Infant Mental Health Journal. Vol. 13, No. 4, Winter 1992

Strange Bedfellows? Reproductive Technology and Child Development

KYLE D. PRUETT Yale University Child Study Center

New Haven, Connecticut

ABSTRACT: As new reproductive technologies become more available, parents and professionals alike must struggle increasingly with the issue of the child’s knowledge and perception of his or her biologic origins. In this article. scvaal prevailing approaches dealing with disclosure or nondisclosure of this essential fact about the child’s existence are presented and examined. Whereas thae are no currently available reliable empirical data on the impact of either approach, an interim rationale is proposed, based on accepted child development and psychological maturation principles. which favors well-timed and developmentally appropriate disclosure.

&SUM& De nouvellu; technologies de reproduction devenant de plus en plus disponibles. les parents et les professiomels doivent faire face au probltme de la connaissance et de la perception qu’a I’enfant de ses origines biologiques. Dans cet article, plusieurs approches actuellement rtpandues concernant la rtvtlation ou la non rtvtlation de ce fait essentiel sur I’existence de I’enfant sont prbentks et examinks. Alors qu’il n’existe pour I’instant aucunes donntts empiriques solides sur I’impact de ces approches, un raisonnement provisoire est proposd, bask sur les principes gtntralement accept& de dtveloppement de l’enfant et de maturitt psychologique. Ce raisonnement favorise une rtvtlation faite au bon moment et appropritc au dtveloppement.

RESUh4EN A medida que nuem tecnologias reproductivas e s t h maS disponibles. tanto 10s padres como 10s profesionales deben luchar con ahinco con el punto del conocimiento y la percepci6n que el Nfio tiene de su origen biol6gico. En este adculo. se presentan y examinan varios a c e r d e n t o s predominantes que tratan del descubrimiento o la no revelaci6n de este hecho esencial acerca de la existencia del nifio. Considerando que no hay disponible en este momento ninguna infomaci6n empirica confiable acerca del impact0 de un a c e r d e n t o u otro, se propone un intcrin racional. basado en 10s principios aceptados del desarrollo y la maduraci6n sicol6gica del niito. 10s cuales favormn un dcxrubrimiento apropiado tanto en el tiempo como en el desarrollo.

This paper was onginaUy presented at the World Association for Infant Psychiatry and Allied Disciplines Sccond Pacific Rim Conference. Melbourne, Australia. 27 Apd, 1991. The author would like to acknowledge Donald Cohen. Jay Katz. Robert Abramovitz. Linda Mayes, and David Lonic for their kind assistance with various aspects of this paper.

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K. D. Pruett 3 I3

There is little doubt of the prodigious impact the extraordinary new reproductive technologies have on family life. But do these new beginnings in and of themselves affect the way children and their parents think and feel about, or conceive of, their beginnings over time? All souls seem bent on knowing their inceptions, for whatever reasons. Though conceived in the common way himself, Sophocles wrote he was com- pelled to “pursue the trail of knowing to the end ti1 I have unraveled the mystery of my birth.”

The assisted reproductive methods that have allowed childless couples to become parents are near miraculous in their technical applications. Yet they contain in their very solutions confusions that obscure the horizon of each person’s “knowing the mystery” of his or her origins. What are the implications for the family faced with the child who asks, “Where did I come from?” Should parents disclose or not?

Although there is nothing new about the power of the mystery of one’s origins, it is important that those of us informed by developmental and metapsychological expertise participate in the debate about disclosure. The arguments are shaped by stones and myths about our ongins, so precious, vital, and private to us all. But the common practice of keeping the gamete donor’s identity a secret (Kremer, Frijling, 8c Nass, 1984) can leave an important gap in the personal narrative of each child born of an anonymous donor. They are literally the “unknown” conceptus of an unknown donor - an “inconceivable conception.” The facile reasoning of the new technology must be questioned on behalf of the children whose questions are coming, and who deserve our best answers, as do their often befuddled, ill-advised families.

Infertility is under increasing scrutiny, as fertility rates seem to be on the decline in a variety of cultures (Tyler, 1983). It is common in the United States for a couple who remain unsuccessful after 6 months of unprotected intercourse to consider in- tervention (Curie-Cohen, Luttrell, & Shapiro, 1979). Increasing the fertilization efficacy of intercourse through the use of temperature charts, “predictor kits,” or the avoidance of scrota1 heat, known to inhibit sperm production (e.g., the avoidance of hot baths, saunas), are common beginnings. The least intrusive laboratory study is a sperm assay, which is better done sooner than later. Infections in both the female (e.g., pelvic inflammatory disease) and the male (prostatitis), both of which are usually treatable, must be ruled out. Laparoscopy for fallopian tube obstruction or adhe- sions and varicocelectomy for testicular varicose veins are next. Investigation for en- dometriosis may follow.

If none of the above is successful, couples then may turn to more “high-tech” (and expensive) solutions administered by infertility specialists. Artificial insemination (although there is nothing artificial about the tissue involved, only the behavior) may follow (e.g., insertion into the uterus of sperm from the husband or from a donor when ovulation is occurring). GIFT (gamete intra-fallopian transfer) involves an egg harvested from the ovary and placed in the fallopian tube, with fertilization taking place inside the body using either the husband’s or donor sperm. The third option is in vitro fertilization (IVF), in which an ovum (either the donor’s or the woman’s own)-which has been fertilized by either the husband’s or donor sperm in a petri

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dish-is inserted into the uterus. Finally, surrogacy in a variety of modes is increasingly used. A donor egg may be “artificially” inseminated in a petri dish with sperm from the husband and then transferred to the uterus during an appropriately synchronized menstrual cycle. Another form of surrogacy uses the harvested egg, fertilized with the husband’s sperm in vitro, and then implanted into the womb of a surrogate, who will then carry the fetus, giving birth to a child who is genetically both the gamete mother’s and her husband’s. There is a plethora of technologies, and the list of acronyms is ever expanding (Singer & Wells, 1986).

Those of us more accustomed to thinking of the inner lives of children than of the manipulation of organs, gametes, and tissues, find ourselves wondering about the infarits and families who participate in this often exhausting as well as exhilarating, hopeful as well as anxious, clinical adventure. Not only do we feel concern for the individuals involved, but there is much of theoretical value in observing how these families and their helping professionals solve the dilemmas that potentially plague the essential nurturing relationships that evolve over time, given such beginnings.

Object relations (Bowlby, 1969) and attachment theory (Ainsworth, Blehar, & Waters, 1978) have repeatedly instructed us in the paramount desire to be connected to those humans who keep us alive through their nurturing attendance to us. Although children are shaped much more profoundly by the nurturing domain than by the con- ceptual circumstances of their existence, beginnings are enormously important, psychologically and physiologically.

And therein lies the source of concern-the essential reciprocity of the early rela- tionship between infant and caregiver is sustained by the knowledge of mutual belong- ing and commitment to each other’s well-being. The introduction of an unknown identity, or parental (biological) contribution, can have a perturbing effect in this early ballet between mind and heart. It is to maximize this reciprocity throughout the formative early years, in particular, that it is logical for mystery and confusion to be kept to a minimum. Consequently, when the argument about known donor- ship is informed by child development principles, the case for known donor insemina- tion is strengthened significantly. .

The question of “Whose child is this really?” obviously begins in the parent’s mind lirst. As with any important concern about intactness, it finds its way soon enough into the mind of the child through stones and behavior in the family about the origins of this particular child’s existence. A pamphlet for IVF families called Donor Insemina- tion: Do We Tell Our Child? published by the New South Wales (Australia) Infertility Social Workers Group describes the dilemma thus:

Beginnings are important. A couple’s decision to have a child with the help of donor insemination is a significant and often difficult decision. However, it is also a decision full of hope, love and excitement about the future. . . .

Any child born after a battle with infertility is so precious that parents obviously want to do their best for him or her. Concern about whether or not to “tell” is often about how the truth will affect the child and relationships within the family. , . . “Do I have the right to keep this information from my child?” (p. 3)

Two separate processes affect the way reproductive technologies impact on the child’s nurturing experience. The first is how the circumstances of the child’s origins affect the development of a sense of self over time. The second is the way the cir- cumstances of that birth affect the sense of belonging between parent and child.

K. D. Pruett 315

Emde (1983) reminds us that the development of a sense of self is a process that refers to a “vital set of synthetic functions which increase in complexity and depth as development proceeds across and throughout the life span“ (p. 169). Thus, it is not a fixed, static process of skill acquisition but, instead, one that evolves throughout the course of the child’s existence, continually refining and elaborating in complexity. Consequently, it is just as confusing to the concept of the self to be called a “premium” or “miracle” baby as it is to have important chunks of one’s narrative life history unavailable to promote and sustain that sense of self. The consistency of the story of one’s life is strongly supportive of a sense of continuity of affect and defensive adaptation.

How do the circumstances of the child’s origin affect the relational connection between mother, father, and child? Mothers are not the only parents who are pro- foundly affected by the relational capacities of infants. Be they traditionally conceived, adopted, or reproductively assisted, babies and their nurturing caregivers are predisposed to being connected. It is helpful here to look at the differences between primary nurturing instincts in men and women. Research into the development of children who are raised by highly involved fathers has shown that men have nurtur- ing instincts that often begin early in their lives and are reiterated, though not always consistently, throughout their life course (Pruett, 1983, 1989; Pruett & Litzenberger, 1992; Russell, 1987).

Because donor insemination is most frequently done due to male infertility (Sorosky, 1991), it is important to consider the impact of that infertility on the man’s paternal and nurturing instincts, as well as his sense of self. One of the deeply personal ques- tions for the man is whether or not he has the potency to be a father psychologically and a functioning adult male in the world, even though he is infertile. The failure to grieve adequately his biological generativity may interfere significantly with his ability to interact appropriately with a child who so desperately seeks his love, com- mitment, and sense of belonging. How does this relate to the disclosure issue? Rosenkuist (1 991) has pointed out a direct association between the lack of resolution of such grief and the intensity of the desire for donor anonymity. But let us not be confused about who the “real father” is for these children. He is the one in the child‘s heart and soul and not the one in the petri dish or testis.

In one of the few studies of the familial impact of assisted reproduction, Baran and Pannor (1989), in their study of 171 American subjects, found that a premature decision regarding donor insemination without adequate resolution of paternal grief had a profound negative effect on family dynamics.

When that grief is more completely resolved, the father is much more likely to be free to make a vigorous emotional commitment to the well-being of (what he’ll more likely feel is) his child. Both Manuel (1980) and Czyba and Chevret (1979) have followed French children and have concluded that there was a significant emotional investment in the children by both parents, obsewing even an overinvolvement in certain fathers of DI children.

By now, I hope we can appreciate why it matters for children to have a sense of the continuity of their origins and their nurturing domain. Four decades ago, Wellisch (1952) introduced the concept of “genealogical bewilderment” to explain a finding in his adoption studies. He felt this “bewilderment” led to a sense of incompleteness

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and lack of well-being in some of his subjects (i.e., the lack of knowledge of at least one of the child’s biological parents). He described a consequent state of confusion that undermined the child’s sense of well-being and security, rendering a less stable concept of self and status in the human community.

The child‘s psychological or familial identity cannot be separated from genetic identity in any useful way because of the paradigm of the self as a process. The mystery of origins inherent in the anonymous reproductive technology (i.e., the not knowing) has the potential to evolve into an important missing piece in the child’s sense of self over time. As explained by Rayner (1987), “It is through the anonymity of the donor that the child is robbed of the right and ability to accept himself as a child of these particular parents, and thus fulfill the obligation of its own existence” (p. 285).

Obviously, were appropriate disclosure universally accepted dogma, this paper and discussion would be superfluous. There are many competing, complex concerns in this arena on ethical, moral, and religious grounds. It should be clear that the need of the children for a consistent narrative of the origins of their life is not yet widely accepted as the single guiding principle in these matters by any means. For example, Israeli Rabbinic courts are still struggling with whether artificial insemination is to be considered as adultery and therefore serve as grounds of divorce. To date, these same courts state that the husband is not considered the child’s legal father (Green, 1991).

Another legitimate concern is that of psychiatrists and psychoanalysts regarding the impact of identifying donor information on the inner life of the parent, and subse- quently on that of the child. These data might be akin to a kind of psychological eugenics which concern themselves with the impact of fantasy stimulated by know- ing certain facts and the nor knowing of others. Especially powerful are facts about the biological parent that affect the psychological narrative in the parent’s mind about fhk particular child (J. Katz, personal communication, May 11, 1992). Our experience with adoption may be useful in this context.

But, until the essential prospective, longitudinal studies are done on these children and their families, it is my best clinical judgment that we should err on the side of disclosure over secrecy, as it is less damaging to the child’s inner emotional world than the gap in the narrative of the self. Knowing the circumstances of one’s origins is less psychologically malignant than not knowing, assuming the content of the knowledge is not especially nefarious or emotionally charged for a particular family or parent. By knowing the facts of one’s conception, these children have a better chance of feeling and understanding that they were conceived in love (if not in situ), a knowledge reassuring to all young beings pondering the mystery of their origins and its human connection. As Noble (1987) has articulated, all involved in the anonymity collusion are nega-

tively affected:

the donor who never knows his offspring, the doctor who perjures the birth certificate, the geneticist who had no data on DI to research. the psychologist who counsels the genealogical bewilderment. the psychiatrist who treats the mother’s [or father’s] fantasia of the unknown donor, the future spouse of the D1 child who might commit incest, and, ultimately, society in general which helps to shroud this sorry state of affairs. (p. 155)

K. D. Pruett 317

Because we are dealing with complex and deep human fears and feelings regarding intimacy, reproductive adequacy, concern for the donor sperm and egg supply, the profit motive, and the fear of our children replacing us, the decision to tell a child about the circumstances of his or her origin must be informed primarily by the psychological readiness of the child with regard to the timing and content of that disclosure, and not the professional‘s curiosity as to how the child will respond. Ob- viously, it requires knowing children well to know when they are “ready,” as well as when they are not ready. After all, this is not the single most relevant factor of a child’s existence, and should not be discussed compulsorily on a yearly basis.

The information could be conveyed in levels of increasing complexity, given the child’s developmental level and curiosity. At the simplest level, only the most basic genealogical information is appropriate within the first 4 to 5 years of life (i.e., “Babies are grown in a special place in Mommy’s body called the womb or uterus. There is a special place between her legs for the baby to come out of when it is ready to be born”).

At the second level of complexity, the child can be informed that there are various ways for babies to begin growing-‘“Seeds and eggs can be put together inside or out- side the mommy’s body.” Once again, infertility is not relevant to this level of under- standing. The last level, the third level, might be stated: “One way to make babies is for a seed to come from another man and be mixed with Mommy’s egg [or vice versa] to start growing into you.”

The distinction between a “birth father’! and a “life father” can be easily understood at this particular juncture and can be helpful both to the parent and to the child, especially if the parent says honestly which job seems more important, specifically the “life father” (B. Abramovitz, personal communication, March, 1991).

A very positive aspect of known donorship may make its appearance here in that it may be clear to the child that the donor father is a real person who wanted (for reasons known best to the donor) actually to provide the sperm that brought this child into the world with the help of the mother. This allows an affirmation of the importance of the child‘s existence based on intentionality and not mere “accident,” enhancing the historical dimensions of the child’s identity. The child of DI is therefore affirmed and confirmed as normal.

By the time children reach adolescence, more specific data may be sought. The child is now aware of the complexity of human relationships based on his or her own tentative understandings of sexuality and intimacy. A variety of donor programs in which records are kept, especially in perpetuity as they are in Australia, have begun collecting identifying personal data in the form of tape recordings, letters, or photographs to be shared later.

In summary, I concur with this excellent clinical advice from Donor Insemination: Do We Tell Our Child?: “ . . . significant facts about a child’s life are better given earlier than later, so the knowledge can be absorbed over a period of time as the child grows” (p. 4). This paper has been an effort to apply appropriate clinical child development principles to the belief that these things of life are important to say to one another.

In closing this very preliminary discussion, it is important to reiterate that we are as yet uniformed by the real experts on this issue, the children and parents who work

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on this debate together over time and permit us to learn from them. Research is desperately needed here. Yet, with 10,OOO children a year conceived through assisted reproduction, the questions are coming and the confusion is expensive to them and their families. We owe them our best effort in the meantime.

REFERENCES

Ainsworth. M.. Blehar. M., Waters, E., & Wall. S . (1978). Patterns of aftachment: A psychological study of the sfrange situarion. Hillsdale. NJ: Erlbaum.

Baran. A,, & Pannor. R. (1989). Lethal secrets. New York: Warner. Bowlby. J. (1969): Attachment and loss, Vol. I: Attachment. New York: Basic Books. Curie-Cohen, M.. Luttrell. M., & Shapiro. S..(1979). Current practice of artificial insemination by donor

Czyba. J. C., & Chevret. M. (1979). Psychological reaction of couples to artificial insemination with

Emde, R. N. (1983). The pre-representational self and its affective core. The Psychoanalytic Study of

Green, J. (1991). Artificial insemination in Israel: A legal view. Jewish Medical Ethics, 2(1), 21-28. Kremer, J., Frijling. B., & Nass. J. (1984). Psychosocial aspects of parenthood by artificial insemina-

tion by donor. Lancet. 83. 2628. Manual, C.. et al. (1980). Handling of secrecy by artificial insemination coupla. In G. David & W. Price

(Eds.). Human A1 and semen production (pp. 121-132). New York: Plenum. Noble, E. (1987). Having your baby by donor insemination. Boston: Houghton Mifilin. Pruett, K. D. (1983). Infants of primary nurturing fathers. The Psychoanalytic Study of the Child, 38,

Pruett, K. D. (1989). The nurturing male: A longitudinal study of primary nurturing fathers. In S. Cath et al. (Eds.), Fathers and their families (pp. 389-409). New York: Analytic Press.

Pruett, K., & Litzenberger, B. (1992). Latency development in children of primary nurturing fathers: Eight year follow-up. The Psychoanalytic Study of the Child, 47, 85-101.

Rayner, K. (1987). Artificial insemination by donor- Social Responsibility Commission on Human Aritificial Insemination, The Anglican Church Office, Adelaide, South Australia. In E. Noble (Ed.), Having your baby by donor insemination (pp. 285-317). Boston: Houghton MitTlin.

Rosenkuist. H. (1991). Donor insemination: A prospective socio-psychiatric investigation of 48 couples. David Medical Bullerin. 28. 4.

Russell. G. (1987). Sharcd-carcgking families: An Australian study. In M. E. Lamb (Ed.), Nontmdirional families: Parenting and child development (pp. 139-172). Hillsdale, NJ: Erlbaum.

Singer. P.. & Wells, D. (1986). The reproductive revolution: New ways of making bobies. New York: Oxford University Press.

Sorosky, A. (1991). Infertility. adoption, and artificial insemination. In R. Pasnau (Ed.), Psychosocial aspects of medical practices (pp. 16-26). Menlo Park: Addison-Wesley Press.

Tyler, E. (1983). The clinical use of frozen semen banks. Ferrility and Sterility, 24(5). 413416. Wellisch, E. (1952).

in the United States. New England Journal of Medicine, 300, 585-620.

donor semen. Internationol Journal of Fertility. 24(4). 240-245.

the Child, 38. 165-192.

257-281.

Children without genealogy: A problem of adoption. Mental Health, 13, 1.