An attractive 21-year-old sits across from me, exhibiting little of the anxiety present in my psychotherapy or psychoanalytic patients who settle on the same sofa. This woman, not a patient, is poised, thoughtful and curious. I tell her I’d like to learn about her plan to be an egg donor and indicate my evaluation will explore emotional and psychological implications—many unknown—of egg donation, helping her reach a fully considered informed consent before proceeding.
This consultation spans a range of questions. I invite her to describe her fantasies and thoughts about the baby that might result from her donation. What do you imagine the intended parents will tell their child about you? Do you think it will be important to tell a future partner you’ve been a donor? How have your parents responded to your plan? What could it be like for your own children to learn they might have a genetic half-sibling whom they don’t know? What if you donate now and face infertility later?
Medical advances produced millions of babies conceived in a petri dish over the last three decades, creating social and psychological challenges. We can now deconstruct “mother” into layered components: the genetic mother who supplies the egg; the biological gestational mother who carries and gives birth; and the social mother who raises the baby. These interlocking roles create a myriad of lenses through which women experience their attachments.
The American Society for Reproductive Medicine, which issues guidelines for considering the suitability of donor and surrogate candidates, advises that all parties, including hopeful parents, be evaluated to address their psychological capacities in preparation for what lies ahead. I provide families, physicians and attorneys a picture of each candidate, synthesizing history and character to illuminate potential ease and challenges moving forward. These consultations are quasi-therapeutic, offering an unexpected exploratory space even as participants try to present themselves in a favorable light. By the time candidates reach me, they have successfully jumped through multiple social and medical hoops. Although a history of mental instability or marital strife or hints of coercion might lead me to deem proceeding inadvisable, this rarely occurs.
I have conducted hundreds of psychological evaluations of women who want to be surrogate mothers, gestational carriers and egg donors. Compelling questions drive this consultation: Why would a woman choose to use her body to help create a baby in order to relinquish it? Why would anyone seek to carry a baby with whom she might have no contact after its birth? Why would a woman elect to anonymously donate her genes to help create a baby she will likely never identify?
Listening carefully to these women, themes and tensions emerge. Here, I explore how the deconstruction of our notion of mother reveals inherent losses and gains. Each “mother” plays a complementary role in this complex medical, ethical, legal and, most importantly, psychological process as she forms or suppresses her attachments.
Though an unconventional choice, becoming a surrogate requires determination, perseverance, and psychological, social, and financial stability. A potential surrogate reads an advertisement placed by an attorney, medical center or
agency and something resonates within her. A television program, a popular article about surrogacy, or an acquaintance who struggled with infertility or has been a surrogate piques her interest. Coincidences come together, confirming her deep feeling, “This was meant to be. I can do this.”
A surrogate typically describes strong positive maternal strivings. Therefore, her personality style must facilitate the minimization of her maternal attachment to the baby and understate any unsettling future implications of her role. Even surrogates presenting as warm and gregarious tend to be affectively closed in some areas, relatively concrete and rational in approach to problems, and avoidant of uncomfortable emotions. She is predisposed to defenses that keep her from forming an attachment to the baby, protecting her from her loss at relinquishment, all the while affording her a sense of well-being. A surrogate carries a baby, sometimes conceived with her own ovum, yet retains the notion that it is not hers. She wards off attachment by stopping short of integrating the full experience. In essence, she unconsciously deconstructs the notion of mother in order to sustain her cognitive and emotional construction that the baby is not hers.
Ms. Curry, a 28-year-old woman, de-emphasizes her attachment to the baby she will carry by distinguishing her role as gestational surrogate from her three earlier, more fully integrated pregnancy experiences. “It will look like its parents. I won’t consider it mine. I think of it as a gift I’m carrying. I won’t get attached and want to keep it. It belongs to them. It’s their baby. I’m the house. I’m just feeding it.” The assertion, “It’s not my baby,” is typical, and the self-referential analogy of “incubator” or “babysitter for nine months” is commonly used. Whether or not the surrogate contributes her egg, she minimizes her biological maternal connection to the baby and treats her body as a house.
Stated motivations of surrogate candidates comprise two broad categories: financial and altruistic. However disparate these categories may initially appear, they are often linked by the common motivation, either conscious or unconscious, to make psychological reparation.
In many respects, the surrogate’s financial motivations are straightforward. Women who regard their surrogate pregnancy as a job usually report easy, uncomplicated pregnancies. A surrogate pregnancy affords a path to earn money while holding another job or raising children. A woman focusing on the monetary reward of surrogacy is thinking about improving her own children’s lives and futures. She is financially secure, albeit not well-off, and envisions the additional income as a down payment on a house or car, a debt reduction, or as an investment for her children’s education.
However, even in situations where the financial compensation appears dominant, the surrogate’s motivation requires fuller scrutiny as it seems unlikely that money alone could compel her to initiate this physically and emotionally taxing endeavor. Surrogate candidates note, “There are many easier ways to earn money,” and express altruistic motivations as well.
Ms. Elmer, with three children, considered surrogacy for a dozen years. She explains, “I didn’t feel like putting a price on it. I’m just helping someone out. It’s not a job. It’s compassion alone. The money doesn’t make a difference. I would do it for free.”
More commonly, women overtly blend their financial and altruistic motivations. While downplaying the exchange of money, they deem it appropriate and fair. As Ms. Jennings explains, “It’s like mutual help. It’ll give me more time with my kids while I’m going to school. It’ll help their family by giving them what they need.” In this way, serving as a surrogate strengthens a mother’s attachment to her own children.
Ms. Star feels comfortable with remuneration, but emphasizes her altruism. She considered surrogacy while pregnant with her fourth child at age 30. She saw a television program in which a surrogate arrangement “went bad,” leading to a complex custody battle. She says, “It was so easy for me. I love my kids so much. I can’t imagine never
having children. I feel bad for people who can’t have kids.” She continues, “It’s something I have really wanted to do for somebody. I can’t think of anything else that would mean so much. If I can do it, I should do it.”
Many surrogates are motivated, overtly or implicitly, to compensate for or repair an earlier loss or sense of damage. Indeed, the surrogate’s ability to separate her maternal inclinations from any maternal attachment toward the baby may stem from her effort to manage prior losses that might have overwhelmed her if fully experienced.
Often, there is a reproductive-related loss, such as prior adoption, abortion or miscarriage, for which the surrogate seems to be making direct reparation. She masters an earlier loss with the distinct feeling she is restoring internal balance by giving in this way. Ms. Yerk has three children, terminated two pregnancies, and suffered a late miscarriage. She asserts that the surrogate process will allow her to compensate for her abortions. She says, “I feel guilty about my abortions. I unconsciously said if I can find a way to pay that back, I would. It’s an urge. This is something that’s meant to happen.”
While some losses which a surrogate attempts to make amends for are reproductive, others involve the untimely death of a close family member or friend. Ms. Frank, who considered surrogacy for years, ties her motivation to the suicide of her brother-in-law. She views the surrogate pregnancy as “the replacement right there.” She says, “For everyone you lose, there is someone who wants to give. His brother took away, and I’m giving back.” Her attachment is not to a baby but to a narrative of equanimity and restoration.
Many surrogates are motivated, overtly or implicitly, to compensate for or repair an earlier loss or sense of damage.
Occasionally, I meet the unusual surrogate who has a damaged sense of herself, perhaps tied to abandonment or abuse by a parent. These women appear to derive vitality, self-worth and self-cohesion by doing something profoundly benevolent for another.
Ms. White, mother of two, has a history of abortion and a difficult divorce. Her close cousin was killed in a tragic accident. Since early childhood, her mother painfully criticized her. Feeling she was treated “unfairly” by her parents, she resonates with the idea that it is “unfair” that couples wanting a baby, are unable to have one. She is comforted by rectifying that sense of injustice, thus fortifying herself by helping others. “It will give me a sense of fulfillment to help someone else.”
While the surrogate usually does not focus on the baby or any actual or fantasied relationship with the baby, she does anticipate a strong reparative attachment with the expectant couple. Before and during the pregnancy, she feels uplifted by the attention from the intended parents. Ms. Victor looks forward to the couple’s involvement in her pregnancy. She views the expectant mother as an extension of her pregnant self. She states, “Just because she [the social mother] can’t hold the baby, doesn’t mean she can’t be as involved as possible. It’s not just me holding the baby. I told the mother we have to have a baby shower. Even though it’s not mine, I’ll be just as excited. This is a ‘we’ effort, not just me.”
The surrogate may identify with the baby, idealizing the intended mother and father who provide love and care not only for the unborn child but also for her. This vicarious parenting can ameliorate her childhood deprivations and nourish her after the baby is born. Ms. Ridgeway, with three children, wrestles with unresolved loss following the death of the aunt who raised her when her own mother was unavailable. Being a surrogate appears to represent an opportunity for Ms. Ridgeway to unconsciously undo her own losses: to give when she has felt deprived, and to benefit vicariously without having to feel selfish or needy.
The reparative aspect of being a surrogate is often linked to a sense of control. A woman may have felt victim to an earlier loss or felt compelled to relinquish a baby for adoption or have an abortion. Now she plans to control the outcome and takes responsibility for seeking it. Loss and repair are inextricably bound.
For example, years earlier, Ms. Sanger became pregnant in a casual sexual relationship and relinquished her baby for adoption. Addressing unsettled feelings, she asserts, “This will be much more positive. I am making a decision. This is not something I’ve fallen into. I’m not forced to deal with this. It is my choice to give. It will give me closure because I will know who the baby is going to and where he will live.”
The psychological evaluation of a donor candidate is less comprehensive than a surrogate’s. She is not getting pregnant, or carrying and relinquishing a baby, and her concrete participation as a genetic mother is time-limited and
clearly defined. Nevertheless, she is screened medically and psychologically, monitors her body, gives herself hormonal injections to synchronize her ovulatory cycle with the recipient’s, and undergoes retrieval with anesthesia. For both surrogate and donor, respective roles can recede into the background once they fulfill their commitment. Like the surrogate, the donor deconstructs layers of mother, and, I contend, gains meaningful psychological enhancement.
Donors tend to deny any loss they might encounter by distancing themselves from emotional attachment to their ova. They minimize the permanence of their donation, accentuating their time-bound active role. These women downplay the contribution of nature, have little investment in their genetic line, and place greater emphasis on nurture and the social construct of mothering. Donors overlook the potential psychological ramifications of their role by concentrating on the medical risks of donation. Emotionally, donors highlight their satisfaction in helping. “I know a lot of people who want to get pregnant and have a hard time. I can’t imagine not having my kids. To help someone do that is really special.”
Donors intellectually understand their genetic material produces a child they will not know, but draw a sharp distinction between their genetic gift and the baby.
As 21-year-old Ms. Crip says, “I don’t see it as my kid; I know it’s my egg. It’s kind of weird. But I also have family members I never met and don’t know who they are.” Ms. Crip demonstrates self-awareness: “I couldn’t be a surrogate because I would get attached. This is a medical procedure. I would feel a connection if the child grows with me for nine months. That would be different.” She distinguishes between genetic and gestational aspects of mother, and the particular emotional significance she gives each role.
Like the surrogate, the donor deconstructs layers of mother, and … gains meaningful psychological enhancement.
While surrogates usually have their own children who carry their genes, donors are younger women who see parenting as distant in their future, allowing them to privilege the impact of nurture over nature. Ms. Blake explains, “Most of a child is the environment they’re brought up in. I have plenty of family, I don’t need to seek out some random DNA connection. I would never refer to them as my future kid’s siblings. They’re not siblings, not family. I’m a biology major. We are all technically sharing DNA. Somebody out there with my egg is not my family.”
Like surrogates who form an attachment with intended parents, but not the baby, donors usually feel an empathic bond with the recipients and avoid thinking about the offspring. Most anonymous donors will never know whether the beneficiary of their ova becomes pregnant. However, they do fantasize. “I think the woman is pregnant and that makes me happy, but I don’t think that child is mine,” one typical donor notes. “Hopefully it will grow up in a happy family and have a lot of possibilities in life.” Donors usually have positive memories of growing up and supportive relationships with their parents and predict that for the baby.
Strikingly, many bright donors have not contemplated what recipients might tell their child about the circumstances surrounding their conception. Ms. Janey, 22, says, “I haven’t thought about that, but hopefully the parents will explain it so the child will understand and know its parents love it because it’s their child.” Most donors ignore feelings of loss or attachment in the future. Pondering the possibility that the offspring of her donation may one day try to contact her, Ms. Janey elaborates, “I hope if the parents do tell about me, the child will be grateful and feel loved because they wanted a baby so badly they went to these lengths. I hope the child doesn’t feel it’s just a science experiment; it’s the gift of life.”
Even the uncommon donor who has children with whom she has a strong attachment deconstructs her view of mother to de-emphasize her genetic contribution. Ms. Arden, a repeat donor with two young children, explains, “To me, a parent is not DNA, but a person who raises the children. Even though we share DNA, it’s not my child. The parents
are the ones who raise the kid and take care of the kid. I hope the child would understand and wouldn’t be angry and won’t try to find me. I’ve heard of kids trying to find the donor. I would answer questions and feel no attachment. I would say, ‘Nice to meet you, but I’m not your mother. I helped out your parents when they wanted to have you. I have my own family.’“ While acknowledging that offspring of her donation may be “kinda like my kids in their characteristics,” she does not accentuate this.
Like surrogates, donors feel personally bolstered and emotionally invested in helping generate life. Donors draw deep satisfaction from their altruistic strivings, often growing up in family cultures valuing altruism and community service. There is typically explicit recognition that something is gained when something is given. Sometimes a donor has a sister, an aunt or a family friend who has had trouble conceiving, heightening her empathy and augmenting her desire to give.
Donors, like surrogates, often blend financial and altruistic motivations. Usually donors view their ova as “something I’m not using anyway.” While Ms. Arden states it is “nice to be compensated, “she clarifies, “I don’t think it’s necessary. I would do it for free if I could.”
Many donors explicitly recognize the importance of their reliability and dependability, deriving pride and emotional strength from their role. For example, Ms. Brent explains, “I will do everything I can to do 100 percent correctly so my eggs have the best shot of working because they’re taking a big leap of faith in me. I will always feel proud and happy I gave this gift.”
Ms. Jerome, a biology graduate student, says, “My biggest motive in life is to make a difference. I know I’ll be giving someone a chance to have a child. I’m not emotionally invested in my eggs. It’s an opportunity, a piece of genetic material that will help them. I have the satisfaction of knowing I did this.”
Unable to have babies in the expected conventional way, women who turn to a donor or surrogate are acutely aware of their loss. From medical necessity, they are compelled to separate the genetic mother from the gestational mother from the social mother. They’ve experienced failed attempts at pregnancy using their own eggs or have suffered repeated miscarriages. By the time they sit with me, they are juggling tenuous feelings of optimism with realistic expectations of disappointment. They grapple with how to mother a baby genetically related only to their husband and the imbalance this may cause. They wonder if their attachment to this baby will be weaker. They wonder if they are less a woman or less a mother because they rely on the assistance of another woman. Through hard work of grieving, they make peace with the loss of their genetic connection to their wished-for child.
The mother who watches her baby develop inside another woman hopes to form a strong attachment to the baby she will raise. She finds a complementary partner in her gestational carrier, who is wise from her own pregnancies. One surrogate candidate explains, “I view pregnancy as a spectator sport. I want the [intended] mother to be as involved in the pregnancy as possible.” The generosity, “record of success,” and optimistic attitude of the surrogate provide a sense of security and fortify her in forming an attachment.
Through adoption, we are culturally accustomed to separating the genetic and gestational birth mother from the social mother. It is a more recent cultural phenomenon and medical advancement to be able to parse the genetic from the gestational birth mother. While a birth mother may refer to “her baby” she relinquished for adoption, donors and surrogates consistently say, “It’s not my baby.” Here, we clearly pinpoint the importance of expectation, intention and fantasy—”mindset”—as many surrogates and donors describe it. This capacity to deconstruct the components contributing to the role of mother and highlight a mindset that obscures even the obvious is, on the one hand, denial and on the other hand, exactly what allows a particular woman to serve as a donor or surrogate.
The voices of women who choose to be surrogates and egg donors are best understood against a backdrop of loss and reparation. These women attempt to strengthen themselves by amending developmental deficits or uplifting self-esteem by purposefully contributing to a family’s creation. For many surrogates and donors, the feeling of being special, providing something valued, or carrying the embodiment of goodness in the baby are deeply cherished experiences. Certainly, for those women who feel responsible for earlier reproductive or familial loss, or felt diminished in their childhoods, or could not admire their own parents as ideals, assisting another family provides longed-for inner experiences. For such women, the role of donor or surrogate can feel like the ultimate remedy, deeply appreciated by the recipient family and stretching through time.
While the surrogate or donor rarely concentrates on the future, the unconscious strain for her lies in the uncertainty of how her participation will affect her as time passes. Specifically, there is an inherent tension between psychological self-enhancement and loss. The surrogate’s reparative efforts are inextricably bound to the loss she will endure at relinquishment. The donor’s gift is entwined to the loss she might encounter if the personal meaning of her donation changes as she matures. These women protect themselves from feelings of attachment to their genetic or gestational offspring. The surrogate or donor needs to be sturdy and resilient enough to ensure she has the capacity to be enriched by her role. She must be able to tolerate any sorrow she confronts when she no longer stands in the spotlight of the expectant couple’s life or in the immediacy of the attention she obtains.
Stories of women seeking to be surrogates or donors illuminate the significance of anticipating an attachment in order to form it. While the ordinary expectant mother’s attachment to her baby develops over time and even prior to conception, the donor and surrogate enter an arrangement anticipating the absence of attachment to the baby. While financial motivation exists for some, it is overshadowed by the personal investment in helping generate life. Altruistic strivings are complemented by emotional gains. The loss inherent in their gift is balanced by boosted self-esteem and reinforced identity achieved through this self-reparative effort. Indeed, it is fortunate for the surrogate, the donor, and for the families created through their efforts that these feelings extend through the life of the baby, thereby becoming a reverberating source of self-enhancement for the surrogate or donor, even if only in fantasy.
When women serve as surrogates or donors, they must overlook or deny what they are giving up. Each one of these women—the donor, the gestational surrogate, the traditional surrogate, the recipient, the intended mother—must eventually make peace with a deconstructed definition of mother. They need the cognitive and emotional flexibility to separate the genetic, gestational and social dimensions of mother and to build and even undo attachments. Each of these women requires the psychological capacity to grieve what is lost and explain to themselves that something technically theirs is not emotionally theirs; while the parent must feel what they have received from another is emotionally their own. The capacity to deconstruct and reinterpret what constitutes a mother poignantly binds all these women together.
This essay is partially derived from “The Reparative Motive in Surrogate Mothers,” written by this author, published by Adoption Quarterly, Vol. 2(4) 1999, available online: [ArticleDOI].
Clinical material is disguised and composited to protect confidentiality.