Abstract

Objective: To assess whether cancer patients receive timely information on adoption and third-party reproduction and whether discrimination exists in the system. Methods: A convenience sample of 11 cancer organizations, 6 international adoption agencies, and 7 adoption specialists was informally surveyed by phone, by e-mail, and in person. Results: Cancer organizations did not know whether cancer is a barrier to adoption; what a survivor needs to do to adopt; or whether or not a cancer survivor should disclose their cancer history to the adoption agency, home study worker, etc. They could not identify resources for a survivor experiencing discrimination or adoption agencies that are cancer friendly. They did not know whether a survivor should adopt domestically or internationally to increase the likelihood of success. Adoption agencies identified their chief concern as the welfare of the child and were reluctant to discuss how a cancer survivor would be viewed as a potential adoptive parent. Conclusions: Cancer patients lack immediate access to information about adoption and may face discrimination in domestic and international adoption.

INTRODUCTION

Infertility creates psychological challenges. While every infertility patient suffers a unique and painful journey, there are several psychological losses to overcome in nonbiological parenting: loss of biological posterity; loss of self-esteem and a sense of wholeness; loss of the ability to “give” one's partner a child; loss of the fantasized child that will embody the best of both parents; loss of a sense of control, health, and well-being; and loss of the belief in the fairness of life. Resolution of these losses is best conceived as a process. Parenthood options will be experienced differently at different points in this process (1,2).

Third-Party Reproduction

Third-party reproduction generally refers to family building where a third person donates gametes or “lends” their uterus to the intended or recipient parents. Thus, sperm, eggs, and embryos may be donated. Women who carry a pregnancy for the intended parents may have intrauterine insemination with the intended father's sperm (traditional surrogacy) or be implanted with an embryo that is unrelated genetically to the birth mother (gestational surrogacy).

There are three main types of gamete donation (3). In anonymous donation, parents have nonidentifying information about the donor; they may select preferred characteristics such as looks, intelligence quotient (IQ), social history, religion, and blood type. When the donor is willing to disclose their identity, including meeting the parents (and possibly the child) in the future, the donor is referred to as a known donor. A directed donor is a friend or relative of the intended parents who chooses to donate solely to that specific family.

Third-Party Reproduction Versus Adoption

Parents considering either third-party reproduction or adoption express similar concerns: fear that they will not be able to love their child or that their child will reject them in favor of their donors or birth mothers; fear that their child will not be healthy or will have psychological problems; and worry that they will not be able to talk to their child about their origins or that their child will feel stigmatized (4,5). Table 1 presents some the choices that parents weigh in choosing between third-party reproduction and adoption.

Table 1.

Pros and cons of donor gametes over adoption

Pros Cons 
One partner has a genetic connection to the child Unequal genetic connection to child versus the fairness of adoption to both partners 
Some control over genetic and health screening of donor Legal concerns (some states) 
Can choose donors by looks, intelligence, ethnicity, personality, interests Religious, ethical, or moral objections 
Partners can share the pregnancy experience With familial donation, there may be concern about passing cancer risk genes to offspring 
Control of prenatal and immediate postnatal care Female partner may not want medical procedures or hormones, especially if she had cancer diagnosis and treatment 
May avoid stigma of adoption by not disclosing child's origins Must invest money, but pregnancy is not guaranteed 
May be less expensive than adoption (donor sperm)  
Less waiting timed documentation  
Pros Cons 
One partner has a genetic connection to the child Unequal genetic connection to child versus the fairness of adoption to both partners 
Some control over genetic and health screening of donor Legal concerns (some states) 
Can choose donors by looks, intelligence, ethnicity, personality, interests Religious, ethical, or moral objections 
Partners can share the pregnancy experience With familial donation, there may be concern about passing cancer risk genes to offspring 
Control of prenatal and immediate postnatal care Female partner may not want medical procedures or hormones, especially if she had cancer diagnosis and treatment 
May avoid stigma of adoption by not disclosing child's origins Must invest money, but pregnancy is not guaranteed 
May be less expensive than adoption (donor sperm)  
Less waiting timed documentation  

Adoption

The adoption home study is required in all adoptions and includes an examination, usually by a social worker, of the marriage and family relationships; parental motivation and expectations about adoption; feelings about infertility; parenting styles; physical and health history of the applicants; parental education, employment, and finances; references; and a criminal background clearance (6). Many prospective adoptive parents resent its intrusiveness and gate-keeping aspects, but cancer survivors are particularly fearful, unsure of how much they must divulge about their medical histories.

Children adopted after infancy may be vulnerable to attachment disorders, especially if previously abused or neglected (7,8). Parents also worry about the physical health of adoptive children, particularly in international adoption. Some of these children have medical problems that are easily rectified, but some require more care and may have long-term difficulties (9).

Adopted children are at risk for a variety of psychological problems, attentional problems, and learning disabilities. The degree of elevated risk may be inflated, however, since adoptive parents may seek help more frequently than biological parents, given the same set of child problems (9).

Comparing Families

In a long-term, prospective comparison of natural, adopted in infancy, donor sperm, or in vitro fertilization (IVF) children in five European countries were followed to age 12, Golombok and associates (1014) found that parents who conceived without difficulty had higher levels of parenting stress than the other groups. No significant differences were found between types of families in the children's behavior, adjustment at home or school, or feelings toward their mothers or fathers. In assessing the quality of the parent-child relationship, Golombok (10) also found that IVF, DI, and adoptive mothers had higher levels of warmth and emotional involvement with their children; IVF or DI fathers were rated as displaying more warmth toward their children than natural-conception or adoptive fathers.

Cancer Patients

Cancer patients suffer the dual blow of a cancer diagnosis and potential infertility (1519). Areas of concern include the adequacy and timeliness of information available to cancer patients on adoption and third-party reproduction and whether discrimination exists in the adoption system.

MATERIALS AND METHODS

To address these concerns, the author developed a list of semistructured questions and surveyed 7 adoption specialists who work with cancer survivors (four by phone and four in person), 6 large international adoption agencies (three by phone and three in person, covering the countries of China, Russia, Eastern Europe, Guatemala, Kazakhstan, Korea, Thailand, Vietnam, India, Mongolia, and Bulgaria); and 11 cancer organizations (nine by phone and two by e-mail: American Cancer Society; Association of Cancer Resources web site; Breast Friends, Mount Sinai; Cancer Care; Living Beyond Breast Cancer; NABCO; New Beginnings, Beth Israel Medical Center; Post Treatment Resource Center, MSKCC; Share; Young Survival Coalition [YSC]; http://www.breastcancer.org). The adoption agencies (located in the east, midwest, and west coast) were chosen because they were large, licensed, and willing to speak candidly about their policies. The adoption specialists were individuals working in the adoption field for several years who were known to be experienced with cancer survivors and willing to discuss their experiences. Fertile Hope was not approached because the author advises the organization about mental health issues, including adoption after cancer.

RESULTS

Table 2 presents the questions asked of each cancer organization and the number who could provide accurate answers. YSC stood out as knowing the answers to most of the questions. Adoption specialists were also asked about barriers to adoption for cancer survivors; 100% mentioned that in international adoption, many countries do not view any cancer (or, in fact, many illnesses we consider readily treatable) to be curable, so that a cancer history is a contraindication to adopting. All specialists also mentioned that a source of discrimination in domestic adoption is that many birth parents want to place their child in a stable home with the best possible life and are frightened by a cancer history.

Table 2.

Questions for cancer organizations

 No. answering:
 
  
Question Yes No Don't know 
Do cancer patients face discrimination in adoption? 10 
What does a survivor need to do to adopt? 10 
Should they disclose cancer history to an agency or home study worker? 10 
Will birth mothers be frightened by cancer history? 11 
Are some types of adoption more likely to work for cancer survivors (international versus domestic)? 11 
 No. answering:
 
  
Question Yes No Don't know 
Do cancer patients face discrimination in adoption? 10 
What does a survivor need to do to adopt? 10 
Should they disclose cancer history to an agency or home study worker? 10 
Will birth mothers be frightened by cancer history? 11 
Are some types of adoption more likely to work for cancer survivors (international versus domestic)? 11 

All adoption agencies noted that the welfare of the adopted children is their prime concern. Because of legal concerns about discrimination, the agencies requested anonymity when answering the questions in Table 3. Out of the six agencies surveyed, three definitely wanted to know about a cancer history and three did not want to know, particularly if the cancer was early stage and 2 years of disease-free survival had occurred. No agency wished to be publicly known as cancer friendly. The agencies believed that such a label would jeopardize the agency's relationships with the countries providing adoption referrals. Survivors represented from 0.5% to 10% of these agencies' total clientele.

Table 3.

Questions for adoption agencies

 No. answering:
 
  
Question Yes No Don't know 
Would you like to be known as a cancer friendly agency? 
Should a cancer survivor reveal a cancer history? 
How does a survivor find an agency that is cancer friendly? 
Should a survivor adopt domestically or internationally? 
If internationally, are there cancer friendly countries? 
Is cancer a barrier to adoption in most third-world countries? 
If a survivor suffers discrimination, what can they do? 
 No. answering:
 
  
Question Yes No Don't know 
Would you like to be known as a cancer friendly agency? 
Should a cancer survivor reveal a cancer history? 
How does a survivor find an agency that is cancer friendly? 
Should a survivor adopt domestically or internationally? 
If internationally, are there cancer friendly countries? 
Is cancer a barrier to adoption in most third-world countries? 
If a survivor suffers discrimination, what can they do? 

DISCUSSION

Further research needs to be done to clarify the results of this very limited pilot survey, yet the responses demonstrate that cancer patients lack immediate access to information about adoption and may face discrimination in domestic and international adoption. Currently, we can only advise that cancer survivors use networking and the resources listed in Table 4 to find an adoption agency and home study social workers open to working with them. Home study social workers should be interviewed regarding their attitudes toward cancer before beginning the home study, when it is easier to shift agencies and social workers.

Table 4.

Resources for cancer patients wishing to parent

Resource Contact method 
FertileHOPE http://www.fertileHOPE.org 
YSC http://www.youngsurvival.org 
Fertility Preservation Special Interest Group, American Society for Reproductive Medicine http://www.asrm.org 
Yahoo.adoptingaftercancer adoption-after-cancer@yahoogroups.com 
Resolve http://www.resolve.org 
Resource Contact method 
FertileHOPE http://www.fertileHOPE.org 
YSC http://www.youngsurvival.org 
Fertility Preservation Special Interest Group, American Society for Reproductive Medicine http://www.asrm.org 
Yahoo.adoptingaftercancer adoption-after-cancer@yahoogroups.com 
Resolve http://www.resolve.org 

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