherlands (Boele-Woelki et al., 2011; Bos & van Rooij, 2011). Given the lack of reach, surrogacy is a hot topic right now in the Netherlands. Recently the State Commission wrote in their research report that they were feeling positive about potentially legalizing surrogacy in the Netherlands, though there are still some issues with surrogacy that have to be solved before this can occur (Wolfsen et al., 2016). One of these issues is the lack of regulation for the use of surrogacy. Mediation for surrogacy is currently forbidden in the Netherlands and as of now, nothing can be arranged for the surrogate in terms of a settlement (Boele-Woelki et al., 2011). Another issue that concerns the State Commission is that the sale of children is forbidden in the Netherlands (Wolfsen et al., 2016). Due to the fact that the
surrogate receives a settlement during the pregnancy it looks like the baby is bought by the intended parents.
The State Commission is worried about the many unreliable practices of surrogacy, not only in the Netherlands but also abroad (Wolfsen et al., 2016). Due to the fact that
commercial surrogacy is forbidden in the Netherlands, many potential parents seeking
conception through surrogacy are forced to go abroad (Vonk & Boele-Woelki, 2012). In other countries surrogate rights are not as well protected, making little distinction between
surrogacy and selling children. This kind of practice will eventually lead to child trafficking (Wolfsen et al., 2016). The temptation for intended parents to choose surrogacy abroad is due to the fact that there are more available surrogates, the costs for a journey is lower and there is a higher legal certainty, according to the State Commission (Wolfsen et al., 2016).
Despite the many doubts the State Commission is looking positively towards legalizing surrogacy (Wolfsen et al., 2016). The State Commission stated that a child should never be treated as merchandise. According to them if good regulations surround the practice of surrogacy in the Netherlands, this could be an alternative for parents eager to forge their pathway to parenthood through surrogacy. If commercial surrogacy becomes the future norm in the Netherlands, they should keep in mind that it is not only the legalization of surrogacy that is important, but also the cultural and social preparation of the clinics and agencies. Agencies and clinics in particular, should be prepared to deal with same-sex couples that opt for surrogacy in the best way possible. Agencies and clinics can start to learn an affirmative approach towards same-sex couples. In this way the staff can learn to acknowledge the normalcy and positive value of same-sex relationships, allowing for same-sex couples who opt for surrogacy to feel as though they are welcomed by agencies and clinics, with open arms.
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