Anita Rao
Bringing a new baby into the world is a lot of work. And I say that as someone who is a mere observer of the many people in my life who are doing it. Some by having a kid themselves, others after months and years spent doing a wide range of fertility treatments, and a handful of others via surrogacy. That latter route is one I was not very familiar with, and certainly one about which I held my own set of assumptions, judgments, and now in hindsight, misconceptions.
Who chooses this path and how the process goes — both if you're an intended parent and a surrogate — is far more complicated than I ever imagined. And no, going down a Kim Kardashian surrogacy rabbit hole will not give you the full picture.
Surrogacy intersects with big questions about power dynamics, reproductive justice and who gets to make decisions about how you can build a family. But the loudest voices in the conversation are often not the folks whose lives are most influenced by the process: surrogates and intended parents.
This is Embodied, our show tackling sex, relationships and your health. I'm Anita Rao.
Hundreds of babies are born via surrogacy each year in the U.S., and they're one part of a larger global surrogacy industry. Journalists and academic researchers are constantly publishing new analyses of the financial, legal and policy aspects of the process. And I'm not going to lie, on the global scale, things get really complicated. A little over a year ago on the Embodied radio show, we decided to start the conversation by focusing on one slice of this much bigger puzzle: compensated gestational surrogacy in the U.S. If you're thinking, "Compensated? Gestational?" Bear with me, it's going to be explained by the person you're about to meet.
Eloise Drane
When I started in 2007, there was information, obviously, about surrogacy online, but not as much as it is now.
Anita Rao
That's Eloise Drane. She's the founder of Family Inceptions, a surrogacy agency based in Georgia. She's also a three-time surrogate herself.
Eloise Drane
It was just something in my gut that, just, told me that I was supposed to do it. And I really, I do, I really do love helping people. And I felt that it was an ability that I could help somebody else, and really, completely change the legacy of a family.
Anita Rao
At the time of her first surrogacy, Eloise already had four kids of her own, and a husband who took a while to come around to the idea when Eloise first broached the conversation.
Eloise Drane
It wasn't a conversation. It was more of a screaming match that I've lost my mind, a lot of explicit words, and — and a lot of it was because he didn't understand, didn't really understand the process. And a lot of people unfortunately, even to this day, still don't understand the process. You know, I mean, one of his questions initially was like, "You're gonna have to sleep with another man, have you lost your mind?" And I'm like, "No, that's not how this works." And then, of course, there was the concern of my emotional being, my physical being. How am I going to, you know, carry a pregnancy for nine months, and then give this baby back to the parents? I mean, so rightfully so, he had the right questions and the right concerns, just like any other significant other is going to have. And it really was about making sure he was educated enough to really understand how the process works and what was really required of him, of myself, of our family. And then of course, after I explained it to him and got him on board, then I had to turn around and explain it to my parents and, you know, and my siblings. And my parents were definitely more old school, so all of this technology side of things is, just like, "You're doing what to what?"
Anita Rao
Well, I think one of the things you raise that is important to note is that this is very new technology. I mean, surrogacy has been around for a long time, has happened in many ways throughout human history, but this kind of gestational surrogacy that's really common today is fairly new — I mean, really came into play in the '80s, I think. So maybe you can help us understand the types of surrogacy. So I said the word gestational — tell me about gestational versus traditional and how commonly people choose one or the other.
Eloise Drane
So, gestational surrogacy is when the woman carrying the pregnancy has no genetic ties to the child whatsoever. It is not her egg, obviously not her partner's sperm. The embryos are created outside of the body and then transferred into her uterus. In a traditional surrogacy case, the person that's carrying the pregnancy is also genetically related to the egg that will be used. Now depending on the situation, they could create the embryo outside of the body still using the woman's genetic material and then transfer it back in. Or in many instances, they'll do what they call an IUI — or intrauterine insemination. And they would then just go ahead and insert the sperm directly into the woman and hopefully a pregnancy will take. Now there's not as many cases anymore of traditional surrogacy like it used to. Mainly when someone talks about surrogacy now, they're generally just speaking about gestational surrogacy.
Anita Rao
For folks who choose the gestational surrogacy route, there are several steps in the process before embryo implantation even enters the picture. Early on — and in many ways most critical — is finding a good match between surrogates and future parents. When Brian McGunagle and his husband first decided to pursue having a child via a surrogate, they were pretty overwhelmed by how to go about it. So they took a next step that confirms they're certainly my kind of people — they dove headfirst into research. They looked up information about surrogacy agencies and even went to a conference.
Brian McGunagle
We attended a conference called Men Having Babies in New York City — and they have conferences throughout the world. And at that, at that conference, we met several different agencies. We found an agency that was located very local to where we live here in Connecticut, as well as a — as a fertility clinic that's located close by in Connecticut. And what we liked about our agency was that it wasn't so much that we got to choose the surrogate, the surrogate was in the position to choose the family. And so we put together a profile — a little bit like match.com, in a sense — but, we put together a profile, and the agency then showed it to several potential surrogates. And the surrogate we were matched with, you know, chose us. You know, we did meet her, and, you know, had our first, kind of, introduction, but what was important there was that it was her decision who to work with. And until she was comfortable, you know, it wasn't a considered a match.
Anita Rao
Brian and his husband eventually matched with a surrogate named Emily, who was based in Florida. At first, they hesitated given the distance between Florida and their home in Connecticut. But once they had a chance to really get to know her, they were certain it was the right fit.
Brian McGunagle
What I think was cool about the surrogate we were matched with was we did have several different things in common. She was a high school drama teacher, I had done a lot of acting in high school. So we immediately, kind of, hit it off talking about different shows and — and she made a really great connection with my husband as well, who's really into design and interior design. So that was really important. And the other part of it was, you know, making a connection with her family as well. She is a mother of three and has a wonderful husband who we got to know as well through the process. So it became a friendship over, over time, and we would have regular phone calls with her. And I think we probably texted with each other if not daily, every other day, throughout the whole process really to stay in touch — just like you might with a long distance friend. It was a really unique relationship. We're still close to her today. We exchange Christmas cards and presents, we text with each other, you know, when there's big milestone events in each other's lives. So, she's someone that, in our minds, is part of our family and always will be because of the gift that she "gave", in a sense, by helping us have a child.
Anita Rao
Eloise, how does that resonate with your experience? What kind of relationships do you have with the families who you were a surrogate for — the kids and the parents?
Eloise Drane
Well, similar to Brian for — especially with my second and my third family — that I carried for, we definitely still have a relationship to this day as well, where we'll, you know, continue touching base with each other, and reaching out during milestone events and things like that. My first family I don't really have a connection with them any longer, but definitely for the second and third family. One thing about surrogacy is, everybody is so unique and it's so different. And, you know, you just, kind of, have to go with the flow, and you have to remember everybody has different personalities. And what you might experience for one journey, may be different for your next journey.
Anita Rao
You mentioned earlier in the conversation that one of the assumptions, I guess, your husband had, or concerns he had, was about the emotional connection or attachment that you might have with the child that you were carrying. And you wrote a piece for Newsweek about your experience, and one of the lines that really struck me in the piece is that you said you found that you actually had a closer connection to the parents than the baby. And when you gave birth, the loss you felt was for the relationship with the parents. And that — I thought that was so, that was such an interesting way of putting it, because I do feel like a lot of, kind of, the first question that folks have is, well, how is there not an attachment with the hormones and carrying this thing for nine months? Can you talk a bit about that from your perspective?
Eloise Drane
I mean, you go into it knowing it's not your child. So you, of course, you still love that child, and you still care for that child, but the connection that I really had was more so to the parents. Similar to, like, what Brian was saying, he would text with his surrogate every other day, and you, you literally build this friendship, you build this rapport. And then, after this child is born, you know, obviously, the parents have to go and take care of this newborn, they're going to be extremely busy. And you have that sense of loss sometimes. They're — and for me, again, I knew that those babies were going to go back to their parents and, and I was excited that they were going back to the parents — I definitely didn't want to have any more children of my own. But it was also important for me to still feel this connection somehow, and there was a connection to that child there, via their parents.
Anita Rao
The work to lay the foundation for that connection happens in the months before and during the pregnancy. Some folks go to counseling to work through questions and concerns that pop up along the way. But as we alluded to earlier, there is also a lot of contractual and legal work that makes this process possible and safe for all parties involved.
Brian McGunagle
If you're a traditional pregnancy, where, you know, you got pregnant, and you have a baby, there are a lot of things you probably just don't think about upfront. Scenarios like, what if the pregnancy results in twins or triplets? Are you willing to carry triplets? And if, if you're not, are you willing to undergo selective reduction? All these different, kind of, "what if" scenarios and they're — probably the likelihood of them happening is small to none — have to be expressly described. And you have to really have a conversation on each one of those items, and come to an agreement before the fertility clinic will even speak to you about having a — doing a transfer.
Anita Rao
But how much say can you have over someone else's body — even if that body is carrying a child for you? A couple of weeks before we recorded this conversation last year, I watched the film "Together Together." It's about the relationship between a single man, played by Ed Helms, and the surrogate carrying his child, played by Patti Harrison. And there's one scene that stuck out to me at the beginning of the movie when the two are out at dinner.
Together Together Excerpt
Server
"Have you decided?"
Patti Harrison
"Yeah, could I get the free range chicken pesto thing?"
Server
"And would you like bread, potato or salad?"
Patti Harrison
"Potato."
Ed Helms
"Uh un..."
Patti Harrison
"Salad."
Ed Helms
"Mhmm."
Patti Harrison
"And potatoes, please."
Server
"And for you?"
Ed Helms
"Carbonara."
Patti Harrison
"Well, I'm a lot less nervous after the 'Uh un'."
Ed Helms
"You know what? I'm sorry. I just was worried when you ordered the potatoes, because what you eat, they eat."
Patti Harrison
"You ordered pasta with bacon."
Ed Helms
"Yeah, but I'm the only one eating it."
Patti Harrison
"But I only matter for, like, the next, like, nine months or so. And you matter for the next 18-plus years. You're like 40 something. So yeah, if I were you, I would not be eating pasta with bacon."
Ed Helms
"That's a really good point, actually."
Anita Rao
So yeah, the Ed Helms character tried to discourage his surrogate from eating potatoes. It is a spot on portrayal of food policing, but the scene also made me wonder how common this kind of experience is for surrogates — that someone has a very specific request for how they treat their bodies during pregnancy. I put the question to Eloise.
Eloise Drane
I was very upfront with my parents of: I've had four pregnancies. I know what I need to do. I definitely recognize that I'm carrying a pregnancy for another person who was putting all of their trust to me, to hopefully deliver a healthy pregnancy. And so I will do everything in my power to ensure that I take care of your child, just like if you brought your child to me, and the child was here, and I was babysitting for you, I'm going to protect your child in utero as I would protect your child if I had them in my house. But at the same time, I'm a coffee drinker. Know that I will drink one cup of coffee every single day. I am not changing that for you or for anybody else. It's also unrealistic — especially when somebody is pregnant, where she wants McDonald's French fries — that because that's not something you think is a good idea, that you're going to tell her she can't have McDonald's French fries. It's just not — It's not reality. And you also have to remember, although this person is carrying a child for you, she's still a human being with her own autonomy for her body.
Anita Rao
And I guess that brings up the question of who become surrogates and the process to do that. I was shocked to know how few people who apply are actually able to become surrogates — somewhere between 1% or 5%, depending on the state. So can you talk about that, and, kind of, the rigorous screening that folks go through?
Eloise Drane
For someone to become a carrier — or gestational carrier, or surrogate — she must have delivered a child, full term, without any complications. Various agencies do, as far as age, might be different. But the ASRM — Assisted Society for Reproductive Medicine — has the age range for a candidate to be between 21 and 45. They can't actually be on any form of government assistance. And they do have to go through medical screening, they have to complete psychological screening. In some instances in some agencies, they also do a home visit. They have to go through bloodwork. There's a lot that somebody has to go through in order to even be qualified to be a candidate, with all of the screening and the testing. You know, we always say in the agency, they have to be physically, mentally, spiritually and emotionally sound in order for them to proceed forward.
Anita Rao
I mean, and as you said, you mentioned some of the financial aspects, there are some long standing stereotypes that surrogates are attracted to the work because of financial vulnerability. I'm curious to get your take on that, and how you think it shapes the narrative around surrogacy that we have in this country?
Eloise Drane
Absolutely. A lot of women apply to be surrogates because of the money factor, which is totally okay. It is okay for you to want to get compensated for what you're doing. What is not okay is for it to be your sole motivating factor, because there's a lot that you're going to be doing without getting compensated a single penny. It's okay to want to get compensated. But you also have to think about, okay, you're getting compensated for this time, but when you finally get pregnant, it's not like you're tired today, or your child is sick, or whatever, and you can just put that baby on the shelf and say, "I'll come back to you." You are pregnant for nine months, and all the things that come with the pregnancy, you have to deal with. And if money is your only factor, when you break it down, I mean, you're not even getting minimum wage for the time that you're pregnant in the entire process that it takes to get to the finish line.
Anita Rao
Base pay for first time gestational surrogates in the U.S. — pre-pandemic — started at around $30,000. And experienced gestational surrogates received up to $80,000 in some states. Surrogate shortages in the wake of the pandemic may now be driving those rates higher. And the total cost for the gestational surrogacy process from start to finish can be between $100,000 to $200,000. That includes fees for surrogate compensation, embryo creation at a fertility clinic, egg donation, agency fees, legal fees, insurance costs and other expenses, like a surrogate contingency fee — something that would come up in situations of unexpected twins or an unplanned C-section. So how do you pay for all this? Likely a combination of funding sources, including personal savings, loans or tapping into some available grants. Only a very small portion of workplaces offer some reimbursement for surrogacy costs as part of their benefits package, and most health insurance plans exclude costs of a surrogate pregnancy. So money is a huge obstacle for many families who want to go the surrogacy route.
Brian McGunagle
For most gay male couples, I think the only, the only thing that's covered by insurance is a test of your sperm to see your sperm count. Anything after that is out-of-pocket. So surrogacy can be a six-figure journey or more depending on kind of what happens. And so it can place it out of reach for many people. And so I'd love to see more resources available. I know that the fertility clinic we work with, and some other organizations, do offer assistance or scholarships for people, but I'd love to see more of that. It is something that you go into that you have to have a financial plan around how you're going to manage that.
Anita Rao
Eloise, anywhere that you'd like to see more support or advocacy for folks who are surrogates, who are carriers or in the industry generally?
Eloise Drane
Insurance covers nothing, absolutely nothing. And if we're going to start having the conversations, it needs to begin having the conversations through employers, and through insurance companies, and being able to add fertility care through policies, because it's not happening anywhere. Fertility care needs to become one of the options that they're providing to their employers, as well, to assist, because it is a huge issue.
Anita Rao
For both surrogates and intended parents in the U.S., how easy the process is — and how much red tape there is to navigate — depends in large part on the state where you live. In Connecticut, where Brian's family lives, gestational surrogacy is legal and can be compensated. Surrogates and intended parents can sign what's called a pre-birth order, which designates the legal parents of the child before they're born and renders an adoption after birth unnecessary. It's also possible there for both intended parents to be listed on the child's birth certificate.
In Georgia, where Eloise is, there are no established surrogacy laws, which means that surrogacy is permitted by the legal system, but you'd want to work with an attorney to make sure the needs of both the surrogate and intended parents are properly covered as you embark on the process. But if you head to other states in the South, like Louisiana, or over to the Midwest to Nebraska or Michigan, compensated surrogacy contracts are illegal. The argument against paid gestational surrogacy in the U.S. and other countries is that offering money for pregnancy can lead to the exploitation of poor and low income women. But some experts argue that regulation and international standards for surrogacy would protect vulnerable populations more effectively. These big picture questions about finance, power dynamics and human relationships within the surrogacy industry have long intrigued sociologist Heather Jacobson.
Heather Jacobson
When I first began research on surrogacy, I was initially interested in what a lot of people are interested in, and that's the motivations that bring women to engage in surrogacy — to become surrogates themselves. One of the things that really surprised me that I had not been fully aware of was the amount of work that goes into being a surrogate — especially here in the U.S. I began to really be interested in how surrogates think about the labor in which they're engaging.
Anita Rao
Heather, who works as a professor at the University of Texas Arlington, also wanted to know how U.S. gestational surrogates conceptualized their pregnancies. Did it feel mostly like a job with financial compensation? Or did they have other competing motivations for getting involved?
Heather Jacobson
And one of the things — the women that I spoke to — that they identified as something that initially drew them to being a surrogate was their love of pregnancy, their enjoyment of the pregnancy and birthing experience and their desire to help others. But of course, the majority of surrogates in the U.S. are compensated. But I found that surrogates, many intended parents and those too who work in the surrogacy industry were uncomfortable — as many people in the U.S. — at this intersection of the family and the market. So they don't think about it as a job, per se.
Anita Rao
It does not surprise me that the intersection of family and money makes things complicated. We are terrible at talking about money generally, let alone when enter some of our most private and intimate relationships. Heather got into the messiness of all of this in her book, "Labor of Love: Gestational Surrogacy and the Work of Making Babies." She wrote it after spending many months interviewing U.S. gestational surrogates, their families, intended parents and surrogacy professionals. And one thing that stood out to her after all this research: the large networks of support behind surrogates that made their job possible.
Heather Jacobson
When I began collecting data, the women who I first spoke with said to me, "You really need to talk to my husband," or "You really need to talk to my partner," or "I'd love for you to talk to my mother-in-law, they helped me in this process." And I really see that structured into the U.S. surrogacy industry. You know, the industry relies on that labor that surrogates' support network play in their lives. The surrogacy, you know, industry also, you know, often has that as one of the criteria when they're screening women. To make sure that she has a solid support network, that she has, you know, people in her life that will help and support her. And if she's legally married, that her legal spouse agrees to the arrangement. And so it's really important — both from a legal standpoint, from the industry standpoint — but then also women who I spoke with who were surrogates really spoke to the important role that their spouse played and that their children played as well.
Anita Rao
And it's, yeah, I mean, it's such a big, it's obviously such a big commitment in the industry we've been talking about — mostly in the U.S. But I want to talk briefly as we close, about the industry and how it operates internationally. People go to different countries to find or be surrogates. What drives people to do this, and what patterns have you seen emerging as you've been tracking these trends?
Heather Jacobson
Most countries either have nothing on the books about surrogacy, or it's illegal in that country, or they only allow for altruistic surrogacy. And so you have many people, you know — over, people from over 150 countries come to the U.S. for ART services — we have a very robust Assisted Reproductive Technology industry in the U.S. So surrogacy right now only represents about 4% of all annual ART cycles in the country, but we do have many people who come from countries where surrogacy is illegal, or we have many gay people coming to the U.S. In their home countries, not only is surrogacy illegal, but adoption as well for them.
Interestingly, we also have people who are using — hoping to use surrogacy as a route to extend their families in the U.S. unable to continue in ART treatment here in the U.S. because of cost. And so they'll kind of be pushed out of the U.S. ART market into other markets. So India, in the past, had been a very popular location for surrogacy. Ukraine, Mexico, Belarus, Thailand. It's a very interesting, kind of, landscape where — sometimes it's money that drives people to other markets and sometimes there are other motivations. Some people have come to the U.S. market because they see it as more ethical because of the relationships that intended parents are encouraged to, and many do, form with surrogates in the U.S. Some people have been uncomfortable in other countries, you know, not being able to meet the surrogate, or feeling it's in a more exploitative process in other parts of the world. And so, it's a very, kind of, complex and interesting — from a sociological standpoint — you know, market to study.
Anita Rao
So I want to close with having you reflect on the future of the surrogacy industry. I think what's been so interesting in, in researching this is realizing that, you know, science has advanced faster and more quickly than policy has been able to catch up, certainly in this case. So there, there's a lot that still needs to be figured out. From your conversations with, with surrogates, with intended parents, with folks inside the industry, do you have a couple of things that you think — that you're watching out for moving forward, in terms of policy change and changes to the industry?
Heather Jacobson
I think it's really important that wherever the industry goes, that we have input from stakeholders. One of the problems that often concerns me is that the voices of surrogates and the experiences of surrogates are often not part of those dialogues, and I think that's really important. It's one of the reasons why I really wanted to talk with surrogates themselves. And I think it's really, really important, you know, not to go in with assumptions about why people might become a surrogate, but to really listen to surrogates and to hear what they have to say. And then to use their experiences to help shape, you know, what we might move forward with in terms of regulation, or dealing with ethical dilemmas.
Anita Rao
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This episode was produced by Kaia Findlay, Amanda Magnus is our editor, Audrey Smith also produces for our show. Jenni Lawson is our sound engineer, and Quilla wrote our theme music.
Until next time, I'm Anita Rao, taking on the taboo with you.