A stigmatizing effect of the carrier status for cystic fibrosis?

Carrier testing in children and adolescents

Many international guidelines recommend that carrier testing in minors should be postponed either until the age of majority or until the child can be actively involved in the decision making process. Although a number of high school programs exist which provide carrier screening to adolescents in at-risk populations, recent guidelines published by the American Society of Human Genetics do not advocate this testing. Despite this, there are some circumstances in which carrier testing does occur in minors. This testing might be intentional, in which identification of carrier status is the goal of the test, or unintentional, where carrier status is identified as a by-product of testing. In this review we outline the situations in which carriers may be identified in childhood and the positions of professional guidelines that address carrier testing in children. We then review the arguments for and against carrier testing presented in the literature and compare this to the empirical evidence in this field.

Three-month follow-up of Western and non-Western participants in a study on preconceptional ancestry-based carrier couple screening for cystic fibrosis and hemoglobinopathies in the Netherlands

OBJECTIVE

To study psychological outcomes, knowledge, recall and understanding of test-results, satisfaction, and reproductive intentions among 97 Western and 46 non-Western participants in a unique preconceptional carrier screening study for both cystic fibrosis and hemoglobinopathies in a multiethnic population the Netherlands, in which a couple's eligibility for cystic fibrosis and/or hemoglobinopathies testing was based on both partners' ancestry.

METHODS

Questionnaires before and after pretest consultation, and 1 week and 3 months after receiving test-results. Three cystic fibrosis and seven hemoglobinopathy carriers were identified, but no carrier couples.

RESULTS

Overall, anxiety levels were low, knowledge improved after pretest consultation but decreased after 3 months. Ninety-four percent remembered their test-results. Western compared with non-Western participants had higher knowledge-scores and better understanding of test-results. None of the carriers felt less healthy, six felt relieved, and one felt disappointed. Four carriers were unaware of the residual risk of having an affected child. Participants intended to draw reproductive decisions from test-results, were satisfied, did not regret participation, and did not report major feelings of discrimination or stigmatization.

CONCLUSIONS

Similar to previous studies, no major adverse psychological effects were demonstrated among the Western and non-Western participants in this study, and they would draw reproductive decisions on test-results. No arguments for rejecting a combined offer of preconceptional ancestry-based cystic fibrosis and hemoglobinopathies carrier screening were found. An extensive implementation study should be carried out, in which understanding of test-results needs further attention, to investigate whether or not this type of screening should be implemented on a large scale in the Netherlands.

Living with genetic risk: effect on adolescent self-concept

The purpose of this study is to describe the interplay of adolescent girls' and young womens' self-concept, coping behaviors, and adjustment associated with knowledge of genetic risk for fragile X syndrome. We will report here findings on self-concept. Using a multi-group cross-sectional design this study focused on girls ages 14-25 years from families previously diagnosed with fragile X syndrome, who knew they were (1) carriers (n = 20; mean age 18.35 years s.d. 2.5), or (2) noncarriers (n = 18; mean age 17.78 years s.d. 2.69), or (3) at-risk to be carriers (n = 15; mean age 17.87 s.d. 3.18). The girls completed the Tennessee Self-Concept Scale (TSCS:2), a visual analog scale, and a guided interview. Total and all subscale scores on the TSCS:2 were in the normal range for all three groups. However, threats to self-concept were found in personal self (physical self, genetic identity, and parental role), social self, and family self (family genetic identity) as they specifically related to the meaning of genetic information and varied based on risk status. Our findings suggest that risk information itself is threatening and for some girls, may be as threatening as learning one is a carrier. Certainty related to genetic risk status appears to make a positive difference for some girls by allowing them the opportunity to face the challenge of their genetic risk status and to begin to consider the meaning of this information.

Illness Representations, Self-Regulation, and Genetic Counseling: A Theoretical Review

In this article the Self Regulatory Theory (Leventhal, 1970; Leventhan H., Benyamini, Brownlee, Diefenbach, Leventhal E.A., Patrick-Miller, & Robitaille, 1997) is presented as a framework for conceptualizing genetic counseling. Findings published in the genetic counseling literature are re-interpreted from the perspective of the theory. Clients are seen as active information processors rather than passive receivers of information. Research related to clients' representations of genetic causality of disease and specific genetic conditions is reviewed. Associations of genetic illness representations to self representations, coping and health behaviors are examined, and suggestions are made for applications of the theory in research and clinical practice.

How does the mode of inheritance of a genetic condition influence families? A study of guilt, blame, stigma, and understanding of inheritance and reproductive risks in families with X-linked and autosomal recessive diseases

PURPOSE

While the mode of inheritance of a genetic condition has long been considered to have not only medical, but also psychosocial consequences for families, this supposition has never been tested.

METHODS

We surveyed 112 members of 51 families (59% response) with chronic granulomatous disease to determine the influence of mode of inheritance on parents', siblings', and patients' (1) knowledge of inheritance and reproductive risk; (2) concern about risk to future family-members; (3) feelings of guilt and blame; and (4) feelings of stigmatization. Ninety-six members of 51 families (49% response) with Duchenne/Becker muscular dystrophy and spinal muscular atrophy types II/III were also studied.

RESULTS

X-linked families had better understanding of inheritance (P < 0.001) and reproductive risks (P < 0.01). X-linked mothers worried more about risks to future generations; other autosomal-recessive family members were as worried. X-linked mothers were more likely to feel guilty (P < 0.01) and blame themselves (P < 0.001). X-linked fathers blamed their child's mother (P < 0.05) and X-linked mothers felt more blamed by the father (P < 0.01). X-linked family-members were more likely to consider being a carrier stigmatizing (P < 0.05).

CONCLUSION

When providing genetic counseling, attention should be given to guilt and blame in X-linked families and understanding reproductive risks in autosomal recessive families.

What is in a cause? Exploring the relationship between genetic cause and felt stigma

PURPOSE

Concern over stigma as a consequence of genetic testing has grown in response to the recent increase in genetic research and testing resulting from the Human Genome Project. However, whether a genetic or hereditary basis necessarily confers a stigma to a condition remains unexamined.

METHODS

We performed a qualitative interview study with 86 individuals with one of four conditions: deafness or hearing loss, breast cancer, sickle cell disease, and cystic fibrosis. The first two groups were divided approximately between people who ascribed their conditions to a genetic or hereditary cause and those who did not.

RESULTS

Respondents interpreted genetic or hereditary causes and nongenetic causes in a variety of ways. Subjects with breast cancer reported the most consistently negative interpretation of genetic cause. This response concerned future ill health, not an enduring sense of stigma. Deaf and hard of hearing subjects provided the most consistently positive comments about a genetic or hereditary basis to their condition, casting familial hearing loss as a vital component of group and individual identity. Respondents with sickle cell disease and cystic fibrosis offered similar and positive interpretations of the genetic cause of their condition insofar as it meant their conditions were not contagious.

CONCLUSIONS

Although some subjects report feeling stigmatized as a result of their condition, this stigmatization is not uniformly associated with the condition's cause, genetic or otherwise. Instead, stigma emerges from a variety of sources in the context of the lived experience of a particular condition.

Population screening for cystic fibrosis: knowledge and emotional consequences 18 months later

We assessed cystic fibrosis (CF) knowledge and emotional consequences of CF population testing 18 months after screening was offered. Questionnaires were sent to 593 individuals and 353 responded (59.5%). All respondents had sound knowledge of CF disease, although carriers were more likely to correctly state the pattern of CF inheritance and CF carrier rate in Australia. Eleven of 47 carriers falsely believed they were only very likely to be carriers, while nearly a third of test-negative individuals falsely believed they were definitely not carriers. Imprecise recall of the meaning of results may be due to memory loss over time, simplification of result meaning and minimization of risk. The Health Orientation Scale (HOS) was used to assess emotional consequences of CF carrier testing 18 months after testing. Both carriers and test-negative individuals thought most carriers would experience more negative feelings than most non-carriers. Carriers experienced less positive feelings about their test result compared to non-carriers. Interestingly, the carriers' own feelings about their result were more positive compared to how they thought most carriers would feel. These results suggest that carriers experience minimal adverse psychological effects, although a negative social stigma may be attached to carrying the CF gene mutation.

Gender differences in psychosocial reactions to cystic fibrosis carrier testing

Gender differences involving genetic testing have become a topic of research as feminist critiques assert that women may be affected differently, and possibly more significantly, than men by genetic carrier testing information. It is possible that men and women differ in their reactions to learning whether they are or are not a carrier of a specific mutation. It is also possible that men and women may differ in their reactions to different methods of genetic testing. Data on gender differences in reactions to cystic fibrosis (CF) carrier testing in a high-risk population and to gender differences in reactions to home-based as opposed to clinic-based testing are reported. This analysis suggests that at least for CF carrier testing, men and women do differ in terms of their risk perceptions, negative psychological affect, perceptions about themselves, and the convenience of testing. However, there was only one difference between men's and women's reactions to the method of testing. A better understanding of gender differences in response to carrier testing, as well as to interactions between gender and methods of genetic testing, may inform better approaches to carrier testing and to considering alternative methods of such testing.

Carrier testing of children for two X-linked diseases: A retrospective study of comprehension of the test results and social and psychological significance of the testing

OBJECTIVE

To evaluate long-term consequences of genetic carrier testing performed in childhood in terms of awareness and comprehension of the test result, and the social and psychological significance of such testing.

STUDY DESIGN

The families of 66 young females who had been tested for carriership during childhood between 1984 and 1988 were approached. Of the 66 families, 23 young females in families affected by Duchenne muscular dystrophy (DMD), 23 young females in families affected by hemophilia A (HA), and their mothers participated in our study. We used a questionnaire including multiple-choice and open-ended questions.

RESULTS

Of the young female participants tested in the families affected by DMD or HA, 65% knew their test results. Only 65% of DMD mothers and 78% of HA mothers remembered correctly the test results of their daughters. The majority (83%) of the young females tested sought no genetic counseling when reaching adulthood. The reason for this was not determined. Most (78%) reported that the test result had not influenced their lives, whereas some felt relieved to know they had not been carriers. Talking about hereditary disease in the family and between friends was open, and results of the carrier test had usually been told to friends.

CONCLUSION

Carrier testing was in most cases correctly understood and the matter openly discussed. Our results do not suggest that testing in childhood had caused serious harm to the young individuals tested. On the other hand, we found no obvious benefits from this early testing.

Cognitive representations of breast cancer, emotional distress and preventive health behaviour: a theoretical perspective

Individuals at high risk for developing breast and/or ovarian cancer are faced with difficult decisions regarding genetic testing, cancer prevention and/or intensive surveillance. Large interindividual differences exist in the uptake of these health-related services. This paper is aimed at understanding and predicting how people emotionally and behaviourally react to information concerning genetic predisposition to breast/ovarian cancer. For this purpose, the self-regulation model of illness representations is elaborated. This model suggests that health-related behaviour is influenced by a person's cognitive and emotional representation of the health threat. These representations generate coping behaviour aimed at resolving the objective health problems (problem-focussed coping) and at reducing the emotional distress induced by the health threat (emotion-focussed coping). Based on theoretical considerations and empirical studies, four interrelated attributes of the cognitive illness representation of hereditary breast/ovarian cancer are described: causal beliefs concerning the disease, perceived severity, perceived susceptibility to the disease and perceived controllability. The paper also addresses the complex interactions between these cognitive attributes, emotional distress and preventive health behaviour.

Population screening for cystic fibrosis in Western Australia: community response

We measured acceptance of carrier testing for cystic fibrosis in the community when offered in a primary care setting, determined variables influencing acceptance, and assessed knowledge of cystic fibrosis 3-6 months later. A total of 5,102 individuals age 18-50 years attending general practices or a family planning clinic in Western Australia completed questionnaires about knowledge of cystic fibrosis and the State Anxiety Inventory. Testing for the delta F508 gene was offered. After 3-6 months, carriers, a sample of consenting participants who were not tested, and a sample of test-negative participants were sent a further questionnaire; 43.5% of participants chose to be tested for cystic fibrosis carrier status. Women, younger people, people with higher education, people without children, and people planning to have children were more likely to be tested. After 3-6 months, carriers gave correct responses to questions about cystic fibrosis more frequently than those who tested negative or were not tested; 82.2% of carriers knew that they were definitely a carrier and 31.1% of test-negative individuals believed they were definitely not carriers. Thus, population carrier screening for cystic fibrosis offered in a community setting in Western Australia was acceptable to almost half of those offered testing, particularly younger people and those planning to have children, for whom knowledge of carrier status could be useful in making reproductive decisions. There was evidence that tested individuals recalled information in a way that minimised their risk of being a carrier.

Carrier testing and prenatal diagnosis of haemophilia--utilisation and psychological consequences

Attitudes towards prenatal diagnosis, and abortion vary widely between different countries, religions, cultures and over time. Carrier testing and prenatal diagnosis (PD) of haemophilia have become an integrated part of the comprehensive care for haemophilia in Sweden as well as in many other countries. Almost all carriers are interested in carrier testing if they are aware of the possibility. With the development of PD by chorionic villus sampling in the first trimester, the method became acceptable for many carriers, and it has in Sweden actually had an effect on the incidence of haemophilia in the 1990s. The use of PD is more common among women who perceive haemophilia as a very serious disease and who have a positive attitude towards legal abortion. The main reason for carriers not to use PD was that they do not find haemophilia to be a sufficiently serious disorder to justify an abortion. Women and their spouses are under a great deal of psychological pressure in association with the PD procedure, and the psychological consequences of having to terminate a pregnancy are long-lasting. At follow-up, about 6 years after PD and abortion, these women, however, do not have more signs of psychological distress than women without PD experience. Nevertheless, they must be offered qualified assistance both before and after PD as well as adequate follow-up after an abortion to help them cope with the emotional strain they are under.

Genetic advances in cystic fibrosis: to screen, to treat or both?

Since the identification of the cystic fibrosis (CF) gene in 1989 there have been considerable advances in treatment and fierce debate concerning CF screening programmes. Cystic fibrosis imposes a burden of suffering, of onerous treatment and of reduced lifespan. New emerging treatments are very expensive but are expected to improve survival and quality of life. Treatments and screening programmes should not be played off against one another in choices for funding. This paper presents an argument for the appropriate use of newer treatments which could be funded from savings arising from the effects of widespread implementation of newborn and active cascade carrier detection programmes. Newborn screening delays the need for expensive treatments reserved for those with advanced disease, by reducing pre-diagnosis tissue damage and the rate of progression of the disease. Carrier screening has the capacity to decrease the numerical burden of affected children born and increases the number of children born free of disease. For the present, carrier screening in the absence of a family history could be funded by the individuals who wish it or by those prepared to buy this service. All types of screening presume quality control, an existing laboratory and counselling infrastructure and an established method of communicating results.

Social and psychological issues associated with the new genetics

This paper discusses two prevailing views--optimistic and pessimistic--about the potential benefits and risks arising from developments in human genetics and argues that we do not yet have enough evidence to assess which elements (if any) of either view are likely to be correct.

Risk perception after CF carrier testing and impact of the test result on reproductive decision making

A correct interpretation of the result of a CF carrier test and a correct understanding of the risk of having a CF child is complicated by the limited sensitivity of the DNA test. The present paper addresses this problem, with special attention for the residual risk after a negative test result. Secondly, the impact of the test results on child bearing decisions is evaluated. Seventy percent of a sample of 200 subjects tested in the Center for Human Genetics in Leuven answered a mailed questionnaire and participated in an interview. Knowledge about the recessive transmission of CF was weak. In the case of both partners receiving a negative test result, more than half the subjects were not aware of the restrictions of DNA testing, and were convinced that there was no residual risk. Two thirds of the subjects from the 'carrier + negative test result couples' were aware of the residual risk of having a CF child. This risk did not hamper further reproduction. Carriers who were single or whose partner was not tested, had much difficulties to understand the risk. Although most of them had no idea about their exact risk level, it influenced their childbearing decisions to some extent. It was also shown that the own risk of having a CF child had an impact on attitudes toward reproduction in hypothetical situations with different risk levels.

Carrier screening for cystic fibrosis in primary care: evaluation of a project in South Wales. The South Wales Cystic Fibrosis Carrier Screening Research Team

Population carrier screening for cystic fibrosis (CF) was offered to all patients aged 16-45 in one general practice in South Wales, excluding those in couples with a current pregnancy. Out of 1553 patients in this group, 481 subjects were tested, giving an overall uptake rate of more than 30%. The rate of uptake varied with the mode of invitation. Twenty-six carriers were identified, giving a prevalence of identified carriers of 5.4% (1 in 18.5) for those with no family history of CF. A further 18 carriers were identified by cascade testing of these 26. We describe the practical difficulties encountered in setting up this programme in primary care in South Wales. Questionnaires were administered or distributed to all subjects before and after testing. The response rate for the pre-test questionnaire was 95%, and 40-50% for the post-test questionnaires. These showed that, at 3 months post-test, 1 in 4 screen-negative subjects did not appreciate that they had a residual risk of being a carrier. At the same time, 15% of this group thought that there was a 1 in 4 chance of a child being affected if one parent was screen-positive (carried an identified mutation) and the other was screen-negative, and 40% thought there was no risk. Anxiety in relation to testing did not appear to be a major problem, although individual patterns of response to carrier status varied widely and more sensitive indicators of psychosocial impact of genetic tests are required. A pilot study of couple screening showed that this approach is unlikely to be useful in primary care, although we did not assess couple testing during pregnancy. For any programme of CF carrier screening to be established in primary care, it will be necessary to involve the primary care team from the earliest planning stage, so that the opportunity costs, training needs and other costs of the programme can be fully resourced.

The CF carrier status is not associated with a diminished self-concept or increased anxiety: results of psychometric testing after at least 1 year

To evaluate whether the CF carrier status has any lasting effect on anxiety and on self-concept at least 1 year after the disclosure of the test result, an in-depth interview and additional psychological tests were administered in a group of adults who participated in a previous study which suggested a slight stigmatizing effect of the CF carrier status. Besides carrier status, the role of a second factor-degree of relationship-was investigated. Analysis of Variance (MANOVA or ANOVA) revealed no effect on state and trait anxiety (STAI) and almost no effect on the six subscales of the Tennessee Self-Concept Scale. The absence of a lasting negative effect of the CF carrier status on anxiety and self-concept is a very important finding. Nevertheless, an intriguing significant interaction effect was found: the group of sibs carrying the CF gene felt less integrated in the family than the group of non-carrier sibs. This effect of carrier status was not found in the more distant relatives. It is important to pay sufficient attention to this problem during genetic counseling when brothers or sisters of a CF patient receive a test result.