{n “title”: “Attitudes Toward Surrogacy Questionnaire (ATSS)”,n “content”: “
1. Abstract
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The Attitudes Toward Surrogacy Questionnaire (ATSS), also referenced in psychometric and bioethical literature as the Attitudes Toward Surrogacy Survey, is an original 14-item self-report psychometric instrument developed to evaluate and quantify public and individual attitudes toward gestational and traditional surrogacy, with a dedicated operational emphasis on religious, moral, ethical, and socio-legal dimensions. Formulated initially in the Turkish language by an interdisciplinary panel of specialists in health sciences, nursing, bioethics, linguistics, and applied statistics, the instrument was translated and culturally adapted into English through rigorous forward-backward translation protocols. The scale was validated in a landmark multinational investigation spanning 11 geographically, culturally, and denominationally diverse countries: Turkey, India, Iran, the Turkish Republic of Northern Cyprus (TRNC), Madagascar, Nepal, Nigeria, Pakistan, Mexico, England, and Japan. Administered electronically to adult populations ranging from 18 to 81 years of age, the ATSS captures cognitive evaluations across diverse worldview frameworks, including Islam, Christianity, Hinduism, Buddhism, and secular or atheist perspectives.
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The scale employs a standard 5-point Likert response format ranging from 1 (\”Strongly Disagree\”) to 5 (\”Strongly Agree\”). Psychometrically, the instrument demonstrated acceptable reliability, yielding an internal consistency coefficient of Cronbach\’s α > 0.70 during its initial pilot phase and a final Cronbach\’s α of 0.73 across the international sample. Eight items are reverse-coded to capture ethical apprehensions, perceived violations of natural order, fears of child identity confusion, and female commodification, while six positively keyed items index perceived altruism, reproductive autonomy, hope for infertile couples, and legal institutionalization. Advanced computational evaluations of the instrument\’s predictive validity were established utilizing machine learning frameworks and artificial neural networks (ANN), positioning the ATSS as an essential psychometric assessment tool in cross-cultural bioethics, reproductive health psychology, medical sociology, and comparative religious studies.
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2. Keywords
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Attitudes Toward Surrogacy Questionnaire, ATSS, surrogacy attitudes, bioethics, reproductive ethics, cross-cultural psychometrics, religious beliefs, assisted reproductive technology, commodification of women, altruistic surrogacy.
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3. Authors
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The Attitudes Toward Surrogacy Questionnaire was developed and validated by an international, multidisciplinary consortium of researchers representing health sciences, medicine, theology, psychology, and management:
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- Metin Yıldız, Ph.D. (Corresponding Author) — Sakarya University, Faculty of Health Sciences, Department of Nursing, Sakarya, Turkey. Email: [email protected]
- Ezomo Ojeiru Felix, Ph.D. — Tottori University, Faculty of Medicine, Department of Adaptation Physiology, Yonago, Japan. Email: [email protected]
- Olugbenga Ademiju, Ph.D. (ORCID: 0000-0002-4755-4911) — Anchor Care and Education, United Kingdom. Email: [email protected]
- Tajudeen Oluwafemi Noibi, Ph.D. (ORCID: 0000-0002-7175-4120) — Universidad Autónoma de Ciudad Juárez, Ciudad Juárez, Mexico. Email: [email protected]
- Roseline Florence Gomes, Ph.D. — Jyoti Nivas College Autonomous, Department of Psychology, Bengaluru, Karnataka, India. Email: [email protected]
- Abraham Tanimowo, M.Sc. (ORCID: 0000-0002-4089-4729) — University of Ibadan, College of Medicine, Institute of Child Health, Ibadan, Nigeria. Email: [email protected]
- Muhammed Tayyeb, MBBS, FCPS — Bacha Khan Medical College (BKMC), Medical Teaching Institution, Department of Anaesthesiology, Mardan, Khyber Pakhtunkhwa, Pakistan. Email: [email protected]
- Ram Bahadur Khadka, Ph.D. — Tribhuvan University, Faculty of Management, Kathmandu, Nepal. Email: [email protected]
- Andrianirina Rhino, Ph.D. (ORCID: 0000-0002-8670-9648) — Catholic University of Madagascar, Department of Management, Economy, and Finance, Antananarivo, Madagascar. Email: [email protected]
- Rabia Yildiz, M.A. — Sakarya University, Faculty of Theology, Sakarya, Turkey. Email: [email protected]
- Kiarash Ramazanzadegan, DDS — Ankara University, Faculty of Dentistry, Ankara, Turkey. Email: [email protected]
- Mehmet Salih Yildirim, Ph.D. — Agri Ibrahim Cecen University, Vocational School of Health Services, Ağrı, Turkey. Email: [email protected]
- Ebru Solmaz, Ph.D. (ORCID: 0000-0003-1962-8669) — Agri Ibrahim Cecen University, School of Health, Department of Midwifery, Ağrı, Turkey. Email: [email protected]
- Çiğdem Müge Haylı, M.Sc. — Hakkari University, Faculty of Health Sciences, Department of Nursing, Hakkari, Turkey. Email: [email protected]
- Aylin Şengan, M.Sc. — Sakarya University, Institute of Health Sciences, Department of Midwifery, Sakarya, Turkey. Email: [email protected]
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4. Purpose
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The primary purpose of the Attitudes Toward Surrogacy Questionnaire (ATSS) is to provide an empirically robust, cross-culturally validated metric capable of assessing how individuals perceive, evaluate, and morally position themselves regarding surrogacy arrangements. Assisted reproductive technology (ART) has advanced at an unprecedented clinical pace, yet the socio-ethical, religious, and legal frameworks governing these biomedical innovations vary drastically across the globe. While surrogacy provides a viable pathway to genetic or biological parenthood for individuals facing structural or biological infertility—such as couples with severe uterine factor infertility, single prospective parents, or same-sex couples—it simultaneously challenges traditional conceptualizations of motherhood, lineage, bodily commodification, and sacred familial duty.
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Prior to the introduction of the ATSS, empirical investigations into surrogacy attitudes frequently utilized non-standardized, single-nation questionnaires or isolated ad-hoc items that lacked rigorous cross-cultural adaptation and psychometric stability. Such instruments frequently conflated distinct ethical, biological, and religious concerns or suffered from pronounced ethnocentric bias. The ATSS was engineered specifically to bridge this methodological gap. By examining attitudes through a standardized 14-item operational framework across Western, Middle Eastern, Latin American, South Asian, East Asian, and African societies, the instrument allows researchers to disaggregate universal bioethical hesitations from culturally or religiously contingent prohibitions.
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In clinical, public policy, and psychological domains, the ATSS serves several critical functions:
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- Cross-Cultural Bioethics Research: It enables comparative analyses assessing how major doctrinal systems (e.g., Sunni and Shia Islam, Roman Catholicism, Protestantism, Hinduism, Theravada and Mahayana Buddhism, and secularism) shape moral reasoning regarding gestational versus traditional surrogacy.
- Reproductive Health Counseling: Mental health practitioners, reproductive endocrinologists, and clinical social workers can utilize the scale to assess systemic ambivalence, familial stigma, or moral injury experienced by intending parents or potential surrogates entering cross-border or domestic third-party reproduction.
- Legislative and Bio-policy Assessment: The ATSS offers empirical data to health ministries, bioethics committees, and international legal bodies debating the legalization, decriminalization, or commercial restriction of surrogacy arrangements by capturing authentic public acceptance levels.
- Predictive Computational Modeling: Designed to interact effectively with advanced demographic classifiers, the ATSS provides reliable numeric feature inputs for machine learning architectures, enabling researchers to predict public sentiment trends based on socio-demographic, geographic, and religious input vectors.
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5. Psychological Construct
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The central psychological construct evaluated by the ATSS is the individual\’s overall evaluative disposition toward surrogacy—conceptualized as an integrated attitude along a continuum ranging from strong moral condemnation and bio-legal opposition to enthusiastic ethical endorsement and reproductive rights advocacy. Attitudes, within cognitive and social psychology, represent enduring organizations of beliefs, feelings, and behavioral tendencies toward socially significant objects, practices, or groups. In the context of surrogacy, this psychological construct is inherently complex, balancing ethical values, biological assumptions, perceived relational risks, and human rights philosophies.
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The ATSS operationalizes this construct across multiple substantive thematic domains, which coalesce to form a comprehensive measure of surrogacy acceptance:
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5.1. Ontological and Natural Order Concerns
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This dimension taps into the cognitive schema regarding human nature, the biological essentialism of motherhood, and the perceived sacred integrity of natural reproduction. Items such as \”Surrogacy is contrary to human nature\” (Item 1) capture essentialist beliefs that separating gestation from legal and social motherhood disrupts intrinsic ontological boundaries. Individuals scoring high in opposition on this dimension frequently endorse conservative philosophical views regarding reproductive finality and natural law.
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5.2. Socio-Economic Vulnerability and Female Commodification
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This facet assesses an individual\’s ethical concern regarding social justice, exploitation, and the instrumentalization of women\’s bodies. Reflected in statements such as \”Surrogacy leads to the commodification of women\’s bodies\” (Item 2) and \”Surrogacy exploits financially disadvantaged women\” (Item 10), this domain reflects feminist, Marxist, and humanitarian critiques of commercial surrogacy markets. It evaluates the degree to which an individual fears that economically marginalized women are coerced into high-risk biological labor for affluent commissioning parties.
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5.3. Religious and Moral Transgression
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Religious schema serve as primary cognitive heuristics for bioethical evaluations. Captured directly by \”Surrogacy is not acceptable according to my religious beliefs\” (Item 3) and \”Surrogacy leads to ethical and moral corruption in society\” (Item 8), this dimension reflects the alignment of third-party reproduction with sacred texts, theological traditions, and canonical law. Across religious frameworks, theological concerns range from adultery and preservation of the genetic lineage (nasab in Islamic jurisprudence) to the integrity of the sacramental marital union in Catholicism.
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5.4. Developmental and Relational Attachment Disruptions
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The scale measures an individual\’s psychological anxieties regarding the prospective child\’s well-being and maternal-infant bonding. Evaluated through items such as \”Surrogacy harms the psychological bond between mother and child\” (Item 5) and \”Children born through surrogacy may experience identity problems in the future\” (Item 9), this sub-construct reflects the perceived developmental risks of gestational separation, attachment trauma, and genealogical bewilderment in donor- or surrogate-conceived offspring.
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5.5. Procreative Liberty, Reproductive Hope, and Altruistic Empathy
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Conversely, positive evaluations of surrogacy are grounded in constructs of reproductive autonomy, clinical benevolence, and prosocial altruism. Statements like \”Surrogacy offers hope to couples who cannot have children\” (Item 4), \”People should have the right to have children through surrogacy if they wish\” (Item 6), and \”Being a surrogate mother is an act of altruism and help\” (Item 11) capture the conceptualization of surrogacy as a compassionate, medically justified response to involuntary childlessness and an expression of fundamental human procreative rights.
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5.6. Institutional Legitimacy and Personal Behavioral Intent
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Finally, the construct extends into socio-legal legitimation and hypothetical self-behavior. Items such as \”Surrogacy should be legally permitted and regulated by the state\” (Item 7), \”Financial compensation should be allowed for women who act as surrogates\” (Item 13), and \”I would consider surrogacy if I/my partner were unable to have a child biologically\” (Item 14) assess structural acceptance of state regulation, commercial compensation, and prospective personal adoption of the technology under conditions of personal biological infertility.
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6. Theoretical Framework
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The construction and validation of the Attitudes Toward Surrogacy Questionnaire are informed by an intersection of foundational models from social psychology, bioethics, and cognitive anthropology.
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6.1. The Theory of Planned Behavior (TPB)
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Rooted in the socio-cognitive modeling of Icek Ajzen (1991), the Theory of Planned Behavior asserts that behavioral intentions and actions are directly governed by three components: attitudes toward the behavior, subjective norms, and perceived behavioral control. In the ATSS, general evaluative beliefs regarding surrogacy form the foundational attitudinal pillar. Items assessing state regulation (Item 7) and normative family structures (Item 12) correspond to the subjective normative climate, while personal willingness to utilize surrogacy in the face of infertility (Item 14) serves as the proximate behavioral intention metric. The ATSS operationalizes how underlying cognitive beliefs translate into behavioral readiness within reproductive contexts.
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6.2. Moral Foundations Theory (MFT)
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Proposed by Jonathan Haidt and colleagues, Moral Foundations Theory posits that human moral judgment relies on several evolutionary, intuitive moral systems: Care/Harm, Fairness/Cheating, Loyalty/Betrayal, Authority/Subversion, and Sanctity/Degradation. The ATSS aligns with these foundational domains:
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- Sanctity/Degradation: Represented by Item 1 (\”contrary to human nature\”) and Item 8 (\”ethical and moral corruption\”), reflecting feelings of physical and spiritual desecration when human reproduction is extracted from the natural marital sanctuary.
- Care/Harm: Reflected in Item 5 (harm to maternal-infant psychological bonding) and Item 9 (identity struggles of the resulting child), which monitor potential harm inflicted upon vulnerable parties.
- Fairness/Cheating: Captured in Item 10 (exploitation of poor women) and Item 13 (just compensation for surrogate labor), balancing equity and the prevention of social exploitation.
- Liberty/Oppression: Expressed in Item 6 (procreative right to access surrogacy), highlighting reproductive freedom and autonomy against paternalistic prohibitions.
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6.3. Principlism in Biomedical Ethics
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The philosophical foundation of the ATSS is deeply informed by the four-principles approach to bioethics articulated by Tom Beauchamp and James Childress (2019):
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- Autonomy: Operationalized in the scale through the fundamental right of adults to pursue parenthood through assisted reproductive pathways and the surrogate\’s autonomous decision to carry a pregnancy.
- Beneficence: Reflected in the alleviation of infertility-induced suffering and the altruistic framing of gestational service.
- Non-maleficence: Captured through items warning against the commodification of women\’s bodies, psychological trauma, and long-term developmental harm to offspring.
- Justice: Addressed through legal equity, state regulation, and the ethical management of financial compensation to prevent class-based exploitation.
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7. Validity
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The psychometric validity of the ATSS was established through a structured validation framework that incorporated qualitative expert consensus, translational equivalence, cross-national construct evaluation, and advanced predictive computational modeling.
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7.1. Content and Face Validity
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Initial item generation was conducted following an exhaustive review of global literature surrounding reproductive technologies, international surrogacy laws, and theological treatises on assisted reproduction. An expert panel comprising scholars from the health sciences, nursing, midwifery, bioethics, theology, linguistics, and applied statistics reviewed the preliminary item pool. This interdisciplinary evaluation ensured that each item demonstrated high thematic relevance, conceptual clarity, and cultural neutrality, resulting in a refined 14-item survey instrument free of ambiguous phrasing.
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7.2. Cross-Cultural Adaptation and Translational Validity
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To ensure linguistic and conceptual equivalence across the multinational cohorts, the original Turkish instrument was translated into English using standardized forward-backward translation procedures. The English draft was back-translated into Turkish by independent bilingual translators blinded to the original version. Discrepancies were resolved through committee review until complete semantic, idiomatic, and conceptual equivalence was achieved, allowing the questionnaire to be administered reliably across English-speaking, Turkish-speaking, and multilingual international cohorts.
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7.3. Construct and Predictive Validity via Machine Learning Architectures
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In the primary validation study by Yıldız et al. (2023), traditional validity assessments were supplemented with machine learning models and Artificial Neural Networks (ANN). Rather than relying solely on conventional correlations, the authors utilized the 14 ATSS items as predictive input variables to model religious group affiliations and national classifications across the 11 study nations (Turkey, India, Iran, TRNC, Madagascar, Nepal, Nigeria, Pakistan, Mexico, England, Japan).
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The neural network architectures demonstrated that individual ATSS items possessed substantial discriminatory power. Specific items, notably Item 3 (religious prohibition), Item 10 (exploitation of disadvantaged women), and Item 14 (personal consideration of surrogacy), exhibited high normalized importance values in predicting an individual\’s cultural and religious background. Atheist and secular respondents exhibited the highest overall acceptance scores, followed by distinct response patterns across Christian, Hindu, Buddhist, and Muslim cohorts, confirming the instrument\’s strong criterion and known-groups construct validity.
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8. Reliability
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The reliability of the Attitudes Toward Surrogacy Questionnaire has been demonstrated across exploratory and confirmatory international phases, establishing its internal consistency.
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8.1. Internal Consistency
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During the pilot testing phase conducted among adult respondents, the ATSS achieved an initial Cronbach\’s alpha coefficient exceeding α = 0.70, satisfying the standard psychometric threshold for exploratory and descriptive measurement tools. In the broader multinational administration comprising respondents aged 18 to 81 years across 11 countries, the overall internal consistency for the final 14-item scale was observed at α = 0.73. In cross-cultural psychometrics, where instruments are subjected to wide theological, linguistic, and socio-economic variance across disparate global cohorts, a Cronbach\’s alpha of 0.73 demonstrates solid internal reliability without excessive item redundancy.
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8.2. Item-Total Characteristics
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Item-analysis protocols conducted during the tool\’s development demonstrated that all 14 items contributed meaningfully to total scale variance. The exclusion of any individual item did not result in a significant elevation of the overall Cronbach\’s alpha, confirming that each item measures a distinct yet aligned facet of the overarching surrogacy attitude construct. The balanced inclusion of 8 reverse-scored items alongside 6 positively scored items acts as an effective psychometric safeguard against acquiescence bias, extreme response sets, and automated survey-taking behaviors common in electronic web-based data collections.
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9. Factor Analysis
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The structural dimensionality of the ATSS reflects the complex nature of bioethical decision-making, where positive endorsements of procreative rights often exist in tension with ethical, social, and religious concerns.
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9.1. Dimensionality and Factor Structure
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While the ATSS is primarily utilized and scored as a unidimensional composite index measuring overall surrogacy acceptance (yielding a global score ranging from 14 to 70), underlying exploratory factor extractions indicate a robust multi-component structural organization reflecting two primary latent dimensions:
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- Dimension 1: Moral, Religious, and Social Concerns (Ethical Opposition): Composed predominantly of the 8 reverse-scored items (Items 1, 2, 3, 5, 8, 9, 10, 12). This factor captures perceived violations of natural order, bodily exploitation, spiritual condemnation, and fears regarding developmental disruption in the offspring.
- Dimension 2: Reproductive Autonomy, Hope, and Social Acceptance (Procreative Endorsement): Composed of the 6 directly scored items (Items 4, 6, 7, 11, 13, 14). This factor captures therapeutic hope, individual reproductive rights, altruistic motivation, state institutionalization, and personal behavioral intention.
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9.2. Machine Learning Weighting and Feature Importance
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In lieu of traditional orthogonal rotations, Yıldız et al. (2023) subjected the 14 items to multi-layer perceptron (MLP) neural network architectures. The model\’s hidden layers revealed that items capturing legal regulation (Item 7) and personal willingness to consider surrogacy under conditions of infertility (Item 14) had strong loading interactions with the procreative endorsement dimension. Conversely, items addressing bodily commodification (Item 2) and religious alignment (Item 3) loaded heavily on the moral opposition axis, confirming the structural validity of the two distinct, correlated sub-dimensions within the composite scale.
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10. Instrument / Measurement Tool
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The Attitudes Toward Surrogacy Questionnaire (ATSS) is an easily administered, self-report psychometric survey designed for cross-cultural, clinical, and sociological research contexts. Below are the structural specifications and scoring procedures for the instrument:
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- Instrument Name: Attitudes Toward Surrogacy Questionnaire (ATSS) / Attitudes Toward Surrogacy Survey
- Test Type: Original multi-item self-report questionnaire / psychometric attitude inventory
- Administration Format: Self-administered; optimized for electronic, online, and pen-and-paper survey formats
- Target Population: General adult population (aged 18 years and older, encompassing young adulthood through advanced age; validated on individuals aged 18–81)
- Item Count: 14 items
- Response Scale: Authentic 5-point Likert scale formatted as follows:\n
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- 1 = Strongly Disagree
- 2 = Disagree
- 3 = Undecided / Neutral
- 4 = Agree
- 5 = Strongly Agree
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- Scoring Instructions:\n
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- Directly Scored Items (Positive Attitudes): Items 4, 6, 7, 11, 13, and 14 reflect positive, supportive evaluations of surrogacy. These are scored directly from 1 to 5 (1 = 1, 2 = 2, 3 = 3, 4 = 4, 5 = 5).
- Reverse-Scored Items (Negative Attitudes): Items 1, 2, 3, 5, 8, 9, 10, and 12 reflect negative attitudes, perceived ethical harms, or religious objections. These must be reverse-scored prior to calculating total composite scores using the transformation formula:
New Score = 6 - Original Score(i.e., 1 → 5, 2 → 4, 3 → 3, 4 → 2, 5 → 1).
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- Score Range & Interpretation:\n
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- Total scale scores range from a minimum of 14 to a maximum of 70.
- Higher aggregate scores (e.g., 50–70) reflect highly positive, accepting, and supportive attitudes toward surrogacy, marked by endorsements of reproductive autonomy, altruism, and legal recognition.
- Moderate aggregate scores (e.g., 36–49) indicate ambivalent, conditional, or undecided attitudes, often supporting altruistic surrogacy while expressing strong ethical reservations regarding commercialization.
- Lower aggregate scores (e.g., 14–35) reflect negative, unaccepting, or prohibitive attitudes toward surrogacy, anchored in strong religious prohibitions, perceived commodification, and violations of traditional family structures.
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- Estimated Completion Time: Approximately 4 to 7 minutes.
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11. Permissions & Fee and Test Year
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Test Year: The Attitudes Toward Surrogacy Questionnaire was developed, validated, and officially published in 2023 in the Journal of Religion and Health.
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Fee and Licensing: The ATSS is an open-access, fee-free instrument designed for academic, non-commercial research, clinical health assessments, and educational use. There are no associated licensing or usage fees required to administer the instrument.
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Permissions and Inquiries: Researchers, clinical psychologists, and bioethicists wishing to utilize, translate, or adapt the ATSS are requested to contact the corresponding author to ensure institutional tracking of cross-cultural adaptation data and psychometric normative updates:
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- Corresponding Author: Assoc. Prof. Dr. Metin Yıldız
- Institutional Affiliation: Sakarya University, Faculty of Health Sciences, Department of Nursing, Sakarya, Turkey
- Direct Email: [email protected]
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12. References
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- Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. https://doi.org/10.1016/0749-5978(91)90020-T
- Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.
- Constantinidis, D., & Cook, R. (2012). Australian attitudes to surrogacy: Emerging issues and unexpected results. Australian Journal of Emerging Technologies and Society, 10(2), 101–113.
- Graham, J., Haidt, J., Koleva, S., Motyl, M., Iyer, R., Wojcik, S. P., & Ditto, P. H. (2013). Moral foundations theory: The pragmatic validity of moral pluralism. Advances in Experimental Social Psychology, 47, 55–130. https://doi.org/10.1016/B978-0-12-407236-7.00002-4
- Moscovici, S. (1988). Notes towards a description of social representations. European Journal of Social Psychology, 18(3), 211–250. https://doi.org/10.1002/ejsp.2420180303
- Sözeri, C., & Cevahir, R. (2019). Knowledge and attitudes of university students towards surrogacy. International Journal of Caring Sciences, 12(3), 1692–1699.
- Yıldız, M., Felix, E. O., Ademiju, O., Noibi, T. O., Gomes, R. F., Tanimowo, A., Tayyeb, M., Khadka, R. B., Rhino, A., Yildiz, R., Ramazanzadegan, K., Yildirim, M. S., Solmaz, E., Haylı, Ç. M., & Şengan, A. (2023). Attitudes of different religions toward surrogacy: Analysis of 11 countries\’ situation using machine learning approach and artificial neural networks. Journal of Religion and Health, 62(5), 3230–3251. https://doi.org/10.1007/s10943-023-01782-y
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