John E. Kurtz, Ph.D.
Department of Psychological and Brain Sciences, Villanova University, Villanova, PA, USA
Psychological testing, using a standardized and empirically validated instrument, is a recommended component of psychoeducational evaluations conducted in accordance with the guidelines of the American Society for Reproductive Medicine . When interpreted by a qualified mental health professional with the appropriate education and training in measurement and testing principles, the results of testing effectively complement the clinical interview in making decisions about the suitability of gamete donor and gestational carrier candidates. The Personality Assessment Inventory (PAI; ) is commonly used in psychological evaluations for third party reproduction. This instrument assesses a broad array of mental disorders, behavior problems, and major personality patterns, allowing mental health professionals to make informed judgements about psychological functioning that serve the interests of all parties involved. There are a variety of strategies for making decisions about egg donor and gestational carrier candidates with the PAI, and the recently introduced PAI-plus report  offers several new scores and features for test interpretation. One feature of particular interest to clinicians working in reproductive medicine settings is a mean score profile for egg donors and gestational carriers, one of nine context-specific profiles available with the PAI-plus report. These data from 1,044 donor and carrier candidates originate from PAI research carried out by Sims and colleagues . The mean PAI score profile from Sims et al. can be presented as an “overlay” to facilitate comparisons with the profile of scores obtained from an individual respondent. The correlation between the obtained profile and the context-specific profile is reported as a “coefficient of fit” to egg donor and gestational carrier candidates. Although this procedure appears promising to facilitate the screening process, there is little explicit guidance on how to interpret these coefficients of fit to the context-specific profiles or how such comparisons can assist in making decisions about candidates. The purpose of this article is to provide such guidance to users of the PAI for screening donors and carriers.
To understand context-specific profile comparisons, it is necessary to understand the place of profile fit strategies as a general interpretative strategy with the PAI. The development of the PAI included the assembly of a clinical standardization sample of 1,246 respondents from various inpatient and outpatient mental health settings. The mean score profile was computed for many subgroups of this larger clinical sample who shared specific clinical diagnoses (e.g., major depressive disorder) or behavioral features (e.g., suicide history). The score profile for a given case can be compared to each of these clinical subgroups to narrow down the diagnostic possibilities. For example, the test interpreter may entertain the diagnosis of schizophrenia if a high coefficient of fit is obtained between the current case profile and the mean profile for 126 patients with diagnoses of schizophrenia in the clinical standardization sample. A high fit coefficient is not the end point of interpretation, however; it prompts the examiner to compare the two profiles using the overlay feature in the PAI Clinical Interpretive Report. If the current profile deviates from the schizophrenia overlay in areas that are relevant to a schizophrenic diagnosis (e.g., on scales that assess paranoid ideas, thought disorder, etc.), then the examiner will be less inclined toward the diagnosis than if the scores converge well in these relevant areas of the profile. That is, two different cases may obtain the same coefficient of fit to the schizophrenia profile, but the pattern of scores for one of them may provide a more compelling indication of the diagnosis than the other.
What does a high fit coefficient to the “egg donors and gestational carriers” context-specific group signal to the examiner? Unlike the example for schizophrenia above, the examiner already knows that the person taking the PAI is a member of this group before the testing began. Strong fit to this mean profile only tells the examiner that the obtained PAI results are very typical of what can be expected in evaluations of egg donor and gestational carrier candidates. There may be a temptation for evaluators to infer that a typical result (i.e., a high fit coefficient) means that the candidate would be a “good” egg donor or gestational carrier, but this is a highly dubious inference for several reasons. First, the cases presented by Sims et al.  are unselected cases, some of them may have been rejected and it is unknown how many of those who passed represent ultimately positive outcomes. Second, data from egg donors and gestational carriers are aggregated in the mean profile despite some significant differences in scores between the two groups reported by Sims et al. Third, the mean profile belies the fact that there is significant variability in the hundreds of cases from which it is derived. The average profile does not reflect the best candidate. In fact, the conceptually best test result – in which the validity scales and the clinical scales are squarely average – will obtain a very low fit coefficient when compared to the donor/carrier profile. Finally, and most important, the validity scale findings reported by Sims et al. indicate that these candidates were often defensive, with most cases yielding scores indicating questionable validity, so the mean profile is not an honest or accurate depiction of the true psychological status of these candidates.
Further understanding of the context-specific profile for egg donors and gestational carriers can be achieved by examining its correlations with other context-specific profiles available in the PAI-plus report. The donor/carrier profile shows a very high coefficient of fit with the mean profile for law enforcement officer candidates (r = .98), potential kidney donors (r = .98), and child custody evaluations (r = .93). PAI users will often notice that their obtained profiles fit these other context-specific groups as much or more than the donor/carrier group. This occurs because the profile for egg donors and gestational carriers is more indicative of the general context of screening and selection assessment than it is of the specific context of evaluating women aspiring to assist in third party reproduction. What these assessment contexts share in common is a strong demand for the respondent to engage in positive impression management (PIM) in their approach to the PAI. When PAI results indicate defensiveness and high PIM, it is more informative for interpretation and decision making to compare the obtained profile to similarly defensive profiles using PIM-predicted or Fake-Good profile overlays or the PIM-specific adjusted scores. Empirical research supports the validity of these procedures for identifying potential problem areas for further evaluation, even with highly defensive respondents [5, 6].
Like most people responding in a screening or selection context, egg donor and gestational carrier candidates are often highly defensive. The context-specific profiles in the PAI-plus offer little more than to confirm the typicality of this result, so their use in standard interpretation is not recommended. PAI users should not apply the egg donor and gestational carrier overlay when generating the clinical interpretive report. At best, the context-specific overlay clutters the candidate’s obtained score profile with extraneous information. At worst, the coefficient of fit to the context-specific profile implies a short cut to decision making that risks oversimplifying the often complex process of PAI interpretation. Fortunately, there are several established approaches for dealing with defensive and positively distorted PAI results and for discerning whether the candidate is engaging in efforts to conceal problems that are critical to informed decisions about suitability. Mental health professionals using the PAI in reproductive medicine are encouraged to continue using these procedures to make the best decisions about egg donor and gestational carrier candidates.
- Practice Committee of the American Society for Reproductive Medicine and the Practice Committee for Society for Assisted Reproductive Technology. Guidance regarding gamete and embryo donation, Fertil Steril 2021;115:1395-1409.
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- Sims, JA, Thomas, KM, Hopwood, CJ, Chen, SH, Pascale, C. Psychometric properties and norms for the Personality Assessment Inventory in egg donors and gestational carriers. J Pers Assess 2013;95:495-99.
- Kurtz, JE, Henk, CM, Bupp, LL, Dresler, CM. The validity of a regression-based procedure for detecting concealed psychopathology in structured personality assessment. Psychol Assess 2015;27:392-402.
- Kurtz, JE, Bupp, LL, Henk, CM. Novel approaches to adjusting for positive response distortion with the Personality Assessment Inventory. In Kumar, U. ed. Wiley handbook of personality assessment. Oxford, England: Wiley-Blackwell, 2016:374-86.