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Psychological assessment of gestational carrier candidates: current approaches, challenges, and future considerations

2020; Elsevier BV; Volume: 113; Issue: 5 Linguagem: Inglês

10.1016/j.fertnstert.2020.02.104

1556-5653

Mary P. Riddle,

Homicide, Infanticide, and Child Abuse

The role of a mental health professional (MHP) in the psychological assessment of gestational carrier (GC) candidates has evolved over time, with clinical practices well established in the United States. Current ASRM guidelines recommend that all GC candidates undergo a psychosocial consultation and psychological testing (where deemed appropriate). Practice standards are relatively consistent among mental health disciplines, with assessments typically involving a clinical interview and the administration of a single, objective, self-report personality inventory. Although recent studies have established normative data for GCs, there has been little research into which assessment protocols are best suited to answer the referral questions of interest. Current challenges for MHPs placed in a gate-keeping role include providing a thorough screening using measures that typically yield defensive profiles that make them difficult to interpret. Research is emerging that suggests that using a multimethod approach in the psychological assessment of GCs may yield a more comprehensive psychological profile of GC candidates. This could allow MHPs to determine psychological appropriateness with more confidence and contribute additional data to be used in pre-surrogacy counseling. Assessing the psychological appropriateness of a woman to serve as a GC is a complex process, and there are a multitude of factors that must be considered, not the least of which are the psychological well-being of a potential GC, her partner, and her children throughout the process and beyond. The role of a mental health professional (MHP) in the psychological assessment of gestational carrier (GC) candidates has evolved over time, with clinical practices well established in the United States. Current ASRM guidelines recommend that all GC candidates undergo a psychosocial consultation and psychological testing (where deemed appropriate). Practice standards are relatively consistent among mental health disciplines, with assessments typically involving a clinical interview and the administration of a single, objective, self-report personality inventory. Although recent studies have established normative data for GCs, there has been little research into which assessment protocols are best suited to answer the referral questions of interest. Current challenges for MHPs placed in a gate-keeping role include providing a thorough screening using measures that typically yield defensive profiles that make them difficult to interpret. Research is emerging that suggests that using a multimethod approach in the psychological assessment of GCs may yield a more comprehensive psychological profile of GC candidates. This could allow MHPs to determine psychological appropriateness with more confidence and contribute additional data to be used in pre-surrogacy counseling. Assessing the psychological appropriateness of a woman to serve as a GC is a complex process, and there are a multitude of factors that must be considered, not the least of which are the psychological well-being of a potential GC, her partner, and her children throughout the process and beyond. Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/users/16110-fertility-and-sterility/posts/59753-29798 Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/users/16110-fertility-and-sterility/posts/59753-29798 As awareness of the psychosocial complexities inherent in surrogacy arrangements has grown, so has the role of the mental health professional (MHP) as a gate-keeper in the process (1Braverman A.M. Mental health counseling in third-party reproduction in the United States: evaluation, psychoeducation, or ethical gatekeeping?.Fertil Steril. 2015; 104: 501-506Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar). The inclusion of a psychological assessment in the consideration of a gestational carrier (GC) candidate is a well-established practice in the United States. From the publication of the first ASRM Practice Committee Guidelines for using gestational carriers (2American Society for Reproductive Medicine Practice CommitteeRecommendations for practices utilizing gestational surrogates: an ASRM Practice Committee guideline.Fertil Steril. 2012; 97: 1301-1308Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar), recommendations have included that GC candidates undergo a psychosocial consultation and psychological testing (where deemed appropriate). The current guidelines (3American Society for Reproductive Medicine Practice CommitteeRecommendations for practices utilizing gestational surrogates: an ASRM Practice Committee guideline.Fertil Steril. 2017; 107: e3-e10Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar) recommend topics to be included in pre-surrogacy counseling, as well as mental health exclusion criteria for a potential GC candidate. Additional recommendations include psychosocial education of both the intended parents and potential GCs (3American Society for Reproductive Medicine Practice CommitteeRecommendations for practices utilizing gestational surrogates: an ASRM Practice Committee guideline.Fertil Steril. 2017; 107: e3-e10Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar). The assessment process also includes an MHP meeting with all parties, the GC and her partner and the intended parents, both separately and together, to address topics of relevance to the arrangement. Although standard practice in the psychological screening of GC candidates in the United States typically includes a clinical interview and the administration of a single broad-band personality self-report questionnaire (either the Minnesota Multiphasic Personality Inventory−2 [MMPI-2] or the Personality Assessment Inventory [PAI] (4Hathaway S.R. McKinley J.C. MMPI-2 manual for administration and scoring. University of Minnesota Press, Minneapolis, MN1989Google Scholar, 5Morey L.C. The Personality Assessment Inventory professional manual. Psychological Assessment Resources, Odessa, FL1991Google Scholar), there is to date no uniform interpretation of the guidelines or research into which psychological protocols might best address the referral question of appropriateness. The psychological consideration of a woman to become a GC is complex, and a multitude of factors must be considered, not the least of which is the potential GC's psychological well-being throughout the process and beyond. The physical and psychological risks inherent in the process are significant, and MHPs have both tremendous responsibilities and challenges when placed in a gate-keeping role. How do MHPs screen thoroughly, interpret defensive data, and also extract therapeutic value in the data collected? The need for competent clinicians to psychologically screen and assess potential GC candidates continues to grow, as does the number of assisted reproductive technology (ART) cycles utsing embryo transfers to gestational carriers. Given the increasing numbers of surrogacy arrangements as well increased numbers of MHPs conducting these types of assessments, it seems timely to consider the ideal uses of data collected in these types of screening assessments. The current membership of the Mental Health Professional Group (MHPG) of ASRM is at an all-time high of 592 members (A. Malave, personal communication, January 10, 2020), and the goal of this article is to provide all parties (MHPs, MDs, lawyers, agencies, clinics) with a deeper understanding of the purpose of a GC screening, an overview of current practices and challenges, and the best methods to obtain the information necessary to make ethical decisions regarding gestational surrogacy arrangements. Assessment of GCs includes not only the question of psychological appropriateness to proceed, but how to best prepare and counsel women for the experience of surrogacy while keeping their psychological best interests first and foremost in the process. This paper will look back on the evolution of psychological evaluation in the practice of surrogacy, discuss ways to consider the referral question of appropriateness, and comment on future directions in the psychological assessments of GC candidates. The early references to an evaluation process lie at the intersection of the psychological, legal, and ethical concerns inherent in the process of surrogacy. The concern over potential litigation, exploitation of women, and unknown emotional costs all contributed to an evolving focus on appropriate screening methods (6Schwartz L.L. Psychological and legal perspectives on surrogate motherhood.Am J Fam Ther. 1991; 19: 363-366Crossref Scopus (4) Google Scholar). Noel Keane, the Michigan lawyer sometimes credited with brokering the first documented surrogacy arrangement in the United States (7Meinke S.A. Surrogate motherhood: ethical and legal issues.https://repository.library.georgetown.edu/handle/10822/556906Date accessed: January 18, 2020Google Scholar), wrote that he personally "screened" candidates in early arrangements, looking for women with "character, strength, and generosity of spirit," but soon acknowledged the need for mental health expertise (8Keen N.P. Breo D.L. The surrogate mother. Everest House Publishers, New York1981: 52-53Google Scholar). Subsequent early screening practices were to determine a surrogate's motivations and her ability to relinquish an infant (6Schwartz L.L. Psychological and legal perspectives on surrogate motherhood.Am J Fam Ther. 1991; 19: 363-366Crossref Scopus (4) Google Scholar). Clinicians in the psychological community who were screening surrogates were using standardized personality measures such as the Minnesota Multiphasic Personality Inventory (MMPI) (H. Hanafin, personal communication, January 12, 2020). However, until 1991, no references in the literature had yet emerged on a formal assessment process or the recommendation of any particular screening instruments. The earliest publication mentioning of the use of standardized psychological testing being used in our field was a paper by Franks published in 1981 that looked at using the MMPI to characterize a small sample of traditional surrogates who had been cleared to move forward (9Franks D.D. Psychiatric evaluation of women in a surrogate mother program.Am J Psychiatry. 1981; 138: 1378-1380Crossref PubMed Scopus (30) Google Scholar). However, as with much of the early literature, the goal of the paper was not to present a particular screening protocol, but to describe the motivations and characteristics of the women who became surrogates. The highly publicized custody battle over Baby M, when traditional surrogate Mary Beth Whitehead contracted with a couple to bear their child and then changed her mind, brought renewed attention and criticism to the process. Interestingly, Mary Beth Whitehead had undergone a psychological evaluation and was "cleared" to proceed even though a psychologist had clearly documented that Whitehead expected that she would have very strong feelings about relinquishing a baby. The psychologist, whose report was introduced as evidence in the trial, recommended further exploration of these feelings (10Hanley R. Father of Baby M thought mother had been screened.https://www.nytimes.com/1987/01/14/nyregion/father-of-baby-m-thought-mother-had-been-screened.htmlDate accessed: January 15, 2020Google Scholar). The Baby M case highlighted much of what critics believed was wrong with the process of surrogacy—the perceived unnaturalness of relinquishing one's baby for money, and the fear that there would be long-lasting psychological scars for women who underwent this process (6Schwartz L.L. Psychological and legal perspectives on surrogate motherhood.Am J Fam Ther. 1991; 19: 363-366Crossref Scopus (4) Google Scholar, 11Hanafin H. Surrogacy and gestational carrier participants.in: Covington S.N. Hammer-Burns L. Infertility counseling: a comprehensive handbook for clinicians. 2nd Edition. Cambridge University Press, Cambridge, UK2006Google Scholar). Around the time of the Baby M controversy, advances in reproductive technology led to the first birth of a baby by a gestational carrier (12Utian WH, Sheean L, Goldfarb JM, Kiwi R. Successful pregnancy after in-vitro fertilization and embryo transfer from an infertile woman to a surrogate 1985;313:1351–1352.Google Scholar). The shift towards the use of GCs, and away from traditional surrogacy, began around 1986−1987. By 1991, advocacy and recommendations for a more formalized psychological assessment process started to emerge in the literature. Lita Schwartz (6Schwartz L.L. Psychological and legal perspectives on surrogate motherhood.Am J Fam Ther. 1991; 19: 363-366Crossref Scopus (4) Google Scholar, 13Schwartz L.L. Surrogate motherhood and family psychology/therapy.Am J Fam Ther. 1990; 18: 385-392Crossref Scopus (0) Google Scholar), a board-certified forensic psychologist, wrote that lawyers were relying on MHPs to assess all parties and to counsel surrogates to protect their emotional well-being. The fear on the part of professionals involved in this process was that women would suffer grief at relinquishing an infant, and MHPs were seen as critical to managing feelings that surrogates might have afterward (6Schwartz L.L. Psychological and legal perspectives on surrogate motherhood.Am J Fam Ther. 1991; 19: 363-366Crossref Scopus (4) Google Scholar). Schwartz's 1991 paper was published soon after the Baby M controversy and was the first to propose a more formal evaluation process for surrogates as she specifically identified the MHP role as an evaluative one. The recommendation was that the mental health consultation should include a clinical interview along with one or more standardized tests, with exclusion factors including mental instability or the possibility that a woman would be unable to relinquish an infant (6Schwartz L.L. Psychological and legal perspectives on surrogate motherhood.Am J Fam Ther. 1991; 19: 363-366Crossref Scopus (4) Google Scholar). There was even a recommendation to include the surrogate's husband/partner and children into the evaluation process as a way to prevent future negative sequelae (6Schwartz L.L. Psychological and legal perspectives on surrogate motherhood.Am J Fam Ther. 1991; 19: 363-366Crossref Scopus (4) Google Scholar). Although the Schwartz article was written with traditional surrogacy in mind, the move toward more formal evaluation practices had begun. In 1992, Braverman and Corson cautioned that the long-term emotional costs of surrogacy were unclear, and sought to start a discussion on best practices (14Braverman A.M. Corson S.L. Characteristics of participants in a gestational surrogate program.J Assist Reprod Genet. 1992; 9: 353-357Crossref PubMed Scopus (28) Google Scholar) by describing the psychological evaluation process in a gestational carrier program. Their paper was the first to describe the psychological characteristics of a sample of GCs. Over time, it became routine to ask MHPs to screen and to counsel GC candidates for psychological appropriateness, and historically these types of screenings typically have included clinical interviews and the administration of an objective measure of personality functioning. With the inception of ASRM guideline recommendations, it is now standard practice for MHPs to screen GC candidates and "clear" them to proceed. In general, mental health clinicians conducting any type of psychological assessment have the task of answering the referral question by synthesizing multiple data sources as a means of aiding in clinical decision making (15Groth-Marnat G. Handbook of psychological assessment.5th ed. John Wiley & Son, Inc, Hoboken, NJ2009Google Scholar). Inherent in the request for a psychological assessment are several points of consideration: What is the question we are trying to answer? Who is asking the question? How will the answer be used (16Butcher J.N. Clinical personality assessment: practical approaches. Oxford University Press, New York1995Google Scholar)? To do this, we must moderate what we need to know by what we already know. What we know about surrogates emerged from early studies that, although not designed to illuminate possible screening methods and criteria, served to identify common personality traits of surrogates (both traditional and gestational). Early research sought primarily to explore the motivations and demographics of surrogates (9Franks D.D. Psychiatric evaluation of women in a surrogate mother program.Am J Psychiatry. 1981; 138: 1378-1380Crossref PubMed Scopus (30) Google Scholar, 17Parker P.J. Motivation of surrogate mothers: initial findings.Am J Psychiatry. 1983; 140: 117-118Crossref PubMed Scopus (67) Google Scholar), and subsequent research started to explore the psychology of these women (18Hanafin H. The surrogate mother: an exploratory study [dissertation]. California School of Professional Psychology, Los Angeles1984Google Scholar). As evaluation processes began to emerge, so did studies describing ways to implement them (14Braverman A.M. Corson S.L. Characteristics of participants in a gestational surrogate program.J Assist Reprod Genet. 1992; 9: 353-357Crossref PubMed Scopus (28) Google Scholar). The psychological profile of a "typical" surrogate began take form: surrogates have been described as women who may suffer from low self-esteem (14Braverman A.M. Corson S.L. Characteristics of participants in a gestational surrogate program.J Assist Reprod Genet. 1992; 9: 353-357Crossref PubMed Scopus (28) Google Scholar), are deeply contented with pregnancy, and find joy in the process (17Parker P.J. Motivation of surrogate mothers: initial findings.Am J Psychiatry. 1983; 140: 117-118Crossref PubMed Scopus (67) Google Scholar, 19Blyth E. "I wanted to be interesting. I wanted to be able to say 'I've done something interesting with my life'": interviews with surrogate mothers in Britain.J Reprod Infant Psychol. 1994; 12 (189–8)Crossref Scopus (86) Google Scholar, 20Ciccarelli J.C. Beckman L.J. Navigating rough waters: an overview of psychological aspects of surrogacy.J Soc Issues. 2005; 61: 21-43Crossref PubMed Scopus (97) Google Scholar, 21Jadva V. Murray C. Lycett E. MacCallum F. Golombok S. Surrogacy: the experiences of surrogate mothers.Hum Reprod. 2003; 18: 2196-2204Crossref PubMed Scopus (159) Google Scholar, 22van den Akker O. Psychosocial aspects of surrogate motherhood.Hum Reprod Update. 2007; 13: 53-62Crossref PubMed Scopus (111) Google Scholar). They have been described as women who feel that the experience of surrogacy will give them a sense of personal achievement (thereby making them feel special) and increase feelings of self-worth (19Blyth E. "I wanted to be interesting. I wanted to be able to say 'I've done something interesting with my life'": interviews with surrogate mothers in Britain.J Reprod Infant Psychol. 1994; 12 (189–8)Crossref Scopus (86) Google Scholar,22van den Akker O. Psychosocial aspects of surrogate motherhood.Hum Reprod Update. 2007; 13: 53-62Crossref PubMed Scopus (111) Google Scholar,23van den Akker O. Genetic and gestational surrogate mothers' experience of surrogacy.J Reprod Infant Psychol. 2003; 21: 145-161Crossref Scopus (72) Google Scholar). It has also been suggested that GCs may be somewhat unorthodox and do not necessarily conform to traditional gender roles (24Klock S.C. Covington S.N. Results of the Minnesota Multiphasic Personality Inventory–2 among gestational surrogacy candidates.Int J Gynecol Obstet. 2015; 130: 257-260Crossref PubMed Scopus (9) Google Scholar). No studies have suggested that these are women who exhibit significant psychopathology. In the United States, the profile of a "typical" GC is a woman who loves being pregnant, desires a feeling of accomplishment, and who has compassion for the childless. She may be motivated by financial incentive, but that appears to be secondary to altruism (25Simpson T.H. Hanafin H. Counseling surrogate carrier participants.in: Covington S.N. Fertility counseling: clinical guide and case studies. Cambridge University Press, Cambridge, UK2015: 122-135Crossref Scopus (4) Google Scholar). Early literature references suggest that professionals involved in surrogacy arrangements were most interested in making sure potential surrogates were free from psychopathology and that they would be able to relinquish an infant at the end (6Schwartz L.L. Psychological and legal perspectives on surrogate motherhood.Am J Fam Ther. 1991; 19: 363-366Crossref Scopus (4) Google Scholar, 7Meinke S.A. Surrogate motherhood: ethical and legal issues.https://repository.library.georgetown.edu/handle/10822/556906Date accessed: January 18, 2020Google Scholar, 8Keen N.P. Breo D.L. The surrogate mother. Everest House Publishers, New York1981: 52-53Google Scholar, 9Franks D.D. Psychiatric evaluation of women in a surrogate mother program.Am J Psychiatry. 1981; 138: 1378-1380Crossref PubMed Scopus (30) Google Scholar). Mental health considerations evolved over time and eventually became the current guideline recommendations (3American Society for Reproductive Medicine Practice CommitteeRecommendations for practices utilizing gestational surrogates: an ASRM Practice Committee guideline.Fertil Steril. 2017; 107: e3-e10Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar), which include 35 counseling topics, nine exclusion criteria, and eight relative exclusion criteria. These criteria are both well documented in the practice guidelines and detailed in the literature devoted to the evaluation process (11Hanafin H. Surrogacy and gestational carrier participants.in: Covington S.N. Hammer-Burns L. Infertility counseling: a comprehensive handbook for clinicians. 2nd Edition. Cambridge University Press, Cambridge, UK2006Google Scholar, 25Simpson T.H. Hanafin H. Counseling surrogate carrier participants.in: Covington S.N. Fertility counseling: clinical guide and case studies. Cambridge University Press, Cambridge, UK2015: 122-135Crossref Scopus (4) Google Scholar). These topics and exclusion criteria drive typical content in an assessment, which include a GC's personality, the presence of significant psychopathology, her ability to provide consent, her motivations, relationships in her life, present life stressors, life transitions, and her social support network. Some of the most challenging areas of assessment include managing GC expectations of the process as well as the potential impact of surrogacy on her life, her family, and her future (3American Society for Reproductive Medicine Practice CommitteeRecommendations for practices utilizing gestational surrogates: an ASRM Practice Committee guideline.Fertil Steril. 2017; 107: e3-e10Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 11Hanafin H. Surrogacy and gestational carrier participants.in: Covington S.N. Hammer-Burns L. Infertility counseling: a comprehensive handbook for clinicians. 2nd Edition. Cambridge University Press, Cambridge, UK2006Google Scholar, 25Simpson T.H. Hanafin H. Counseling surrogate carrier participants.in: Covington S.N. Fertility counseling: clinical guide and case studies. Cambridge University Press, Cambridge, UK2015: 122-135Crossref Scopus (4) Google Scholar). Common to all the early literature and standard practice among MHPs in the United States is the administration of different types of psychological tests. In addition, although the majority of studies have sought to characterize surrogates and not necessarily to prescribe any particular testing protocol, a number of studies have reported on the use of both self-report measures and process-oriented measures (9Franks D.D. Psychiatric evaluation of women in a surrogate mother program.Am J Psychiatry. 1981; 138: 1378-1380Crossref PubMed Scopus (30) Google Scholar, 14Braverman A.M. Corson S.L. Characteristics of participants in a gestational surrogate program.J Assist Reprod Genet. 1992; 9: 353-357Crossref PubMed Scopus (28) Google Scholar, 24Klock S.C. Covington S.N. Results of the Minnesota Multiphasic Personality Inventory–2 among gestational surrogacy candidates.Int J Gynecol Obstet. 2015; 130: 257-260Crossref PubMed Scopus (9) Google Scholar, 26Bruss G.S. Nunno K.M. Axis I and personality profiles of gestational surrogates.Fertil Steril. 2002; 77: S18Abstract Full Text Full Text PDF PubMed Google Scholar, 27Kleinpeter C.H. Hohman M.M. Surrogate motherhood: personality traits and satisfaction with service providers.Psychol Rep. 2000; 87: 957-970Crossref PubMed Scopus (17) Google Scholar, 28Sims J.A. Thomas K.M. Hopwood C.J. Chen S.H. Pascale C. Psychometric properties and norms for the Personality Assessment Inventory in egg donors and gestational carriers.J Personal Assess. 2013; 95: 495-499Crossref PubMed Scopus (14) Google Scholar, 29Eihwohner J. Who becomes a surrogate: personality characteristics.in: Offerman-Zuckerberg J. Gender in transition: a new frontier. Plenum, New York1989: 123-132Crossref Google Scholar). Over time, the rationale for the use of testing has developed more fully and includes liability issues, attempts to standardize care, and the importance of screening for both psychopathology and specific personality characteristics that could have an impact on outcomes (such as compliance determinations, risk of relinquishment issues, and presence of significant psychopathology) (14Braverman A.M. Corson S.L. Characteristics of participants in a gestational surrogate program.J Assist Reprod Genet. 1992; 9: 353-357Crossref PubMed Scopus (28) Google Scholar, 24Klock S.C. Covington S.N. Results of the Minnesota Multiphasic Personality Inventory–2 among gestational surrogacy candidates.Int J Gynecol Obstet. 2015; 130: 257-260Crossref PubMed Scopus (9) Google Scholar, 28Sims J.A. Thomas K.M. Hopwood C.J. Chen S.H. Pascale C. Psychometric properties and norms for the Personality Assessment Inventory in egg donors and gestational carriers.J Personal Assess. 2013; 95: 495-499Crossref PubMed Scopus (14) Google Scholar). Specific recommendations in the literature (6Schwartz L.L. Psychological and legal perspectives on surrogate motherhood.Am J Fam Ther. 1991; 19: 363-366Crossref Scopus (4) Google Scholar), the forensic implications of these types of screenings (6Schwartz L.L. Psychological and legal perspectives on surrogate motherhood.Am J Fam Ther. 1991; 19: 363-366Crossref Scopus (4) Google Scholar), and the fact that it is well validated and effective when used in conjunction with clinical interviews for screening for psychopathology (30Purewal S. van den Akker O.B.A. Systematic review of oocyte donation: investigating attitudes, motivations, and experiences.Hum Reprod Update. 2009; 15: 499-515Crossref PubMed Scopus (104) Google Scholar), the MMPI (and the revised MMPI-2) emerged as the early leader among tests to use for the purposes of GC evaluations. A second instrument, the Personality Assessment Inventory (PAI) also emerged, making these two tests the most widely used diagnostic measures used in the psychological screening of GCs in the United States. The MMPI-2 and PAI are both considered to be objective self-report inventories designed to assess personality. A personality test seeks to measure motivations, emotional status, and a variety of interpersonal characteristics and attitudes and these tests should be distinguished from psychological tests of intelligence or abilities (31Anastasi A. Urbina S. Psychological testing.7th ed. Prentice-Hall, Upper Saddle River, NJ1997Google Scholar). Given the suggested content areas of assessment, tests that look at motivations, interpersonal characteristics, and the presence or absence of psychopathology would be appropriate to use in a GC screening. The MMPI and MMPI-2 are constructed using something called "criterion keying." This means that questions included in an instrument are not derived theoretically but are chosen based on whether or not the population of interest answers questions differently from the group against which they are being compared (an "external criterion") (15Groth-Marnat G. Handbook of psychological assessment.5th ed. John Wiley & Son, Inc, Hoboken, NJ2009Google Scholar). Unlike the MMPI/MMPI-2, the PAI is based on a construct validation framework. This means that the items chosen for inclusion are theoretically driven and the clinical scales comprise items that can assess the full range of a particular clinical construct (5Morey L.C. The Personality Assessment Inventory professional manual. Psychological Assessment Resources, Odessa, FL1991Google Scholar). This allows for determining milder ranges of clinical functioning, whereas the MMPI-2 simply reports on the presence or absence of clinical pathology. Currently, the PAI may be the more frequently used test. This is because, like the MMPI and MMPI-2, it is both well validated and well researched, but it is also shorter and therefore takes less time to administer. Most importantly, however, it addresses the limitations of a forced choice test (true/false) such as in the MMPI and MMPI-2. This is because the PAI allows for a determination of gradations of problems, and it can detect clinical issues along a continuum rather than simply determining the presence or absence of certain problems. Both the MMPI-2 and the PAI pose significant challenges for MHPs who use them to screen GC candidates. This is because the test profiles of GCs on both instruments have been shown to be consistently defensive and difficult to interpret (24Klock S.C. Covington S.N. Results of the Minnesota Multiphasic Personality Inventory–2 among gestational surrogacy candidates.Int J Gynecol Obstet. 2015; 130: 257-260Crossref PubMed Scopus (9) Google Scholar, 28Sims J.A. Thomas K.M. Hopwood C.J. Chen S.H. Pascale C. Psychometric properties and norms for the Personality Assessment Inventory in egg donors and gestational carriers.J Personal Assess. 2013; 95: 495-499Crossref PubMed Scopus (14) Google Scholar). Therefore, the question that remains is whether or not a single standardized measure is sufficient to evaluate the multitude of complex elements determining the psychological appropriateness of a woman becoming a gestational surrogate. As practice standards emerged, so did studies seeking to develop profiles and norms for GCs. Studies seeking to create MMPI-2 and PAI norms for this population have concluded that GCs show a consistent tendency to underreport and deny problems and to show effortful attempts to present favorably (24Klock S.C. Covington S.N. Results of the Minnesota Multiphasic Personality Inventory–2 among gestational surrogacy candidates.Int J Gynecol Obstet. 2015; 130: 257-260Crossref PubMed Scopus (9) Google Scholar, 28Sims J.A. Thomas K.M. Hopwood C.J. Chen S.H. Pascale C. Psychometric properties and norms for the Personality Assessment Inventory in egg donors and gestational carriers.J Personal Assess. 2013; 95: 495-499Crossref PubMed Scopus (14) Google Scholar). Both the MMPI-2 and the PAI have validity scales that detect positive impression management and are designed to reveal symptom minimization suggestive of defensive denial, which can modify interpretations of clinical scales. For GCs with test profiles suggesting positive impression management and elevated defensiveness, there can be challenges with the validity of the assessment, and results may be uninterpretable. An important consideration in a defensive profile is that it may not be possible to separate deliberate positive impression management (which might be harmless) from naivete about possible negative pregnancy outcomes (32Riddle MP, Jenkins SR. Clinical considerations in the psychological evaluation of gestational surrogates: uses of narrative assessment. Hum Fertil (In press).Google Scholar). The ability to identify issues such as lack of insight into one's own psychological processes or inability or unwillingness to think through possible negative pregnancy outcomes would be a critical consideration for MHPs placed in the gatekeeping role. Even with statistical corrections for positive impression management, characteristics that are considered socially desirable can be overreported on self-report test items, which then make accurate interpretations of the data more difficult. It is well established in the assessment literature that one's understanding of the purpose of an evaluation affects performance on the assessment (33Finn S. In our client's shoes: theory and techniques of therapeutic assessment. Taylor & Francis, New York2007Google Scholar). Psychological assessment of GC candidates is no different in that the women presenting for evaluation are very hopeful to be "chosen" to become GCs. Therefore, there are often efforts from GCs toward positive impression management that can prove challenging to the MHP charged with "clearing" a woman to move forward. The use of psychological tests represents a valid contribution to answering important clinical questions. However, the rapid expansion of the use of some of these tests has led to their misuse and perhaps some unrealistic expectations of their capabilities (31Anastasi A. Urbina S. Psychological testing.7th ed. Prentice-Hall, Upper Saddle River, NJ1997Google Scholar). Some may see psychological tests as analogous to a blood test, where the extracted information presents indisputable facts and answers our questions in a definitive way (16Butcher J.N. Clinical personality assessment: practical approaches. Oxford University Press, New York1995Google Scholar). However, experienced clinicians well versed in the strengths and limitations of psychological tests know that this is not the case. More recent research in the field of personality assessment has shown that personality characteristics of individuals may be either unwilling or unable to self-report accurately can best be assessed by a multi-method approach (34Mihura J.L. Graceffo R.A. Multimethod assessment and treatment planning.in: Hopwood C.J. Bornstein R.F. Multimethod clinical assessment. Guilford Press, New York2014: 285-318Google Scholar). The multi-method approach involves combining several tests for the purpose of developing a more comprehensive psychological profile (35Hopwood C.J. Bornstein R.F. Introduction to multimethod clinical assessment.in: Hopwood C.J. Bornstein R.F. Multimethod clinical assessment. Guilford Press, New York2014: 1-18Google Scholar). Given the propensity of GC candidates to present defensively on self-report, consideration of a multi-method approach to assessment warrants closer attention. More research is needed in the area of psychological assessments for GC candidates. Studies are beginning to emerge that adopt a multi-method approach (32Riddle MP, Jenkins SR. Clinical considerations in the psychological evaluation of gestational surrogates: uses of narrative assessment. Hum Fertil (In press).Google Scholar, 36Cabra R, Alduncin A, Cabra JR, Ek LH, Briceno M, Mendoza PB. Gestational surrogacy. Medical, psychological and legal aspects: 9 years of experience in Mexico. HROpen 2018:1: hox029. Available at: https://doi.org/10.1093/hropen/hox029. Accessed February 27, 2020.Google Scholar). Cabra et al. used a multi-method approach with Mexican GC candidates and described the psychological complexity of the process and the desire for a more comprehensive psychological profile as their primary reasons for doing so (36Cabra R, Alduncin A, Cabra JR, Ek LH, Briceno M, Mendoza PB. Gestational surrogacy. Medical, psychological and legal aspects: 9 years of experience in Mexico. HROpen 2018:1: hox029. Available at: https://doi.org/10.1093/hropen/hox029. Accessed February 27, 2020.Google Scholar). They describe an in-depth assessment process taking place over approximately 15 sessions, and the researchers state that a more comprehensive test battery allows them to exclude for psychological reasons with more confidence. Recent research here in the United States examining the use of a multi-method approach proposes a theoretical framework to include a set of psychological constructs that include personality factors to prioritize in a GC evaluation (32Riddle MP, Jenkins SR. Clinical considerations in the psychological evaluation of gestational surrogates: uses of narrative assessment. Hum Fertil (In press).Google Scholar). These constructs, which the researchers note may be best assessed using more than one psychological test, include the following: Self-Esteem/Need for Achievement; Self-Efficacy; Resiliency; Problem Solving/Coping Skills; and Interpersonal Relationships. A multi-method approach would include adding in additional psychological measures that may tap into the psychological constructs of interest more fully and that might compensate for limitations inherent in any single measure. The MMPI-2 and PAI are self-report, symptom-based psychopathology measures and are not designed to address many of the psychological variables that must be considered in a GC assessment. Adding in additional screening methods may provide incremental validity to screening methods and address limitations inherent in administering only one assessment instrument (32Riddle MP, Jenkins SR. Clinical considerations in the psychological evaluation of gestational surrogates: uses of narrative assessment. Hum Fertil (In press).Google Scholar). Although psychological screening of a GC may never be a completely standardized protocol (37Trull T.J. Prinstein M.J. Clinical psychology.8th ed. Wadsworth Cengage Learning, Australia2013Google Scholar) given the wide array of mental health disciplines and theoretical orientations represented, competent clinicians are well versed in the choices of psychological tests. Therefore, they should be able to provide a clinical rationale for the assessment measures used in pursuit of addressing the referral question. Since the early days of traditional surrogacy in the United States, the importance of a MHP in the psychological consideration of surrogates has been acknowledged. As gestational surrogacy has become the norm, best practices have included an assessment to determine the psychological appropriateness of a woman to become a GC. There are significant challenges for MHPs charged with screening GC candidates. One of the greatest challenges is to interpret defensive profiles, as there are often efforts on the part of GCs toward positive impression management. In addition, although this has been well demonstrated in studies seeking the establish normative data for this population with both the MMPI-2 and PAI (24Klock S.C. Covington S.N. Results of the Minnesota Multiphasic Personality Inventory–2 among gestational surrogacy candidates.Int J Gynecol Obstet. 2015; 130: 257-260Crossref PubMed Scopus (9) Google Scholar, 28Sims J.A. Thomas K.M. Hopwood C.J. Chen S.H. Pascale C. Psychometric properties and norms for the Personality Assessment Inventory in egg donors and gestational carriers.J Personal Assess. 2013; 95: 495-499Crossref PubMed Scopus (14) Google Scholar), the challenge of defensive test profiles is significant, and more work needs to be done to address how to collect meaningful data and not just accept a defensive profile as "normal." Although many MHPs adopt a similar approach to assessment, there is no research at present as to what methods may best answer the question of psychological appropriateness. In particular, it remains unclear how ASRM guidelines might be interpreted in regard to the use of psychological tests. The competent and ethical use of psychological tests by MHPs in the assessment of GC candidates has the potential to enhance the evaluation process: first, by validating findings from the clinical interview; and second, by identifying areas of vulnerability that might then be incorporated into counseling prior to the surrogacy process. However, no psychological measure used in any type of psychological assessment is perfect. Many methods of assessment may exhibit good reliability, validity, and clinical usefulness, but all assessment measures have limitations. Current thinking in the field of personality assessment is that relying on any single assessment instrument will present significant challenges for the assessor (15Groth-Marnat G. Handbook of psychological assessment.5th ed. John Wiley & Son, Inc, Hoboken, NJ2009Google Scholar). A thoughtfully constructed battery of tests by a well-trained clinician may be better suited to answer the referral question (16Butcher J.N. Clinical personality assessment: practical approaches. Oxford University Press, New York1995Google Scholar). The choice of specific tests will ultimately be influenced by clinician theoretical orientation (16Butcher J.N. Clinical personality assessment: practical approaches. Oxford University Press, New York1995Google Scholar). In addition, though there are now studies emerging that demonstrate the potential utility of a multi-method approach in psychological assessment of GCs (32Riddle MP, Jenkins SR. Clinical considerations in the psychological evaluation of gestational surrogates: uses of narrative assessment. Hum Fertil (In press).Google Scholar, 36Cabra R, Alduncin A, Cabra JR, Ek LH, Briceno M, Mendoza PB. Gestational surrogacy. Medical, psychological and legal aspects: 9 years of experience in Mexico. HROpen 2018:1: hox029. Available at: https://doi.org/10.1093/hropen/hox029. Accessed February 27, 2020.Google Scholar), more research is needed to demonstrate which tests might be best and to help create the rationale for their use. Whatever screening methods are used, foremost in the assessment process should be the consideration of a GC's psychological well-being, along with the well-being of her family. From the earliest literature about psychological considerations of surrogates, concern for the well-being of the surrogate, her partner, and her children have been mentioned as important considerations in the psychological clearance process (6Schwartz L.L. Psychological and legal perspectives on surrogate motherhood.Am J Fam Ther. 1991; 19: 363-366Crossref Scopus (4) Google Scholar, 11Hanafin H. Surrogacy and gestational carrier participants.in: Covington S.N. Hammer-Burns L. Infertility counseling: a comprehensive handbook for clinicians. 2nd Edition. Cambridge University Press, Cambridge, UK2006Google Scholar, 38Ethics Committee of the American Society for Reproductive MedicineConsideration of the gestational carrier: an Ethics Committee opinion.Fertil Steril. 2018; 110: 1017-1021Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar). Although current ASRM guidelines recommend both counseling and the consideration of the surrogate's family members, only a handful of studies have been devoted to this topic (39Jadva V. Imrie S. Children of surrogate mothers: psychological well-being, family relationships and experiences of surrogacy.Hum Reprod. 2014; 29: 90-96Crossref PubMed Scopus (45) Google Scholar, 40Riddle M. An investigation into the psychological well-being of the biological children of surrogates.Cogent Psychol. 2017; 4: 1Crossref Scopus (5) Google Scholar, 41Riddle M.P. Michaud S.C. Redden Q.D. Pozza O.R. Scanlan B.L. The psychological impact of surrogacy on the families of gestational carriers: implications for clinical practice.Fertil Steril. 2019; 112: e378-e379Abstract Full Text Full Text PDF PubMed Google Scholar). More research into the impact of surrogacy on the family system is needed to aid in counseling GCs on the potential impact of the process on their family. Future considerations should also include expanding on the use the information garnered by a psychological assessment. Some of the personality characteristics that GCs appear to possess may also present particular vulnerabilities as they move forward in the process of surrogacy. It is important that these be identified and addressed during pre-surrogacy counseling. In his book, "In Our Client's Shoes," Stephen Finn speaks to the "power and potential" of psychological assessment (33Finn S. In our client's shoes: theory and techniques of therapeutic assessment. Taylor & Francis, New York2007Google Scholar). The "power" of a GC screening is clear: women who want to become GCs must "pass" a psychological screening so that they may move forward in the process. The "potential" remains a work in progress. With thorough, appropriate, ethical assessment conducted by competent mental health professionals, the potential for doing good is immense. We have the opportunity not just to evaluate and to clear, but to gather data that might have therapeutic potential in identifying psychological vulnerabilities in a GC candidate that may not exclude that individual but that can be used for therapeutic benefit in counseling and psychological preparation of women as they move forward in the process of surrogacy.