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How do we view alternative families?

21 July 2008
By Olga van den Akker
Professor of Health Psychology and Head of Department of Psychology at Middlesex University, London and associate of the Centre for Human Reproductive Sciences, Birmingham Women's Health Care Trust.
Appeared in BioNews 467
Most cultures are advocates of procreation partly because it stabilises communities, it makes individual and collective economic sense, and it is culturally the norm. Consequently, not being able to conceive naturally sets infertile individuals and couples apart from the fertile majority of people who do not have to think about their reproductive capacities. A diagnosis of infertility, its treatment and the uncertainty about the outcome are therefore accompanied by psycho-social hardship as is reported in much (though not all) social sciences research (1)

With infertility rates increasing across the world, the many and varied treatment options currently available are in high demand. However, with the availability of choices, decisions have to be made about the most preferred options for treatment. It is, for example, increasingly becoming recognised that infertile couples start off hoping to pursue treatment resulting in a genetically related child. It is only if that is not a possibility that other options become considered. Clearly, the more unusual the option is (such as the use of donated gametes, embryos, surrogacy or adoption), the least likely it is to be a first choice. These considerations of alternative methods of overcoming childlessness which are furthest removed from natural conception, are also frequently picked up by the media.

It is important to stop and think to find out why genetic or gestational procreation as in gamete/embryo donation, surrogacy and adoption, is not as intuitively popular as fertility treatment with a couples' own gametes and gestation. Apart from the increased economic burden of egg/embryo donation and surrogacy, these solutions provide the involuntary childless couple with as good a chance - and, in some cases, the only chance - to become a family.

Post modern researchers on the family argue that the desire for a biological child tends to be based on societal pressures, and has little or nothing to do with biological drives. Since the cultural norm is to have a biological (genetic and gestational are implied) family, when infertility causes biological childlessness, adults having non-biological (or non-genetically/gestationally linked) offspring are failing to conform to this societal norm leading to an added layer of distress, discomfort and stigma. A recent review of the literature on surrogacy and motherhood (2) showed that fertile people appear not to have had to redefine 'parenthood', so their attitudes are likely to be different and more traditional from those of people who are faced with treatment and genetic link options they were not previously familiar with.

General population surveys enquiring about people's views of the creation of alternative families through surrogacy and oocyte donation are therefore influenced by what people believe the norm is. Furthermore, respondents on attitude surveys of reproductive assistance are not only influenced by these normative beliefs, they are in turn also likely to be shaped by negative portrayals of alternative ways to become a family in the media.

Two recent studies investigated the views of women from the general public on surrogacy and oocyte donation, and their potential willingness to become surrogate mothers or oocyte donors, using the theoretical components of a behavioural theory (the Theory of Planned Behaviour - TPB, 3). The theory proposes that people's behavioural intentions are predicted by their attitudes, by how much control they believe they have over their own behaviours and what they consider to be general social norms. The surrogacy attitude survey (4) showed that a small proportion of participants were willing to consider becoming a surrogate mother. Normative beliefs also predicted (un)willingness to become a surrogate mother.

The second study, on attitudes towards oocyte donation (5), showed that the theoretical components of positive attitudes towards oocyte donation, towards the consequences of donation (for example the donor child contacting the donor 18+ years later) and younger age, were predictors for oocyte donation confirming some of our predictors for surrogacy. This is reassuring because, similar results were earlier reported in a Swedish population study (6) and because although the processes involved in egg (oocyte) donation and surrogacy are significantly different, in both studies broadly the same theoretical components predicted intentions to helping others to become families using alternative (non genetic/gestational) methods.

Women who were definitely not interested becoming a surrogate or potential oocyte donor rated all aspects of recruitment, advertising and the consequences of surrogacy/oocyte donation significantly more negatively, possibly reflecting views held by the majority of the population not involved with assisted reproduction. These traditional and unchallenged views of 'the family' are likely to influence the prevailing reports of stigma associated with alternative families such as having used donated gametes or surrogate motherhood. It may therefore be timely to develop population educational targets to improve people's perception of oocyte donation and surrogacy by linking the practice with positive family values.

1) van den Akker, O.B.A. (2002) The Complete Guide to Infertility: Diagnosis, Treatments,  options. Free association Books, March. ISBN: 1-85343-540-6
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2) van den Akker, O.B.A.  (2006)  Psychosocial aspects of surrogate motherhood. Human Reproduction Update, 12,2, 91-101.
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3) Ajzen, I., & Madden, T. J. (1986). Prediction of goal-directed behavior: Attitudes, intentions, and perceived behavioral control. Journal of Experimental Social Psychology, 22.
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4) Poote, A & van den Akker, O.B.A (2008) Attitudes to surrogacy in a UK population. Psychology and counselling. Human Reproduction  23(suppl_1): p. i226
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5) Purewal, S., & van den Akker, O.B.A.  (2008).  Psychological factors influencing women's willingness towards oocyte donation. Journal of Reproductive & Infant Psychology, 26,3.
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6) Skoog-Svanberg,A., Lampic, C., Bergh, T. and Lundkvist, O.  (2003)  Public opinion  regarding oocyte donation in Sweden.  Human Reproduction, Vol.18(5), pp.1107-1114.
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