Thursday, 26 May 2011
Monday, 23 May 2011
Michael CondonI delievered a paper yesterday by Michael Condon to the Fertility Nurses of Australia conference. Michael's paper was about surrogacy counselling. Michael is a well known and respected psychologist and infertility counsellor. He is the senior counsellor for the Queensland Fertility Group. Here is Michael's paper:
The primary purpose of counselling prior to surrogacy is to ensure as much as possible that the welfare of any future and existing children is best achieved. Surrogacy counselling aims to fully inform all parties of psychological and psychosocial surrogacy considerations, as well as assist them to see future and plan for future needs resulting from the surrogacy.
Counselling prior to surrogacy is a legal requirement in all Australian States that permit surrogacy. The Australian andNew Zealand Infertility Counsellors Association (Anzica) has developed draft surrogacy guidelines to provide consistency of counselling for all clients involved.
Surrogacy requires both the commissioning parents and the surrogate and partner to have a high degree of trust in each other. Counselling can engender that trust by ensuring that all potential aspects re the surrogacy, positive and negative, are openly and fully discussed prior to a conception, both by each couple, and between couples. This can lead to an openness of communication, as well as an open discussion regarding what may or may not happen, how it will go, and if this will be positive to both couples. It is wise not to presume that everybody is on the same page at all times.
Surrogacy is a new area for most people contemplating surrogacy. Counselling can assist by helping people understand the psychological aspects in surrogacy, and how to handle psychological and psychosocial aspects, from the perspective and with the guidance of a counsellor experienced in surrogacy. The counsellor can assist people to examine the issues involved, identify any potential difficulties, as well as help problem solve any difficulties that may present themselves in advance or in the future.
The hope for most people is a baby, and that all will turn out well. However, all parties need to be aware that a baby may not happen, or that what is planned by all may not eventuate. Looking at how they may handle disappointments, how the surrogate will handle pregnancy, handing a baby over and separation issues, the surrogate’s family response to surrogacy and handing a baby to another couple, and acceptance of that baby not only by the commissioning couple, but also by the wider family.
More basic aspects include whose eggs and sperm to use, and if donor is used, will the donor be identifiable to the child in the future. Gestational surrogacy, where the surrogate does not use her own eggs, is recommended. If using her own eggs, then there may be a greater chance of separation issues following birth, as well as potential issues for the existing children.
Once a child is conceived, considerations need to be given to who else needs to know, when will the child be informed and how might this happen, the needs of existing children of either couple and other family members, and future contact between the surrogate and the child. As Alice Kirkman, the first child born by surrogacy in Australia in 1988, has raised, a child has “two mothers”, but only “one mum”. The two mothers are important in a child’s life, not just the “mum”. These aspects all need to be discussed before conception, rather than a “wait and see what happens” approach. This means that most aspects can be pre-discussed and thoughtfully contemplated. Final decisions are not made until if and when needed.
Psychological stability of both couples is important. Counselling can explore aspects of mental health history, as well as explore personality aspects and psychological vulnerabilities which may create difficulties during or after surrogacy, especially aspects of relinquishing a baby, and accepting a baby.
Areas often covered in counselling include physical and mental health histories, stress factors and management, relationship stability, details of surrogacy and pregnancy considerations, handover, future psychological implications, future disclosure to a child and others, and needs of the existing children and wider families. Also covered are aspects of potential difficulties during pregnancy, pregnancy loss, prenatal screening and possible implications, refusal of handover or acceptance, psychological aspects of handover, possible disability of child, possible change of mind at any time, and future relationship between the couples and the child.
Detailed questions covered in surrogacy include
- Relationships between the couples and implications of surrogacy (capacity to make independent decisions- are there any financial or emotional dependence issues between the couples?). When meet, how and ongoing relationship.
- Commitment to and motivation for surrogacy and its unique demands, potential benefits and costs to surrogate, including motivations to use or be a surrogate.
- Reproductive and infertility history of the commissioning couple, how these have been coped with, and the reproductive history of surrogate.
- Informed consent for all parties, and change of mind for a party before or during the process. Do all fully understand the need to be fully informed, and that a change of mind at any time is possible by each couple.
- Significant stress factors in your life, any recent major upheavals or transitions, current life stresses and coping strategies used to manage these stresses or upheavals.
- Physical and mental health history (including aspects of depression, anxiety, and other psychological difficulties) and current physical and mental health of all parties.
- Psychological and marital/relationship stability of both couples. This includes a brief relationship history of each couple, as well as how each couple get on with their respective partner.
- Implications for any existing children of either party and risk factors (any loss issues and how parents intend to deal with them), as well as psychological implications for any child born through the intended surrogacy arrangement. This includes if the children have been informed, how they have responded, if not yet informed how this could occur and when and how it is felt they would respond.
- Possibilities of complications that may affect couples or individuals: e.g. relationship breakdowns, medical problems, even death of an individual. What would happen to the surrogacy and future child.
- Attitude of both parties to prenatal screening and/or termination, has this been jointly discussed and is agreement in principal present.
- Issue of relinquishment or possible refusal to do so by surrogate, refusal to accept a child by the commissioning couple. How would this be handled by each couple.
- Dealing with a disabled child, refusal by commissioning couple to take on such a child.
- Ideas re future relationships between each couple and any existing or future children. The child has a mother and a birth mother. All need to be aware of the importance of this for a child over time, and how this can be best managed. Future openness to children is essential.
- Intentions re disclosure to child re birth parent and surrogacy, openness and honesty to a child over time, and explanations to others, timing of same.
- Differences in parenting styles between the couples. If the couples are close to each other, would this have any future impact?
- Awareness and acceptance of legal ramifications. Has legal advice been given yet, and are everyone aware of and accepting of the non-legal binding of a surrogacy
- Abilities of commissioning couple that may lead to good parenting. Abilities of the surrogate to engender a healthy pregnancy.
18. Financial stability to raise a child and plans re early care of the child by the commissioning couple.
19. History of all parties: including for each person of current or prior alcohol, smoking and illegal drugs, history of abuse or neglect, and wider family mental health and physical health aspects.
20. Future acceptance of any child by wider family of commissioning couple, as well as response's by surrogate’s family to the proposed surrogacy.
A brief personal history of each person is taken, including schooling/education completed and when, work history, relationship history, and immediate family history.
Post Surrogacy Counselling
Post Surrogacy Counselling is required in an application for a Parenting Order in both Queensland and New South Wales. In Queensland the Counsellor must be appropriately qualified, different to the pre-surrogacy counsellor and independent of any medical doctor involved in the surrogacy.
For example, in Queensland, The Independent Counsellor must prepare a Surrogacy Guidance Report for the Court that includes (see Surrogacy Act 2010, Queensland)
(a) The independence and appropriate qualifications of the counsellor;
(b) that, for the application, the counsellor interviewed the birth mother, the birth mother’s spouse (if any), another birth parent (if any) and the applicant, or joint
applicants, (the relevant persons);
(c) the date or dates of the interviews;
(d) the counsellor’s opinion formed as a result of the interviews relevant to the application for a parentage order including, for example, about the following
(i) each relevant person’s understanding of—
(A) the social and psychological implications of the making of a parentage order on the child and relevant persons;
(B) openness and honesty about the child’s birth parentage being for the wellbeing, and in the best interests, of the child;
(ii) the care arrangements that the applicant, or joint applicants, have proposed for the child;
(iii) whether the making of a parentage order would be for the wellbeing, and in the best interests, of the child.
Surrogacy Support Counselling
Each clinic needs to have the availability for client support counselling at any time. This can include doctor, nursing and counsellor support. Similar to IVF support, counselling support from a nurse counsellor or clinic counsellor needs to be available (if needed) during and after all procedures to gain a pregnancy, or if any procedure or the overall surrogacy is unsuccessful.
Counselling during and after pregnancy
Dr. Martyn Stafford-Bell, CanberraFertility Centre, has been practicing surrogacy since 1990 in Australia. Dr. Stafford-Bell is a strong advocate of counselling, and has done much to shape surrogacy counselling in Australia. As well as the above counselling, Dr. Stafford-Bell suggests counselling at 12, 28, 35 weeks of pregnancy, and 6-8 weeks post-partum, and 3, 6, 12 months after delivery. He also recommends that the patient or surrogate is able to contact the clinic nurse or counsellor at any time if concerned.
Clinics need to be aware that issues may arise for people in the future, including the surrogate and partner, the commissioning parents, and any existing or future children. Clinics will need to plan for this possible future need in resource allocation.
Queensland Fertility Group