http://qhr.sagepub.com/Qualitative Health Research

http://qhr.sagepub.com/content/early/2014/10/09/1049732314554096The online version of this article can be found at:

 DOI: 10.1177/1049732314554096

published online 14 October 2014Qual Health ResElia Wyverkens, Hanna Van Parys and Ann Buysse

Experiences of Family Relationships Among Donor-Conceived Families: A Meta-Ethnography  

Published by:

http://www.sagepublications.com

can be found at:Qualitative Health ResearchAdditional services and information for    

  http://qhr.sagepub.com/cgi/alertsEmail Alerts:

 

http://qhr.sagepub.com/subscriptionsSubscriptions:  

http://www.sagepub.com/journalsReprints.navReprints:  

http://www.sagepub.com/journalsPermissions.navPermissions:  

What is This? 

- Oct 14, 2014OnlineFirst Version of Record >>

by guest on October 14, 2014qhr.sagepub.comDownloaded from by guest on October 14, 2014qhr.sagepub.comDownloaded from

Qualitative Health Research 1 –18© The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.navDOI: 10.1177/1049732314554096qhr.sagepub.com

Evidence for Practice

Worldwide, approximately 1 in 10 couples is affected by fertility problems (Boivin, Bunting, Collins, & Nygren, 2007; Covington & Burns, 2006). Research indicates that the inability to conceive alters one’s identity, strains rela-tionships, and diminishes self-esteem (Cousineau & Domar, 2007). New medical techniques, such as in vitro fertiliza-tion, enable couples to pursue parenthood. For some of these techniques, donor gametes are used: sperm or eggs of a person who will not be a future parent. This form of fam-ily building implies that the child has a genetic link to one parent (genetic parent) but not to the other parent (social parent). Within Euro-American cultures, building a family through donor conception is often challenging for parents given that (a) genetic connectedness is prevailing as the basis for family bonds and (b) the medical importance of genetic ties is often emphasized (for instance, genetic test-ing, bone marrow transplantation; Becker, Butler, & Nachtigall, 2005; Grace & Daniels, 2007; Hargreaves, 2006). Over the past several decades, empirical research on donor-conceived (DC) families has focused on the well-being of families and especially offspring (Golombok et al., 2002; Golombok, Cook, & Bish, 1995). This work has revealed that DC families are typically characterized by stable marital relationships, good parent–child relations, and good functioning, relative to naturally conceived fami-lies (see Bos & Van Balen, 2010; Brewaeys, 2001).

In recent years, researchers have shifted their focus from family well-being to how parents manage the

information about the donor origin in their family. This has resulted in a body of research on disclosure decisions about the nature of conception to the offspring (Daniels, Grace, & Gillett, 2011; Hahn & Rosenberg, 2002; Stevens, Perry, Burston, & Golombok, 2003). Much of this research has specifically focused on open-identity donation, in which DC offspring are given access to the donor’s identity once they reach maturity. Proponents of this trend argue that children have the right to know their genetic heritage (Daniels et al., 2011; Hahn & Rosenberg, 2002). Opponents stress the parents’ right for privacy and their freedom of choice with regard to their disclosure decision (Shehab et al., 2008). This ongoing debate has led many countries to abandon donor anonymity and to promote openness about the donor origin in families (e.g., Sweden, The Netherlands, Norway, Austria, Switzerland, United Kingdom, New Zealand, and Australia [Victoria and Western Australia]). Recently, Indekeu et al. (2013) synthesized the available qualitative, quantitative, and mixed-method evidence on disclosure decision-making process in heterosexual couples. Their article provides an intensive overview of intrapersonal, interpersonal, social,

554096QHRXXX10.1177/1049732314554096Qualitative Health ResearchWyverkens et al.research-article2014

1Ghent University, Ghent, Belgium

Corresponding Author:Elia Wyverkens, Faculty of Psychology and Educational Sciences, Ghent University, Henri Dunantlaan 2, 9000 Ghent, Belgium. Email: elia.wyverkens@ugent.be

Experiences of Family Relationships Among Donor-Conceived Families: A Meta-Ethnography

Elia Wyverkens1, Hanna Van Parys1, and Ann Buysse1

AbstractIn this qualitative evidence synthesis, we explore how family relationships are experienced by parents who used gamete donation to conceive. We systematically searched four databases (PubMed, Web of Science, PsycINFO, and ProQuest) for literature related to this topic and retrieved 25 studies. Through the analysis of the qualitative studies, a comprehensive synthesis and framework was constructed. Following the meta-ethnography approach of Noblit and Hare, four main themes were identified: (a) balancing the importance of genetic and social ties, (b) normalizing and legitimizing the family, (c) building strong family ties, and (d) minimizing the role of the donor. Underlying these four main themes, a sense of being “different” and “similar” at the same time was apparent. Findings are discussed in terms of their implications for studying and counseling donor-conceived families.

Keywordsinfertility; meta-ethnography; reproduction; review

by guest on October 14, 2014qhr.sagepub.comDownloaded from

2 Qualitative Health Research

and family life cycle features that influence the disclosure decision in parents. With this review, the authors high-light the complexity of disclosure decisions as well as a lack of theoretical accounts that explain how the identi-fied factors influence disclosure.

Besides studies on disclosure outcomes, a number of qualitative studies have focused on different aspects of family relationships in this context: the meaning of resemblances (Becker et al., 2005), the construction of social and genetic ties (Hargreaves, 2006), and the role of the donor (Kirkman, 2004b). These studies offer insight into how parents build their families and how the mean-ing of social and genetic parenthood is constructed. Even though high-quality research has been published on this topic, it is difficult to obtain a comprehensive overview of these research findings. Moreover, studies have been conducted in different social–legal–cultural contexts and, as a consequence, have led to fragmented results.

In the current review, we synthesize the available qual-itative studies on family-building experiences and family relationships for DC families. In doing so, we aim to con-tribute to the field of family studies in particular and reproductive health care in general. Within the field of family psychology, a large body of quantitative research has been conducted to date, which has focused on the psy-chological well-being of parents and children as well as the quality of their relationships (e.g., Casey, Vasanti, Blake, & Golombok, 2013; Golombok et al., 2004). With our qualitative synthesis, we move beyond the study of family outcomes and investigate family processes in more detail. Applying the method of meta-ethnography (Noblit & Hare, 1988), we aimed to improve our understandings of family processes in DC families and the extent to which (the absence of) genetic connectedness plays a role in their experiences. Meta-ethnography is one of the most devel-oped and widely used methods for synthesizing qualita-tive data (Hannes & Lockwood, 2012; see, for instance, Varcoe, Rodney, & McCormick, 2003; Yick, 2008). This systematic and interpretative method goes beyond sum-marizing by classifying the identified concepts into a higher order theoretical structure (Dixon-Woods, Agarwal, Jones, Young, & Sutton, 2005).

Our decision to include only qualitative research find-ings was related to the assumption that qualitative research best fits experiential research questions and is able to provide a rich description of people’s meaning-making processes (Smith, Flowers, & Larkin, 2009). In addition, we focused on only one family type—hetero-sexual families—to be able to obtain consistency in our systematic review. Unlike lesbian- and gay-parented fam-ilies, heterosexual couples face fertility problems, and this can deny them the possibility to conceive genetic children of their own. This specific context, in which the traditional way of constituting a genetically related fam-

ily is unexpectedly impossible, was part of the family-building experiences we wanted to investigate.

Method

We conducted a systematic review of the qualitative research literature, following the meta-ethnography approach advocated by George Noblit and Dwight Hare (1988). Noblit and Hare developed this method in response to the practical problem of dealing with reports of different case studies on the same topic (Hannes & Lockwood, 2012). They both have a background in education research and were interested in the use of qualitative research meth-ods. In their conceptualization of this interpretative approach, Noblit and Hare sought to counter the prevailing positivist forms of knowledge synthesis which emphasized the aggregation of evidence through statistical meta-analy-sis (Hannes & Lockwood, 2012). Meta-ethnography was developed as a method of qualitative meta-synthesis that aimed to integrate and interpret findings from multiple qualitative studies (Kinn, Holgerson, Ekeland, & Davidson, 2013). The task of the synthesis is to translate studies into another, thereby providing new interpretations, rather than attempting to provide generalization (Hannes & Lockwood, 2012). This translative aspect distinguishes meta-ethnogra-phy from other methods for qualitative synthesis and proved useful in our review. The merits of meta-ethnogra-phy furthermore include its systematic approach and the high level of interpretation, which differentiates meta-eth-nography from traditional literature reviews (Dixon-Woods et al., 2005; Hannes & Lockwood, 2012). That said, one of the problems is the lack of guidelines on how to select and appraise studies, what to consider “data,” and how to synthesize the findings of the individual studies (Bondas & Hall, 2007; Kinn et al., 2013). Furthermore, the depth of the analysis and interpretations often differs from article to article (e.g., very descriptive or very theoretical), making it difficult to integrate findings. Zimmer (2006) argued that “metasynthesis is the synthesist’s interpretation of the interpretations of primary data by the original authors of the constituent studies” (p. 312). Therefore, the synthesis is always a result of constructed and intersubjec-tive meanings (Kinn et al., 2013). We tried to increase the transparency of the interpretative work by discussing every step in the research process within our research team and providing a detailed table with the identified concepts and themes (see Table 2). Below, we explain the seven phases of the meta-ethnography.

Identifying Topic of Interest and Search Strategy

In the first phase of the review, we identified our topic of interest: to discover how parents experience family

by guest on October 14, 2014qhr.sagepub.comDownloaded from

Wyverkens et al. 3

relationships when their traditional notion of a biologically related family is challenged. Subsequently, we consulted four search engines for our literature search: PubMed, Web of Science, PsycINFO, and ProQuest. Our threefold search string consisted of a combination of following keywords (and synonyms): (a) experiences, interview, qualitative; and (b) donor insemination, intracytoplasmic sperm injec-tion, in vitro fertilization, assisted reproductive technolo-gies, embryo donation, oocyte donation, sperm donation; and (c) kinship, family relationship, family building, fatherhood, motherhood. The systematic search yielded 1,321 references, which were reduced to 20 articles after evaluation of the title, the abstract, and the full text of the articles (see Figure 1). Through reference chaining, we included 5 additional studies, resulting in a total of 25 included studies.

Selection and Reading Process

In the second phase, we used the following inclusion criteria: Studies must (a) have reported empirical data on the experiences of family relationships after gamete donation, gathered from the perspective of heterosex-ual parents and (b) have made use of qualitative data collection methods and qualitative methods of analy-sis. No cutoff dates were set given that the field of family studies on donor gamete families is still in its infancy (our first included study dated from 1993). With regard to our first criterion, we systematically evaluated the “conceptual richness” of the articles and their relation to our review topic, and when the article

did not fit with the review question, it was excluded (e.g., it concerned a study about cell survival). Studies were also screened for their relevance using the fol-lowing screening questions: Does the article report on qualitative data? Does it mention a qualitative method of analysis? Does the analysis consist of an inductive phase in which codes result from a bottom-up analyti-cal process? and Are sufficient quotes given? In case one criterion was not met, inclusion decisions were made based on the relevance of the study and the rich-ness of the data. For instance, in Hargreaves (2006), no qualitative method of analysis was mentioned; how-ever, the findings proved to be a relevant contribution to our synthesis. Studies with a mixed sample (homo-sexual and heterosexual parents) or mixed methods (qualitative and quantitative data) were included in the review. However, in such cases, we only used qualita-tive data that were from the perspective of heterosex-ual couples. All phases of selection (on title, abstract, and full text) were carried out independently by the two main researchers (first and second author) and were followed by discussions to gain additional con-sensus on the final set of articles.

Identifying Key Concepts and Determining How Studies Are Related

In the third phase, each of the 25 articles was read, and characteristics of the studies were listed (see Table 1). Here, we sought to develop an in-depth understanding of the articles key concepts. Fourth, we extracted these key

Database search

Stage 1: evaluation of titlen = 1321 potentially relevant studies

Stage 2: evaluation of abstractn = 418 potentially relevant studies

Web of Science n =124

Stage 3: evaluation of full textn = 53 potentially relevant studies

Included in systematic reviewn = 25 relevant studies

PubMed n = 306

Studies excluded because of method, participants or topic n = 1296

Studies included after reference chainingn = 5

PsycInfon = 469

ProQuestn = 422

Figure 1. Process of study selection.

by guest on October 14, 2014qhr.sagepub.comDownloaded from

4

Tab

le 1

. C

hara

cter

istic

s of

Incl

uded

Stu

dies

in t

he R

evie

w.

Sour

ce a

rtic

leC

ount

ry s

ettin

gSe

ttin

gPa

rtic

ipan

t ch

arac

teri

stic

sD

ata

colle

ctio

nD

ata

anal

ysis

Beck

er, B

utle

r, a

nd

Nac

htig

all (

2005

)U

nite

d St

ates

Rec

ruitm

ent

thro

ugh

11 in

fert

ility

pr

actic

es +

1 s

perm

ban

k in

N

orth

ern

Cal

iforn

ia.

148

disc

losi

ng a

nd n

ondi

sclo

sing

he

tero

sexu

al c

oupl

es (

79 E

D/6

2 D

I/7 c

ombi

natio

n) C

hild

ren

from

in

fanc

y to

19

year

s ol

d.

Sem

istr

uctu

red

inte

rvie

ws:

C

oupl

e in

terv

iew

fo

llow

ed b

y so

lo

inte

rvie

w 3

mon

ths

late

r.

In-d

epth

pro

cess

of

code

dev

elop

men

t, co

mpa

ring

cod

es u

ntil

agre

emen

t of

95%

or

mor

e.Bl

ake,

Rea

ding

s, Ja

dva,

an

d G

olom

bok

(201

0)U

nite

d K

ingd

omR

ecru

itmen

t th

roug

h 9

fert

ility

cl

inic

s in

the

Uni

ted

Kin

gdom

. Pa

rt o

f a lo

ngitu

dina

l stu

dy.

23 d

iscl

osin

g m

othe

rs (

10 D

I, 13

ED

), 15

of t

heir

par

tner

s (7

DI,

8 ED

) an

d 12

chi

ldre

n (6

DI,

6 ED

). A

nony

mou

s do

natio

n an

d 1

know

n ED

. Chi

ldre

n ag

ed 7

yea

rs o

ld.

Sem

istr

uctu

red

stan

dard

ized

inte

rvie

ws

with

par

ents

sep

arat

ely

and

with

chi

ldre

n.

Con

tent

ana

lysi

s

Blyt

h, L

angr

idge

, and

H

arri

s (2

010)

Uni

ted

Kin

gdom

Rec

ruitm

ent

thro

ugh

2 U

nite

d K

ingd

om s

uppo

rt g

roup

s,

Don

or C

once

ptio

n N

etw

ork

and

the

Dai

sy N

etw

ork

(bot

h gr

oups

pro

mot

e di

sclo

sure

).

15 d

iscl

osin

g m

othe

rs a

nd 1

2 of

the

ir

part

ners

(13

DI,

2 ED

). C

hild

ren

aged

3-1

8 ye

ars

old.

Iden

tity-

rele

ase

dona

tion.

Sem

istr

uctu

red

inte

rvie

ws

with

par

ents

sep

arat

ely

Her

men

eutic

(in

terp

retiv

e)

phen

omen

olog

ical

ps

ycho

logy

Brew

aeys

, Pon

jaer

t-K

rist

offe

rsen

, Van

St

eirt

eghe

m, a

nd

Dev

roey

(19

93)

Belg

ium

Rec

ruitm

ent

thro

ugh

the

Cen

tre

for

Rep

rodu

ctiv

e M

edic

ine

of

the

Brus

sels

Uni

vers

ity H

ospi

tal.

25 h

omos

exua

l par

ents

(D

I) an

d 25

dis

clos

ing

and

nond

iscl

osin

g he

tero

sexu

al p

aren

ts (

DI)

thro

ugh

anon

ymou

s do

natio

n. C

hild

ren

aged

3

mon

ths

to 7

yea

rs.

Ope

n-en

ded

ques

tionn

aire

Qua

litat

ive

rese

arch

m

etho

d of

McC

rack

en

Burr

(20

09)

Uni

ted

Kin

gdom

Rec

ruitm

ent

thro

ugh

The

Fer

tility

C

entr

e (C

AR

E) a

nd t

he D

onor

C

once

ptio

n N

etw

ork.

10 w

omen

and

7 c

oupl

es (

DI),

di

sclo

sers

and

non

disc

lose

rs.

Ano

nym

ous

dona

tion.

Chi

ldre

n ag

ed 1

to

8 ye

ars

old.

Sem

istr

uctu

red

inte

rvie

ws,

10

alo

ne a

nd 7

con

join

t.Id

entif

icat

ion

of t

hem

es

follo

wed

by

mor

e de

taile

d in

terp

retiv

e co

ncep

tual

ana

lysi

s.D

anie

ls, G

race

, and

G

illet

t (2

011)

New

Zea

land

Rec

ruitm

ent

thro

ugh

a fe

rtili

ty

clin

ic in

Dun

edin

. Par

t of

a

long

itudi

nal s

tudy

.

12 h

eter

osex

ual n

ondi

sclo

sing

pa

rent

s (o

f sev

en fa

mili

es)

thro

ugh

DI.

Chi

ldre

n ag

ed 1

6-21

yea

rs.

Sem

istr

uctu

red

inte

rvie

ws,

co

njoi

nt a

nd s

epar

atel

yT

hem

atic

ana

lysi

s

Dan

iels

, Lew

is, a

nd

Gill

ett

(199

5)N

ew Z

eala

ndR

ecru

itmen

t th

roug

h th

e D

uned

in

Infe

rtili

ty C

linic

in N

ew Z

eala

nd.

48 d

iscl

osin

g an

d no

ndis

clos

ing

coup

les

who

had

a c

hild

/chi

ldre

n as

a

resu

lt of

DI.

Sem

istr

uctu

red

conj

oint

in

terv

iew

s an

d qu

antit

ativ

e da

ta.

Con

tent

ana

lysi

s

Dan

iels

(19

94)

New

Zea

land

Rec

ruitm

ent

thro

ugh

the

Dun

edin

In

fert

ility

Clin

ic in

New

Zea

land

.54

dis

clos

ing

and

nond

iscl

osin

g pa

rent

s th

roug

h D

I.Se

mis

truc

ture

d co

njoi

nt

inte

rvie

ws

and

quan

titat

ive

data

.

Con

tent

ana

lysi

s

Frie

se, B

ecke

r, a

nd

Nac

htig

all (

2008

)U

nite

d St

ates

Rec

ruitm

ent

thro

ugh

11 in

fert

ility

pr

actic

es +

1 s

perm

ban

k in

N

orth

ern

Cal

iforn

ia.

79 d

iscl

osin

g an

d no

ndis

clos

ing

hete

rose

xual

cou

ples

(ED

). C

hild

ren

from

infa

ncy

to 1

9 ye

ars

old.

Sem

istr

uctu

red

inte

rvie

ws:

C

oupl

e in

terv

iew

fo

llow

ed b

y so

lo

inte

rvie

w 3

mon

ths

late

r.

In-d

epth

pro

cess

of

code

dev

elop

men

t, co

mpa

ring

cod

es u

ntil

agre

emen

t of

95%

or

mor

e.G

race

and

Dan

iels

(2

007)

New

Zea

land

Part

of a

stu

dy c

ondu

cted

in

1990

with

het

eros

exua

l cou

ples

re

crui

ted

thro

ugh

an in

fert

ility

cl

inic

in N

ew Z

eala

nd.

41 d

iscl

osin

g an

d no

ndis

clos

ing

hete

rose

xual

cou

ples

(D

I) in

clud

ing

divo

rced

or

sepa

rate

d co

uple

s.

Ope

n-en

ded

inte

rvie

ws:

23

con

join

t in

terv

iew

s an

d 18

sep

arat

e in

terv

iew

s.

The

mat

ic a

naly

sis

(con

tinue

d)

by guest on October 14, 2014qhr.sagepub.comDownloaded from

5

Sour

ce a

rtic

leC

ount

ry s

ettin

gSe

ttin

gPa

rtic

ipan

t ch

arac

teri

stic

sD

ata

colle

ctio

nD

ata

anal

ysis

Gra

ce, D

anie

ls, a

nd

Gill

ett

(200

8)N

ew Z

eala

ndPa

rt o

f a s

tudy

con

duct

ed in

19

90 w

ith h

eter

osex

ual c

oupl

es

recr

uite

d th

roug

h an

infe

rtili

ty

clin

ic in

New

Zea

land

.

41 d

iscl

osin

g an

d no

ndis

clos

ing

hete

rose

xual

cou

ples

(D

I) in

clud

ing

divo

rced

or

sepa

rate

d co

uple

s.

Ope

n-en

ded

inte

rvie

ws:

23

con

join

t in

terv

iew

s an

d 18

sep

arat

e in

terv

iew

s.

The

mat

ic a

naly

sis

Hah

n an

d R

osen

berg

(2

002)

Uni

ted

Stat

esR

ecru

itmen

t th

roug

h ce

nter

fo

r as

sist

ed r

epro

duct

ion

in

Mid

wes

tern

tea

chin

g ho

spita

l.

31 d

iscl

osin

g an

d no

ndis

clos

ing

pare

nts

thro

ugh

ED. A

nony

mou

s do

natio

n. C

hild

ren

aged

6 m

onth

s to

5 y

ears

.

Aud

iota

ped

tele

phon

e in

terv

iew

s an

d qu

antit

ativ

e da

ta.

Con

tent

ana

lysi

s

Har

grea

ves

(200

6)N

ew Z

eala

ndR

ecru

itmen

t th

roug

h N

ew

Zea

land

fert

ility

clin

ics

and

New

Zea

land

Infe

rtili

ty S

ocie

ty.

Exte

nded

fam

ily m

embe

rs w

ere

cont

acte

d by

the

par

ticip

atin

g pa

rent

s.

4 di

sclo

sing

and

non

disc

losi

ng

hete

rose

xual

cou

ples

(D

I) an

d th

e ex

tend

ed fa

mily

mem

bers

of t

wo

coup

les.

Chi

ldre

n fr

om in

fanc

y to

5

year

s ol

d.

Sem

istr

uctu

red

inte

rvie

ws

Des

crip

tion

of t

hem

atic

an

alys

is b

ut n

o ex

plic

it re

fere

nce

to t

hem

atic

an

alys

is

Har

grea

ves

and

Dan

iels

(2

007)

New

Zea

land

Rec

ruitm

ent

thro

ugh

New

Z

eala

nd fe

rtili

ty c

linic

s an

d N

ew Z

eala

nd In

fert

ility

Soc

iety

. Ex

tend

ed fa

mily

mem

bers

wer

e co

ntac

ted

by t

he p

artic

ipat

ing

pare

nts.

25 d

iscl

osin

g an

d no

ndis

clos

ing

hete

rose

xual

par

ents

(D

I) an

d 2

lesb

ian

coup

les

(DI).

Chi

ldre

n ag

ed

7 m

onth

s to

12

year

s.

Sem

istr

uctu

red

inte

rvie

ws

Des

crip

tion

of t

hem

atic

an

alys

is b

ut n

o ex

plic

it re

fere

nce

to t

hem

atic

an

alys

is

Hun

ter,

Sal

ter-

Ling

, and

G

love

r (2

000)

Uni

ted

Kin

gdom

Rec

ruitm

ent

thro

ugh

the

DI

Net

wor

k (s

uppo

rt g

roup

pr

omot

ing

disc

losu

re).

83 d

iscl

osin

g pa

rent

s (D

I; 39

cou

ples

an

d 5

wom

en).

Chi

ldre

n ag

ed 1

1 w

eeks

to

15 y

ears

.

Qua

ntita

tive

and

qual

itativ

e da

taC

onte

nt a

naly

sis

Kir

kman

(20

03)

Aus

tral

ia, C

anad

a,

Uni

ted

Stat

es,

Uni

ted

Kin

gdom

, and

A

rgen

tina

Cal

l for

par

ticip

atio

n vi

a se

vera

l ch

anne

ls: N

ewsl

ette

rs,

mag

azin

es, i

nfer

tility

clin

ics

in

Aus

tral

ia, s

now

ball

sam

plin

g.

55 d

iscl

osin

g an

d no

ndis

clos

ing

pare

nts

(thr

ough

DI,

ED, a

nd

embr

yo d

onat

ion)

and

12

child

ren.

A

nony

mou

s an

d kn

own

dona

tion.

32 in

terv

iew

s in

per

son,

18

audi

otap

ed in

terv

iew

s,

20 e

mai

l int

ervi

ews,

16

wri

tten

inte

rvie

ws,

and

1

tele

phon

e in

terv

iew

Nar

rativ

e an

alys

is

Kir

kman

(20

04b)

Aus

tral

ia, C

anad

a,

Uni

ted

Stat

es,

Uni

ted

Kin

gdom

, and

A

rgen

tina

Cal

l for

par

ticip

atio

n vi

a se

vera

l ch

anne

ls: N

ewsl

ette

rs,

mag

azin

es, i

nfer

tility

clin

ics

in

Aus

tral

ia, s

now

ball

sam

plin

g.

87 d

iscl

osin

g an

d no

ndis

clos

ing

part

icip

ants

(58

par

ents

, 22

dono

rs, a

nd 1

2 of

fspr

ing)

. Don

ors

and

reci

pien

ts o

f spe

rm, e

ggs,

or

embr

yos.

Ano

nym

ous

and

know

n do

natio

n.

32 in

terv

iew

s in

per

son,

18

audi

otap

ed in

terv

iew

s,

20 e

mai

l int

ervi

ews,

16

wri

tten

inte

rvie

ws,

and

1

tele

phon

e in

terv

iew

Nar

rativ

e an

alys

is

Kir

kman

(20

04a)

Aus

tral

ia, C

anad

a,

Uni

ted

Stat

es,

Uni

ted

Kin

gdom

, and

A

rgen

tina

Cal

l for

par

ticip

atio

n vi

a se

vera

l ch

anne

ls: N

ewsl

ette

rs,

mag

azin

es, i

nfer

tility

clin

ics

in

Aus

tral

ia, s

now

ball

sam

plin

g.

87 d

iscl

osin

g an

d no

ndis

clos

ing

part

icip

ants

(58

par

ents

, 22

dono

rs, a

nd 1

2 of

fspr

ing)

. Don

ors

and

reci

pien

ts o

f spe

rm, e

ggs,

or

embr

yos.

Ano

nym

ous

and

know

n do

natio

n.

32 in

terv

iew

s in

per

son,

18

audi

otap

ed in

terv

iew

s,

20 e

mai

l int

ervi

ews,

16

wri

tten

inte

rvie

ws,

and

1

tele

phon

e in

terv

iew

Nar

rativ

e an

alys

is

(con

tinue

d)

Tab

le 1

. (co

ntin

ued)

by guest on October 14, 2014qhr.sagepub.comDownloaded from

6

Sour

ce a

rtic

leC

ount

ry s

ettin

gSe

ttin

gPa

rtic

ipan

t ch

arac

teri

stic

sD

ata

colle

ctio

nD

ata

anal

ysis

Kir

kman

(20

08)

Aus

tral

ia, A

rgen

tina,

an

d C

anad

aC

all f

or p

artic

ipat

ion

via

seve

ral

chan

nels

: New

slet

ters

, m

agaz

ines

, inf

ertil

ity c

linic

s in

A

ustr

alia

, sno

wba

ll sa

mpl

ing.

21 d

iscl

osin

g an

d no

ndis

clos

ing

wom

en (

19 E

D a

nd 2

em

bryo

do

natio

n). (

Part

of p

roje

ct w

ith

87 p

artic

ipan

ts).

Ano

nym

ous

and

know

n do

natio

n.

10 in

terv

iew

s in

per

son,

4

by e

mai

l, 4

by le

tter

, 2

by a

udio

tap

e, a

nd 1

by

tele

phon

e

Nar

rativ

e an

alys

is

Lalo

s, G

ottli

eb, a

nd

Lalo

s (2

007)

Swed

enR

ecru

itmen

t th

roug

h 2

DI

cent

ers

in S

wed

en (

Kar

olin

ska

Uni

vers

ity H

ospi

tal,

Stoc

khol

m,

and

Uni

vers

ity H

ospi

tal,

Um

eå;

follo

w-u

p of

stu

dy in

200

0).

19 (

disc

losi

ng a

nd n

ondi

sclo

sing

) pa

rent

s th

roug

h D

I. Id

entit

y-re

leas

e do

natio

n. C

hild

ren

aged

1 t

o 15

ye

ars.

Sem

istr

uctu

red

tele

phon

e in

terv

iew

sT

ext

was

ana

lyze

d by

co

nten

t an

d cl

assi

fied

into

cat

egor

ies

and

them

es.

Lind

blad

, Got

tlieb

, and

La

los

(200

0)Sw

eden

Rec

ruitm

ent

thro

ugh

the

Um

eå U

nive

rsity

Hos

pita

l an

d K

arol

insk

a H

ospi

tal i

n St

ockh

olm

.

148

disc

losi

ng a

nd n

ondi

sclo

sing

pa

rent

s (D

I). Id

entit

y-re

leas

e do

natio

n. C

hild

ren

aged

1 t

o 11

ye

ars

and

olde

r.

Que

stio

nnai

re w

ith o

pen

and

clos

ed q

uest

ions

.O

pen

codi

ng

Lyce

tt, D

anie

ls, C

urso

n,

and

Gol

ombo

k (2

005)

Uni

ted

Kin

gdom

Rec

ruite

d fr

om K

ing’

s C

olle

ge

Hos

pita

l Ass

iste

d C

once

ptio

n U

nit

(pro

mot

ing

disc

losu

re).

46 d

iscl

osin

g an

d no

ndis

clos

ing

pare

nts

with

a 4

- to

8-y

ear-

old

DI-c

once

ived

chi

ld. I

dent

ity-r

elea

se

dona

tion.

Stan

dard

ized

and

se

mis

truc

ture

d in

terv

iew

s: 3

6 co

njoi

nt

inte

rvie

ws

and

10

inte

rvie

ws

with

mot

her

only

.

The

mat

ic a

naly

sis

Mac

Dou

gall,

Bec

ker,

Sh

eib,

and

Nac

htig

all

(200

7)

Nor

ther

n C

alifo

rnia

, U

nite

d St

ates

Rec

ruitm

ent

thro

ugh

11 m

edic

al

infe

rtili

ty p

ract

ices

and

1 s

perm

ba

nk.

112

disc

losi

ng c

oupl

es (

48 D

I and

64

ED).

Chi

ldre

n ag

ed 1

to

19 y

ears

.Et

hnog

raph

ic in

terv

iew

w

ith c

oupl

e, fo

llow

ed b

y in

divi

dual

inte

rvie

w w

ith

each

of t

he t

wo

part

ners

3

mon

ths

late

r

The

mat

ic a

naly

sis

Sheh

ab e

t al

. (20

08)

Nor

ther

n C

alifo

rnia

, U

nite

d St

ates

Rec

ruitm

ent

thro

ugh

11 m

edic

al

infe

rtili

ty p

ract

ices

and

1 s

perm

ba

nk.

141

disc

losi

ng a

nd n

ondi

sclo

sing

co

uple

s w

ho h

ad c

once

ived

a c

hild

us

ing

dono

r ga

met

es (

62 D

I and

79

ED).

Chi

ldre

n ag

ed 1

to

19 y

ears

.

Ethn

ogra

phic

inte

rvie

w

with

cou

ple,

follo

wed

by

indi

vidu

al in

terv

iew

with

ea

ch o

f the

tw

o pa

rtne

rs

3 m

onth

s la

ter

The

mat

ic a

naly

sis

Yee

, Bly

th, a

nd T

sang

(2

011)

Can

ada

Rec

ruitm

ent

thro

ugh

hosp

ital-

base

d IV

F cl

inic

in a

Can

adia

n ci

ty.

18 d

iscl

osin

g an

d no

ndis

clos

ing

mot

hers

and

15

know

n do

nors

(E

D).

Kno

wn

dona

tion.

Chi

ldre

n ag

ed 1

to

7.

Sem

istr

uctu

red

face

-to-

face

or

phon

e in

terv

iew

.T

hem

atic

ana

lysi

s

Not

e. IV

F =

in v

itro

fert

iliza

tion,

ED

= e

gg d

onat

ion,

DI =

don

or in

sem

inat

ion.

Tab

le 1

. (co

ntin

ued)

by guest on October 14, 2014qhr.sagepub.comDownloaded from

Wyverkens et al. 7

concepts and explained and interpreted them in the con-text of the study as a whole (Hannes & Lockwood, 2012; Noblit & Hare, 1988). This process of identifying and interpreting concepts was conducted by the first two authors independently for 14 out of 25 articles. The remaining studies were analyzed by the first author and discussed with the second author to check for accuracy. In the fifth phase, we compared the identified concepts of each article with concepts of other articles to obtain broader themes across studies (on a meta-level). The syn-thesis focused on parents’ talk (first order constructs) and authors’ interpretations of their talk (second order con-structs; Noblit & Hare, 1988). In this phase, we mainly approached the analysis with a hermeneutics of faith, which means that we aimed to restore meaning to the text and to give “voice” to the participants (Josselson, 2004). The meta-analysis was performed in chronological order of publication, beginning with Brewaeys, Ponjaert-Kristoffersen, Van Steirteghem, and Devroey (1993) up to Yee, Blyth, and Tsang (2011) (see Table 2).

Translating Studies and Expressing the Synthesis

In the sixth phase, we attempted to create overarching themes while preserving the uniqueness of the individual studies. Both researchers participated in the development of the synthesis and the translation of the concepts. We com-bined studies by means of reciprocal translation analysis, meaning that concepts from individual studies were trans-lated into one another by constructing overarching concepts (Bondas & Hall, 2007; Kinn et al., 2013). We interpreted author’s interpretations (third-order constructs), mostly driven by a hermeneutics of suspicion, which means that we attempted to decode meanings that were more disguised (Josselson, 2004). Periodically, the synthesis was discussed with the third author until a coherent structure was achieved. The synthesis is expressed in the “Results” section, using quotes from the original studies. This is the seventh and final phase of the meta-ethnography.

Results

Study Characteristics

The set of included articles consisted of eight studies con-ducted in the United Kingdom, another eight in the United States, seven studies in New Zealand, five in Canada, four in Australia, four in Argentina, two in Sweden, and one in Belgium (see Table 1).1 The sample size ranged from 4 to 148 couples. Eight studies consisted of mixed samples with parents using egg donation, sperm dona-tion, and/or embryo donation. Thirteen studies solely focused on parents using sperm donation and four studies

solely on parents using egg donation. Policy and legisla-tive procedures varied from country to country. Sweden was in 1985 the first country to abandon donor anonym-ity. In Australia and New Zealand, only known donation is allowed, and openness about the donor conception is encouraged. More recently, the Human Fertilization Embryology Authority (HFEA) removed donor anonym-ity in the United Kingdom, allowing children to obtain identifying information on reaching age 18. In the United States, there are no regulations, only expert groups (e.g., American Society for Reproductive Medicine [ASRM]) that provide recommendations and guidelines. The remaining countries (Argentina, Canada, and Belgium) have an anonymous gamete donation policy and are char-acterized more by secrecy and taboo. Studies took place both before and after these legislative changes. Few stud-ies explicitly mentioned the type of donation (anony-mous, known, or identity-release), and information on the legal context and policy was often missing.

Description of Themes

Four major themes emerged when synthesizing the trans-lations: balancing the importance of genetic and social ties, normalizing and legitimizing the family, building strong family ties, and minimizing the role of the donor. Table 2 reflects the key concepts and themes we identi-fied. When we expressed the synthesis, we found the overarching notion that parents experienced “being dif-ferent” as well as “being similar,” compared with other families. We describe this dialectic tension after present-ing the four main themes.

Balancing the importance of genetic and social ties. Genes are regarded as significant connectors for the family, and parents are constantly reminded of the primacy of genes (Hargreaves, 2006). For DC families, the construction of family life based on genetic connection is challenged, and novel discourse needs to be built. Grace and Daniels (2007) show how couples tend to downgrade the impor-tance of genetics, except in medical contexts. One father using donor sperm states that providing information about the nature of conception can be important when confronted with a health crisis, but overall, genes are irrelevant for connectedness, relatedness, and the con-struction of the family:

Yeah, I don’t have a problem with that, I mean that’s important that that is the case. Um but ah, that’s just a, that’s just a genetic, ah, that’s just a medical thing. Ah, that isn’t, still to me, anything to do with who he is and who I am, and who [F] is, and who we are as a family. It’s not relevant. That’s just ah, that’s mechanics. It’s not the oil that makes the engine run. It’s just the bits of the engine, so yeah. (p. 703)

by guest on October 14, 2014qhr.sagepub.comDownloaded from

8

Tab

le 2

. N

ew D

eriv

ed T

hem

es F

rom

Con

cept

s of

Ori

gina

l Stu

dies

.

Der

ived

the

mes

Bala

ncin

g th

e im

port

ance

of g

enet

ic

and

soci

al t

ies

Nor

mal

izin

g an

d le

gitim

izin

g th

e fa

mily

Build

ing

stro

ng fa

mily

tie

sM

inim

izin

g th

e ro

le o

f the

don

or

Brew

aeys

, Pon

jaer

t-K

rist

offe

rsen

, Van

St

eirt

eghe

m, a

nd

Dev

roey

(19

93)

Try

ing

to b

e (p

erce

ived

as

) a

“nor

mal

fam

ily.”

Dis

clos

ure

as a

thr

eat

to fa

ther

–chi

ld r

elat

ions

hip.

Tal

king

abo

ut t

he d

onor

can

be

pain

ful

and

tens

e.“R

educ

tion”

of d

onor

is c

halle

nged

in

som

e si

tuat

ions

.D

anie

ls (

1994

) C

hild

bel

ongs

to

them

thr

ough

pr

egna

ncy

and

gene

tic t

ie w

ith

one

pare

nt.

Earl

y pa

rent

–chi

ld b

ondi

ng in

ca

se o

f don

or in

sem

inat

ion

(in

com

pari

son

to a

dopt

ion)

.

Pers

onal

nee

ds o

f chi

ldre

n ca

nnot

be

take

n in

to a

ccou

nt

whe

n ch

oosi

ng d

onor

con

cept

ion.

Dan

iels

, Lew

is, a

nd

Gill

ett

(199

5)

Stre

ssin

g th

e ir

rele

vanc

e of

don

or

conc

eptio

n m

akes

it r

elev

ant.

Dec

idin

g ab

out

disc

losu

re is

an

ongo

ing

proc

ess.

Non

disc

losu

re a

s a

way

to

prot

ect

the

child

.D

iscl

osur

e as

thr

eat

to fa

ther

–chi

ld r

elat

ions

hip.

Bio

logi

cal

pare

nt c

ompr

omis

es in

dec

isio

n to

dis

clos

e be

caus

e of

im

bala

nce

in g

enet

ic c

onne

cted

ness

with

chi

ld.

Hun

ter,

Sal

ter-

Ling

, an

d G

love

r (2

000)

Emph

asiz

ing

the

uniq

uene

ss o

f the

chi

ld w

hile

nor

mal

izin

g fa

mily

bui

ldin

g.

In s

earc

h fo

r sc

ript

s fo

r di

sclo

sure

.D

iscl

osur

e as

pot

entia

lly h

arm

ful t

o pa

rent

–chi

ld

rela

tions

hip.

Fear

for

unin

tend

ed d

iscl

osur

e by

oth

ers.

Earl

y di

sclo

sure

per

ceiv

ed a

s ea

sier

.Li

ndbl

ad, G

ottli

eb, a

nd

Lalo

s (2

000)

Dis

clos

ure

initi

ated

by

seve

ral a

spec

ts (

cont

ext,

time,

kno

wle

dge,

que

stio

ns).

Dis

clos

ure

posi

tivel

y ex

peri

ence

d.

D

iscl

osur

e as

pot

entia

lly h

arm

ful t

o pa

rent

–chi

ld

rela

tions

hip.

Non

disc

losu

re a

s a

way

to

prot

ect

the

child

.Ea

rly

disc

losu

re p

erce

ived

as

easi

er.

Hah

n an

d R

osen

berg

(2

002)

Am

bigu

ity a

roun

d ne

cess

ity t

o kn

ow g

enet

ic h

isto

ry.

Chi

ld b

elon

gs t

o th

em t

hrou

gh

preg

nanc

y.

Dis

clos

ure

and

nond

iscl

osur

e as

pot

entia

lly h

arm

ful.

Biol

ogic

al p

aren

t co

mpr

omis

es in

dec

isio

n to

dis

clos

e be

caus

e of

imba

lanc

e in

gen

etic

con

nect

edne

ss w

ith

child

.R

easo

ns t

o ch

oose

for

(non

)dis

clos

ure

in fa

vor

of

pare

nt–c

hild

rel

atio

nshi

p.C

hild

’s q

uest

ion:

Clu

e to

con

vers

atio

n.In

sea

rch

for

scri

pts

for

disc

losu

re.

Kir

kman

(20

03)

Rea

sons

to

choo

se fo

r (n

on)d

iscl

osur

e in

favo

r of

pa

rent

–chi

ld r

elat

ions

hip.

D

iscl

osur

e ha

s ve

rbal

and

non

verb

al a

spec

ts.

In s

earc

h fo

r sc

ript

s fo

r di

sclo

sure

.Bu

ildin

g na

rrat

ive

is a

n on

goin

g pr

oces

s.

(con

tinue

d)

by guest on October 14, 2014qhr.sagepub.comDownloaded from

9

Der

ived

the

mes

Bala

ncin

g th

e im

port

ance

of g

enet

ic

and

soci

al t

ies

Nor

mal

izin

g an

d le

gitim

izin

g th

e fa

mily

Build

ing

stro

ng fa

mily

tie

sM

inim

izin

g th

e ro

le o

f the

don

or

Kir

kman

(20

04b)

Irre

leva

nce

of g

enet

ics

to

conn

ecte

dnes

s vs

. abs

ence

of

gene

tic t

ie a

s lo

ss.

Sign

s of

diff

icul

t bo

ndin

g at

trib

uted

to

lack

of g

enet

ic c

onne

ctio

n.M

eani

ng o

f gen

etic

inhe

rita

nce

deco

ntex

tual

ized

from

con

text

of

fam

ily r

elat

ions

hips

.Fo

r so

cial

par

ent

bond

ing

with

ch

ildre

n in

crea

ses

over

tim

e.So

cial

fath

er fe

ars

to b

e re

ject

ed

duri

ng p

uber

ty.

Kir

kman

(20

04a)

V

alui

ng t

he s

perm

pro

vide

r im

plie

s de

valu

ing

the

soci

al fa

ther

.Sh

iftin

g id

eas

abou

t do

nor.

Lyce

tt, D

anie

ls,

Cur

son,

and

G

olom

bok

(200

5)

Mea

ning

of g

enet

ic in

heri

tanc

e de

cont

extu

aliz

ed fr

om c

onte

xt o

f fa

mily

rel

atio

nshi

ps.

Fear

for

unin

tend

ed d

iscl

osur

e by

oth

ers.

Dis

clos

ure

coul

d be

har

mfu

l to

pare

nt–c

hild

rel

atio

nshi

p.C

onfid

ence

in s

tren

gth

pare

nt–c

hild

rel

atio

nshi

p at

the

ba

se o

f dis

clos

ure.

Min

or r

eact

ions

of c

hild

ren

in c

ompa

riso

n to

ant

icip

ated

fe

ars.

Beck

er, B

utle

r, a

nd

Nac

htig

all (

2005

)

Irre

leva

nce

of g

enet

ics

to

conn

ecte

dnes

s vs

. abs

ence

of

gene

tic t

ie a

s lo

ss.

App

eari

ng a

s a

fam

ily in

th

e so

cial

con

text

.(N

on)r

esem

blan

ce t

alk

as d

iscu

rsiv

e ac

t.

Har

grea

ves

(200

6)

Irre

leva

nce

of g

enet

ics

to

conn

ecte

dnes

s vs

. abs

ence

of

gen

etic

tie

as

mea

ning

ful.

Mea

ning

of g

enet

ic in

heri

tanc

e de

cont

extu

aliz

ed fr

om c

onte

xt o

f fa

mily

rel

atio

nshi

ps.

Res

embl

ance

tal

k as

dis

curs

ive

act

(sup

port

ing

disc

ours

e of

rel

ated

ness

).

For

soci

al p

aren

t bo

ndin

g w

ith

child

ren

incr

ease

s ov

er t

ime.

Gra

ce a

nd D

anie

ls

(200

7)M

eani

ng o

f gen

etic

inhe

rita

nce

deco

ntex

tual

ized

from

con

text

of

fam

ily r

elat

ions

hips

.

Try

ing

to b

e (p

erce

ived

as

) a

“nor

mal

fam

ily.”

Con

trad

icto

ry a

ttitu

de t

owar

d di

sclo

sure

.

Ir

rele

vanc

e of

gen

etic

s to

co

nnec

tedn

ess

vs. a

bsen

ce o

f ge

netic

tie

as

loss

.

St

ress

ing

irre

leva

nce

of d

onor

co

ncep

tion

mak

es it

rel

evan

t.

(con

tinue

d)

Tab

le 2

. (co

ntin

ued)

by guest on October 14, 2014qhr.sagepub.comDownloaded from

10

Der

ived

the

mes

Bala

ncin

g th

e im

port

ance

of g

enet

ic

and

soci

al t

ies

Nor

mal

izin

g an

d le

gitim

izin

g th

e fa

mily

Build

ing

stro

ng fa

mily

tie

sM

inim

izin

g th

e ro

le o

f the

don

or

Har

grea

ves

and

Dan

iels

(2

007)

Dis

clos

ure

and

nond

iscl

osur

e as

pot

entia

lly h

arm

ful.

Rea

sons

to

choo

se fo

r (n

on)d

iscl

osur

e in

favo

r of

pa

rent

–chi

ld r

elat

ions

hip.

In s

earc

h fo

r sc

ript

s fo

r di

sclo

sure

.Bi

olog

ical

par

ent

com

prom

ises

in d

ecis

ion

to d

iscl

ose

beca

use

of im

bala

nce

in g

enet

ic c

onne

cted

ness

with

ch

ild.

Earl

y di

sclo

sure

per

ceiv

ed a

s ea

sier

.

Lalo

s, G

ottli

eb, a

nd

Lalo

s (2

007)

In s

earc

h fo

r sc

ript

s fo

r di

sclo

sure

.C

hild

’s q

uest

ion

as c

lue

for

conv

ersa

tion

or c

lue

for

prot

ectin

g th

e tr

uth

even

mor

e.C

onfid

ence

in s

tren

gth

pare

nt–c

hild

rel

atio

nshi

p at

the

ba

se o

f dis

clos

ure.

Belie

f “op

enne

ss le

ads

to g

ood

fam

ily r

elat

ions

hips

.”V

aria

bilit

y in

sto

ry t

ellin

g: F

rom

tec

hnic

al t

o fa

iry

tale

.

Mac

Dou

gall,

Bec

ker,

Sh

eib,

and

Nac

htig

all

(200

7)

Stru

gglin

g w

ith a

ssoc

iatio

n be

twee

n bi

olog

ical

link

and

rea

lnes

s of

pa

rent

hood

.

Try

ing

to b

e (p

erce

ived

as

) a

“nor

mal

” fa

mily

.St

reng

th p

aren

t–ch

ild r

elat

ions

hip

as b

uffe

r fo

r do

ubtin

g po

sitio

n so

cial

par

ent.

Dis

clos

ure

proc

ess

adju

sted

to

the

child

.C

reat

ing

cond

ition

s fo

r op

timal

acc

epta

nce

of d

onor

co

ncep

tion.

Dis

clos

ure

as a

n on

goin

g pr

oces

s.

Sheh

ab e

t al

. (20

08)

Res

embl

ance

tal

k as

cha

lleng

e an

d re

assu

ranc

e.

One

par

ent

com

prom

ises

in d

ecis

ion

to d

iscl

ose

in

vari

ous

way

s.

Frie

se, B

ecke

r, a

nd

Nac

htig

all (

2008

)C

once

rn a

bout

soc

ial

legi

timac

y of

fam

ily.

Fear

for

unin

tend

ed d

iscl

osur

e by

oth

ers.

Gra

ce, D

anie

ls, a

nd

Gill

ett

(200

8)T

ryin

g to

be

perc

eive

d as

a “

norm

al”

fam

ily.

Stre

ssin

g do

nor

is n

ot fa

ther

(in

co

mm

unic

atio

n w

ith c

hild

ren)

. Int

eres

t in

link

bet

wee

n do

nor

and

child

ren.

Er

asur

e of

don

or fa

cilit

ates

“se

nse

of

fam

ily.”

Red

uctio

n of

don

or c

halle

nged

in

som

e si

tuat

ions

.K

irkm

an (

2008

)M

eani

ng o

f gen

etic

inhe

rita

nce

deco

ntex

tual

ized

from

con

text

of

fam

ily r

elat

ions

hips

.

Stre

ngth

par

ent–

child

rel

atio

nshi

p as

buf

fer

for

doub

ting

posi

tion

soci

al m

othe

r.Ex

pres

sing

gra

titud

e an

d re

sent

men

t to

war

d un

know

n eg

g do

nor.

U

ncer

tain

ty a

bout

rea

lnes

s of

m

othe

rhoo

d.

(con

tinue

d)

Tab

le 2

. (co

ntin

ued)

by guest on October 14, 2014qhr.sagepub.comDownloaded from

11

Der

ived

the

mes

Bala

ncin

g th

e im

port

ance

of g

enet

ic

and

soci

al t

ies

Nor

mal

izin

g an

d le

gitim

izin

g th

e fa

mily

Build

ing

stro

ng fa

mily

tie

sM

inim

izin

g th

e ro

le o

f the

don

or

Burr

(20

09)

Soci

al a

nd p

hysi

cal b

ound

arie

s ar

ound

fam

ily m

ore

impo

rtan

t th

an la

ck o

f gen

etic

bon

d w

ith

child

.

Res

embl

ance

as

subs

titut

e fo

r m

issi

ng

gene

tic li

nk b

etw

een

fath

er a

nd c

hild

.

Am

bigu

ous

posi

tion

tow

ard

dono

r.

Blak

e, R

eadi

ngs,

Jadv

a,

and

Gol

ombo

k (2

010)

Preg

nanc

y an

d de

liver

y m

ore

impo

rtan

t th

an g

enet

ic t

ie (

for

fam

ily r

elat

edne

ss).

Mon

itori

ng p

aren

t–ch

ild r

elat

ions

hip

thro

ugho

ut

disc

losu

re p

roce

ss.

Chi

ld’s

neu

tral

/acc

eptin

g re

actio

n re

assu

ring

.C

once

rn a

bout

mea

ning

don

or c

once

ptio

n fo

r ch

ild’s

pe

rspe

ctiv

e on

par

ent–

child

rel

atio

nshi

p.

Blyt

h, L

angr

idge

, and

H

arri

s (2

010)

Coh

eren

t fa

mily

sto

ry a

s a

way

to

pres

erve

fam

ily b

onds

.Bo

okle

ts o

ffer

voca

bula

ry fo

r pa

rent

–chi

ld c

onve

rsat

ions

.Be

lief “

open

ness

lead

s to

goo

d fa

mily

rel

atio

nshi

ps.”

Dis

clos

ure

as im

pera

tive

(“go

od p

aren

t gi

ves

child

all

he

or s

he n

eeds

”).

Dis

clos

ure

open

s ne

w s

ocia

l com

plex

ity.

Dan

iels

, Gra

ce, a

nd

Gill

ett

(201

1)C

hild

’s q

uest

ion

as c

lue

for

conv

ersa

tion

and

to p

rote

ct

the

trut

h ev

en m

ore.

In

sea

rch

for

scri

pts

for

disc

losu

re.

Pa

rent

s en

tang

led

in v

icio

us s

ecre

cy c

ircl

e.

La

ck o

f con

fiden

ce in

str

engt

h pa

rent

–chi

ld r

elat

ions

hip

at

the

base

of n

ondi

sclo

sure

.

O

penn

ess

in p

aren

t–ch

ild r

elat

ion

enda

nger

ed b

y no

ndis

clos

ure.

Ea

rly

disc

losu

re p

erce

ived

as

easi

er.

Yee

, Bly

th, a

nd T

sang

(2

011)

Add

ed c

ompl

exity

in c

ase

of k

now

n do

natio

n.M

inor

rea

ctio

ns o

f chi

ldre

n in

com

pari

son

to a

ntic

ipat

ed

fear

s.Pa

rent

s (r

ecei

vers

) ar

e en

title

d to

dis

clos

e.V

aria

bilit

y in

sto

ry t

ellin

g: F

rom

tec

hnic

al t

o fa

iry

tale

.

Tab

le 2

. (co

ntin

ued)

by guest on October 14, 2014qhr.sagepub.comDownloaded from

12 Qualitative Health Research

Participants engaged in a protective discourse favoring social relationships and stressed the importance of social bonds, commitment, love, time, and shared experiences. They seemed to decontextualize the meaning of genetic inheritance from the context of family relationships (Grace & Daniels, 2007; Hargreaves, 2006; Kirkman, 2004b, 2008; Lycett, Daniels, Curson, & Golombok, 2005). Although having genetically related children was always their first choice, they challenged the idea that bio-logical ties would bring them and their children intrinsi-cally closer (Hargreaves, 2006). However, throughout parents’ attempts to minimize the relevance of genetics to the family, genetics seem to become relevant anyway. Put another way, their efforts to create a new discourse (favor-ing social ties) show the importance that they attach to genetic relationships. Two seemingly contradictory stances became apparent: Sharing genes is unnecessary to form a family while the absence of genetic links is per-ceived as a loss and a difficulty. In five articles, this ambi-guity is evident (Becker et al., 2005; Grace & Daniels, 2007; Hargreaves, 2006; Kirkman, 2004b, 2008).

When it comes to family well-being, participants regard the intention to parent and the act of parenting as more essential than genetic links. Two notions are put forward with regard to the development of the parent–child bond in DC families. First, experiencing pregnancy (and the deliv-ery) seemed to be central in bonding with the child (Blake, Readings, Jadva, & Golombok, 2010; Hahn & Rosenberg, 2002). Parents refer to differences with adoption and sug-gest that through pregnancy and the genetic tie with one parent, they have the feeling that the child belongs to them from the start (Daniels, 1994). Second, the idea that bond-ing with the child does not occur immediately, but develops gradually, was also present in two studies (Hargreaves, 2006; Kirkman, 2004b). The social parent experiences increased bonding over time as well as increased confi-dence in the power of social family ties, which eventually becomes evident. However, as soon as bonding does not occur “naturally,” genetics become relevant again. Stated another way, in cases where “instant” attachment with the child is difficult, parents tend to emphasize the importance of genetics and attribute problems to the lack of genetic connection (Kirkman, 2004b). In several studies of Kirkman (2004b, 2008), concerns about the “realness” of social par-enthood are put forward. Parents fear being rejected by their children because they are not the “real” mother or father, suggesting that genetic parents are more genuine. However, it is also assumed that a good parent–child relation would form a “buffer” (Kirkman, 2008). Balancing the importance of genetic ties is strongly influenced by the outside world, which we address in the following theme.

Normalizing and legitimizing the family. Parents aim to be perceived and received as a “normal” family to join

society and facilitate integration (Becker et al., 2005; Brewaeys et al., 1993; Friese, Becker, & Nachtigall, 2008; Grace & Daniels, 2007; Grace, Daniels, & Gillett, 2008; Hunter, Salter-Ling, & Glover, 2000; Kirkman, 2008; Mac Dougall, Becker, Sheib, & Nachtigall, 2007). A key issue here is resemblance talk. In general, resem-blances within the family are experienced as a marker of kinship. When comments are made about (the presence or absence of) similarities, it has the potential to create dis-tance and feelings of loss as well as to embody connect-edness and feelings of happiness and pride. Parents relate to resemblance talk in a rather complex way; they use resemblance talk to support the sense of “being a family,” and they fear resemblance talk because it challenges the legitimacy of their family. Regarding the former, Becker et al. (2005) note how parents install resemblance talk to protect feelings of “familiarity” and “sameness.” Resem-blance talk is seen as a meaningful act, supporting a dis-course of relatedness (Hargreaves, 2006). Talking about likenesses forms a substitute for missing a genetic link between father and child (Burr, 2009), and parents tend to use physical resemblance to evoke relatedness with the social parent and to downgrade the connection to the donor (Hargreaves, 2006). However, when resemblance talk is initiated by others, it also threatens parents because it somehow questions their legitimacy as a family (Becker et al., 2005). Parents are sensitive to resemblance talk, as they want to normalize their family and to avoid the sense of “being different.” In addition, when comments are made about appearances, it triggers both disclosure and nondisclosure in parents (Becker et al., 2005; Shehab et al., 2008). Some parents clarify their situation by dis-closing the conception method, whereas nondisclosing parents use resemblance talk to reinforce and reassure their appearance as a seemingly genetically related fam-ily. This concept is made explicit by one woman:

We were open about it, and then as soon as we had the kids, our neighbours said, “Oh, your child looks just like you.” You don’t say, “That’s interesting because we used a donor.” I found myself not saying that and surprised I didn’t say it. I think as soon as you have children, you are so protective of them. You don’t want there to be a sense of they’re different. I’ve just found myself being totally private. (Becker et al., 2005, p. 1305)

Another way of normalizing the family is by maxi-mizing the resemblances between the child and the social parent. To do so, physical characteristics of the social parent are often matched with the donor (Becker et al., 2005; Grace & Daniels, 2007). Common to these strategies is the idea that families want to appear as a “normal” family by simulating genetic connectedness. One study about older motherhood touches on difficul-ties in this path to form a “normal” family and states that

by guest on October 14, 2014qhr.sagepub.comDownloaded from

Wyverkens et al. 13

appearing as an older mother can be socially interpreted as having used donor oocytes and cause unintended dis-closure (Friese et al., 2008). Mothers in this study fear being stigmatized, and as a result, they stress the legiti-macy of their motherhood. For instance, they “tried to link older motherhood with longstanding discourses regarding ‘good’ motherhood practices” (Friese et al., 2008, p. 70).

Finally, normalization is also present in communica-tion with the children, as parents try to present their way of family building as a “normal” and “natural” issue (Hunter et al., 2000; Mac Dougall et al., 2007)

It’s a difficult balance of bringing up the subject occasionally, or grabbing any opportunity as it suddenly arises, and not over emphasizing it to make him feel unusual. It has to seem the most natural thing in the world [mother of a 1-year-old]. (Hunter et al., 2000, p. 160)

Parents are careful not to picture the donor conception as something that “deviates” from the norm. This careful-ness that parents evince when communicating with their children is related to their more general focus on strong parent–child relationships and will be discussed in the next theme.

Building strong family ties. When we relate articles on the disclosure decisions and outcomes to our research ques-tion, what seems apparent are the concerns about family well-being and the strength of family relationships. In 13 studies, parents’ motivation to disclose—as well as their reasons to keep the donor origin secret—is presented as a choice that is made in the best interest of the child (Blake et al., 2010; Blyth, Langridge, & Harris, 2010; Brewaeys et al., 1993; Daniels et al., 2011; Daniels, Lewis, & Gillett, 1995; Hahn & Rosenberg, 2002; Hargreaves & Daniels, 2007; Hunter et al., 2000; Kirkman, 2003; Lalos, Gottlieb, & Lalos, 2007; Lindblad, Gottlieb, & Lalos, 2000; Lycett et al., 2005; Mac Dougall et al., 2007). Whether parents chose secrecy or (selective) disclosure, they express benign intentions: to protect their children from the pos-sible harm that secrecy or disclosure would cause. Specifi-cally, this means that some parents try to make the parent–child relationship stronger by being transparent and not keeping secrets, whereas others fear the prospect of endangering their relationship with their child by talk-ing about sensitive issues. Besides the effects that disclo-sure has on the strength of the relationships with their children, parents also regard the strength of the parent–child relationship as an important condition prior to telling (Daniels et al., 2011; Lalos et al., 2007; Lycett et al., 2005; Mac Dougall et al., 2007). High confidence in the strength of their relationship is foundational to disclosure, and a lack of confidence is one reason for nondisclosure.

Some parents chose to keep the DC a secret because they fear the psychological distance talking about this issue would create and the possible search for the donor: “[We] do not yet regard it as relevant whether we will tell . . . afraid that she will distance herself from her father. She is still so young” (Lindblad et al., 2000, p. 197). More arguments for nondisclosure are found across stud-ies. For instance, in four studies, participants claim that the donor origin is only a trivial matter. Through mini-mizing the importance of genetics, parents argue that knowing one’s genetic history is irrelevant, and therefore disclosing the conception method becomes superfluous (Daniels et al., 1995; Hahn & Rosenberg, 2002; Lindblad et al., 2000; Lycett et al., 2005):

We do not find it relevant to discuss this, when the legal father has always felt like the real dad. It is important to build a secure world for the child and not to talk about trifling matters. (Lindblad et al., 2000, p. 196)

At the same time, parents try to keep the DC silent, because it feels threatening to the family (Brewaeys et al., 1993; Grace & Daniels, 2007; Hargreaves & Daniels, 2007; Hunter et al., 2000). The “realness” of their parent-hood is questioned, and they are afraid that this might also become an issue for the child (Blyth et al., 2010). Thus, an apparent paradox is present as the donor concep-tion is not relevant or important to them, and at the same time, it feels threatening. The implicit primacy of genetic ties seems to prevail and causes parents to feel uncom-fortable with disclosing their family structure (Becker et al., 2005). On top of that, parents who keep the donor conception secret often feel bad about themselves and experience it as an instance of lying to their children (Daniels et al., 2011).

Other parents choose to be open because their great-est fear is that the child would devaluate the parent–child relationship, out of a sense of betrayal (in case of an accidental discovery). They believe that being trans-parent and valuing openness in their relationship will lead to strong and trusting family relationships (Blyth et al., 2010). In their narrative about the conception method, they emphasize how “special” and “unique” their child is (Hunter et al., 2000). In this way, they attempt to install an “acceptable” narrative to preserve the bond with the child (Blake et al., 2010). They also try to monitor the child’s meaning making by adapting the amount of information the child receives or the moments when donor conception is discussed. Blyth et al. (2010) also describe how disclosure opens new social complexity because, from that moment onward, children become storytellers themselves. Parents are no longer in control, and this is experienced as a threat to their privacy.

by guest on October 14, 2014qhr.sagepub.comDownloaded from

14 Qualitative Health Research

Many questions arise about the content, the manner, the timing, and the initiator of disclosure (Hunter et al., 2000; Lalos et al., 2007; Lindblad et al., 2000). Parents search for examples and advice to find out how, what, and when to tell. They navigate in a vacuum of scripts and construct their own strategies to do the best for their chil-dren. Hunter et al. (2000) highlight that the earlier parents informed the children, the easier it is. This was also found in three other studies where participants conveyed that late disclosure is more difficult (Daniels et al., 2011; Hargreaves & Daniels, 2007; Lindblad et al., 2000). Parents seem to be entangled in a vicious circle of delay-ing telling out of fear, which often makes disclosure even more difficult (Daniels et al., 2011).

In addition, disclosure decisions are embedded in mar-ital relationships, with biological parents mostly support-ing the social parent and giving more say to him or her in the decision to disclose or not. This is usually motivated by a perceived imbalance in connectedness with the child (Daniels et al., 1995; Hahn & Rosenberg, 2002; Hargreaves & Daniels, 2007). However, the study of Shehab et al. (2008) shows that one of the parents can compromise in the decision to disclose in various ways, for example, on the basis of experiential or emotional expertise in one of the partners. Hargreaves and Daniels (2007) point out that a loyalty conflict could occur in the biological parent between the needs of the children and the needs of the social parent. Besides taking care of the parent–child relationship, partners seemed to care for each other and to ensure that the position of the social parent is protected as well (Hargreaves & Daniels, 2007; Lindblad et al., 2000; Mac Dougall et al., 2007).

To summarize, the disclosure process seems a difficult and sometimes stressful task which challenges couples’ comfort and confidence in their parental role. In this pro-cess, building strong family ties is parents’ main concern.

Minimizing the role of the donor. To facilitate the experi-ence of “normative nuclear family bonds,” parents tend to “erase” the donor in their family constellation (Brewaeys et al., 1993; Burr, 2009; Grace et al., 2008). They stress the fact that in daily life, the donor’s existence is marginal and irrelevant (Grace et al., 2008). One female participant explains that “he just helped us get what we wanted at that time and then he was out of the picture, basically, for us. We’ve never thought about it in that respect again” (Grace et al., 2008, p. 306).

However, sometimes the donor issue arises once more in the family context (Brewaeys et al., 1993; Grace et al., 2008). For instance, when traits of the children cannot be recognized in the parents, this evokes thoughts about the donor. Also in medical contexts, parents are reminded of the donor’s existence. In three studies, the relation with the (sperm or oocyte) donor seems ambivalent (Burr,

2009; Kirkman, 2004a, 2008). Participants’ attitude toward the donor shifts from grateful to fear and resent-ment, and from curiosity to disinterest:

Helen: Yes, there was an amusing sort of situation as we walked back to the car parked round here [following their treatment] and we’re looking at people, going “Is that him? Or is that him? Nah surely not!” Mike: [Nodding in agreement] “It’s just a strange thing. There’s a sort of curiosity and a need to understand and know, but when you look you really don’t want to know.” (Burr, 2009, p. 711)

Parents are interested in the donor and the link he or she has with the children while they are trying to place him or her outside the family. Furthermore, they try to avoid talking about the donor because this is experienced as something painful, especially by the social parent who is reminded of his or her infertility (Brewaeys et al., 1993; Kirkman, 2004a). Families therefore struggle with the link society makes between a genetic parent and a “real” parent, whereas the social parent is the “real” parent for them (Hargreaves, 2006; Kirkman, 2004a; Mac Dougall et al., 2007). Grace et al. (2008) find that in family com-munication, the donor is systematically called “it” or “donor” instead of father, to minimize his role and to feel like they have a child of their own.

Dialectics of being different and being similar. All studies in our synthesis show how participants relate themselves to the nuclear family ideal and how they are occupied with acceptance by their social environment as they do not want to be considered as “abnormal” or “different” (e.g., Becker et al., 2005; Brewaeys et al., 1993). The concern parents feel with regard to the legitimacy of their family is not always directly described within the studied arti-cles. Rather, it seems to be present at a more implicit level. Most of the studies focus on ways to handle this concern, rather than providing experiential accounts of what parents exactly feel and fear. In this meta-ethnogra-phy, we sought to bring the experience of family relation-ships in this specific context to the fore. In doing so, we found that parents’ experiences are characterized by a dialectic tension of feeling “different” and “similar” at the same time. For instance, parents prove their “nor-malcy” by pointing out the irrelevance of genetic ties, and at the same time, they feel different because of the absence of genetic ties (first and second theme; e.g., Grace & Daniels, 2007; Hargreaves, 2006). Second, deci-sions about disclosure are found to be challenging for parents (e.g., Hunter et al., 2000; Lalos et al., 2007). Some thought it pointless to talk to the children about the method of conception because they feel like a normal family (Lindblad et al., 2000). Although they present the DC as something irrelevant, they put a lot of efforts into

by guest on October 14, 2014qhr.sagepub.comDownloaded from

Wyverkens et al. 15

trying to keep it a secret, thus making it relevant. Other parents struggle with integrating the narrative of DC in family life while seeking normalcy and recognition by the society (e.g., Blyth et al., 2010). Both disclosing and nondisclosing parents want to be good parents and are afraid of being judged for their decisions. Therefore, it could be that they rationalize and justify their choices as being made in the best interest of the child. Finally, the donor seems to be both absent and present in the family narrative (fourth theme). Parents erase the donor and yet are sometimes curious or concerned about genetic inheri-tance (e.g., Burr, 2009). Overall, they both refuse and embrace differences in their family narrative.

Discussion

With our meta-ethnography, we attempted to integrate the qualitative literature and to gain additional insight into the experiences of family relationships in DC families. We found that parents’ attempts to minimize the impor-tance of genetics, to normalize their family, to build strong families, and to minimize the role of the donor were characterized by a dialectic tension between feeling “different” and “similar” at the same time.

The participants of the studies in our review all lived in Western cultures where genetic connectedness is taken for granted and considered as inherently attached to the parent–child relationship (Hargreaves, 2006). However, for these couples, the most logical way (societal and bio-logical) to build a family seemed impossible. This might lead parents to revise their attitudes toward the relevance of genetics. Whereas the meaning of social and genetic ties is intertwined in the general population, these parents can consider the meaning of these bonds separately. As a consequence, an artificial division of family relationships is created (genetic and nongenetic). In this respect, the meaning that would be attributed to the “hybrid” of social and genetic bonds is sometimes attributed to social ties alone, because genetic ties are partly missing. In our review, we found that parents focused on the importance of love, time, and shared experiences and built a protec-tive discourse favoring social bonds as the basis for fam-ily ties (Grace & Daniels, 2007; Hargreaves, 2006; Kirkman, 2004b, 2008; Lycett et al., 2005). However, parents’ efforts to underplay the genetic connection intrinsically point at the fact that genes seemed signifi-cant to them. The heterosexual nuclear family (based on blood ties) remains the reference point and dominant definition of “the family.” In this respect, the contempo-rary focus on genetic explanations for health, illness, and personality and the increasing medicalization puts pres-sure on parents. They become responsible for the genetic makeup of the family (or the absence of genetic connec-tion in the family). Also, on a legal and ethical level, the

focus is on children’s right to know their genetic origin (Ravelingien, Provoost, & Pennings, 2013), again high-lighting the dominance of the genetic discourse.

Central to our synthesis was the parents’ underlying wish to be recognized as a “normal” family and their attempts to preserve strong familial bonds. In doing so, parents simultaneously minimized genetics and found it relevant, talked about their way of building a family and wanted to keep it secret, erased the donor and brought him to the fore, and so forth. While these attitudes might seem contradictory, we interpreted them as dialectic ten-sions that coexist as opponent forces. In general, dialec-tics refer to the assumption that in social life, people experience tensions between opposites and contradic-tions they cannot resolve. The theory of dialectics goes back to philosophical writings of Hegel (1807/1977) in his work, The Phenomenology of Mind, and the Russian philosopher Bakhtin (1981). Within family psychology, some researchers have studied dialectical processes in marital relationships (Baxter, 2011; Baxter & Montgomery, 1996), parent–child relationships (De Mol, Lemmens, Verhofstadt, & Kuczynski, 2013), and thera-peutic relationships (Rober & Seltzer, 2010). The way we interpreted the dialectic tension in our synthesis is differ-ent from these dialectical approaches in the sense that we did not identify dialectics within family relationships but rather in relation to the ideas about families in society. Parents see their families as “normal” families, which might lead them to keep the DC secret or to normalize their family situation to others. At the same time, they are confronted with medical narratives, resemblance talk, and societal ideas privileging blood ties, which make them feel “different.” The dialectic tension thus takes place between (interpersonal and intrapersonal) experi-ences of difference and normalcy, experiences that are influenced by ideas about families in society.

The tensions we identified are not entirely new to the existing literature on nontraditional families. Empirical studies with lesbian families show similar processes as identified here. For example, Nordqvist (2010) found that talking about family resemblances can create distance as well as connectedness in the context of lesbian families. Nordqvist and Smart (2014) also described how connec-tions to the donor introduce unanticipated questions and how parents manage ideas about genetic connectedness, which has become central in contemporary society. Hequembourg and Farrell (1999) and Ben-Ari and Livni (2006) also identified a dialectic tension between the mar-ginal and mainstream identity in lesbian mothers. By becoming mothers, they join the mainstream identity as a mother, whereas lesbianism is still considered as marginal in society. Also for adoptive single mothers, tensions occur as they feel autonomous and empowered by becoming a single mother on a personal level, whereas from an

by guest on October 14, 2014qhr.sagepub.comDownloaded from

16 Qualitative Health Research

interpersonal viewpoint they are considered as deviant (Ben-Ari & Weinberg-Kurnik, 2007). Although we found similar tensions in the broader literature on nontraditional families, the struggle to become a “normal” family seemed more difficult for lesbian-parented families or single moth-ers because they are more “visible” as a DC family, and they are confronted with social stigma related to the lack of a (male) parent. Besides becoming a nongenetic parent, they also face difficulties in building a nonheterosexual family. Nordqvist and Smart (2014) argue,

Donor-conceived families are the most recent of the new families and they are facing sensitive issues about whether they can fit in and look just like other families or whether they should embrace their difference while still insisting that they are perfectly proper families. (p. 7)

With our review, we have shown that this tension char-acterizes current research findings on DC families and points at a core issue that should be taken into account in counseling practice.

Some limitations need to be addressed. In line with Indekeu et al. (2013), we found it difficult to translate results from one country to other countries with different legislative contexts. At the same time, we identified very similar debates and concerns in all countries where donor-assisted conception was practiced. These debates generally focused on whether or not donor anonymity should be abandoned and whether or not openness about DC should be promoted. In the primary data, all parents expressed their concerns and doubts about disclosure and information about the donor. However, the way these debates and con-cerns are presented is very context specific. For example, Lindblad et al. (2000) presented the disclosure process as a positive experience, with parents feeling relieved and chil-dren reacting with curiosity. However, this study was con-ducted in Sweden, where disclosure is very much promoted, and this message was implicitly (even explicitly) reflected by the authors. Also, Hunter et al. (2000) recruited parents via the Donor Insemination Network in the United Kingdom and found that the earlier parents told their chil-dren about DC the better, but this is also recommended by those support groups. Thus, the social climate and the advices in counseling practice might have influenced find-ings. A more detailed study on the impact of policies and social climates is needed to make statements about its influence on family life. Second, in our attempt to analyze the family experiences in detail, we found our themes to be closely intertwined. We are aware that the presented struc-ture is only one way of interpreting the studies. However, our methodological rigor (by analyzing independently and systematically) helped to support our findings.

Our review demonstrates that—instead of studying the needs of isolated family members, motivated by societal

debates (for instance, “the need of the child to know his genetic origin”)—we need to take into account the family context. Therefore, we argue that it is necessary to hold on to a more systemic approach and to pay attention to the long-term goals in family relationships (De Mol & Buysse, 2008), as they might explain how parents relate to disclo-sure decisions and the importance they attach to genetics. In general, parents looked for ways to preserve strong family bonds and good parent–child relations (i.e., long-term goals), and their alternative way of conceiving played a marginal role in their family building. Our findings also indicate that posttreatment counseling could be beneficial to provide support and space for parents to talk about their concerns (for instance, regarding disclosure decisions). However, the identified tension of feeling “similar but dif-ferent” could prevent parents from going to counseling. Counseling usually takes place in the context of the fertil-ity centers, which possibly symbolizes parents’ experi-ences of feeling “different” (in comparison to naturally conceiving couples) because they are reminded of the fact that their children are DC. By contrast, the medicalization and narrow focus on the goal of procreating, together with the clinics’ efforts to create “normal” families and to mini-mize the differences from a genetically related two-parent family (for instance, through matching the social parent with the donor), ignore and create little space for parents’ sense of “otherness.” For counseling practice, we suggest that these dialectic tensions in trying to be seen as a nor-mal family while feeling different, as well as parents’ needs to talk and not to talk about the donor origin, should be acknowledged.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: the Special Research Fund of Ghent University.

Note

1. Four studies included participants from different countries: Australia, Canada, United States, United Kingdom, and Argentina.

References

Bakhtin, M. (1981). The dialogic imagination. Austin: University of Texas Press.

Baxter, L. A. (2011). Voicing relationships: A dialogical per-spective. London: SAGE.

Baxter, L. A., & Montgomery, B. M. (1996). Relating: Dialogues & dialectics. New York: Guilford Press.

by guest on October 14, 2014qhr.sagepub.comDownloaded from

Wyverkens et al. 17

Becker, G., Butler, A., & Nachtigall, R. D. (2005). Resemblance talk: A challenge for parents whose children were conceived with donor gametes in the US. Social Science & Medicine, 61, 1300–1309. doi:10.1016/j.socsci-med.2005.01.018

Ben-Ari, A., & Livni, T. (2006). Motherhood is not a given thing: Experiences and constructed meanings of biological and nonbiological lesbian mothers. Sex Roles, 54, 521–531. doi:10.1007/s11199-006-9016-0

Ben-Ari, A., & Weinberg-Kurnik, G. (2007). The dialectics between the personal and the interpersonal in the experi-ences of adoptive single mothers by choice. Sex Roles, 56, 823–833. doi:10.1007/s11199-007-9241-1

Blake, L., Readings, C. J., Jadva, V., & Golombok, S. (2010). “Daddy ran out of tadpoles”: How parents tell their chil-dren that they are donor conceived, and what their 7-year-olds understand. Human Reproduction, 25, 2527–2534. doi:10.1093/humrep/deq208

Blyth, E., Langridge, D., & Harris, R. (2010). Family building in donor conception: Parents’ experiences of sharing infor-mation. Journal of Reproductive and Infant Psychology, 28, 116–127. doi:10.1080/02646830903295018

Boivin, J., Bunting, L., Collins, J. A., & Nygren, K. G. (2007). International estimates of infertility prevalence and treat-ment-seeking: Potential need and demand for infertil-ity medical care. Human Reproduction, 22, 1506–1512. doi:10.1093/humrep/dem046

Bondas, T., & Hall, E. O. C. (2007). Challenges in approaching metasynthesis research. Qualitative Health Research, 17, 113–121. doi:10.1177/1049732306295879

Bos, H. M. W., & Van Balen, F. (2010). Children of the new reproductive technologies: Social and genetic parent-hood. Patient Education and Counseling, 81, 429–435. doi:10.1016/j.pec.2010.09.012

Brewaeys, A. (2001). Review: Parent-child relationships and child development in donor insemination families. Human Reproduction Update, 7, 38–46. doi:10.1093/humupd/7.1.38

Brewaeys, A., Ponjaert-Kristoffersen, I., Van Steirteghem, A. C., & Devroey, P. (1993). Children from anonymous donors: An inquiry into homosexual and heterosexual par-ents’ attitudes. Journal of Psychosomatic Obstetrics & Gynecology, 14, 23–35.

Burr, J. (2009). Fear, fascination and the sperm donor as “abjec-tion” in interviews with heterosexual recipients of donor insemination. Sociology of Health & Illness, 31, 705–718. doi:10.1111/j.1467-9566.2009.01171.x

Casey, P., Vasanti, J., Blake, L., & Golombok, S. (2013). Families created by donor insemination: Father–child relationships at age 7. Journal of Marriage and Family, 7, 858–870. doi:10.1111/jomf.12043

Cousineau, T. M., & Domar, A. D. (2007). Psychological impact of infertility. Best Practice & Research Clinical Obstetrics & Gynaecology, 21, 293–308. doi:10.1016/j.bpobgyn.2006.12.003

Covington, S. N., & Burns, L. H. (2006). Infertility counseling: A comprehensive handbook for clinicians. Cambridge, UK: Cambridge University Press.

Daniels, K. R. (1994). Adoption and donor insemination: Factors influencing couples’ choices. Child Welfare, 73(1), 5–14.

Daniels, K. R., Grace, V. M., & Gillett, W. R. (2011). Factors associated with parents’ decisions to tell their adult off-spring about the offspring’s donor conception. Human Reproduction, 26, 2783–2790. doi:10.1093/humrep/der247

Daniels, K. R., Lewis, G. M., & Gillett, W. (1995). Telling donor insemination offspring about their conception: The nature of couples’ decision-making. Social Science & Medicine, 40, 1213–1220. doi:10.1016/0277-9536(94)00251-N

De Mol, J., & Buysse, A. (2008). The phenomenology of chil-dren’s influence on parents. Journal of Family Therapy, 30, 163–193. doi:10.1111/j.1467-6427.2008.00424.x

De Mol, J., Lemmens, G., Verhofstadt, L., & Kuczynski, L. (2013). Intergenerational transmission in a bidirectional context. Psychologica Belgica, 53(3), 7–23. doi:10.5334/pb-53-3-7

Dixon-Woods, M., Agarwal, S., Jones, D., Young, B., & Sutton, A. (2005). Synthesising qualitative and quanti-tative evidence: A review of possible methods. Journal of Health Services Research & Policy, 10, 45–53. doi:10.1258/1355819052801804

Friese, C., Becker, G., & Nachtigall, R. D. (2008). Older moth-erhood and the changing life course in the era of assisted reproductive technologies. Journal of Aging Studies, 22, 65–73. doi:10.1016/j.jaging.2007.05.009

Golombok, S., Brewaeys, A., Giavazzi, M. T., Guerra, D., MacCallum, F., & Rust, J. (2002). The European study of assisted reproduction families: The transition to adoles-cence. Human Reproduction, 17, 830–840. doi:10.1093/humrep/17.3.830

Golombok, S., Cook, R., & Bish, A. (1995). Families created by the new reproductive technologies: Quality of parent-ing and social and emotional development of the children. Child Development, 66, 285–298. doi:10.2307/1131578

Golombok, S., Lycett, E., MacCallum, F., Vasanti, J., Murray, C., Rust, J., . . . Margara, R. (2004). Parenting infants con-ceived by gamete donation. Journal of Family Psychology, 18, 443–452. doi:10.1037/0893-3200.18.3.443

Grace, V. M., & Daniels, K. R. (2007). The (ir)relevance of genetics: Engendering parallel worlds of procreation and reproduction. Sociology of Health & Illness, 29, 692–710. doi:10.1111/j.1467-9566.2007.01010.x

Grace, V. M., Daniels, K. R., & Gillett, W. (2008). The donor, the father, and the imaginary constitution of the family: Parents’ constructions in the case of donor insemination. Social Science & Medicine, 66, 301–314. doi:10.1016/j.socscimed.2007.08.029

Hahn, S. J., & Rosenberg, M. C. (2002). The disclosure deci-sions of parents who conceive children using donor eggs. Journal of Obstetric Gynecologic & Neonatal Nursing, 31, 283–293. doi:10.1111/j.1552-6909.2002.tb00050.x

Hannes, K., & Lockwood, C. (2012). Synthesizing qualitative research: Choosing the right approach. West Sussex, UK: Wiley-Blackwell.

Hargreaves, K. (2006). Constructing families and kinship through donor insemination. Sociology of Health & Illness, 28, 261–283. doi:10.1111/j.1467-9566.2006.00492.x

Hargreaves, K., & Daniels, K. (2007). Parents dilemmas in sharing donor insemination conception stories with their children. Children & Society, 21, 420–431. doi:10.1111/j.1099-0860.2006.00079.x

by guest on October 14, 2014qhr.sagepub.comDownloaded from

18 Qualitative Health Research

Hegel, G. W. F. (1977). The phenomenology of mind (translated by A. V. Miller). Oxford, UK: Clarendon Press. (Original work published 1807)

Hequembourg, A. L., & Farrell, M. P. (1999). Lesbian mother-hood: Negotiating marginal-mainstream identities. Gender & Society, 13, 540–557. doi:10.1177/0891243990-13004007

Hunter, M., Salter-Ling, N., & Glover, L. (2000). Donor insemination: Telling children about their origins. Child Psychology & Psychiatry Review, 5, 157–163. doi:10.1017/S1360641700002355

Indekeu, A., Dierickx, K., Schotsmans, P., Daniels, K. R., Rober, P., & D’Hooghe, T. (2013). Factors contributing to parental decision-making in disclosing donor conception: A systematic review. Human Reproduction Update, 19, 714–733. doi:10.1093/humupd/dmt018

Josselson, R. (2004). The hermeneutics of faith and the hermeneutics of suspicion. Narrative Inquiry, 14, 1–28. doi:10.1075/ni.14.1.01jos

Kinn, L. G., Holgerson, H., Ekeland, T.-J., & Davidson, L. (2013). Metasynthesis and bricolage: An artistic exercise of creating a collage of meaning. Qualitative Health Research, 23, 1285–1292. doi:10.1177/1049732313502127

Kirkman, M. (2003). Parents’ contributions to the narrative identity of offspring of donor-assisted conception. Social Science & Medicine, 57, 2229–2242. doi:10.1016/S0277-9536(03)00099-6

Kirkman, M. (2004a). Genetic connection and relationships in narratives of donor-assisted conception. Australian Journal of Emerging Technologies and Society, 2(1), 1–20.

Kirkman, M. (2004b). Saviours and satyrs: Ambivalence in nar-rative meanings of sperm provision. Culture, Health & Sexuality, 6, 319–335. doi:10.1080/136910503 10001645041

Kirkman, M. (2008). Being a “real” mum: Motherhood through donated eggs and embryos. Women’s Studies International Forum, 31, 241–248. doi:10.1016/j.wsif.2008.05.006

Lalos, A., Gottlieb, C., & Lalos, O. (2007). Legislated right for donor-insemination children to know their genetic origin: A study of parental thinking. Human Reproduction, 22, 1759–1768. doi:10.1093/humrep/dem063

Lindblad, F., Gottlieb, C., & Lalos, O. (2000). To tell or not to tell—What parents think about telling their children that they were born following donor insemination. Journal of Psychosomatic Obstetrics & Gynecology, 21, 193–203. doi:10.3109/01674820009085588

Lycett, E., Daniels, K., Curson, R., & Golombok, S. (2005). School-aged children of donor insemination: A study of parents’ disclosure patterns. Human Reproduction, 20, 810–819. doi:10.1093/humrep/deh703

Mac Dougall, K., Becker, G., Sheib, J. E., & Nachtigall, R. D. (2007). Strategies for disclosure: How parents approach telling their children that they were conceived with donor gametes. Fertility and Sterility, 87, 524–533. doi:10.1016/j.fertnstert.2006.07.1514

Noblit, G. W., & Hare, R. D. (1988). Meta-ethnography: Synthesizing qualitative studies. Newbury Park, CA: SAGE.

Nordqvist, P. (2010). Out of sight, out of mind: Family resem-blances in lesbian donor conception. Sociology, 44, 1128–1144. doi:10.1177/0038038510381616

Nordqvist, P., & Smart, C. (2014). Relative strangers: Family life, genes and donor conception. Hampshire, UK: Palgrave Macmillan.

Ravelingien, A., Provoost, V., & Pennings, G. (2013). Donor-conceived children looking for their sperm donor: What do they want to know? Facts, Views & Vision in Obstetrics and Gynaecology, 5, 257–264.

Rober, P., & Seltzer, M. (2010). Avoiding colonizer positions in the therapy room: Some ideas about the challenges of dealing with the dialectic of misery and resources in fami-lies. Family Process, 49, 123–137. doi:10.1111/j.1545-5300.2010.01312.x

Shehab, D., Duff, J., Pasch, L. A., Mac Dougall, K., Sheib, J. E., & Nachtigall, R. D. (2008). How parents whose children have been conceived with donor gametes make their disclo-sure decision: Contexts, influences and couple dynamics. Fertility and Sterility, 89, 179–187. doi:10.1016/j.fertn-stert.2007.02.046

Smith, J. A., Flowers, P., & Larkin, M. (2009). Interpretative phenomenological analysis: Theory method and research. London: SAGE.

Stevens, M., Perry, B., Burston, A., & Golombok, S. (2003). Openness in lesbian-mother families regarding mother’s sexual orientation and child’s conception by donor insemi-nation. Journal of Reproductive and Infant Psychology, 21, 347–362. doi:10.1080/0264683031000-1622141

Varcoe, C., Rodney, P., & McCormick, J. (2003). Health care relationships in context: An analysis of three eth-nographies. Qualitative Health Research, 13, 957–973. doi:10.1177/1049732303253483

Yee, S., Blyth, E., & Tsang, A. K. T. (2011). Views of donors and recipients regarding disclosure to children following altru-istic known oocyte donation. Reproductive BioMedicine Online, 23, 851–859. doi:10.1016/j.rbmo.2011.06.003

Yick, A. G. (2008). A metasynthesis of qualitative findings on the role of spirituality and religiosity among culturally diverse domestic violence survivors. Qualitative Health Research, 18, 1289–1306. doi:10.1177/1049732308321772

Zimmer, L. (2006). Qualitative meta-synthesis: A question of dialoguing with texts. Journal of Advanced Nursing, 53, 311–318. doi:10.1111/j.1365-2648.2006.03721.x

Author Biographies

Elia Wyverkens, MaPsy, is a doctoral student at the Department of Experimental Clinical and Health Psychology, Faculty of Psychology and Educational Sciences, University of Ghent, Belgium.

Hanna Van Parys, PhD, is a postdoctoral researcher at the Department of Experimental Clinical and Health Psychology, Faculty of Psychology and Educational Sciences, University of Ghent, Belgium. She is also a family therapist at the Psychiatric Unit of the University Hospital Ghent, Belgium.

Ann Buysse, PhD, is a full professor in family psychology at the Department of Experimental Clinical and Health Psychology, Faculty of Psychology and Educational Sciences, University of Ghent, Belgium.

by guest on October 14, 2014qhr.sagepub.comDownloaded from