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It's as new as Dolly the cloned sheep, and as ancient as the Old Testament story of Sarah and Hagar, in which Hagar served as the surrogate mother for Sarah's child, Ishmael.
The "it" is technically assisted reproduction, and just as Hagar's surrogate motherhood led to a blood feud that rent the fabric of ancient tribes, so do today's reproductive technologies pose monumental challenges for both individuals and society. The role of psychiatrists in helping patients and caregivers deal with the complex emotional and medical issues raised by assisted reproduction was the topic of an APA annual meeting symposium in Toronto last month.
Reproductive technology has outpaced the social conventions that guided societies since the dawn of man, said panelist Perry Ottenberg, M.D., a clinical professor of psychiatry at the University of Pennsylvania. "The technology is way ahead of what we as doctors need to know to prepare patients."
People "do not appreciate the revolutionary aspects of this in terms of liberating women from age, men, sex, menopause-it liberates her from her uterus-and people don't realize this," he asserted.
The reproductive revolution also provides one way for lesbian and gay couples to have children, he added. "In 10 or 20 years there may be enough gay couples with children that it may really take the heat out of a lot of the political and religious opposition."
But with this liberation come potential issues that need to be addressed, such as whether children should be born within marriage or should have two heterosexual parents. A related issue-exemplified by a recent technologically assisted birth in a 65-year-old woman-is whether it is ethical for an elderly woman to give birth when she is likely to die before the child has grown up.
For many people, the absence of children represents a "deep emotional emptiness" that can trigger depression, said Ottenberg. The technology itself is dehumanizing and often somewhat traumatizing for aspiring parents, he noted.
"You go to the doctor, and you're told to go to the restroom and give us some sperm. Women repeatedly have to give their vaginal temperature." Both literally and psychologically people are "stripped naked."
Between partners there is often the issue of blame, of "who is at fault" in the infertility, said Ottenberg. This can "polarize the marriage and be a source of discontent."
Ian Alger, M.D., who moderated the panel, specializes in couples counseling and family therapy.
Although the advent of the new technologies has fostered new psychological and social problems, it has also greatly expanded the ways of helping involuntarily childless couples, Alger observed. As the technology has expanded and become increasingly available, however, it has become clear that socioeconomic factors limit its application almost exclusively to more affluent people. This may further stratify a society already beset with worrisome stratification over the availability of other costly technological goods and services.
The role of psychiatrists in assisted reproduction must be truly "biopsychosocial," said Alger. The psychiatrist "must grasp not only the effects of medications and procedures" but also how those procedures impact individuals and a couple's relationship. Fertility drugs often cause distressing side effects, including mood swings. They may also trigger multiple pregnancies, which may necessitate aborting some fetuses to allow one or more to survive. For some people, this raises moral issues.
Aparticularly challenging area for psychiatry is the need to identify "the depression, grief, and despair that so commonly accompany unsuccessful treatment and to understand and differentiate those symptoms" from preexisting or comorbid psychiatric disorders, said Alger.
The role of reproductive technologies is likely to increase as economic and social pressures lead more and more people to postpone having children until well past the biologically optimal age for reproduction, Alger observed. Cloning, while not yet widespread and not approved anywhere for humans, may become "a new and controversial option," said Alger.
Panelist Jane Rosenthal, M.D., is an assistant clinical professor of psychiatry at Columbia Presbyterian Medical Center in Manhattan and a private practitioner. "I think that it's important for many psychiatrists to know more about the assisted technologies and what is possible," she commented.
In particular, psychiatrists must familiarize themselves with the different causes of infertility and their associated psychological impact, Rosenthal said. For example, a woman diagnosed with premature menopause may have very different feelings about her infertility than would a woman made infertile from exposure to a sexually transmitted disease.
There are also "time issues," she noted. Psychiatrists working with patients in long-term psychotherapy need to be aware that as time passes, fertility diminishes.
A key issue for psychiatrists in a counseling role is helping couples or individuals make a decision about whether to use reproductive technologies, adopt, or live without children. Another issue is "dealing with the uncertainties and feelings that arise with the prospect of using donor eggs or sperm," which may include anxiety about the identity of the unknown donor and later explaining the child's origins to him or her.
Panelist Miriam Rosenthal, M.D., is an associate professor of psychiatry and reproductive biology and director of the division of behavioral medicine in obstetrics and gynecology at Case Western Reserve School of Medicine in Cleveland.
"There is no evidence that couples who go through assisted reproduction have any higher degree of psychiatric disorders, but they deal with a lot of very stressful situations," she said. "And when it doesn't work, they often experience a tremendous sense of failure and loss of control in their lives."
An assisted reproduction program is "a good place for someone with mental health expertise," said Rosenthal. It is an opportunity for meaningful work with patients, staff, and families, she added. Psychiatrists have to deal with unusual medical and interpersonal issues. They may have to treat depressed patients without medication to minimize potential fetal risk, for example. A highly sensitive area is that of sexual harmony, since the process of getting help in conception is invariably highly technological and anti-romantic, she noted. Psychiatrists can often play a key role in partner counseling and helping couples restore sexual pleasure to their lives.
With egg and sperm donation and surrogate motherhood, other issues arise. These include the ambivalent feelings involved in having a child that may be genetically unrelated to one or both parents. A surrogate mother may experience inner conflict as the pregnancy progresses and she prepares to give up the child, Rosenthal explained.
The annual meeting panel was organized by the Social Issues Committee of the Group for the Advancement of Psychiatry, and all panelists are members of the committee.