Perinatal distress affects approximately 10% of fathers, but little is known about how gay fathers experience the challenges surrounding childbirth and early parenting of a child. This study explored gay fathers’ experiences of having a baby via transnational surrogacy, raising that baby as a gay parent, and the context of the COVID-19 pandemic. In-depth qualitative interviews were conducted with 15 Israeli men to understand their experiences of surrogacy and early parenthood, focusing on the impact on their mental health and the relational factors involved. Secondary narrative analysis revealed that fathers constructed surrogacy as a perilous quest that required strong intentionality to undertake. The first year of parenthood was conceptualised alternately as a joyful experience and/or one that challenged fathers’ identities and mental health. A relational framework was applied to better conceptualise the fathers’ narratives, revealing that actual connections—and the potentials for links—considerably shaped experiences of surrogacy, perinatal distress and recovery. Implications for research and policy are discussed. In tandem with both the increased number and visibility of gay, lesbian, bisexual, trans, and queer or questioning (LGBTQ+) parents , scholarThis is particularly important not only because comparisons of gay fatherhood to heterosexual families reinforces heterosexuality as the preferred mode, but also because it renders invisible pathways into—and trajectories of—parenthood among gay men , 9. FortCertainly, there is mounting evidence that a substantial proportion of expectant and new  fathers experience significant psychological distress and symptoms of mental ill-health during the perinatal period , 13. ForIncreasingly, scholars have drawn on theories of hegemonic masculinity—a relational conceptualisation of masculinity that highlights the contribution of others to the production of gender, focusing on unequal and competitive gendered relations between women and men, and among men themselves , 24—as aTo the extent that heterosexual fathers experience and manifest psychological distress differently to mothers, practitioners working with men may struggle to distinguish male distress from traditional masculine traits, such as being stoic, expressing aggression, or taking risks . Indeed,Until now, little attention has been paid to the lived reality of parenting—including experiences of psychological distress—in gay fathers , 40. ThiSecond, there is some evidence that gay fathers may experience particular difficulties negotiating the transition to fatherhood, especially in the context of heteronormativity . For insFinally, the specific sociocultural context in which gay fatherhood is enacted may also pose specific challenges for gay fathers and their mental health . In IsraAside from the need for sociocultural specificity, there is also a need to consider specific experiences in temporality. For instance, recent research has shown how the COVID-19 pandemic exacerbated the uncertainty of the surrogacy process, with usual practices of travelling to visit the surrogate, attend the birth, and return home with the infant, compromised by lockdowns, travel restrictions, and isolation requirements . ProhibiIn view of review above, we sought to better understand experiences of surrogacy, early parenthood, and mental health in Israeli gay fathers and in the context of the COVID-19 pandemic. Specifically, we took an epistemologically relational approach to ask the question: Among gay fathers, how does distress develop, organise, and transform in relation to others in the experience of surrogacy? As indicated above, hegemonic masculinity is an inherently dynamic relational theory that relies on the participation of others, even if hegemony  is frequently characterised by scholars as an individualised, static, and/or toxic state in the scholarly literature . SurrogaSaid another way, the social world can be seen to consist of mutually constituting relations rather than separated out individuals . In thisThis interpretative qualitative study involved a secondary analysis of narratives collected through semi-structured, one-to-one interviews. The study was reviewed and approved by the Ethics Committee at The Academic College of Tel Aviv-Yaffo, Israel  and all participants provided written informed consent.Participants were recruited using homogeneity purposive sampling, a non-random method where participant characteristics are defined before recruitment . LimitinParticipants were recruited between September 2020 and June 2021 via an advert on Internet forums, surrogacy Facebook groups, and in Meir Garden, a popular venue in Tel-Aviv among LGBTQ individuals, including gay fathers. Seventeen responses were received and those who replied were sent an email informing them about the study. Two respondents declined to participate at this point, citing time constraints. Nevertheless, a sample of 15 was considered sufficient for this study to reach data saturation . AlthougParticipants provided written informed consent and completed a demographic survey before taking part in one-to-one interviews. All participants were interviewed alone about their own individual experiences. Six of the participants interviewed were in relationships with other participants, specifically men with the following pseudonyms: Pasach and Avi; Abram and Malachi; and Calev and Samuel. The remaining nine participants were not in relationships with other people in the study, although most were in relationships with men not interviewed as part of the study. Participant demographics are reported in Interviews were semi-structured and narrative in style, encouraging participants to select, organise, and evaluate meaningful events to construct their experience of surrogacy and parenthood . An inteInterviews lasted on average an hour, were audio-recorded, and took place on encrypted video-conferencing software, ensuring confidentiality and eliminating COVID-19 risk. The interviews were conducted in Hebrew by two trained researchers with experience in qualitative research at the second author’s institution. Participants were fully debriefed, offered a list of mental health resources, and invited to contact the researchers if questions arose after the interview. All interviews were digitally transcribed, manually translated into English by a confidentiality-bound transcription service, and pseudonymised before being received for secondary analysis by a research team not originally involved in the study. Secondary analysis is the practice of using data from already existing studies for the purpose of research . OriginaJohnston’s  evaluatiData was interpreted using narrative analysis, which centres story as its object of investigation, prioritising an understanding of events through the way they are constructed by participants , 82. Whihear the narratives, and inhabit the reflective posture of in-dwelling most strongly  life”. More recently he experienced a gradual change in how he related both to his inner life and the prospect of children:I began to feel more and more that I am in this place in life. I remember that one day… I suddenly viewed things… that seemed central and fulfilling in my life… [as] meaningless and empty… And I just began to view children differently, my life and what I desire. My thought in this matter shifted… I think it was quite related to my therapy… it started occupying an expandingly larger portion of my soul…Only once this affective decision had been reached did Jonah reflect on the practicalities, considering financial and practical support. Logistical considerations in decision-making developed in all participants’ accounts. Narratives conveyed a sense that “gays in Israel have the longest preparation process” (Avi), as it took so long to convert the intention of having children into reality. Shlomo expanded:We always knew we wanted children. It’s hard to decide—timing, finances, because it requires full dedication to the process, travelling a lot to the U.S., finding a surrogate, egg donation. It could take a few years.Deciding and planning went hand in hand: participants needed to feel emotionally ready and practically prepared. They moved towards readiness in several ways: by talking to friends, other parents, psychologists, and surrogacy agencies; browsing parenting and surrogacy threads on social media; exploring shared parenting; saving money; waiting for promotions; or moving homes. Binyamin characterised this period as a trajectory:Along the way it was a few years of learning, conventions, reading every relevant Facebook post, collecting any information that comes up in the comments, hunting down any couple in our situation or further along the track, to learn from.The bureaucratic, logistical, and financial difficulties of having a child as a gay couple was a dominant feature in all participants’ narratives. Many made links between the difficulty in becoming parents as gay men, strong intentionality, and the anticipated relationship with the child, as Pasach highlighted:It is parenthood that arrives out of difficulty, a challenge. I always say [my child] was chosen. He did not arrive by accident… He arrived following a mental upheaval and he is a desired, extremely loved child who we expected for a long time.Intentionality and considerations of how to relate to children extended beyond the surrogacy period. Pasach, for example, said that “this week, actually, we are trying to develop our parenthood as working parents”. It was important for him to parent in a thoughtful, reflective manner, despite pressures of work. In this way, intentionality is a theme of gay parenting more broadly, both before and well beyond the birth.Across all narratives, there was strength derived from intentionality. As Binyamin commented, gay fathers do not become parents by accident, or before they are ready: they are people who “planned this move for so many years… who truly experience it as amazing”. Jonah reflected on potential future challenges, acknowledging that he did not know how his child would react to the absence of a particular relationship, when they “discuss the fact that he has no mother”. His imagined answer emphasised positive intentionality:I will not tell him that he was delivered by a stork. I will explain all about how he was created. I think it’s pretty cool to understand that people worked so hard for you to exist. That they devoted a lot of time, effort, money, understanding and intention for you to arrive.Participant narratives revealed a perilous quest fathers had to undertake. Isaac explained: “You discover a whole new world… until entering, you do not realise how complicated it is”. Participants constructed this process using various metaphors: a staircase, a rocky path, a journey, or a roller-coaster. They described multiple stages, complicated by the international nature of the process, and for some, the COVID-19 pandemic. Many conceptualised distinct stages of the quest, allowing them to compartmentalise tasks involved to avoid feeling overwhelmed. Isaac explained:If you’re currently waiting for the surrogate for 8 months, this is what you’re busy with… You don’t think about pregnancy questions—you are currently dealing with this. When you need to choose a donor, then you deal with the madness of selecting a donor, and I think there is something about it, at least for me personally, this conception made the process easier to cope with. One thing at a time.Quests were not one forward motion, but a series of movements backwards and forwards. Some participants characterised the process not in terms of milestones achieved, but in terms of hurdles presented, demonstrating the extent to which setbacks shaped their experience. Narratives intersected with setbacks on both a personal level  and a global level .Some fathers knew from the outset that it would be a difficult journey. Others realised during or after. Abram used the language of a physical journey to describe his gradually developing awareness of the trauma involved in surrogacy:[My partner] brought up the idea, and I went along, and we headed out on the way. It was exciting, I was happy to head out, but the path turned rocky, it was a nerve-wracking process. Terrible. Horrible and extremely tough that lasted 4 years.He explained that his child was born on the thirteenth attempt, characterising this period as “years and years and years of failures and shattered hopes”. He, like others, described almost giving up: continuous loss through miscarriages made coping financially and emotionally appear almost impossible.Participants depicted the highly relational—and thus fraught—process of surrogacy as holding no guarantee of success. They felt “anything could flash a red light” and you could only “wait” for and “receive” news (Shlomo). Several participants used the language of fortune and fate, positioning themselves as powerless to control a process involving destiny. Shlomo exemplified this, explaining, “you need the entire cosmos to converge for everything to go well”. The lack of certainty engendered anxieties, which could manifest as a desire to control everything possible. Participants constructed the journey as a series of choices , where getting it wrong risked everything. Underneath these attempts at control, however, participants understood they had little power to ensure a healthy baby would arrive. This induced fear in many narratives, which was strongest for those who could not raise more money. Shlomo explained:There are fears and concerns that you will lack finances and need more money. Insurances do not cover miscarriages, God forbid, nor premature intensive care units, and that is a fear that accompanies the entire journey up until the day of delivery… There are no second chances here, to be precise. I’m not undermining the process of straight people… but the recovery process, even if it’s a year or two… after that you can just try to conceive again, there is no financial aspect you need to recover from.Fathers also found the physical distance—and thus absence of relational cues to closeness—between themselves and their foetus particularly difficult, producing a sense of separation and longing to be nearer. Some tried to bridge the gap by consuming media about pregnancy . The fact that the pregnancy was happening in a different country, time zone and language, also created a sense of remoteness and associated anxiety. Shlomo explained that when his surrogate had a uterine cyst, he did not know what it meant which, “affect[ed] us and cause[d] us distress”. Whereas, in a biological pregnancy, ailments could be felt, assessed for pain, and often treated—with the help of healthcare practitioners—by the pregnant person, the fathers were relatively powerless. To alleviate fear, participants relied on pregnant/postpartum women around them to contextualise medical issues. Communication and connections with surrogates also emerged as crucial in easing anxiety, as Binyamin’s words demonstrate:There could definitely have been more moments [of distress] had we gone through the process with someone else, if [our surrogate] hadn’t shared and been so into it, sharing things of her own initiative. Because sometimes we didn’t know what to ask, since it was our first experience. So, she would share what she experienced and how she felt, and the tests that needed to be done.Relationships with surrogates made clear that closing the distance between fathers and surrogate—with trust, information, and communication—could be a tonic.The COVID-19 pandemic compounded the quest’s difficulty, complicating the logistics of attending the birth. Isaac’s narrative—which contrasted his experiences of having a baby before the pandemic and during the pandemic—illuminated this. Being abroad with his first child was “a period of grace”; with his second it was “180 degrees different”. Participants experienced severe anxiety that they would not be able to travel. Isaac found that even when travelling became possible, the anxiety he was feeling ensured there was something else to fret over:It was an experience of anxiety, great distress, and uncertainty, that lasted approximately 3 months until flying. From the moment we boarded the flight, it was a different type of anxiety. Because you say: ‘Okay, I am on an airplane, so I will be there during the delivery’. But you are scared because you are in a foreign place, it is not like the Israeli health system. I do not know anyone, what happens if I get infected? So, it is very stressful and also very lonely, it was only us…After babies arrived, the pandemic continued to impact participants. They had to isolate upon arrival to the United States and Israel, could only go out for walks, and could not see anyone face-to-face. Some were not allowed in the delivery room for the birth. Isaac viewed these stressors as cumulative:I will try to think if there was a certain moment. Meaning, the thing that frustrates so much during this period, is the fact that it does not end… meaning, it just keeps accompanying and you do not really see the end of it… the COVID-19 pandemic.When the quest finally ended with the arrival of healthy babies, participants all felt they had achieved something incredible, making the hardship worthwhile. Shlomo summed up this feeling, expressing his pride at having “contain[ed] and cope[d] with” something “insane”.All participants spoke about the routine ways a new baby impacts life: sleep deprivation, lack of free time, loss of time for previous hobbies, and lack of time for the couple’s romantic and sexual relationship. Isaac constructed the change as both practical (“a collection of endless things to do”), as well as having a “more essential and deeper aspect”. He described the affective shift involved in realising his new obligations to another:Parenting has something… a sort of load on your shoulders. And now you sink with this burden because it is a very, very great responsibility. It is something that is hard to conceptualise, but it is present in every layer of your life. The responsibility, the worry, add another sort of dimension, between depth and heaviness of something that I now have, that I am responsible for. This thing is very serious. So, it really, really changes your life.Several participants constructed the change as fundamental and even biological. For example, Samuel used a documentary about parental brain neural alteration to explain how the change felt for him.For certain fathers, the emergent self involved in fatherhood constituted a period of emotional upheaval. This was sometimes amplified by the travel involved in surrogacy. Avi, for example, found it difficult to adjust to the label of “father” in two different countries. In the United States, spending time alone with his partner and child, he experienced a “sense of perfect harmony” and believed “that it was very natural to me, that I was born to be a father”. Returning to Israel—where he had grown up believing gay men could only have children via a closeted heterosexual life—ruptured his fatherhood identity. He constructed returning home as rebuilding “everything from scratch”, which led to him feeling that “everything was falling apart”:Personally, when we came back home, the house felt estranged because I initially raised [my son] for the first month of his life in a foreign country, a different apartment. But this was arriving at a house I know, but in a different role, with another person, and it turned into a very foreign place. I felt as though… I don’t know how to describe it, that I was in an estranged alien place I must readjust to, become accustomed to my title as a father, and in retrospect, I realised that I was suffering from postpartum depression.Other men’s experiences of psychological distress centred on their relationship with their babies. Fathers talked about difficulties bonding and not feeling “as if we were flooded with joy and love for the kids from day one” (Shlomo). One link to distress that emerged was the day-to-day difficulty of parenthood, which participants saw as a potential barrier to feeling close to their children. This pattern played out in Abram’s narrative: he became “traumatised” from his new-born’s constant crying. He described feeling distressed “all the time”; even on the nights when it was not his turn to wake up for the baby, as he panicked about the next night. Abram’s narrative painted a picture of hopelessness, driven by his fear of the baby crying. He felt “incapable of recruiting my soul’s positive forces”, and reflected that even at the time of interview it “is still hard for me to hear him cry”.Certain depressive symptoms reported by participants were typical of postnatal distress regardless of gender and sexual orientation, such as not being able to get out of bed, hopelessness, and feeling disconnected from loved ones. Others were more male-typical symptoms, such as feeling numb or experiencing rage. Several men remembered moments where they felt like throwing their child as a symptom of extreme frustration and being “pushed to the edge” (Samuel). Samuel remembered a parenting workshop leader explaining how to deal with rage: “if the baby cries a lot… do not shake the baby, but lay them down and leave the room for a couple of minutes to take a deep breath”. At the time, Samuel was scornful of how obvious this advice was, but in retrospect acknowledged it was important.Other men explained how they suppressed their feelings to cope, throwing themselves into jobs and household tasks instead. Uri considered his “practical and mission-driven” approach as unhealthy in retrospect, noticing that suppressing feelings led to his distress emerging in ways he could not control. He spoke about “disproportionate reactions” to everyday frustrations, which alerted him to the fact that, underneath his calm exterior, he felt “grief about the life that [he] had and lost”.Only two participants—Avi and Abram—labelled their experience explicitly as postnatal depression. Both their narratives illuminated poor understanding of the condition in their social worlds. Abram’s phrasing that he “truly felt as if [he] had postpartum depression”, revealed some uncertainty in staking a claim to the condition. Similarly, when Avi tried to discuss the condition with his friends, he “could not name it”, knowing only it was “something unfamiliar”. This uncertainty added to the feeling of isolation:People were not so aware of what I experienced. I did not understand what was going on with me… [My partner] …did not comprehend what was going on with me, and neither did I. So, we experienced miscommunication, and it was not pleasant. I felt that no one understands what was going on with me. (Avi)Partners of men suffering with postnatal depression could struggle to recognise what was happening. They described frustration and an inability to communicate with or help their partners. Recognition of postnatal depression emerged as key to being able to support their partner and cope themselves, as Malachi—Abram’s partner—noted:I just realised that Abram was experiencing a mental difficulty beyond the existing physical one, and that first—I need to be non-judgmental towards him, because this is not something he chose, and it is out of his control. I just need to comprehend, contain him, step in his shoes, with utmost possible empathy, and see how I may help.Various avenues were reported as important for recovery from postnatal depression: therapy, self-care, hobbies, sourcing childcare so participants could go out, and communication and connection with partners, friends, and family. Additionally, fathers found positive time spent with their baby helpful. Abram’s account of his journey towards recovery elucidates the connection that formed alongside postpartum depression easing.Some people love their child immediately after he is born. For some people, it takes a bit more time, and sometimes it might take a while. There is no need for self-flagellation, because you know, it was strange for me, I did not have any exceptional love when I first saw him, or fireworks. The opposite—I felt irritated, helpless… and time goes by, day by day… that connection formed.All participants’ narratives, regardless of the level of distress they experienced, emphasised the importance of weaving a thread from the old self to the new self as a father. Many did this by creating time for activities that fulfilled them before they had children, including exercise, yoga, meditation, music, and eating out. Overall, participants felt their lives changed completely with the birth of their child, but that as time went on, their routine settled and they could connect to previous activities and identities, which supported well-being.All participants constructed narratives of accomplishment and pride, typified by a conversation Pasach remembered with an employer’s child:My former boss… introduced me to her son and said: ‘This is Pasach, he has a husband and child by surrogacy. Do you know what surrogacy is?’ He is a child in fourth grade! I had the chills. And the kid said: ‘O.K.’ and moved on. It did not constitute any drama or anything. In a larger circle, there could be a gay child in his class, someone who freely came out of the closet, someone childfree, someone in a relationship. When I grew up, a gay person was compared to someone who will die alone.Pasach’s embodied affective reaction mirrors his emotional response to the mother’s frank, nonchalant explanation, and the child’s easy acceptance of his situation. His assertion that future queer people will be able to come out “freely” illustrates his pride in challenging homophobia and contributing to normalising gay-parent families.Overall, the fathers received positive reactions to their family formation, rarely encountering homophobia, despite anticipating it, as Isaac summarised:The attitude we have been experiencing is amazing… I am even positively surprised. We receive a lot of support everywhere we arrive. There is great support and great empathy. I never encountered negative reactions anywhere. There is something about them being children, that neutralises homophobic people. Meaning, once children are involved, everyone becomes very positive.Almost all participants told stories of family members coming to the airport or their home, excited to meet the child(ren). In situations of tension, the men more often had stories of movement towards resolution than they did of lasting rifts. However, participants still encountered microaggressions and found bureaucratic systems exclusionary. A common microaggression was unwanted parenting advice, with participants divided on how frustrating they found this, from highly offensive to a minor annoyance. Levi reported developing an ability to “screen” interfering comments, to stay “focused on…what you think is right”. Avi described being asked often who the “biological parent” is as “very difficult” and “so inappropriate”. He responded by making people feel uncomfortable, to alert them to the disrespect their question implied by construing parental legitimacy through heterosexual biology. Several fathers encountered the belief that a child needs a mother from gay friends  or parents, painting a picture of broadly supportive families who made occasional unhelpful, heteronormative comments. Participants also told stories of their family formation changing their parents’ minds: Samuel’s parents “now think differently”, seeing that a child can be raised excellently by two men.When it came to bureaucracy, the picture was also nuanced. Some had a positive experience, such as Uri, who was aided by his background as a lawyer:The Ministry of Interior—the person was so politically correct while speaking with us, to the point that I was wondering whether he went through training. He wanted to ask who [our son] belongs to, but then apologised and amended: ‘I did not mean that. I meant that he belongs to both of you, but I referred to the genetic aspect…’More commonly, fathers found the bureaucratic process difficult. The extreme length and “draconian” rules “generated… rejection feelings [and] unbelonging” for Samuel. Shlomo expanded:There is no justification that upon my return, only one child is registered as mine, and the other must be adopted by me. This is unfounded, it is completely unreasonable to have only one child recognised in the official documentation, and the other child misrecognised by the Ministry of Interior, you cannot report this child to the tax authorities, it makes no sense.The narratives constructed systems as clunky and counter-intuitive for gay fathers, as they were built for heterosexual, biological conception. Some participants noticed the same pattern at work:Parental leave: I informed someone at human resources about the pregnancy and told her, ‘Give me a hug’ or something, and the first thing she said to me was, ‘I do not think you are eligible for parental leave…’ Although they pay full regular salaries to women on parental leave, in my situation she said no. (Noam)Participants indicated a range of support they would like to see to make gay parenthood easier. Financial support was a priority, as currently only the most affluent gay couples could have children. Channels of information-sharing were suggested: psychological support groups; online workshops; and a specific guidebook for the gay community on surrogacy and parenting.Participants felt services should predominantly be for all family types, with several participants wanting to be treated exactly the same as heterosexual-parent families. Others found services designed specifically for gay-parent families offered more tailored advice and a sense of belonging. Noam found gay parenting workshops helpful because of their specificity, as outlined in the first quote below. The value in creating safe spaces for gay parents to discuss things uniquely affecting their family is discussed by Uri in the second quote about an online environment:[It covered] specific topics of men’s parenting. How to define the nuclear family with the child, what are the boundaries. Whether my mother or sister have the authority to tell [my child] things… Because she is a mother or woman?It is an extremely supportive community, I must say. Starting with surrogacy, and then parenthood. There are Facebook groups, and everyone is very happy to help, want to, and every answer receives 20 replies, private messages, etc.The need for safe environments can be gleaned in the participants’ stories of negative experiences. Isaac attended parent-and-baby events and was asked if he was sent by his wife. It made him feel “very, very much that I do not belong in the situation… I felt a bit lonely there”. It left him with a desire for a group with parents “just like me”, in order to feel “comfortable”. Similarly, Samuel’s partner tried to join a mothers’ Facebook group, but was not accepted.Finally, several participants mentioned they had set up routes to support themselves. Many spoke about the importance of passing on information, through speaking with friends, posting on Facebook groups, meeting strangers on Zoom to discuss the surrogacy process, or setting up physical spaces for mutual support . Where the state could not cater for their needs, these fathers were proactive in creating their own support networks.This study explored Israeli gay men’s transition to fatherhood, focusing on difficulties during the surrogacy process and first years of parenthood. In language that aligns with valued forms of masculinity, fathers embarked upon a quest for a child, requiring strong intentionality, that had the real potential for men to prevail and leave a legacy. For some it was difficult but not unmanageable, where others recounted it as a period that negatively affected their psychological well-being and sense of self. Once babies were born, some parents felt immediate reward and happiness, while others struggled mentally. Ultimately, all fathers achieved fulfilment and a sense of pride, contributing to a legacy of gay fatherhood beyond their own family unit.valency, whereby people are at the centre of a kind of asterisk of connections. Some stems are firmly connected to people, while others are more loosely attached; and yet others are vacant, available and seeking to bond. The fathers in this study can be viewed as having a particularly dynamic asterisk of connections, in particular between what Beier [Throughout, fathers’ relationships (or lack thereof)—with their babies, partners, surrogate, family, bureaucracy and information—could work to assuage or intensify their affective dramas and difficulties. One participant’s conception of many “people” bringing his child into existence captures this journey as the inherently relational experience it is. Elias  viewed tat Beier  deemed tThe initial absent bond between father and child, and the potential for future connection and disconnection, was a focus of all narratives. The emergent bond variably induced hope and fear, closeness and alienation, and comfort and longing. Fathers who had not experienced the trauma of failed surrogacy attempts described more comfort in allowing this bond to form during pregnancy, whilst still lamenting the physical distance involved. This echoes Ziv and Freund-Eschar’s  propositConnection with the child was also crucial to recovery from distress, both from prenatal anxiety and postnatal depression. With prenatal anxiety, feeling able to prepare for the baby’s arrival  combatted the lack of connection and control that distance produced. For postnatal depression, finding ways to overcome isolation and relate to the baby was often cited as key to mending. Growing research positions recovery as a social process , wherebyThe men constructed their connection to their child as one where genetics held varying levels of importance. For Nebeling Petersen , this isThroughout the narratives, partners were constructed as primary sources of support, and in masculine terms, teammates on the quest, and in relational terms, integral parts of self. This was important in responding to the pressures of surrogacy, especially where the difficulties of postnatal depression presented . Here, pThe men’s bond with their surrogate—the final member of the ‘surrogacy triad’ —ranged iLooking beyond the surrogacy triad, participants also existed within a social web of family, gay community and institutions, related to the Israeli Jewish national habitus , which iFrom a complementary angle, the existential rejection anxieties that are prevalent in Israeli society may help to underpin homophobia that is perpetuated through systems. In particular, situations of risk and identity threat , social and psychological processes of scapegoating, that is, the exclusion and rejection of marginalised groups , which sDespite this study’s important focus on an under-researched population, a number of limitations should be considered. First, all participants were on high salaries, with all but two completing further education. Many could afford weekly therapy and regular childcare. Given that poverty and poor mental health are risk factors for postnatal depression and that there is an established link between poverty and poor mental health , it is rit to speak across realms, sites, and contexts”  [Thirdly, related to Israel’s military service requirement, not to mention the financial requirements of parenthood, it is likely that many Israelis start their families at a later age as compared to other young adults in other countries. This is manifested in the relatively older ages (35–49 years) of the fathers in our sample. Fourthly, all participants were Jewish and the vast majority defined themselves as secular. The similarity of the men could have shaped similiar beliefs, experiences, reactions from family, friends, and/or community, thus limiting generalisability of the findings to non-Jewish or secular fathers. Nevertheless, it is the development of concepts, specifically relationality in this study, that means qualitative research can be used to elucidate and make clear what “the data mean at a broader level, thus allowing riginal) . FifthlyFinally, there were relatively few very “dark” instances recorded in these contemporary narratives. However, difficulties we uncovered were profound and included depression, “unequal power and financial dynamics involved in surrogacy”, and encounters with stigma, homophobia and some resistances to gay parenting. While we might be accused of “soft-pedaling” the difficulties of gay surrogacy, we were at pains to avoid overplaying the idea that gay fathers will necessarily encounter trying levels of homophobia, stigma, and so on. In line with contemporary qualitative research showing a collapse in the power of homophobia to shape men’s lives , the livThese limitations notwithstanding, the present study provides important insights into the lived experiences of gay fathers and their experiences of surrogacy and parenthood. Their voices have rarely before contributed to the discourse on perinatal mental health, making this study particularly important. The narrative themes identified highlight how the surrogacy process produces anxiety and how the transition to parenthood produces both happiness and mental anguish. Surrogacy was easier with increased connection between the surrogacy triad. Similarly, parenthood struggles were alleviated by connection with partners, babies, families, and one’s former sense of self, as well as by regular psychological support and childcare. Paternal postnatal depression emerged as a label participants struggled to claim, though the eventual ability to claim this label contributed to recovery for some fathers. In particular, findings emphasised the inadequacy of bureaucratic and institutional systems to assist and include same-sex families, and the subsequent harmfulness to gay parents needs to be considered. The accounts described in this study indicate the need for widespread adoption of inclusive language across institutions, increased support throughout the surrogacy process, increased publicity of perinatal distress in men, and improvements to the diagnostic process of perinatal distress in men .


With growing attention on the importance of values, beliefs and worldviews in shaping environmental outcomes, there remains little research on religion and sustainability transformations. We explored the impact of the Archbishop of Canterbury’s environmentally themed Lent Book 2020 “Saying Yes to Life” on environmental values, attitudes and behaviours of lay Christians. An online survey administered before and after reading the book assessed environmental values, New Ecological Paradigm (NEP), connectedness to nature and environmental behaviours, and collected open responses to questions about participants’ perceptions. Follow-up focus groups were also held to understand experiences of cognitive and behavioural change. Analysis of paired data revealed significant increases in environmental behavioural intentions after completing the book, especially for energy use, food and recycling. Some evidence for strengthening of NEP scores and connectedness to nature was also found. Open text responses corroborated with quantitative measures of behaviour change. Additionally, the majority of participants reported some form of reinforcement, confirmation, or further development or change in their beliefs and attitudes. This included a reduction in anthropocentric beliefs and greater appreciation of and obligation towards the natural world. Focus group discussions revealed diverse participant experiences, including having pre-existing theological beliefs affirmed, responding with new practical actions, connecting with spiritual experiences, and discovering systemic origins of unsustainability. Findings suggest potential for environmental interventions within religious contexts to shape mindsets, integrate theological views with environmental concerns, activate latent beliefs, and initiate and sustain pro-environmental behaviour. More intentional engagement with religion may facilitate transformative change for sustainability internally and externally, and across individual, organisational and societal domains.The online version contains supplementary material available at 10.1007/s11625-022-01197-w. Sustainability scholarship has begun to highlight the deeply ingrained values, beliefs and worldviews that underlie the twin crises of biodiversity loss and global warming. These span scales from societal economic paradigms that emphasise material consumption and productivity, to individual anthropocentric beliefs and apathetic or exploitative attitudes towards nature. This has led some scholars to identify systems of customs, values and social norms as lying at the root of planetary breakdown   associated with external behaviour change? These questions were pursued via a mixed method programme of research. Results are used to propose a model of how environmentally relevant beliefs and cognitions may change in religious contexts. The article concludes with a discussion of how religious communities can be effectively engaged for action on sustainability.https://spckpublishing.co.uk/saying-yes-to-life). The text was structured around the creation story in the Christian Bible, and covered environmental challenges such as water scarcity, air pollution, land degradation, biodiversity loss, and energy use. Additionally, theological themes were discussed such as dispensationalist beliefs , dualism between matter and spirit, and ethics of stewardship. Stories of the experiences of communities in the Global South who are grappling with impacts from climate change and environmental degradation were also included. Each chapter ended with discussion points and a contribution for spiritual reflection (e.g. a prayer). As such, the book was designed to stimulate thought and reflection, and elicit a practical response towards sustainable behaviour in the reader.The intervention for this study was the book titled “Saying Yes to Life” (SYTL), authored by Dr Ruth Valerio, and published as the Archbishop of Canterbury’s Lent book 2020 . One question asked how people engaged with the book, e.g. reading alone, discussing with others, or aiding personal prayer. Attitudes towards the environment were measured using the revised New Ecological Paradigm scale (NEP-R)  conceptions of God and nature, (ii) people’s thoughts on Church, missionSurveys were administered online using Qualtrics. They were advertised using social media, namely Twitter and Facebook—the latter via a group set up by the book’s author as an online forum for discussion and interaction. A pre-test, post-test design was employed whereby participants were asked to respond both before reading the book (T1), and after completing it (T2). The survey was modified accordingly so that the first iteration included a subset of the full complement of questions for key baseline data to be collected. The first baseline (T1) survey was open between 6 March and 2 April 2020, and the follow-up (T2) survey between 21 April and 5 June 2020. The total number of responses was 245: 81 before and after (pre- and post-test), 112 before only (pre-test), and 52 after only (post-test). In the UK, the survey coincided with the first wave of the COVID-19 pandemic, with government restrictions on social activity coming into force after the baseline survey had been released. Consequently, behavioural intentions were included in the phrasing of the follow-up survey question on self-reported behaviour because government rules would have impacted participants’ routines and lifestyles. While this was not ideal, research has shown that behavioural intentions moderately predict actual behaviours . The cohort was well educated, with 76% holding an undergraduate degree or higher degree. The majority of respondents identified as Anglican (59%), with the next largest groups Baptist and “other” (12% each), followed by “no denominational affiliation” (7%). The high representation of Anglican/Church of England respondents is likely due to the text primarily being promoted within Church of England settings. Nevertheless, as a religious institution, the Church of England is known to encompass diverse theological and socio-political perspectives. A range of political persuasions was recorded with a bias towards liberal/progressive views. 60% of participants self-identified as “very liberal” or “somewhat liberal”, 23% as “centre”, and 18% as “somewhat conservative” or “very conservative”. Most participants recorded themselves as middle income, with 59% rating themselves as 4, 5, or 6 on the 9-point scale.To further explore participants’ experiences of engaging with the text and understand the process of observed change, participants were given the opportunity to partake in a focus group discussion. Consenting survey respondents were invited by email, with 16 participants accepting. 15 respondents were available to participate and were organised into three groups based on availability. All groups were facilitated by the same researcher for consistency. Due to the difficulty of arranging focus groups within COVID-19 social distancing regulations, focus groups were held online via Microsoft Teams. Participants were grouped on availability as opposed to other factors , or the use of pre-existing networks. Discussions followed a semi-structured format, following protocols set out by Longhurst . Key queβ = 0.80, α = 0.05) to detect a small population effect size (Cohen’s dz = 0.32). One-sided paired t tests (H1: T2 > T1) were used to test for the effect of the intervention (reading the text) on a number of dependent variables: environmental behaviours and behavioural intentions, New Ecological Paradigm, values, and Nature Relatedness. Additionally, due to the small sample size, Bayes factors were estimated to determine the quality of evidence underlying any observed effects  were analysed. Sensitivity analysis using G*Power , Nature Relatedness (NR), and values are reported in Table To understand associations between observed behavioural differences and socio-demographics , political persuasion, religiosity, biospheric values and Nature Relatedness, Pearson correlation tests were performed .Approximately 80% of respondents felt that SYTL had either reinforced or changed the way they intended to live. While it was not possible to determine the degree to which behavioural intentions were translated to lifestyle changes due to the study coinciding with COVID-19 lockdowns, qualitative responses shed light on behavioural priorities and processes of change identified by participants. Individual behaviour changes mirrored many of those covered in the closed question section of the survey, such as making more sustainable consumer choices regarding manufactured products , energy (“I was prompted to switch to a renewable electricity supply after reading an early chapter”), and food . Interestingly, behaviours also extended to personal religious practices, with one respondent stating “I will thank God for my water. I will listen more intently to subjects on environmental issues, being now prepared to add my voice and to pray”. While not all participants reported behaviour change, there was evidence that the text may have helped to overcome cognitive barriers: “It really made me think about actually acting on the things I've been wanting to change in my life for a long time but never had the motivation to do”. Collective action was also evident. Examples spanned encouraging pro-environmental initiatives within their church community  to participation in local action groups .In addition to the text initiating new behaviours, 25% of responses to this question mentioned that reading and engaging with the text reinforced or sustained existing pro-environmental efforts. For example, one respondent claimed that “It supported/accelerated what I'm already trying to do”, while another said “I was fairly engaged already but it motivated me to keep going and continue pushing for changes where I can influence things”. Elsewhere, one respondent alluded to a sense of strengthened hope amidst collective inaction: “By reading some of the examples, it was easy to see how small actions that individuals took turned into something significant within their communities. I often dismiss the thought that this is possible, so I found this challenging”. Finally, some respondents commented on the role of the text in increasing awareness and concern around inequality and injustice worldwide and links with environmental issues. For example, “I will be more aware of the impacts of my life choices on the environment and world at a wider scale.”Two questions enquired into impacts of the text on respondents’ attitudes and beliefs related to theology. They were (i) “Did ‘Saying Yes to Life’ change the way you think about God and creation? If so, how?”, and (ii) “Did ‘Saying Yes to Life’ change the way you think about Church, mission, or how Christians should live?”. A spread of responses was recorded to the first question regarding God and creation. Over 25% of responses indicated that the text did not change their thinking, with this being a combination of a few individuals who disagreed with the book’s messages and a larger number who already agreed. For example, one respondent reported “No [change], perhaps if it had been a more balanced book”, while another said “I already held the view that God did not give humans authority to exploit the environment”. Elsewhere there were suggestions that the book’s environmental messages represented a progressive political agenda, which was being uncritically adopted by the Church: “In places, it felt like this was agenda theology, with interpretation to fit an environmental message”. In contrast, 22% of respondents indicated some form of reinforcement, confirmation or further development of existing thinking, while 37% reported a change in thinking in some way. Many responses indicated elements of both, while responses from a small subset did not relate directly to the question posed. Comments that indicated a more profound or marked change related to decreased anthropocentrism and mastery-over-nature orientation (pro-dominion attitudes) . Others showed a decreased tendency toward dualistic perception of the physical world (nature/creation) as separate from and/or inferior to the spiritual world . Comments indicating reinforcement of beliefs spanned (i) increased awareness of God’s relationship to and concern for creation (“…so much more aware of how God and creation are intimately intertwined”), (ii) increased sense of obligation to care for creation , (iii) increased appreciation for creation , (iv) increased sense of participants’ own nature connectedness and/or interdependence (“I think it just enhanced my feeling that we are part of rather than over and above creation”), and (v) greater integration of beliefs about creation with soteriological  and eschatological (end of world) beliefs .Responses to the question “Did ‘Saying Yes to Life’ change the way you think about Church, mission, or how Christians should live?” revealed insights into the potential for collective action on the part of faith communities. As with the previous question, a number of responses emphasised a reinforcement of existing beliefs about the Church’s actions, e.g. “I don't think it changed the way I think about those things, but I think it has helped to re-inspire me to inspire my congregations to think about those things”. A second theme that emerged related to the inadequacy of the Church’s response to climate change and environmental crises. This was expressed in responses such as “the Church has failed badly to take appropriate action to advocate for the importance of climate care”, with some individuals suggesting that an inadequate response was impacting the Church’s modern-day relevance . A third theme emphasised the importance of integration of stewardship beliefs in church activities. For example, “I suppose I thought of it [environmental action] as slightly peripheral to the Church's main mission- the book emphasised how integral it actually is”. Finally, many responses mentioned an increase in perceived collective efficacy as part of wider Christian community. This included a sense that together Christians have a capacity to achieve substantial pro-environmental change  as a function of being part of a likeminded, global faith community, and that being part of such a community helped respondents to feel less alone in their environmental concerns . The former point was articulated by one respondent as follows: “If the churches of the world were to mobilise towards effective environmental initiatives, our planetary problems could be solved”, with another expressing a similar sentiment: “The church could change the planet if it woke up to this reality and lead a global change”. The latter was exemplified by one participant as “How behind 'my' church is! Gosh, it is hard work sometimes so good to find I'm (we're) not alone”.The focus group discussions revealed experiences of participants in engaging with SYTL, processes of change in beliefs and behaviours, and relationships between internal and external systemic dimensions of sustainability. First, differences were evident in how intellectually accessible participants found the text to be. Many in Focus Group 1 were highly educated and familiar with academic writing and biblical theology, and demonstrated deep engagement with the book. In contrast, those less academically inclined (particularly Focus Group 2) found the text to be somewhat inaccessible. One participant, for example, explained that some of their Bible study members “found it very difficult. They said it was like reading a university document and couldn't cope with it”. Yet, for those in Focus Group 2, it was the inclusion of real-world stories, examples, and opportunities for discussion with others that enabled them to engage with the themes and respond. One participant, for example, explained “I also really loved the way that she [Valerio] drew on lots of other cultures and religious backgrounds as well… I think I find it a lot more personal, a lot more moving when you hear someone’s story”. Second, many focus group participants shared that it was engagement with associated spiritual practices that allowed the text’s environmental messages to have impact in their lives. The most prominent across all focus groups was appreciation of the transmutation of intellectual content into prayer. One participant explained that “Finishing with what we can pray about is good. [Prayer can] lead us into what we can actually do, and that's also an important feature that comes out of the book”. In addition to individual prayer, communal and congregational prayer was also mentioned, with one participant encouraged to integrate the environment into their regular Sunday morning service prayers.Discussions about the processes through which SYTL influenced beliefs and behaviours revealed different responses, in accordance with results identified from the survey. The majority of participants, particularly in Focus Group 1 and Focus Group 3 experienced an affirmation of existing personal beliefs, rather than a change per se. Yet others did report a shift in beliefs. One participant recounted an experience of reflecting on their lifestyle: “I probably started reading it thinking that I was reasonably aware and responsible in terms of the way I act towards the planet, but then realised that I probably wasn't, not as much as I could be or should be”. Another expressed a deeper shift in beliefs: “it [the book] made me think very differently about how I want to look after things. It’s part of God and so of course I want to look after it”. In discussions about behaviour change, participants commonly connected their personal practices with theological reasoning, even though only 6 of the 15 participants reported making intentional alterations to their lifestyle. These individuals often expressed a greater sense of resolve to continue to try to live environmentally considerate lives. Interestingly, many participants referred to the use of stories and examples from around the world as helping to illustrate theological points. The principle of loving one’s neighbour was a particular focus, with one participant sharing that “being a Christian is nothing to do with loving your neighbour unless you look at the neighbour as part of the whole of God's creation”.Finally, all focus groups commented on the need for change to go beyond the personal and spiritual domains to also encompass economic, political and social systems. One participant commented on how the text alerted him to ethical dimensions of global climate injustices: “I think that she's [Valerio] alerted me anew to the ethical dimensions of climate change and how particularly disadvantaged parts of the world are suffering a kind of double whammy: not only had they not had the benefits of industrialisation, but they’re suffering the consequences of it”. In accordance with this global perspective, participants highlighted the potential for a global faith community – churches, Christian charities and institutions, and other faith-based organisations – to influence environmental change on a wider economic, political and social scale, particularly when they adopt the beliefs, values, attitudes and behaviours described in the text.These results suggest that there may be multiple pathways for effective engagement (not just cognitive) when designing interventions. The first pathway indicated primarily from Focus Groups 1 and 3 was a process of reading and personal reflection, which allowed a greater understanding of the links between theology, prayer and the environment, alongside new consideration of the role that faith can have in influencing economic, political and social systems. The second pathway was through discussion with others (mostly Focus Group 2). These participants were less “theologically-minded or deep-thinking” and were less environmentally aware before reading SYTL. Desired changes in attitudes and behaviours among these participants came through a process of discussing ideas, opinions and practices with others in the group.This study demonstrated that environmental messages couched explicitly within a religious tradition can bring about both external and internal change among people of faith. Externally, enhanced pro-environmental behavioural intentions were reported, with some behaviours shown to respond more readily to the intervention (e.g. recycling) than others (e.g. dietary choices). Additionally, qualitative evidence showed that these behavioural changes were recognised by participants as being expressions of internally held (religious) beliefs, values and worldviews and behaviour. This suggests that religious contexts may be especially important for activating latent beliefs and unleashing values . Links between internal phenomena such as values, goals, mindsets and worldviews, and external structural or behavioural change have been recognised within conceptual frameworks for understanding sustainability transitions/transformation. Frameworks include leverage points  and strong existing beliefs. They responded positively to logic and argument to integrate these beliefs and activate behaviour change or reinforcement. For others, it was a less intellectual exercise, with profound attitudinal and behavioural changes facilitated through interaction and discussion with others, as well as hearing stories. Both cases align with a social practice understanding of environmental behaviour change rather than simple, linear information deficit models . Audience segmentation research from secular environmental engagement initiatives may be just as relevant in faith contexts. Examples of this include the Britain Talks Climate project by Climate Outreach  has been embraced as offering “an ethical order of trusteeship (Amana أمانة)” towards the climate Below is the link to the electronic supplementary material.


In the short 10 years following the introduction of non-invasive prenatal testing (NIPT), it has been adapted in many countries around the world as a standard screening test. In this review, this development was analyzed with a special focus on Germany. As a result, it can be stated that all known advantages of NIPT apart from “compensating for having no access to centers offering invasive diagnostics” are valid for Germany. In addition, following a review of the international literature, all documented issues with NIPT are also observed in Germany. However, the German Gene Diagnostics Act (GenDG) addresses a number of these issues, for example, the regulations by GenDG hamper induced abortions, based exclusively on an abnormal NIPT result. At the same time, GenDG has created new problems, as a possible collusion between the “right not to know with regard to parts of the examination result” may occur, or that the sex of the fetus must not be reported to the pregnant woman before the 12th week of gestation. Main conclusions drawn are that appropriate training and the continuing education of the physicians providing NIPT-related counseling are needed, as well as the provision of balanced and comprehensive information for the pregnant woman or the couple that is imperative. During the last five decades, a dream of humankind has come true; what was previously purely science fiction is now reality: owing to the technical progress over this period it became routine and commonplace that pregnant women could obtain sound “prenatal information”, regarding the health of their unborn child . At firsInvasive prenatal genetic diagnostics depends on fetal or placental tissues, which can only be acquired by approaching the unborn with a needle to gain this material for further in vitro studies. Conversely, non-invasive tests do not disturb the fetal or placental tissues at all; they depend on sonography, on proteins or free placental DNA accessible from the maternal blood. While all, so-called “non-invasive prenatal diagnostic approaches,” are in reality screening tests, it is only invasive tests, based on fetal tissue that can provide clear answers on whether the unborn has a specific genetic condition or not ,2,3. All invasive prenatal tests involve a certain risk for the fetus. In the 1980s to 1990s, chorionic villi sampling (CVS) from placenta, amniocentesis (AC) or umbilical cord blood (UCB) acquisition had an abortion risk between >1% and 3% , which dThe aforementioned initially relatively high-risk figures of invasive approaches ,5 stimulThe newest non-invasive prenatal diagnostic test approach is the so-called non-invasive prenatal testing (NIPT), also referred to as non-invasive prenatal screening (NIPS) or non-invasive prenatal diagnostics (NIPD). However, the wording NIPD should not be used, as NIPT is clearly a screening test ,2,3. As NIPT is based on free placental DNA, intentionally and misleadingly referred to as ‘cell free fetal DNA = cffDNA’ in NIPT-related literature, from the very beginning . This cfTechnically, NIPT is predominantly based on whole genomic sequencing (WGS), either shotgun massively parallel sequencing (s-MPS), targeting massively parallel sequencing (t-MPS) or single nucleotide polymorphism (SNP) based WGS. In MPS based approaches, the maternal and placental DNA cannot be distinguished; aneuploidies are recognized as changes in copy numbers for the studied chromosomal regions. Only the SNP-based approaches allow the separation of cffDNA from the maternal, serum derived DNA, and also allow for the detection of triploidy . In addiA major problem of the publications reporting on NIPT, is that these technical differences between platforms are not discussed extensively ,18. NIPTApart from these problems, NIPT-studies can include testing for(a)trisomy 13, 18 and 21, only;(b)aforementioned trisomies and for changes in the copy numbers of sex chromosomes;(c)all mentioned in b) plus only DiGeorge syndrome ;(d)all mentioned in b) plus other selected microdeletion or microduplication syndromes ;(e)all mentioned in (b), (c) or (d) plus all other copy number changes of all other autosomes;(f)whole genome, for any kind of copy number alteration.(g)Finally, some NIPT providers have started to also offer screening for point mutations of specific genes, such as the Rhesus factor and blood groups.Overall, there are dozens of variants of NIPT available, but they are not really distinguished in the literature ,21. ThisI.can be applied earlier than other tests during pregnancy;II.has the potential to reach populations with no access to centers offering invasive diagnostics ;III.can exclude and detect a trisomy 21 with the highest probability of all non-invasive approaches—the positive predictive value (PPV) in cases of a NIPT suggesting trisomy 21 is >99%;IV.can bring a psychological relief to an anxious pregnant woman in the case of a normal NIPT result; andV.can lead to an early pregnancy termination in cases of an early detection of an adverse genetic condition via NIPT ,14,18.The idea to perform NIPT, based on WGS is indisputably brilliant. The concept to study cells from the placenta without bothering or endangering the developing individual is laudable. Screening the literature for bolstering-points for NIPT include conclusions that the platform:Interestingly, these are the only five points to identify in the literature as advantages of NIPT. Moreover, as outlined in the next chapter, the interpretations of NIPT results are either not really understood in detail and/or at the least not well communicated ,18. FurtSome of the problems of NIPT have already been reviewed in this paper and were recently summarized by our group ,18; thus(a)The term NIPT suggests to the uninformed public that the platform studies cell free fetal DNA (cffDNA); however, all cell free DNA in the pregnant individual’s blood  derives from the placenta (and not the fetus); thus, in 1–2% of the cases studied by NIPT, a placenta confined mosaic condition must be expected. They constitute a part of the false positive and negative NIPT results ,18.(b)Each abnormal NIPT result has to be checked by an invasive prenatal test, optimally an AC, as indicated by each commercial NIPT provider in the package leaflet . However(c)A normal NIPT result can maximally exclude (to a certain extent) genetic conditions, which are covered by the NIPT platform used. A normal NIPT is never synonymous with the statement: ‘a healthy child will be born’ . As rece(d)90% of aneuploid fetuses detected in NIPT would be aborted naturally and do not survive to birth . Thus, 9(e)5–10% of NIPTs provide no result at the first attempt—this is most often due to the low fraction of cell-free placenta derived DNA. The greater the obesity severity in pregnant women, the more likely a ‘no-call’ result will occur ,18. The (f)False positive NIPT results can be due to confined placental mosaicism, a vanishing twin, a maternal sex chromosome mosaic, or a maternal undetected tumor ,14,18.(g)There can be unexpected findings, even for NIPTs evaluating only trisomies 13, 18 and 21. Partial trisomies or even tetrasomies, e.g., supernumerary isochromsome 18p syndrome can be picked up: several publications report this surprise detection in the literature e.g., ,27,28).,28.27,28(h)As aforementioned, the PPV for trisomy 21 is >99% in all available NIPTs; however, it is neither known nor studied why screening for trisomies 13 and 18, is less reliable. PPVs for all other tested copy number changes  remain substantially lower between 5 and 60—which means 40 to 95% of women receiving an abnormal NIPT result have indeed received a false positive result [(i)In a worldwide perspective, there are hints in the literature that in ~20% of cases, there is a strong tendency to trust an abnormal NIPT result so much that a second test is skipped and termination of the pregnancy is simply based on a single screening test ,29. SuchAs recently summarized, all of these nine points must be considered and should be covered in pre-test counselling for everyone considering a NIPT. Therefore medical specialists working with and offering NIPT need to be aware of these peculiarities ,18,31. I(1) “The high specificity, efficiency and safety (non-invasiveness) of NIPT can effectively improve the detection rate of common chromosomal aneuploidy, thereby reducing the occurrence of birth defects” [; or (2) “NIPT has revolutionized the approach to prenatal diagnosis and, to date, it is the most superior screening method for the common autosomal aneuploidies”. [defects” ; or (2) oidies”. NIPT was introduced in Germany shortly after the first commercial provider brought it to the market in 2012. The first company offering NIPT in Germany even managed to spread the news advertising this new test in the major evening news program on television (the Tagesschau), extensively praising the test as the major medical breakthrough of the century, following its introduction by the end of 2012. Lobbying continued, and while FTS is still not reimbursed by insurance companies in Germany, from 2022 onwards, NIPT is covered under certain conditions:Although the NIPT is part of the statutory health insurance benefits, it is not one of the generally recommended preventive examinations for all pregnant women. This has been repeatedly emphasized by the Federal Joint Committee, which decides on health insurance benefits. The fund pays for the test if there are indications of a trisomy, such as a conspicuous ultrasound, or if “a woman, together with her doctor, comes to the conclusion that the test is necessary in her personal situation”, according to the information for insured persons. Maternal age alone - often a risk factor for a trisomy—is not yet a reason for a NIPT”.“(translated from )In an official statement, the German health insurance companies declared:The trisomy test NIPT has been included in the statutory benefits catalog of health insurance companies. Only specialists in gynecology and obstetrics with the qualification “specialized genetic counseling, as well as specialists in human genetics” are allowed to perform the NIPT test after intensive counseling. The NIPT is not part of the generally recommended screening examinations during pregnancy. It is only paid for by health insurance companies if the doctor and patient decide together, after intensive counseling, that the trisomy test makes sense in the personal situation of the pregnant woman. The trisomy test can be useful, especially if there are indications of trisomies through the normal screening examinations or as part of the FTS”.“(translated from )With regard to the advantages I to V of NIPT, mentioned in chapter 3, all of them hold true for Germany, apart from “advantage II”. Germany not only has an excellent network of centers offering invasive diagnostics, it also requires that all citizens residing in Germany take out a health insurance. Correspondingly, each pregnant woman can access the free preventive medical checkups, as regulated in the “Maternity Guidelines” . Thus, NTaking into consideration the nine critical points of NIPT from chapter 4 (a to i), each is addressed separately below:for(a) It is not clear to the German public that cffDNA tested in NIPT derives from the placenta ; even th(b) German women are not always aware that a positive NIPT must be tested invasively ,25, and(c) a normal NIPT result, is often inappropriately used synonymously with the statement ‘a healthy child will be born’ in Germany, as in other parts of the world ,25.p < 0.0001) in induced abortions from 13.69% down to 10.62% of all pregnancies between 2012 to 2021. This decline was only observable in terminations before the 12th w.o.g. from 13.34% down to 10.28% ((d) There is no data for Germany on the number of positive NIPTs, however, the use of NIPT has not led to increases in induced abortions within the last 10 years. There was even a statistically significant decline (Chi squared test: o 10.28% . The rea(e) ‘No-call’ results are also a problem in Germany, but no detailed data is available.(f) False positive NIPT results experienced in Germany have been described in a newspaper article in 2020 , and neg(g) unexpected findings for NIPTs evaluating only trisomies 13, 18 and 21 were also observed in the lab of the author.(h) The fact that women with false positive NIPT results feel that not enough recognition to this issue is available to the public, cannot be understated; views that have also been highlighted in the previously mentioned interviews completed by a journalist  that cov(i) According to Thus, eight of the nine critical points for NIPT from chapter 4 are also valid in Germany, apart from point (i), as discussed. In addition, the following peculiarities must be considered when NIPT is carried out by German MDs.The GenDG has been interpreted by the GEKO. Surprisingly, the GEKO classified NIPT not as a “prenatal risk screening” but in opposition to all of the corresponding literature data (see above), as a “prenatal genetic analysis for determining the genetic properties” . This isper se only be financed by the insurance companies in Germany if trisomies 13, 18 or 21 are tested exclusively. Other chromosomal imbalances, such as microdeletion and microduplication syndromes are not recommended for evaluation by NIPT in Germany, as they largely result in more invasive procedures in normal fetuses [According to GenDG, it is valid that “if the sex of an embryo or fetus is determined during a prenatal examination, the pregnant woman may be informed of this after the 12th w.o.g. with her consent” (translated from ). Thus,  fetuses .Therefore, if a pregnant woman wishes to continue a pregnancy for a child with Down syndrome, because she considers this finding reasonable, she may not realize this” (translated from [right not to know with regard to parts of the examination result” defined in the GenDG [Hessel and Henn  (2022) ated from ). Furthehe GenDG ,43. Givehe GenDG .Overall, providers of NIPT, which in Germany are exclusively physicians, are well advised to include in their pre-NIPT counselling all 4–5 positive and 11–12 mentioned possibly problematic issues associated with the use of this test. This is most likely impossible to accomplish by gynecologists and obstetricians, and owing to the small number of specialists in human genetics, these extensive counselling needs cannot at present be covered in Germany. A way to address this issue may be the long demanded accreditation of clinical laboratory geneticists  into genWe are only at the beginning of a worrisome development because more tests for genetic dispositions are in development and are about to be approved”; and “We are united in our conviction that prenatal screening for trisomy 21, 18 and 13 and others must not become routine in pregnancy under any circumstances”.“(translated from )Fact is, that the NIPT is perceived by many pregnant as a standard measure for pregnant women and is carried out unquestioningly” . This ated from . Thus, ated from  are urgeted from  this canted from . If thisted from .