Accepted Manuscript. Is blood thicker than water? Donor conceived offspring subjective experiences of the donor: A systematic narrative review

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1 Accepted Manuscript Is blood thicker than water? Donor conceived offspring subjective experiences of the donor: A systematic narrative review Canzi Elena, Accordini Monica, Facchin Federica PII: S (19) DOI: Reference: RBMO 2115 To appear in: Reproductive BioMedicine Online Received date: 5 June 2018 Revised date: 14 November 2018 Accepted date: 27 November 2018 Please cite this article as: Canzi Elena, Accordini Monica, Facchin Federica, Is blood thicker than water? Donor conceived offspring subjective experiences of the donor: A systematic narrative review, Reproductive BioMedicine Online (2019), doi: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo editing, typesetting, and review of the resulting proof before it is published in its final form. Please note that during this process changes will be made and errors may be discovered which could affect the content. All legal disclaimers that apply to the journal pertain.

2 1 Is blood thicker than water? Donor conceived offspring subjective experiences of the donor: A systematic narrative review Canzi Elena*, Accordini Monica*, & Facchin Federica** *Family Studies and Research University Centre, Catholic University of Milan ** Department of Psychology, Family Studies and Research University Centre, Catholic University of Milan Corresponding Author: Elena Canzi, Family Studies and Research University Centre, Catholic University of Milan, Largo Gemelli, Milan (Italy). elena.canzi@unicatt.it Phone: (+39) Fax: (+39)

3 2 Abstract The aim of this study was to provide a systematic narrative review of the published research articles on donor conceived (DC) offspring s subjective experiences of their donor. A systematic search of electronic databases provided 29 published quantitative and qualitative studies matching our inclusion criteria. The analysis of the studies outcomes led to the identification of four main themes: a) views/representations of the donor; b) desire to contact the donor (in terms of desire to meet the donor, reasons for wanting to contact the donor, type and frequency of contact); c) reactions to discovering the donor s identity and contacting the donor; d) identity issues. Our findings revealed that genetic ties do matter to DC people, especially during adolescence or adulthood. Many DC people were interested in contacting the donor and all of them needed to make meaning of the role of the donor, as well as to integrate it into their family life and self-concept. Besides curiosity and medical reasons, many people reported wanting to contact the donor to see what he/she looked like, to have access to their own ancestry and genetic history. Key message: Many DC people, especially during adolescence and adulthood, are interested in contacting the donor. Making meaning of the role of the donor and integrating him/her in one s individual and family history are key to DC offspring. Keywords: Donor-conceived offspring; Donor search; Donor figuration; Donor representation; Systematic narrative review

4 3 Introduction The use of gamete to overcome infertility is not a novelty for couples. Studies report that donor insemination was practiced in both Europe and the US since the beginning of the 19 th century (Beeson et al., 2011; Blyth, 1999; Cahn, 2009a, 2009b; Daniels and Golden, 2004). Nowadays, the increase in infertility rates (Chandra et al., 2013; Ferraretti et al., 2013), the spread of same-sex couples wanting to have children (Goldberg et al., 2014), along with the emergence of commercial sperm and oocyte banks (Harrigan et al., 2015; Marquardt et al., 2010), as well as of informal settings (Whyte et al., 2017) have led to a rapid increase in the number of families recurring to donor conception, although exact figures are difficult to determine due to the lack of normative or standardized procedures across countries and infertility clinics. Research on the topic has mainly focused on children psychological adjustment and wellbeing (Freeman and Golombok, 2012; Golombok et al., 2002; Vanfraussen et al., 2003), quality of family relations and/or overall family functioning as perceived by parents and teachers, or evaluated observing parent-child interactions (Berger, 2007; Golombok et al., 2006, 2011). Only a few studies directly examined views and experiences of donor conceived (DC) people, mostly due to the secrecy characterizing the whole process of donor insemination, including the donor identity (Blake et al., 2010; Cahn, 2009a, 2009b; Jadva et al., 2009). However, in recent years, there has been increasing openness both from prospective parents and infertility clinics (Hargreaves and Daniels, 2007; MacDougall et al., 2007), to the point that several European countries, along with New Zealand and some Australian territories, have legislated open-identity, according to which offspring will have access to donors details when they reach age 18 (Pennings, 2002; Tallandini et al., 2016; Zadeh et al., 2017a). Moreover, some ethical committees (e.g. ASRM-Practice Committee of the American Society of Reproductive Medicine, 2008; HFEA-Human

5 4 Fertilisation and Embryology Authority, 2010) have endorsed identity release. Although an increasing number of families are choosing open identity donors and deciding to be open to their children about the whereabouts of their conception (Brewaeys et al., 2005; Scheib et al., 2005), the topic is still largely controversial (Cahn, 2009a, 2009b) and numerous studies have stressed the difference between intention to disclose and actual disclosure. In this regard, parents may express the desire to tell their children about their origin on one hand, and the struggle to find the right time to do so on the other (Mac Dougall et al., 2007; Jadva et al., 2009; Tallandini et al., 2016). Reasons for not disclosing may be related to: 1) moral or legal issues associated with donor conception, as well as to the social stigma attached to infertility (Cahn, 2009b; Daniels and Golden, 2004; Daniels and Meadows, 2006); 2) the need to avoid negative consequences such as demasculinization and stigmatization of social fathers (Courtenay, 2000; Hertz et al., 2013) and damages to family relationships (Gottlieb et al., 2000; Mac Callum and Golombok, 2007); 3) fear of rejection (Jadva et al., 2010); 4) difficulties in finding the right terms to refer to the donor (Malmquist et al., 2014). Identity release may also lead to a decrease in the number of donors (Garcia- Velasco and Garrido, 2005), although recent studies showed an increase in s after the ban of anonymity (Adams et al., 2016). By the same token, wanting to know the outcome has been found to be one of the strongest incentives for both sperm and oocyte donors (van den Akker, 2006; Van den Broeck et al., 2013). Several studies suggested that disclosure is in the children best interest as it endorses their right to access their genetic origin (Bos and Gartrell, 2011; Ravelingien et al., 2015); on the contrary, secrets have been found to have detrimental effects on children wellbeing and family functioning (Daniels and Taylor, 1993; Turner and Coyle, 2000). Moreover, parents generally feel either neutral (Blake et al., 2010) or relieved and positive about disclosure (Mac Dougall et al., 2007).

6 5 Children s reactions to disclosure may be affected by multiple variables, such as type of family, age at disclosure, quality of attachment, and perception of mother s mental health (Beeson et al., 2011; Jadva et al., 2009). For instance, adolescents and adults who are told about their donor conception are more likely to report shock and confusion compared to younger children due to identity disruption and feelings of anger and mistrust towards the other family members (Turner and Coyle, 2000; Blyth, 2012a, 2012b). Despite the relevance of the topic, only a few studies have investigated the subjective experiences of DC people (in terms of perspectives, thoughts, feelings, and personal meanings) regarding their origins (and thus the donor) focusing on their individual accounts. This paucity of research may be due to difficulties in finding large samples of DC subjects who are aware of their origin and, at the same time, have an appropriate age to express their opinion (Beeson et al., 2011; Blake et al., 2010; Jadva et al., 2009). Given this scenario, the aim of this study was to provide a systematic narrative review of research articles exploring DC offspring s subjective experience of their donor on the basis of their personal account. Methods The current review was performed according to the PRISMA statement for reporting systematic reviews (Moher et al., 2009). Compliance with these guidelines was ensured by completing the PRISMA checklist. From December 2017 to February 2018 we conducted a systematic search of two electronic databases (Psycinfo and PubMed). Appropriate search terms were constructed after careful examination of title, abstract, keywords, and full text of a sample of research articles focused on donor offspring s views and experiences of the donor. Our search terms were derived from the combination of subject heading terms including donor conceived children, donor conceived offspring, and donor conceived adults. Because our aim was to take a broad overview of this topic, we included both qualitative and quantitative published research articles written in English and having donor

7 6 offspring as direct informants. Case studies, commentaries, reviews, opinion papers that did not report new material were excluded. We did not adopt any specific restriction regarding the type of family, which would have limited our analysis. However, we did not include studies focused on surrogacy, which represents a different and very specific phenomenon. No restriction was also applied in terms of the date of publication. All articles identified through electronic database searching were screened by the three authors independently (E.C., M.A., and F.F.). Titles, abstracts, and, when necessary, full texts were examined in order to remove ineligible articles and duplicates. A data extraction sheet designed by the three authors was applied to each document to extract relevant information (authors, year of publication, country, research question and aim, study design and methods, sample description, type of donor conception, family type, key findings and themes). These data were organized in an Excel recording spreadsheet. The quality of evidence of the studies selected (either quantitative or qualitative) was assessed independently (and subsequently discussed) by the three authors (E.C., M.A., F.F.) according to seven criteria (see Shepherd et al., 2006): a) presence of an explicit and comprehensive theoretical framework outlining a rationale for the study; b) clear aims and objectives; c) clear description of factors important for the interpretation of results; d) precise sample description; e) clear description of materials and methods; f) data analysis performed by more than one researcher; g) rigorous (i.e., not speculative) interpretation of results based on sufficient original material provided by the study. Following the work of other authors (Culley et al., 2013; Dancet et al., 2010), a study had to meet four out of the seven criteria to be included in our review. All discrepancies among the three judges were discussed until full consensus was reached. A thematic analysis was conducted using an inductive (i.e., data driven) approach aimed at identifying prominent themes in the selected literature (Dixon-Woods et al., 2005).

8 7 We followed a three-step procedure that involved: a) reading each article in order to identify the relevant issues addressed; b) organizing these issues under higher order categories (prominent themes); c) developing a narrative synthesis of the findings. Results Search, screening and selection The database searches resulted in a total of 739 papers. Duplicates and ineligible documents were excluded. After screening titles and abstracts, 719 articles were excluded while the remaining were further examined by reading the full text. After quality assuring full texts, one study (Ehrensaft, 2007) was excluded, resulting in 21 papers for inclusion. Eight further papers were identified by consulting the reference list of the selected articles, resulting in a total of 29 papers. Characteristics of papers Table 1 provides an overview of the heterogeneity of the data extracted with regard to: author/date/country, study aims, research design and method, sample, type of conception, and type of family. In four studies, the same two datasets were used twice by two sets of authors (Jadva et al. 2009, 2010; Vanfraussen et al. 2001, 2003). Setting. More than two-thirds (N=23) of the papers were published between 2010 and 2017, indicating an increasing research interest on the social and psychological impact of donor conception. The papers came from just five countries: USA (12 studies), UK (seven studies), Belgium (six studies), Australia (two studies), and North Europe (Norway and Sweden) (two studies). Design. Most studies used qualitative (14 articles) and mixed methods (12 articles). The three remaining quantitative studies used self-report questionnaires (mostly online questionnaires), and ad hoc scales. Qualitative studies mainly used interview methods and only a small number collected data by examining website postings, empirical reports, and written

9 8 autobiographies. Almost all papers reported findings from cross-sectional studies, while only one (Blake et al., 2010) used a longitudinal design. Participants. Sample size varied considerably: from six to 741 donor-conceived children. Based on the information provided on participants gender, a total of 1304 females and 670 males were involved in the selected studies. While all the papers included involved spermdonor-conceived offspring, only four articles also reported data on egg-donor-conceived offspring. The majority of participants in the selected studies had been conceived through unknown donors, with little or no opportunity to know the donor s identity. Twelve studies involved children, 11 involved adolescents, 11 involved young adults, and nine involved adults. All studies comprised only individuals who were part of DC families. With respect to family type, lesbian couples (18 studies), single mothers (10 studies), as well as heterosexual couples (eight studies) are all represented in the selected papers, with five studies reporting on differences across family types. Findings on DC offspring s subjective experiences of the donor The key categories identified in the thematic analysis were: a) views/representations of the donor (17 studies); b) desire to contact the donor (in terms of desire to meet the donor, reasons for wanting to contact him/her, type and frequency of contact; 16 studies); c) reactions on discovering the donor s identity and contacting the donor (10 studies); d) identity issues (three study). a) Views/representations of the donor Findings from studies (Malmquist et al., 2014; Proovost et al., 2017; Tasker and Grandville, 2011; Vanfraussen et al., 2001; Van Parys et al., 2015; Zadeh et al., 2017a, 2017b) that involved children showed the presence of diverse narratives about the donor. Some children drew upon notions of biological parenthood, using terms like dad, parent, unknown father, family. In this regard, some authors (Proovost et al., 2017; Raes et al., 2015;

10 9 Scheib et al., 2005) suggested that the traditional and more familiar concepts of mother and father may shape the way in which DC children conceptualize the donor. Other children used impersonal terms, such as seeds, donor, unknown man, or talked about the donor as a social parent, using terms like friend, uncle. In the study by Zadeh and colleagues (2017b), the donor was specifically referred to as a stranger. In several studies, some of the children interviewed were reluctant to talk about the donor mainly due to perceiving a loyalty conflict towards their families (Zadeh et al., 2017a, 2017b). When asked about their thoughts, feelings, and perceptions about the donor, most children expressed neutral or positive feelings such as, for example, gratitude and kindness, and only a few especially those with insecure-disorganized attachment patterns (Zadeh et al., 2017b) reported negative perceptions (Blake et al. 2010, 2013; Zadeh et al., 2017b). On the other hand, children with a secure-autonomous attachment displayed greater curiosity and interest in knowing more about the donor conception (Slutsky et al., 2016). In a similar fashion, studies involving adolescents and young adults showed a great variability in the narratives used to refer to the donor. Goldberg and Allen (2013) reported that, for some DC offspring raised by lesbian couples, the donor was an external individual who provided genetic material, rather than a member of the family. In the same study, other participants referred to the donor as a family member with whom they shared their genes, but not as an actual parent. Other DC offspring perceived the donor as an actual parent, although he was given less importance than their mothers. Overall, the words used to define the donor ranged from relational terms, such as biological father, donor dad, and dad (to the point that some participants were willing to put the donor s name on their birth certificate), to impersonal ones like sperm donor and donor (see Hertz et al., 2013; Mahlstedt et al., 2010). According to Hanseen (2015), knowing vs. not knowing the donor s identity shape the offspring s representations. Specifically, when anonymity is preserved, the donor remains an

11 10 external individual, a shadow actor (p. 285), outside the actual family, while when the donor s identity is known, he becomes a third parental actor (p. 291), such as an intimate friend or even an actual paternal figure. Overall, findings revealed that older DC people, as well as offspring who learned about their conception at an older age, were more likely to use relational terms (such as donor father) to define the donor (Hertz et al., 2013). Moreover, DC offspring raised in single-mother families used words like father or dad more frequently compared to those raised by heterosexual or lesbian couples (Jadva, 2009; Scheib et al., 2005). b) Desire to contact the donor Several studies reported that most DC offspring were willing to know the donor s identity and some also wished to have contacts with him/her. In a study by Hertz and colleagues (2013), for example, over four-fifths of the participants wanted to contact the donor and over half of them wanted to be known by the donor, although the interest in contacting the donor (i.e., knowing and/or being known) did not necessarily imply an interest in having an actual relationship with him. More specifically, older DC individuals, as well as those who learned about their conception at an older age, showed greater interest and curiosity compared to younger DC people (see also Goldberg and Allen, 2013). The most common reasons DC offspring reported for wanting to contact the donor were: 1) to see what the donor looked like; 2) to know more about their ancestry and genetic history (such details were deemed important not only for themselves, but also for their children); 3) to gain useful information in order to avoid medical risks and consanguineous relationships; 4) curiosity (Hertz et al., 2013; Jadva et al., 2010; Ravelingien et al., 2013; Rodino et al., 2011; van den Akker et al., 2015). Feelings of frustration, loss, and disappointment were found among offspring who could not retrieve such information (Kirkman, 2003; Tuner and Coyle, 2000). The donor search process frequently started during or after important life transitions (such as

12 11 becoming a teenager, or getting married), or personal crises, and was not limited to the donor him/herself, as it often also involved genetic half siblings or the donor s family (Blyth, 2012; Jadva s et al., 2010; Mahlstedt et al., 2010; Scheib et al., 2005; Turner and Coyle, 2000; Vanfraussen et al., 2001, 2003). While in a few cases (i.e. the DC child didn t have the legal age to retrieve the information) the search was initiated by one or both parents (Jadva et al., 2010), several DC offspring reported not having told their parents about their willingness to contact the donor for fear of their reaction or in order to avoid hurting them (especially the social parent) (Beeson et al., 2011; Goldberg and Allen, 2013; Hertz et al., 2013; Jadva et al., 2010; Mahlstedt et al., 2010; Van Parys et al., 2015; Vanfraussen et al., 2003). DC offspring of lesbian couples showed some specificities. For instance, they were particularly interested their donor s appearance as well as in his personality; boys were especially willing to know the donor s identity, perhaps due to the absence of an actual father (Beeson et al., 2011; Scheib et al., 2005; Vanfraussen et al., 2001, 2003). In this population, feelings of loyalty towards social mothers and fear of betraying them were the main reason for not being interested in gaining information about the donor, or not being able to admit such interest (Vanfraussen et al., 2001, 2003). Among the teenagers of the US National Longitudinal Lesbian Family Study (Bos and Gartrell, 2011) having as-yet-unknown donors (permanently unknown donors and donors who can be contacted when the offspring reach the age of 18), about 40% indicated that they did not care about the donor s identity, about 37% had no opinion about this issue, while 23% claimed that they regretted not knowing their donor. Mixed findings have been reported with regards to the influence of gender, with some authors (i.e. Jadva et al., 2010) stating that females are more interested in contacting the donor and others (i.e. Vanfraussen et al., 2001) stating that the same is true for boys. c) Reactions on discovering the donor s identity and contacting the donor

13 12 Most adults conceived following anonymous reported that learning their donors identity was an emotionally charged and yet positive event (Blyth, 2012; Jadva et al., 2010). Knowing their donor s identity is reported to be associated with several benefits for DC offspring, such as the possibility to gain information relevant to their health as well as to develop a fuller sense of their own identity and to situate themselves both historically and biologically (Blyth, 2012; Hertz et al., 2013; Hanseen, 2015; Jadva et al., 2010; Kirkman, 2003; Slutsky et al., 2016). Moreover, several authors (Blyth, 2012; Jadva et al., 2010; Ravelingien et al., 2013; Scheib et al., 2016; Tasker and Granville, 2011) reported significant extensions in the offspring s familial/kinship networks following contacts with the donor. Many of the individuals who got access to their donors identity also reported having regular and mutually enjoyable contact with them (Blyth, 2012; van den Akker et al., 2015), this was especially true for DC people raised in single mother or lesbian families (Jadva et al., 2010). Significant changes in one s representations of family have also been reported following contacts with the donor (Hertz et al., 2013; van den Akker et al., 2015) with barely any negative consequences on existing family relationships. d) Identity issues In their study on the identity construction Harrigan and colleagues (2015) found that anonymous sperm DC adults drew upon a wide array of both positive and negative narratives to describe themselves. More specifically, some DC adults described themselves as victims who had been robbed, silenced, hurt, or deceived (p. 81) or as enigmatic and puzzling to others. In contrast, other participants considered themselves as highly wanted and loved children, although this positive perception did not prevent them from feeling victims. Finally, some participants referred to themselves as either storytellers or dynamic processes, thus implying that their self concept is in constant change and evolution.

14 13 According to Kirkman (2003), when DC offspring found out about their origins during adulthood they tended to experience a greater disruption of their narrative identity and a sense of confusion about themselves. Attachment style also influences the process of identity development in DC children, with securely attached children being more prone to explore their origin and to talk about their donor conception (Slutsky et al., 2016). Discussion Assisted Reproductive Technologies (ART) and donor conception challenge the long established dualism between nature and culture (Hanssen, 2015) and consequently raise new legal, ethical, and practical issues. By openly questioning natural laws and bypassing cultural practices and norms, donor conception techniques call for a redefinition of the concept of parenthood, kin as well as of the very basis of family ties. Such issues permeate many DC offspring s narratives and may lead them to put into question their own idea of family and to renegotiate their identity (Harrigan et al., 2015; Hertz et al., 2013). Our findings showed that genetic ties do matter to DC people (see also Zadeh et al., 2018), especially when they find out the circumstances of their conception during adolescence or adulthood. Offspring who learned about their conception at an older age were more likely to refer to the donor using relational terms in their narratives, to show greater interest and curiosity about the donor (Hertz et al., 2013; Goldberg and Allen, 2013), and to experience a greater disruption of their narrative identity and a sense of confusion about themselves (Kirkman, 2003). Our results also revealed that offspring s desire to contact the donor and representations of the donor were affected not only by their age, but also by other variables, such as gender, quality of attachment, and type of family. While results with respect to the role of gender are still controversial (see Jadva et al., 2010 and Vanfraussen et al., 2001) and further research is needed, securely attached children have been found to hold more positive

15 14 representations of the donor and to be more likely to accept their origin (Slutsky et al., 2016; Zadeh et al., 2017b). Children of lesbian and single mothers expressed more curiosity about the donor and a greater desire to establish a relationship with him; for these children, it was easier to reveal such feelings to their parent(s), especially when compared to children of heterosexual couples. These latter were often not comfortable in discussing issues related to their conception with their fathers and tended not to tell them about their willingness to search for the donor (Beeson et al., 2011; Jadva et al., 2010; Mahlstedt et al., 2010). More than being due to sexual orientation, such differences can be imputed to the presence of the father within heterosexual families: while the absence of a father made it easier for children raised in lesbian or single mother households to accept the presence of their donor and to integrate them their narratives, children grown in dual heterosexual families had to find a way to have both their social and genetic fathers coexist in their narratives while not being supported, in such process, by any social or juridical standard (Beeson et al., 2011; Mahlstedt et al., 2010). Differences in the wording used to describe the donor were also found according to family type. More specifically, children raised by lesbian mothers or single parents were more likely to draw on terms comprising the words father or dad (Mahlstedt et al., 2010; Malmquist et al., 2014). Again, such differences may be due to the tension, inherent in heterosexual families, between the role of the genetic vs. the social father, which are generally played by the same person. Irrespectively of family type, the wording used to refer to the donor signals his/her ambiguous role within DC offspring s lives. According to our findings, the donor was either referred to with impersonal terms denying him/her personhood (Hertz et al., 2013; Mahlstedt et al., 2010; Provoost et al., 2017), or, most often and especially when the donor s identity was known, with more personal and specific terms including the words father or dad

16 15 (Hanssen, 2015; Harrigan et al., 2015; Hertz et al., 2013; Jadva et al., 2010; Mahlstedt et al., 2010). Most DC people did not use a univocal term to refer to the donor, they rather drew upon different worlds of meaning (Hertz et al., 2013), further indicating that finding the donor a role within their lives is a long process requiring both inner negotiation and negotiation with their families (Harrigan et al., 2014; Harrigan et al., 2015). Such findings are consistent with studies describing donor-related disclosure as a journey for parents (Hargreaves and Daniels, 2007, p. 424), that is, as a path that takes time to be completed (Provoost et al., 2017). Far from being a one-time event, the acceptance of one s origin and the integration of the donor conceived identity into one consistent self narrative requires a process of co-construction in which both the DC individual as well as his/her parents play an active role (Van Parys et al., 2015). Irrespectively of age, gender, and family type, our findings showed that many DC people were interested in contacting the donor (Beeson et al., 2011; Bos and Gartrell, 2011; Hertz et al., 2013; Jadva et al., 2010) and all of them needed to make meaning and negotiate his/her role whether him being known or unknown within their family and their conception of themselves. Besides curiosity about physical appearance and personality traits that might have been transmitted and medical reasons, many people reported wanting to contact the donor to get to know themselves, to have access to their own ancestry as well as to make sense of their own history, attitudes and preferences (Hertz et al., 2013; Jadva et al., 2010; Ravelingien et al., 2013; Rodino et al., 2011; van den Akker et al., 2015; Slutsky et al., 2016). In some cases this was expressed as a right rather than merely as a desire (Turner and Coyle, 2000) as well as a duty and act of responsibility on the donor s side (Hertz et al., 2013). DC people expressing the desire to contact their donors were strongly driven by the quest for identity (Harrigan et al., 2015). Tracing one s own genetic origins places him/her in a given place and time and within a specific culture, thus providing him/her with a history

17 16 and a base upon which to built a self-narrative and develop a consistent identity (Canzi, 2018; Hanssen, 2015). Despite showing curiosity about the donor s identity and integrating him/her in their narratives, not all DC people wanted to have a relationship with their donors. As suggested by Hertz and colleagues (2013, p. 62) the donor is both claimed and kept at a distance, in an ambivalent and conflicting position, possibly due to existing loyalty conflicts towards one s parents. For instance, some DC offspring reported that they renounced seeking information about the donor to avoid hurting the social parent, whose position is certainly more delicate inasmuch as there is no genetic bond with the child. In this view, the delayed start of the donor search process might be connected to such loyalty conflicts: becoming more independent from one s family of origin and entering adulthood frees DC offspring from the guilt feelings that prevented them from initiating the search for the donor. Moreover, after reaching 18 years old, DC offspring have the right to initiate and manage a relationship with the donor without the mediation of their parents (Beeson et al., 2011; Goldberg and Allen, 2013; Hertz et al., 2013; Jadva et al., 2010; Mahlstedt et al., 2010; Van Parys et al., 2015; Vanfraussen et al., 2001, 2003). Often times, the practical search for the donor was prompt by a change in the offspring s personal lives, a significant event, or a period of personal crisis, when the issue of identity became salient. For instance, for those DC people who had children, the search for the donor was aimed at providing both themselves and their own offspring with an ancestral history and heritage (Jadva et al., 2010; Rodino et al., 2011). These findings show that donor conception can influence the self narratives and the identity development of DC people while further reinforcing the idea that the integration of one s DC identity is a process and that such process will have a better outcome if positive and genuine intrafamily communication is flanked by a growing sense of security (Slutsky et al., 2016).

18 17 Despite being influenced by multiple variables, DC offspring s reactions to contact with the donor have been reported to be generally positive as they allowed them to achieve a fuller sense of their own identity and have a more complete picture of their own history (Blyth, 2012; Jadva et al., 2009; van den Akker et al., 2015). Although the present systematic narrative review showed interesting outcomes, some methodological considerations and limitations suggest caution in interpreting the results. Literature about DC offspring s experiences of their donor is limited and shows some weaknesses. First, the data available were mainly descriptive and involved small samples often constituted by offspring raised in lesbian families, therefore data regarding oocyte were extremely scarce. Secondly, the samples often included different type of families (when reported), thus affecting results generalizability. Thirdly, sample recruitment strategies might have affected findings. Since many of the studies reviewed recruited their samples through donor offspring connection websites results cannot be considered as representative of the overall DC people population. People who subscribe to such websites are probably more interested in knowing about their donor, more motivated to search for him/her, and more likely to value genetic relatedness than DC individuals who do not join these websites. Moreover, the young age of most interviewees might have affected their ability to provide good and rich narratives. Finally, while longitudinal studies would have allowed a better understanding of the long-term consequences of being donor-conceived and a thorough exploration of the changes in the DC people views of their donor over time, almost all of the studies were cross-sectional and used non standardized measures for data collection. Prospective studies should consider using standardized measures in order to allow comparisons to be made; mixed methods, combining the strengths of both qualitative and quantitative research, are also highly advisable. Future studies should also involve wider and more representative samples while careful consideration in reporting all the relevant data

19 18 regarding the family structure and the participants background should be placed in order to capture differences and similarities among family types.

20 19 References Adams, D.H., Ullah, S., de Lacey, S., Does the removal of anonymity reduce sperm donors in Australia? J Law Med, 23(3), American Society of Reproductive Medicine (ASRM) Practice Committee, Guidelines for gamete and embryo : A practice Committee report. Fertil Steril, 90(5), S30 S44. doi: /j.fertnstert Beeson, D.R., Jennings, P.K., & Kramer, W., Offspring searching for their sperm donors: How family type shapes the process. Hum Reprod, 26(9), doi: /humrep/der202 Berger, P.M.S., Topic avoidance and family functioning in families conceived with donor insemination. Hum Reprod, 22(9), doi: /humrep/dem174 Blake, L., Casey, P., Jadva, V., & Golombok, S., I was quite amazed : Donor conception and parent-child relationships from the child s perspective. Child Soc, 28(6), doi: /chso Blake, L., Casey, P., Readings, J., Jadva, V., & Golombok, S., Daddy ran out of tadpoles : How parents tell their children that they are donor conceived, and what their 7-year-olds understand. Hum Reprod, 25(10), doi: /humrep/deq208 Blyth, E., Secrets and lies: barriers to the exchange of genetic origins information following donor assisted conception. Adopt Foster, 23(1), doi: / Blyth, E., Genes r us? Making sense of genetic and non-genetic relationships following anonymous donor insemination. Reprod BioMed Online, 24(7), doi: /j.rbmo Bos, H.W., & Gartrell, N.K., Adolescents of the US National Longitudinal Lesbian

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25 24 Jadva, V., Freeman, T., Kramer, W., & Golombok, S., Experiences of offspring searching for and contacting their donor siblings and donor. Reprod BioMed Online, 20(4), doi: /j.rbmo Kirkman, M., Parents contributions to the narrative identity of offspring of donorassisted conception. Soc Sci Med, 57(11), doi: /S (03) Mac Dougall, K., Becker, G., Scheib J.E., & Nachtigall R.D., Strategies for disclosure: How parents approach telling their children that they were conceived with donor gametes. Fertil Steril, 87(3), doi: /j.fertnstert Mac Callum, F., & Golombok, S., Embryo families: Mothers decisions regarding disclosure of donor conception. Hum Reprod, 22(11), doi: /humrep/dem272 Mahlstedt, P.P., LaBounty, K., & Kennedy, W.T., The views of adult offspring of sperm : Essential feedback for the development of ethical guidelines within the practice of assisted reproductive technology in the United States. Fertil Steril, 93(7), doi: /j.fertnstert Malmquist, A., Mollerstrand, A., & Wikstrom, M., A daddy is the same as a mummy : Swedish children in lesbian households talk about fathers and donors. Childhood, 21(1), doi: / Marquardt, E., Glenn, N.D., & Clark, K., My daddy s name is donor: A new study of young adults conceived through sperm, Institute for American Values, New York, NY. Moher, D., Liberati, A., Tetzlaff, J., & Altman, D.G., The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care

26 25 interventions: explanation and elaboration. PLoS medicine, 6(7), e doi: /journal.pmed Pennings, G., An overview of the regulation regarding the collection and provision of information about persons involved in sperm in jurisdictions outside the UK. Expert report made for the Human Fertilisation and Embryology Authority and the Secretary of State for Health. Retrieved March, 15, 2018, from Provoost, V., Bernaerdt, J., Van Parys, H., Buysse, A., De Sutter, P., & Pennings, G., No daddy, A kind of daddy : Words used by donor conceived children and (aspiring) parents to refer to the sperm donor. Cult Health Sexual, 24, doi: / Raes, I., Van Parys, H., Provoost, V., Buysse, A., De Sutter, P., & Pennings, G., Two mothers and a donor: Exploration of children s family concepts in lesbian households. Facts Views Vision Obgyn, 7, Ravelingien, A., Provoost, V., & Pennings, G., Donor-conceived children looking for their sperm donor: What do they want to know? Facts Views Vision Obgyn, 5(4), Ravelingien, A., Provoost, V., Pennings, G., Open-identity sperm : How does offering donor-identifying information relate to donor-conceived offspring s wishes and needs? J Bioethic Inq, 12(3), doi: /s Rodino, I.S., Burton, P.J., & Sanders, K.A., Donor information considered important to donors, recipients and offspring: An Australian perspective. Reprod BioMed Online, 22(3), doi: /j.rbmo

27 26 Scheib, J.E., Riordan, M., & Rubin, S., Adolescents with open-identity sperm donors: Reports from year olds. Hum Reprod, 20(1), doi: /humrep/deh581 Shepherd, J., Harden, A., Rees, R., Brunton, G., Garcia, J., Oliver, S., & Oakley, A., Young people and healthy eating: a systematic review of research on barriers and facilitators. Health Educ Res, 21(2), doi: /her/cyh060 Slutsky, J., Jadva, V., Freeman, T., Persaud, S., Steele, M., Steele, H., Golombok, S., Integrating donor conception into identity development: Adolescents in fatherless families. Fertil Steril, 106(1), doi: /j.fertnstert Tallandini, M.A., Zanchettin, L., Gronchi, G., & Morsan, V., Parental disclosure of Assisted Reproductive Technology (ART) conception to their children: A systematic and meta-analytic review. Hum Reprod, 31(6), doi: /humrep/dew068 Tasker, F., & Granville, J., Children s views of family relationships in lesbian-led families. J GLBT Fam Stud, 7(1-2), doi: / X Turner, A.J., & Coyle, A., What does it mean to be a donor offspring? The identity experiences of adults conceived by donor insemination and the implications for counselling and therapy. Hum Reprod, 15(9), doi: /humrep/ van den Akker, O.B.A., A review of family donor constructs: Current research and future directions. Hum Reprod Update, 12(2), doi: /humupd/dmi038 van den Akker, O.B.A., Crawshaw, M.A. Blyth, E.D., & Frith, L.J., Expectations and experiences of gamete donors and donor-conceived adults searching for genetic relatives using DNA linking through a voluntary register. Hum Reprod, 30(1), doi: /humrep/deu289

28 27 Van den Broeck, U., Vandermeeren, M., Vanderschueren, D., Enzlin, P., Demyttenaere, K., D Hooghe, T., A systematic review of sperm donors: Demographic characteristics, attitudes, motives and experiences of the process of sperm. Hum Reprod Update, 19(1), doi: /humupd/dms039 Van Parys, H., Provoost, V., Wyverkens, E., De Sutter, P., Pennings, G., & Buysse, A., Family communication about the donor conception: A multi-perspective qualitative study with lesbian parents and their children. Qual Health Res, 26(14), doi: / Vanfraussen, K., Ponjaert-Kristoffersen, I., & Brewaeys, A., An attempt to reconstruct children s donor concept: A comparison between children s and lesbian parents attitudes towards donor anonymity. Hum Reprod, 16(9), doi: /humrep/ Vanfraussen, K., Ponjaert-Kristoffersen, I., & Brewaeys, A., Why do children want to know more about the donor? The experience of youngsters raised in lesbian families. J Psychosom Obst Gyn, 24(1), doi: / Whyte, S., Savage, D.A., & Torgler, B., Online sperm donors: The impact of family, friends, personality and risk perception on behaviour. Reprod Biomed Online, 35(6), doi: /j.rbmo Zadeh, S., Freeman, T., & Golombok, S., 2017a. What does donor mean to a four-yearold? : Initial insights into young children's perspectives in solo mother families. Child Soc, 31(3), doi: /chso Zadeh, S., Jones, C.M., Basi, T., & Golombok, S., 2017b. Children s thoughts and feelings about their donor and security of attachment to their solo mothers in middle childhood. Hum Reprod, 32(4), doi: /humrep/dex016

29 28 Zadeh, S., Ilioi, E.C., Jadva, V., & Golombok, S., The perspectives of adolescents conceived using surrogacy, egg or sperm. Hum Reprod, 33(6), doi: /humrep/dey088

30 29 Vitae: Elena Canzi gained the PhD in Social Psychology in 2015 at the Catholic University of Milan, Italy. She collaborates with the Family Studies and Research University Centre at the same university since She is actually a postdoctoral researcher. Her research interests are focused on adoptive families, assisted reproductive technology, and sexual education for adolescents.