Shifting surrogacies: Comparative ethnographies

Abstract

Gestational surrogacy is a reproductive arrangement where a woman gestates a child for others—the “intended parents”—in order to be handed over to them after birth. Since the turn of the millennium, demands for surrogacy have continuously increased due to social and demographic changes, rising rates of infertility, and the normalization of new, non-heteronormative, family forms. Many countries prohibit surrogacy, and others that previously permitted this reproductive arrangement closed down as a result of political decisions or surrogacy scandals. Moreover, surrogacy is offered at greatly varying costs, ranging from approximately US$50,000 in countries like the Republic of Georgia to US$200,000 in fertility clinics in California. Accordingly, many of these arrangements are transnational, with intended parents who cannot access surrogacy or afford surrogacy in their home country commissioning it in countries such as the United States, until recently Ukraine, and today increasingly in the Republic of Georgia. Existing research has focused on surrogacy from different angles, such as practices of kinning and de-kinning, inequality and stratification, the political economy of the fertility industry, and its gender dimensions. We engage in, but further these debates by drawing attention to settings, accounts, experiences, and new theoretical notions that diverge from “mainstream” presentations of surrogacy. Moreover, in this Special Issue, we experimented with writing joint papers with a deliberative aim to provide comparative analyses and emphasize the links between and diversity of different cases of surrogacy. Therefore, all papers have an explicit comparative character and are all based on empirical studies from more than one field site. They provide nuanced understandings of surrogacy arrangements, grounded in empirical data rather than ideological, political, or moral assessments.

Introduction

The introduction of in vitro fertilization (IVF) techniques in 1978, that is, the creation of embryos outside the human body in a lab, made it possible for a woman to gestate a child she is genetically not related to. This technology is used in gestational surrogacy arrangements, where a child is carried for others (using the egg and the sperm of the intended parents or gamete donors) in order to be handed over to them after birth. Such arrangements have offered intended parents, who cannot or—more rarely—do not wish to carry a pregnancy, the opportunity to pursue their desires for a family. Since the turn of the millennium, demands for surrogacies have continuously increased (Birenbaum-Carmeli and Montebruno, 2019) with social and demographic changes such as delays to childbearing, rising infertility rates, and aspirations of LGBTQI (lesbian, gay, bisexual, transgender, queer, and intersex) couples to form biological families (Smietana et al., 2014). In parallel, restrictions of surrogacy in many countries, as well as local catastrophes such as the 2015 earthquake in Nepal or Russia’s war of aggression in Ukraine, have resulted in the closing of some surrogacy locations while creating new routes for cross-border surrogacy in countries with (more) favorable regulations or a lack of such regulations (König and Jacobson, 2021; United Nations, 2018: 5–6). Therefore, today, many of these arrangements are transnational, with the surrogate living in one country and the intended parents in another. Moreover, surrogacy constitutes one branch of a global multi-billion-dollar fertility industry. This reproductive market is facilitated and mediated through digital communication technologies, affordable global transport links, and the movement of cryopreserved gametes, medical professionals, and technologies—and lately even of surrogates—across the globe. This has led to a great variety in the organization and practices of surrogacy, from arrangements within national borders to a global industry promising rapid, accessible, and affordable surrogacy options across national borders.

Research on surrogacies

There are a wide range of empirical studies of surrogacy. At first conducted primarily in countries of the Global North (e.g. Markens, 2007; Ragoné, 1994), following the shifting geopolitics of surrogacy, they have been progressively conducted also in countries of the Global South (e.g. Dasgupta and Dasgupta, 2014; Deomampo, 2016; Majumdar, 2017; Pande, 2014; Rudrappa, 2015; Whittaker, 2019). To date, major anthropological ethnographies and sociological studies have contributed to a nuanced view of the local specificities, cultural differences, and complexities of surrogacy in a number of different national settings including in Israel (Teman, 2010), India (Deomampo, 2016; Majumdar, 2017; Pande, 2014; Rozée et al., 2019; Rudrappa, 2015; Stockey-Bridge, 2017), Russia (Weis, 2017, 2019), Ghana (Gerrits, 2016), Mexico (Hovav, 2019; Olavarría, 2018; Schurr, 2017), Thailand (Whittaker, 2019), Canada (Lavoie and Côté, 2018), and the United States (Berend, 2016; Jacobson, 2016; Markens, 2007; Ragoné, 1994). These studies pay attention to surrogates and intended parents’ experiences and subjectivities and consider surrogacies and other types of third-party-assisted reproduction as forms of interactive encounters at the bodily, local, and national levels, shaped by processes of globalization. A large body of psycho-social work focuses on the well-being of intended parents, surrogates, and children (Armuand et al., 2018; Golombok, 2015; Golombok et al., 2004, 2011; Jadva et al., 2012, 2003; Lamba et al., 2018; Söderström-Anttila et al., 2015: 8).

Specific Issues

Several key questions run through the extant literature on surrogacies. From the existing studies in a range of sites, it becomes clear that surrogacy arrangements may differ considerably depending on the particular context. That is, surrogacy as practiced in India, Thailand, Russia, Ukraine, the United States, or Ghana shares some elements, but at the same time differs greatly due to the social, cultural, and economic context in which it takes place. The conditions under which surrogacies take place, including the legal regulation, the nature of the facilitation company, and conditions of the medical care involved, all vary across and sometimes even within countries (like India, Mexico, and the United States), as well as between clinics. For this reason, our Special Issue is addressing surrogacies—in the plural—to critique monolithic depictions of surrogacy and explicitly acknowledge the fact that surrogacy is not a singular phenomenon, but a socio-medical practice that is differently shaped and given meaning to in different contexts (Inhorn, Birenbaum-Carmeli, 2008). The plurality expressed in our use of this term also recognizes surrogacies as intersectional arrangements between persons of different positionings and interests.

Fundamental to the demand for surrogacy is that it offers the possibility of conceiving a child and becoming parents for people who, usually for medical or social reasons, would otherwise be unable or for whom it would be extremely difficult to create the family of their choice. An investigation of surrogacies offers insights into the primacy of and value placed upon genetic relationships as a conventional basis for kin as propagated by the current Euro-American model of kinship (Strathern, 2005). This in some ways counters ideas and practices of non-biological kinning and other ways of dealing with infertility, parenting, and family formation (Côté et al., 2018; Smietana et al., 2018). Genetic kinning narratives within gestational surrogacy, when a surrogate carries a child genetically related to one or both intended parents, act to legitimize the claims of intended parents to their surrogacy-born children. In turn, these narratives are used by surrogates to distance themselves from the child they bear—and they are not genetically related to—as has, for example, been shown in research with surrogates in the United States (Berend, 2016) and Ghana (Gerrits, 2016) who reject any suggestion of a kinship relation with the child they gestate. The quandaries over genetic connections are highlighted among gay fathers making their decisions about how they will become parents—whether through surrogacy, adoption, or co-sharing arrangements. In surrogacy, gay men utilize a range of tactics when deciding upon the genetic connections their children will share, such as both partners donating sperm and having one embryo from each transferred to a surrogate or deciding that only one man should be the genetic parent (Murphy, 2015). As Smietana et al. (2014) note in a comparative article on gay fathers in Belgium, Spain, and the United Kingdom, the decisions made by gay fathers are based on their perceptions of the importance of genetic relatedness as well as their views on sexually differentiated parenting roles, their desire for autonomy in parenting, and their moral views on options such as surrogacy.

As much as surrogacies have changed the formation and imaginary of families, they have not collapsed older forms of inequalities and, therefore, stratification in the field of reproduction (also see Colen, 1995). While this is true for economic and class inequalities, more recently, researchers are also examining reproduction through an intersectional lens. Accordingly, surrogacies have created new opportunities, both for global activism and for mobilization, but also for direct forms of economic exchange and exploitation. Studies revisiting the vulnerability and exploitation arguments explore race, class, gender, and sex disparities between surrogates, intended parents, and medical doctors, including the real risk of exploitation due to differences in social and economic status between surrogacy protagonists in transnational surrogacy (Dasgupta and Dasgupta, 2014; Pande, 2021; Saravanan, 2018; Schurr, 2017; Twine, 2011). The regional and global circulation of traveling surrogates and ova donors, as well as embryos and gametes raise new opportunities, but also threats to women, particularly to poor women from developing countries as the sources of these body products.

A large body of work has described the organization of surrogacy and its political economy (see Whittaker, 2020, for a review). This work is characterized by the recognition of surrogacy as a form of labor (Cooper and Waldby, 2014; Pande, 2010; Rudrappa, 2015), described in various ways as: alienated work (Saravanan, 2016), social work (Vora, 2010), reproductive labor (Pande, 2010), clinical labor (Cooper and Waldby, 2014), sacred work (Deomampo, 2014), obscured labor (Jacobson, 2016), and intimate work (Boris and Parreñas, 2010). Considering surrogacy as work allows us to move beyond the usual binary analysis of surrogacy (exploitation vs liberty) and to go beyond the emotional, maternal, and affective dimensions of surrogacy, to better understand its complexity and its gendered dimensions (Rozée, 2020). This perspective allows us to consider the economic stratifications within the industry whereby women in poorer countries, or those deemed less biologically desirable, are paid less. But it also allows us to consider the stratifications of risk arising from this labor. Surrogates and ova providers may carry the burden of risks in these procedures, not only in the surrogate pregnancy but also afterward due to the common use of cesareans in surrogacy and the lack of post-partum medical follow-up (Hovav, 2020).

Rather than assuming surrogates are passive subalterns (Deomampo, 2013), a number of studies complicate questions over surrogates’ agency, noting their active decisions to undertake surrogacy as a means to fulfill economic and social aspirations within a context where alternative means of employment are less satisfactory or lucrative (Gerrits, 2016; Kirby, 2014; Rozée et al., 2020; Rudrappa, 2015). Several authors emphasize the need to empower surrogates, rather than prohibiting the practice to avoid a potential illegal and underground market (Haimowitz and Vaishali, 2010), or turning surrogacy into solely an altruistic and relational form (performed by relatives without remuneration) (Rudrappa, 2017). In addition, ethnographic research has also indicated that in some locations (such as the United States and Israel) surrogates’ stated motivations are explicitly tied to the enjoyment of the embodied experience of pregnancy and birth (Berend, 2016; Jacobson, 2016; Teman, 2010). There is a need to be attentive to the voices of surrogates themselves, not merely as objects of academic enquiry but as active participants in knowledge production with a view to a dialogue toward reproductive justice (Pande, 2021).

At the individual level, investigations of the motivations of intended parents that drive international surrogacies have reached beyond front-line understandings of it as stemming from differential prices, and circumvention of legal restrictions, to tease out the underlying logics of care, affective labor, and choice embedded in particular historical, geographical, and personal circumstances. Intended parents, often cast as savvy consumers, in fact find themselves vulnerable in their interactions with clinics and facilitators, often under conditions of great emotional and financial stress as they pursue their imagined family (König, 2018; Stockey-Bridge, 2017; Whittaker, 2019).

Finally, mainly due to legal changes in former “reprohubs” (Inhorn, 2015) such as India, Mexico, or Thailand, the surrogacy industry has in the last few years become more fluid, and new forms of multi-national surrogacy have developed in which gametes, embryos, ova providers, or surrogates may cross several borders to facilitate the surrogacy. Reprohubs are thus currently transforming into “reprowebs” (König and Jacobson, 2021) which may span several countries and flexibly react to local changes. International surrogacies also reflect the transnational segmentation of healthcare markets, as well as the importance of borders as both barriers and facilitators of healthcare provision and access (Ormond, 2015; Whittaker, 2015). Exploring issues around this leads to questions of how surrogacy may be linked to constructions of national identity, pride, and consciousness, what has been termed “reproductive nationalism” (Nadkarni, 2014; Ragoné and Twine, 2000; Whittaker, 2001).

Objectives of this Special Issue

The papers in this Special Issue aim to engage in and further these debates, but also draw attention to settings, accounts, experiences, and new theoretical notions that diverge from “mainstream” presentations of surrogacy. The papers deal with surrogacy at a number of scales—from individual subjectivities through to the political economy. The Special Issue is also concerned with examining various aspects of the “global surrogacy assemblage”—the conglomeration of biomedical technologies, people, companies, ideologies, regulations, social media, reproductive materials, and potentials that together facilitate and mediate this form of reproduction (Inhorn, 2015; Ong and Collier, 2005; Whittaker, 2015, 2019).

The set of papers presented in this Special Issue arise from an international network of anthropologists and sociologists who have collaborated for several years now. Usually, we work on surrogacy in distinct sites or among distinct groups. In order to emphasize the benefits and synergies of a collaborative approach, in this Special Issue we experimented with writing joint papers with a deliberative aim to provide comparative analyses and emphasize the links between and diversity of different cases of surrogacy.

All papers have an explicit comparative character and are all based on empirical studies from more than one field site. As a result, the authors of the papers pay attention to both the local particularities and cultural assumptions operating in the respective field sites as well as interrogating the degree to which these are shared across the global negotiations and contestations that accompany it. They provide nuanced understandings of surrogacy arrangements, grounded in empirical data rather than ideological, political, or moral assessments. We also aim to update what is already explored and known on surrogacy.

Major approaches and themes

Such comparative work is productive in several ways. First, the papers cover a diverse range of countries and political and economic regimes, with various shades of authoritarianism and democracy, and different combinations of neoliberal, market-based, and centrally planned economies and different regulatory structures and healthcare systems. The field sites explored in these papers include: Germany, Ghana, India, Israel, Kazakhstan, Laos, the United Kingdom, and the United States. Second, it allows us to compare the strategies and organization of “global fertility chains” (Vertommen et al., 2022) and the “global surrogacy industry” (Vertommen and Barbagallo, 2021) in different national settings and of individuals’ experiences within these diverse and shifting settings and to go further in the analyses. It thus contributes a better understanding of the many differences that exist between different kinds of surrogacies. Finally, writing together was productive in the identification of novel concepts and approaches such as “repronubs” (Whittaker, Gerrits and Weis) or “strategic racialization” (Smietana and Twine) that apply in different contexts.

The Special Issue starts with a consideration of the development of smaller regional centers of surrogacy in the countries of Ghana, Kazakhstan, and Laos (Whittaker, Gerrits and Weis)—settings which have hardly been addressed in social science literature and media coverage on surrogacy, in contrast to some well-known and larger “reprohubs” (Inhorn, 2015). They focus on “repronubs,” smaller regionally focused surrogacy locations that may or may not develop into larger hubs. These three sites have a number of differences in histories, practices, and attitudes toward assisted reproduction, regulation, and expertise, and yet each is a site that has a thriving regional industry involved with surrogacy. Their paper shows the importance of “repropreneurs” (Kroløkke and Pant, 2012) in articulating the clinical services and markets together to enable the industries to develop. The authors also show how the emergence and the particular “global surrogacy assemblage” at each of these sites are related to a number of specific developments and circumstances, in the countries itself, in their region, and/or more globally.

This is followed by Jacobson and Rozée in their paper examining the inequalities of surrogacy using an intersectional lens. Based on fieldwork in the United States and India, they criticize and deconstruct the sole emphasis on racial and socioeconomic disparity in the international public discourse on surrogacy. They suggest that this overemphasizes assumptions of inequalities and exploitation at the local and national context.

The opinions of surrogates themselves lie at the center of the next paper by Teman and Berend, who provide insights into how surrogates’ views and attitudes toward regulations differ in two different national contexts, Israel and the United States. While surrogates are key players in this field, they are rarely heard in the debate about these regulations. The authors argue that both the cultural contexts and the neoliberal versus nationalist ideologies, respectively, in these countries affect surrogates’ views.

Apart from human actors, surrogacy arrangements involve a range of material things, such as technology, pharmaceuticals, or, as König and Majumdar discuss in their article, documents and paperwork. They consider two different national contexts, Germany and India, and the links between them by exploring the ways in which bureaucratic documents issued by the state and courts facilitate or hinder the travel and legitimacy of children born to foreign (in this case, German) couples commissioning commercial surrogacy in India. Through showing differences in “paperwork” in their respective study sites, but also the links between them, this comparison also shows how in both places documents are part of the making and unmaking of persons and of belonging, to both other persons (i.e. parents) and a state (in the form of citizenship).

The role of nation-states is also at the center of the article by Sharmila Rudrappa and Daphna Birenbaum-Carmeli—in this case, the United States and Israel—and their discussion of “genetic kinning” narratives. This role, they argue, is particularly accentuated for gay couples in cases of cross-border surrogacy where intended parents need to receive travel documents, including passports, and subsequently citizenship, for their children born through surrogacy.

The last paper in this Special Issue (Smietana and Twine) examines the decision-making processes of gay intended parents in the United States and the United Kingdom regarding their choice of an egg donor. The authors examine how a racial logic informs these intended parents’ decision with the aim of creating a racial resemblance between themselves and their children, thereby reinforcing a genetic model of kinship. Building on Thompson’s concept of “strategic naturalization” (Thompson, 2005), which is widely used in the theorization of medically assisted reproductive technologies, they develop the approach of “strategic racialization” in order to analyze the mobilization of racial categories within the realm of third-party reproduction.

Cross-cutting themes

A number of cross-cutting themes emerge from the papers in this Special Issue which define and articulate the nature of global surrogacy assemblages.

The first aspect described in this Special Issue is that global (and local) surrogacy assemblages consist of and are shaped by a range of actors, including states, private hospitals, facilitation companies, and intermediaries, as well as ova providers, surrogates, intended parents, and the supporting people around them. At times, these actors work in tandem, and at other times they are in tension. In addition, while several of the articles provide insights into the role of the state or—in some cases—rather the absence of the state, most articles focus on and/or present the perspectives of a variety of actors. Furthermore, in the case of König and Majumdar’s and Birenbaum-Carmeli and Rudrappa’s contributions, “paper work” and “travel documents,” but also the people who issue them (or not) and the state that prescribes a certain way of dealing with them, play powerful roles in defining, limiting, and regulating kinship relations and appointing citizenship.

Second, collectively, the papers emphasize the need to understand contemporary global surrogacy assemblages in the larger context of history, the state, geopolitical, and socio-economic realities. As the papers in this collection explore, a range of local regulatory, health system, (geopolitical) economic, socio-cultural, and historical factors influence the organization, demand, and flows of people and technologies, the availability of women as surrogates and egg providers, and social understandings and support of surrogacies. Who may travel, where they travel, who assists with surrogacy, and how it is arranged are not merely questions of choice but rather molded by a range of other, often invisible, structural factors.

A final consequence of global surrogacy assemblages that becomes evident in the papers that make up this Special Issue is the construction of identities through surrogacies. The forming of a family through surrogacy requires a set of new relationships, be it an identity as a “surrogate” or “ova donor,” “gay dad,” intended parent, child born through surrogacy, or the assignment of a national identity as a citizen of a certain country. As seen across several papers, these processes of identity formation and belonging can be uncertain, vexed, or incomplete but also usher in new biosocialities through advocacy and support groups, kinship relations, and imaginaries of family connections or future children. Identities are co-shaped through support group narratives, clinical socialization, social media relationships, and paperwork as much as the bodily processes of pregnancy and birth.

Across the papers of this Special issue, there are a number of conceptual innovations that are useful for thinking about surrogacies. The first is the term repronubs (Whittaker, Gerrits, and Weis) as a description of places but also processes through which smaller regional articulations of people and assisted reproductive technologies come to be formed, catalyzed by local repropreneurs, who may or may not be medical professionals. As a means of mapping out the various intersections in the “reprowebs” (König and Jacobson, 2021) (or networks and routes of travel for assisted reproduction), the notion of repronubs allows for the consideration of how regional networks articulate with larger networks or webs, as well as questions of how they come to develop despite their apparent differences.

An emphasis on transnational gender disparities is another innovation which highlights the need for analyses to consider the potential transnational nature of gendered inequalities. It calls for a nuanced approach to the various intersectional inequalities within and across transnational relationships. A further innovation is the investigation of the role of documentation and bureaucratization in surrogacies to permit and ratify reproduction and define family and citizenship. Finally, building on the notion of “strategic naturalization,” this Special Issue (Smietana and Twine) introduces the notion of “strategic racialization” to further the analysis of the mobilization of racial categories within the realm of third-party reproduction and family formation.

Studying surrogacy—and in particular transnational and global commercial surrogacy—is not an easy undertaking, as it is generally highly sensitive for all actors involved; for some it is an extremely secretive encounter, and the monetary and legal arrangements that are involved are not always discussed in the public domain. As a collection, these papers highlight the unique strengths and contributions of ethnographic methods to undertake research on such sensitive issues and in difficult locations. All authors of this Special Issue were confronted with a number of methodological and ethical issues that they had to resolve, before and during the conduct of fieldwork and/or the writing process. These range from locating intended parents and surrogates willing to share their experiences; dealing with social media; maintaining anonymity in locations with only a few clinics; navigating the barriers posed by protective gatekeepers at surrogacy agencies or in clinical settings; mistrust from facilitators concerned about their commercial secrets or recruiting strategies being disseminated; the logistics of studying mobile subjects traveling across borders; and in some settings, overcoming the secrecy and stigma attached to surrogacy or its illegal status. The authors of these papers have all been involved in long-term studies of surrogacies, overcoming such difficulties with patience and persistence.

Conclusion

At the time of finalizing this Introduction, Ukraine—one of the most popular surrogacy destinations worldwide and an important reprohub—was invaded by Russia. Prior to that, the surrogacy industry in Ukraine and globally had already been strongly affected by the Covid-19 pandemic and the resulting restrictions regarding the travel of persons, but also gametes and embryos. According to surrogacy agents, the Ukrainian surrogacy market had just gained momentum again when Russia began its war of aggression (Anika König, 2022, personal communication with various surrogacy agents working in Ukraine and beyond). At the time of Russia’s invasion in February 2022, the Ukrainian surrogacy industry was estimated to be supporting around 2500 international surrogacies per year (Motluk, 2022). As in other prior catastrophes (such as a severe earthquake in Nepal in 2015 which notoriously saw Israeli babies born through surrogacy airlifted from Nepal, leaving the surrogates behind (Rudrappa, 2018), or the coup d’état and sudden closures of international surrogacy arrangements in Thailand (Whittaker, 2019)), these events highlight the vulnerabilities of surrogates and intended parents. Due to the system of so-called “closed” surrogacy programs, where intended parents and surrogates are prohibited to contact one another (and, therefore, do not have each other’s contact information), many intended parents who participate in such closed programs cannot contact the women carrying their pregnancies. Moreover, some agencies have stopped working and their surrogates are thus unable to contact them or the clinics responsible for their care. In addition, many surrogates do not wish to leave Ukraine, whereas their intended parents wish for them to do so. The medical, legal, and psychological vulnerabilities are heightened as surrogates and intended parents must cross borders to find shelter in other countries in Europe which may not recognize surrogacy arrangements or into Ukraine in order to collect their children. These messy realities are a stark reminder of how geopolitics affects even the most intimate decisions and experiences of family formation, of the precarity and vulnerabilities of transnational reproduction, and of life itself.

The authors of these papers militate against any simplistic reading of surrogacies as practiced in diverse places and contexts. Rather, the papers in this issue highlight the complex global surrogacy assemblages of interests, people, things, technologies, regulations, body products, and imaginaries that sustain surrogacies. This Special Issue uniquely offers a comparative overview of current—and constantly shifting—practices and challenges posed by the pursuit of forming a family through surrogacy in a globalized world.