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Background:
Systematic Review

Exploring Attachment Dynamics in Surrogacy: A Systematic Review

by
Rebeca Santamaría-Gutiez
1,2,
Eva María González-Albors
1,
Francisco González-Sala
3 and
Laura Lacomba-Trejo
3,*
1
Faculty of Psychology and Speech Therapy, Universitat de València, Blasco Ibáñez Avenue, 21, 46010 Valencia, Spain
2
Clinical Psychology Resident, General Universitary Hospital of Valencia, Avenida Tres Cruces, 2, 46014 Valencia, Spain
3
Developmental and Educational Psychology Department, Faculty of Psychology and Speech Therapy, Universitat de València, Blasco Ibáñez Avenue, 21, 46010 Valencia, Spain
*
Author to whom correspondence should be addressed.
Psychiatry Int. 2025, 6(4), 145; https://doi.org/10.3390/psychiatryint6040145
Submission received: 27 June 2025 / Revised: 31 August 2025 / Accepted: 29 October 2025 / Published: 21 November 2025
Browse Figure
Versions Notes

Abstract

Surrogacy involves a surrogate carrying a baby to transfer to the intended parents after birth. This study examines how surrogacy impacts attachment patterns compared to traditional pregnancies or assisted reproductive technologies. Using PRISMA guidelines, a systematic review of databases like Scopus and PubMed identified nine relevant studies from 806 initial records, involving 1317 participants (115 pregnant women and 118 children). Key variables included maternal–fetal attachment, depression, anxiety, and somatization in surrogates, alongside intended parents’ support and children’s exploration of their origins. Findings reveal the complexity of attachment dynamics in surrogacy, emphasizing the need for psychological support and preparation to foster secure attachments among surrogates, children, and intended parents.

1. Introduction

Surrogacy is a controversial reproductive method often employed in cases of infertility to establish biological ties with offspring [1]. It can be categorized into traditional and gestational types. In traditional surrogacy, the gestational carrier’s eggs are used, making her genetically related to the child. In gestational surrogacy, an egg donor is involved, resulting in no genetic link between the carrier and the embryo [2]. Although both traditional and gestational surrogacy aim to achieve parenthood through assisted reproduction, they differ substantially in their psychological implications. In traditional surrogacy, the genetic link between the surrogate and the child may heighten emotional complexity, making the separation process more difficult and increasing the risk of emotional distress [3]. Gestational surrogacy, by contrast, tends to facilitate emotional distancing due to the absence of a genetic connection, which some surrogates perceive as helpful in preparing for relinquishment [4]. Nonetheless, emotional attachment may still emerge during pregnancy regardless of genetic ties, particularly when surrogates feel involved in the pregnancy or connected to the intended parents [5]. These psychological nuances underscore the importance of considering the type of surrogacy when analyzing attachment patterns and emotional outcomes for all parties involved.
For this reason, surrogacy practices vary considerably across countries, both culturally and legally, and these differences can profoundly influence the relational dynamics between gestational carriers, intended parents, and children. While some countries have adopted clear regulations, others prohibit surrogacy altogether or operate in a legal vacuum, leading to widely heterogeneous experiences and degrees of protection for the parties involved.
In many European countries—including Austria, France, Germany, Italy, Portugal, and Spain—surrogacy is explicitly banned. Others, such as Belgium, the Netherlands, Greece, and the United Kingdom, allow only altruistic surrogacy under strict regulation, excluding any form of commercial agreement. Still, in countries like Poland or the Czech Republic, no specific laws regulate surrogacy, which creates legal uncertainty for all involved [6,7].
Outside Europe, legal frameworks diverge even further. Commercial surrogacy is legal in countries such as Georgia, Ukraine, Russia, Israel, India, and some U.S. states (notably California), while others—including Canada, Australia, and New Zealand—only permit altruistic arrangements [8]. In Spain, the gestational carrier is always considered the legal mother at birth, and intended parents must go through an adoption process after the surrogate formally renounces her maternal rights in court, even when there is no genetic link between the surrogate and the child [9]. This legal approach discourages the domestic use of surrogacy and pushes Spanish citizens to seek such services abroad, often under different legal and ethical standards.
Cultural and legal contexts also shape how surrogacy is experienced, negotiated, and emotionally processed. In societies where surrogacy is stigmatized or framed as morally problematic, both gestational carriers and intended parents may experience higher psychological distress, secrecy, or lack of social support, potentially interfering with the development of secure attachment [10]. Moreover, the presence or absence of regulatory frameworks impacts informed consent, access to psychological support, and the legal certainty of parenthood—all factors that are central to fostering secure emotional bonds.
In this sense, the psychological effects of surrogacy on both the gestational carrier and the child are not fully understood [11]. Research indicates that surrogates may develop less attachment to the developing embryo [12]. This emotional detachment might serve as a coping mechanism to avoid forming bonds with the embryo, thereby reducing the emotional impact of relinquishing the child [3].
Attachment theory suggests that the attachment formed during pregnancy generally transfers to the child after birth [13]. According to Bowlby, attachment is an enduring emotional bond that forms in early childhood and guides the individual’s expectations in close relationships. Ainsworth later identified different types of attachment based on early caregiver-child interactions: secure, anxious-ambivalent, avoidant, and later, disorganized. These early attachment patterns are considered foundational for socio-emotional development across the lifespan.
In the context of surrogacy, it is important to distinguish between attachment and prenatal bonding. While the term fetal attachment is often used, it has been argued that a more accurate term would be prenatal bond or gestational bonding, as attachment, strictly speaking, refers to a postnatal behavioral system between child and caregiver [14,15]. Prenatal bonding refers to the emotional connection developed by the gestational carrier toward the fetus during pregnancy. This bond may influence later caregiving behaviors and affect the gestational carrier’s psychological well-being. Surrogates who do not bond with the embryo may use emotional distancing or avoidance as coping strategies, potentially mitigating feelings of loss when the baby is born [3].
Additionally, it is important to conceptually differentiate between maternal–fetal bonding, parental attachment representations, and child attachment, as each refers to different psychological and developmental constructs. Maternal–fetal bonding describes the emotional experience of the gestational individual during pregnancy and is not considered part of the attachment system as defined in attachment theory. Parental attachment representations refer to the internal models adults develop about close relationships, often based on their own early attachment experiences, which in turn influence their caregiving behavior and sensitivity toward their children [16]. Finally, child attachment refers to the behavioral and emotional strategies infants develop to seek proximity and safety from caregivers, typically classified into secure, avoidant, ambivalent, or disorganized categories.
These three levels—maternal–fetal bonding, parental attachment representations, and child attachment—interact in complex ways, particularly in surrogacy contexts where the gestational carrier and primary caregiver are not the same person. Current research often examines these dimensions separately, but future work should aim to integrate them more coherently to understand how prenatal, parental, and child-level processes jointly contribute to early relational development in surrogacy settings.
Observations indicate that surrogates with a commercial perspective may experience psychological detachment as preparation for emotional separation, though this may lead to long-term difficulties [17,18].
Regarding children born via surrogacy, a longitudinal study found that most do not report negative impacts on their relationships with their parents due to the lack of a genetic or gestational connection [19]. Many parents and children perceive surrogacy positively, with children expressing pride and gratitude for their mothers’ roles as surrogates. However, some children have shown ambivalence, anxiety, and sadness about the experience [20].
Recent reviews suggest that gestational carriers might face long-term psychological effects, such as anxiety, depression, or feelings of insecurity [21]. The varying degrees of attachment formed during pregnancy could contribute to these psychological challenges upon relinquishing the child [22].
Considering these complexities, surrogacy presents significant ethical, legal, and psychological implications [21]. It constitutes a multifaceted phenomenon that raises important questions regarding identity, bodily autonomy, and the definition of parenthood [21]. Beyond its legal and biomedical dimensions, understanding attachment dynamics between surrogate carriers and newborns is crucial [11], as these early bonds can influence both maternal and infant physical and mental health [11]. As surrogacy becomes more prevalent in contemporary society [23], examining its impact on emotional bonding, caregiving representations, and long-term relational adjustment becomes essential [20]. For this reason, this study aims to analyze attachment patterns in surrogacy through a systematic review, exploring its psychological and social implications. The research question guiding this study is: How does surrogacy affect attachment patterns between children born through this method and their intended parents compared to children born through conventional pregnancies or assisted reproductive techniques [24]?

2. Materials and Methods

2.1. Procedure & Ethical Considerations

A qualitative systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [25]. The corresponding checklist is provided as supplementary material (Table S1). The protocol for this review was registered with PROSPERO (CRD42024534262).
Databases searched included Web of Science, Scopus, PubMed, and ProQuest. The search was conducted in March 2024. Boolean expressions used were as follows: (TS = (surrogacy OR surrogate motherhood OR assisted reproduction OR gestational carrier OR surrogate mother OR gestational surrogacy) AND TS = (attachment OR bonding OR bond * OR mother attachment OR child attachment)) in Web of Science; (TITLE-ABS-KEY (surrogacy OR surrogate motherhood OR assisted reproduction OR gestational carrier OR surrogate mother OR gestational surrogacy) AND TITLE-ABS-KEY (attachment OR bonding OR bond * OR mother attachment OR child attachment)) in Scopus; noft (surrogacy OR surrogate motherhood OR assisted reproduction OR gestational carrier OR surrogate mother OR gestational surrogacy) AND noft (attachment OR bonding OR bond * OR mother attachment OR child attachment) in ProQuest; and in PubMed using the [Title/Abstract] field (surrogacy OR surrogate motherhood OR assisted reproduction OR gestational carrier OR surrogate mother OR gestational surrogacy) AND (attachment OR bonding OR bond * OR mother attachment OR child attachment).
Inclusion criteria were: (a) studies evaluating factors related to attachment in surrogacy, (b) published in peer-reviewed scientific journals, (c) published in any language, and (d) published from 1959 to 2024.
Exclusion criteria included: (a) grey literature such as conference papers, (b) doctoral theses, (c) narrative reviews, (d) single-case studies, (e) articles not reporting results specific to surrogacy, (f) articles not evaluating attachment, (g) studies analyzing only the epidemiology or prevalence of surrogacy, and (h) articles not primarily focusing on surrogacy. Studies published before 1959 were excluded because this is the earliest year for which indexed records are available in the Web of Science database, which was used as one of the core sources in our systematic search. Additionally, surrogacy as a formalized medical and legal practice did not emerge until the late 1970s, and gestational surrogacy using assisted reproductive technology was first documented in the mid-1980s. Therefore, it is highly unlikely that studies published before 1959 would meet the conceptual and methodological criteria relevant to the current review.
Retrieved articles were uploaded to HubMeta [26], an online platform for screening and data extraction in systematic reviews and meta-analyses. Duplicates were automatically removed. Two researchers (E.M.G.-A. and L.L.-T.) independently reviewed titles and abstracts to exclude studies that did not meet the inclusion criteria. Articles with discrepancies in the blind evaluations of the two researchers underwent detailed individual blind reading and re-evaluation to ensure adherence to the inclusion and exclusion criteria.
To assess inter-rater reliability, Cohen’s Kappa (κ) was calculated [27]. Values between −1 and 0.40 are considered unsatisfactory, values between 0.41 and 0.75 are considered satisfactory, and values of 0.76 or greater are considered very satisfactory [28].
Databases searched included Web of Science, Scopus, PubMed, and ProQuest. The search was conducted in July 2025. Boolean expressions used were as follows: (TS = (surrogacy OR surrogate motherhood OR assisted reproduction OR gestational carrier OR surrogate mother OR gestational surrogacy) AND TS = (attachment OR bonding OR bond * OR mother attachment OR child attachment)) in Web of Science; (TITLE-ABS-KEY (surrogacy OR surrogate motherhood OR assisted reproduction OR gestational carrier OR surrogate mother OR gestational surrogacy) AND TITLE-ABS-KEY (attachment OR bonding OR bond * OR mother attachment OR child attachment)) in Scopus; noft (surrogacy OR surrogate motherhood OR assisted reproduction OR gestational carrier OR surrogate mother OR gestational surrogacy) AND noft (attachment OR bonding OR bond * OR mother attachment OR child attachment) in ProQuest; and in PubMed using the [Title/Abstract] field (surrogacy OR surrogate motherhood OR assisted reproduction OR gestational carrier OR surrogate mother OR gestational surrogacy) AND (attachment OR bonding OR bond * OR mother attachment OR child attachment).

2.2. Quality Assessment

The quality of the included studies was independently and blindly assessed by the authors (E.M.G.-A. and L.L.-T.) using an adapted version of the “Quality Assessment Tool for Quantitative Studies” developed by the Effective Public Health Practice Project [29]. This assessment was based on seven criteria: study design, selection bias, withdrawals and dropouts, confounders, data collection, data analysis, and results.
Each study was rated on 4 to 8 components based on these criteria, and an overall score was determined from these ratings. Studies were classified as “strong” if there were no “weak” ratings and at least three “moderate” ratings; “moderate” if there was one “weak” rating or fewer than three “strong” ratings; and “weak” if there were two or more “weak” ratings [30].
The total score was derived by averaging the ratings across the criteria and was categorized as weak, moderate, or strong. Scores ranged from 1 to 5, with 1 indicating low risk and high methodological quality, and 5 indicating high risk and low methodological quality [30].

2.3. Study Selection and Screening

Figure 1 illustrates the study selection process. After conducting the literature search and applying the search criteria, duplicate articles (n = 1079) were removed, resulting in 804 articles for initial analysis. During the first selection stage, 778 studies were excluded based on title and abstract evaluation for not meeting the inclusion and exclusion criteria.
The full texts of the remaining 24 articles were then reviewed. The inter-rater reliability between the two independent evaluators (E.M.G.-A. and L.L.-T.) for screening titles and abstracts was excellent (κ = 0.89).
In the second selection phase, 15 papers were excluded: 7 for not providing the evaluated measures or variables, 7 for being theoretical articles or reviews, and 1 for being a case report. Consequently, 11 studies were selected for final analysis. The agreement between evaluators at this stage was also excellent (κ = 0.90).

3. Results

3.1. Study Characteristics3

3.1.1. Participants

Participant characteristics are summarized in Table 1. The eleven selected articles included a total of 1767 participants, comprising women, men, and children. Among the women (n = 528), 115 (6.50%) were gestational carriers [12,30,31], 143 (8.09%) were mothers who did not conceive through surrogacy [12,31,32,33], and 270 (15.28%) were lesbian mothers who conceived through assisted reproductive techniques, specifically donor insemination [33,34,35,36].
Among the men (n = 566), 475 (26.88%) were gay fathers who used surrogacy [30,33,34,35,36,37,38,39], and 91 (5.15%) were heterosexual fathers, with 28 through surrogacy [37] and 63 through assisted reproductive techniques, specifically gamete donation [33,34].
Children (n = 673) participated in the studies, comprising 38.09% of the sample. Specifically, 179 (26.60% of 673) were born through surrogacy [30,34,35,38], 67 (9.96% of 673), through donor insemination [34,35], 21 (3.12% of 673) through gamete donation [34], and the remaining 317 (47.10% of 673) were a control group of children born conventionally [35] and 21 (3.12% of 673) from not specified ART [33].
Three of the eleven articles included gestational carriers [12,31,32], six included both parents and children born through assisted reproductive methods [30,33,34,35,36,38], and two included only parents through assisted reproduction [34,37].

3.1.2. Sample Selection and Research Design

For sample selection, participants in five studies were recruited through internet forums [30,32,35,37,38]. Additionally, seven studies used surrogacy contact associations [30,32,34,35,37,38]. Specifically, six studies involved “Rainbow Families,” the primary association of LGBTQ+ parents using assisted reproduction in Italy [30,33,34,35,36,38,40]. Four studies recruited through surrogacy agencies [12,31,32], three through same-sex parenting events [30,35,38], and six used snowball sampling [30,34,35,37,38,40].
Regarding research designs, four studies were longitudinal, with two evaluations each [30,31,36,38]. One study evaluated during gestation and after birth [31], while two studies evaluated years after birth [30,36,38]. The average evaluation period was 16 months, with a range of 13 to 18 months between evaluations.
The remaining seven studies were cross-sectional [12,32,33,34,35,37,40].

3.1.3. Validity and Reliability of the Assessment Tools

Multiple instruments with varying degrees of validity and reliability were used, many of which were adapted or validated for the specific cultural and linguistic contexts of the samples analyzed.
Attachment
Adult Attachment Interview (AAI; [16,41]). The instrument was applied in studies by Carone et al., (2023) [34], Carone et al. (2023) [39] and Quintigliano et al. (2025) [33]. In both cases, the procedure for transcribing and coding responses is detailed, which involves the participation of two independent and trained coders who used the coding scheme proposed by Main et al. (2002) [16]. It is reported that, in the three studies, the agreement between evaluators was ĸ = 0.86 (p < 0.001) for the three main classifications, and ĸ = 0.81 (p < 0.001) for the unresolved status/CC category.
Maternal–Fetal Attachment Scale (MFAS; [42]). Fischer & Gillman (1991) [12] reported that the original scale had validity coefficients between 0.61 and 0.83 for the subscales and the overall scale, as well as validity coefficients between 0.29 and 0.60 between the subscales and Cronbach’s alphas between 0.52 and 0.73 for the subscales and 0.85 for the overall scale in the study by Cranley (1981) [42]. A modified version of the MFAS with yes/no response options to aid understanding by the participants was applied by Lambda et al. (2018) [31], reporting Cronbach’s alphas of 0.74 and 0.59 for Emotional Prenatal Bonding and Instrumental Prenatal Bonding, respectively.
Interview for the Identification of the Primary and Secondary Attachment Figures. Carone et al. (2025) [36] applied an interview which was adapted from the original version created by Hazan and Zeifman (1994) [43] and administered individually to each parent, following the sensitivity task.
Attachment Q-Set (AQS; [44]). It was applied in Carone et al. (2025) [36], reporting an interrater reliability (rICC, absolute agreement) on 25% of the videos (n = 37) was 0.81.
The Attachment Figure Interview [45]. The authors [33] did not report any information about the reliability of the instrument in their study.
Security Scale Questionnaire [46]. Carone (2022) [37] and Carone et al. (2020) [35] applied this instrument, providing references about moderate stability over time and convergence with observations of children’s interactions with parents in child and adolescent samples. Carone et al. (2020) [40] applied the Italian validation [47,48]. Cronbach’s alpha was 0.78 in Carone et al. (2020) [35] study, 0.80 and 0.78 for children of gay and heterosexual single fathers, respectively, in Carone (2022) [37] and 0.85, 0.71, and 0.80 for safe haven support, secure base support, and total attachment security, respectively, in Carone et al. (2020) [40] study.
Paternal Antenatal Attachment Scale (PAAS; [49,50]). Carone et al. (2021) [38] and Carone et al. (2023) [39] applied the Italian validation of this scale, reporting Cronbach’s alpha of 0.81.
Psychopathology
Patient Health Questionnaire (PHQ-9; [51,52]). Carone et al. (2021) [38] reported a Cronbach’s alpha of 0.79 in their study.
Patient Health Questionnaire (PHQ-15; [53]). In Carone et al. (2021) [38] study, Cronbach’s alpha was 0.83.
General Anxiety Disorder scale (GAD-7; [54]). A Cronbach’s alpha of 0.81 was reported in Carone et al. (2021) [38] study.
Anxiety, Depression and Stress Scale (ADSS; [55]). Lambda et al. (2018) [31] applied this instrument, developed in India and the standardization included participants from illiterate and marginalized groups. The internal consistency of the original scale was 0.81 and >0.85 in Lambda’s study [31].
Hospital Anxiety and Depression Scale (HADS; [56]). The authors [32] did not report any information about the reliability of the instrument in their study.
Other Variables
Personal Resource Questionnaire (PRQ; [57]). The authors [12] report that Brandt and Weinert’s (1981) [57] study found an internal consistency of 0.89 for part 2 of the scale and between 0.61 and 0.77 for its subscales. In addition, validity coefficients between 0.21 and 0.23 (p < 0.004) were found for part 1, and between 0.30 and 0.44 (p < 0.001) when correlating the PRQ with measures of family functioning and marital adjustment. However, they do not report data on the internal consistency or validity of the instrument in their study.
Reflective Functioning Scale (RFS; [58]). In the studies conducted by Carone et al. (2023) [34], as well as by Quintigliano et al. (2025) [33], the instrument following the AAI-RF system proposed by Fonagy et al. (1998) [58] was applied by two independent and certified coders. Both studies reported interrater reliability according to the intraclass correlation coefficient of κ = 0.83 (p < 0.001).
Friends and Family Interview (FFI; [59]). It was administered by Carone et al. (2023) [34], by two certified coders, resulting in interrater reliability of κ = 0.84 (p < 0.001) for categorical agreement on FFI patterns. The authors mentioned that the FFI has demonstrated good interrater reliability and construct validity across studies and has also been applied to diverse samples of children younger than 8 years, although it was originally developed for children older than 8 years.
Verbal Comprehension Index of the Wechsler Intelligence Scale for Children, IV version (VCI-WISC-IV; [60,61]). The authors [34] did not report any information about the reliability of the instrument in their study.
Parenting Stress Index–Short Form (PSI; [62,63]). Cronbach’s alpha was 0.92 in Quintigliano et al. (2025) [33] study.
Parent–Child Relational Self-Efficacy questionnaire (PCRSE; [64,65]). Quintigliano et al. (2025) [33] reported that the composite reliability of the PCRSE was 0.88 in their study.
The Parental Acceptance-Rejection Questionnaire–Short Form (PARQ–SF; [66]). Cronbach’s alpha was 0.77 in Quintigliano et al. (2025) [33] study. Furthermore, authors pointed that it has been found to have good reliability coefficients, homogenous effect sizes [67], and good convergent and discriminant validity [66].
The Positivity Scale (POS; [68]). Cronbach’s alpha was 0.81 in Quintigliano et al. (2025) [33] study.
Maternal Adjustment and Maternal Attitudes Questionnaire [69]. In Fischer & Gillman’s (1991) [12] study, pointed out that criterion-related validity reported by Kumar et al. (1984) [69] with student’s was t of 3.03 to 6.69, p < 0.001 and p < 0.005, for four of the subscales, test retest reliability coefficients ranged from 0.81 to 0.95, and split-half reliability coefficients ranged from 0.72 to 0.82 for the subscales.
25-item short version [70] of the Maternal Behavior Q-Sort (MBQS; [71]). In Carone et al. (2025) [36] study, the instrument has a threshold of 0.30 for sensitivity predicting attachment security and the interrater reliability (rICC, absolute agreement) on 25% of the videos (n = 37) was 0.86.
Coparenting in the Family of Origin [72]. In Carone’s study (2022) [37], Cronbach’s alphas were 0.87 and 0.89 for gay and heterosexual single fathers, respectively.
Family Alliance Assessment Scale (FAAS), version 6.3 [73]. This instrument was applied in Carone’s (2022) [37] study by a single reliable coder. To test interrater reliability, 25% of the videos were coded by a second reliable coder, reporting Cohen’s ĸ = 0.81 and 0.72 for the family alliance; overall, 15 scale scores, respectively, p < 0.001.
Parental Scaffolding During Surrogacy-Related Discussions [74,75]. Carone et al. (2020) [35] reported applying this instrument by two independent coders, resulting resulted in an interrater reliability of κ = 0.79.
Interview about Children’s Exploration of Their Surrogacy Origins. An adaptation of Minnesota/Texas Adoption Project [76,77] interview was applied by Carone et al. (2020) [35] and Carone et al. (2023) [39]. In their study, a second coder rated 30% of the interviews (n = 9), resulting in an interrater reliability of κ = 0.7.
Multidimensional Scale of Perceived Social Support [78,79]. In the Carone et al. (2021) [38] study, Cronbach’s alpha was 0.90.
Life Events Inventory [80]. The authors [38] did not report any information about the reliability of the instrument in their study.
Interpersonal Reactivity Index (IRI; [81]). No data about the reliability of the instrument was reported by Lorencaeu et al. [32]
Important People Interview (IPI; [82,83]). No data about the reliability of the instrument was reported by Carone et al. (2020) [40].
Childrearing Practices Q-set (CRP; [84]). Carone et al. (2020) [40] reported that Cronbach’s alphas were 0.72 and 0.71 for mothers and fathers, respectively, in their study.
Etch-A-Sketch task [85] and Co-Construction task [86]. Carone et al. (2020) [40] coded the sessions using the Parent–Child Interaction System (PARCHISY; [87]) that has been widely used with children with typical behavior as well as those with behavioral and/or emotional problems. The intraclass correlations (ICC, single measure) for positive control, negative control, warmth, rejection, and parent’s responsiveness to child were 0.84, 0.79, 0.81, 0.72, and 0.86, respectively.
In general terms, the instruments mentioned showed satisfactory evidence of validity and reliability in the various linguistic and cultural contexts of the studies analyzed. When necessary, linguistic and cultural adaptations were made, such as translation and back-translation processes, elimination of irrelevant items, and the use of certified and trained coders, to ensure the accuracy and consistency of the measurements. However, some studies did not provide complete information on cultural adaptation or specific psychometric properties for their samples, which represents a limitation to be considered when interpreting the results. Furthermore, several of the instruments used in the studies analyzed do not have specific psychometric validation in surrogates.

3.1.4. Variables: Attachment Evaluation

The studies evaluated a range of dependent variables, with a focus on attachment evaluation. Five studies assessed child attachment [30,34,35,37,40] using the modified SS Questionnaire [47,48,88], the Paternal Prenatal Attachment Scale (PAAS; [49,50]), and interviews with friends and family (FFI; [34]). One study [33] assessed child–parent Attachment Security using Attachment Q-Set (AQS; [44])
Maternal–fetal attachment was evaluated in three studies [12,31,32] using the Maternal–Fetal Attachment Scale [42] and the Maternal Prenatal Attachment Scale (MAAS; [49]). Additionally, parental attachment states were measured using the Adult Attachment Interview (AAI; [16,41]). in four studies [33,34,36,38]. Parental identification of attachment figures and their willingness to act as a reference figure were also assessed [33,35,36].

3.2. Main Results

3.2.1. Attachment

Two studies [12,31] reported that surrogate gestational carriers exhibited a lower maternal–fetal bond compared to the control group. This diminished bond was characterized by reduced emotional connection, less interaction, fewer attributions of characteristics and intentions to the unborn baby, and less differentiation between the “self” and the unborn baby.
Another study [32] found that the type of surrogacy influenced the quality of maternal–fetal attachment, and the bond with the intended parents affected the number of gestational babies born. Attachment security was found to impact children’s exploration of their origins through surrogacy [30]. It did not differ by family type or surrogacy method, whether for gay fathers or lesbian mothers [35]. Additionally, attachment security was predicted by parents’ willingness to act as attachment figures and their parenting behaviors [35]. Furthermore, another study found a positive relationship between the quality of co-parenting experienced by single parents in their families of origin and attachment security in their own surrogacy families [37], indicating that co-parenting influences the attachment between parents and children in surrogacy [38].
In contrast, other studies [33,34,36] found no significant differences in the distribution of attachment patterns among children born through surrogacy compared to those born through other assisted reproductive methods or from the general population. One study [36] found that over 60% of children were securely attached in both types of family: 67.11% of children born through assisted reproductive methods in lesbian mother families and 68.06% of children through surrogacy in gay father families.
A positive relationship (moderate in lesbian families and small in gay families) between parental sensitivity and later attachment security was found across different parent genders and attachment figure role [36].

3.2.2. Pregnancy Experience and Support

Gestational surrogates exhibited more positive attitudes toward their body image and sexual health [12] and demonstrated higher levels of attention and care for the unborn baby [31]. However, they also reported more negative attitudes toward pregnancy and the baby compared to the control group [12].
Regarding support, surrogates perceived less social support compared to non-surrogate mothers [12].

3.2.3. Psychopathology

Three studies assessed depression, anxiety, and somatization. One study found that the nationality of surrogate mothers influenced their levels of depression [32]. Lamba and colleagues (2018) [31] observed that surrogate gestational carriers exhibited higher levels of depression compared to the control group of mothers during pregnancy and after childbirth. Additionally, surrogate fathers experienced higher levels of depression during the pandemic compared to gay fathers who had children before the pandemic [40].
Regarding anxiety, one study found no significant differences between surrogate carriers and other types of mothers during pregnancy or after childbirth [31].

3.2.4. Influential Variables

Age was found to affect both gestational and traditional surrogacy, as well as the number of gestational children and surrogacy for gay couples [32]. Similarly, the type of surrogacy influenced the number of gestational or traditional children born [32].

3.2.5. Process of Exploring Origins

The age of the children, attachment security, and parental scaffolding and support [30] were significant predictors of greater exploration, the interaction between information disclosure and parental mental coherence predicted higher levels of exploration in children [38].

3.2.6. Cultural Context

In terms of cultural context, Anglo-Saxon and European surrogate mothers showed lower levels of maternal–fetal attachment, attachment quality, and empathy [32].

3.2.7. Contextual Factors

Carone and colleagues [40] observed that the COVID-19 pandemic significantly affected the father-child bond in surrogacy families. Surrogate fathers experienced higher levels of anxiety and increased somatization compared to those who had children before the pandemic [40].

3.3. Quality Assessment

Table 2 presents the quality ratings assigned to the studies. The average quality score was 1.98, indicating generally moderate quality across all evaluated studies. Quality scores range from 1 to 5, with 1 representing the highest quality (lowest risk of bias) and 5 representing the lowest quality (highest risk of bias). The quality assessment was conducted by one evaluator (E.M.G.-A.).
Although the “Quality Assessment Tool for Quantitative Studies” does not provide a numerical scoring system, the classification of studies followed established guidelines based on the presence of weak, moderate, or strong ratings across key domains. The most commonly lacking criteria among the included studies were the absence of randomized controlled designs, limited use of control or comparison groups, and the cross-sectional nature of many designs, which reduces the ability to assess temporal and causal relationships. Additionally, some studies did not clearly report strategies to control for confounders or had limited reporting of dropout rates. For future research, we recommend employing standardized and validated instruments, adopting longitudinal designs when feasible, and increasing the use of comparison groups to improve internal validity and interpretability of results.

4. Discussion

This study aims to understand how surrogacy affects attachment patterns between children born through this technique and their intended parents compared to children born through conventional pregnancies or assisted reproductive methods. The main findings indicate that maternal–fetal attachment and attachment security are influenced by various factors, including the type of surrogacy, the quality of the bond with intended parents, the parents’ willingness to act as attachment figures, their parenting behaviors, the stressful experience of the COVID-19 pandemic, and the quality of co-parenting.
Firstly, surrogate mothers show a weaker maternal–fetal bonding compared to women with their own pregnancies. This weaker bonding is characterized by reduced emotional connection, less interaction and little attribution of characteristics or intentions to the baby [12,31,32]. This phenomenon could be understood as an adaptive psychological mechanism to protect against the planned separation from the baby. This adaptive strategy also carries risks, as evidenced by previous studies suggesting that this type of emotional distancing can lead to difficulties in emotional regulation and risky behaviors [89]. Likewise, the type of surrogacy (traditional vs. gestational) and the relationship with the intended parents have been found to significantly influence the quality of attachment during gestation, underscoring the importance of the pre-birth context in shaping early emotional bonding [32]. Importantly, recent studies highlight that prenatal bonding not only influences maternal well-being during pregnancy but also predicts the quality of mother–infant bonding after birth, underscoring the continuity between pre- and postnatal processes [90,91]. Evidence suggests that maternal prenatal anxiety can undermine bonding during pregnancy, which subsequently predicts poorer maternal–infant bonding in the first months of life and, in turn, is linked to toddlers’ externalizing and emotional difficulties [90]. This highlights the mediating role of postnatal bonding in the relationship between maternal prenatal distress and later child socio-emotional outcomes. Likewise, maternal–infant bonding after birth has been shown to be influenced by a range of psychological and social factors. Depressive and post-traumatic stress symptoms, sleep disturbances, and delivery-related complications are consistently associated with weaker bonding, whereas partner satisfaction, social support, and previous parenting experience emerge as protective factors [92]. Therefore, it seems advisable to monitor throughout pregnancy for possible medium- and long-term psychological complications in the pregnant mother.
In relation to infant attachment, the evidence collected suggests that children born by surrogacy do not present significant differences in attachment security compared to those born by other types of assisted reproductive techniques or by conventional methods [33,34,36]. Some studies [36] point out that more than 60% of children were classified as securely attached in both lesbian and gay-parent surrogated families. Children’s attachment security was associated with variables such as parental sensitivity, parents’ willingness to serve as attachment figures, and with the quality of co-parenting, both in single-parent and same-parent families [30,35,37,38]. Thus, this finding emphasizes that it is not the reproductive technique itself, but the relational dynamics and the quality of the family environment that seem to determine the psychological well-being of children. Therefore, it would be advisable to orient the clinical and social approach towards the support and strengthening of parenting skills and co-parenting to favor healthy child development.
The COVID-19 pandemic was presented as a contextual stressor that exacerbated levels of anxiety, somatization and difficulties in parental bonding in surrogate parents to a greater extent than other gay parents [40], suggesting a vulnerability in coping with crisis situations. Thus, fostering specific support systems in adverse situations could prevent negative impacts on family psychological well-being and protect the quality of the bond.
In relation to psychopathological symptoms, surrogate mothers reported higher levels of depression during pregnancy and postpartum compared to women pregnant by conventional methods [31,32]. Likewise, surrogate parents, especially those who went through the process during the pandemic, presented higher levels of anxiety and somatization compared to those who were parents before this global event [40]. These findings again underscore the need to implement psychological support interventions throughout the entire surrogacy process for both intended parents and intended families.
Longitudinal studies provided evidence for the importance of attachment security and parental support in children’s exploration of their surrogate origins [31,34]. Factors such as transparency in communication and parental emotional consistency favored a safe environment for children to integrate their birth story, whereas attempts to withhold information or avoid the topic may limit such an exploratory process [38]. Thus, in the case where children explore their origins, it would be beneficial to encourage open communication through family interventions in a way that promotes healthy psychological development and an integrated identity.
Despite the relevant contributions of this review, several limitations must be acknowledged. First, the total number of included studies (n = 11) remains small, which limits the generalizability of the findings. In addition, many studies have small sample sizes, nonrandom sampling, and lack of geographic representativeness, which reduces their external validity. Most of the studies had a cross-sectional design, which prevents the establishment of causal relationships. Methodological heterogeneity in terms of design, samples and assessment tools also made it difficult to compare studies. A meta-analysis was not feasible given the heterogeneity of study designs and the limited sample sizes. A relevant limitation is that several of the instruments used in the studies analyzed do not have specific psychometric validation in surrogates. This absence can generate biases and limit the reliability of the results. The lack of large, multicenter longitudinal studies limits the understanding of the dynamic processes of attachment and mental health in this context. At the cultural level, most of the research was conducted in Western contexts, without addressing in depth the implications of diverse cultural regulations and values surrounding surrogacy. Another limitation to consider is the quality of the instruments used to assess the variables analyzed. In some studies, the instruments used showed only moderate internal consistency, especially in initial research. Furthermore, in several cases, the psychometric properties of the tools were not reported, which makes it difficult to assess the validity and reliability of the results obtained.
For future research, it is recommended to increase the number and diversity of the samples, use longitudinal methodologies, apply cross-culturally validated instruments and explore additional variables relevant to the development of attachment, such as the history of adult attachment of the intended parents and surrogates [18], family cohesion [19] and adverse early experiences [20]. It would be advisable for future research to adapt or develop tools that guarantee their suitability for this particular population. It is also relevant to compare different models of surrogacy and to analyze how the experience varies in contexts where surrogacy is legal, ambiguous or prohibited, as well as to investigate the motivations that lead people to participate as surrogates, considering socioeconomic factors that could influence this process. In relation to this last point, there is also a need to take into account variables such as autonomy and informed consent of all parties involved.

Practical Implications

Clinically, these results highlight the importance of incorporating psychological care into surrogacy support programs. Health professionals should be empathetically trained to understand the unique psychological, emotional, and relational dynamics of surrogacy to provide comprehensive support to all parties involved, including intended parents, surrogate carriers, and, ultimately, the children. Psychological preparation and follow-up should be integrated into the care plan before, during, and after the gestational process, addressing topics such as emotional attachment, expectations, coping strategies, and potential grief or identity concerns. For example, given that surrogates often engage in emotional distancing as a protective strategy, preparatory sessions could explicitly address healthy ways of managing emotional attachment (e.g., guided imagery, journaling, and open discussions about anticipated separation) while also promoting adaptive coping strategies to mitigate grief after birth.
In addition, the findings support the development of clear psychological screening protocols for both surrogate carriers and intended parents to assess motivations, emotional readiness, and potential vulnerabilities that may affect bonding and mental well-being. Such screenings could include standardized tools to detect depressive or post-traumatic symptoms, anxiety, and relationship stressors, which have been shown to predict poorer bonding. Based on our results, interventions should include, at a prenatal stage, elements like psychoeducation for surrogates on the normal range of emotions during pregnancy, stress management workshops, and mindfulness-based interventions to reduce anxiety. For intended parents, it would be important to include in interventions counseling on realistic expectations, stress management, and structured guidance on how and when to communicate with their children about their origins (e.g., narrative therapy, age-appropriate disclosure strategies). With respect to family structure, evidence shows that children’s attachment security did not differ by parental sexual orientation, family type, or gender. Children’s outcomes were more strongly linked to parental behaviors and psychological functioning, such as sensitivity, warmth, and reflective functioning. These results highlight that interventions should prioritize enhancing parental scaffolding and reflective capacities, regardless of family configuration. At a postnatal stage, structured debriefing sessions with surrogates to process separation and prevent unresolved grief or PTSD, as well as early parenting support for intended parents could help prevent and mitigate potential psychological distress. Cultural differences also emerged as relevant: Anglo-Saxon and European surrogate mothers presented lower levels of maternal–fetal attachment and empathy, which suggests that screening and support protocols should be culturally adapted and sensitive to the social narratives and expectations surrounding surrogacy in each country.
Although surrogacy is subject to ethical, moral, and legal controversy, and is prohibited in many countries, in those contexts where the practice is legal, it is crucial to ensure it takes place in a framework of maximum safety, dignity, and protection for the surrogate. The aim should not be to ignore or simplify the ethical dilemmas, but to guarantee that, if surrogacy is pursued, it is done under strict regulation that prevents exploitation, ensures full informed consent, and safeguards the rights and mental health of all involved—particularly the gestational carrier, who may be exposed to complex emotional and social pressures.
Recently, the United Nations Special Rapporteur on violence against women and girls (Reem Alsalem) issued a report calling for the total ban of surrogacy worldwide. The report highlights that surrogacy, regardless of whether it is framed as “altruistic” or commercial, often entails multiple forms of violence and exploitation, including economic coercion, reproductive and psychological harm to women, and risks to children’s rights. This international stance emphasizes the urgent need for governments and professional bodies to critically examine the practice and to develop binding ethical and legal safeguards. In this sense, our findings align with the broader call for careful regulation and the provision of psychological assessment and follow-up whenever surrogacy occurs, to minimize harm and to protect the well-being of all parties involved [93].
From a policy perspective, these results emphasize the urgency of implementing legal frameworks that protect all stakeholders, ensuring that both surrogate and intended parents are fully informed and voluntarily consenting. Regulations should include ethical guidelines to avoid exploitation, as well as standardized informed consent procedures and access to independent legal and psychological counseling. The creation of multidisciplinary teams in fertility clinics and maternity services—composed of psychologists, social workers, legal advisors, and medical staff—would foster more holistic and ethical surrogacy practices. Finally, raising social awareness and promoting education on the psychosocial aspects of surrogacy may help reduce stigma and ensure that children’s rights and well-being remain at the center of all decisions.

5. Conclusions

Clinically, these results highlight the importance of incorporating psychological care into surrogacy support programs. Health professionals should be empathetically trained to understand the context and consequences of surrogacy to better support all parties involved.
In conclusion, this review highlights that factors such as the type of surrogacy, the COVID-19 pandemic, and the sexual orientation of intended families may significantly influence attachment patterns between parents and children in surrogacy contexts. The reviewed findings suggest that attachment security, crucial for children’s psychological development, can be affected by family dynamics and external conditions. Both surrogates and intended parents should receive psychological support and preparation to foster a stable environment that promotes secure attachment. Furthermore, the evidence reviewed supports the need to adapt policies and clinical practices to safeguard the well-being of all parties involved in surrogacy.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/psychiatryint6040145/s1, Table S1: PRISMA 2020 Checklist for the systematic review.

Author Contributions

Conceptualization, E.M.G.-A. and L.L.-T.; writing—original draft preparation, E.M.G.-A. and L.L.-T.; writing—review and editing, L.L.-T., R.S.-G. and F.G.-S.; supervision, L.L.-T.; project administration, L.L.-T. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, [L.L.-T.], upon reasonable request.

Conflicts of Interest

The authors declare no conflicts of interest.

AI-Assisted Technology Statement

Portions of the English language editing and phrasing in this manuscript were supported using OpenAI’s ChatGPT (version GPT-5). The tool was employed exclusively to improve grammar, clarity, and academic style after the authors had produced the original scientific content. All intellectual and analytical contributions, study design, data interpretation, and conclusions are entirely the authors’ own. The authors take full responsibility for the integrity and accuracy of the manuscript.

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Psychiatryint 06 00145 g001
Figure 1. Flowchart for study selection.
Figure 1. Flowchart for study selection.
Psychiatryint 06 00145 g001
Table 1. Main Results.
Table 1. Main Results.
Author and YearCountry and ParticipantsVariablesDesignMain Results
Fischer & Gillman
(1991) [12].		USA
42 women (21 GS; 21 pregnant but not through GS)		- Sociodemographic and clinical variables: age, place of birth, marital status, educational level, socioeconomic status, religious affiliation, duration of pregnancy, and average number of children born.
- Psychological variables: number of interpersonal resources and perceived support level, maternal–fetal attachment, maternal attitudes, self-perception, and pregnancy-related behavior.		Observational, descriptive, cross-sectional, comparative.Non-gestational mothers through surrogacy were more bonded to the unborn baby in: differentiation of the “self” from the fetus (t(40) = 8.14, p < 0.05), interaction with the baby (t(40) = 6.91, p < 0.05), and attribution of characteristics and intentions to the baby (t(40) = 2.07, p < 0.05).
Surrogate mothers had more positive attitudes towards body image (t(40) = 2.07, p < 0.05) and attitudes towards sex (t(40) = 2.82, p < 0.05). They had more negative attitudes towards pregnancy and the baby (t(40) = 11.58, p < 0.05).
Lorenceau et al. (2015) [32].France
N = 76 (44 GS; 32 mothers but not through GS)		- Sociodemographic and clinical variables: age, nationality, age at first GS/pregnancy (comparison group), type of GS, number of children by type of GS, number of biological children, number of children by non-gestating parents’ sex, desire to repeat GS experience, and previous losses before GS.
- Psychological variables: empathy (personal distress, empathic concern, perspective taking, and fantasy scale), emotional state (depression and anxiety), desirability scale (social desirability), and attachment (attachment quality and attachment quantity).		Observational, cross-sectional.Anglo-Saxon and European surrogate mothers had lower maternal–fetal attachment (AGEST δ = 0.95) and quality (AGEST δ = 1.52), and less empathy (AGEST δ = 1.04, p < 0.05).
The type of surrogacy had effects on the number of gestational or traditional children born (H(2) = 13.833, p < 0.001), as well as on the quality of maternal–fetal attachment.
Lamba et al. (2018) [31].India
119 women (50 GS; 69 pregnant but not through GS)		- Sociodemographic variables: age, educational level, marital status, number of children, income level, religious affiliation.
- Psychological variables: anxiety, depression, stress, emotional and instrumental prenatal bond, GS experiences including concealment, criticism, living situation, perceived support, satisfaction with payment, meeting the newborn, and meeting the intended parents.		Correlational, longitudinal (T1 between 4–9 months of pregnancy; T2 between 4–6 months after birth).Surrogate mothers had more depression before (χ2(1) = 12.9, p < 0.001) and after (χ2(1) = 6.12; p = 0.01) childbirth than non-surrogate mothers (p < 0.02), lower maternal–fetal attachment (F(1, 116) = 4.19, p = 0.04) but higher attention and care towards the unborn baby (F(1, 116) = 4.27, p = 0.04).
Carone, Barone et al. (2020) [35].Italy
387 children (33 born via GS; 37 children born via insemination; 317 control group) and their families (66 same-sex parents; 74 lesbian parents; 634 heterosexual families).		- Sociodemographic and clinical variables: child’s sex, number of siblings, parents’ ethnic background, parents’ residence, parents’ educational level, parents’ occupation, parents’ employment status, duration of the couple’s relationship, marital status, genetic parenthood, child’s age at the visit, parents’ age, and household income.
- Psychological variables: Identification of children’s primary/secondary attachment figures, attachment, support seeking and affiliative proximity seeking, parenting practices and beliefs.		Observational, cross-sectional.The security of children’s attachment did not differ by family type (gay fathers or lesbian mothers) (F(1, 135) = 2.04, p = 0.16, ηp2 = 0.02, d = 0.30).
Significant associations between attachment security and positive parental control (b = 0.04, t(117) = 1.96, p = 0.053), parental warmth (b = 0.09, t(99) = 4.69, p < 0.001), parental responsiveness (b = 0.10, t(130) = 4.43, p < 0.001), negative parental control (b = −0.08, t(106) = −2.80, p < 0.01), parental rejection (b = −0.10, t(122) = −3.18, p < 0.01) and willingness to serve as an attachment figure (b = 0.19, t(127) = 4.97, p < 0.001).
The willingness of parents to serve as an attachment figure and parental behaviors predicted children’s attachment security better than family type (b = 0.03, t(66) = 0.74, p = 0.46).
Carone (2022) [37].Italy
59 single-parent families (31 same-sex and 28 heterosexuals via GS).		- Sociodemographic and clinical variables: child’s gender, number of siblings, family residence, father’s ethnic background, father’s educational level, father’s employment status, father’s marital status, non-parental caregivers involved in shared parenting, child’s age, father’s age, and annual household income.
- Psychological variables: coparenting, child attachment.		Observational, cross-sectional.There are no significant differences in: co-parenting quality in families of origin between single gay fathers and single heterosexual fathers (F(1, 57) = 0.257, p = 0.614, ηp2 = 0.004); children’s attachment security between children of single gay and heterosexual fathers (F(1, 55) = 0.317, p = 0.860, ηp2 = 0.001), nor between boys and girls (F(1, 55) = 0.586, p = 0.447, ηp2 = 0.011); family alliance by family type (Wilks’ λ(16, 40) = 0.727, p = 0.536, ηp2 = 0.273), nor the child’s gender (Wilks’ λ(16, 40) = 0.739, p = 0.590, ηp2 = 0.261), nor their interaction (Wilks’ λ(16, 40) = 0.784, p = 0.787, ηp2 = 0.216).
Significant relationship between co-parenting quality in the family of origin and children’s attachment security, through conflict observed during family interactions (LTP) (estimated point = 0.561, SE = 0.269, 95% CI [0.084, 1.121], p = 0.037).
No relationship between co-parenting quality in the family of origin and children’s attachment security through support observed during family interactions.
Carone et al. (2021) [38].Italy
80 same-sex parents with GS children (30 during COVID-19 and 50 before).		- Sociodemographic and clinical variables: parents’ age, gender, sexual orientation, country of residence, annual household income, education and employment, number, gender, age, and conception method of the child(ren), the country where GS took or is taking place and expected birth date of the baby.
- Psychological variables: parent–child bond, parents’ mental health, social support, and stressful events.		Observational, cross-sectional.A lower father-child bond was observed during the COVID-19 pandemic (SE = 15.45, CI 2.5–97.5% = 10.20, 73.43, p = 0.010), more depression (SE = 5.53, CI 2.5–97.5% = 4.89, 25.66, p = 0.004), somatization (SE = 6.06, CI 2.5–97.5% = 4.91, 30.96, p = 0.006) and anxiety (SE = 5.92, CI 2.5–97.5% = 7.70, 31.10, p = 0.001), than previously.
Carone, Manzi et al. (2024) [39].Italy
30 children born via GS and their 60 same-sex parents.		- Sociodemographic and clinical variables: child’s gender assigned at birth, number of siblings, family residence, locations where surrogacy agreements were made, egg donors’ identity status at t1, disclosure level at t1, annual household income, duration of the couple’s relationship, father’s ethnicity, father’s education, father’s occupation, father’s employment status, child’s age at t1, child’s age at t2, and father’s age.
- Psychological variables: information about GS, parents’ AAI mental coherence, and children’s exploration of their surrogacy origins.		Observational, longitudinal (T1 mean age of 8 years and 3 months (SD = 1.68). T2 mean age of 9 years (SD = 1.69)).No significant differences were found between boys and girls in the exploration of their surrogacy origins (F(1, 28) = 0.308, p = 0.583, ηp2 = 0.011), nor in mind coherence between genetic parents, non-genetic parents, and parents who did not disclose their (non) genetic status (χ2(2) = 0.443, p = 0.801, ε2 = 0.008).
The interaction between disclosure and parents’ mind coherence at t1 predicted greater exploration in children (β = 0.296, p = 0.013). Parents’ mind coherence at t1 (β = 0.220, p = 0.065), and children’s age at t2 (β = 0.213, p = 0.096), were not significant.
Parents with greater coherence in their interviews (with an AAI range between 1.78 and 6.30) had children who explored their surrogacy origins more deeply.
Carone, Baiocco et al. (2020) [40].Italy
30 children born via GS aged 7 to 13 years and their 66 same-sex parents.		- Sociodemographic and clinical variables: age, child’s sex, number of siblings, parents’ ethnicity, family residence, parents’ education, parents’ occupation, parents’ employment status, duration of the couple’s relationship, child’s age at t1, child’s age at t2, parents’ age, and annual household income.
- Psychological variables: children’s attachment and exploration of their surrogacy origins.		Observational, longitudinal (T1 mean age of children was 8.3 years, T2 was 18 months later).
Observational, cross-sectional, non-experimental.		The age of the children, main and interactive effects of parental support, and children’s attachment security as predictors explained children’s exploration of their origins, with high variance (TCD = 0.34) and low BIC (163.22).
Parental scaffolding * and attachment security are interrelated (β = 0.23, p = 0.048) and affect how children explore their origins.
Children with greater attachment security reported more exploration of their surrogacy origins (β = 0.30, p = 0.009), but only when there were higher levels of parental scaffolding (β = 0.20, p = 0.072). Along with the child’s age factor (β = 0.02, p < 0.001), these predicted greater exploration.
Carone, Mirabella et al. (2023) [34].30 lesbian mother dyads via donor insemination, 25 same-sex father dyads via GS, 21 heterosexual father dyads via gamete donation, and 76 children.- Sociodemographic and clinical variables: child’s gender assigned at birth, parents’ relationship duration, child’s age, number of children, parents’ ethnic background, parents’ educational level, employment status, parents’ age, and net annual income.
- Psychological variables: parents’ attachment and reflective functioning. Children’s attachment and verbal abilities.		Observational, cross-sectional.Children of lesbian mothers (β = 0.46, SE = 0.34, p = 0.180), gay fathers (β = −0.01, SE = 0.36, p = 0.970), and heterosexual parents showed similar levels of attachment security. However, there were no differences based on the parents’ gender (β = −0.15, SE = 0.20, p = 0.450), sexual orientation (β = 0.22, SE = 0.26, p = 0.399), or their interaction (β = −0.38, SE = 0.36, p = 0.289) in mind coherence.
Mothers and fathers showed similar levels of reflective functioning (RF) (β = 0.19, SE = 0.17, p = 0.258). There were no differences in the parents’ sexual orientation (β = 0.43, SE = 0.21, p = 0.040), with gay fathers and lesbian mothers showing higher levels of RF than heterosexual parents (main difference = 0.77, SE = 0.27, p = 0.027). There was a significant interaction between parents’ gender and sexual orientation (β = 0.69, SE = 0.33, p = 0.039).
There were no differences between family types in the distribution of secure and insecure attachment patterns in children according to the FFI, nor in comparisons with international and national data.
There is a significant indirect effect of parents’ mind coherence on children’s attachment security, mediated by parents’ reflective functioning. Parents with greater mind coherence achieved higher levels of RF, and higher RF levels were associated with greater children’s attachment security according to the FFI.
Carone, Quintigliano, Benzi & Brumariu (2025) [36].Italy
148 parent–child dyads (38 lesbian mother families through sperm donation and 36 gay father families through surrogacy, all with children).		- Sociodemographic and clinical variables: child’s gender assigned at birth, length of couples’ relationship duration, child’s age, number of children, parents’ ethnic background, parents’ educational level, biological parenthood, parents’ age, and net annual income.
- Psychological variables: Identification of the Primary and Secondary Attachment Figures, Observed Parental Sensitivity, Child–Parent Attachment Security.		Observational, longitudinal T1 mean age 36 months (SD = 9.16). T2 mean age of 48.38 months (SD = 9.22).Mixed model analyses showed that child gender was not associated with parental sensitivity (p = 0.679) or attachment security (p = 0.888). Additionally, most parents—approximately 79% of lesbian mothers and 75% of gay fathers—exceeded the alternative sensitivity threshold of 0.30. Using a threshold of 0.32, most children in both family types were classified as securely attached (67.11% in lesbian mother families and 68.06% in gay father families). Analyses examining the role of parent gender and attachment figure role (primary vs. secondary) indicated that all groups scored above the sensitivity and attachment security thresholds. Children showed greater attachment security with, and parents demonstrated greater sensitivity in, the context of the primary attachment figure. However, no significant effects emerged for parent gender or for the interaction between parent gender and attachment figure role.
Structural equation modeling (SEM) analyses explored the longitudinal associations between parental sensitivity at Time 1 and child–parent attachment security at Time 2. Across all models, parental sensitivity was positively associated with later attachment security. When stratified by parent gender, the association was moderate in lesbian mother families (estimate = 0.34, p < 0.001) and small in gay father families (estimate = 0.25, p < 0.001). Analyses stratified by attachment figure role found a small but significant association between parental sensitivity and attachment security for both primary (estimate = 0.29, p < 0.001) and secondary attachment figures (estimate = 0.25, p = 0.005), with no significant difference in strength between the two roles. When further stratifying by both parent gender and attachment figure role, the strongest association was observed for primary lesbian mothers (estimate = 0.39, p = 0.001), followed by secondary lesbian mothers (estimate = 0.27, p = 0.035), primary gay fathers (estimate = 0.24, p = 0.001), and secondary gay fathers (estimate = 0.22, p = 0.072). Despite these variations, chi-square difference testing indicated that the strength of the association did not differ significantly across groups.
Quintiliano, Carone, Speranza & Lingiardi (2025) [33].Italy
152 parents (i.e., 60 lesbian mothers, 50 gay fathers, 42 heterosexual parents) and their 76 children		- Sociodemographic and clinical variables: child’s gender assigned at birth, parent biological (un)relatedness.
- Psychological variables: Identification of the Primary and Secondary Attachment Figures, Parents ‘ Attachment state of mind, Parents’Reflective Functioning, Parenting Stress, Parent–Child relation self-efficacy, Parental Acceptance-Rejection, Parent Positivity, Social Desirability. 		Observational, cross-sectional.There were no significant differences in children’s choice of one or both parents as a primary attachment figure based on child gender (χ2(1) = 0.03, p = 0.854) or parental biological relatedness (χ2(1) = 1.10, p = 0.293). Mothers were more likely than fathers to be chosen as a primary attachment figure (β = 56.74, p = 0.019). Gay fathers were more likely to be selected than heterosexual parents (β = 36.29, p = 0.024). Parental reflective functioning (RF) was positively associated with being identified as a primary attachment figure (β = 15.47, p = 0.019). This association was moderated by parent gender. RF was a significant predictor only for fathers (β = 15.47, p = 0.019), but not for mothers (p = 0.113). The interaction between family type and RF showed that RF significantly predicted children’s choice only in lesbian mother families (β = 23.14, p = 0.002). Gay fathers who reported lower levels of parental rejection were more likely to be identified as primary attachment figures (β = 0.12, p = 0.024), while this association was not significant for lesbian mothers or heterosexual parents.
The final model accounted for a substantial proportion of variance in children’s choice of primary attachment figure (R2₍conditional₎ = 0.55), highlighting the relevance of parents’ psychological functioning, especially RF and acceptance-rejection patterns, over demographic or structural factors like gender or biological relatedness.
Note: * Parental scaffolding (the parents’ efforts to accept, encourage, and emotionally support the expression of children’s thoughts and feelings).
Table 2. Quality Assessment.
Table 2. Quality Assessment.
Fisrt AutorDesignRepresentativenessRepresentativeness iiConfounding FactorsData CollectionData AnalysisData ReportingOverall Rating
Fischer & Gillman
(1991) [12].		44N/A2111Low-moderate
Lorenceau et al. (2015) [32].43N/A2111Low-moderate
Lamba et al. (2018) [31].2322111Low-moderate
Carone, Baiocco et al. (2020) [40].2322111Low-moderate
Carone, Barone et al. (2020) [35].42N/A2111Low-moderate
Carone et al. (2021) [38].43N/A2112Low-moderate
Carone (2022) [37].43N/A2112Low-moderate
Carone, Manzi et al. (2023) [39].2322112Low-moderate
Carone, Mirabella et al. (2023) [34].43N/A2112Low-moderate
Carone, Quintigliano et al. (2025) [36].2322111Low-moderate
Quintiliano et al. (2025) [33].43N/A2111Low-moderate
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Santamaría-Gutiez, R.; González-Albors, E.M.; González-Sala, F.; Lacomba-Trejo, L. Exploring Attachment Dynamics in Surrogacy: A Systematic Review. Psychiatry Int. 2025, 6, 145. https://doi.org/10.3390/psychiatryint6040145

AMA Style

Santamaría-Gutiez R, González-Albors EM, González-Sala F, Lacomba-Trejo L. Exploring Attachment Dynamics in Surrogacy: A Systematic Review. Psychiatry International. 2025; 6(4):145. https://doi.org/10.3390/psychiatryint6040145

Chicago/Turabian Style

Santamaría-Gutiez, Rebeca, Eva María González-Albors, Francisco González-Sala, and Laura Lacomba-Trejo. 2025. "Exploring Attachment Dynamics in Surrogacy: A Systematic Review" Psychiatry International 6, no. 4: 145. https://doi.org/10.3390/psychiatryint6040145

APA Style

Santamaría-Gutiez, R., González-Albors, E. M., González-Sala, F., & Lacomba-Trejo, L. (2025). Exploring Attachment Dynamics in Surrogacy: A Systematic Review. Psychiatry International, 6(4), 145. https://doi.org/10.3390/psychiatryint6040145

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