Psychological Screening Before Surrogacy: Assessing Mental Health History, Resilience, and Social Support

Surrogacy offers a profound opportunity for intended parents to build or expand their families when traditional conception is not possible. However, the third-party nature of this reproductive arrangement introduces complex psychological dynamics. Surrogates undertake significant physical, emotional, and legal responsibilities over the course of pregnancy and after birth. For intended parents, entrusting another person with the gestational role can generate anxiety, uncertainty, and relational stress. To safeguard the well-being of both surrogates and intended parents and ultimately the child, comprehensive psychological screening is a cornerstone of responsible surrogacy practice.

The three core domains of psychological evaluation before surrogacy:

1. Mental health history – Identifying preexisting conditions, treatment history, and coping patterns
2. Resilience assessment – Measuring adaptive capacities, stress tolerance, and emotional regulation
3. Social support evaluation – Mapping the surrogate’s relational network and available resources
   

1. Mental Health History

Purpose of Assessment

A thorough review of mental health history aims to identify past or current psychiatric diagnoses, treatment modalities, and risk factors that could interfere with the pregnancy or postnatal period. Conditions such as major depressive disorder, bipolar disorder, post-traumatic stress disorder (PTSD), and severe anxiety disorders require careful evaluation. While many individuals with well-managed diagnoses can serve as surrogates, awareness of history informs safeguards and coordination with mental health professionals.

Assessment Components

• Clinical Interview: A licensed psychologist or psychiatrist conducts a structured clinical interview (e.g., SCID-5) to elicit diagnostic history, symptom patterns, hospitalizations, and medication use.
• Psychiatric Records Review: When available, records from prior treatment providers supplement subjective reporting with documented history.
• Self-Report Inventories: Tools like the Patient Health Questionnaire-9 (PHQ-9) for depression and the Generalized Anxiety Disorder-7 (GAD-7) inventory provide standardized symptom severity ratings.
• Collateral Information: With consent, input from family members or partners can corroborate the surrogate’s recollection, especially regarding functional impairment or crisis episodes.
  
  

Risk Stratification

Based on gathered information, clinicians categorize potential risk levels:

• Low Risk: No history of major psychiatric diagnoses, no psychotropic medication, and no significant functional impairment.
• Moderate Risk: Remission from a prior episode, stable on maintenance treatment, with active coping strategies.
• High Risk: Recent hospitalization, active symptoms requiring treatment changes, or history of self-harm/ideation.

High-risk individuals are typically deferred or require stabilization before proceeding.

2. Resilience Assessment

Defining Resilience in Surrogacy

Resilience refers to the capacity to adapt, recover, and grow when faced with stressors. In surrogacy, resilience encompasses coping with physical discomfort, hormonal fluctuations, emotional attachments, and potential conflicts with intended parents.

Key Resilience Factors

• Stress Tolerance: The surrogate’s ability to manage unexpected medical complications, travel for appointments, or schedule changes.
• Emotional Regulation: Skills for identifying, understanding, and modulating emotional states, preventing overwhelming distress.
• Problem-Solving Skills: Proactive strategies to navigate logistical, interpersonal, or medical challenges.
• Positive Outlook: Maintaining hope and optimism even when setbacks occur.
  

Measurement Tools

• Connor-Davidson Resilience Scale (CD-RISC): A 25-item self-report assessing confidence, flexibility, and persistence.
• Brief Resilience Scale (BRS): A 6-item measure focusing on one’s perceived ability to bounce back from stress.
• Coping Inventory for Stressful Situations (CISS): Evaluates task-oriented, emotion-oriented, and avoidance-oriented coping strategies.
  
  

Clinical Interpretation

Scores on resilience scales guide clinicians in identifying strengths and potential areas for growth. Low resilience scores may prompt referrals to resilience-building interventions such as stress-management workshops, mindfulness training, or cognitive-behavioral therapy (CBT) modules focused on adaptive coping.

3. Social Support Evaluation

Importance of Support Networks

Robust social support buffers stress, reduces risk of depression and anxiety, and promotes adherence to medical regimens. For surrogates, assistance from family, friends, or community organizations can ease childcare demands, transportation, and emotional uplift during prenatal appointments and postpartum recovery.

Domains of Social Support

• Emotional Support: Availability of loved ones to provide empathy, encouragement, and understanding.
• Instrumental Support: Practical assistance help with chores, childcare, transportation, or financial contributions where permissible.
• Informational Support: Access to advice, guidance, or resources about pregnancy, surrogacy laws, or mental health services.
• Appraisal Support: Feedback, validation, and affirmation of the surrogate’s role and decisions.

Assessment Methods

• Social Support Questionnaire (SSQ): Measures perceived availability and satisfaction with support.
• Multidimensional Scale of Perceived Social Support (MSPSS): Assesses support from family, friends, and significant others.
• Genogram Construction: Visual mapping of family structure, relationships, and support dynamics.

Strengthening Support

When support gaps emerge, surrogacy agencies and clinicians collaborate with surrogates to:

• Facilitate support group participation (online or in-person).
• Connect surrogates with mentors, experienced former surrogates who offer guidance.
• Engage intended parents in support planning, clarifying visit schedules, gift-giving, and communication to reinforce partnership.
• Identify community resources—local charities, maternal health programs, or volunteer networks.

4. Integrating the Three Domains into a Comprehensive Screening Protocol

Phased Approach

1. Preliminary Intake: Demographic information, medical history overview, and consent for psychological evaluation.
2. Detailed Assessment Session: 2-hour interview plus administration of standardized instruments covering mental health history, resilience, and social support.
3. Scoring and Interpretation: Clinician aggregates data, assigns risk categories, and drafts a summary report with recommendations.
4. Feedback and Consent: Findings are shared with the surrogate and the intended parents (with surrogate’s consent), clarifying next steps.
5. Intervention Planning: For moderate risks or support deficits, referrals for therapy, resilience training, or support group enrollment.
6. Ongoing Monitoring: Periodic check-ins at key pregnancy milestones (e.g., end of first trimester, pre-delivery, postpartum) to reassess mental health and support needs.
   

Ethical and Legal Considerations

• Informed Consent: Surrogates must understand the scope, purpose, and potential outcomes of psychological screening.
• Confidentiality: Sensitive information is shared only with authorized parties and stored per health privacy regulations.
• Non-Discrimination: A history of treated mental health conditions should not automatically disqualify a surrogate if stable and supported.
• Cultural Competence: Assessments must consider cultural beliefs about family, mental health stigma, and community support norms.

5. Enhancing Screening with Multidisciplinary Collaboration

Psychological evaluation does not occur in isolation. Effective surrogacy programs integrate:

• Medical Team Coordination: Obstetricians, maternal-fetal medicine specialists, and nurses collaborate with mental health professionals to address overlapping concerns (e.g., pregnancy complications exacerbating anxiety).
• Legal Counsel Input: Attorneys ensure that contractual arrangements reflect the surrogate’s informed consent regarding psychological aspects and that liability and confidentiality clauses align with screening outcomes.
• Agency Case Managers: Serve as liaisons, tracking appointments, facilitating referrals, and ensuring consistent communication among stakeholders.
• Peer Support Networks: Organized by agencies or nonprofit groups, providing surrogates with real-world insights and emotional solidarity.
  

Conclusion

Psychological screening before surrogacy is an indispensable pillar of ethical practice. By systematically evaluating mental health history, resilience capacity, and social support availability, clinicians and surrogacy agencies can identify risk factors, bolster strengths, and cultivate a supportive environment. This rigorous approach safeguards the well-being of surrogates, intended parents, and the child, fostering trust and positive outcomes throughout the surrogacy journey. Through multidisciplinary collaboration and ongoing monitoring, surrogacy programs can ensure that each participant is prepared, supported, and empowered from the outset.