Tips On Psychologically Screening Surrogates

When a mental health professional is engaged to assess a potential surrogate, the aim is not to find a “perfect” candidate but to evaluate whether the individual possesses qualities that support a successful surrogacy journey.  Essential qualities in an ideal surrogate include empathy, responsibility, dependability, relationship stability, and a demonstrated ability to manage challenges.  A promising surrogate shows resilience, maturity, and the ability to seek support when needed.  This process aims to identify a person who can navigate the surrogacy journey with strength, self-care, and insight.

Preliminary Screening: Minimum Standards for a Surrogate 

Before beginning a detailed assessment, the professional ensures that the candidate meets specific minimum criteria, including:

1. Parenting Experience: The candidate should have given birth and be actively involved in raising the child.
2. Uncomplicated Pregnancy History: Self-reported past pregnancies should be free of complications.
3. Age Range: Generally, the surrogate should be between 21 and 42. However some mental health professionals recommend a minimum age of 25 due to the risks inherent in any pregnancy, and to better support physical and emotional stability.
4. Health Considerations: The surrogate should report a history of good health. Conditions such as previous social diseases, cancer, significant ongoing medications, or hepatitis should be openly disclosed and assessed by medical professionals, as they may be grounds for not granting medical approval to continue her journey.
5. Weight Parameters: Though ultimately a medical decision, the mental health professional may open a discussion if weight-related concerns emerge.
6. Legal Awareness: The mental health professional should be well-informed about the laws governing surrogacy in the location where it will take place. If surrogacy is illegal in that location, the surrogate must be informed, and the mental health professional should discontinue her screening. The surrogate should also be advised that the goal is for the intended parents’ names to appear on the birth certificate. However, if, due to legal requirements, the surrogate’s name must appear on the birth certificate, even temporarily, she should be informed, and a discussion should take place.
7.  Non-Smoking Requirement: Ideally, the candidate should be a non-smoker for at least one year.
8. Criminal History: While a criminal history does not automatically disqualify a surrogate, any past offenses should be discussed thoroughly to understand context and details.
9. Support System: The surrogate should indicate that she has the support of her spouse or significant other, family, work colleagues, and friends. It is essential to discuss this support network as a positive factor for her journey, as strong emotional and practical support can greatly benefit her well-being throughout the surrogacy process. This support system will provide encouragement and stability, helping her navigate the unique experiences of her journey.

Reviewing the Application: The Role of the Screening Professional

Once the mental health professional has verified that the surrogate meets the initial requirements, a more in-depth review of her written application should follow. The screening mental health professional should request a copy of the surrogate’s application. If the surrogate is unable to write, a video recording should be made, with the questions read aloud to her so she can respond verbally.

Even if a sister or close friend has volunteered to be a surrogate, she should still take the time to complete an application. Completing the application can offer psychological benefits and provide evidence of the surrogate’s voluntary participation in the surrogacy process. If any concerns arise from the application, the mental health professional should document these in detail and communicate them to the surrogate, intended parent, agency, and IVF clinic.

The Intake Interview: A Collaborative Assessment

The mental health professional’s intake interview should be educational and interactive. This screening should be a collaborative process in which the surrogate and mental health professionals explore the expectations, potential risks, and suitability of surrogacy to determine if it is the right path and if the timing is appropriate for all involved. The mental health professionals should begin by explaining their role, which is to guide, encourage, educate, foster good communication, provide resources, establish safeguards, manage expectations, and serve as a coach throughout the journey.

Some key issues a mental health professional needs to assess before clearance is given:

1. Psychological and Family History: Reviewing her background and psychological history helps assess her stability and resilience.
2. Relationship Dynamics: An open discussion about the strengths and challenges within her marriage or significant relationship explores whether the couple can navigate the unique stress of a surrogacy pregnancy.
3. Personality Traits: Traits such as maturity, empathy, and decision-making skills are evaluated.
4. Perspective-Taking Ability: The mental health professional assesses whether the surrogate can empathize with the intended parents and see issues from their point of view.
5. Motivations and Expectations: The surrogate’s motivations for becoming a surrogate are explored alongside her expectations of the intended parents and agency.
6. Support System: The candidate’s support network is examined, especially in cases of potential bed rest or hospitalization.
7. Medical Protocol Familiarity: The mental health professional reviews the medical protocol to the extent possible, ensuring the surrogate understands the procedures involved.
8. Handling of Difficult Topics: Sensitive topics, such as pregnancy termination, miscarriage, and potential pregnancy loss, should be openly discussed to ensure the surrogate has realistic expectations. Issues surrounding termination, including pro-life vs. pro-choice beliefs and the grey areas in between, should also be explored. For example, if a surrogate states, “I will terminate if there is a medical reason to do so,” it is important to clarify what this means—considering scenarios where medical opinions may conflict, or if a doctor provides only a vague prognosis. These discussions help set clear expectations and prepare the surrogate for complex decisions that may arise during the journey.
9. Coping with Loss: It is essential to address how the surrogate will cope with potential losses, such as failure to achieve pregnancy, miscarriage, or termination. Many surrogates, having experienced healthy pregnancies, may believe their bodies will not let them down. However, it is important to help them understand that each pregnancy is unique, and outcomes can vary. Open discussions can help the surrogate and her partner to prepare emotionally for possible challenges and foster resilience throughout the journey.
10.  Discussion of Multiple Gestations: The topic of multiple gestations should be explored thoroughly, as it is important for the surrogate to understand the risks and realities associated with carrying twins or higher-order multiples. Even if only one embryo is implanted, there remains the possibility of it splitting, resulting in a twin pregnancy. This outcome, though uncommon, brings additional medical and emotional considerations, including increased physical strain, higher risk of complications, and potentially extended medical monitoring. By discussing these possibilities upfront, the surrogate, and her support team, can gain a realistic perspective on the challenges and rewards associated with carrying multiple gestations, should they occur, and feel more prepared for any outcome.
11.  Views on Social Media: Social media use is an important topic to address, as surrogates often engage with these platforms daily. The mental health professional should explore how the surrogate plans to use social media during the surrogacy process, including whether she intends to blog about her pregnancy. Additionally, topics such as the level of information she might share about the intended parent(s) and her thoughts on connecting with them on social media should be discussed. Privacy and boundaries must be clearly outlined to ensure mutual respect and understanding regarding online interactions and content shared about the journey by all parties involved.
12. Self-Assertion and Advocacy: Does she demonstrate sufficient self-assertion to protect her interests and advocate for her needs during the process? A surrogate’s ability to set boundaries and express her thoughts openly is important for a successful and respectful surrogacy experience.
13. Open-mindedness: Assess whether she is free from rigid or dogmatic thinking, as flexibility and adaptability can be vital in navigating the emotional and medical complexities of surrogacy.
14. Past Experiences and Relationships: A history or signs of past abuse or abusive relationships should be carefully considered. Past abuse experiences could influence her ability to manage potential stressors during surrogacy.
15. Religious Beliefs: Explore whether she holds any religious beliefs that may influence her behavior or decisions regarding medical procedures, termination, or lifestyle changes. Clear alignment between her beliefs and the surrogacy journey’s requirements is important to avoid conflicts down the road.
16. Coping with Unexpected Discoveries: If her participation in surrogacy leads to or ends with a diagnosis of infertility, consider how she might cope with this realization. Support and counseling resources should be available to help her process any emotional impacts.
17. Handling Rejection from Surrogacy: It is also important to discuss how she would manage if she were not accepted into the surrogacy program or was unable to assist a loved one, such as a sister or best friend, as a surrogate. Addressing this possibility in advance can help her prepare emotionally and understand that such decisions are based on factors beyond personal capability or worth.
18. Contact with Intended Parents and the Child: Encourage open discussion about her thoughts on maintaining contact with the intended parent(s) and the child before, during, and after birth. This conversation helps establish boundaries and mutual expectations, ensuring all parties are comfortable and on the same page regarding future relationships and contact.
19. Future Plans and Commitments: Discuss her plans for the next two years and whether they may be interrupted by pregnancy. Understanding her long-term commitments helps set realistic expectations and ensures that surrogacy aligns well with her personal timeline.

Psychological Testing: An In-Depth Evaluation

Psychological testing is a valuable tool in the screening process, often conducted either before or after the initial interview. These tests, which may include the MMPI-2, PAI, and others, evaluate areas such as personality, stress levels, and any potential for underlying psychological issues. It is important that the testing follows guidelines to ensure a controlled environment, free of outside influence, and that results are interpreted accurately.

Ongoing Support: The mental health professional as a Journey Coach

When a mental health professional is involved throughout the surrogacy process, they take on the role of a “journey coach,” providing proactive support to the surrogate and intended parents. This role involves identifying and addressing potential issues early, fostering open communication, and guiding both parties to recognize and work through misunderstandings or concerns before they escalate. The mental health professional often draws on past experiences to discuss behaviors and actions that have caused miscommunication or conflict in previous cases, helping to prevent similar issues.
Surrogates often come to appreciate the mental health professional’s involvement, especially when challenging situations arise.

“Many surrogates have complained that I am “in their business” to other surrogates. But when something goes wrong, they are grateful that I know the dynamics of their life and marriage and are thankful for the help.”

Psychological Testing Tools Frequently Used

Common tests used in surrogate screenings include:

1. Measure of Psychopathology (e.g., MMPI-2, PAI)
2. Projective Screens (e.g., Sentence Completion for marriage assessment, Thematic Apperception Test)
3. Personality Measures (e.g., 16PF)
4. Stress Level Assessments (e.g., Life Event Checklist, SCL-90R)