Today we’re going to dive into the nitty-gritty of the topic. What is social surrogacy? Who could this be right for if anyone, and what are the real ethical concerns about the topic?
Whoever thought making a baby could be so hard? Luckily, the fertility journey isn’t meant to be traveled alone. Eloise Drane has helped hundreds of people build and grow their families over the last 15 years, and she’s ready to share insider knowledge and expertise with you. So grab a seat and let’s talk fertility and alternative family building in the fertility cafe.
Hello, and welcome to today’s episode of fertility cafe. I’m your host Eloise Drane. Today, we get to talk about a subject that I’ve never really spoken about: social surrogacy, gestational surrogacy is an amazing opportunity for intended parents who are otherwise unable to have a baby of their own. It’s a form of third-party reproduction that has become increasingly accepted in the public eye and more accessible than ever before. There are many reasons for this but one of the biggest ones these days is that gestational surrogacy is pretty much the only way for gay men to have their own biological children.
As LGBTQ rights have expanded, the awareness about surrogacy as an option has hit the mainstream media and the practice has had a more positive spotlight based on it than ever before. Just a couple of months ago, the media celebrated the arrival of Lance Bass and his husband’s twin girls delivered via surrogate. Time Magazine recently featured actress Gabrielle Union’s surrogacy story, as she opened up about her infertility problems that she and her husband Dwayne Wade struggled with. Queer Eyes’ Tan France also welcomed a beautiful baby boy born via surrogacy as well. And he made news for clapping back at an internet troll’s nasty message about it. It’s stories like these that help garner empathy in understanding among the general population. But for every one of these heartwarming stories, there always seems to be a story about a less than ethical arrangement gone wrong.
A quick note here for the scope of this episode, I’m going to be speaking on gestational surrogacy as it’s practiced in the United States. When you start to open up the conversation to include international surrogacy, the ethics, laws, regulations, and viewpoints become far too complicated to address in a single episode. So please keep that in mind for this discussion. While there is still a fraction of the US population who is vehemently opposed to the practice of surrogacy in any circumstance, over 70% of Americans have a favorable view of it, when it’s necessary—that is. In a 2015 YouGov poll, 73% of women and 69% of men approve of surrogacy. Here’s the question they were asked: Surrogacy is the practice by which a woman helps a couple to have a child by carrying to term an embryo conceived by the couple and transferred to her uterus or by being inseminated with the man sperm in either donating the embryo for transfer to the woman’s uterus or carrying it to term. Do you approve or disapprove of surrogacy?
In the grand scheme of things, this is a fine question. However, as a professional immersed in the world of surrogacy, I can tell you, there are many more layers to this. For instance, this question specifically asked about helping a couple have a baby. What about a single man who wishes to become a father? Would the same percentage of people be okay with a gay couple having a baby via surrogacy or a straight unmarried couple? What about a single woman who wishes to have a child without a partner but she cannot carry on her own for medical reasons? Or a single woman who chooses to have a baby via surrogacy when she is otherwise perfectly healthy and has all indications that she could carry a pregnancy safely to term? Heck for that matter, what about a married woman who chooses it for personal rather than medical reasons? This is where it gets pretty hairy.
This last scenario, the one where a woman makes the choice to work with the surrogate rather than carrying her own pregnancy without having a medical reason is quite controversial. When this topic comes up, the conversation about surrogacy always veers back into the wounds for rent rhetoric about wealthy people taking advantage of less wealthy women who become surrogates to earn some money. And I’ll be honest, it’s not really a good look. I mean, think about it.
Let’s say Victoria’s Secret model wants to have a baby but she’s not willing to pause her lucrative and highly visible career to go through the discomfort of pregnancy. She’s afraid pregnancy will be a career-ender for her, that she’ll never get her model-perfect body back. So rather than put a hold on her career, or wait to have children, or explore adoption, she decides to work with a surrogate. She pays a generous amount of compensation to a sweet military wife who plans to use the money for a down payment on their first home. The surrogate is excited to carry for such a beautiful, famous person and appreciates the money. She endures the aches and pains of pregnancy, the new stretch marks, and the pains and risks of labor and delivery, and the intended mother the model call about her business with no perceived changes to her life or body at all for those nine months. You can see how this might cause some controversy, right? This fictional scenario does happen from time to time, and it’s referred to in the industry as social surrogacy.
I’ll also share my personal opinion on the matter which might ruffle some feathers. You’ll have to let me know what you think after you listen, you can follow us on Instagram at family inceptions to share your thoughts.
First things first, let’s define the more traditional reasons someone might seek to have a baby with the help of a surrogate. Perhaps you’re single, a gay couple is struggling with infertility. All of these are considered traditional common reasons why one might undergo a surrogacy journey. To receive a diagnosis of infertility, it typically takes about a year of a couple to try to conceive without success. There are a lot of different causes of infertility, and unfortunately, some people never do find out exactly why they are unable to conceive. Some of the more obvious reasons include being born with an abnormally shaped uterus or uterine cavity or being born without a uterus at all. Someone may have had to undergo a hysterectomy at a young age for reasons such as endometriosis, or fibroids that created all sorts of havoc on her body. In other cases, women must seek out a gestational surrogate due to underlying medical conditions that aren’t really related to the reproductive system, at least not directly. These include conditions that could put a person at risk if they were to become pregnant.
For example, pregnancy could be dangerous for someone with heart disease, kidney disease, or severe diabetes, certain cancers, and their subsequent treatments can make pregnancy impossible or unadvisable. Or perhaps someone may have had a previous pregnancy that ended up being a high-risk case with conditions such as preeclampsia, which in severe cases can be life-threatening. If this intended mother wanted another child, it may be necessary that she undergo gestational surrogacy due to health risks involved or possibly even due to PTSD from the trauma caused by the previous pregnancy or birth.
All of the above reasons for seeking a surrogate assumed there was a female intended parent involved. Of course, that’s not always the case for a single man or a gay couple. Infertility is a moot point. Unless one of the partners has a uterus, there’s no biological way to have a baby, and so gestational surrogacy becomes an option. The fact is, there are a lot of reasons why someone is medically or biologically unable to carry a child on their own. In the US, roughly 10 to 15% of all couples struggle with infertility. That equals about six to 7 million people. And this doesn’t include the 10s of 1000s of intended parents in the LGBTQ community who require assisted reproduction to have a baby. Long story short, there are a ton of people in the United States who have a real biological need for assisted reproduction, including gestational surrogacy. People who choose social surrogacy do not fall into that category.
So what is social surrogacy, who chooses it, and what goes into their decisions? In a nutshell, social surrogacy involves the conscious choice to have a baby via gestational surrogate, even if there was no underlying medical or biological reason. Let’s jump back to the start of today’s episode where I describe the fictional Victoria’s Secrets model who wasn’t willing or able to put her career on hold for nine months. Some individuals such as her want to be parents, but wish not to carry the pregnancy on their own due to personal or work-related reasons. Now, it’s important to know that while surrogacy, in general, has become more accessible over the past decade or so, the same is not true for social surrogacy. Someone who wants to pursue this path to parenthood may face legal and other barriers. For example, in the state of Utah, it requires medical necessity in order for one to enter into a surrogacy agreement.
This means that the intended mother needs to prove that there is a true medical reason in which she is not able to carry the pregnancy. There are also a lot of professionals in the field who will not work with a woman who was choosing surrogacy when traditional pregnancy is within the realm of possibility for her. While there is no federal regulation or centralized body that polices the industry, the American Society for Reproductive Medicine or ASRM is a gold standard for evidence-based best practices. And according to this well-respected body of practitioners, surrogacy is only ethical when there is a medical or biological need, such as infertility or a lack of a uterus. So for those agencies, clinics, and other professionals who adhere strictly to the ASRM guidelines, social surrogacy is a no-go.
That being said, there are plenty of clinics and professionals who are happy to help with social surrogacy arrangements. Some see this as a matter of a woman’s right to bodily autonomy. Social surrogacy could be a way to level the playing field in terms of gender equality. Why should a male politician be relatively unaffected by the pregnancy and birth of his child when his female politician counterpart would have her career and aspirations delayed and possibly thrown off track altogether. Still, for better or for worse, there are plenty of fertility professionals who are happy to work with any intended parent regardless of their reasons. Let’s talk about some specific reasons why a woman might choose social surrogacy. There could be a fear that pregnancy will negatively impact your body with weight gain, stretch marks are all of the other glorious things that come along with pregnancy and delivery. And I can safely say that yes, there are definitely all parts of the deal when it comes to having a baby. Some feel the effects more than others and some bounce back from it differently than others. But I think it’s safe to say that no one is going to walk away from pregnancy and childbirth without some bodily changes. For most of us, that’s simply the price we pay for parenthood, and we can decide if or how much we’ll work to make changes once the baby arrives. But for many people who consider social surrogacy, that price may be seen as too steep when weighed against other factors. Professional models, actors, and athletes rely on their physical appearance and abilities as part of their careers and income. Becoming pregnant could put the career on hold for a significant amount of time or even end their career altogether.
Those with physically demanding jobs such as athletes, firefighters, or women in the military worry about causing harm to their baby by exerting themselves too much physically and possibly even going into preterm labor. Some career-driven women don’t necessarily rely on their physical appearance as a part of their profession, but still feel that pregnancy would hinder their career. There’s the worry that they won’t be able to perform as well and even fear they’ll lose their job from things like morning sickness, lack of sleep, or fatigue. What if they had hyperemesis, extreme morning sickness, as Kate Middleton had. How on earth would they be able to focus on their work, let alone meet important deadlines? Some also worried that their high-stress career could cause harm to a baby in utero. What risks would an investigative journalist who is embedded with soldiers in another country be undertaken? Or how about a marine biologist who is working in an area with high transmission of the Zika virus, which can cause very severe birth defects? These are the types of things that lead some women to embark on a surrogacy journey, despite their medical and biological ability to carry the pregnancy on their own.
I think we can all empathize to one degree or another with some of these tough choices people in these situations face. It’s easy to dismiss a model or actress or even an athlete for wanting to avoid the physical changes of pregnancy. But for those people who truly have jobs that may harm the baby, I can feel for that should that woman be forced to quit her risky, potentially dangerous career in order to carry her own baby? There are some instances where it’s certainly worth debating. There’s a gray area for someone like the biologist working in a high-risk location, for example.
But then there are the so-called designer surrogacy cases. One article originally published in Elle magazine in 2014 quoted a fertility doctor from San Diego who worked with patients who choose surrogacy for reasons like not wanting to get fat and wanting to complete an upcoming marathon. Another patient felt that pregnancy would hinder her from building her photography business to the level she wanted. The response to many of these reasons is often to wait, wait until your career is well established. Wait until the marathon is over. Wait until you’re willing to deal with the physical changes to your body. For some women, though, they feel that they can’t wait much longer. The photographer quoted in the Elle article, for instance, stated that she truly felt her business-building momentum would be destroyed by pregnancy, making her brand completely forgettable after taking time off to have a baby. And yet she said she was getting older and feared it would soon be too late to have a baby of her own. Before gestational surrogacy was an option. The answer would have been making a choice, pick one or the other. But today, they can be a third option. Choose both to keep your career and have a baby with the help of a surrogate. In the case of the successful photographer, she worked with a friend of hers who happened to own a surrogacy agency that had no qualms about her social surrogacy. In fact, her agency had facilitated several social surrogacy arrangements in the past. So this was just part of the course. The photographer and her husband decided that having a baby via surrogate was the best option for them, and they decided that they were willing to face the backlash, and they did receive a considerable amount of backlash from friends, family, and strangers alike. To be clear, social surrogacy is not a particularly common occurrence.
One fertility specialist in San Diego estimates that social surrogacy or convenient surrogacy as he called it accounts for just about 5% of all the surrogacy arrangements he oversees. It does happen though, and I think as surrogacy becomes more common, we will be hearing more about it and debating the big question: Is social surrogacy ethical? Should a woman be able to ask a surrogate to carry her child for the sake of not ruining her body or jeopardizing her career? This is where things can get a bit touchy. Some feel that it is morally wrong and selfish for someone to have a surrogate carry their pregnancy when they are capable of doing so themselves. I think most would agree that you do not need to give birth in order to be a good parent. However, when someone is choosing not to carry their own child for nine months due to superficial reasons, such as ruining their body, some do begin to question their ability to parent that child. Let’s face it, sleepless nights spit up in dirty diapers aren’t the most glorious things to endure. And as one line commentator put it, what else is that parent going to outsource when things get tough? There are sacrifices that need to be made when you have a child. Is it fair that often in straight couples anyway, the female partners tend to be the brunt of most of the sacrifices? Definitely not. Is social surrogacy one way to level the playing field. I’m not so sure about that.
Let’s look more closely at the issues of ethics. As I mentioned before, there is no federal regulation that governs surrogacy in the United States. ASRM is a nonprofit, nongovernmental body of professionals who work to advance third-party reproduction and reproductive medicine. They are committed to researching and publishing opinions and recommendations for the best evidence-based practices in the field. Indeed, according to ASRM, surrogacy should be used only when a true medical condition precludes the intended parent from carrying a pregnancy or would pose a significant risk of death or harm to the woman or the fetus. There are some very clear medical reasons: infertility, heart disease, cancer, lack of a uterus, and so on, but there are also quite a few gray areas. For example, what about a woman who has severe anxiety, what her fear of pregnancy, and her diagnosis of anxiety qualifies her as having a medical need for the help of a surrogate? What about a woman who’s in her 40s, she wants to have a baby of her own but isn’t sure she should take the risk given her age. All medical indications point to her being biologically able to carry a pregnancy, but should she? Would it be ethical for her to bypass a potentially difficult path to getting pregnant without assistance because of the theoretical risks to her or the baby?
As one fertility doctor put it, placing an embryo in the womb of a woman who has given birth successfully in the past dramatically increases the chance of a successful pregnancy. Would it be ethical and maybe even preferable to attempt IVF with a surrogate who has a proven track record of being able to carry a baby rather than attempt the complicated and expensive process with a woman who is 40 plus and statistically far less likely to become and stay pregnant? Other circumstances that aren’t so cut and dried include an intended mother who suffers from depression and isn’t able or willing to risk pregnancy while on medication. Or someone who suffers from PTSD due to past sexual or other trauma. A person whose job exposes them to harmful chemicals or pathogens regularly. What if a woman experienced a particularly difficult or traumatic pregnancy in the past? Would the trauma of pregnancy loss, stillbirth, or a life-threatening complication during pregnancy or delivery justify working with the surrogate? When you really start running through the scenarios, it becomes tricky to define what exactly qualifies as a medical necessity.
According to Dr. Paula Amato, a professor of obstetrics and gynecology and one of the professionals who helped draft the ASRM guidelines, purposely worded the ethical guidelines around surrogacy so medical professionals could have a fair amount of leeway when determining what counts as a medical need. Because truth be told, many of these questions can only be discussed between a woman and her doctor. And it’s certainly not appropriate for me or other members of the public to judge a person who was facing tough choices about parenthood.
However, I do think it is absolutely worth having an educated discussion about the practice of surrogacy by choice. So far, we focused on the potential intended mother and all the factors that can come into play for someone who was considering social surrogacy. I want to flip the conversation now to consider the other very important player in this equation, the surrogate mother. As a three times surrogate myself and as an agency owner who has worked with hundreds of wonderfully selfless surrogates, I can safely make some generalizations about the type of woman who steps into this role. She is first and foremost generous. She sees surrogacy as an act of service, as a calling to contribute something to the greater good. She has a deeply felt empathy for people who can’t have children without help. Some surrogates feel led to work with married couples who have dealt with pregnancy loss and infertility for far too long. Others feel called to help gay couples experience the joys of parenthood as a very real intangible way to show support for equal rights and opportunities.
It’s a rare surrogate who was up for carrying a baby for another person, regardless of the reason why that person can’t carry their own pregnancy. At least that’s been the case in my experience. Asking a woman to be your surrogate is a gigantic request. There are so many physical, emotional, psychological, and practical considerations to be had. You are essentially asking another human being, another mother to put her life on hold for about a year or two. She may have to travel for medical screening for the embryo transfer, and she’ll be taking fertility medications that make her uncomfortable and throw her hormones out of whack. She’ll experience all the morning sickness, the backaches, the swollen ankles, the headaches, and potentially nosebleeds. She may experience complications that keep her from being fully present with her own children or with her spouse. She may miss work or miss out on time with friends and loved ones in order to attend doctor’s appointments. Her doctor may place her on bed rest, and then she will endure the pain of childbirth. Her body will be stretched and torn in places once again. She’ll spend roughly six weeks wearing diaper-like menstrual pads, taking sitz baths to relieve the painful aftermath of birth. And that’s if it’s vaginal birth, potentially a C section could even be worse. And it goes without saying she’ll be abstaining from sex with her spouse during the six-week recovery time. Not to mention the abstinence when she first started the process pre and post embryo transfer. That’s if childbirth goes as planned.
Heaven forbid there’s a serious complication that comes up during pregnancy or labor, preeclampsia, gestational diabetes, anemia, postpartum hemorrhage infection. In 2019 754 women died due to maternal causes in the United States. There are approximately 20 deaths per 100,000 live births in women ages 25 to 39 and 75 per 100,000 for women over the age of 40. The US has one of the highest maternal death rates among developed nations. So while it’s not a huge risk, the risk exists. Then there are the less obvious but still deadly conditions like postpartum depression, anxiety, or rarely postpartum psychosis. So yeah, it’s a huge ask to approach someone about carrying a child for you. We’ve all heard it may be experienced ourselves that every pregnancy is different. It’s true when you’re carrying your biological child and also when you’re carrying as a surrogate.
What stays the same is that each time a person is pregnant, there is a risk. Asking someone to be your surrogate is by definition, asking them to assume the risk of potential complication, illness, or ultimately death. When you put it in those terms, it can be increasingly difficult to justify surrogacy as an option when there is not a medical or biological need. Is a person’s convenience no matter how tied to career or livelihood worth the risk a surrogate would be undertaking? Of course, on the other hand, there is a risk in everything. There is a risk in asking your friend to pick up groceries for you because you don’t have time to stop on the way home. She could get into a car wreck. She could encounter an armed robber in the store, she might trip and fall winding up in the hospital with broken bones.
There are a few things I know to be true about social surrogacy, at least for now. First, it’s likely that a woman who was choosing surrogacy out of convenience and not necessity is going to face an uphill battle in a lot of ways. She will probably be hard-pressed to find a willing surrogate due to all of the above-mentioned risks, but also on principle. As one surrogate expressed wait, I’m supposed to go through pregnancy and childbirth so that women can avoid stretch marks? Social surrogacy doesn’t often garner the same empathy and outpouring of goodwill on the part of the surrogate population, to put it lightly. I mentioned before that it might be difficult to find providers who will work with a social surrogacy arrangement, but I caution that there’s an even greater battle to be fought in the sphere of public opinion. There can be a lot of backlashes if friends, family, and the greater community get wind of someone’s choice to have another person carry her baby. Just take a look at some of the nasty comments online that are directed at celebrities who had babies with the help of surrogates.
Women like Nicole Kidman, Sarah Jessica Parker, and Kim Kardashian have all stated publicly that their decision to work with the surrogate was due to medical reasons, but there is still tons of speculation that they did so for vanity or career reasons. Public opinion is not very forgiving, to say the least. We haven’t even touched on the financial side of things. Surrogacy for any reason can cost upwards of 100 to $200,000. Women who agreed to serve as surrogates earn on average about 40 to 80,000 in compensation for this sacrifice and time commitment. Intended parents often scrimp and save and take out second mortgages on their houses in order to afford this costly, usually last-ditch effort to have a baby. We can’t ignore the fact that a person who is choosing surrogacy for nonmedical or biological reasons, is doing so from a place of considerable financial privilege, and some will offer a premium to their potential surrogates in order to make this social surrogacy agreement more attractive. When there is a 40 to $80,000 price tag on the line it can make some surrogates set aside their moral qualms about the lack of medical need. And I have to say that doesn’t feel quite right. While public opinion seems to be coming around on the practice of surrogacy in general, cases of social surrogacy tend to stir the pot in the opposite direction painting our whole industry in a questionable light.
Here’s how one news article describes the waiting room of a well-known super high-end fertility clinic in Los Angeles. Crystal chandeliers, leather upholstery, plush velvet textures, opulent floral arrangements, flat-screen televisions, cycling through pictures of beautiful newborns. The author goes on to detail several ethically questionable decisions made by this particular clinic’s founder, including helping grieving grandparents have a grandchild after their son, 26 at the time, died in a motorcycle accident. They had his sperm extricated post mortem, obviously without his consent, and then produced the baby boy using an egg donor and surrogate. Yes, really. On the other hand, the doctor at the helm of this clinic was one of the first doctors in the US to help a gay couple have a baby back when it was very, very taboo to even consider this. The article ends with some discussion about whether or not social surrogacy will one day be widely accepted just like gay parenthood via surrogacy is today. Is boundary-pushing actually a good thing since it theoretically allows women to keep their careers rather than being waylaid by pregnancy? Time will tell, I suppose. For now, social surrogacy is still relatively uncommon. It is definitely still taboo and I would say the vast majority of the industry and in terms of public opinion.
So what about my own views? Well, let’s dive in. As an agency owner, and a three-time surrogate, and a mother of four plus a gifted daughter to really be five, I can unequivocally say that social surrogacy is not something I am okay with. Let me first start by reading the mission statement, I have built my business on.
At family inceptions, our mission is to create and grow families by empowering parents, surrogates, and donors to make educated and bold decisions about their future, serving directly from our hearts and with integrity and honesty, honoring the journey of our clients through compassion and empathy, embracing inclusivity, and diversity with open minds and hearts expressing gratitude with a joyful and positive attitude and demonstrating expertise in the field of third party reproduction.
Let me zero in on this part, empowering parents and surrogates to make educated and bold decisions about their future. The choice to become a parent is indeed bold. It’s one of the most significant, courageous, terrifying choices a person can make. To me, the idea that a person who is physically capable of carrying a pregnancy would choose to put her career or other priorities in front of that choice, well, it’s a bit like having your cake and eating it too. Except, in this case, you’re putting the cake maker at a heightened risk of getting burned while baking for you. The very fact that every pregnancy, regardless of whose baby is being carried, is inherently risky. Take social surrogacy off the table for me, maybe it’s because I was a surrogate myself. So I intimately know how big of an ask this is. In my third journey, I experienced complications that resulted in me actually having to have an emergency hysterectomy to save my life. The idea that a woman would gamble with my life in order to save her career or body or lifestyle, well, it doesn’t sit right with me. And so I will not facilitate social surrogacy arrangements, in large part because I won’t be a party to gambling with a surrogate’s life.
One of the major reasons why surrogates receive such significant compensation is because it’s an acknowledgment of the pain sacrifice, discomfort, and risk that she agrees to endure for the sake of a person or couple who desperately wants to become parents. Desperately hopeful parents who have likely exhausted all avenues before arriving at surrogacy. Often to the great financial detriment and always have loads of emotional turmoil. It is a huge ask for someone to become a surrogate and in my opinion, it should only come to that in the most necessary of circumstances. And so no, I am not in favor of social surrogacy, I will not pass judgment on the woman who chooses this route. As we all have to walk our own paths.
However, I also won’t be a party to it, which is why Family Inceptions will not work with women for whom surrogacy is a choice and not a necessity. Others may certainly disagree, and I can respect that. I hope that you can also respect my opinion on the matter. I would love to hear from you on this, please join the conversation over on Instagram at family inceptions. But please, only if you can do so respectfully. I will end on this note, while it’s certainly controversial, the fact that we are even able to have this conversation today is pretty amazing. The leaps and bounds made in the field of third-party reproduction these past couple of decades are incredible. IVF and gestational surrogacy have made parenthood possible for people in ways that used to be unthinkable.
And so of course, it makes sense for there to be a lot of ethical questions and dilemmas to pop up. As we debate about genetic testing and designer babies. This question of using surrogacy by choice is an important discussion to have. It helps us define the blurry line and science and reproductive technology between doing good and taking it too far. I hope you found this discussion helpful. As you weigh your next steps. We will love for you to rate us. So if you haven’t yet, go to your listening platform of choice, and subscribe, rate, and review this podcast. You can follow Fertility Café on its Instagram and Facebook channel at Family Inceptions. We’d also love you to share Fertility Café with friends and family members who would benefit from the information shared. Join us next week for another conversation on modern family building. Thank you so much for joining me today. Remember, love has no limits, neither should parenthood.
Thank you for joining us in the Fertility Café. Whether you’re an intended parent, a woman considering egg donation, thinking of becoming a surrogate yourself, or a friend or family member of someone dealing with infertility, we’re here to help. Visit our website thefertilitycafe.com for resources on fertility, alternative family building, and making this journey your own.
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