 I'm going to be presenting some of our studies that have looked at the psychological wellbeing of surrogates and also their families. The study I'll be talking about was actually a follow-up study to an earlier study of surrogates who were seen one year following the birth of the child. The study was really set up to answer the following questions. Do surrogates experience psychological problems in the longer term? So, these are in the years following the surrogacy. Are they experiencing any psychological issues? Do they stay in contact with the intended parents and the surrogacy child over the years? How do surrogates view their relationship with the family? Do the surrogates own children experience psychological problems? So, though we have seen that there have been studies, our study mainly, of the children who are born through surrogacy, there were also concerns about how children within the surrogates' own family might be thinking about and feeling about their mothers carrying a pregnancy and then seeing that child given to another couple to raise. So, we really wanted to understand more about what it's like for surrogates' own children. And how do surrogates' children view their relationship to the surrogacy child? So, like I mentioned, the current study was a follow-up study of 34 surrogates who were seen one year after the birth of the surrogacy child. So, 10 years after this original study, we tried to contact the surrogates again. We contacted 20 of them who agreed to take part in the study. And in order to increase the sample, we also recruited a further 14 surrogates through surrogacy clinics, sorry, through fertility clinics in the UK. So, in terms of the sample, most of the surrogates had children of their own, only one didn't have any children. Most of them, 65% of them were married or in a cohabiting relationship. In terms of their occupation, we can see that a third of them were in professional managerial occupations, and a third were in skilled non-manual occupations. And in terms of the type of surrogacy that they had completed, around a third of them had done traditional surrogacy, so had used their own egg for the surrogacy arrangement. 41% of them had done gestational surrogacy, so they were not genetically related to the child. And then we found this further group of 24% of surrogates, eight of them who had done both types of surrogacy, traditional and gestational. And we were actually quite surprised to see this category, because previous studies had found that surrogates were either traditional surrogates or they were gestational surrogates. So we were also interested to see why was it that this sort of group was emerging where they had done both types. So why were women deciding to be surrogates? The main reason that they were giving is because they wanted to help a childless couple. Some of them also mentioned wanting to help a childless couple alongside enjoying being pregnant, and other reasons including wanting to help a family member or a friend, or seeing others struggle with infertility, or also valuing their own children and their own families, and wanting others to also experience that. So one of the things that's quite unique to our sample is that the surrogates have done multiple surrogacy arrangements. So although the main surrogacy arrangements that they had done were arranged from one to eight, so we did have surrogates who were doing multiple surrogases, and we wanted to understand why it was that they were continuing to do further surrogacy arrangements. So what were the reasons for doing further surrogacy arrangements? And some of the reasons that they mentioned was wanting to help a family have a sibling for the child, again wanting to help a childless couple, having a previous positive experience of surrogacy and therefore wanting to repeat that positive experience, enjoying pregnancy again, having an unfulfilled expectation from a previous surrogacy, and so then wanting to do a further surrogacy in order to have a more positive experience was also mentioned, payment was mentioned by two of them, request from a surrogacy organisation was also mentioned, and as was not intending to do a further surrogacy arrangement but meeting a couple who needed surrogacy and then changing their mind about this and going forward and helping them. So we assessed, we measured surrogates levels of self-esteem and depression using standardised tests, and we can see that most of the surrogates fell in the average or above average range for self-esteem, and also in terms of their depression, most of them were showing no signs of depression, and remember that this is almost ten years following the birth of the surrogacy child. And we also found no differences in self-esteem or depression between surrogates who had completed gestational, traditional or both types of surrogacy. So do the surrogates stay in contact with a family? So as I said in our sample the surrogates had done multiple surrogacy arrangements, so of the 34 surrogates they had actually done 102 surrogacy arrangements between them, and they stayed in contact with 77% of the surrogacy children, 85% of the mothers and 76% of the fathers. And in terms of how frequently they're seeing or at least contacting the families, we can see that for the child at least it's not very frequent similarly with the father, and the most frequent contact is actually maintained with the mother. We also asked the surrogates how they felt about their level of contact, and what we found was that there is a range of contact that they might have with the families. And in terms of how satisfied they are, most of them actually feel that the amount of contact they have, and this is regardless of whether they are in contact or not, feel that that level of contact is about right. I'm just going to point out some of the numbers here in the column to do with contact with the child. Here we can see that eight of them were not in any contact with the child, and also felt that this wasn't enough, and that was usually when the contact had been stopped by the couple. So when there was an intention to stay in contact with the couple, but then the couple then terminated contact, that's when they felt that they were disappointed in that and wanted more contact. Of the 15 who weren't in any contact with the child but are actually happy with the level of contact, seven of them were actually in contact with the parents, so they were getting updates about the child through the parents. Four of them never wanted contact in the first place. Two said that they will be in contact with the child when the child is older. One said that there was no contact due to the couple's preferences, and one said that they had agreed no contact with the couple from the outset. So I think what this table really highlights is that there is a range of contact preferences that surrogates have, and it's not the case that they always want to maintain contact with the families that they help, or that they don't want to. And often their feelings about contact might change as well, so there might be an intention not to have too much contact, but during the pregnancy they develop close relationships with the families and then therefore continue contact following the birth. So how does surrogates view the relationship with the child? Well, the majority of them reported positive relationships with the child. So, for example, this surrogate said, I think the world of her, there's nothing maternal there, but I love it a bit. She'll always be a special little girl to me. And 11% reported more neutral relationships. So, for example, I think it's like any of my friends' children. I don't get personally involved with them even when they come to visit me. 10% reported no relationship, and 3% said that the child was too young. And what do they call each other? So, you know, these are new relationships that are being formed. So how do surrogates refer to the child born through surrogacy and how does the child refer to them? And some of the terms that they were saying they were using included being referred to as auntie, or a special auntie, or a tummy mummy, and they may refer to the surrogate born child as a niece or nephew or simply just by each other's names. So how does surrogates view their relationships with the couples? Well, the vast majority of them reported positive relationships with the mothers and with the fathers. An example of this included we can just all be ourselves, and we know nobody's perfect, but haven't been through so much with the surrogates. You just get to see it all, and it's nice to have people around that you don't feel you need to put up any barriers. You can just be. So this kind of reflects the positive relationships that can develop between surrogates and the parents. Neutral or ambivalent relationships were reported with 8% of mothers and 9% of fathers. An example of this is the father's fine. I don't tend to have a long conversation with him because he just doesn't. But that's not to say there's anything wrong with him. It's just he's not one for chatting, but he's perfectly okay. So it's a much more neutral kind of relationship being described there. And in terms of no relationships were reported also with 3% of mothers and 6% of fathers. And do the findings differ between gestational and traditional surrogacy? Well, we actually found no differences between gestational and traditional surrogacy arrangements in terms of whether or not surrogates and surrogacy families stayed in contact. The frequency of contact with the child didn't differ. Whether or not surrogates were happy with their level of contact didn't differ. And whether or not they viewed the relationship as being positive didn't differ between gestational and traditional surrogacies. But we did find differences in terms of more frequent contact with intending parents for gestational surrogacies. For gestational surrogates, sorry. And gestational surrogates were more likely to report a special bond with a child compared to traditional surrogates. At the beginning of the study, I'd also said that there was a new category that we weren't expecting of surrogates who had done both types of surrogacies. And we found that the main reasons for doing traditional and gestational surrogacies is because they were meeting a couple who they wanted to help. But that couple required a particular type of surrogacy. So, for example, they may have done traditional surrogacy previously, but they met a couple who needed gestational surrogacy, and so they switched and gestational surrogacy for them. So we were also interested in the experiences of the surrogates' own children. So we interviewed the surrogates' own children if the child was aged over 12. And we did that deliberately because we wanted to ask them quite detailed, in-depth questions about their mother's involvement in surrogacy. So we ended up with a sample of 36 children, so they weren't all children, but they were the children of surrogates. They ranged in age from 12 to 25 with a median of 17. They were aged two to 15 when their surrogates, when their mothers did their first surrogacy arrangements. And the number of surrogacy arrangements their mothers had done ranged from one to eight with a median of three. 39% of them were male, 61% female, and 44% of their mothers or their parents were in a marriage or cabiting relationship, and 56% of the parents had been divorced or separated. And again, we can see these three types of categories in terms of the type of surrogacy that their mothers had completed. So in terms of the psychological health of the surrogates' own children, we found that most of them actually scored either average or above average for self-esteem, and only two of them scored above the cut-off of five, which indicated a likelihood of a psychiatric problem on an assessment of the general health questionnaire which assesses psychological problems in young adults. So how involved is a surrogate's family? The extent of family's involvement in the surrogacy process varied. So for some of them, the surrogacy was kept very separate from their family life. So, for example, she keeps it separate from us really. It doesn't really affect us. It's just family with a bump. And another said that they, in their case, the whole family was involved in the surrogacy process. So this partner of the gestational surrogate, we did also speak to the surrogate's partners as well, said we talk about it as a couple. We are a couple, and we do things as a couple, and the surrogate is one of the things we do as a couple. So again, it really varied between different surrogacy arrangements. So, like I said, we also interviewed some of the partners of surrogates. And in terms of how they felt about surrogacy, the vast majority of those who took part in the study had positive views about surrogacy. So, for example, this partner said, it can make people parents who desperately want to be parents who for no reason of their own cannot be. I can only see it in a positive light, I have to say genuinely only in a positive light. So how do the surrogate's own children view surrogacy? Again, the vast majority of them saw their mother's involvement in surrogacy as being positive. So this child said, I think it's a brilliant thing. I think just for someone to go through what my mum went through to make someone else happy is amazing how someone would do that for someone else. So that was the majority of the kind of responses we were getting. But 14% of five of the children did see, had more sort of neutral or indifferent feeling about their mother's involvement in surrogacy. So for example, this child of a traditional surrogate said, I don't have a problem with it if mum wants to do it, that's her prerogative. So it's sort of a feeling or indifference. We asked the children if there were any difficult aspects of surrogacy for them. And only some of them mentioned factors that they did find difficult. And some of the things that they were talking about was maintaining a relationship with a surrogacy child was difficult, health complications for the surrogate was mentioned by three of them, receiving negative comments from other people, the surrogate not being able to take the child out and the baby being handed over or seeing the surrogate upset was also mentioned, but only in one case for each. We also asked them what they thought the rewarding aspects of surrogacy were and more of the surrogate's children mentioned rewarding aspects and for them rewarding aspects included the relationship with the child and the intending parents, being proud of their mum, helping another family, seeing their mum happy, travelling and meeting people and two mentioned the positive effect it had on their own family. We asked them what would have made surrogacy easier for you and only a minority of them actually responded to this question and had something to say about it. So three of them mentioned surrogacy being less taboo or there being more awareness of surrogacy. Living closer to the intending parents would have made surrogacy easier because sometimes a geographical distance meant that it was much harder for them to maintain contact if they wished to do that. Having a better relationship with the intending parents was mentioned by one or the surrogate having an easier pregnancy was also mentioned by one. So again, what are they calling each other? So these are the surrogate's children who are in contact with the child who has been born through surrogacy and some of the terms that they were using included brother, sister, a surro sister, tummy sister, a surrogate brother, a sort of a cousin, a half brother, half sister and one of the things we found was that there were no differences based on whether or not the surrogate was a traditional surrogate so it used her egg for the pregnancy and whether she was a gestational surrogate and hadn't used her egg. So they were using these terms of brother or sister or half brother or half sister really based on the strength of relationship that had been developed between their family and the surrogate born child. So just to conclude from this study then the surrogates do not experience long-term psychological problems as a result in their involvement in surrogacy. Most surrogates maintained contact with the surrogacy family and most surrogates in surrogacy families continued to see each other in person. The surrogates families felt positive about the surrogates involvement in surrogacy and also a few differences were found between surrogates who had done traditional, gestational or both types of surrogacy. So I also want to briefly just talk about surrogacy in a different context and I know we'll be hearing more about this in detail in the next talk but I think it does highlight that these behind us may obviously not always be replicable to other contexts. So we have also done a study of Indian surrogates. We saw 50 surrogates from a single clinic in Mumbai. All of them are carrying for international intended parents and we compared them to 69 expectant mothers from General Hospital in Delhi and Mumbai. This study was part of a PhD project by colleague of ours, Nishtha Lamba and she interviewed all the surrogates and the comparison group during pregnancy so 4-9 months into the pregnancy and also went back and interviewed them 4-6 months after the birth of the child. We collected data on anxiety, depression and stress. We also assessed the level of bonding to the fetus during pregnancy and here we were re-looking at the levels of instrumental prenatal bonding so this is the extent to which surrogates were showing care and being attentive to the fetus and also emotional prenatal bonding so this was the extent to which surrogates were interacting and also attributing characteristics to the fetus and we were also interested in their experiences of surrogacy. What that study found was that surrogates showed higher levels of depression compared to the comparison group during pregnancy and also after the birth of the child. We didn't find any differences between the two groups in terms of anxiety and stress and surrogates showed higher levels of emotional prenatal bonding and lower levels of emotional prenatal bonding and higher levels of instrumental bonding compared to the expectant mothers. Bonding with the baby in different ways to women who are carrying for themselves. We were also able to see whether there were any factors associated with the pregnancy that might relate to the levels of depression so what we found was that lower perceived support during pregnancy, hiding surrogacy from others and also receiving criticism for being a surrogate significantly predicted higher levels of depression after the birth of the baby and surrogates with lower educational status and who had a positive experience in the surrogate house were more likely to emotionally bond with the fetus. Conclusions from that study were that surrogates were more likely to show high levels of depression than the comparison group of expected mothers but this might also be due to their circumstances prior to the surrogacy. We didn't assess their mental health before they went into a surrogacy arrangement and it's possible that their mental health was already poorer when they entered into the surrogacy arrangement but of course this sample was only recruited from one clinic. So these are some of the references that I've drawn on in this presentation and they're all available on the resources page if you want to read about this study but also the studies that Susan presented on earlier as well.