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'Who's the real Dad?' Two-Father Families and Surrogacy

Any parent can experience mental health difficulties in the perinatal period (from conception to one year following birth), regardless of gender or biological connection to the child. This is common in men with around 1 in 10 fathers experiencing depression and anxiety in the perinatal period. Awareness is growing in relation to the effects that traumatic birth experiences have on fathers, too. But which fathers does this evidence refer to?

I am a Reader at the University of Huddersfield and recently co-authored a good practice guide on involving and supporting fathers and other family members in perinatal mental health services. My research in perinatal mental health began with exploring maternal mental health assessment within maternity (where standardised questions are routinely used at the initial antenatal appointment). Venturing into paternal (fathers’) mental health research, it was easy to interpret the differences between mothers’ and fathers’ mental health experiences and perspectives on help-seeking as being primarily related to gender. But, from my own experiences as a non-birthing parent in a two-mum family, I wasn’t convinced.

Who is included by terms like ‘maternal mental health’ and ‘paternal mental health’? Who is left out? And how may these terms limit our learning?

Most of what we know about fathers’ perinatal mental health comes from research with cisgender men (men whose personal identity and gender is the same as their sex assigned at birth) who are in a heterosexual relationship with the baby’s mother, with whom they live. Often, fathers are considered secondary to mothers — perhaps part of a secondary research objective — and typically recruited to research studies via the mother as a gatekeeper.

What about other groups of fathers? Fathers who aren’t the partner of the mother or birthing person. Fathers who aren’t biologically connected to the child but have a parental role. Fathers who themselves have been pregnant and given birth, and fathers whose male partner has. Fathers who are in a co-parenting relationship with the child’s parent(s) without being in an intimate relationship. And the focus here: fathers who have become parents through surrogacy.

Two-father families through surrogacy are a growing group but accurate numbers are difficult to establish. In part, this is because there are many ways that these families are formed, meaning that different datasets may each capture only part of the picture. It is also because sexual and gender minority parents aren’t adequately visible in data or in services.

Research involving gay fathers through surrogacy has focused on children’s development and parenting quality, the main message being: the children are fine. There is research too on surrogates’ experiences and the politics of surrogacy, particularly concerning cross-border commercial surrogacy (i.e., international arrangements where the surrogate accepts payment in addition to being reimbursed for expenses that occur throughout the surrogacy process). From a perinatal mental health perspective though, what is known about these fathers?

Photo by Kelly Sikkema on Unsplash

Approaching this piece, I am mindful that all of my research has involved expectant or new parents where one (or more) of the parents has themselves been pregnant; none has concerned surrogacy. However, in turning to the literature and meeting with Michael (whose personal experience blog on this topic was published yesterday), what strikes me — alongside aspects that are heightened or distinct — are the commonalities.

Pre-conception, Michael’s experiences of heteronormativity (where binary gender identity and heterosexuality are assumed to be the default position) within assisted conception systems resonate with existing literature. Michael’s comments about the imagery of “posters of happy cis-gendered heterosexuals” show that feeling excluded is accompanied by not feeling able to challenge the lack of inclusivity— because of feeling as if they should be “privileged” to be allowed into this space.

The “who’s the real dad?” message is repeatedly conveyed by forms, systems and interactions with professionals, being physically excluded from appointments, being instructed by a sonographer: “just the ‘real Dad’ please”. Together, these deepen feelings of exclusion and ultimately, feeling “less important” or less valid as a parent.

Notable in Michael’s experiences is the contrast between pregnancies. Research on psychological aspects of pregnancy and parenthood often concern the ‘transition’ to parenthood for a first-time parent, but we see here the need to also consider subsequent parent experiences.

Michael locates this difference with changed dynamics: him having a genetic connection with the couple’s first child and not their second. Lack of legal and social recognition as a parent are repeatedly identified as contributing factors for perinatal mental health difficulties amongst LGBT+ (lesbian, gay, bisexual, and transgender/transsexual) parents but research has not explored how this may vary with different children.

Moreover, we see that with Michael and his partner, Wes, each experiencing both types of connection, there is potential for shared understanding. This may contrast with some of the experiences of fathers in cisgender heterosexual relationships who have reported not knowing what was going on for their partner or how to help.

Instead, we see Wes helping prepare his partner for the potential that this second experience with the birth of a child may be different, sharing his own experiences with Michael for the first time. In doing so, Michael appears better able to voice some of his struggles, and for these struggles to be normalised — without being minimised. This helped to put in place practical steps around the birth, to be actively included, for example through skin-to-skin time with their son. Likely, the conversations also helped to overcome possible barriers to seeking help with his postnatal depression. Here, we see the need to not limit our learning to vulnerability factors but to instead also consider how protective factors may vary.

Barriers to help-seeking exist for all parents, commonly linked to stigma, including fear of being seen as a “bad” parent. Some have been framed as gendered, arguing that men face different, possibly greater, barriers concerning mental health support. Notable in Michael’s account is an aspect distinct to sexual and gender minority groups in this context: fear of “let(ting) the LGBTQ+ parenting side down” — of playing into negative stereotypes of LGBT+ parents being inadequate. This extends previous research where lesbian parents felt their parenting was judged more harshly compared with their heterosexual peers.

Photo by Kelly Sikkema on Unsplash

We know little about the psychological health of gay fathers through surrogacy. Let’s suppose that — in numerical terms — there are no differences in gay fathers through surrogacy compared with other possible comparison groups (e.g., cisgender fathers in heterosexual relationships, or non-birthing co-mothers). Indeed, studies suggest groups may be similar. It follows that some will experience perinatal mental health difficulties and would benefit from formal support. What support is offered to fathers in these circumstances? And how are they identified?

Perinatal services offer routes into mental health support for expectant and new parents. Some are focused around the child (e.g., health visiting and infant mental health services) but most are focused around the birthing parent (e.g. maternity services and specialist perinatal mental health services). Research with cisgender heterosexual fathers finds fathers feeling overlooked by healthcare professionals and services, with limited support available to them.

Although there has been a policy shift to introduce evidence-based mental health assessment and signposting for fathers, it is in the context of being a partner of a mother who has perinatal mental health difficulties. Here, there is no birthing parent, meaning that gay fathers by surrogacy fall into greater gaps with existing perinatal services.

It is not surprising that in Michael’s experience we see missed opportunities for support — healthcare professionals who were not expected to routinely assess his or his husband’s mental health, and perhaps did not pursue certain lines of conversation for fear of “saying the wrong thing”.

Thankfully, Michael contacted his GP and his GP took his concerns seriously, validating that he had postnatal depression and helping him to get appropriate support. It is vital that we have greater awareness that any parent may need help with their mental health at this time of enormous change and that we have services in place to provide help when it is sought.


Editor's Note:

If you have enjoyed this blog, do not miss the full 10-part series that will explore aspects of modern-day fatherhood, men’s mental health, and the science behind it — running through to the 19th of November — which is also International Men’s Day UK.

As part of this series, please find our already published blogs including:

  • Our blog written by our Editor in Chief, Professor Carmine Pariante, where he interviews Elliott Rae, the founder of Music.Football.Fatherhood (MFF) and publisher of the book DAD.

  • A blog written by Arran Williams where he discusses the emotional impact his partner’s two traumatic birth experiences had on him.

  • A blog written by Clinical Psychologist, Jane Iles, in response to Arran’s blog, where Jane explores the impact traumatic births can have on fathers’ mental health from a clinical point of view.

  • A blog written by Joseph Straker, where he discusses his own personal experiences of postnatal depression.

  • A blog written by Vaheshta Sethna, a lecturer in Psychiatry and Mental Health (Education) at King’s College London, where she discusses her research in relation to the topics discussed by Joseph Straker in his blog.

  • A blog written by Jamie Cowen, where he discusses his experience of learning to live with trauma after the loss of his son during his wife’s pregnancy.

  • Dr Kristi Sawyer’s blog which looks at the impact of perinatal loss on Fathers’ mental health.

  • The blog written by Michael, discussed throughout this piece, where he discusses his own personal experience of surrogacy and his ‘Struggles with ‘Imposter Dad’ Syndrome’.

Every Wednesday we will publish a lived-experience piece from one of the fathers who have contributed to the recently published book DAD or the Music. Football. Fatherhood. (MFF) online platform, an online community of Fathers. This will be followed on the Thursday by a scientific piece from one of our contributing scientists exploring the associated mental health aspects.

We hope you enjoy this ITM special series as we shine a spotlight on men’s mental health and fatherhood.


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