Introduction
The mental health and psychological adjustment of those conceived with donor gametes have been of interest for researchers investigating the role of parent–child biological relatedness and family functioning. A systematic review of 11 studies that investigated the psychological outcomes of adolescents (11–18 years), conceived from donor gametes concluded that donor-conceived adolescents were well adjusted psychologically. Reference Ilioi and Golombok1 However, four of these studies used the same sampling frame (the same participants), while another two studies contained adolescents that crossed over into both publications thereby reducing both the number of unique participants analysed and the strength of the conclusions drawn. Studies of younger children have also concluded that they too are psychologically well adjusted compared to their spontaneously conceived peers. Reference Golombok, Blake, Casey, Roman and Jadva2–Reference Kovacs, Mushin, Kane and Baker4
Some of these studies, both of young children and adolescents are under-powered with relatively small sample sizes or implement exclusion criteria restricting participants to healthy singletons making conclusions about the overall mental health of donor-conceived children difficult even though the results so far are reassuring. Furthermore, such investigations are often limited by either the young person’s lack of knowledge of their conception or that the researchers did not assess disclosure. It has been shown through a systematic review that most donor-conceived children and adolescents/young adults have not had their conception disclosed to them, which may introduce a source of bias in the study sampling frame. Reference Tallandini, Zanchettin, Gronchi and Morsan5 Similarly, of those studies included in the systematic review of adolescent outcomes, Reference Ilioi and Golombok1 not all offspring were aware of their conception and, in the case for heterosexual parents, less than 10% had disclosed to their child about their conception. Without the children or adolescents knowing the nature of their conception, it is therefore difficult to examine the relationship between knowledge of conception and psychological outcomes.
While this flaw is noted, these previous studies provide data on the mental health outcomes of donor-conceived young people. Conversely, in the case of adult outcomes, there is a dearth of studies investigating the mental health of adults conceived with donor gametes in comparison to spontaneously conceived adults where the additional elapsed time, and challenges of adult functioning, may reveal specific deficits not apparent in childhood. Although, there are reports in which some adult donor-conceived people have experienced negative feelings surrounding their conception, including feelings of abandonment and deception, and depression. Reference Schrijvers, Bos, van Rooij, Gerrits, van der Veen and Mochtar6–Reference Turner and Coyle10 Adult studies, by nature, require the informed consent of the participant and therefore represent a different subset of the donor-conceived population as these adults know that they are donor-conceived unlike those studies investigating childhood outcomes. A different sample bias will therefore often be inherent in the adult studies through self-selection than those observed in the childhood studies where participation was decided by their parents and potentially involves non-disclosure of their donor conception status.
Due to a lack of studies investigating the mental health of donor-conceived adults in comparison to those who are spontaneously conceived systematically, studies are required to examine not only the mental health status of donor-conceived adults but whether it differs from reports of outcomes of donor-conceived children and adolescents. We, therefore, conducted an online survey of the self-reported physical and mental health of donor sperm-conceived adults in comparison to those who were spontaneously conceived to determine if any differences were reported between the two study groups. This paper reports the findings of mental health data. The physical health outcomes have been reported previously. Reference Adams, Gerace, Davies and De Lacey11
Methods
This quantitative study investigated the physical and mental health outcomes of donor-conceived adults in comparison to those conceived spontaneously. The method has been reported previously for the physical health outcomes, Reference Adams, Gerace, Davies and De Lacey11 but will be described briefly here and include specific differences that pertain to the mental health outcomes assessed.
Participants
A sample of adults aged 18 years and over who could understand English and had internet access was sought for this study. Donor-conceived people were recruited through advertising on various Facebook groups that contain donor-conceived members and through organisations that deal with donor conception. Further recruiting of donor-conceived and spontaneously conceived adults was performed by advertising online through Flinders University, the survey recruitment website Prolific and snowballing.
Measures
Respondents completed the questionnaire anonymously on the SurveyMonkey (SurveyMonkey Inc., San Mateo, CA, USA) website between 1 December 2017 and 31 March 2018. Questions were developed to cover a range of mental health outcomes. The questions covered the following categories: demographics, information regarding the respondent’s birth, their general health and lifestyle, mental health outcomes diagnosed by a mental health professional, mental health outcomes that reflected the respondent’s own experience, and the Depression Anxiety Stress Scale 21 (DASS-21). Reference Lovibond and Lovibond12
The DASS-21 was used to assess how the respondent was feeling over the previous week, unlike all other reported measures which describe the mental health history of the respondent. Subsequently, the DASS-21 is more representative of their current mental health status. All questions were voluntary except for the respondent’s age, sex, and birth status (donor sperm or spontaneously conceived), and whether they had received fertility treatment themselves.
Statistical analyses
Statistical analysis was conducted using SPSS V25 (IBM Corporation, New York, USA). All analyses are of donor sperm-conceived outcomes in comparison to spontaneously conceived outcomes. The effect of sex and maternal complications was analysed through stratification of cohorts as these are known to be associated with mental health outcomes. Reference Seedat, Scott and Angermeyer13,Reference Tuovinen, Raikkonen and Pesonen14 Furthermore, the effect of the country of birth on outcomes was assessed through the analysis of Australian respondents as these represented the largest group of participants.
Continuous variables were summarised using means and standard deviation. They were then subjected to two-tailed, Student’s t-test to determine significance. Binomial outcomes are presented in tables as the number of ‘yes’ responses and as a percentage of the total number of responses received for each question. These results were analysed using two-tailed Pearson’s chi-squared analysis. Two-tailed Fisher’s Exact Tests were used when cross-tabulation resulted in > 20% of cells having an expected count of less than 5 in a 2 × 2 table. Cross tabulations larger than 2 × 2 implemented Likelihood Ratios when > 20% of cells had an expected count of less than 5. Free text input outcomes for unlisted diagnosed mental health outcomes and which mental health professional(s) the respondent had seen were subjected to quantitative content analysis. Free text responses were coded and collapsed into categories of ‘unlisted diagnosed conditions’ or ‘type of mental health professional visited’. These were then subjected to a right-tailed chi-squared distribution analysis. DASS-21 analysis used means and standard deviation, and results were then subjected to two-tailed, Student’s t-test to determine significance.
Large surveys with multiple comparisons can be adversely affected by false-positive results. Subsequently, the Benjamini–Hochberg procedure was implemented on the binomial health outcomes using a false discovery rate at alpha 0.05 level to correct for false positives. Reference Benjamini and Hochberg15 However, it was not used on content analysis data as these were grouped post-hoc, nor was it used for DASS-21 analysis. Results were deemed to be statistically significant if P < 0.05.
Ethical standards
All procedures contributing to this work comply with the Australian ethical standards and guidelines of the National Statement on Ethical Conduct in Human Research 16 in accordance with the National Health and Medical Research Council Act, 17 and with the Declaration of Helsinki. 18 All participants provided informed consent prior to undertaking the survey. This study was approved by the Flinders University Social and Behavioural Research Ethics Committee (Approval number: 7827).
Results
The total sample of 1149 respondents consisted of the following by mode of conception: Donor Sperm-Conceived (n = 272) and Spontaneously-Conceived (n = 877) participants. Questionnaire completion time averaged 10 min, 17 s, with a completion rate of 78%. Response rates could not be calculated due to the number of people viewing the advertisement being unknown. Furthermore, the number of donor-conceived people that exist worldwide is unknown.
Characteristics of respondents
Respondent characteristics by grouping are presented in Table 1. No significant differences were observed between the donor sperm-conceived group and those conceived spontaneously in terms of their mean age, mean height, sex, alcohol consumption, current smoking status, amount and level of exercise per week, and whether they had received fertility treatment themselves. The groups did differ, however, in terms of donor sperm-conceived adults having a lower current mean weight (P = 0.035), and a lower BMI (P = 0.023). Higher levels of education, specifically post-graduate degrees, were observed for donor sperm-conceived adults than spontaneously conceived adults (P < 0.001). Lower prevalence of being a former smoker was reported for donor sperm-conceived adults (P = 0.032). Additionally, higher incidences of currently using prescribed medications (P = 0.002), and recreational/illicit drugs (P = 0.047) were observed in the donor sperm-conceived group compared to those conceived spontaneously.
Table 1. Characteristics of respondents
[ ], Total respondents. P value using Students two-tailed t-test versus spontaneously conceived unless specified by alternative test below.
a Pearson Chi-squared (two-tailed) P value versus spontaneously conceived. Chi-squared results are based on total Chi-squared table results of all outcomes and not individual outcome groupings (i.e., all of the All Donor Conceived outcomes versus all Spontaneously Conceived outcomes).
* Likelihood Ratio P value versus spontaneously conceived people used instead of Fisher’s Exact Test for when > 20% of cells in Chi-squared table have expected values less than 5 in tables larger than 2 × 2. Note, percentages may not equal 100% due to rounding.
Donor sperm-conceived adults reported significantly higher birth and gestational characteristics of being born as a twin (P = 0.004), and higher prevalence of maternal complications during their mother’s pregnancy (P = 0.001).
The five largest countries by the number of respondents for the country of birth and country of current residence is presented in Table 2. All countries and number of respondents are listed in Supplementary Table S1. Belgium, the Netherlands and the United States of America had a higher proportion of donor sperm-conceived respondents than those conceived spontaneously, while Australia and the United Kingdom had a higher proportion of those conceived spontaneously.
Table 2. Country of birth and residency (top 5 countries by number of participants)
Descriptive table of countries of birth and current residence.
Diagnosed mental health outcomes
In comparison to those conceived spontaneously, donor sperm-conceived adults reported significantly higher prevalence of being diagnosed by a mental health professional with attention deficit disorder/attention deficit hyperactivity disorder (10.2% v 3.9%, P = 0.004), and autism/autism spectrum disorder (5.3% v 2.0%, P = 0.044) (Table 3).
Table 3. Diagnosed mental health outcomes
BPD, borderline personality disorder; OCD, obsessive-compulsive disorder; PTSD, post-traumatic stress disorder; Other, all other disorders/conditions not grouped into the above categories such as oppositional defiance disorder, body dysmorphic disorder, adjustment disorders, schizophrenia, and panic disorders. Pearson Chi-squared (two-tailed) P value versus spontaneously conceived people; BH, Benjamini–Hochberg procedure adjusted P value versus spontaneously conceived people; ADD, attention deficit disorder; ADHD, attention deficit hyperactivity disorder; ASD, autism spectrum disorder.
* P value significant (P < 0.05).
a Mental health diagnoses in the ‘Other’ category which had free text input were then subjected to quantitative content analysis which is reported below the dashed line. Note that the n of the categories below the line do not equal those in ‘Other’ due to multiple responses for certain respondents and also some respondents not completing the free text input.
b Fisher’s exact test (two-tailed) P value versus spontaneously conceived people used instead of Pearson chi-squared for when > 20% of cells in chi-squared table have expected values less than 5.
Donor sperm-conceived adults also reported being diagnosed with a significantly higher prevalence of mental health issues not classified in the categories listed (13.2% v 7.2%, P = 0.038), and were able to describe these with free text input. Quantitative content analysis showed that the three categories with the greatest frequency of free text input responses were borderline personality disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. All other disorders/conditions were labelled as ‘ungrouped’ (such as oppositional defiance disorder, body dysmorphic disorder, adjustment disorders, schizophrenia, and panic disorders). No significant differences were observed between donor sperm-conceived adults and those conceived spontaneously in the quantitative content analysis (Table 3).
Own experience mental health outcomes
In terms of respondent’s experiences rather than formal diagnosis of mental health issues, donor sperm-conceived adults were significantly more likely to report higher prevalence of having suffered panic attacks (53.7% v 43.3%, P = 0.038), recurrent nightmares (26.1% v 17.8%, P = 0.038), having difficulty forming their identity (51.8% v 14.1%, P < 0.001), an alcohol/drug dependency (11.5% v 5.9%, P = 0.037), and to have reported learning difficulties (16.9% v 7.1%, P < 0.001) (Table 4). Free text inputs of the significantly increased frequency of seeing a mental health professional (69.8% v 49.5%, P < 0.001) were subjected to content analysis using the categories of psychologist (46.5% v 33.0%, P < 0.001), psychiatrist (21.6% v 16.2%, P = 0.048), and other mental health professional (all other medical health professionals as designated by the respondent such as general practitioner, psychotherapist, mental health nurse, counsellor, cognitive behavioural therapist, etc.) (15.5% v 9.8%, P = 0.013).
Table 4. Own experience mental health outcomes
Pearson Chi-squared (two-tailed) P value versus spontaneously conceived people. BH, Benjamini–Hochberg procedure adjusted P value versus spontaneously conceived people. BH correction not performed on content analysis. Other = all other medical health professionals as designated by the respondent such as general practitioner, psychotherapist, mental health nurse, counsellor, cognitive behavioural therapist.
* P value significant (P < 0.05).
a Mental health professional as designated by the respondent.
Depression, anxiety and stress scales (DASS-21)
The mean total DASS-21 score of donor sperm-conceived adults was higher than those spontaneously conceived, however, the difference was not statistically significant (Table 5). Donor sperm-conceived adults were significantly more stressed in the past week when compared to spontaneously conceived adults (13.43 v 11.65, P = 0.013), but did not experience current elevated levels of depression or anxiety.
Table 5. DASS-21 outcomes
[ ], Total respondents included in analysis. Respondents that did not answer every question were excluded.
* P value significant (P < 0.05) using Students two tailed t-test versus spontaneously conceived.
Effect of sex
Spontaneously conceived females were significantly more likely than spontaneously conceived males to self-report being diagnosed with depressive disorder (34.4% v 16.4%, P < 0.001), anxiety disorder (35.8% v 13.9%, P < 0.001), and other non-listed mental health conditions (8.5% v 1.9%, P = 0.023) (Table 6). Content analysis of free text input for other diagnosed conditions not listed revealed that female spontaneously conceived adults were more likely to be diagnosed with post-traumatic stress disorder (PTSD) (4.3% v 0.6%, P = 0.026). Donor sperm-conceived females did not report any statistically significant differences in the frequencies of being diagnosed with depressive disorder, anxiety disorder, bipolar, ADD/ADHD, autism/ASD, or any other non-listed mental health condition.
Table 6. Significant mental health outcomes by sex
PTSD, post-traumatic stress disorder; BH, Benjamini–Hochberg procedure adjusted P value versus spontaneously conceived people.
* P value significant (P < 0.05).
a Mental health diagnoses in the ‘Other Diagnosed Outcomes’ category which had free text input were then subjected to quantitative content analysis. Categories with significant differences are reported below the first dashed line.
b Mental health professional as designated by the respondent. Other Mental Health Professional = all other medical health professionals as designated by the respondent such as general practitioner, psychotherapist, mental health nurse, counsellor, cognitive behavioural therapist which are reported below the second dashed line when significant. Pearson Chi-squared (two-tailed) P value versus spontaneously conceived people.
c Fisher’s exact test (two-tailed) P value versus spontaneously conceived people used instead of Pearson Chi-squared for when > 20% of cells in chi-squared table have expected values less than 5.
In terms of the respondent’s own experience, spontaneously conceived females were significantly more likely than spontaneously conceived males to self-report experiencing panic attacks (48.5% v 21.4%, P < 0.001), recurrent nightmares (20.5% v 6.3%, P < 0.001), eating disorders (14.3% v 3.8%, P = 0.007), and seeing a mental health professional (53.1% v 34.6%, P < 0.001) (Table 6). Conversely, they were significantly less likely to self-report a dependency on alcohol or drugs (4.7% v 10.7%, P = 0.023). Content analysis of free text input for which mental health professional was consulted showed that spontaneously conceived females were more likely to visit a psychologist (36.5% v 18.2%, P < 0.001), and other mental health professionals such as a general practitioner, psychotherapist, mental health nurse, counsellor, or cognitive behavioural therapist (11.3% v 3.8%, P = 0.004). No differences were observed between female and male spontaneously conceived adults in terms of self-reported frequencies of identity formation issues, insomnia, or learning difficulties. Similar to diagnosed mental health outcomes, donor sperm-conceived females were no different from their donor sperm-conceived male peers in all outcome measures except for self-reports of increased visits to a psychologist (49.3% v 29.4%, P = 0.031).
While the donor sperm-conceived cohort exhibited no differences between females and males in their mental health outcomes apart from visits to a psychologist; spontaneously conceived females, in contrast, fared worse than their spontaneously conceived male peers in a variety of mental health outcomes except for alcohol and drug dependency, which was elevated in males. DASS-21 results were not stratified by sex as it is a separate instrument.
Effect of maternal complications
Stratifying by maternal complications revealed that those spontaneously conceived adults whose mothers experienced maternal complications during pregnancy were significantly more likely than those whose mothers did not experience any maternal complications to self-report being diagnosed with ‘Other’ non-listed mental health conditions (16.0% v 5.9%, P = 0.005) (Table 7). The content analysis did not reveal any significant differences in which conditions were diagnosed. Spontaneously conceived adults whose mothers experienced maternal complications were no different to those gestated without maternal complications in terms of being diagnosed with depressive disorder, anxiety disorder, bipolar, ADD/ADHD, or autism/ASD. No differences were also observed in the diagnosed mental health outcomes between donor sperm-conceived adults whose mothers experienced maternal complications and those who did not experience maternal complications.
Table 7. Significant mental health outcomes by maternal complications
BH, Benjamini–Hochberg procedure adjusted P value versus spontaneously conceived people.
* P value significant (P < 0.05).
a Mental health diagnoses in the ‘Other Diagnosed Outcomes’ category which had free text input were then subjected to quantitative content analysis.
b Mental health professional as designated by the respondent. Pearson Chi-squared (two-tailed) P value versus spontaneously conceived people.
In terms of the respondent’s own experience, spontaneously conceived adults whose mothers experienced maternal complications during pregnancy were significantly more likely to self-report experiencing recurrent nightmares (36.3% v 14.7%, P < 0.001), eating disorders (23.0% v 10.1%, P = 0.004), insomnia (42.0% v 24.0%, P = 0.004), learning difficulties (13.9% v 4.9%, P = 0.011), and seeing a mental health professional (67.3% v 46.3%, P = 0.003) (Table 7). Content analysis of free text input for which mental health professional was consulted revealed no differences between the groups. No differences were observed between spontaneously conceived adults in terms of self-reported frequencies of panic attacks, identity formation issues, or dependency on alcohol and/or drugs. Similar to diagnosed mental health outcomes, donor sperm-conceived adults whose mothers experienced maternal complications during pregnancy were not significantly different to those whose mothers did not experience any maternal complications in all outcome measures.
Stratifying outcomes by maternal complications showed that the donor sperm-conceived cohort exhibited no differences in their mental health outcomes. In contrast, spontaneously conceived adults reported increased incidences of adverse mental health outcomes if their mother had experienced maternal complications during pregnancy.
Effect of the country of birth
The effect of country of birth was determined by restricting outcome measures to Australians only because they represented the largest group for both donor sperm-conceived and spontaneously conceived adults. Stratifying by country of birth revealed that donor sperm-conceived Australians were not more likely than those Australians conceived spontaneously to self-report being diagnosed with depressive disorder, anxiety disorder, bipolar, ADD/ADHD, autism/ASD, or any other non-listed mental health condition (Table 8).
Table 8. Significant mental health outcomes in Australian respondents
Pearson Chi-squared (two-tailed) P value versus spontaneously conceived people. BH, Benjamini–Hochberg procedure adjusted P value versus spontaneously conceived people.
* P value significant (P < 0.05).
In terms of the respondent’s own experience, donor sperm-conceived Australians were significantly more likely to self-report having difficulty forming their identity (54.3% v 13.6%, P < 0.001), but not for the self-reported frequencies of panic attacks, recurrent nightmares, identity formation issues, dependency on alcohol and/or drugs, eating disorders, insomnia, learning difficulties, or visiting a mental health professional (Table 8).
Limitations
Sample bias occurs in this study due to respondents self-reporting their mental health conditions. Reporting bias was reduced in some instances in which respondents were required to only answer ‘yes’ to those conditions which had been diagnosed by a medical or mental health professional. False discovery rate was subsequently controlled through the use of the Benjamini–Hochberg procedure in the statistical analysis.
We were able to obtain a sample of self-identified donor sperm-conceived people through online support and networking groups which were used as the primary recruitment source for donor sperm-conceived respondents. Thereby making them a self-identified subset sample of donor sperm-conceived adults. These respondents potentially have concerns with their conception and may be looking for support or advice in finding information about their biological (donor) parent or siblings. Reference Slutsky, Jadva and Freeman19,Reference Rodino, Burton and Sanders20 With the majority of donor-conceived adults not being aware of how they were conceived, Reference Tallandini, Zanchettin, Gronchi and Morsan5 it is not possible to get a representative cross-section of the donor sperm-conceived population. Subsequently, caution must be used in extrapolating the findings to the broader adult donor-conceived population. Other researchers have reported the same sample bias issue. Reference Mahlstedt, LaBounty and Kennedy8,Reference Jadva, Freeman, Kramer and Golombok9,Reference Zadeh, Ilioi, Jadva and Golombok21,Reference Persaud, Freeman and Jadva22 Until non-disclosure to the child of their origins no longer occurs, the sample bias issue will continue to be an issue for researchers. Notwithstanding, the use of online networking groups such as Facebook has been used by other authors to recruit donor-conceived individuals for studies. Reference Lozano, Fraley and Kramer23,Reference Nelson, Hertz and Kramer24
On many demographic variables, the donor sperm-conceived cohort and spontaneously conceived cohorts were comparable to each other. However, within each cohort, there was a sex bias towards women with over 80% of women in all groups. Sex differences occur in the prevalence of different mental health disorders, 25 and therefore, the results are not representative of a cross-section of donor sperm-conceived people. However, no significant difference was found between sex proportions of the different groups in the study, and therefore, the respondent’s sex did not adversely affect group to group comparisons. Additionally, good invariance between men and women has been found with the use of the DASS-21, Reference Gomez, Summers, Summers, Wolf and Summers26 and accordingly, the sex variation between females and males in this study should not affect DASS-21 outcomes.
Inter-item reliabilities were not measured for each of the mental health outcomes presented in this survey which is a limitation of this study. However, the DASS-21 as a separate instrument has been reported to have good inter-item reliability and has been validated through numerous studies with a systematic review and analysis showing that the bifactor DASS-21 structure returned Cronbach’s alpha values of 0.90–0.95 for the total scale, 0.82–0.92 for the depression scale, 0.74–0.88 for the anxiety scale, and 0.76–0.90 for the stress scale across a variety of cultures and countries. Reference Lee, Lee and Moon27 These cultures/countries included those representing the majority of respondents in this survey.
The diagnostic criteria for each mental health outcome may differ according to the country in which that diagnosis occurred. Furthermore, the meaning that each country/culture may apply to each outcome measure may vary. Subsequently, the invariance between each diagnosed and own experience outcomes are unknown and, therefore, a limitation of this study. The respondent’s own experience, which can be described as ‘self-rated health’, is nonetheless a valid measurement in young adults. Reference Fosse and Haas28 The average age of respondents in this survey (donor sperm-conceived = 32.6 years, spontaneously conceived = 33.2 years), could subsequently be described as being young adults. Additionally, increasing validity of self-rated health has meant that it has become a strong predictor of mortality. Reference Schnittker and Bacak29 The reliability of self-rated health, such as the NHANES data used as reference data in this study, has been reported to have moderate test-retest reliability. Reference Zajacova and Dowd30 In general, however, self-reports of health, including mental health, are commonly used in epidemiological studies. Reference Singh-Manoux, Martikainen, Ferrie, Zins, Marmot and Goldberg31
Limitations aside, this study represents the first attempt to characterise mental health outcomes from a subset of adults conceived with the use of donated gametes, which is a rapidly growing sector in the population that have been poorly studied. A strength of this study is that the donor sperm-conceived cohort in comparison to those spontaneously conceived was well-matched with no significant differences in terms of their: mean age, mean height, sex ratios, alcohol consumption, current smoking status, levels of exercise conducted per week, whether their mother smoked during pregnancy, and whether they had received fertility treatment themselves.
Discussion
This study highlighted that the adult donor sperm-conceived respondents in this survey experienced more mental health issues than their counterparts and were more likely to have seen a mental health professional. Out of the DASS-21 categories of recent depression, anxiety and stress, only stress was found to be significantly elevated in the donor sperm-conceived cohort. These findings reflect previous reports highlighting that some donor sperm-conceived adults have issues with their conception both mentally and emotionally. Reference Allan32–Reference Allan34
The number of adverse mental health differences experienced by the donor sperm-conceived participants in this study in comparison to those conceived spontaneously were more numerous than the physical health outcomes observed in the same cohort. Reference Adams, Gerace, Davies and De Lacey11 However, due to the age of the cohort, we may anticipate further differences in age-related chronic diseases to emerge in future years. Physical and mental health are both directly and indirectly linked. Reference Ohrnberger, Fichera and Sutton35 This link may contribute to the finding of increased mental health issues observed in the donor sperm-conceived cohort, which also reported increased incidences of adverse physical health outcomes. Furthermore, considering that some donor-conceived people feel that they suffer as a consequence of being separated from biological kin, the loss of family history, the lack of medical health history, and being deceived of their origins by their parents, Reference Adams36 these may potentially be associated with the poorer mental health outcomes observed in this study.
The lack of significance for the DASS-21 depression score is in contrast to the elevated incidences of donor sperm-conceived respondents being diagnosed with a depressive disorder. However, the DASS-21 assessment is of how the respondent felt during the previous week and is not necessarily indicative of their diagnosed mental health history.
The mental health outcomes analysis after stratification by sex, maternal complications of pregnancy and country of birth, was hampered by a lack of statistical power in the donor sperm-conceived cohort due to sample size and the number of reports. Subsequently, no conclusions can be drawn on the effects that these may have had on the mental health outcomes of adult donor sperm-conceived people except for an observed increase in the difficulty in forming their identity for Australian donor sperm-conceived adults. The identity formation difficulty is consistent with previous literature. Reference Adams36 For spontaneously conceived adults, the sample size was significantly larger, thereby imparting greater confidence in the stratification analysis.
In spontaneously conceived females, an increased incidence of adverse mental health outcomes including depressive disorder, anxiety disorder, PTSD, panic attacks, recurrent nightmares, eating disorders, and seeing a mental health professional were observed. However, males were more likely to suffer from substance abuse issues with a dependency on alcohol or drugs. These sex-based differences are consistent with previously published data highlighting that females are more likely to experience mental health issues including anxiety, depression, PTSD, and mood disorders, while men are more likely to experience substance abuse. Reference Seedat, Scott and Angermeyer13,Reference Steel, Marnane and Iranpour37
Spontaneously conceived adults whose mothers experienced pregnancy complications were significantly more likely to report being diagnosed with other non-listed mental health conditions and to experience increased incidences of recurrent nightmares, eating disorders, insomnia, learning difficulties, and visiting a mental health professional. Maternal complications, in particular, hypertensive disorders of pregnancy in spontaneous conceptions have been associated with increased mental health disorders in the adult offspring. Reference Tuovinen, Raikkonen and Pesonen14,Reference Tuovinen, Aalto-Viljakainen and Eriksson38 Therefore, the findings of increased adverse mental health outcomes for adult donor sperm-conceived people that was associated with an increase in reported maternal complications during pregnancy is consistent with the literature.
There is very little published literature on quantitative mental health outcomes for the adult donor-conceived population. However, there is one study which has reported that donor sperm-conceived adults had no significant differences in mental health compared to similar-aged emerging adults. Reference Koh, Bos and Gartrell39 Interestingly this study was conducted in a cohort of younger adults in comparison to our study, and that these adults were raised in lesbian-parent families in which the use of donor conception is typically not hidden from the child/adult. Subsequently, that cohort is likely to have key differences making comparisons difficult.
Studies of donor-conceived children, in general, show positive results in terms of psychological adjustment. Notwithstanding the limitations of those studies, adult participants in this survey had more self-reported adverse outcomes than their spontaneously conceived peers. While this study is not without its limitations, the results are consistent with the observations of outcomes in other adult donor-conceived studies. Reference Schrijvers, Bos, van Rooij, Gerrits, van der Veen and Mochtar6–Reference Turner and Coyle10 The difference between children and adults may reflect instrumentation effects from the assessment methodology and capacity for self-report or the emergence of mental problems due to aging effects,
Disclosure to a person of their donor sperm-conceived status at an early age has been associated with less psychological trauma. Reference Jadva, Freeman, Kramer and Golombok9,Reference Ilioi, Blake, Jadva, Roman and Golombok40 Parental attitudes towards disclosure has changed over time from being mostly opposed to disclosure, Reference Leeton and Backwell41–Reference Durna, Bebe, Steigrad, Leader and Garrett44 to increasing openness. Reference Godman, Sanders, Rosenberg and Burton45–Reference Isaksson, Sydsjö, Skoog Svanberg and Lampic48 While the age of disclosure or discovery of their conception was not investigated, many participants in this study were conceived during a period when secrecy was the accepted practice. Subsequently, many respondents in this study may have had their conception disclosed in adulthood, which may contribute to the findings.
Additionally, they may have reassessed their feelings concerning their conception and started searching for information once they had started their own family, or after the death of a parent. These situations have been observed in adult adoptees. Reference Crawshaw49 Similarities between adoptees and donor-conceived people in terms of biological family separation, loss of family and health histories, and being deceived of their origins have been reported. Reference Crawshaw49–Reference Triseliotis51 Therefore, the poorer mental health of adult donor sperm-conceived people might also potentially be influenced by adulthood triggers. Adult adoptees have been shown to suffer worse mental health outcomes than non-adoptees, Reference Tieman, van der Ende and Verhulst52–Reference Bohman and von Knorring55 and therefore, the results of this study are also consistent with studies on adult adoptee outcomes.
An alternative and possible contributing factor to the differences observed between donor-conceived children and adults is that developmental defects only become apparent through adult based psychological diagnoses and under conditions of adult functioning. This factor is plausible if one considers variations in adult function as an extension of the already demonstrated increased risk of adverse perinatal outcomes in donor-conceived neonates. Reference Moreno-Sepulveda and Checa56–Reference Mascarenhas, Sunkara, Antonisamy and Kamath58 Furthermore, studies have highlighted that perinatal outcomes such as low birth weight (<2500 g), are associated with adverse adult psychological outcomes and responses, Reference O’Donnell and Meaney59,Reference Ward, Moore, Steptoe, Cockington, Robinson and Phillips60 including ADHD, Reference Sucksdorff, Lehtonen, Chudal, Suominen, Joelsson and Gissler61,Reference Banerjee, Middleton and Faraone62 as was found in this study. These findings of adverse perinatal outcomes being associated with poorer adulthood mental health outcomes are a function of the Developmental Origins of Health and Disease (DOHaD) phenomenon. Reference O’Donnell and Meaney59
The implications for DOHaD on mental health outcomes are further highlighted by the increased incidence of preeclampsia associated with the use of donor sperm. Reference Smith, Walker, Tessier and Millar63–Reference Kyrou, Kolibianakis, Devroey and Fatemi65 The results from this study are also consistent with published data showing a correlation between preeclampsia and an increased risk for mental disorders in the offspring, Reference Tuovinen, Raikkonen and Pesonen14,Reference Dachew, Scott, Mamun and Alati66,Reference Lahti-Pulkkinen, Girchenko and Tuovinen67 that also include depression, Reference Tuovinen, Räikkönen and Kajantie68 ADHD, and ASD. Reference Sun, Moster, Harmon and Wilcox69
The donor sperm-conceived adult cohort self-reported significantly higher incidences of being diagnosed with various mental health issues, as well as experiencing an increased range of adverse mental health outcomes in comparison to the spontaneously conceived adult cohort. As is the case with adoption, donor conception may be an important consideration for clinicians when dealing with mental health issues of donor-conceived people. With very few studies investigating the mental health and emotional wellbeing of adult donor-conceived people, more studies are required.
Acknowledgements
The authors would like to thank the following organisations for their support in advertising the survey: VARTA (Victorian Assisted Reproductive Treatment Authority); Donor Children online registry; Donor Conception Network (United Kingdom); Donor Conception Support Group (Australia); FIOM (Netherlands); and VANISH (Victorian Adoption Network for Information and Self Help). The authors would also like to thank the administrators of the following Facebook groups: Worldwide Donor Conceived People Network; We Are Donor Conceived; RUDC; Donor Conceived Offspring, Siblings, Parents (Sperm or Egg); DNA for the Donor Conceived; TangledWebs; and the email list PCVAI – People Conceived Via Artificial Insemination, for advertising the survey on our behalf.
Financial Support
D.A. is supported by an Australian Government Research Training Program Scholarship.
Conflicts of Interest
None.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/S2040174421000210
