11/10/2025
Special thanks to Michael Johnson-Ellis, Co-founder of TwoDads UK & My Surrogacy Journey, for bringing this study to my attention.
A recent JAMA Network Open study from Ontario, Canada, reported higher rates of mental health diagnoses among gestational surrogates (6.9%) compared to women with unassisted conceptions (5.2%).
However, surrogates represented only 0.1% of the study population, with the remaining 99.9% being non-surrogates. Such an extreme imbalance makes the comparison fragile — just 10 additional cases in the surrogate group could meaningfully change the results, potentially erasing the reported difference.
The study’s stated objective was “to study the association between gestational carriage and new-onset mental illness.” If that were truly the aim, why limit the analysis to Ontario, where surrogates are such a small fraction of births? Expanding the dataset to include surrogates from other provinces, or even other countries, could have increased the sample size and improved the reliability of the findings.
It also appears the study did not examine how “new-onset mental illness” was coded. In surrogacy, attending one or two routine mental health evaluations or consultations is common and often billed under mental health codes. Under the study’s criteria, these visits could count as mental health cases even when no disorder was diagnosed, potentially inflating the surrogate group’s numbers without reflecting actual illness.
Other important factors the study did not address include:
Gestational carriers typically have more medical appointments and check-ins than other pregnant women, creating more opportunities for diagnoses to be recorded.
Surrogates may face complex legal obligations, emotionally sensitive relationships with intended parents, and, in altruistic systems, the absence of compensation despite the significant commitment. These stressors are unrelated to the medical course of the pregnancy but may still affect mental health.
Most surrogates undergo mental health evaluations before being approved and may have ongoing access to counseling. This exposure increases the likelihood that even mild symptoms will be recognized, reported, and documented.
If surrogates are older than the general pregnant population, their risk for conditions such as gestational diabetes and hypertension increases, both of which are associated with greater psychological strain.
Without addressing these methodological gaps, the findings risk overstating the link between surrogacy and mental health diagnoses and may reflect differences in monitoring, coding, and demographic profiles rather than true differences in mental health outcomes.