For some couples, surrogacy is a miracle: an opportunity to have a child even if they’re unable to conceive one naturally. But it’s also big business. Not only is surrogacy expensive — think six figures — but it’s also largely unregulated. And that last part is becoming a bigger problem. 

Just last week, a California couple was arrested on child abuse charges after it was revealed that they had over 20 children from different surrogate mothers living in a large mansion in Arcadia, a city near Los Angeles. Many of the surrogates are currently fighting for custody through the courts of the children they carried.

The Arcadia case, however, is only the most recent example of how surrogacy can go wrong. Every case is different, but every one illuminates how opaque — and often ripe for abuse or legal issues — the American surrogacy industry is. 

Emi Nietfeld is a reporter at Washington Sun who writes about surrogacy, IVF, and how we build families. She spoke with Today, Explained co-host Noel King about what’s kept lawmakers from regulating the surrogacy industry, the recent high-profile cases bringing these problems to light, and why more regulation doesn’t necessarily offer a straightforward fix. 

Below is an excerpt of their conversation, edited for length and clarity. There’s much more in the full podcast, so listen to Today, Explained wherever you get podcasts, including Apple Podcasts, Pandora, and Spotify. 

The United States does not regulate the surrogacy industry seemingly at all. What is going on? Why not?

The lack of federal regulation is both political and financial. Politically, this goes all the way back to the start of IVF. Anti-abortion Republicans were not comfortable with the idea of creating and destroying embryos during IVF, and so they fought against efforts to regulate it. 

People on the left were worried that limiting what kinds of technology you could access would lead to the government controlling who could have families. You still see these arguments today. People who think that IVF is murder don’t want to have any surrogacy. And people on the left don’t want the government saying who can and cannot have a family.

One of the issues raised by the New Yorker story is that there are surrogacy agencies that connect parents and potential surrogates. And it makes you wonder who gets to do that? Who can own and operate a surrogacy agency in the US today?

Anyone.

Oh. Oh no.

Only one state, New York, requires a special license. And everywhere else it’s easier to open an agency than a hot dog stand or a nail salon. This has resulted in the rise of so-called pop-up agencies where businesses come onto the scene, and nobody really knows who owns them or who’s running them. That has led to many people who aren’t experienced, who sign up with these agencies, then feeling like they weren’t prepared or that they were deceived in entering the agreement.

Have we ever tried in the past to regulate this better? Have there been efforts made?

In the 1980s, there was the case of Baby M. That was called traditional surrogacy where Mary Beth Whitehead was the surrogate, but it was also her egg. So the child she delivered was genetically related to her. After she gave birth, she changed her mind. She kidnapped the child, went on the run for several months, and it was a national crisis where this was all over the news. 

Ultimately, a judge in New Jersey ruled that the surrogacy arrangement was unenforceable. Commercial surrogacy arrangements became illegal in New Jersey, and they stayed illegal in New York until 2020.

Part of why regulation looks the way it does is because in 1995, Congress passed a piece of legislation saying that there would be no federal funding for embryo research, which means no federal funding for IVF. That left all of the research, development, innovation up to the free market. And so while that could be seen as an attempt to regulate IVF, it actually meant that those things would no longer be under the government’s purview.

In the US, we’ve seen over the past few years some really high-profile cases that are making lawmakers reckon with the fact that we do not have laws around this. Tell me about some of those cases.

There’s the Mark surrogacy case in California, which is both a really unique case and also illustrates some of the fears around Chinese intended parents coming to the United States to have their kids. This is part of larger geopolitical tensions between the US and China, which are playing out in the surrogacy industry.

There’s the case of Xu Bo, the Chinese video gaming billionaire who is rumored to have more than 100 children via surrogacy in America. His story taps into fears of birth tourism and people from other countries, especially China, coming to the United States to do surrogacy so that their kids are American citizens. 

Republican lawmakers are talking a lot about the idea that people could come from enemy countries, have American citizens, and raise them with the intent that they might one day become spies or president of the United States and be double actors.

In Texas, there’s the case of McKenna West, where she learned at 20 weeks’ gestation that the baby was very sick. The intended parents asked her to get an abortion. She refused to do so. McKenna went to Texas and began fighting for custody to keep the baby while the parents objected. They wanted the baby, and she petitioned the Supreme Court, which declined to hear the case. 

And finally, there’s the case of Kyla Simpson in Florida, whom I wrote about for New York Magazine, and she gave birth for a single dad in China who wasn’t there for the birth. He hadn’t applied for a visa to come to the United States, and when he did apply, he was rejected. Kyla Simpson tried to adopt the kids and is now fighting for custody in a case that’s still working its way through the Florida courts.

These examples are extraordinary, and they point to just chaos. But how common are they? Are they outliers? Is this going on all the time?

Most of the time things go right. In the academic papers around surrogacy, surrogates are usually happy with their experience. Attorneys and surrogates tell me that it’s absolutely beautiful to hand people the baby that they’ve been working hard for. The issue is that when things do go wrong, there’s often not a lot of recourse or there’s a really big legal mess that parents and surrogates have to go through.

I wonder if there is a case against more regulation. As disastrous as some of these examples are, you said that most of the time, it does go right. And it seems like we could get into tricky territory if we start saying who can and can’t have a kid.

Surrogacy is already really time-consuming. It often takes several years, and it’s expensive, usually costing between $150,000 to $250,000 for a single pregnancy. Regulation tends to make things more expensive and take longer. A lot of people fear that if you introduce more requirements and more burdens, surrogacy will become even more out of reach to people. 

There’s also the fear of government overreach. If you ask the government how many kids a gay couple should have, the answer might be zero. And that libertarian streak is driving a lot of opposition to things that most people might consider common sense. 

For example, there’s a lot of talk around whether intended parents should go through background checks before they have kids via surrogacy. Right now, no state in America requires intended parents to go through a criminal background check before having a kid. Critics of regulation say heteros don’t need a background check to have sex in the back of a car and make a baby the old-fashioned way, so it’s unfair to require that from people who need to do surrogacy to have a family. 

Most people can agree that surrogacy could be better regulated, but like many things in our country, it’s almost impossible right now because of politics.

Editor’s note, October 4, 8 am ET: We’re bringing you some of our best-loved Your Mileage May Vary columns while Sigal Samuel is on parental leave. The one below was originally published last year.

This unconventional advice column offers you a unique framework for thinking through moral dilemmas. It’s based on value pluralism: the idea that each of us has multiple values that are equally valid but that often conflict with each other. Submit your own question here.

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My partner and I did IVF recently and luckily we ended up with several embryos. One of those will be implanted in me so I hopefully get pregnant. But which one?

My fertility clinic is encouraging me to do PGT-A testing, which would screen for things like Down syndrome and would also let me see the sex of each embryo so I could potentially choose whichever I want. (And to be honest, I really want a girl!) I’m also hearing about these new companies that can test embryos for all kinds of things — like how smart the kid might be, how tall they’ll get, and whether they’ll have a lower chance of getting breast cancer, diabetes, mental illness, stuff like that.

I don’t know how to feel about any of this. On the one hand, it feels weirdly eugenics-y to do so much tinkering with embryos, and I can’t help feeling a little pressured into overmedicalizing everything with these expensive tests. But then again, if I could do something to make my baby healthier and happier, don’t I kind of have to do everything in my power? What does a parent owe their child?

Dear Expecting,

This is such an exciting — and also confusing — time. You’re about to have your first kid, and that comes with all sorts of fears and insecurities and hopes and dreams. You want to do the right thing — no, the best thing! — for your child. It’s a beautiful impulse. Unfortunately, it makes it easy for companies to prey on you.

So let me walk you through what these companies can and can’t really provide. After we talk about the science, we can talk about the ethics. 

The simpler test you mentioned, PGT-A, has been around since the 1990s. It can indeed screen for conditions like Down syndrome and let you see the sex of each embryo. Mind you, that doesn’t predict what gender your child will ultimately end up identifying with — more on that soon.

The newer testing you mentioned is called polygenic testing. The conditions it screens for are complex ones, influenced by thousands of genes. We’re talking about everything from breast cancer to depression. Some companies even offer screenings not for disease prevention, but for genetic enhancement — so you can select for a taller kid or a kid with higher IQ.

Polygenic testing companies claim to predict each embryo’s risk for each condition, and the potential reduction of risk you’ll get if you choose one embryo over another. As the statistical geneticist Sasha Gusev explains, it’s very, very easy to be misled by this claim. If the company claims to lower absolute risk of Type 2 diabetes by 12 percent, you might think this means, “The chance of my kid ever developing diabetes just went down by 12 percent — great!” But really what it means is that, all else equal, a kid who would’ve developed diabetes is likely now at the high end of pre-diabetes instead, or just develops diabetes a few years later. The same holds true for other conditions, like breast cancer. Sure, if your kid is going to develop diabetes or breast cancer, you’d rather they develop it later — but it’s not the bill of perfect health customers might imagine.  

“Typical risk reduction estimates tend to exploit statistical assumptions to overstate their benefits and lead to confusion,” Gusev writes.

It’s also important to note that there’s a difference between a physical disease like cancer, which is straightforwardly and universally negative, and a complex mental health condition like depression. For one thing, polygenic scores don’t perform as well in psychiatry, as the psychologist Eric Turkheimer notes. Plus, most mental health conditions come in mild to moderate to severe forms, and it’s not clear that we should want to get rid of mild or moderate manifestations. 

“Sure, it would be nice if no one ever got depressed, but what would that actually mean?” Turkheimer writes. “People are going to be sad, and the most modern models of psychiatric disorders view most of them as extremes on continuous dimensions of normal behavior. I don’t think we want some kind of genetic version of Soma.”

To give a personal example: I have generalized anxiety with some obsessive tendencies. Is that a major pain in the butt sometimes? You bet. But if I could wave a magic wand and get rid of it, would I? No. In my experience, this trait is linked to another trait I deeply value: my creativity. The same thing that propels me down rabbit holes of worry also propels me down rabbit holes of getting super curious about some topic, researching it into the wee hours of the morning, and then writing a novel or children’s book about it.

That brings me to one other scientific issue: pleiotropy. It’s a fancy term for a simple truth, which is that genes can have an effect on more than one trait. When it comes to behavioral polygenic testing, we actually know very little about which genes cause what — a gene that’s correlated with depression or anxiety may also be correlated with a bunch of other things. So, if everyone were to start selecting embryos to try to protect their kids from depression or anxiety, what would happen? We don’t know! 

Pleiotropy is a scientific issue, but it’s also a moral issue, because in trying to protect your kid from a negative outcome, you could also be accidentally barring them from a positive one.

And that’s just the tip of the moral iceberg.

Another issue is the potential psychological harm that can result from commodifying our kids — treating them like consumer objects with selectable parts. Let’s say you use polygenic testing to try to select for high IQ. Even if the company’s predictor is right 80 percent of the time, that means it’s wrong 20 percent of the time. What happens if it’s wrong about your kid, and they end up with a low IQ instead of a high one? How will your kid feel? Unless you hide the truth from them, they’ll know that they are not what you wanted, that they failed to live up to the vision you went out of your way to chase.

The same goes for sex selection via good old PGT-A. I know you really want a girl. But what would happen if you select for a girl, and then your child grows up and turns out to be trans? They may feel an extra sense that they’re letting you down by not conforming to the gender expectations you had for them.

Then there are the ethical questions around unequal access. Polygenic testing isn’t cheap. (One company, Orchid, charges $2,500 per screened embryo. Test 10 embryos and that’ll cost you $25,000.) So, at least in the short term, that raises the specter of entrenching a caste system, where the gap between rich and poor expands dramatically as the rich get smarter and stronger.

Technologies tend to get cheaper over time, so maybe everyone will ultimately be able to afford polygenic testing. But that raises another problem: implicit coercion. If more and more of us make ourselves smarter and stronger, we may create a society in which everyone feels pressure to alter their child’s biology — even if they don’t want to. To refuse embryo selection would mean to put a child at a huge professional disadvantage, or to face moral condemnation for making “suboptimal” kids when optimization is possible. Society may no longer offer health insurance benefits or accommodations for kids with disabilities (or even non-enhanced IQ), reasoning that “it was the parents’ choice.” 

Some philosophers, like Julian Savalescu, already argue that parents have a “moral obligation to create children with the best chance of the best life.” Polygenic testing companies love that argument; Orchid founder Noor Siddiqui tells parents that “the responsible decision” is to “protect their children” from disease, using language like, “What if you could have stopped it…but chose not to?” And we generally live in a culture that’s obsessed with optimization. 

So it’s no wonder that you find yourself asking, “If I could do something to make my baby healthier and happier, don’t I kind of have to do everything in my power?” 

It’s a view that will be very appealing to utilitarians, who believe the right action is the action that maximizes well-being or happiness. But maximizing principles can be dangerous. If we’re laser-focused on maximizing one value, however noble it may be, that can lead us to overlook a host of other important values. Think about diversity, for example; polygenic testing could lead to a less diverse world. 

And it’s not even clear how to maximize well-being given that each embryo will have some downsides: How would you choose between one embryo with a slightly elevated risk for schizophrenia, another with a moderately elevated risk for cancer, and a third with a high risk for Alzheimer’s? You’d have to decide how to rank the importance of each condition, which would require a dizzying bit of moral math: How much weight do you put on the longevity associated with each condition, how much on patient-reported quality of life for each condition, and how much on your own ability to cope with each — and society’s ability (which will change over the years)? Plus, even if the screening does end up optimizing life for your individual child, it could have negative effects on the population level, for the reasons we covered above.

As the Nobel laureate Herbert Simon pointed out, many problems contain way more variables and way too much uncertainty for maximizing along a single axis to be feasible or even desirable. So it often makes sense to just go with an option that’s “good enough.” He coined the term “satisficing” — a portmanteau of “satisfying” and “sufficing” — to describe opting for this good enough choice.

What would satisficing look like in the context of embryos? If there’s a very serious condition that runs in your family — like Tay-Sachs or the BRCA mutation that markedly increases cancer risk — then I do think there’s a strong case for screening for that. These conditions are debilitating and can lead to early death. Nobody wants them. Genetic testing that lets us prevent them is an awesome gift. 

Then there are conditions that can include suffering, like autism, but can also be very compatible with a happy life. Mental health conditions in particular are heavily socially constructed — a lot of the associated suffering comes about because society constructs a certain biological reality as a problem and doesn’t support the people who have it. In these cases, if you want to give your child a “good enough” or even “optimized” life, remember that you don’t have to achieve that by biological means; working to change the social environment can be just as important, and it doesn’t carry the societal risks associated with polygenic testing. 

Ultimately, when considering what counts as a “good enough” life, each parent will draw the line in a slightly different place. And there’s a part of that that can’t be boiled down to objective facts about disease, because this is also about how well-resourced the parent feels — emotionally, socially, and financially — to deal with a certain condition. What feels manageable to one parent may feel crushingly hard to another. 

So, I can’t tell you exactly which screenings to do and which to forgo. What I do want to tell you is to resist being bullied or shamed by others, especially those with a profit incentive to push you in a certain direction.

As the epidemiologist Abby Lippman has noted, genetic testing is supposed to offer parents more choice, but it too often has the opposite effect. When someone like Orchid’s Siddiqui says about a disease, “What if you could have stopped it…but chose not to?” — well, that language preys on parents’ worst fears and insecurities. It holds parents hostage while pretending to be giving them more autonomy. 

You are nobody’s hostage. You are a moral agent free to look at the many different relevant factors, weigh them all in the balance, and then make the choice that works well enough for your family.   

Bonus: What I’m reading

• Silicon Valley is obsessed with IQ, so it’s no surprise that tech execs there are using polygenic testing in hopes of creating supersmart babies. This article shows the kind of mental pretzels customers get into when trying to figure out whether to select the embryo with the highest predicted IQ or that with the lowest risk of disorders. One couple asks: “How much additional risk of ADHD cancels out against 10 extra IQ points?”

• Rereading “The Last Children of Down Syndrome,” Sarah Zhang’s 2020 Atlantic feature on prenatal testing, it struck me that when people think “prenatal testing,” Down syndrome is often the first condition that comes to mind, even though it’s not the most severe or straightforwardly negative (it’s compatible with a happy life). It’s just that Down syndrome was easy to test for, so we started testing for it early. I wonder if that built up the condition as a bogeyman in the expectant parent’s imagination — if the fact that we could screen for it shaped the public’s perception of Down syndrome as something that should be screened for and potentially screened out.

• One trait that many people assume we should select for is a great memory. But I highly recommend the short story “Funes the Memorious” by Jorge Luis Borges. It’s a reminder that having too good a memory is not always a benefit.  

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There’s a lot to be anxious about as AI agents and bots get more integrated into every aspect of our lives. Meta, which recently agreed to pay over $17 billion to settle a lawsuit related to harming kids, now wants you to hand over all your online accounts to an inexplicably cute “agent” named Muse that might give a stranger your home address. OpenAI just introduced little blobs called Dots that can supposedly automate routine tasks, like planning dinner and ordering it from your favorite neighborhood spot. AI companies don’t just want you to talk to their chatbots; they want their agents to be an indispensable part of your daily routine.

As a parent, however, I think that perhaps the worst thing AI could do is be my kid’s friend. 

AI companions have been around longer than ChatGPT, and they’re growing in popularity with young users. More than half of teens have interacted with AI companions at least a few times a month, and one in three decided to talk about a serious issue with AI companions instead of real people, according to a Common Sense Media survey conducted last year. In certain groups and situations, a chatbot could offer some benefit — a lifeline for, say, LGBTQ youth who don’t have any in-person support networks, one study found. But even so, there are important caveats and risks.

Meanwhile, other experts are telling parents never to let their kids access AI companions, warning them that these chatbots have a history of offering dangerous advice and engaging in sexualized conversations. Sixteen-year-old Adam Raine died by suicide last April after developing a relationship and discussing his plans with ChatGPT.

If you have kids, these are horrifying stories to hear. It’s reasonable to wonder how widespread the issues are, and who they are affecting most. As of right now, the majority of younger kids aren’t using AI for companionship (phew!). But for those who are, where do the issues arise? And how do they go from using ChatGPT for help with their homework to opening up to it about their problems to preferring it to their human friends? 

Some answers are starting to emerge from research. 

For even young adolescents, there’s a direct link between AI companion use and mental health issues, according to a new study by researchers at the University of North Carolina at Chapel Hill. Their paper, which is still under review, is the first longitudinal study in the US that has looked at the bidirectional association between AI companionship in adolescents and mental health issues, according to one of the researchers. It charted AI use among 2,300 middle schoolers and found that about one in five used AI for emotional companionship. Those who used AI more reported higher levels of loneliness.

“It’s not just that the lonely kids are using AI, and they’re otherwise unharmed,” said Anne Maheux, an assistant professor of psychology and neuroscience at UNC Chapel Hill and the lead author on the study. “It is that using AI comes first, and middle school students are increasing their sense of loneliness following the use of AI.”

I recently spoke to Maheux about her research and the role of technology in young people’s lives. We discussed how much parents and teachers know about what is going on, what kids get out of human relationships that AI can’t provide, and whether she’d let a child under her care use an AI chatbot. While she said there is a lot to be scared of right now, there is some evidence that, when designed with the intention of promoting child learning and development and under the supervision of a caring adult, AI can offer some benefits, and, ultimately, she’s optimistic that we can design a better future for kids. 

The conversation below has been lightly edited for length and clarity.

How do so many kids end up with an AI companion? Do kids start using AI for homework help and end up in an emotional relationship with the technology? 

At a high level, AI companions — in our darkest vision of what that might look like — would be a kid calling an AI chatbot their best friend. That phenomenon is still quite rare. There are certainly plenty of kids who are experiencing that, but it’s not to say that it’s all kids or even most kids. I think that’s good news. 

But it’s also true that the line between opening up AI to ask a question about your homework and a full-blown AI companionship relationship involves a lot of gray areas. There’s evidence, mostly preliminary and anecdotal evidence, to suggest that very few people open up to AI with the primary initial goal of developing an intimate friendship or relationship. 

Most people open it out of a curiosity, sense of novelty, or seeking an answer to a question that’s very pragmatic. Then that can potentially evolve into something more akin to seeking personal advice or help making a decision or help making sense of one’s recent experiences with other humans. And that can potentially evolve to something that’s a bit more emotional.

What did your latest study on adolescents, AI companions, and mental health reveal?

Some kids seek out AI for certain purposes in different ways than other kids. For some kids, AI companionship is particularly attractive, especially the kids who maybe don’t have close friends or social networks in their offline life and who are already lonely. 

It’s a chicken-and-egg problem. Is it that these kids are seeking out AI companions or is it that having an AI companion is exacerbating those potential vulnerabilities or exacerbating risk for mental health problems? What we found is that interacting with an AI companion in a way that’s akin to emotional intimacy among middle school students is longitudinally associated with increases over time in loneliness. So the kids who are seeking out these companions, who are presumably already lonely, are also experiencing an increase in loneliness over time. 

There is this potential directionality question that we’re starting to answer here: It’s not just that the lonely kids are using AI, and they’re otherwise unharmed. It is that using AI comes first, and middle school students are increasing their sense of loneliness following the use of AI. In other words, middle school students using AI for emotional intimacy and companionship developed greater loneliness over time.

Do you have a sense of how often these kids are using the chatbots? 

In our sample — so again, these are US middle school kids — about 15 to 20 percent say that they’re using it at least a few times a week for any purpose. We don’t have specific rates of use for companionship because the questions that we asked were just not framed in a frequency measure, but more in how emotionally intimate they felt with the chatbot.

What else could have been causing that loneliness?

There are almost definitely many causes, and I think that our data suggests that AI companionship may be one cause. It certainly isn’t definitive. Obviously, I have to say that. I’m a scientist and trying to be hesitant about these things, but the reality is that whether or not AI use causes loneliness in this particular case, there are definitely other things that are also causing loneliness. 

That could be a myriad of things about the kid, maybe they have a lot of social anxiety, maybe they struggle with social skills, maybe the kid has had struggles in their family life and doesn’t have a strong sense of connection and belonging at home. It could be structural things. The kid just doesn’t have enough access to appropriate resources. So certainly there’s other things that are at play here, and typically technology use is one of many factors that can influence a kid’s mental health. 

And how much do you think that parents and teachers know about what’s going on, and how well-equipped do you think they are to intervene or to just be more involved in how these kids are using this technology? 

It’s a very slippery technology. The way kids are using it has changed rapidly in just the last year or two years. I would expect that parents, teachers, people who care about kids are probably struggling with the rapidity of change. But it’s also true that all the things that we have known for a long time about supporting kids and helping them thrive, those things are still true and they’ll be true with whatever technology comes after AI that kids are exploring. 

Those things include being curious, asking kids questions about their lived experiences online and offline, having conversations with kids so that they can understand the implications of different technology use. They can understand how, for example, AI is embedded within a broader system of social and political and economic factors, including the fact that many companies are trying to exploit kids’ attention in order to make money, which many kids are quite interested to hear about. 

Supporting kids also means providing a warm and supportive space for them to learn, to make mistakes, to be kids in the offline world, to have the frictionful, challenging, awkward conversations and first dates and all of the things that parents are sometimes trying to protect kids from by providing a safe container for them to explore those things. All of that can also provide avenues for kids to learn what they need to learn and develop — all the resources for a long life of thriving, even in the context of AI or other new technologies. 

What do kids learn from having these kinds of conversations with other humans that they can’t get from AI? 

Kids need to engage with other people, period. That’s true for all of us. We’re an incredibly social species. Simply being around other people and talking to strangers, let alone having strong social bonds, is really good for us. And all those things are uniquely important during adolescence, when kids have this neurobiological sensitivity to social information and reward. That’s when kids learn how to engage in conversation, they learn how to maintain eye contact, how to read body language, how to read emotions and perceive the world from the lens of someone else, to take their perspective. That’s not to mention other things, like being a member of one’s culture, what is valued, and what is expected. All of that is learned in the context of other human social relationships or relationships with broader social groups that a kid might be a member of. 

AI obviously can’t and never will be able to offer some of those things. It can’t actually experience empathy or care. It can’t engage in a true mutual human relationship. It may be able to simulate some of those things, and there’s some evidence that it can serve as a source of social practice. It can help kids work through the potential for difficult conversations and then serve as a bridge to engaging with other people. But there are aspects of AI that just simply can never replace the core sacred aspects of humans. 

Can you be more specific? What is it about human relationships that can’t AI simulate?

The way that AI systems are currently designed, which is not an inherent feature, but is a design choice, is to be sycophantic, highly agreeable, anthropomorphized, and all of those things can lead to kids developing expectations or understandings of interactive relationships that are actually fundamentally at odds with a normal human relationship. Some of the most consistent things that I’ve seen in the educated hypotheses on this topic and also in the emerging empirical research is that people need the friction that comes with human relationships. 

Human relationships are just hard and messy, and they’re also really beautiful. They’re what make so much of human life valuable and worth living. And with AI that’s always agreeable, that’s always available, that has no needs of its own, that can’t care or be cared for, it just doesn’t serve the same context to help kids learn things like conflict resolution or negotiation, being pro-social or caring for someone else who has needs. So many of those aspects that can feel uncomfortable in the moment, dealing with another person or a person who’s not responding right away, those things are actually important in the building blocks of developing the skills and capacities to be a functioning and thriving person in the social adult world. 

This is a problem with AI in general, isn’t it? It makes things effortless, but if you choose this path of least resistance, you’ll avoid the friction that causes you to learn and develop and build skills you need to exist in the world. 

Absolutely. And I think that all these things are connected too. AI offers this effortless, frictionless solution to our day-to-day problems, whether they’re social problems, whether they’re problems doing our homework, and those immediate solutions feel really good in the moment, so they’re quite tempting to keep coming back to. But there’s this real possibility that in the long term, that erodes our capacity for not only social relationships or cognitive skills, but just a general ability to withstand the momentary day-to-day distress of being a person living a normal life. And so I think every domain of human psychology comes together at that point, whether it’s social, emotional, mental health, or cognitive. 

Do you think that there are interventions that legislators could make or even that tech companies could make that would improve outcomes for kids, maybe make them a little less lonely? 

There are a million specific design changes that I would recommend. I think at a very minimum, AI systems can afford a pretty phenomenal amount of access to information, but there’s been no benefits that I’ve seen of them acting as friends. Kids need other human friends, full stop. Designing systems that are intended to exploit kids’ vulnerability or sensitivity to human social information and relationships, I think, is bad for kids. 

At the federal level, it seems that regulation is not coming, but at the state level, there have been many state regulations intended to protect kids, intended to create safer systems, to put in guardrails, to modulate different aspects of the models, the design, the user interface. These things could potentially make a real difference, I think.

What do you recommend parents do with regard to AI and their kids? Should they let them use chatbots? 

In short, no. But I am not a parent, and it’s much easier to dole out advice than it is to enact it. Parenting decisions about technology are not one-size-fits-all. Kids, parents, family dynamics, technology, and the context in which it is used differ, and in so many cases are personal choices (parents must weigh various potential opportunities and risks). Decades of research indicate what conditions a child needs to thrive. Extremely minimal research addresses the effects of AI on youth, and what we have so far suggests that the risks outweigh the benefits. 

I would not give a child under my care AI chatbots of any kind to use without me or another trusted adult present. I would talk to them openly about AI and its risks and benefits, but to me AI, like all technology, should be a tool used to promote human thriving, and when the evidence is unclear or suggestive of harms, I think it’s best not to experiment on kids. Currently, the off-the-shelf AI chatbots most kids are using appears more likely to undermine well-being for vulnerable users, especially children. 

Well, as a father of two daughters, I’m definitely terrified of what’s to come in the next few years. 

There’s a lot to be scared of, but there’s a lot to be hopeful of too. I think that everyone wants kids to thrive. Some of us are under different incentives, and some of those incentives might be perverse. But most of us are working really hard to design a better world for kids. 

We found lots of math-filled and science-rich toys for tiny nerds to assemble, bake, squish—or even tear apart and rebuild.

If your friend is in the depths of newborn survival, these gifts and gadgets can go a long way to make parenting a little easier.

“From the outset, reproduction is a collaborative venture,” writes Anna Louie Sussman, a journalist who has spent years reporting how people all over the world try, and too often fail, to build the families they want. Her work explores how the collaborators of reproduction keep multiplying: doctors, employers, legislators, insurers, and a fertility industry that increasingly promises not just a baby but a better one. 

In her new book, Inconceivable: The Impossibility of Family in an Age of Uncertainty, Sussman traces the economic, political, and psychological negotiations that stand between people and the children they say they want. Her reporting challenges the assumption that falling birth rates can be fully explained by metrics like income, marriage and education that demographers tend to focus on. She argues the answers are much more personal and resistant to measurement. 

I wanted to better understand what Sussman meant by this idea of “impossibility of family” — and how one would even determine that, whether as a prospective parent or as a policymaker. What are the biggest barriers to having kids and how do people tell the difference between what they can’t afford and what they’ve come to believe they need? How much does the media conversation about these issues inform people’s choices? 

I spoke with her about what Rep. Alexandria Ocasio-Cortez’s egg freezing reveals about women who aren’t running for president, what countries that subsidize fertility treatment tell us about the demand going unmet here, and why she hesitates to say outright that having children is good. Our conversation has been lightly edited and condensed for clarity.

You started working on this book seven years ago. What has most surprised you about how the conversation around fertility and family formation has changed in that time? 

There are some people on the left who have always paid attention to family issues, like Elizabeth Warren with her work on bankruptcy and the “two-income trap,” but I do think we’ve been seeing a lot more movement there, with groups like the Congressional Dads Caucus [in 2023], and care infrastructure ideas like those in the Build Back Better Act. There’s also been all this movement around paid leave in the states, 3-K and pre-K, and attempts for more affordable child care. 

On the right there’s been the rise of this strange pronatalism and the turn that’s taken with what I’ve wound up calling “kid-maxxing.” Plus this embrace in Silicon Valley and among the super rich with so-called super babies and the really overt embrace of technology to make children on this industrial scale. I also did not expect Roe to be overturned. I would have hoped that would’ve come with a lot more attention on the right to support for mothers and children, but that really hasn’t come to pass in a big way.

I was startled to read that you found some philosophers attempting to reclaim the term “eugenics.” You cite one who wrote a paper called “Defending eugenics,” which sets out to “reclaim the spirit” of eugenicists like Charles Darwin and Francis Galton. You cite another who calls for “liberal eugenics” grounded in the freedom of parents to choose how to enhance their children in accordance with their own values.

One Oxford philosopher even says parents have a duty of “procreative beneficence” and should select embryos or fetuses “most likely to have the best life” based on the genetic information they have.

That was also surprising to me. Like you, I also thought it was a discredited and taboo word. It’s hard to know how widespread those views are. I mean to be clear, eugenics has always been part of our culture in the US. I think people forget that a lot of Nazi policy was inspired by American eugenic policies, and it’s an attitude that has never really gone away. We still see it in a lot of subtler forms that I mention in the book. I mean, even just how people are choosing embryos and terminating pregnancies based on certain genetic conditions. 

“Clearly you could have a lot more children being born if these technologies were more accessible.”

This eugenicist rhetoric is gaining steam at a moment when some people are also really hard at work on developing technologies that could enable this sort of thing. While some of these philosophers will definitely make a distinction between parents making some individual choices vs. a state sponsored program, I think it’s the attitude that’s at the root of this, and that’s what we really need to work on criticizing and dismantling.

So the book is arriving just as Rep. Alexandria Ocasio-Cortez has been documenting her egg freezing journey, and talking about how she wants to push to expand insurance coverage and federal support for fertility treatments. What does her experience — and the reaction to it — say about our current moment? Some on the right were so mad, as if she should just throw in the towel or eschew hope and agency at age 36. 

What’s so interesting about her experience that I think that people miss is, yes, is it exceptional that she’s contemplating a run for president? Sure. Not many of us are doing that. But on many other levels, she’s doing what a lot of women who can afford to do in their late 30s do when they’re still single. In the book I mention the research of Marcia Inhorn, who interviewed about 150 women who sought to freeze their eggs. And what’s interesting is if you look at their profiles, they were city-dwelling professionals who were on average nearly 37 at the time of freezing.

That is AOC to a tee, and if you asked those study participants why they were doing it, most were not doing so because they felt like they needed to put their families on hold to pursue careers. A full 82 percent cited their lack of a partner as the prime motivation. They wanted to have a family at some point and didn’t want to rule that out. 

What do you think we should take from other countries that do subsidize egg freezing?

So the city of Tokyo has subsidized egg freezing and they were totally oversubscribed. So many women took up the city’s offer, and France has also started offering it. More places offer IVF coverage for people who need it because they treat infertility like a disease, which is how the World Health Organization defines it.

What’s interesting is when you look at places where there is more coverage, it also gives you a sense of the scale of need for it. So in Denmark, where you can get something like up to six rounds of treatment publicly funded for your first child and another six rounds for your second child; I believe about one in nine children is born there with assisted reproductive technologies. If you compare that with the US, it’s closer to one in 36. So clearly you could have a lot more children being born if these technologies were more accessible.

In the book you cite historian Sara Matthiesen, who argues that since legal abortion helped transform having a child into more of a personal choice, pregnancy thus became understood as chosen, with parents then sacrificing or forfeiting some of their claim on societal help. I couldn’t tell where you landed on that argument. Do you find it persuasive?

So I find it persuasive in the sense that I feel like conservatives will grab onto any argument to avoid state responsibility towards families and children. The fact that you can terminate a pregnancy is one more reason that can be provided to individualize the responsibility of parenthood. 

But I think that we’re also seeing the mirror image of that — where the choice to remain or not remain pregnant has also been taken away in so many places post-Roe. And I don’t think that has resulted in the converse of her argument, which is that when that choice is taken away and you can no longer sever pregnancy and motherhood, then states and society will step up to acknowledge that reality. 

In the middle of your book you recall an ex-boyfriend, who was divorced and felt it would be impossible to afford a second kid. You were surprised by this, and later cite a pregnant woman in Venezuela you met while traveling, who was worried about money but excited about parenthood. She told you the Venezuelan proverb that “a baby comes with a loaf of bread under his arm.” The subtext was that they believe things will work out. The subtitle of your book is The Impossibility of Family in Age of Uncertainty. So where do you land? Is it impossible, as your ex said?

I think that’s what people are trying to negotiate with themselves. That’s where things like faith, agency, and disposition come into play. One of the reasons I wanted to write this book was I feel like birth rates and demography are always discussed in terms of these data points that people can measure, like how many people are married and how old are they, and do they have college education or not? Do they earn X, Y, Z income, or not? Do they have a job? 

But it’s just all so personal. So the Venezuelan woman was an optimist, whether that’s culturally or dispositionally, and she did believe things would be okay. And I think we all know stories of people who’ve grown up who came from very challenging backgrounds and wound up achieving some sort of fame, fortune, success…so we know that things are always possible. And that’s where questions of what one is prepared to sacrifice come into play, or what expectations do you have of what you want to provide a child. 

The thing I really want to highlight is how individual these negotiations are, whether you come down on it being impossible or whether you want to lower your standards and maybe your child doesn’t get in-home violin lessons or if music’s really important to you and you can’t imagine a universe in which your child doesn’t play an instrument.

I cover these issues too and I think about a lot about what our role in the media is. I share your view on reproductive justice, and wanting to help people live the lives they want. But you also wrote about experiencing what you called “money dysmorphia” — when someone is feeling insecure about their financial situation even when they are in fact okay. What role do we have as journalists to help people distinguish between genuine financial impossibility and the fear that they can never be secure enough? And if we don’t do that, how do we not end up in a world where only rich people are encouraged to have kids?

So I try to be optimistic, but I also feel like as a country, there’s no bottom to how far someone can fall in America. As Elizabeth Warren found, having a child is a huge predictor of bankruptcy. I would like to be more positive. And I do believe that there’s so many easy policy fixes, so many ways to make parenting easier. But for people I know who’ve gone through serious financial distress because of things in their life changing, there’s a limit to what I can do or say without giving them all my resources. 

Regardless of our job as media, I wish I could say that everything will work out fine. And in some cases it can. Again, people do really great jobs being parents with so much less than I have, which is something I try to keep in mind all the time. But I also would say as a society that we let people fall all the way through the floor and then some. We just don’t have a safety net. So I find it hard to say that everything will work out and you’ll wind up fine.

At the beginning of your book you talk about how having children is an intensely personal decision and you’re not interested in writing about if it’s “good” or “bad” or “worth it.” One of the critiques conservatives make about people like us is that we can be so averse to making any kind of normative statement about having kids that we’ve lost the plot. I’m curious for your thoughts on that. In a book arguing that we need more family-friendly policies, do you think you need to more explicitly say that having kids is a good thing to do?

What I would say is loving relationships are good, and having kids is one of those. I think parenthood is an exceptional one just in the level of responsibility that you’re inviting. Having kids for people who want to have kids is good. But I don’t know, I do hesitate to privilege that relationship above all others because of what doing so means. If you say having kids is good, well, who has kids? That immediately has gendered implications and instantly puts an onus on women.

Though we say public libraries are good and that doesn’t mean we have to make libraries against people’s will. But yeah, I guess I wonder if that position avoids the ways this kind of relationship is different from other loving relationships. While this isn’t what personally motivates me, I think one can definitely make a case that having kids is more of a social good than some other kinds of relationships.

When we say society should be more family-friendly and fund it with tax dollars, it’s not just so everyone can live out the lives they want, but also so we can support our society now and in the future.

Lyman Stone I think gets at this, he says children are good because people are good. Again, I would say if you feel like you might be a good parent and enjoy that relationship, that specific relationship, the whole point of my book is I want that to be more accessible because from what I’ve seen and now in my own experience, it is an amazing relationship. It’s not a relationship like any other one I’ve ever had. But I guess it’s not clear to me what the corollary is of saying having kids is good. It’s definitely good for people who want to have kids, but it’s definitely not good for people who don’t want to have kids.

Though I’m not someone who always wanted to have kids myself. And while I’m strongly against coercing people into having children, I think there are millions of people like me who are like, “I don’t know. I’m not sure. I can’t really picture it.” 

There are people on the right who say, “Therefore, just do it because you’ll like it.” And I don’t think that’s appropriate. But it’s also true that for most of human history, people were simply not asked to come down on this question of: “Do I want it or not?” Now today I’m so glad I have a child and the choice to decide, but if you had asked me five years ago I would have said, “I don’t really like little kids. It’s never been my thing.”

So the identity question becomes interesting and confusing to me, and I think it leaves me more uncomfortable with the idea that we should just support whatever anyone’s choice or desire is today when we know that our choices and desires do change, including based on what people absorb in the media.

I think a lot of young people are just really struggling. I see this all the time on Reddit threads or listening to young people talk about their lives who say, “If I can barely take care of myself, how can I take care of someone else?” We don’t have a society that makes any form of caregiving easy, and people are really struggling to find work. We have a society that doesn’t make it easy to care for oneself, for one’s parents, for one’s friends, for one’s partner.

I mean I did have a kid before I felt totally comfortable and I was just really fortunate that it worked out. I do agree with some of the people on the right who say that a lot of the things you think you need to become a parent, you don’t. And we know that really great people grow up all over the world where they have much fewer resources and infrastructure and everything. So I do think kids need a lot less than we often imagine they need. And that is part of thinking about your own expectations and what you want for a child and also, again, what you’re prepared to sacrifice.

I joke that I go to an annual yoga class fairly regularly. I don’t really cook anymore. I had a single mom who was just resourceful, though she was lucky to be in New York City, where there actually are resources to access. If you’re living in Tennessee or Mississippi those types of resources would probably not be available. 

Mingaile Kieraite remembers what it felt like observing those close to her become parents. As family members shared updates on their pregnancies and friends dragged her to kid-friendly events, she began to feel isolated, as if she wasn’t being let into an exclusive club.

But Kieraite, 33, had already decided she didn’t want to join the club. From a young age, Kieraite never had an intense, or even middling, desire to have kids. She’d helped raise her cousin, a responsibility that was foisted upon her, and found the experience challenging. Now with more control over her circumstances, she considered what she really wanted. And it wasn’t children.

But at some point in her 20s, she had a confounding experience. The hosts of some of her favorite podcasts and YouTube channels announced they were having babies, and instead of parasocial excitement or even apathy, Kieraite was caught off guard by what she felt — a little sad, jealous even. She started to wonder if she should follow suit. 

As a thought experiment, Kieraite tried to imagine what being a parent would be like. Her mind immediately went to the good parts — feeling useful, having company — not the early mornings or the ultimate sacrifice of free time. “But that’s not how it works,” Kieraite told Vox. She was still adamant in her choice not to have children, but she felt a sense of loss for an experience she will never have. 

“How is it,” Kieraite said, “that I grieve something I don’t want to have?”

Whether it’s the choice of having kids or some other path not taken — a job offer you turned down, that person you never quite got the courage to ask out — the finality of major life decisions is wrought with a complicated and very relatable sense of grief. Not quite regret, the tension between who you are and what you could have been can dredge up feelings of self-doubt. What if? can give way to Did I make the right choice? Accepting who you are now means letting go of who you could have been. 

The number of American adults who don’t want kids is growing — 47 percent of non-parents under 50 say they’re unlikely to have children, up from 37 percent in 2018 — but they’re running headlong into an increasingly pro-family culture and political sphere. While alternative family structures are becoming more common, most people say they want children. And remaining childfree — intentionally choosing not to become a parent — remains relatively niche. Women between the ages of 30 to 50 who don’t have children are among the minority. Only around 20 percent of adults in their 50s and 60s do not have kids. Cultural messaging and social rituals surrounding marriage and child-rearing — weddings, baby showers — reinforce the idea that having kids is the norm, and a milestone worth celebrating. Bucking those trends can inspire a deep sense of FOMO, or even profound loss.

Like Kierate, childfree people may be surprised by their emotions. After all, they’ve made a deliberate choice. But they still experience a loss: a life they don’t get to live, a future they need to relinquish, even if it wasn’t what they wanted in the first place. Rather than signaling regret, this grief is often rooted in a desire to be seen and to be included. And there are ways to navigate these thorny, undiscussed emotions.

Unrecognized and alienated

Though there are more adults who don’t want kids than ever before, a stigma remains. People who choose to not have children, particularly women, are seen by society (and, at one time, the pope) as selfish, callous, lonely, and potentially regretful. “We do have that natural expectation of people to have children or families in traditional ways,” Brittany Stankhe, an assistant professor in the department of social work at East Tennessee State University, told Vox. 

In a culture that values parenthood, childfree people can feel alienated or carry shame, even if they know not having kids is the right choice. Their extended family might not understand why their loved one chose to be childfree — they can’t afford to have kids, are concerned about the future, or simply don’t want to — and thus not see it as a legitimate choice. They might also be excluded from family-centered get-togethers. “Maybe you really don’t want to be part of all these kid events,” Bella DePaulo, the author of Single At Heart: The Power, Freedom, and Heart-Filling Joy of Single Life, told Vox. “But it’s still another way in which you’re getting the message that you don’t really count, or you don’t count the way people who are parents count.”

When a baby is born, the parents’ wider community traditionally hosts baby showers, provides material support in the form of gifts and childcare, and recognizes they have entered a new life phase. “Choosing not to have children usually has no corresponding ritual,” licensed psychotherapist Annie Wright told Vox. “No one gathers to celebrate the life you’ve deliberately built or the clarity and pain it took to choose it. So many people can feel so deeply confident in their decision and still feel sad it isn’t witnessed or celebrated or understood in the same way.”

Holly, a 46-year-old who asked Vox not to publish her last name so she could speak freely about her friendships, didn’t feel that her multiple advanced degrees were sufficiently celebrated by loved ones compared to her friends’ pregnancies. “I got a couple congratulations, but it’s like, freaking do something for me,” Holly told Vox. “Give me a cake. I want to pick colors for something, and all those little novelty things I appreciate and enjoy that don’t really come from many other things other than having a baby.” She sees the glorification of traditional milestones as only furthering the stereotype that women are only worthy if they get married and have children.

Though Holly and her husband don’t want kids, there is some part of her that wishes she did. Holly was reminded of a recent shopping trip where she held her friend’s toddler in her lap while her friend went to the bathroom. She was struck by the warm smiles she received from strangers and felt a sense of sorrow. “No one will ever look at me like that for any reason, no matter what I do,” she said. 

A different kind of grief

For about a 10-year period starting in her mid-20s, many people in Jennifer Chalmers’s life were having kids. Though she’s never wavered in her decision not to have children, she did suspect her friends were experiencing something she wasn’t. “You start thinking, ‘I’m the only one who’s not doing that. Have I chosen the wrong path?’” Chalmers, 61, told Vox. But once her friends moved out of the child-rearing phase of their lives, that existential question abated. 

Chalmers’s experience is among the many documented examples of childfree people who live full and happy lives. According to research, childfree adults do not experience any more regret than parents, and they also report high life satisfaction. Instead of mourning a path not taken, childfree people “might be grieving an identity or a set of rituals or a particular relationship to adulthood, or their imagined place in a future family,” Wright said.

Letting go of these theoretical roles can be difficult because they aren’t necessarily losses. Society has an easier time recognizing the grief of people who want to have kids but, for one reason or another, are unable to. The sadness associated with choosing a somewhat unique path is less concrete. Nearly four decades ago, Kenneth J. Doka, a senior vice president of the Hospice Foundation of America, coined the term disenfranchised grief to describe the sorrow people feel when their loss isn’t acknowledged by society — perhaps the death of a pet or neighbor. “If you want to talk about it, if you want to explore that choice, if you want to process your grief, there’s nobody for the most part who does,” Doka told Vox. Mourning a life you didn’t even want can be a form of disenfranchised grief, Doka said, since you made a conscious choice to be childfree.

Another experience, known as ambiguous loss, developed by therapist Pauline Boss in the 1970s, refers to the grief associated with absences without closure, like a breakup. “Boss’s work on ambiguous loss centered on the soldiers lost in battle,” Wright said. “But her work helps us understand losses that don’t have a clean ending or a clearly recognized object.” Grieving a potential future can be a form of ambiguous loss, too, she said.

But how to process a loss of something you never had — and never wanted? Something that lacks boundaries and closure? According to Doka, admitting to yourself the existence of a loss is helpful, as is communicating that pain to someone who will acknowledge it as such. “Saying, ‘I made a choice. There were things I liked about that choice. I had a good life because of that choice, but now there are some aspects of that choice that I do in fact regret,’” he said. Wright said to consider that the decision not to have kids — all decisions, really — have costs. There will always be a life you didn’t get to have.

As I enter my mid-30s, that alternative life is becoming ever clearer. Like Chalmers in her 20s, I’m at the point where many of my peers are having kids or solidifying their decisions not to. Since my teenage years, when for a school project I was tasked with caring for a baby doll programmed with software enabling it to cry and fuss, I understood the limits of my maternal instincts. Namely, that I had none.

Still, I wonder if my life will have meaning, if having children is the most worthy way to leave a legacy. I’m reminded that my choices reverberate every time my mother sends me a video of a baby doing something silly with the comment “This is why you have kids.” 

But it isn’t a good enough reason to have kids. When I’m saddled with doubt, I open my eyes to the world around me: the privilege of laying in bed on weekends, the thrill of a spontaneous evening with friends, the ultimate blessing of silence. I don’t need to reimagine myself as anyone else, because my life is exactly how I always imagined it. I can lose myself for hours in a run, spend an afternoon reading by the pool, keep my house tidy. These simple pleasures would be made more difficult for me with the presence of a small human.

Nicola Marchant, a 37-year-old who is similarly questioning her purpose in life if she doesn’t have kids, copes with these feelings by confiding in other friends who don’t plan on having children and engaging with childfree content on Reddit and TikTok. Hearing from older people who don’t have kids that their lives aren’t empty and devoid of meaning brings her solace. “It’s content like this that shakes me out of my spiraling and makes me laugh and realize I’m not alone in these doubts and fears,” Marchant told Vox in an email. “My advice to others would be to do the same, surround yourself with voices that feel the same as yours, speak to older people you know without kids; if you don’t know any, find some online.”

Regardless of what you call it — disenfranchised grief, ambiguous loss — the feelings are real. Moving through a world that still values and recognizes traditional family structures can be exclusionary. But there is freedom in embracing the life you do have, even if it isn’t celebrated in the same way. It doesn’t make it wrong.

“I actually don’t think the goal is to stop feeling anything complicated,” Wright, the therapist, said. “It’s to make room for the grief without allowing it to erase the meaning and fullness of the childfree life you chose.”