Adult adoptees and their use of direct-to-consumer genetic testing: Searching for family, searching for health

Policy Guidance for Direct-to-Consumer Genetic Testing Services: Framework Development Study

BACKGROUND

The online offer of commercial genetic tests, also called direct-to-consumer genetic tests (DTC-GTs), enables citizens to gain insight into their health and disease risk based on their genetic profiles. DTC-GT offers often consist of a combination of services or aspects, including advertisements, information, DNA analysis, and medical or lifestyle advice. The risks and benefits of DTC-GT services have been debated and studied extensively, but instruments that assess DTC-GT services and aid policy are lacking. This leads to uncertainty among policy makers, law enforcers, and regulators on how to ensure and balance both public safety and autonomy and about the responsibilities these 3 parties have toward the public.

OBJECTIVE

This study aimed to develop a framework that outlines aspects of DTC-GTs that lead to policy issues and to help provide policy guidance regarding DTC-GT services.

METHODS

We performed 3 steps: (1) an integrative literature review to identify risks and benefits of DTC-GT services for consumers and society in Embase and Medline (January 2014-June 2022), (2) structuring benefits and risks in different steps of the consumer journey, and (3) development of a checklist for policy guidance.

RESULTS

Potential risks and benefits of DTC-GT services were mapped from 134 papers and structured into 6 phases. In summary, these phases were called the consumer journey: (1) exposure, (2) pretest information, (3) DNA analysis, (4) data management, (5) posttest information, and (6) individual and societal impact. The checklist for evaluation of DTC-GT services consisted of 8 themes, covering 38 items that may raise policy issues in DTC-GT services. The themes included the following aspects: general service content, validity and quality assurance, potential data and privacy risks, scientific evidence and robustness, and quality of the provided information.

CONCLUSIONS

Both the consumer journey and the checklist break the DTC-GT offer down into key aspects that may impact and compromise individual and public health, safety, and autonomy. This framework helps policy makers, regulators, and law enforcers develop methods to interpret, assess, and act in the DTC-GT service market.

Does the amount of family history matter? Perspectives of adult adoptees

Family history is considered the gold standard for risk assessment of inherited conditions and is often used to inform preventative care. There are currently no provider guidelines that address caring for patients with a lack of family history, and adoptees report inconsistent care because of this. Through this qualitative study, we explored (1) how the amount of family history impacts adoptees' perceptions of healthcare and (2) adoptees' suggestions for improvement of their healthcare. Fourteen adult adoptees participated in semi-structured interviews via telephone or Zoom audio. Transcripts were analyzed using thematic analysis and interpretive phenomenology. Results revealed five themes: adoptees should have access to their family health history; several factors influence the importance of family history (reproduction, identity formation, age, and health concerns); many adoptees use direct-to-consumer testing to gain information about health risks or to find family members; completing history forms or being asked about family health history invokes negative emotions in adoptees; experiences with healthcare providers are variable for adoptees. These results show that unknown family health history can contribute to a negative perception of healthcare. Adoptees perceive family health history as important to know, and not having this information brings up complex emotions in the healthcare setting. To help mitigate the disparities and the negative emotions that adoptees feel, genetic counselors should consider acknowledging the complex emotions, reassuring adoptees with available preventative care, and revising preclinical paperwork, such as family health history questionnaires, to be more inclusive of those who lack this information. These changes have the potential to significantly improve healthcare experiences for adoptees. Healthcare providers, especially genetic counselors, need to continue to learn about and advocate for this population.

The Landscape of Direct-To-Consumer Genetic Testing in Reproductive Health Contexts: An Analytical Framework of Stakeholders and Their Competing Motivations

We propose a theoretical framework that identifies (a) the different categories of stakeholders and (b) the normative values that drive their attitudes toward direct-to-consumer genetic testing, with an emphasis on the reproductive health contexts. We conducted a literature search using varied combinations of search terms, including direct-to-consumer genetic testing, decision-making, reproductive health, and policy. Using a grounded theory approach to existing literature and in combination with a narrative review, we present a systematic framework of five categories of stakeholders (i.e., genome-driven stakeholders, industry-driven stakeholders, history-driven stakeholders, value-driven stakeholders, and social justice-driven stakeholders) that shape the public's discourse. Moving beyond the dialectical ethics that have governed the public discourse, we also identify the normative values and interests that motivate different stakeholders' attitudes and decision-making through theoretical sampling under the grounded theory. We investigate the competing and conflicting values within the same category of stakeholders. For example, despite being industry-driven stakeholders, medical professionals' attitudes are driven by concerns about standards of care; in contrast, health insurance companies' concerns are centered on profit. We further explore the tensions between these stakeholders that impact their strategic alliances and pose challenges to the practices of direct-to-consumer genetic testing. Finally, we examine how these stakeholders and their corresponding values may shape future development and policies of direct-to-consumer genetic testing in the context of reproductive health.

Parents' Perspectives on Secondary Genetic Ancestry Findings in Pediatric Genomic Medicine

PURPOSE

With advances in genome sequencing technologies, large-scale genome-wide sequencing has advanced our understanding of disease risk and etiology and contributes to the rapidly expanding genomic health services in pediatric settings. Because it is possible to return ancestry estimates following clinical genomic sequencing, it is important to understand the interest in ancestry results among families who may have the option of receiving these results.

METHODS

We conducted 26 semi-structured qualitative telephone interviews of parents with children/newborns with likely genetic conditions from two studies of clinical genome sequencing. Using a purposive sampling approach, we selected parents from the SouthSeq cohort, Clinical Sequencing Evidence-Generating Research (CSER Phase 2) project active in Alabama, Mississippi, and Louisiana, or an earlier Clinical Sequencing Exploratory Research (CSER Phase 1) initiative based in the same region. Our interviews focused on parental knowledge about, attitudes on, interest in, and preferences for receiving genetic ancestry results following clinical genome sequencing in the neonatal intensive care unit or in pediatric clinics.

FINDINGS

Overall, parents prioritized clinical results or results that would help guide the diagnosis and treatment of their child, but they were also interested in any genetic result, including genetic ancestry, that potentially could enhance the meaning of information on disease risk, prevention and screening guidance, or family planning. While parents thought that ancestry results would help them learn about themselves and their heritage, the had concerns over the privacy, security, and accuracy of genetic ancestry information, although parents indicated that they had greater trust in ancestry findings provided as part of clinical care compared with those offered commercially. Parents also wanted ancestry results to be returned in a timely manner by knowledgeable staff, with kid-friendly materials and online tools available to aid, as needed, in the understanding of their results.

IMPLICATIONS

Taken together, our results highlight that despite being in high-stress situations, such as having a newborn in the neonatal intensive care unit, parents were interested in receiving genetic ancestry results along with their clinically relevant findings.

A Study Evaluating Consumer Motivations, Perceptions, and Responses to Direct-to-Consumer Canine Genetic Test Results

Direct-to-consumer genetic services allow companion animal guardians to purchase a DNA test and receive detailed results about their pet's ancestry, health, and traits results. In collaboration with Wisdom Panel, we present novel findings about consumer motivations, perceptions, and responses to their use of canine genomic services. Wisdom Panel customers were invited to complete an online survey anonymously in which they were asked about their reasons for using a genetic test for their dog, how they perceived the test's results, and how they responded to the results they received. Participant data revealed most utilized a test that provided more ancestry/breed results (75.9%) as compared to health-related results. The majority of participants perceived the breed test results as accurate (52.0% strongly agree, 27.6% somewhat agree) and the genetic services provided as having great value (49.6% strongly agree, 32.7% somewhat agreed). In responding to their dog's results, participants indicated they shared the information with family (88.1%) and friends (84.2%). Collectively, our study indicates consumers are more focused on their dog's ancestry than other test results. Using these findings and previous literature on human direct-to-consumer genetic testing, human-animal dyads, and identity construction, we consider the possibility of "breed options theory" and future areas of research.

Adoptees’ views and experiences of direct-to-consumer (DTC) genomic testing: an exploratory interview study from the UK

Direct-to-consumer (DTC) genomic testing for ancestry and health may appeal to adoptees looking to fill gaps in their family information. There are only a handful of published studies on adoptees’ views and experiences of DTC testing and none of these is from the UK. The recent UK House of Commons Science and Technology Committee report (GB Parliament, House of Commons 2021) did not address the gains or challenges for adopted people specifically, although the Committee did consider that robust evidence of opportunities or risks for any user of a DTC testing kit is limited. In this study presented here, semi-structured interviews were conducted with ten UK adult adoptees recruited via social media. Reflexive thematic analysis (Braun and Clarke 2006, 2019) of the interview transcripts identified three main themes: Decisional influencers of longing, uncertainty and normalisation of DNA kit use; Informational drivers to gain clarity but avoid new worrisome information; and talk around Negotiating Visibility to birth family and commercial third parties. A further theme of Meaning Making related to adoptees’ views of testing outcomes as bringing feelings of resolution or discordance. This study identified many challenging deliberations for adoptees in evaluating whether to take a DTC test and what to do when their results were returned. Additionally, adoptees’ consideration of data privacy issues appears hampered by already having shared identifying information about themselves in their wider adoptee search. Further research is encouraged.

Family secrets: Experiences and outcomes of participating in direct-to-consumer genetic relative-finder services

In recent decades, genetic genealogy has become popular as a result of direct-to-consumer (DTC) genetic testing. Some DTC genetic testing companies offer genetic relative-finder (GRF) services that compare the DNA of consenting participants to identify genetic relatives among them and provide each participant a list of their relative matches. We surveyed a convenience sample of GRF service participants to understand the prevalence of discoveries and associated experiences. Almost half (46%) of the 23,196 respondents had participated in GRF services only for non-specific reasons that included interest in building family trees and general curiosity. However, most (82%) also learned the identity of at least one genetic relative. Separately, most respondents (61%) reported learning something new about themselves or their relatives, including potentially disruptive information such as that a person they believed to be their biological parent is in fact not or that they have a sibling they had not known about. Respondents generally reported that discovering this new information had a neutral or positive impact on their lives, and most had low regret regarding their decision to participate in GRF services. Yet some reported making life changes as a result of their discoveries. Compared to respondents making other types of discoveries, those who learned that they were donor conceived reported the highest decisional regret and represented the largest proportion reporting net-negative consequences for themselves. Our findings indicate that discoveries from GRF services may be common and that the consequences for individuals, while generally positive, can be far-reaching and complex.

Exploratory content analysis of direct-to-consumer pet genomics: What is being marketed and what are consumers saying?

Mars Petcare introduced the first direct-to-consumer domestic dog genetic test in 2009 and Basepaws introduced the first direct-to-consumer cat genetic test in 2016. Social science research has evaluated numerous aspects of the human direct-to-consumer market, yet no such exploration has evaluated the occurrence of pet owners pursuing pet genetic tests. Using a mixed methods approach, we conducted an exploratory content analysis of direct-to-consumer pet genetic company webpages and consumer reviews shared on Amazon. Initial data reviews indicated some companies may be key industry players, relative to others. Our results present content frequency for each group (key industry players, all other companies), though the primary themes for each remained the same. Analysis showed genetic companies are primarily sharing product and purchasing information, along with trustworthiness to establish the merit of the company and their products. Companies also used statements directed towards pet owners that are suggestive of both pets and "pet parents" benefiting from the test results. The primary themes identified in consumer reviews involved consumers sharing their perception about the tests (e.g., accuracy), what aspects of the test results they focused on (e.g., breed information), and experiences with using the test (e.g., ease of use). Amazon reviews were primarily positive, though the companies with smaller review numbers had higher percentages of negative and ambiguous sentiments. Of interest, reviews most often indicated tests were being used to determine a pet's breed identity, while companies most frequently promoted the health advantages of using their products. Reviews revealed some consumers respond to tests by sharing their pet's results with someone or by altering their pet's care. Considering these results in addition to the growing popularity of this industry and the advancements of genomic technology, further research is needed to determine the role pet genetic testing may have in society and on human-animal relationships.

Health and kinship matter: Learning about direct-to-consumer genetic testing user experiences via online discussions

Background

Millions of people have undergone direct-to-consumer genetic testing (DTC-GT), but little is known about individuals' motivations and experiences (e.g., discussion topics and emotions after obtaining the test results) in engaging with DTC-GT services. Previous studies either involved only a small number of DTC-GT consumers or were based on hypothetical scenarios.

Objective

Our study aimed to fill this gap by investigating online discussions about DTC-GT that developed naturally among tens of thousands of social media users.

Methods

We focused on the posts that were published in the r/23andme and r/AncestryDNA subreddits, which correspond to the two companies with the largest number of consumers in the DTC-GT market. We applied computational methods to infer and examine the topics discussed, temporal trends in posting rates and themes (e.g., aggregation of related topics), and emotions expressed in these online forums.

Results

We collected 157,000 posts published by 16,500 Reddit users between 2013 and 2019. We found that the posting rates increased sharply after popular promotional events (e.g., each Amazon Prime Day and Black Friday) and most posts were inquiries into, or status updates about, testing progress. The inferred themes of Ancestral Origin and Kinship/Feelings were the two most frequently discussed, while discussions about the Health Risks theme focused primarily on submitting DTC-GT raw data to third parties for interpretation. The Kinship/Feelings theme exhibited the largest range of emotional response. A qualitative review of the posts with extreme emotions showed that some people became excited because they found their biological parents or other kin, while others became upset because they unexpectedly found that their parents or other kin were not biologically related to them.

Conclusion

This research demonstrates that online social media platforms can serve as a rich resource for characterizing actual DTC-GT experiences. The findings suggest that DTC-GT consumers' purchasing behaviors are associated with societal events and that future investigations should consider how DTC-GT challenges our understanding of kinship structure and function, genomic privacy, and the interpretation of health risks.