html xmlns=”http://www.w3.org/1999/xhtml” xmlns:mml=”http://www.w3.org/1998/Math/MathML” xmlns:epub=”http://www.idpf.org/2007/ops”>
“‘Why don’t you just adopt?’ she said…I was so upset…I felt like saying ‘If you think adoption is so great then why did you have your two biological sons?’ I don’t want to adopt…I don’t want someone else’s child. I want my own child!”
Susan is a woman suffering from infertility describing an exchange with a close friend that captures a common interaction around infertility as well as the profound longing for a child “of my own”: the biogenetically related child. Susan is now a proud and happy adoptive parent. How did this change happen?
This chapter presents information for Mental Health Professionals (MHPs) to help people with infertility problems explore adoption and, when relevant, prepare for adoptive parenting. For some people this means learning about adoption as a viable alternative family building option. For others it means embracing a child “as one’s own” through social, legal and interpersonal connections instead of through a biogenetic link. For adoptive parents this means embarking on a personal and social life-long journey involving additional parenting tasks. Fertility counseling may be instrumental in preparing future adoptive parents like Susan by promoting an understanding of the lifelong experience of adoption, strengthening coping skills, facilitating personal growth and healing, and promoting resilience. In the best-case scenario, adoption exploration initiates a journey of adaptation and transformation concerning what it means to belong in a family. This journey may begin in the office of an MHP working in fertility counseling.
Susan’s story
Susan is a professional woman, married in her mid 30s, who sought counseling because of her deep distress about her infertility and the constant failure of fertility treatments. At the beginning of counseling I urged Susan and her husband to explore all their family building options, including adoption, in order to learn about these alternatives and also to create continuity in the event that their original plan was unsuccessful. Reluctantly, Susan researched the third party reproduction and adoption options. With time, as Susan started to lose hope for a biogenetic pregnancy, she began to grieve the immense loss of a longed-for genetically related child. The middle part of the treatment involved processing her profound pain and losses while also finding hope for a way forwards. In working through her feelings, and with self-examination and reflection, Susan began to feel hope that a non-genetic path to parenthood would be successful. Her feelings of failure and self-blame gradually gave way to faith and hope that she would have a child to parent. Susan desperately wanted to be pregnant, but after more disappointments with egg donation, she and her husband decided to adopt. Susan described this as “climbing another mountain,” but felt more confident that adoption would be successful. Susan’s initial fears about adopting were about attachment. She worried that she would not be able to love the child. She feared rejection and imagined an angry teenager saying: “You’re not my real mother!” These fears and other concerns gradually dissipated as she read about adoption, talked to adoptive families and attended adoptive parent meetings and conferences. She found herself surprised at one adoptive parents’ meeting when she realized that she was feeling identified with adoptive parents. Initially interested in domestic adoption, she had a strong negative reaction to the idea that she had to be chosen by a birthmother, which made her feel out of control (replicating feelings of infertility). She was also worried that the birthmother would change her mind. She was initially angry about being evaluated in a “home-study” process by the adoption agency social worker. She felt threatened by the idea of an open adoption and imagined that this would interfere with her future family integrity. Time passed as Susan kept processing her losses and learning more about adoption. After disappointments with domestic adoption she and her husband eventually adopted a daughter in an intercountry and transracial adoption. By the end of the counseling Susan was a strong adoption advocate, questioning why she had waited so long to adopt (her grief crowded out by joy at this time) and, ironically, wondering out loud about her friends who were still undergoing fertility treatments: “Why don’t they just adopt!”
Although finally a parent, Susan’s story as part of an adoptive family has just begun. In the future she will experience the common joys and difficulties of being a parent, as well as the additional layers of adoptive family life.
Adoption today
Adoption is currently practiced around the world in a family, social and global system. Adoption has served both public and private needs as a social solution to the problem of finding safe and permanent families for children whose birthparents are unable or unwilling to raise them and a personal solution for people who seek children to parent. In adoption, traditionally, a child is born to one set of parents and raised by other parent/s in permanent social arrangements, after having been orphaned, abandoned, relinquished, or taken away from parents who were unable to look after them by the state. Adoption terminates the parental rights of the birthparents to children and provides those children with the same rights and responsibilities in their adoptive families as other children who join their families through birth. All adoptive families are created by laws, social contracts and attachment relationships, rather than by birth, blood or genetic ties.
Adoption today includes domestic, international, intercountry, transracial and familial (relative/kinship) adoptions; adoption by a step-parent; “stranger” adoption; adoption by single parents and Lesbian, Gay, Bisexual and Transgendered (LGBT) parents; through agencies, government child welfare systems, or directly from relinquishing parent(s). People adopt because they are unable to have children, to expand their family, for social, economic and legal reasons including access, and availability, protection of legal parenting rights in ART family building and for purposes of inheritance and political alliances. The focus of this chapter is on people who adopt after experiencing infertility through “stranger adoptions.” With advances in ART, adoption is no longer a linear process: there is a bidirectional influence and overlap between adoption and ART and an increase in blended families with children from increasingly diverse origins.
All adoptive parents must fulfill their region-specific legal requirements in areas such as psychological and physical health, financial stability, home environment and motivation to adopt. There are barriers for some people wanting to adopt including age limitations, laws and discrimination, prohibitions against criminal backgrounds, and health and medical conditions. Other obstacles include the diminishing availability of desirable children (i.e., infants) who are eligible for adoption. Approval can be lengthy with many steps and much paperwork. Intercountry adoptions require additional steps, including fulfilling the legal requirements for sending and the receiving countries as well as the Hague International Treaty [1]. Increasingly mandatory formal pre-adoption training and post-adoption supervision is required.
Adoption is not a onetime event but a life-long process that affects all parties within the adoption triad/triangle, other members of their families and extended families for present and future generations, and the society and world in which they live. The focus of this chapter is on adoptive parents. The life-long journey of the adoptive family is heavily influenced by that family’s particular individual, extended family, social, cultural and geographic environment as well as the socioeconomic and racial and ethnic diversity (heterogeneity vs. homogeneity) of the country in which they live. All families formed through adoption share characteristic similarities and differences with mainstream biogenetic families. The adjustment to family building through adoption as well as the life-long experience of being part of an adoptive family, for parents and their children alike, is fundamentally related to the navigation and integration of these similarities and differences.
As an experience, adoption contains the profound polar opposite experiences of tragedy and joy, fortune and misfortune, solution and problem, loss and gain, and risk and resilience. Therefore it draws forth highly emotional and polarized responses in individuals and in groups. Although in the Western developed world the guiding principle is “in the best interests of the child,” the history and practice of adoption is filled with conflict and controversy, rhetoric and debate, competing interests, and diverse reactions to different parts of the adoption experience, including issues of social justice. In learning about adoption, it is important to hold its full complexity in mind rather than oversimplify in response to external or internal polarizations and pressures.
Adoption today is increasingly heterogeneous as social and political forces impact on individual, family, social and global systems. Adoptive families continue to become more diverse as a wider range of potential adoptive parents have access to adoption and as the range of available children changes. Despite this multiplicity there remain groups who lack access to children that they wish to adopt.
History of adoption
Adoption is the oldest and original family building choice after infertility, and historically it was the only alternative. Adoption has existed in all societies from ancient times onwards, across all periods of history and all cultures [2]. The earliest adoptions were informal, arranged mainly for economic purposes of inheritance, religion, peacekeeping, political alliances, providing for care in old age and labor needs. The first orphan asylums were created in the fifth century in the Byzantine Empire and in ad 787 in the West [3]. Foundling homes were first created in the thirteenth century [4]. During the nineteenth century, migrations from Europe to countries including the United States, Canada and Australia, combined with the industrial revolution and urbanization, resulted in disrupted families and increasing numbers of orphaned children. In the USA these children were first housed in almshouses, then in orphanages: by the mid nineteenth century, public concerns about poor conditions in these institutions led to adoption [5].
As adoptions became more common, laws were developed to protect these children. The earliest adoption law is found in the Code of Hammurabi in 2800 bc [6]. In much of Europe adoption laws were created in the 1700 and 1800s. England developed adoption laws in 1926 [6] and Canada and Australia also developed adoption laws in the 1920s. In the United States the first adoption law was passed in 1851 [6].
In recent history there have been changes in the origins of children who have been adopted. Intercountry adoption developed mainly due to wars (World War II, Korean and Vietnam wars), internal conflicts in Latin American countries, the fall of communism in Romania and Russia and the one-child policy of China. Almost always poverty has played a fundamental role, with an exception being Korea, which has one of the strongest economies in the world [7]. Politics has also played a role in governmental policies in adoption: for example, after embarrassing publicity during the 1988 Korean Olympic Games about South Korea’s status as a “leading exporter” of children, these adoptions slowed down considerably; this was repeated during the 2009 Chinese Olympic Games. And recently Russia placed a ban on US adoption of Russian children, partly in response to a US law that targeted alleged Russian human-rights violators and also in protest about Russian children adopted by Americans who have died from abuse, neglect or other causes while in the care of their adoptive parents [8].
According to Selman’s 2009 estimate, nearly one million children were adopted internationally between just after the end of World War II (1948) and 2010 [7]. By 2004 there was a peak of a minimum of 45000 international adoptions worldwide [9]. On a global level, some countries are mainly “sending countries” and some mainly “receiving countries.” Some countries are both a sending country and receiving country: for example, the USA sent 99 children to be adopted in other countries in 2012 [10]. Tables 14.1–14.3 summarize changes in intercountry adoption and the shifts of the top sending and receiving countries [7,9].
1980–1989 | 1998 | 2003 | 2006 |
---|---|---|---|
Korea | China | China | China |
India | Russia | Russia | Russia |
Colombia | Vietnam | Guatemala | Guatemala |
Brazil | Korea | Korea | Ethiopia |
Country | 2003 | 2004 | 2007 |
---|---|---|---|
China | 11 228 | 13 404 | 8753 |
Russia | 7745 | 9425 | 4873 |
Korea | 2287 | 2258 | 1265 |
Ethiopia | 854 | 1527 | 3031 |
Country | Total Adoptions per 100 000 in 1980 | Total Adoptions per 100 000 in 2004 |
---|---|---|
Sweden | 20.5 | 12.3 |
Denmark | 15.0 | 9.8 |
The Netherlands | 11.0 | 8.1 |
USA | 2.2 | 7.8 |
UK | unknown | 0.6 |
The USA is the largest receiving country with approximately a half million children adopted since 1971: two-thirds from Asian countries, and the rest from Latin America, Eastern Europe and (recently) Africa. However the USA has by no means the highest concentration per 100 000 population, as seen in Table 14.3 [7]. The fluctuation has been extreme in some countries: for example, the growth of intercountry adoption in Spain has been dramatic, with numbers almost tripling between 1998 and 2004 when it was one of the countries receiving the highest number of children in relation to its population [11]. In some countries, particularly in Western Europe, adoption predominantly consists of intercountry adoptions, most of which are also transracial adoptions.
Concerns about the international abuses and corruption in adoption, including trafficking in children, have led to the development of an international treaty called The Hague Adoption Convention on Protection of Children and Co-operation in Respect of Inter-Country Adoption, established in 1993 to safeguard and protect the best interests of the child and promote best intercountry adoption practices [1]. According to this agreement, intercountry adoption should only be pursued after proper effort has been made to find a domestic adoption placement within the child’s country of origin. Although many proponents of this treaty applaud its efforts, opponents are concerned that it has resulted in fewer children finding permanent homes.
These worldwide policy changes in adoption have resulted in a significant drop in intercountry adoptions from 45 299 in 2004 to 19 540 in 2012 [12]. Tables 14.4–14.5 summarize intercountry adoptions to 23 receiving states and top 5 states of origin (“sending countries”) between 2003 and 2011 reported on October 7, 2013 [12]. As an example of this decreasing trend, figures from the US State Department for 2013 showed 7094 adoptions into the USA, a decrease of 18% from 8668 in 2012, and 69% from the high of 22 884 in 2004 [13,14]. This decrease is partly due to Russia’s ban on adoptions by Americans [8]; adoptions from South Korea and Ethiopia also dropped significantly.
Year | Total Number of Adoptions |
---|---|
2003 | 41 535 |
2004 | 45 229 |
2008 | 34 785 |
2012 | 19 540 |
Rank | 2003 | 2007 | 2009 | 2011 |
---|---|---|---|---|
1 | China | China | China | China |
2 | Russia | Russia | Ethiopia | Ethiopia |
3 | Guatemala | Guatemala | Russia | Russia |
4 | South Korea | Ethiopia | Vietnam | Colombia |
5 | Ukraine | Vietnam | Ukraine | Ukraine |
Adoption continues to evolve over time as it seeks solutions to problems for the three parties involved: the child who needs a family, the birthparents who are unable to raise their child, and the adoptive parents who seek a child to parent. The balance between the needs of members of the adoption triad as well as reactions to adoption corruption has led to adoption reforms and international laws including greater attempts at placing children domestically within their countries of origin. These changes mean that sources for children available for adoption have become limited for some people. Therefore it is expected that in the future prospective adoptive parents will expand the range of children they seek to adopt, and increasingly cross boundaries of race (in transracial adoption), age (adopting older children and sibling groups), type of adoption (adopting from the public/foster care system) and health (adopting children with special needs).
Adoption theories
The first adoption theory, developed by H. David Kirk, a Canadian sociologist, was based on research in the 1950s at a time when most adoptive parents (and professionals) expected adoptive parenthood to replicate birth parenthood [15]. Kirk suggested that all members of the adoption triad experience role handicaps that impact adoptive family adjustment. Kirk determined that parents who acknowledged difference (AD) were more likely to be empathic with their children, and better able to communicate about adoption and establish a healthy family life than parents who rejected or denied difference (RD). Others have built on Kirk’s work, in particular Brodzinsky, who amended this model by adding an “insistence on difference” (ID) category and argued that there is a curvilinear relationship between RD and AD, with problems at both extremes [16].
Attachment theory, based on the work of Bowlby, has direct relevance for adoption, with its focus on attachment, loss and separation [17,18]. Here, every child develops an internal working model of attachment through a reciprocal process of responsive interactions with a parenting figure, which then informs how that child will interact with other people thereafter. Changes in care-givers put a child at risk for attachment difficulties, although the experience of making one attachment makes it more likely that a child will be able to attach again. Due to pre-adoption risks, there are attachment difficulties in some adopted children. Adoptive parents may also have their own attachment difficulties.
While most adoption theories have focused on the children, some have focused on adoptive parents. Daniluk and Hurtig-Mitchell presented a “Hope and Healing” model of adjustment to adoptive parenthood based on their research [19]. Their subjects went through a process of needing to know they had done all they could do to have “their own child,” of acknowledging their losses, of separating the desire to reproduce from the desire to parent, of evaluating the options of childlessness and adoption, and a process which Daniluk and Hurtig-Mitchell called “resocialization” during which they changed their personal identity from biological to adoptive parents. Other aspects were the suddenness of becoming parents, the fears the child would be taken away from them, and negotiating open relationships with birthfamilies. These parents were able to attach to the children they adopted and transform into adoptive parents comfortably. Hendry and Netherwood address the emergence of infertility issues over the lifespan and the accompanying additional challenges [20]. They suggest that infertility feelings can be triggered throughout the lifespan for parents (into grandparenting) and adopted individuals alike; and that infertility feelings also re-emerge when individuals search for birthparents, which is often triggered when they become parents themselves. Shapiro, Shapiro, and Paret and Palacios have developed theoretical approaches that emphasize the influence of context [21,22]. From this perspective, past adoption research that emphasized psychopathology has negatively affected perceptions about adoptive families in the general public, while current adoption research emphasizes “normality” and resilience within the complexity that adoption requires and deserves [22].
Theories of adoption have come full circle from the sociological approach of H. David Kirk, through an emphasis on the losses and identity formation of individuals who have been adopted and communication within adoptive families, to the increasingly complex process of recognizing the context and environmental influences and healing and resilience within adoptive families [15,16,23–25].
Adoption research
Adoption as a field of inquiry began around the middle of the last century as mental health and other professionals became interested in adoption as a unique experience. Prior to that time, adoption was viewed under the domain of child welfare and social services, when society-emphasized sameness and attention primarily addressed practical concerns. Early adoption research was largely atheoretical and primarily focused on clinical populations and the topics of the psychological and behavioral adjustment and outcomes of children who had been adopted. Research has demonstrated that most children who have been adopted function within the normal range. However, these children are overrepresented in the mental health field. Some children experience increased psychosocial, emotional and behavioral struggles in the middle childhood and adolescent years, which remit by early adulthood. Adoptive parents seek the help of MHPs more frequently and more readily than other parents. Pre-adoption risk factors include prenatal intrauterine difficulties, malnutrition, poor medical care, deprivation in nurturance and deficits in sensory stimulation, abuse experiences, a history of multiple placements, older age and institutionalization. Adoption is a protective and buffering experience that reduces risk and promotes resilience. “Catch-up” (e.g., developments in cognition and behavior) after adoption is significant but within limits. Curiosity about origins and searching behaviors are normal. Adoption discrimination exists, and being different from family and peers is difficult for some people who have been adopted. For reviews of adoption research, see Palacios and Brodzinsky and Van Ijzendoorn and Juffer [26,27].
Over the last 30 years adoption research has changed dramatically, leading to an increased complexity in investigating and interpreting research findings, increased consideration of known and unknown pre-adoption risk factors, the use of qualitative and meta-analytic as well as quantitative studies, and changes in methodology such as using more appropriate control groups. There is a growing interest in international collaboration and a multidisciplinary approach, including social scientists and professionals in fields as varied as Immigration, Law, Ethics, Social Anthropology and Sociology. It has been largely assumed by MHPs that the experience of infertility remains alive in the adoptive family system over the course of that family’s lifetime; however, there has been very little research on the experience of adoption after infertility. Instead research has focused more on motivation for adoption after infertility and the adjustments involved in adoptive parenthood after infertility.
Adjustment to adoption after infertility
In the first nationally representative survey of adoptive parents in the United States, 72% listed infertility as a primary motivation for adoption [28]. Other motivations included wanting to expand their family (92%) and wanting to provide a permanent home for a child (90%). According to health statistics in the USA from 2002, approximately one-quarter (26%) of infertile women who had used fertility treatments unsuccessfully and not given birth adopted a child by the ages of 40–44 [29].
In a prospective longitudinal study of 1338 couples initiating infertility treatment in Denmark (a country that offers socialized healthcare and free infertility treatments) Pinborg and colleagues found that only 5.9% of the women adopted [30]. In a US study, Zhang and Lee investigated the motivations behind the high demand for intercountry/international adoption [31]. Beyond the common motivation of infertility, the researchers reported that race played a part in the decision due to “… a perception that American children available for adoption (i.e. mainly Black children) presented difficult problems whereas foreign children presented interesting challenges.” White adoptive parents had a “hierarchy of race,” and some parents adopting transracially showed a preference for adopting non-Black children. Other motivating factors for intercountry adoptions reported by the researchers were fears of potential problems with birthparents, wanting a young child, shorter waiting periods and possible health issues of older children.
In a Swedish study, Hogström and colleagues compared the quality of life among couples who had adopted a child 4–5.5 years previously, couples who had undergone successful or unsuccessful IVF treatment, and couples who had conceived spontaneously (control group) [32]. The researchers found that adoptive couples had the highest quality of life scores, while the couples who had undergone unsuccessful IVF living without children had lowest quality of life scores. The researchers concluded that quality of life was independent of the IVF outcome as long as there were children in the family.
In a study from the United Kingdom, Triseliotis and colleagues explored the experiences and perspectives of 93 birthmothers and 93 adoptive parents [33]. Of the adoptive parents, 79% reported that feelings of loss and sadness about infertility did not persist over time and described adoption as a healing factor. The 21% of adoptive parents for whom feelings of loss persisted rated the closeness of their relationship to their adopted adolescents lower than the other parents. Of the adoptive parents who later gave birth, over 87% found their relationships with their adopted and biological children similar.