Mental Health Considerations

The Emotional Landscape of Surrogacy: Why Mental Health Matters

Surrogacy offers hope and possibility, but along with that come emotional complexities that can affect all parties involved. Recognizing mental health as a central pillar—not an afterthought—is critical to ensuring a healthy journey and a positive experience for everyone.

• Emotional stakes are high: intended parents often come to surrogacy after years of fertility struggles, grief, and loss.

• Surrogates undertake profound altruistic work, but also carry (literally) hopes, expectations, and the weight of eventual separation.

• The relationship dynamics between surrogate and intended parents add layers of expectation, boundaries, trust, and communication.

• Hormonal changes, health risks, pregnancy uncertainties, and postpartum adaptation further influence mood and psychological states.

In short: taking care of mental health is not optional; it must be built into every surrogacy plan.

Key Psychological Challenges & Risk Periods

For Intended Parents (IPs)

1. Hope, Anxiety & Uncertainty

• The process is long and fraught with unknowns (embryo transfer success, surrogate health, pregnancy complications).

• Anxiety about outcomes, legal risks, delays, or unplanned scenarios is common.

2. Attachment & Distance

• Some IPs struggle with how “present” they can be in the pregnancy (especially if not able to attend medical visits).

• Feeling disconnected from the developing pregnancy can foster guilt, frustration, or emotional distance.

3. Grief & Loss

• There may have been previous failures, miscarriages, or losses. Each step, decision, or setback can reactivate grief.

• Even positive outcomes may come with a sense of loss over the “normal” pregnancy path they didn’t take.

4. Relationship Stress & Decision Fatigue

• Differences in expectations, communication gaps, or stake mismatches between IPs and between IPs & the surrogate may strain relationships.

• Emotional fatigue from repeated decisions, medical updates, legal steps, and logistical hurdles.

5. Identity, Parenthood & Anxiety After Birth

• Adjusting to becoming parents via surrogacy can bring unexpected emotional reactions.

• Some may wrestle with questions: “Am I really the parent?” or “Will society accept me as the parent?”

For Gestational Carriers / Surrogates (GCs)

1. Emotional Attachment vs. Professional Boundaries

• Some surrogates may form emotional bonds with the fetus or the intended parents, which must be anticipated and managed.

• Others may intentionally maintain distance; both approaches may carry emotional costs.

2. Relinquishment & Postpartum Loss

• After childbirth, surrogates face the transition of giving the child to someone else—some may experience sadness, ambivalence, or grief.

• Hormonal shifts and postpartum mood changes can exacerbate emotional vulnerability.

3. Depression, Anxiety & New-Onset Mental Illness

• Emerging evidence suggests gestational carriers have an elevated risk of new-onset mental illness during pregnancy and postpartum compared to women who conceive naturally. JAMA Network+2ices.on.ca+2

• Prior psychiatric history, limited social support, secrecy or stigma about surrogacy, or high stress may increase vulnerability. ices.on.ca+3PMC+3PMC+3

4. Social & Community Pressures / Stigma

• Some surrogates keep their work secret from family/community due to stigma; that secrecy can contribute to isolation and distress. The Fertility Agency+3PMC+3PMC+3

• Criticism, misunderstanding, or moral judgment from others may weigh on their mental well-being. The Fertility Agency+3PMC+3PMC+3

5. Role Conflict & Identity

• Balancing one’s identity as a mother, partner, or community member with the surrogate role may cause internal tension.

• Coping with the physical demands, medical oversight, and relational expectations of surrogacy can add to stress.

Evidence from Research: What We Know (Risks, Outcomes, Gaps)

It’s important to ground our guidance in empirical evidence. Below is a summary of major findings, strengths, and gaps in current literature.

What Research Shows

• A review of gestational surrogacy literature suggests no strong evidence of substantial adverse psychological outcomes in carriers or their children, when adequate screening and support are provided. PubMed+2WCM Newsroom+2

• Some longitudinal studies report that surrogate mothers generally do not experience long-term psychological harm; increases in distress may be seen in the immediate postpartum period but tend to stabilize within 6–12 months. WCM Newsroom+3OUP Academic+3ScienceDirect+3

• However, more recent large-scale data suggest gestational carriers have a higher risk of new-onset mental illness during pregnancy and the year postpartum compared to women who conceive naturally. JAMA Network+1

• Among studied surrogates, emotional bonding with the fetus is often reported lower than in typical pregnancies. PMC+1

• Long-term contact arrangements between surrogates and the resulting children/families are frequently viewed positively; surrogates often report satisfaction with chosen levels of contact. ScienceDirect+1

• For intended parents, psychological well-being of those who become parents via surrogacy is often comparable or better than that of those who have used other routes of assisted reproduction. ScienceDirect+1

Gaps, Caveats & Research Needs

• Many studies have small sample sizes and rely on self-report, potentially biasing toward positive outcomes.

• Longitudinal data beyond 3–5 years are limited.

• Cultural, socio-economic, and legal contexts vary widely; findings from one jurisdiction may not generalize universally.

• Many studies focus on altruistic (noncommercial) surrogacy; outcomes in compensated arrangements may differ.

• More rigorous prospective psychological monitoring (pre-pregnancy, during, and several years postpartum) is needed.

Psychological Screening & Readiness Assessment

Proper screening is foundational: it helps identify risk, set expectations, and prepare both surrogates and intended parents emotionally for potential challenges.

Goals of Screening

• Assess motivations, expectations, understanding of risks, and emotional preparedness

• Detect prior psychiatric history, vulnerabilities, or poor coping history

• Evaluate social support, stressors, and relationship health

• Clarify boundaries, communication preferences, and expectations

• Establish a baseline psychological profile for monitoring

Components of a Good Screening Process

1. Clinical Interview / Assessment

   • Discussion of life history, prior pregnancies, stress reactions, relationships, personality, coping styles

   • Explore motivations, fears, expectations, understanding of relinquishment, and potential conflicts

2. Standardized Psychological Testing / Scales

   • Depression, anxiety, trauma, personality inventory, stress resilience scales

3. Support System & Life Stress Evaluation

   • Evaluate family, partner, financial, work, community support

   • Assess concurrent life stressors (e.g. health problems, caregiving, relationship conflict)

4. Education & Reality Check

   • Provide clear information about emotional challenges ahead (attachment, relapse risk, boundaries)

   • Clarify roles, rights, expectations, and relinquishment plans

5. Ongoing Consent & Opt-out Mechanisms

   • Screening should be framed as supportive rather than gatekeeping

   • Surrogates or IPs must be allowed to withdraw or adjust as process unfolds

• Gaps, Caveats & Research Needs

• Initial screening prior to contract / matching

• Reassess at key milestones (e.g. prior to embryo transfer, early pregnancy, third trimester, postpartum)

• Use check-ins / questionnaires at periodic intervals

Ongoing Support: Counseling, Monitoring & Interventions

Screening alone is not enough. Ongoing psychological care should be integrated into the entire surrogacy process.

For Intended Parents

• Counseling sessions (individual or couples) to manage anxiety, expectations, relationship stress

• Support around uncertainties and emotional rollercoasters

• Guidance on communication with surrogate, boundaries, and parallel emotional coping

• Preparation and adaptation after baby’s birth

For Surrogates / Gestational Carriers

• Regular mental health check-ins throughout pregnancy

• Access to a licensed reproductive mental health professional experienced with third-party reproduction

• Peer support groups or networks of prior surrogates

• Crisis plan for emergent emotional distress or mood changes

• Postpartum follow-up, especially in first 3–12 months

Monitoring & Intervention Thresholds

• Use standardized mood / anxiety screening tools (e.g. EPDS, GAD-7, PHQ-9) at defined intervals

• Flagging systems: sudden mood changes, withdrawal, crying spells, sleep disruptions

• When above thresholds, referral to therapy or psychiatric support

• Coordination between mental health team and medical / obstetric team for holistic care

Coping Skills, Resilience & Self-Care Strategies

Psychological preparation includes building internal resources and resilience tools.

Core Strategies

• Mindfulness & Grounding Techniques (breathing, body scan, meditation)

• Cognitive Restructuring / Reframing (identifying and challenging catastrophic or rigid thoughts)

• Journaling / Reflective Writing (tracking emotional changes, triggers, gratitude)

• Physical Self-Care (sleep hygiene, nutrition, gentle exercise, rest)

• Boundaries & Time Management (knowing when to pause, say “no,” limit stress exposure)

• Social Support & Sharing (trusted friends, family, peer groups, support forums)

• Imagery & Visualization (visualizing positive outcomes, rehearsing coping)

• Crisis Tools (hotline numbers, grounding worksheets, mental health plans)

Tailoring Strategies for Each Role

• IPs: techniques for anxiety, waiting, managing “lack of control”

• GCs: strategies to maintain emotional balance, manage separation grief, maintain sense of self

• Joint coping: partner exercises, check-ins, shared journaling (if agreed)