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What's in a name? Variations in terminology of third-party reproduction

Published:September 15, 2015DOI:https://doi.org/10.1016/j.rbmo.2015.09.004

      Abstract

      The terminology used to discuss third-party reproduction, as with other new biomedical processes, can ease or impede communication and even influence behaviour. In an effort to sensitize analysts and stakeholders to variations in terminology and to facilitate communication on issues arising from international surrogacy arrangements, this paper examines variations in terms used. We introduce some of the issues previously raised by scholars concerned with analysis of discourse related to third-party reproduction. We then survey the terms used in English-language discussions to denote specific actors, including ‘surrogates,’ ‘intended parents,’ gamete providers and children, as well as terms used to describe ‘surrogacy arrangements.’ We conclude with a discussion on navigating and negotiating the use of these various and value-laden terms.

      Keywords

      Introduction

      The terminology used to discuss third-party reproduction has become increasingly contested and diverse as reproductive technologies have proliferated. When Louise Brown, conceived in vitro, was born in the UK in 1978, headlines referred to her as the world's first ‘test-tube baby.’ Soon after there were other ‘firsts.’ For example, in 1983, an Australian menopausal woman became pregnant with the help of a younger woman's eggs (
      • Trounson A.
      • Leeton J.
      • Besanko M.
      • Wood C.
      • Conti A.
      Pregnancy established in an infertile patient after transfer of a donated embryo fertilized in vitro.
      ). And, in 1985, a woman without a uterus had one of her own eggs fertilized in vitro and then transferred into the uterus of another woman who would gestate it for her (
      • Utian W.H.
      • Goldfarb J.M.
      • Kiwi R.
      • Sheean L.A.
      • Auld H.
      • Lisbona H.
      Preliminary experience with in vitro fertilization-surrogate gestational pregnancy.
      ). These achievements, and others that rapidly followed, opened the floodgates for a booming fertility industry that drew far more women into the process than those hoping to become parents. The new developments, unlike artificial insemination, which had been practised for nearly a century, both inspired and required new terminology, at times creating debate about which terms were most appropriate for the processes as well as for the participants. Such semantic differences are not surprising given the rapidity of developments in the area and the controversial nature of the subject matter. Yet, one's choice of terms to describe new biomedical processes, often a challenge in the in case of many new technologies, can impede or ease effective communication and even influence behaviour (
      • Beeson D.
      • Lippman A.
      Egg harvesting for stem cell research. Medical Risks and Ethical Problems (p. 428).
      , ). This is apparent most recently in the challenges faced by the Hague Conference on Private International Law as it seeks to reconcile differences among national policies regarding cross-border surrogacy practices. To facilitate communication on this topic, the Hague Conference included a glossary in one of its recent official documents on the topic (
      • Permanent Bureau
      Preliminary Document No 10, A preliminary report on the issues arising in relation to international surrogacy arrangements.
      ). This glossary was amended in a subsequent report eliminating the term ‘commercial surrogacy,’ and replacing it with ‘for-profit surrogacy’ (
      • Permanent Bureau
      Preliminary Document No 3B, The Desirability and Feasibility of Further Work on the Parentage / Surrogacy Project.
      ). A footnote explains that the change was made following feedback from ‘intending parents’ who found the word ‘commercial’ to be offensive. This change, which some may find curious or problematic, provides a good example of the difficulty in establishing consensus regarding terminology.
      In an effort to sensitize policy makers, users, providers and researchers to variations in terminology and to facilitate effective communication on issues arising from international surrogacy arrangements, we surveyed key terms used by clinicians, scholars, journalists, advocates and participants, as well as those found in official documents addressing this rapidly expanding area of human reproduction. We present our findings in this paper. We first describe the methods we used to compile relevant terms and follow this with a brief background section highlighting some of the points previously raised by scholars concerned with the analysis of discourse related to third-party reproduction. We then consider the terms used to describe the key participants involved in making these arrangements possible – the various ‘who's. Next, we discuss terms used to describe the arrangements themselves – the ‘what.’ Often, these terms also address the ‘how’ so we give this some attention as well.
      Although all the terms that refer to third-party reproduction, including those that purport to be neutral, scientific, or both, are value laden, our analysis is descriptive, rather than prescriptive. We do, however, point out some usages that are clearly inaccurate or misleading. We conclude with a discussion on negotiating the use of these various and value-laden terms.

      Materials and methods

      We began by compiling terms about practices and participants that the three authors had encountered during the three decades in which third-party reproduction has been part of our academic, policy or public interest work. Next, we added terms gleaned from articles recommended to, and written by, participants in the International Forum on International Adoption and Global Surrogacy held in August 2014 in The Hague, which two of us (DB and MD) attended. In preparation for a co-authored presentation at this forum, all three authors searched anthologies, ethnographies, research reports and other sources cited in these documents.
      In addition, we used PubMed, Google and Google Scholar as search tools to locate relevant sources. Together, they yielded tens of thousands of documents, including articles from professional journals in the fields of medicine, nursing, social work, sociology and psychology. Key words such as ‘surrogacy’ and ‘egg donation’ alone also identified tens of thousands of documents, making it clear that a thorough search of related terms within each source was impractical, if not impossible. As a result, we simply scanned titles to identify potential sources, reading relevant abstracts, searching through lists of key words, and in some cases reading whole articles. We continued to mine specific sources where it appeared new terms might be found until each line of inquiry reached a point of ‘saturation,’ that is, failed to yield new terms.
      From the discussion of terminology at the 2014 forum, we obtained a few further terms, and, in preparation for this publication, we continued to search for additional news stories, government websites and legal documents related to third-party reproduction that might be of use as well as websites of patient advocacy groups and agencies promoting surrogacy among diverse clientele including single men and women, gay men, and lesbians. We limited our search to English-language terms, although even a cursory consideration of terminology in other languages might have yielded new insights. As well, we have mostly excluded the sometimes colorful albeit frequently offensive metaphors (such as ‘angels,’ ‘buns in the oven’ (
      • Berkhout S.G.
      Buns in the oven: objectification, surrogacy and women's autonomy.
      ), ‘incubators’ (
      • Rothman B.K.
      Recreating Motherhood: Ideology and Technology in a Patriarchal Society.
      ,
      • Teman E.
      The Surrogate Body and the Pregnant Self.
      ) or ‘biological coolies’ (
      • Dhillon A.
      Indian surrogacy law stalled, leaving women on their own.
      ) found in more popular, or lay contexts.
      Finally, recognizing that potentially relevant new terms are constantly emerging in different social arenas, we consulted by email in June 2015 with a few strategically located scholars and patient advocates with extensive experience working in this field in Australia, Canada, India, Israel, the Netherlands, New Zealand, South Africa, the UK and the USA to obtain their feedback on the terms we had found, asking them also to propose any we might have missed (see acknowledgements for their names). This resulted in still further additions to our lists and the tables that we present here.

      Background

      The terms used by those writing about third-party reproduction, whether in popular media, or in medical, legal, ethical, social science or policy documents, are typically presented as if they were neutral. They may, nonetheless, reflect an attempt either by proponents to legitimize or promote the practice, or by critics to invoke a particular political position or general opposition to the practice. Many who try to be ‘neutral’ simply adopt the language they assume is most commonly used and therefore most likely to be understood. Consequently, an author who explicitly rejects one commonly used term as biased, may then use a term for a related topic that is equally problematic. Word choice inevitably, perhaps necessarily, reflects a particular standpoint on an issue: words are rarely, if ever, neutral.
      • Pande A.
      The power of narratives: negotiating commercial surrogacy in India.
      refers to terms used in writing about third-party reproduction in India, as ‘discursive tools.’ That is, they are selected to downplay certain relationships or issues while emphasizing others. This is consistent with
      • Teman E.
      The Surrogate Body and the Pregnant Self.
      observation that surrogates in Israel strategically select and use metaphors that implicitly uphold the core categories of family, motherhood and nature.
      Terms may arise from values or ideologies that vary significantly from one cultural context or country to another. This is not surprising; legislation and case law about surrogacy arrangements differ dramatically between countries, and even among jurisdictions within one country (as in the USA and Australia).
      • Bailey A.
      Reconceiving surrogacy: toward a reproductive justice account of Indian surrogacy.
      has argued that uncritically applying terms and frameworks that originate in the West in non-Western contexts raises the specter of ‘discursive colonialism.’ Her concern is that unless the imposition of Western moral frameworks, including feminist ones, is seriously questioned we can distort or misunderstand the experiences of non-Western women.
      Professional organizations and commercial enterprises, i.e. those who earn money from and provide services related to third-party reproduction, often exert great global power and influence on language and explicitly promote the use or exclusion of specific terms.
      • DasGupta S.
      • Das Dasgupta S.
      Business as usual? The violence of reproductive trafficking in the Indian context.
      further suggest that the rhetoric surrounding surrogacy is constructed and managed by the intermediaries of the trade. These authors argue, ‘this rhetoric purposefully ignores differentials in global economic and political power and assumes a level playing field.’
      Given that terminology about third-party reproduction is almost unavoidably politically loaded, what language should we (as scholars, policy analysts and women's rights advocates) use? How can we be sensitive to, and respectful of, differing standpoints as we write, speak and attempt to reach points of agreement?
      We do not claim to have definitive solutions to these concerns. Nor do we offer a thorough analysis of all uses of the relevant terms or of the larger discourses and ideologies in which they may be grounded. Rather, our goal is simply to open a discussion on terminology among those with different perspectives, potentially a useful first step in finding common ground among them.

      Who: the woman who gives birth

      We begin by discussing terms applied to the woman who becomes pregnant and gives birth with the intention of relinquishing the child to another. The word most widely used to describe her, ‘surrogate,’ entered the lexicon before there was a specific term (surrogacy) to describe the practice as a whole.
      The earliest use of ‘surrogate’ in scholarly literature involving reproduction seems to come from Harry
      • Harlow H.
      The nature of love.
      in the context of his experiments with monkeys in the 1950s. Harlow removed rhesus macaque infant monkeys from their mothers to study their responses to wire and cloth substitutes that were either lactating or non-lactating. He referred to these substitutes as ‘surrogate mothers’ and ‘mother surrogates.’
      The term ‘surrogate mother’ was used in legal documents relevant to custody disputes in the 1970s to refer to substitutes for the birth mother. When the term appears in the context of third-party reproduction, however, these earlier meanings are reversed and the birth mother herself is referred to as the surrogate. This occurs in a 1980 article in People magazine on the birth of an infant conceived as part of a ‘traditional’ surrogacy agreement (
      • Kane E.
      Surrogate Mother Elizabeth Kane Delivers Her “Gift of Love,” Then kisses Her Baby Good-bye.
      ). The headline reads: ‘Surrogate mother Elizabeth Kane delivers her gift of love – then kisses her baby goodbye.’
      Law Professor John Robertson used the term with its new meaning in the title of a 1983 piece in the Hastings Center Report albeit acknowledging problems with doing so. ‘Indeed, it is the adoptive mother who is the surrogate mother for the child,’ he explained (
      • Robertson J.A.
      Surrogate mothers: not so novel after all.
      ). This comment emphasizes the fact that before the development of third-party reproduction, a woman who gave birth but did not play other maternal roles, as in adoption, was referred to as the ‘birth mother’ or ‘biological mother’, sometimes even with the single but contested word ‘birthmother.’ These terms were applied to distinguish her from the ‘adoptive mother’.
      The term ‘surrogate mother’ to refer to ‘a woman who ‘carries’ the pregnancy for another woman’ is included in the glossary of the first edition of the feminist classic, Test-Tube Women (
      • Arditti R.
      • Klein R.D.
      • Minden S.
      Test-tube Women: What Future for Motherhood.
      ). This term is also included in the second edition 5 years later. The 1989 preface, however, explains, “We put ‘surrogate’ in quotes because we want to point out that it is a misnomer; ‘surrogate mothers’ are mothers in every sense of the word.” They charge that ‘[t]he use of this term is one more example of the male take-over of language to create a false reality’ (
      • Arditti R.
      • Klein R.D.
      • Minden S.
      Test-tube Women: What Future for Motherhood.
      , p. xvii).
      • Nelson H.L.
      • Nelson J.L.
      Cutting motherhood in two: some suspicions concerning surrogacy.
      seem to take a complementary position. They have noted that ‘the term surrogate is inappropriate from the point of view of the child she bears,’ pointing out that ‘the surrogate would be the woman to whom the child is turned over for care – the woman who performs maternal functions on behalf of the birth giver’ (yet another term, but one that seems to be rarely used). Their statement echoes the way Harlow envisaged the surrogate role, as well as law professor and ethicist Alexander Capron's position when he stated, in a 1987 lecture:“The term ‘surrogate mother’ is inaccurate because in ordinary parlance a woman who raises another woman's offspring would be called their surrogate mother (
      • Capron A.
      Alternative birth technologies: legal challenges.
      ).”
      With the expansion of assisted reproduction, the adjectives, as well as the nouns used to describe the birth mother, have multiplied. Interestingly, countries such as Norway and Germany that prohibit most or all surrogacy arrangements seem to define motherhood as the woman who gives birth to the child. Elsewhere, particularly in those jurisdictions that are ‘surrogacy friendly,’ various terms limit the relationship of that woman to the child while also recognizing her maternal contribution. In these situations qualifying terms such as ‘gestational mother’ or ‘surrogate mother’ are frequently used. Contending that these, too, are inappropriate, Françoise
      • Baylis F.
      Transnational commercial contract pregnancy in India.
      proposes that a more appropriate term is ‘gestating woman.’ She writes:‘a pregnant woman is not a mother to her foetus(es), Mothering relationships are between women and born children (with whom the women may or may not have a biological relationship). It follows that a pregnant woman is not a mother unless she has (or has had) children.’
      Therefore, once a child has been born to a ‘gestating woman,’ Baylis recognizes the ‘gestational mother’ as one of the child's ‘biological mothers’. In contrast, a number of commonly used terms erase the maternal dimension of the relationship of the birth mother to the child entirely by referring to her only as a surrogate, surrogate carrier (), gestational carrier (
      • ASRM (American Society of Reproductive Medicine)
      Reproductive Facts.
      ), gestational surrogate (
      • ASRM (American Society of Reproductive Medicine)
      Reproductive Facts.
      ) or gestational host (
      • Lascarides D.E.
      A plea for the enforceability of gestational surrogacy contracts.
      ).
      Contributing to the trend away from defining, or even acknowledging, the woman who gives birth as the mother of the child may be the social process known as ‘geneticization’ (
      • Lippman A.
      Prenatal genetic testing and geneticization: mother matters for all.
      ). This refers to a tendency to understand humans primarily in terms of their DNA and may position genes as definitive in determining legal and popular understandings of parenthood. Therefore, the proliferation of surrogacy arrangements in which the eggs used to create the embryo are not those of the woman who gestates and gives birth can become a rationale to limit her claims to motherhood. This has been an important legal issue in several countries.
      Another alternative to the terms ‘surrogate,’ ‘surrogate mother’ or ‘gestational mother’ is ‘contract pregnant woman.’ This was used in an article in the 2007 Oxford Handbook of Bioethics where, interestingly, ‘surrogate’ and ‘surrogacy’ do not appear at all (
      • McLeod C.
      For dignity or money: feminists on the commodification of women's reproductive labour.
      ). More recently ‘contract pregnancy’ has been used by philosophers, bioethicists and in legal documents. This term highlights the legal and contractual nature of this process and emphasizes the arrangements made (see below). For a more complete list of terms used to refer to the woman who gestates a fetus for another, see Table 1.
      Table 1Terms referring to a woman who gives birth with the intention of relinquishing the baby to another.
      Biological motherGestating woman
      Birth giverHired womb
      Birth mother/birthmotherHost
      BreederNatural mother
      CarrierReproductive laborer
      Carrying motherSurrogate
      Contract pregnant motherSurrogate carrier/host
      Contract pregnant womanSurrogate mother/woman
      Gestational carrierSurrogate worker
      Gestational hostTummy mommy
      Gestational motherWoman working as a surrogate
      Gestational surrogate

      Who: prospective parents

      In popular media, material from the fertility industry and online discussions, the most common term for those seeking children via these arrangements appears (from Google search results conducted in March of 2015) to be ‘intended parents.’ This terminology reflects the legal reasoning behind numerous court decisions in the USA about surrogacy that give priority to the intention and interests of those who set such an arrangement in motion. The glossaries provided by the Hague Conference (
      • Permanent Bureau
      Preliminary Document No 10, A preliminary report on the issues arising in relation to international surrogacy arrangements.
      ,
      • Permanent Bureau
      Preliminary Document No 3B, The Desirability and Feasibility of Further Work on the Parentage / Surrogacy Project.
      ) include the term ‘intending parents’ to refer to ‘the person(s) who request another to carry a child for them.’
      Among the more common alternatives to ‘intended parents’ is ‘commissioning couple.’ This term is used in British legislation. A frequent variation, one sometimes used interchangeably with it, is the term ‘commissioning parents.’ Clearly, the latter is more supportive of the perspective of those seeking to parent the child than is ‘couple’ or ‘person.’ Irish, English and other European critics of commercial surrogacy, as well as some British and American scholars who support regulation of the practice often use the term ‘contracting’ parents or individuals (
      • HFEA (Human Fertilization and Embryology Authority)
      Clinic Staff, Code of Practice, Guidance.
      ).
      When the contracting (intending, commissioning) woman is, herself, the source of the eggs used, she tends to be referred to as the ‘genetic’ or ‘biological’ mother. These biomedical terms are often preferred over the alternatives of ‘social mother’ or ‘adoptive mother’ to strengthen or clarify the woman's legal claim to the child. In the famous California case of Johnson v. Calvert, the trial court, the appeals court and the California Supreme Court all concluded that Christina Calvert, whose fertilized eggs were gestated by Anna Johnson, was the ‘natural mother under California law’ (
      • Krim T.
      Beyond Baby M: international perspectives on gestational surrogacy and the demise of the unitary biological mother.
      ). The source of the eggs in determining the legal mother, however, is usually ignored when someone other than an intending parent provides the eggs. In these cases the term ‘legal mother’ is often used to reference the commissioning woman, illustrating that in this situation, intention trumps genetics.
      Occasionally, the woman who provides eggs for another woman to gestate is referred to as the ‘biological mother’ to distinguish her from the gestating woman. Insofar as this term is meant to suggest that only the genetic contribution is biological, it is an erroneous, but not uncommon, reduction of biology to genetics. It denies, or at least ignores the profoundly biological contribution of the process of gestation. Surprisingly, even the American Society of Reproductive Medicine (
      • ASRM (American Society of Reproductive Medicine)
      Reproductive Facts.
      ) conflates these terms in its definition of ‘gestational carrier’ as the preferred term for the woman who gives birth, stating: ‘The carrier does not provide the egg and is therefore not biologically (genetically) related to the child.’ That medical authorities would reduce biology to genetics and fail to recognize the biological contributions of the woman who is gestating the fetus is rather unfortunate, especially in view of the growing attention to the roles of epigenetics and microbiomes in human development (not to mention the biological process of gestating a developing fetus itself).
      • Deomampo D.
      Defining parents, making citizens: nationality and citizenship in transnational surrogacy.
      describes a case in which agents of the US Department of State defined biological motherhood solely in terms of genetics. Her reference is to a 2009 recommendation by the American Citizen Services in Mumbai to carefully document medical procedures used in a surrogacy arrangement in order to establish the facts of ‘biological ties’ and to how DNA testing could be used as verification of the relationship between mother and child. The use of the term ‘biological mother’ in this context also ignores the substantial biological contribution of the woman gestating the fetus.
      Various other terms may also be used, and these are listed in Table 2.
      Table 2Terms referring to those seeking a child via ‘surrogacy.’
      Adoptive mother/father/parent(s)Intending mother/father/parent(s)
      Biological mother/father (if her eggs/his sperm)Legal mother/father/parent(s)
      Commissioning parent(s)/couple/ person(s)Prospective mother/father/parent(s)
      Contracting parent(s)/couple/person(s)Rent-a-womb couples
      Fertility tourist(s)Reproductive exiles
      Genetic mother/father (if her eggs/his sperm)Social mother/father/parent(s)
      Intended mother/father/parent(s)

      Who: gamete providers

      Among the most widely used and clearly euphemistic terms for gamete providers is ‘donors.’ Although the term ‘donation’ is used in both egg and sperm markets,
      • Almeling R.
      Sex Cells: The Medical Market for Eggs and Sperm.
      observes that, in the USA, egg donation is understood as a gift whereas sperm donation is considered a job. She adds:‘In stoking the connection between egg donor and recipient, staffers make it possible for women to construe their participation in this market as an altruistic act for which they are compensated, which seems to offer a protective effect against other unsavory narratives that could be generated, such as being paid for body parts or even prostitution.’
      Similarly,
      • Pande A.
      Transnational commercial surrogacy in India: gifts for global sisters?.
      observes that altruism and the concept of both eggs and the child as gifts, thus donated rather than purchased, are often invoked by intended mothers and surrogacy programmes ‘to soften the pecuniary image of commercial surrogacy.’
      Despite multiple challenges to use of the terms ‘donation’ and ‘donors’ over the years, there has been little change. As
      • Majumdar A.
      The Rhetoric of the Womb: The Representation of Surrogacy in India's Popular Mass Media in DasGupta and Das Dasgupta.
      has pointed out, surrogates, intended agents and doctors or agents use the gift relationship to their advantage: Such usage is not accidental, she argues, but rather is meant to lend ‘sanctity and legitimacy’ to the commodification of intimate relationships. She explains that this language ‘creates a façade of altruism.’
      • Baylis F.
      Transnational commercial contract pregnancy in India.
      articulates clearly the position of those opposed to the euphemistic term ‘donor.’
      I only use such terms as ‘donor,’ ‘donation,’ and ‘donor offspring’ when gametes have been altruistically gifted. When there is a known commercial transaction, I use the term ‘provider’ and write about ‘selling’ or ‘trading.’
      Other scholars and women's health advocates, similarly seeking to better reflect the reality of what is happening, also use the term egg ‘providers’ (
      • Norsigian J.
      • Darnovsky M.
      Center for Genetics and Society and Our Bodies Ourselves Receive MacArthur Foundation Award.
      ). See Table 3 for a more complete list of terms.
      Table 3Terms referring to gamete providers.
      FemaleMale
      Biological mother/bio-momBiological father/Bio-dad
      Egg/oocyte/ovum donorDonor dad
      Egg/oocyte providerGenetic father
      Egg/oocyte/ovum seller/vendorSperm donor
      Genetic motherSperm provider
      Sperm seller/vendor
      Terminology for those whose spermatozoa is used in third-party reproduction is somewhat less complicated than that applied to women whose eggs are used. This may be a reflection of the less controversial nature of the practice and the fact that usually only one man is involved in third-party reproduction (Table 3). Those who provide sperm are most commonly referred to as ‘sperm donors,’ even though they usually receive payment for doing so. The term ‘sperm provider’ is also used (), but not nearly as frequently.

      What: the arrangement and what we call it

      Before the mid-1980s, the term most frequently used to describe the practice of one woman bearing a child for another was ‘surrogate motherhood.’ A Google Scholar search (February 11, 2015) for the years 1975–1983 located 30 citations using the term ‘surrogacy,’ many of which have nothing to do with human reproduction. The term ‘surrogate motherhood’ yielded 149 citations for the same time period. The single word ‘surrogacy’ begins to replace it in the mid-1980s appearing in the UK document known as the Warnock Report (
      • Warnock M.
      • Anisuddin Q.
      • Baker T.
      • Barnes J.
      • Carriline M.
      • Davies D.
      • Dyson A.
      • Edwards N.
      • Greengross W.
      • Irwin W.
      • Marshall J.
      • Macnaughton M.
      • McLaren A.
      • McNeil D.
      • Rawnsley K.
      • Walker M.
      Report of the Committee of Inquiry into Human Fertilisation and Inquiry. London: Her Majesty's Stationery Office.
      ), where it is defined as ‘the practice whereby one woman carries a child for another with the intention that the child should be handed over after birth.’ It becomes even more widely used in the context of human reproduction after 1986, especially in the extensive media coverage of the ‘Baby M’ case in the USA (). Numerous additional terms to refer to the practice can be found in scholarly and popular documents as indicated in Table 4.
      Table 4Terms referring to the practice.
      Altruistic surrogacyHost surrogacy
      Baby businessIVF surrogacy
      Commercial surrogacyNon-commercial surrogacy
      Commercial surrogate motherhoodNot-for-profit surrogacy
      Compensated surrogacyPaid surrogacy
      Contract motherhoodPartial surrogacy
      Contract pregnancyReproductive exile
      For-profit surrogacyStraight surrogacy
      Fertility tourismSurrogacy
      Full surrogacySurrogate motherhood
      Gestational surrogacyTraditional surrogacy
      The terms ‘straight surrogacy’ and ‘partial surrogacy’ are sometimes used in UK publications to describe pregnancies in which the ‘intended host is inseminated with the semen of the husband of the commissioning couple’ (
      • Brindsen P.R.
      Gestational surrogacy.
      ). In such cases the resulting child is genetically related to the ‘surrogate mother’ or ‘host.’
      Some scholars who approach the issue from a legal, philosophical or bioethical perspective prefer the term ‘contract pregnancy’ to ‘surrogacy.’ The earliest examples we found of this phrasing were in papers by Moller
      • Okin S.
      A critique of pregnancy contracts: comments on articles by Hill, Merrick, Shevory, and Woliver.
      and
      • Shanley M.L.
      A case against pregnancy contracts: embodied selves, liberal theory and the law.
      . Stanford philosophy professor Debra
      • Satz D.
      Markets in women's reproductive labor.
      also prefers ‘contract pregnancy,’ explaining:‘I will use the terms ‘contract pregnancy’ and ‘pregnancy contract’ in place of the misleading term ‘surrogacy’. The so-called surrogate mother is not a surrogate; she is the biological and/or gestational mother.’
      • McLeod C.
      • Botterell A.
      A Hague Convention on contract pregnancy (or “surrogacy”): avoiding ethical inconsistencies with the convention on adoption.
      maintain that contract pregnancy is ‘a more neutral term, morally speaking, than surrogacy.’ Similarly, but from a reproductive justice perspective,
      • Bailey A.
      Reconceiving surrogacy: toward a reproductive justice account of Indian surrogacy.
      and
      • Darling M.
      A welfare principle applied to children born and adopted in surrogacy.
      also prefer the term ‘contract motherhood,’ albeit both also occasionally use the terms ‘surrogacy.’
      It is worth noting that one's use of the term ‘surrogacy’ is not a reliable indication of the author's position on the acceptability of the practice or the arrangements made between the parties involved. For example, one of the most critical discussions of such arrangements can be found in the writing of Swedish feminist Kajsa Ekis
      • Ekman K.E.
      Being and Being Bought: Prostitution, Surrogacy and the Split Self.
      who nevertheless uses the same term (surrogacy) to criticize the process as those who actively promote this arrangement. Similarly, ‘surrogacy’ is also the term used in a recent call by feminists and human rights activists from several countries for an international convention to abolish the practice (
      • CoRP
      Contribution of a grouping of Feminist and Human Rights Organizations to the work of the Hague conference on Private International Law regarding legal issues concerning international surrogacy conventions (“parentage/surrogacy project”).
      ).
      Before the first successful pregnancy using eggs provided by someone other than the impregnated woman in 1984, surrogate pregnancies were established by inseminating a woman with sperm from the intending male parent, with the pregnant woman then expected to relinquish the child at birth. The newer arrangement, involving IVF and provided or donated eggs is a very different medical procedure. It involves the use of synthetic hormones to prepare the ‘surrogate's’ body for implantation of an embryo created from an egg provided by the intending mother or by a third party. Unsurprisingly, its emergence also triggered new terminology.
      The earliest published example we found of a term that clearly distinguishes the newer method from the older is ‘gestational surrogacy’ (
      • Grobstein C.
      • Flower M.
      Current ethical issues in IVF.
      ). This term was quickly adopted in US medical and legal circles, whereas the term ‘traditional’ subsequently emerged in the USA as the medically sanctioned modifier of ‘surrogacy’ when referring to the older method that relied on artificial insemination. British observers sometimes use the terms ‘straight’ or ‘partial’ surrogacy for the traditional method, and ‘full’ or ‘host’ for gestational surrogacy (), whereas some Canadian information sources refer to the earlier method as ‘classical surrogacy’ (
      • VFC (Victoria Fertility Clinic)
      Surrogacy (Third Party Parenting, Gestational Carrier): What is Surrogacy.
      ).
      Although the medical aspects of surrogacy are fundamental to any definition, increasingly salient are its economic, ethical and legal dimensions. To some extent, use of the term ‘contract pregnancy’ necessarily opens these issues. But this term does not make explicit whether the contract involves payment to the gestational carrier. When this is an issue, the terms ‘altruistic surrogacy’, ‘commercial surrogacy’, or both, are often used to distinguish the circumstances.
      Despite the shift in terminology proposed by the Hague Conference's
      • Permanent Bureau
      Preliminary Document No 3B, The Desirability and Feasibility of Further Work on the Parentage / Surrogacy Project.
      , use of the term ‘commercial’ is so widely accepted by both proponents and critics that it is difficult to imagine it being replaced by ‘for-profit surrogacy’ in many arenas. (A further complication in the use of ‘for-profit’ is the ambiguity about to whom the ‘profit’ accrues: is it the woman who will give birth to a baby or the companies, attorneys and brokers making the arrangements between the parties involved?)
      The explanation given in a footnote about changing ‘commercial’ to ‘for-profit’ was:‘[W]hilst such arrangements may involve compensation beyond expenses for a surrogate mother; they are not usually ‘commercial’ in nature (
      • Permanent Bureau
      Preliminary Document No 3B, The Desirability and Feasibility of Further Work on the Parentage / Surrogacy Project.
      , p. i).’
      This does not, however, explain why exchanges that involve compensation beyond expenses should not be defined as commercial, as the first definition of that word simply refers to things related to the buying and selling of goods and services. The answer may depend on some narrow definition of the term commercial that the authors have not provided, or perhaps it has legal or policy implications that they have not explained.
      In her book analysing the ‘fertility industry,’
      • Spar D.
      The Baby Business: How Money, Science and Politics Drive the Commerce of Conception.
      examines the ‘commerce of conception,’ concluding with the statement: ‘It's no use being coy about the baby market or cloaking it in fairy-tale prose.’ Similarly, in explaining her emphasis on commercial aspects of this new form of family building,
      • Rudrappa S.
      Mother India: outsourcing labor to Indian surrogate mothers.
      writes:‘To propose that there is a market in babies is not to suggest that egg and sperm donors, intended parents, surrogate mothers, and the various market mediators who bring the parties together are immoral…my purpose is to explain how such a consumer-driven commodity chain comes to exist, being shaped, while simultaneously shaping individuals’ experiences of infertility, feelings of loss, and potential for recovery.'
      When third-party reproduction is not clearly commercial, i.e., no money beyond some possible reimbursement of the gestating woman's direct expenses is exchanged, it is often referred to as ‘altruistic.’ It may also be described as ‘non-commercial’ or ‘not-for-profit’ surrogacy. The question remains, however: what does this mean in current practice? The distinction regarding surrogacy that is for-profit as opposed to altruistic is not made by every analyst or in every country. For example, German law makes no distinction between commercial and altruistic surrogacy because surrogacy of any kind is prohibited (
      • Gossl S.I.
      Germany.
      ). It is, however, a central distinction in many policy discussions elsewhere. For example, it was the basis of Canadian legislation, which prohibited paying a surrogate mother for her services or paying anyone for arranging for the services of a surrogate mother, but left open what the Canadian federal government refers to as altruistic surrogacy, in which ‘a surrogate mother may be repaid for out-of-pocket costs directly related to her pregnancy’ ().
      Blurring the line between commercial and altruistic surrogacy is considered problematic by many Canadians. By contrast, American sociologist Rene
      • Almeling R.
      Sex Cells: The Medical Market for Eggs and Sperm.
      maintains that making a dichotomy between a gift and a commodity oversimplifies the realities of economic life. She argues that the same thing sometimes can be both a gift and a commodity, and she challenges the assumption that ‘commodification is inherently and uniformly degrading.’ In a similar vein, some Australians, including the Chief Justice of the Family Court of Australia, are calling for changing current laws that prohibit paying a woman to carry a child for someone else (
      • Brennan B.
      Commercial surrogacy should be legalized, Family Court Chief Justice Diana Bryant says.
      ). They would prefer to apply the term ‘compensated surrogacy’ to ‘commercial surrogacy,’ arguing that payment alone cannot be used to differentiate ‘good’ surrogacy arrangements from ‘bad’ ones (
      • Everingham S.
      • Bell-King S.
      • Hammarberg K.
      Australian's use of surrogacy.
      ,
      • Millbank J.
      Rethinking “commercial surrogacy” in Australia.
      ).
      The cross-border dimension of third-party reproduction is identified using a number of terms (Table 5). These include ‘international surrogacy,’ ‘reproductive tourism,’ ‘international medically assisted reproduction’ and ‘cross-border reproductive care’ (a term preferred by many in the industry). The ‘outsourcing of reproduction’ and ‘reproductive trafficking’ necessarily imply economic motives, the latter also suggesting that the practice is illegal, immoral and a violation of human rights. In addition, numerous other terms make explicit reference to the commercial dimension of these global arrangements. These include ‘the global baby business,’ the ‘global fertility industry’ and ‘transnational commercial surrogacy.’
      Table 5Terms referring to the cross-border dimension.
      Cross-border reproductive carePregnancy outsourcing
      Cross-border surrogacyProcreative tourism
      Fertility tourismReproductive biocrossing
      Global surrogacyReproductive tourism
      Intercountry surrogacyReproductive trafficking
      International surrogacy arrangement (ISA)Transnational surrogacy
      In her analysis of the global nature of this phenomenon and its effect on Indian women and families, and seeking language that captures its complexity,
      • Gupta J.A.
      Reproductive biocrossings: Indian egg donors and surrogates in the globalized fertility market.
      draws on the work of Bharadwaj and uses the term ‘reproductive biocrossings.’ She defines this phrase as ‘a crossing between biology, biology and machine, and across geo-political, commercial, ethical and moral borders.’ The complexity of these interconnections in what Gupta refers to as ‘globalized reproduction’ makes negotiating this terrain so challenging for policy makers and women's and children's advocates and scholars. It also leads to the coinage of new terminology.
      As reproductive ‘arrangements’ have become increasingly global in nature, so too has been the growth of clinics and companies offering services. A recent Google search for ‘international surrogacy services’ yielded 75,900 results. Many of these represent news items, but there are also multiple advertisements by clinics, agencies, brokers and attorneys. The proliferation of such ads is clear evidence of the continuing efforts by industry actors to develop new terms to describe their services and to attract new clients. Unfortunately, these ads often rely on euphemistic language and the kind of imagery that mask the nature of the arrangements being offered. Planet Hospital, for example, which was until recently considered one of the most successful of such international businesses, used to market what it called the ‘India Bundle’: having two embryos transferred into two surrogates at the same time, with the option to have any ‘extra’ pregnancy aborted, or twins reduced to a singleton, depending on how many babies the clients wanted or decided they could afford (). The ‘India Bundle’ was discontinued at the advice of Planet Hospital lawyers and company founder Rudy Rupak has now acknowledged in a front-page New York Times article, ‘There is a lot of treachery and deception in IVF/fertility/surrogacy because there is gobs of money to be made’ (
      • Lewin T.
      A Surrogacy Agency that Delivered Heartache.
      ). And as
      • Spar D.
      The Baby Business: How Money, Science and Politics Drive the Commerce of Conception.
      also makes clear, unlike most commercial markets, there is no ceiling in the reproductive market. Under these conditions both technical and professional-sounding terms can easily mislead.

      The children

      Although the women who give birth are sometimes rendered invisible in discourses about surrogacy, the lack of attention to the children produced in this way is even more striking. There are many ways to explain this, one of which may be that children play a more passive role in the process than do other participants. An important exception to the general silence about the children is the emphasis on ‘the best interests of the child’ in the recent International Forum on Intercountry Adoption and Global Surrogacy and in the ongoing work of the Hague Conference on Private International Law (
      • Cheney K.
      Executive summary of the International Forum on Intercountry Adoption and Global Surrogacy.
      ).
      Clearly, the terminology used to refer to children of third-party reproduction has evolved. For example, a 1986 Associated Press story published in the Los Angeles Times reads, ‘Surrogate Mother Gives Birth to Test-Tube Baby’ (
      • AP (Associated Press)
      Surrogate Mother Gives Birth to Test-tube Baby.
      ). Today, such language is rarely encountered. Instead we find, for example, the term ‘surrogate-born children’ in the headline of a 2013 article in the Daily Mail reporting findings of research on the topic. Belgian authors sometimes use the term ‘gestational child’ (
      • Innes E.
      Surrogate-born children more likely to suffer depression than those carried by their real mother.
      ). UK psychologist
      • van den Akker O.
      The importance of a genetic link in mothers commissioning a surrogate baby in the UK.
      used the term ‘surrogate baby,’ and writing with social work colleagues later referred to ‘children born through surrogacy’ (
      • Crawshaw M.
      • Blyth E.
      • Akker O.
      The changing profile of surrogacy in the UK – Implications for national and international policy and practice.
      ). British scholars have also used the term ‘surrogate children’ distinguishing them from children born to women who later serve as surrogates. They refer to the latter as ‘surrogates’ children' (
      • Crawshaw M.
      • Purewal S.
      • van den Akker O.
      Working at the margins: the views and experiences of court social workers on parental orders work in surrogacy arrangements.
      ,
      • Jadva V.
      • Imrie S.
      Children of surrogate mothers: psychological well-being, family relationships and experiences of surrogacy.
      ).
      Children born as a result of assisted reproductive procedures that use gametes other than those of their social parents are often referred to, and many refer to themselves, as ‘donor conceived.’ But as Wendy Kramer, co-founder with her son of the Donor Sibling Registry, and her co-author Naomi Cahn explain:‘We don’t yet have standard language for the person conceived via donor sperm or eggs (the offspring, donor baby, donor child, or donor-conceived person). It can be challenging for us to even describe our own families, not because language is imprecise, but because of the varied emotions associated with the terms… We know that there are no terms that will make everyone happy’ (
      • Kramer W.
      • Cahn N.
      Finding Our Families: A First-of-Its-Kind Book for Donor-Conceived People and their Families.
      ).
      It is not clear whether the term ‘donor-conceived’ will or should be used for children born as a result of ‘surrogacy arrangements.’ This depends in part on how effectively the framework of the gift relationship is adopted in discourses regarding for-profit surrogacy, and whether terminology develops to distinguish between children born as a result of third-party gametes and those gestated and given birth to by a third party.

      Discussion

      Our informal survey of terms most often used in discussions of third-party reproduction has revealed that virtually all terminology on this topic is value laden and highly contested. We have found that those who object strongly to the use of certain terms may nevertheless overlook the contested nature of other similarly biased terms. We have also noted how terminology may vary by scholarly discipline, ideological perspective, geography and culture. These complex realities may create significant snags in identifying common ground for discussions of third-party reproduction. Are there ways to guide our choices of terminology and sustain dialogue between those with possibly different positions? We would like to offer a few closing thoughts on the subject with the hope of stimulating further discussion of these issues.
      First, we suggest that some terms should be eliminated from use on the grounds of inaccuracy. The best example of this is the term ‘biological mother’ to distinguish the intended mother (in those instances when her own eggs are being used) from the gestational mother. The former may correctly be referred to as the ‘genetic mother,’ but she is but one of two biological mothers. Another inaccurate term to reject —this one very widely used – is ‘donor’ when the gamete provider is being paid beyond reimbursement for direct expenses connected to the retrieval process. This usage has been repeatedly challenged (
      • Baum K.
      Golden eggs: towards the rational regulation of oocyte donation.
      ,
      • Baylis F.
      • McLeod C.
      The stem cell debate continues: the buying and selling of eggs for research.
      ,
      • Dickenson D.
      All that Matters.
      ,
      • Murray T.
      New reproductive technologies and the family.
      ,
      • Murray T.
      The Worth of a Child.
      ), but to little effect.
      There are not likely many other terms that can so easily be rejected; more typically, where a variety of expressions exists, none will be clearly inaccurate. This means that a choice of terms is usually less an issue of fact than of standpoint, notwithstanding how the same term may be claimed by those with opposing positions. Nevertheless, there may still be ways to agree about ‘how’ we speak and write, even if the words we use vary.
      One tactic (that may work better in writing than in speaking) is to use quotation marks or the qualifier ‘so-called’ to indicate that the term being used does not necessarily reflect the author's preferred language and to signal awareness of its contested nature. For example, the International Federation of Social Workers uses the term egg ‘donors,’ but with donors in quotes (
      • International Federation of Social Workers
      Cross-border reproductive services.
      ). Another tactic is to use more than one term. For example, some authors alternate the use of ‘surrogacy’ and ‘contract pregnancy’ in their oral or written presentations. This approach of using more than one term may implicitly acknowledge some of the problems attached to the exclusive use of either term. In addition, it avoids the problem of having to overuse one term, which can make reading or listening to a talk tedious.
      Another helpful tactic may be to explain one's choice of terms, particularly when using language not universally shared; this is what some of those preferring the term ‘contract pregnancy’ have taken pains to do. Interestingly, some terms that scholars contend reflect bias are often perceived as neutral in many contexts, and thus are used by supporters and opponents alike. Probably the best example of this is the term, ‘surrogacy’ itself, which is accepted as the appropriate term by some (but not all) of the sharpest critics of the practice. Thus some explanation of one's choices can clarify matters and thereby facilitate rich substantive discussions.
      In conclusion, we repeat our claim that most relevant terminology related to third-party reproduction is necessarily value laden and in consequence, contested. This has been true in intense debates over terminology related to the topic of abortion, and is apparent, too, in the multiple and often highly contested terms used to describe controversial new techniques that combine genetic modification and assisted reproduction. For example, press reports about proposed techniques to prevent transmission of a subset of mitochondrial diseases have used the term ‘three-parent embryos’ (; ), whereas others opt for the similar phrase ‘three-person embryos’ (
      • Callaway E.
      World hails UK vote on three-person embryos.
      ,
      • Darnovsky M.
      • Cussins J.
      Britain is on the brink of a perilous vote for “three-person in vitro fertilization.
      ), which avoids assumptions about social relationships. The UK uses the term ‘mitochondrial donation’ even though it has been challenged as being ‘scientifically inaccurate’ and as intentionally ‘easing the way to public acceptance of these manipulations’ (
      • Newman S.
      Deceptive Labeling of a Radical Embryo Construction Technique.
      ). We can expect similar controversies in the debate about using new ‘gene editing’ tools on human embryos. Because word choices may differ according to discipline, country/culture, context, and standpoint, terminology will no doubt continue to vary and to evolve with social, political and technological change.
      Although differences in terms warrant attention, we must also be aware that terminology choices are not always a reliable reflection of the policy position of the user. Each of us may be sensitive to the oppressive implications of using some key terms and yet remain unaware of equally problematic issues regarding others. Keeping this in mind may at least restrain us from judging others' usage too harshly. Sensitivity to terminology is probably essential for facilitating effective communication. But even more important than the specific words we use are continued discussions and dialogues among us from which we can all learn.

      Acknowledgements

      The authors would like to thank the following scholars and patient advocates for review of our tables and for suggesting additions: Diane Allan, Sonia Allan, Kate Bourne, Ayesha Chatterjee, Daisy Deomampo, Donna Dickenson, Jyotsna Gupta, Amrita Pande, Elly Teman, and Sally Whelan. We would also like to thank the anonymous reviewers for their many helpful suggestions.

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      Biography

      Diane Beeson is Professor Emerita and former Chair, Department of Sociology and Social Services, California State University, East Bay. She is Associate Director of the Alliance for Humane Biotechnology and a Fellow at the Center for Genetics and Society. She received her PhD from the University of California, San Francisco, in 1980. A former Pew post-doctoral Fellow, she also served as a Visiting Fellow at Stanford University's Center for Biomedical Ethics Program in Genomics, Ethics and Society. She has authored numerous articles in professional journals and anthologies on prenatal diagnosis, genetic testing, and social challenges of new reproductive technologies.

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