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The Handmaid's Tale premieres on Hulu today. It's a book-based TV series, starring Elizabeth Moss, depicting a dystopian government where women are disenfranchised and used primarily just for their ability to reproduce. But what many fans of the story (and the new show) might not realize is that this reductionist and coercive treatment of women is not just a fictional plot line. Outside of Margaret Atwood’s story, the practice of gestational surrogacy is the harsh reality for many women across the globe. 

Traditional commercial surrogacy involves a woman carrying a child for a couple in exchange for payment. Often the father's sperm is used to fertilize the surrogate's own egg. In vitro fertilization, or IVF, however, has become a common practice today, in which the surrogate is implanted with an egg from the mother that has been fertilized by the father. In other words, IVF surrogates have no genetic connection to the baby; they are "birth mothers" not "biological mothers." 

Today, issues with infertility and the rise of non-traditional couples have made surrogacy a popular topic; one often revered as a positive option for people who are unable to bear children naturally. But The Handmaid's Tale shows the side of surrogacy much less talked about—but not the least bit uncommon. In reality, surrogacy is not simply a means to an end. For many surrogates, the process is rooted in coercion, exploitation, and emotional distress. 

I became interested in helping women exploited by third-party reproduction when I saw it happening all around me throughout my 25-year career as a pediatric critical care nurse, a hospital administrator, and a senior-level nursing manager. I eventually turned my desire to help these women into the Center for Bioethics and Culture, based in the San Francisco Bay Area. Since then we have provided resources and a voice for exploited women who find no support elsewhere.

Surrogacy is coercive when women are not given all the facts about the risks of the decision they are making. When their financial need is so great, often they feel surrogacy is their best option in order to provide for themselves. Women in such countries as India, Thailand, and Cambodia have long experienced the exploitation of coercive surrogacy. In March 2015, HBO’s Vice showcased the coercive situations in India where surrogate mothers are in high demand because the prices are lower than, say, America. The investigative journalists found it was worse than they thought; the surrogacy agencies were so profit-seeking that they had a surplus of babies born even before parents had claimed them. But these same countries have also recently made legislative changes to make surrogacy more restricted in observance of the exploitation happening to both women and children. After the European Union outlawed surrogacy, India proposed legislation last year to ban surrogacy based on its exploitation of poor women. 

Asia isn't the only place making headlines for this practice, though. In April 2016, surrogacy came under fire when “baby Gammy,” a Down Syndrome child, was rejected by an Australian couple who kept Gammy's twin Pipah. The case was further complicated by the fact that the father paying for the children was discovered by the birth mom to be a sex offender; still she was left with Gammy, and an Australian judge deemed the parents fit to keep Pipah.

The American Society for Reproductive Medicine reported a 30 percent increase in surrogate births between 2004 and 2006, for a total of 1,059 live births in 2006, the most recent year for which it could provide data. Industry experts estimate that the actual number is much higher since many surrogate births go unreported. Commercial surrogacy accounts for billions of dollars annually, and there is no shortage of willing participants. In a 2014 New York Times piece, Rudy Rupak, founder of Planet Hospital, a global IVF provider, was quoted saying, “Here’s a little secret for all of you. There is a lot of treachery and deception in I.V.F./fertility/surrogacy because there is gobs of money to be made.” Those are the facts, but what this growing industry doesn’t want the world to hear are the stories. 

One such story is that of a woman named Kelly from South Dakota. Kelly is a mom of three in her thirties, who has given birth to five surrogate babies. She says she started considering surrogacy "after having two children of my own, seeing people struggling with infertility, I thought I could help these couples." Kelly came to see me in California at the Center for Bioethics and Culture, after the intended parents of one of her surrogacies took the child she bore and left her with thousands of dollars in unpaid medical bills. This past March for the UN Commission of the Status of Women, Kelly told her story. “If it sounds too good to be true it most likely is,” she said. “Both my international couples were through an agency. I have now had my eyes opened to the fact that this is really about money. Not the children. Two international couples exploited me, lied to me, and have caused me so much suffering and heartache.” Kelly hoped that through being a surrogate she could continue what she loved, “being pregnant and helping others, while making some money,” but now she says, “I am a broken woman who has been used, lied to, and exploited. If I could take back my surrogacy journeys I would in a heartbeat, because it changed me for the worse.”

Kelly, like so many surrogates, was drawn to the practice by false promises—both financial and humanitarian. Surrogacy often is coercive in that it offers much needed money for low income and poor women in economically developing countries, but it treats them as little more than breeders. Or, as here in the United States, surrogacy agencies require women to sign away their rights in contracts. Beyond that, women are paid little relative to the time put in, and they're at risk for grave physical and mental health complications.

In the United States, the cost to the intended parents, including medical and legal bills, runs from $40,000 to $120,000. That price tag is high for the average person, but still the demand for qualified surrogates is well ahead of supply. The surrogate herself typically is paid $20,000 to $25,000 in the U.S., which averages approximately $3.00 per hour for each hour she is pregnant, based on a pregnancy of 266 days or 6,384 hours. 

Due to the high costs involved in surrogacy and the strong desire to boost success rates, multiple embryos are often transferred into the surrogate. In addition to the increased risk of caesarian sections and longer hospital stays, the British Journal of Medicine warns, “Multiple pregnancies are associated with maternal and perinatal complications such as gestational diabetes, fetal growth restriction, and pre-eclampsia as well as premature birth." Lupron use in preparing a gestational surrogate to receive transferred embryos has also been documented to put a woman at risk for increased intracranial pressure.

When problems arise during the pregnancy, the wellbeing of the fetus tends to be given precedence over the health of the woman serving as a surrogate since the intended parents are paying large sums of money for the baby being produced. Care of the surrogate ends with the birth of the baby even when the woman who bears the child suffers lasting effects.

If the intended parents’ circumstances change during the pregnancy, or if the child is born with health problems or disabilities, the infants may be left to the surrogate or abandoned, as seen in the case of Gammy. Intended parents may find that they face unplanned financial costs and inadequate legal protections. As a result, women are often left with unpaid medical bills and no legal representation. Often the surrogates, naturally bonded, worry about the children born from their wombs and feel guilty if anything goes wrong in the pregnancy or transfer of care. The agencies take advantage of these compromised feelings, disenfranchising women and banking on the knowledge they can say it's the woman's fault, and she'll take it to heart. 

We need to expose the myth that surrogacy is as charitable an endeavor as many think it is. In fact, it leaves countless exploited women in its wake. We need to provide a clearer picture of the reality that such women are not left economically empowered. We need to work together as feminists, activists, experts, and academics to stop this global trading on the female body. We need to encourage the United States to catch up to the rest of the world in putting regulations and restrictions on surrogacy. 

Surrogacy degrades a pregnancy to a service and a baby to a product. I wish the harms of surrogacy existed only in the confines of dystopian novels and TV series. Unfortunately, they exist in the real world. Here’s hoping our outrage at the fictional mistreatment of women in The Handmaid's Tale will lead to outrage in the real world.

Photo Credit: Hulu